Critical mental health has a brain problem

A common critical refrain in mental health is that explaining mental health problems in terms of a ‘brain disorder’ strips meaning from the experience, humanity from the individual, and is potentially demeaning.

But this only holds true if you actually believe that having a brain disorder is somehow dehumanising and this constant attempt to distance people with ‘mental health problems’ from those with ‘brain disorders’ reveals an implicit and disquieting prejudice.

It’s perhaps worth noting that there are soft and hard versions of this argument.

The soft version just highlights a correlation and says that neurobiological explanations of mental health problems are associated with seeing people in less humane ways. In fact, there is good evidence for this in that biomedical explanations of mental health problems have been reliably associated with slightly to moderately more stigmatising attitudes.

This doesn’t imply that neurobiological explanations are necessarily wrong, nor suggests that they should be avoided, because fighting stigma, regardless of the source, is central to mental health. This just means we have work to do.

This work is necessary because all experience, thought and behaviour must involve the biology of the body and brain, and mental health problems are no different. Contrary to how it is sometimes portrayed, this approach doesn’t exclude social, interpersonal, life history or behavioural explanations. In fact, we can think of every type of explanation as a tool for understanding ourselves, rather than a mutually exclusive explanation of which only one must be true.

On the other hand, the strong version of this critical argument says that there is ‘no evidence’ that mental health problems are biological and that saying that someone has ‘something wrong with their brain’ is demeaning or dehumanising in some way.

For example:

“such approaches, by introducing the language of ‘disorder’, undermine a humane response by implying that these experiences indicate an underlying defect.”

“The idea of schizophrenia as a brain disorder might offer further comfort by distancing ‘normal’ from disturbing people. It may do this by placing disturbing people in a separate category and by suggesting uncommon process to account for their behaviour…”

“The fifth category… consists people suffering from conditions of definitely physical origin… where psychiatric symptoms turn out to be indications of an underlying organic disease… medical science has very little to offer most victims of head injury or dementia, since there is no known cure…”

“To be sure, these brain diseases significantly affect mental status, causing depression, psychosis, and dementia, particularly in the latter stages of the illness. But Andreasen asks us to believe that these neurological disorders are “mental illnesses” in the same way that anxiety, depression, bipolar disorder, and schizophrenia­ are mental illnesses. This kind of thinking starts us sliding down a slippery slope, blurring distinctions that must be maintained if we are to learn more about why people are anxious, depressed, have severe mood swings, and lose contact with reality.”

There are many more examples but they almost all involve, as above, making a sharp distinction between mental health difficulties and ‘biological’ disorders, presumably based on the belief that being associated with the latter would be dehumanising in some way. But who is doing the dehumanising here?

These critical approaches suggest that common mental health problems are best understood in terms of life history and meaning but those that occur alongside neurological disorders are irrelevant to these concerns.

Ironically, this line of reasoning implies that people without clearly diagnosable neurological problems can’t be reduced to their biology, but people with these difficulties clearly can be, to the point where they are excluded from any arguments about the nature of mental health.

Another common critical claim is that there is ‘no evidence’ for the causal role of biology in mental health problems but this relies on a conceptual sleight of hand.

There is indeed no evidence for consistent causal factors – conceptualised in either social, psychological or biological terms – that would explain all mental health problems of a certain type, or more narrowly, all cases of people diagnosed with say, schizophrenia or bipolar disorder.

But this does not mean that if you take any particular change conceptualised at the neurobiological level that it won’t reliably lead to mental health problems, and this is true whether you have faith in the psychiatric diagnostic categories or not.

For example, Huntingdon’s disease, dementia, 22q11.2 deletion syndrome, Parkinson’s disease, brain injury, high and chronic doses of certain drugs, certain types of epilepsy, thyroid problems, stroke and many others will all either reliably lead to mental health problems or massively raise the risk of developing them.

Critical mental health advocates typically deal with these examples by excluding them from what they consider under their umbrella of relevant concerns.

The British Psychological Society’s report Understanding Psychosis simply doesn’t discuss anyone who might have psychosis associated with brain injury, epilepsy, dementia or any other alteration to the brain as if they don’t exist – despite the fact we know these neurological changes can be a clear causal factor in developing psychotic experiences. In fact, dementia is likely to be the single biggest cause of psychosis.

In a recent critical mental health manifesto, the first statement is “Mental health problems are fundamentally social and psychological issues”.

This must ring hollow to someone who has developed, for example, psychosis in the context of 22q11.2 deletion syndrome (25% of people affected) or depression after brain injury (40% of people affected).

It’s important to note that these problems are also clearly social and psychological, but to say mental health problems are ‘fundamentally’ social and psychological, immediately excludes people who either clearly have changes to the brain that even critical mental health advocates would accept as causal, or who feel that neurobiology is also a useful way of understanding their difficulties.

All mental health problems are important. Why segregate people on the basis of their brain state?

The ‘not interested in mental health problems associated with brain changes’ approach tells us who critical mental health advocates exclude from their zone of concern: people with acquired neurological problems, people with intellectual disabilities, older adults with dementia, children with neurodevelopmental problems, and people with genetic disorders, among many others.

I’ve spent a lot of time working with people with brain injury, epilepsy, degenerative brain disorders, and related conditions.

Humanity is not defined by a normal brain scan or EEG.

