“Mental illness,” “Medical Model, ” and “stigma”

Mental illness has acquired a negative connotation due to an overly identification with medical model of “illness” and has weakened a focus on psycho-social-cultural factors impacting  various other  dimensions of mental illness. This  over-emphasis of  biological intervention and the concept of “treatment” (“find the cause, eliminate the cause, and remove or reduce symptoms” be it through biological, psycho-social or a combination of both interventions to a degree), has limitations, specifically for “psychological maladies”  that do not fit the “illness model” neatly.

As I understand,  illness is defined by any society as “ behavioral anomaly” resulting in some degree of impaired functioning.  For psychosis and schizophrenia or any other form of serious and persistent  mental illness,  it involves exhibiting atypical thinking and behavior symptoms associated with a generalized breakdown in social communication, “perceived  deficits” in personal independence management of life, which may often be considered by “significant others” of person’s life as being associated with current or potential  “at risk behavior” to self or to others, all of which may be characterized by some existing socially defined criteria of “disability.”  The problem of “stigma” may be  related not to the use of concept of “illness” per se,  rather being viewed  in the context for current lack of knowledge, and absence of more effective  biological and psycho-social interventions models to address the “disability” associated functions.   A study reported in August issue of Schizophrenia Research, 2015 by Nasralla et al. cites 91% of patients identified with schizophrenia with mean average of 15 years of duration; continue to exhibit “mild-moderate-severe” symptoms, in spite of active medication treatment. This is similar to what Javitt and Coyle, reported in the Scientific American (2004) stating that “two-thirds gain some relief from anti-psychotics yet remain symptomatic throughout life, and the remainder shows not significant response.”

Yes, instances of recovery are noted in many  anecdotal or published case reports , but they, I believe, constitute a small fraction of people associated with long-term psychosis and schizophrenia.   Many of them may be  gifted with a high degree intelligence and education, and or having the other forms of supportive psycho-social support systems than what we often see  present in the general population of schizophrenia and psychosis. With increased knowledge and development of technology in both biological and psycho-social interventions,  as well as consumer knowledge and advocacy,  the  “disability” associated with “mental illness”  may be  considerably ameliorated  or compensated, and consequently,  any stigma associated with concept of mental illness, I believe will also be reduced, hopefully in the future.

I do not believe that merely label change will  accomplish the abolition of negative stigma. More knowledge, research, change in social policies, consumer advocacy are all important elements toward an  improved outcome. While waiting for more improved social condition and cultural climate, use of normalization principle to all kinds of “disabilities,” and emergence of a more egalitarian society,  we will still need a form  of labeling, with categorical description of identification,  if people are to receive some “special services” from society. That’s where the reality of linearity of typical-atypical behaviors needs to categorized for the sake of clarity.

Finally, behavior has multidimensional aspect of “Reality” that includes constant interaction of brain-behavior-social-physical environmental as well as genetic involvements. One can assume psychological functioning is assumed to reflect brain changes and functioning, and vice versa.  As a practicing psychologist, I don’t’ have any qualm in believing  that whatever psycho-therapeutic intervention I may engage with clients. I assume that  brain changes do occur with such interventions  just as with any biological and psych-social interactions,  but my focus is to evaluate any  functional behavior changes by use of psychological intervention techniques that I have been trained to use.    For an effective  psycho-social advocacy for mental illness treatment, it does not need to contradict other intervention approaches, but need to highlight the benefits of its specific intervention perspective,  and make consumers more  knowledgeable about its  efficacy,  while not necessarily countering efficacies of other discipline involved interventions, and letting consumers and the significant other’s involved in the consumer’s care make decisions and choices as to what specific intervention or a combination of interventions that may be best appropriate.