Mental health problems in people with neurological diagnoses are just as personally meaningful.

Social and psychological approaches can be just as valuable.

If your approach to ‘destigmatising’ mental health problems involves an attempt to distance one set of people from another, I want no part of it.

What a more inclusive approach shows, is that there are many causal pathways to mental health problems. In some people, the causal pathway may be more weighted to problems understood in social and emotional terms – trauma, disadvantage, unhelpful coping – in others, the best understanding may more strongly involve neurobiological changes – brain pathology, drug use, rare genetic changes. For many, both are important and intertwine.

Unfortunately, much of this debate has been sidetracked by years of pharmaceutical-funded attempts to convince people with mental health difficulties that they have a ‘brain disease’ – which often feels like adding insult to injury to people who may have suffered years of abuse and exclusion.

But what’s under-appreciated is the over-simplified ‘brain disease’ framework also rarely helps people with recognisable brain changes. Their mental health difficulties reflect and incorporate their life history, hopes and emotional response to the world – as it would with any of us.

So let’s work for a more inclusive approach to mental health that accepts and supports everyone regardless of their measurable brain state, and that aims for a scientific understanding that recognises there are many pathways to mental health difficulties, and many pathways to a better future.

31 thoughts on “Critical mental health has a brain problem”

  1. What a great post. I read the first 2 examples and felt my blood beginning to boil. You’ve brought up some important points, for sure. I appreciate it.

  2. Great article Vaughan. Whilst I’m sympathetic to those critical of biological explanations of psychological and emotional distress, I often find their argument veers towards the opposite extreme. In part, this is due to a lack of biological knowledge amongst clinical psychologists (relative to our psychosocial knowledge, and the biological knowledge of our psychiatric colleagues).

    I think that this leads to straw-man arguments, presenting the “biomedical model” and then attacking its weaknesses. Actual psychiatrists (at least the good ones, that I’ve met, and I acknowledge my sample may not be representative of the discipline as a whole) truly understand the weaknesses of biological etiology, and acknowledge psychosocial causes within a biopsychosocial model. If you Google the “biomedical model” you don’t actually see anyone defending it as a real and useful thing, you only find social constructivist critiques. I don’t think the “biomedical model” actually exists as they construct it, outside of the marketing departments of pharmaceutical companies, and the terrifying adverts they put on TV in America. It is perhaps through marketing, rather than psychology or psychiatry, that such models enter the minds of our clients, and perhaps our GPs.

    Curiously, even the most staunch social constructivist colleagues of mine, who argue that certain psychiatric labels lack validity (a separate argument from whether they increase stigma or not) are actually very compassionate when they encounter clients with learning disabilities, autistic spectrum conditions, ADHD, brain injury etc… I hope that you haven’t encountered colleagues who are uncaring about people with these difficulties, as your post implies. Strangely, these colleagues seem totally willing to accept a partially bio explanation for these difficulties, at the same time as refusing to accept partially bio explanations for things like depression.

    I think its all complicated by the fact that ideas like “depression” are an umbrella term for a whole bunch of etiologically distinct difficulties with low mood, anhedonia, hopelessness etc. For some people these might primarily be due to social causes, such as poverty and unemployment, suggesting the social critiques of CBT and medication have some validity. However, this doesn’t help us to explain those poor and unemployed who are not depressed. Furthermore, some difficulties may be more to do with the interpretation of events, which plays into the validity of the CBT model, and possibly 3rd wave models such as Mindfulness, which help us to let go of distressing thoughts by not judging them or becoming emotionally involved with them.

    The tricky part is that there may also be people for whom their depression is quite biologically driven. These might be the people who swear by SSRI medication, as opposed to the large group of people for whom it seems ineffective. The problem is that people with primarily social, primarily psychological or primarily biological depression may have very similar presentations, at least in the GP surgery, and may misattribute the causes of their own difficulties (no offense intended to anyone experiencing depression is intended). This can result in someone who might benefit from therapy, or a good social worker, being prescribed SSRIs, or conversely, someone who might actually benefit far more from an SSRI, being given therapy to little effect. Our standard methodological tools, which compare means to measure statistical significance and effect size, disguise the large proportions of compared groups for whom a drug and/or therapy is ineffective.

    To truly address this problem, clinical psychology as a discipline needs to get over this psychiatry bashing, and move towards complex biopsychosocial models of emotional distress. The bio part is only at the front because it rolls off the tongue more easily, and is in no way priviledged in terms of causality. We need to recognise that chronic psychosocial stressors we are used to exploring with clients lead to real biological effects in the brain (reduced hippocampal volume, reduced neurogenesis, increased amygdala activity etc…) and that there is also evidence that both pharma and psycho interventions can be effective at reversing these bio symptoms, along with the psychological and emotional distress.

    Admittedly, this will require research which addresses bio, psycho and social factors simultaneously. Such research is rarely engaged in, because it generally falls outside the expertise of most research teams, and because of the practicalities (sample size) of detecting effects when there are such complex interactions. In the meantime, I think clinical psychology training could perhaps benefit from additional training in bio etiology, so that we can synthesize the existing knowledge, rather than it simply being a speciality of neuropsychologists.

    1. Yes, yes, and yes! I cannot agree with Tom’s original comment more (to thought provoking original post). The analysis shows a deep understanding of the problem, and a nuanced critique of both sides.

      Suffering from mental illness myself, yet also having worked in a top psychiatric neuroscience lab focused on the nexus between psychosocial and neurobiological interactions, I was offered a relatively rare and unique view of the problem you describe. Our lab was one of a few that truly tried to understand these complex interactions giving equal weight to both the psychosocial and the biological aspects of mental illness.

      The picture that emerged convinced me that biology and psychology are simply two vantage points to describe the exact same phenomenon. Of course in some cases (eg trauma) the cause is clearly tilted towards a psychosocial cause, but both the biological predisposition toward “pathology” and the effects on the brain are just as real. In other disorders such as autism, the causal agent is largely tilted towards biology, but the psychosocial consequences are nevertheless extremely salient to the patient and his or her family. In this sense, regardless of causality, (and even diagnostic categorization), a full understanding of an individual, the disorder they struggle with, and the potential treatments they might benefit from, is simply not complete without considering both aspects.

      With this in mind, I think there are a few positive trends in psychiatry and clinical psychology which are worth mentioning:

      1) A growing body of evidence is slowly revealing that to best understand the etiology and course of a mental disorder, you have to consider both psychosocial and neurobiological factors which explain unique variance in predicting outcomes. The promising element to this research is the use of novel yet sound statistical tools which overcome the problem of traditionally underpowered studies when attempting to account for many potentially causal factors. (for a fresh example http://www.medscape.com/viewarticle/861683)

      2) There is a growing recognition that as common fields , clinical psychology and psychiatry need to move beyond diagnostic categories and move towards dimensional models which look at specific aspects (both psychological and biological) of psychopathology which cut across categories. The hope is these “phenotypes” and biomarkers will provide a much needed toe hold for providing better targeted and therefore more effective treatments. (rdoc at NIMH being a prime example).

      Ideally I see the need for a unifying model which can give the same general information to both psychologists and psychiatrist yet still offer a specialization towards psychosocial causes and treatments and biological causes and treatments respectively. In other words they need to share the same language but be more versed in one aspect or the other depending on the field, therefore facilitating crosstalk and coordinated treatment. Though there are many who critique the shift in Psychiatry towards “solely medication management”, the truth is that a) it’s here to stay and b) it may not be such a bad thing considering no one professional can adequately do both. The problem lies in the lack of cross talk and coordination in part due to the two speaking two different “languages”.

      Perhaps one model which could accomplish this unification is the transactional model from developmental psychopathology which crucially understands an individual’s location on the health-psychopathology spectrum as the result of a series of temporally interacting biological and psychosocial factors throughout development, which depending on external or even internal factors, can be tilted towards health or illness. This last point is crucial in that it provides the needed theoretical framework for prevention, which is widely acknowledged to be a highly cost effective and important goal, so long as it is targeted.

      Of course the history and evolution of separate disciplines has created some mighty academic and clinical silos. But recent trends offer glimmers of hope that this is slowly changing.

      1. Thank you for your praise Carlos.

        I think that those of us who work in mental health practice or research, but also have lived experience of mental health difficulties are in some ways in a good position to comment on the ways in which these difficulties are conceptualised and communicated to us.

        If, for example, we are experiencing depression, a pharmaceutical advert, or busy GP (meaning no offense to GPs, I just understand how busy they are) might give us a simplistic “chemical imbalance” biological explanation, i.e. “you are depressed because the chemicals in your brain are wrong.”

        On the other hand, a depressed person seeing an overworked IAPT CBT therapist might get an overly simplistic “You are depressed because your thinking about these situations is wrong.” Again, no offence is intended to IAPT workers, whom I’m sure for the most part would give more compassionate and balanced explanations than this.

        Conversely, a person centred counsellor might offer an explanation in terms of the social events taking place in a person’s life, empathise and understand that perhaps anyone in a similar position might experience depression. This is very nice and validating, but actually some people are able to experience similar social events or environments, and are somehow able to function without experiencing as much distress. Purely social explanations are validating and kind, but can potentially give people the message that they are something of a victim of circumstances.

        A proper biopsychosocial formulation of a person’s difficulties would probably start at the kind and empathic person centred counselling place, move into exploring whether a person’s thinking or behaviours, whilst understandable, might actually be contributing to or perpetuating their difficulties. We might also acknowledge that biology and the brain are involved in these kind of difficulties, but only partially. This enables a person to benefit from medication if possible, but not expect a magic cure from it, or conversely, not to feel helpless, as though things are out of their control. This balanced approach to formulation and intervention is what I try to do therapeutically. I am still learning more from every client I meet.

        On the idea of different “phenotypes”, I agree with this in principle, but in practice I think it would be too difficult from a pragmatic standpoint. I think you are correct in theory that genetic influences in mental health are real and that our phenotype will effect our presentation. The problem is, that there are as many phenotypes as there are individuals (even identical twins have different epigenetic expression due to small environmental differences). So, an exhaustive list of phenotypes would basically be the individual formulation which people like Lucy Johnstone is arguing for. I think this is excellent in therapy, and to be encouraged, but for the purposes of having a quick shorthand to communicate in MDT meetings, its useful to have concepts like “depression”. This is also true for research: What could we put into Google instead of “depression” ?

        I am very glad to hear that your research team is investigating biosocial interactions. Unfortunately the link you provided just took me to a login page.