In this day and age, where any health service intervention, biological, psychological, or any other form is  provided  in the context of “service-profit-consumer satisfaction” framework, and every service provider is engaged in providing services and making a living out it, marketing information, focusing on consumer benefits that takes into account improved functional outcome and increased satisfaction, and consumer knowledge, and informed consent become very important, notwithstanding advocacies by different stake holders in mental health or any other service industries and politics of mental health. The challenge for any practicing clinician is to figure out what is possible, in terms of providing services that is consistent with one’s professional training and roles, while ensuring one’s livelihood, and what is desirable in terms of professional goals and attainments, but this may be  often  difficult to implement  within the context of one’s working environment. The same constraint may apply to what one needs to do for advocacy, self-education, or being involvement in group enlightenment process outside one’s work environment. This  can also  become very frustrating and challenging navigation process in one’s particular  work environment.

It is often better  to assume that we do not know a lot in this  particular  field  of mental health service , and that  we need to learn a lot, and  that our knowledge is evolving and fluid.  As such,  one needs to adapt any model that one chooses to use to specific individual clients with changes and modifications.  Given the dilemma of time constraints and consideration of what aspect of one’s clinical time work is “billable” or not “billable”, in clinical practice environment,  it is often difficult to engage in collaborative dialogues with others involved in client/patient care in addressing many of the important considerations within an open dialogue of collaborative framework.  So each discipline effectiveness, I believe, becomes very limited, and may often work counter to each other’s perspectives.

From an existential perspective, human behavior and knowledge may reflect the cosmic status, whereby only 5% of the Universe is composed of the known baryonic matter of physical entities we see and perceive, and  95% is Unknown and Unknowable,  consisting supposedly of  Dark Matter and Dark Energy. My sense is that our knowledge and understanding of human behavior may reflect the same status  in many ways. .

My take on the issue of diagnosis is also similar. It is a label used by society to determine eligibility for service recipients and  for the service providers, and constraints of  reimbursement of service exchange that takes place within the broad framework of health industry. The criteria for a diagnosis is not static, but a fluid process, based on advancement of knowledge and science, and must take into account  a common understanding of a social framework to address behavioral anomalies in the context reducing or eliminating personal and associated social distress.

While the” illness model” (somebody has an anomaly that needs to be fixed by outside intervention) using a biological determinism and interventions involving biological and supportive psycho-social interventions, is palatable and acceptable  to many, but “mental illness” as many of us understand have  psychogenic origins with  major involvements  of psycho-social factors, and may be viewed  as  “personal existential crises,”  associated with  personal and social distress ( which may or may not involve demonstration of ” at risk behaviors” or potential for such behaviors).

The  “illness” model of  “treatment,” that implies a sense of dependency on external intervention for one’s well being,   may also violate a sense of personal freedom, ownership for one’s thinking and behavior, originating from within one’s self system, and may be perceived as working  counter to one’s  sense of “personal independence,”  and ones personal unique ways of adapting to one’s “existential reality, ”  which is  valued as  an important component to one’s well being and to a  sense of autonomy.

Many believe that social experiences and conditions that promote people to develop what one considers “mental illness,” the focus should be fixing the “social community and environment,” rather stigmatizing people with a mental illness criterion. Compounding the issue, many people diagnosed to have “long-term mental illnesses” do not have the social support and therapeutic milieu so to speak,  and may present at risk” behavior tendencies.

In an ideal society, if a “therapeutic milieu” is provided to all, and all kinds of people can access participation in various supportive group activities, and where “at risk status” can be monitored within the context specialized support and milieu along with social rule of law for managing any “at risk deviation,” while protecting personal freedom and values,  then there will be no need for any “destigmatizing” illness label. Persons may choose to enter or exist based on perceived ‘benefits,” and responsibility and onus on providing such satisfaction in entirely on the providers, just like in any consumer oriented buying and selling exchange of goods.

Additional issue is that “destigmatization” for a specific “mental illness,” such as “schizophrenia” is more of a perception of meaningful lack of progress with the “existing treatment modalities.”  For many diagnosed with this “malady,” the so-called “symptoms” continue to persist with “impaired level of functioning”  in spite of years of involvement in “treatment.” In order to have this egalitarian ideal into practice, societies must be able to routinely build in provisions for all such “entitlements.”

But this may again violate many people’s political and social values that one holds, giving too much power to “society” over individuals”