      2. Tom, thanks for the reply. I like the three examples you give, and I would venture to say they support my point about biology and psychology being two views of the exact same phenomenon. Essentially, the GP, CBT therapist, and person centered therapist are basically correct about EACH aspect of the problem they focus on, without this negating the validity of the other two views. As an example, adversity does cause changes in brain functioning in certain individuals which can result in maladaptive thoughts and behaviors which together push a person towards depression. But that is exactly my point, that it is not either one or the other, or even partly one or the other–it’s all of the above. No matter how much one aspect prevails In a specific case, the other aspects are always a part of the picture. We all have a brain, this Braun gives rise to thoughts and actions, and those thoughts and actions interact with the environment.

        Importantly research needs to be done within that framework in order to reveal the best understanding of and treatment for different mental disorders. I think in practice I completely agree with your approach of moving from one domain to another as you try to understand each client’s needs. But I would posit that your job could be tremendously enhanced by a more specific understanding of which types of individuals are better suited for which types of treatments. This is the promise of personalized medicine in general, but Psychiatry and Clinical Psychology stand to gain tremendously from such an approach.

        You mention that a phenotype could manifest itself in myriad ways. Sure, but there are also very clearly marked patterns of cognitive and behavioral differences between and among people suffering from mental illness. The same can be said for biological markers. And while I agree that we need labels such as depression, these are only general approximations, and it is about time that more precise diagnostic approaches can be formulated that can allow more targeted and therefore more effective treatments.

        Sorry the link I gave you needed a log in. Here is a direct link to the paper. And also to the national Institutes of mental health rdoc criteria to evaluate markers across several levels of analysis (from bio to social) as a spring board for better diagnosing.

        http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0151174

        http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml

  3. The one thing I remember from 2007 Phyiciatric therapy was the complete failure of a dozen prescriptions at different doses and this slipping out from the p-doc, “we really are still in the dark ages.”

    I had to self committ to a hospital spending 3 weeks being warehoused b/c I was sleep deprived after taking the prescription Abilify which of course kept me awake. I looked at the bill after the 3 weeks and the staggering amounts billed to my insurance by doctors I saw for minutes or even seconds. This was pre-ACA. God help ACA after this profession gets through with it.

  4. Tom, thanks for a very thoughtful reply to the post.

    Just to clarify, I haven’t encountered anyone of the critical mental health persuasion who has been less than completely compassionate to people with neuro diagnosis and difficulties and I wouldn’t expect them to be. Without exception, I’ve found them to be professional and empathetic to everyone they work with. However, my problem is with the arguments as detailed above and how they implicitly exclude people with measurable brain changes.

    Nevertheless, I’m struck by how people who typically argue against the medicalisation of mental health rely on i) the scientifically unsustainable but pragmatic medical distinction between ‘functional’ and ‘organic’ – with ‘functional’ problems being the focus of concern; and ii) service organisation categories, with the people they include in their scope of their arguments typically seen in adult or mainstream child mental health services rather than neurodevelopmental, intellectual disability, neuro or dementia services.

    I find it ironic that the people who are most likely to argue against ‘medicalisation’ remain conceptually hemmed in by medical categories, and indeed, rely on them when it suits.

    I want to make clear I think this is an implicit prejudice, and I don’t think anyone has an explicit prejudice here. But if we consider implicit prejudices to be a form of conceptual blind spot, we know these are often best addressed by experience, but experience is shaped by the sort of service you work in. On the other hand though, it’s true that a large minority of people in adult mental health services will have neuro difficulties (brain injury, drug use and epilepsy are common) that are typically under-addressed perhaps because they’re often not asked about.

    1. Hi Vaughan,

      Thanks for clarifying. I’m glad you’ve not actually encountered less than compassionate colleagues. It hadn’t occurred to me before that denying the possibility of biological involvement in mental illness, and making out that the psychosocial factors can explain everything could potentially be as stigmatising or excluding as the “biomedical model” often critiqued by such people.

      So long as we and our colleagues are able to conceptualise these different areas of cause and effect as overlapping, or intertwined as you suggested in your post, we should be OK. I’ve often formulated quite biologically, which reflects my background in science prior to psychology. This means I can relate quite well with psychiatrists and “speak their language” to an extent, but have had to learn from wiser and more experienced colleagues to formulate the full range of psychosocial factors in addition to the obvious (brain injury, autistic spectrum condition etc…)

      Fortunately, I have since had the pleasure of working with some great psychiatrists, who have been very compassionate and made great efforts to empathise with the social situations of our clients, and how they might be feeling about things. I’ve had consultant psychiatrists tell anxious patients that “therapy with Tom” will be more helpful than medication, and trainee psychiatrists remind me that the emotional experience of being given a psychosis diagnosis could be as influential as the actual symptoms of the illness. For this reason, I find it quite difficult when members of my own profession engage in psychiatry bashing behind closed doors. Its possible that these colleagues may have encountered less enlightened or sympathetic psychiatrists than me however.

      We can make mistakes though. I’ve met clinical psychologists who have attributed a brain injured person’s distress to “emotional lability”, i.e. a neurologically caused lack of emotional control, rather than thinking of it as a depression reaction. As you rightly point out, there’s not enough evidence to make this distinction, which means that a functional/organic distinction is probably a false dichotomy. Its probably a bit of both in clients with ABI, and as you rightly point out, its probably a bit of both in plenty of adult CMHT clients too.

      Anyway, goodnight 🙂

  5. Illuminating OP and comments. Many thanks. I notice that there is no mention of PTSD. Being a simple layperson, but having known quite a few people who are afflicted by a range of mental health symptoms resulting from trauma, it seems to illustrate very well the argument that environmental factors and organic brain changes are inextricably intertwined and that people with mental health problems cannot be arbitrarily divided up as the social constructivists like to claim. The attempt to divide people in that arbitrary way result from a hidden political agenda on the social construcivists’ part, imo. Much more still needs to be brought to light about this.

  6. What an eminently sensible comment! We need to leave our guild and ideological identities at the office doorway and remember that we’re all in the “helping” professions. Thanks…

  7. There is some seriously muddled thinking in this blog.

    The problem with the notion that the conditions we call ‘schizophrenia’ and so on are brain disorders isn’t one of (implied or actual) prejudice. The problem is that it isn’t true.

    Of course it isn’t demeaning or dehumanising to ascribe someone’s difficulties to a TBI, or to Parkinson’s, or to dementia, or whatever, if that is what they are suffering from. But yes, it IS demeaning and dehumanising to ascribe responses to life adversities, such as rape, domestic violence, bullying, and all the other known causal factors in mental distress, to bodily dysfunction. As you yourself say, this can add insult to injury to people who have already suffered years of abuse and exclusion.

    Psychologists – critical and otherwise – all recognise the need to work with the personal and social aspects of neurological problems, while recognising that there is a primary brain dysfunction or injury of some kind. That’s why formulation is a core skill across all specialties (DCP 2011.) The reason this falls outside critiques of psychiatry is because this model is totally appropriate in the field of neurology. But it isn’t appropriate in the vast majority of AMH presentations. However, if we suddenly observe a trend to describe epilepsy or Huntington’s as primarily psychosocial in origin, and treatable by psychotherapy (which would be the equivalent conceptual error) then I am sure there would be plenty of critics to dispute it – including, presumably, yourself.

    Yes, there are biological correlates to all human experience. No, it does not make sense to describe all human experience in terms of medical ‘illness’. Most people understand the difference between reactions to difficult life circumstances versus the emotional and behavioural consequences of dementia, stroke and so on. I am not sure why you do not seem to accept this distinction yourself.

    1. Hi Lucy, thanks very much for your thoughtful comments.

      When you say “I am not sure why you do not seem to accept this distinction yourself” the reason is because the distinction is used by critical mental health advocates in the false ‘one versus the other’ manner that I’m afraid you demonstrate in your comments.

      For example, you say it would be demeaning to ascribe problems arising from rape, domestic violence or bullying to bodily change but it wouldn’t be demeaning when problems arise from TBI or Parkinson’s. But this is exactly the biological reductionism I’m trying to argue against. Do you really think all the problems of someone with TBI or Parkinson’s can be so easily explained?

      Trauma doesn’t suddenly cease to be a problem because your brain is injured. Your social circumstances don’t immediately cease to be relevant when your neurons start decaying. Disabling seizures don’t make your unemployment any easier to deal with.

      I don’t think you personally intend this to be the approach but this is clearly an implicit bias in the critical mental health literature and you can see this in the fact that it only ever mentions people with brain changes to exclude them from consideration. Mental distress doesn’t care about the state of your brain, in which case, neither should we.

      When you say “The reason this falls outside critiques of psychiatry is because this model is totally appropriate in the field of neurology” I can’t help but see this as boxing yourself into medical categories you claim to reject. If you’re interested in escaping medicalisation I think you’d be better off by not defining your interests by the organisation of medical services and focus on mental health problems as lived experience regardless of which service they’re managed in. A truly critical mental health would include everyone with mental distress, regardless of the state of their brain or how ‘primary’ or ‘secondary’ you think their problems are.

      By the way, the classification of mental health problems as ‘primary’ or ‘secondary’, or ‘functional’ and ‘organic’, is another medical shorthand that is used uncritically in ‘critical mental health’. It criticises psychiatric diagnosis for reducing people’s problems to labels but is quite happy to do the same when it comes to brain changes.

      And that’s one of my problems with ‘critical mental health’ as it currently stands, anti-medicalisation when it suits, relies on medicalisation when convenient.

      To avoid these problems, I find medicine works best as a tool, not an ideology to promote or fight against. Compassion, however, should rely solely on the fact people are people, and we don’t stop being people because our brains are different.

  8. Thank you for your reply. But we seem to be talking at cross-purposes here. I wrote: ‘Psychologists – critical and otherwise – all recognise the need to work with the personal and social aspects of neurological problems…’ You replied by calling this ‘biological reductionism.’ I am at a loss to understand this response. Of course people with brain disorders may have complex social and psychological problems as well, whether previously existing or arising out of their injuries, and of course we need to address those too. To repeat, ‘That’s why formulation is a core skill across all specialties.’

    You then refer to ‘boxing yourself into medical categories you claim to reject.’ I am at a loss here too. No sensible person rejects legitimate medical diagnoses such as Parkinson’s, dementia, epilepsy and so on. Certainly I don’t. But critical mental health professionals DO reject the expansion of such categories into areas where they are clearly not justified or helpful. This isn’t a case of ‘anti medicalisation when it suits (but) relies on medicalisation when convenient.’ It’s a case of bringing much-needed clarity to the question of which experiences of distress are best understood as disease processes, and which are not. As I said, not every human experience is best understood as a medical illness.

    You then suggest that ‘a truly critical mental health would include everyone with mental distress, regardless of the state of their brain or how primary or secondary you think their problems are.’
    I have good news for you! I have plenty of colleagues in Health, LD and OA who object to the translation of understandable responses to adversity into psychiatric disease categories, whether or not there is also a medical/neurological/developmental problem of some sort. For example, they would argue that it makes no sense to say that someone distressed by a diagnosis of terminal cancer has simultaneously developed ‘major depressive disorder’. Equally, they would believe it is wrong and dehumanising to overlook the effects of abuse in people with a learning difficulty by calling it ‘schizophrenia’. I’m less familiar with neurology but Ste Weatherhead’s book ‘Narrative approaches to brain injury’ makes similar points. Perhaps clinicians in these areas can supply some relevant ‘critical’ references?

    The DCP Good Practice Guidelines on Formulation (2011), for which I was lead author, make this position very clear. They specify that best practice psychological formulation ‘is not premised on a psychiatric diagnosis’ (p. 29) but that formulating to include the whole range of psychosocial factors and adversities should be practised across all specialties. They specifically note that this applies to specialties such as LD, OA, Health and Neuropsychology as well, so that the focus is wider than just the medical/organic/developmental causal factors (p.16.)

    I think you have conflated ‘excluding neurology from our critiques’ with ‘reducing people to their neurological injuries.’ Obviously the two are not the same, and I don’t know anyone, ‘critical’ or otherwise, who needs to be told that ‘we don’t stop being people because our brains are different.’

    I hope this clarifies the arguments.

    1. You make it sound so easy Lucy. There are occasions where medical diagnosis is valid and explains mental distress, and there are other times when it is not valid and one has to understand people’s life history and perception of meaning. Any complexity is apparently solved by formulation as if it were an all purpose magic bullet and not something that is only as good as the assumptions and information it rests on.

      I find this approach worrying because of what it implies about how easily problems of people with brain changes can be explained away and I feel it is associated with an implicit prejudice about the meaningfulness of people’s lives who live with neurological conditions which is reflected in the critical mental health literature’s constant referral to brain disorders as demeaning.

      So here’s a simple test: produce some critical mental health writing that speaks positively of people with brain disorders and includes their mental health problems as part of understanding mental health problems as a whole.

      And I think I’ll leave it there.

      1. Vaughan – we seem to be going round in circles here. See my previous comments which demonstrate that there is no implication that the problems of people with brain changes can be ‘easily explained away’, nor that it is demeaning to suffer such problems. To repeat: I think you have conflated ‘excluding neurology from our critiques’ with ‘reducing people to their neurological injuries.’

        I’m going to set you a counter-test! Produce some critical mental health writing – or any writing – that states that having a brain disorder makes you less of a person and means we don’t need to look at your wider psychosocial environment. Then I will be more convinced by the ‘implications’ you claim to have identified…..

        I agree it is time to leave it there… but thanks for the discussion.

  9. Hi Lucy,

    During my clinical training, I have learned a great deal about balanced formulation, and the critiques of an overly medical approach to emotional distress. When the arguments that you and others, such as Bentall, and many of my colleagues make are made in a balanced way, I am generally in agreement with them. I’ve read the BPS DCP formulation guidelines and also a book on formulation you co-authored.

    However, if there is a problem with the arguments that you and others in critical mental health make, it is that you (and I mean the general you here, rather than you specifically) tend to present something of a straw man argument of psychiatry. I may have been fortunate enough to encounter very kind, caring and enlightened psychiatrists, who are deeply compassionate, although I have certainly heard some terrible stories of the opposite from colleagues of mine. It has been my experience though that in cases of emotional trauma, such as rape, abuse and bullying, that not a single psychiatrist would label this as a biologically caused illness. They might come up with a simplistic formulation such as “they are depressed because of the trauma they have been through” but typically none of them would consider this an abnormal reaction, and they would generally be very sympathetic and understanding. Psychiatrists in the MDTs I have worked in would typically refer such clients to one of us in psychology, or a psychotherapist, acknowledging the psychosocial realities of their distress.

    If you Google the “biomedical model”, there is basically no one that is defending it. Instead, we find the critical arguments with which we are familiar. The fact that there is no one really defending a “biomedical model” is to me at least anecdotal evidence that it is a straw man argument. At interdisciplinary training with trainee psychiatrists, the trainees all said that their textbooks emphasise biopsychosocial models of distress. I think this is a very good sign, as it demonstrates that clinical psychology is influencing other disciplines in terms of formulation. If I raise biological factors in an MDT meeting (e.g. a client’s cannabis use) I am pleased that I now have psychiatric colleagues reminding me about psychosocial factors. This is good.

    I think the problem can occur because the headlines of critical mental health arguments are often more extreme than the details of those arguments. In turn, this can cause people who are perhaps a little more biologically minded than the average psychologist (such as Vaughan and myself) to perceive your argument as perhaps being more extreme than it actually is. In turn, we might then respond by mentioning biological etiological factors, which in turn, might cause you to perceive us as being more biologically extreme than we actually are, as if we were defending (through the muddled thinking you mentioned) the biomedical model you and others seek to critique. In turn, you might respond by emphasising the psychosocial causes further etc…

    An interesting thing in formulation arguments is that, whilst we all formulate clients, we often fail to formulate other members of the MDT, or our intellectual or academic critics. If I am correct in my thinking, that we are each perceiving the other side as being more extreme than it actually is, and are responding by emphasising the opposite view, which in turn makes them perceive us as being more extreme than we really are, then the argument becomes more polarising, falling into black and white false dichotomy type thinking. We would never encourage clients to think in this way, or to read the minds of others to guess their views of motivations, but its easy to do when we get into argument mode as opposed to reflective mode.

    I think that a more useful way of being critical of existing models is to ask questions like: To what extent can constructs of emotional distress, such as “depression” be explained by a combination of biological, psychological and social causes? Often times, these causes are intertwined, as Vaughan explains in the OP. For example, the awful trauma of abuse, rape or bullying causes a stress hormone and immune system response, which causes inflammation, heightened amygdala activity, reduced hippocampal volume, as well as the emotional, cognitive and behavioural responses with with we are very familiar. Rather than viewing these phenomena as “different things” can we instead think of them as different aspects of the same phenomena? The question then becomes, two what extent is it useful to formulate a client’s difficulties as biological, psychological, or social in cause? Is it stigmatising? Or helpful?

    I had one client who viewed depression as purely biological, but changed his minds after a course of therapy. That client’s psychiatrist congratulated me on helping the client change their view and feel less dependent on medication. Equally though, following a course of fairly unsuccessful therapy, a client who had been total anti-medication decided that he would actually like to try some, which for him was quite helpful. Again, psychiatric colleagues were pleased with this, totally opposite outcome.

    I think if we can view all of these labels as being pragmatically useful, without getting bogged down in whether they are ontologically “real” or conversely purely social constructs, we can make more progress with helping alleviate distress.

    1. Tom – Thank you for these thoughts. I won’t respond at similar length, but here are a few comments:

      1. You say that psychiatrists don’t typically think about distress in narrow biological ways. I agree. But the fact that you made this point at all seems to betray an assumption that this is a guild dispute. It isn’t – as is illustrated by this very conversation. You, I and Vaughan are all psychologists with rather different perspectives, while Duncan Double, a psychiatrist, has just written a response which accords closely with my own views. http://criticalpsychiatry.blogspot.co.uk/ It’s about ideas, not professions. Calling it ‘psychiatry bashing’ just creates distrust and bad feeling and I suggest you avoid such phrases.

      2. I’m less reassured than you by the ‘biopsychosocial’ model, which, as you rightly say, is what most professionals draw on in current practice. ‘Biopsychosocial’ can mean several things. At one level, it is a truism; biology mediates all our experience. No one at all is saying that ‘there is absolutely no involvement of biology in depression.’ That really is a ‘straw person’ argument. At a more specific level, as you point out, biology can inform our understanding of reactions to traumatic experiences – hypervigilance etc. Please note, though, that this understanding of ‘biopsychosocial’ as applied to doesn’t imply ‘illness’ – rather, it implies that all of us share evolved biological capacities to respond to threat. Incidentally, this fits with Carlos Zevallos’s call for an integrated model. I would argue that we already have the integrated ‘sociopsychobio’ model we need, in the form of the trauma-informed model, which draws on neuroscience and attachment theory to understand our reactions to complex trauma.

      However, ‘biopsychosocial’ can also be used to smuggle in the notion of biology as primary cause, with other life events reduced to the status of ‘trigger’ – as in ‘schizophrenia/depression/bipolar disorder triggered by stress/abuse/neglect/violence.’ And the implications of this ARE demeaning, whether this is intended or not – ie, that others without this hypothesised biological deficit would have coped better with prolonged sexual abuse, domestic abuse, poverty, and so on. This is how the medical model continues to exert its influence – not in a narrow ‘it’s all genes and biochemical imbalances’ sense but by assuming the primacy of the entirely unproven ‘bio’ bit.

      You say that ‘biopsychosocial’ doesn’t necessarily privilege biological causal factors, and it’s true that it doesn’t necessarily do so, and it’s also true that there is a welcome increase in recognition that ‘trauma reaction’ is often a better description. But we wouldn’t need to talk about ‘schizophrenia’, ‘bipolar disorder’ ‘major depressive disorder’ ‘personality disorder’ and so on at all, without the covert assumption that biology IS the prime explanatory factor in such cases.

      Although it is not always easy to draw the line, the distinction between ‘medical illness’ and ‘reaction to life circumstances’ remains a meaningful and important one. That is why there was such an outcry when DSM-5 proposed the medicalisation of grief, childhood tantrums and so on.

      So – invoking the ‘biopsychosocial model’, which is the basis of all MH practice, not just that of psychiatrists, doesn’t necessarily solve the problem. Obviously there are profound implications for the whole way we think about and intervene in ‘mental illness’. In the meantime, blurring the distinction between ‘biology as primary cause’ and ‘biology as mediator of reactions to adversities’ seems to be the main strategy maintaining the status quo at present.

      Anyway, this is my last contribution, and it’s been an interesting debate.

      1. Thanks for the reply Lucy, I’ll try to keep mine brief.

        I’m glad your views are not intended as a guild dispute. However, I have unfortunately seen such arguments turn into guild disputes on a number of occasions, although typically just in conversations with psychologists, rather than openly in the MDT. I take your point though, and will no longer use the term psychiatry bashing when discussing critical mental health views.

        I’m also glad to hear that you don’t think there is no involvement of biological factors in mental health. I’m sorry that I misunderstood your argument and didn’t intend to present a straw-person argument of your view. However, this still doesn’t take away from the fact that attacks on a “biomedical model” which no-one else is defending are also something of a straw man argument. Perhaps this gets into the mis-perception of each others views, which can lead to us over-emphasising the opposite view, and therefore being perceived as more extreme ourselves, as I suggested earlier.

        I am also in agreement with you on terms like “disorder” as being stigmatising, and would also prefer terms like post traumatic stress reaction instead. However, I think that it is the language we use that is stigmatising, rather than the role of biology per se.

        For example, bipolar disorder (poorly named I agree) seems to have a higher heritability rate than regular “depression”. I also agree that even the names are somewhat arbitrary labels for presentations which can vary immensely from one individual to the next. For this reason, I support a move to more individual formulation, but with the caveat that such terms are pragmatically useful in both the MDT and for research purposes. If we didn’t have terms like bipolar disorder or depression, what would we put into Google? If we couldn’t categorise difficulties in order to research them, how could we ever determine that regular “depression” is less biologically driven than “bipolar depression”?

        I agree that the biopsychosocial model underlays all mental health, but am dismayed that easily 95% or more of our training is on psychosocial factors. Again, this is just pragmatism – clinical psychologists cannot also have a psychiatric qualification for reasons of time and money. I think that we would benefit from more interdisciplinary training on clinical psychology training courses (and psychiatry courses) as this could potentially lead to more balanced thinking and less guild disputes all round.

    2. Tom, you say:

      “I may have been fortunate enough to encounter very kind, caring and enlightened psychiatrists, who are deeply compassionate, although I have certainly heard some terrible stories of the opposite from colleagues of mine. It has been my experience though that in cases of emotional trauma, such as rape, abuse and bullying, that not a single psychiatrist would label this as a biologically caused illness. They might come up with a simplistic formulation such as “they are depressed because of the trauma they have been through” but typically none of them would consider this an abnormal reaction, and they would generally be very sympathetic and understanding.”

      This is not the problem that I have faced in practice. The problem is that often, nobody is looking hard enough for the trauma. I have seen numerous of cases of severe and complex trauma reactions, in which the only things that have been picked up are the symptoms of psychosis. The client has then been treated with very standard ‘medical-model’ psychosis approach, which is medication and a nod towards psycho-social interventions. And I’m talking about what were actually by national standards, really good services. These interventions had little chance of succeeding because of the failure to address both the trauma causes and the trauma sequelae such as social phobia, agoraphobia and clearly understandable paranoia.

      When eventually (sometimes after 20 years or more), someone takes the time (and to be fair, is allowed the time by the system) to really investigate, things can finally move forwards. Generally speaking (but not always) when the case is presented with this new, trauma focussed formulation, it is welcomed and accepted by the team, especially if there is someone to take on the intervention indicated. The problem in my experience is not that psychiatrists can’t or don’t accept a truly bio-psycho-social model, it is really that a tradition of treating ‘schizophrenia’ for example, gets in the way of really seeing what is going on for the client.

  10. This sounds like a health psychology perspective on (critical) mental health. Would probably be a good thing. Although at present it does not address the problem of broad categories of human mental health problems being categorized as well-delimited brain diseases and subsequently predominantly treated pharmaceutically despite no evidence it should be nearly that simple.

  11. The issue Vaughan identifies is evident when Lucy says “yes, it IS demeaning and dehumanising to ascribe responses to life adversities, such as rape, domestic violence, bullying, and all the other known causal factors in mental distress, to bodily dysfunction.”

    This is presented as though it were un-problematically a description of the causes of all mental health problems. Is is not. A great many people with diagnoses of “schizophrenia”, “depression” etc. do not have problems that result from those causes (which is why the “functional/organic” distinction works well in theory but not in practice). The nub of the issue that is raised when we say “schizophrenia is an invalid construct” lies in the fact that schizophrenia represents a heterogeneous bundle of experiences and difficulties. Some of these are best construed as responses to difficult life events (I will give a nod here to Eleanor Longden’s experience of hearing voices as an example), while others are best construed as brain diseases (and here I will give a nod to people who are diagnosed with schizophrenia when they in fact have an as-yet-unidentified illness like in the case NMDA receptor encephalitis, which was only classified in 2007). It is this fact which critical mental health is so bad at acknowledging. Many people who receive psychiatric diagnoses *do* have brain diseases which are poorly recognised and understood. For this reason it simply won’t wash to say that those people belong in neurology or and these people belong in psychology. Apart from the obvious issue of exclusion, we currently have no way of differentiating the two broad sorts cases satisfactorily. To compound the issue, they are not always going to be in principle possible to distinguish.

    This is part of the “brain problem” Vaughan has identified, and it runs deep. Now, before this gets too heated, let me just be sure to say that I am a big fan of much critical mental health writing, and I think it is invaluable in order to check simplistic assumptions. However, one of the best ways to be critical is to also be self-critical, and I am sure critical mental health writers will be glad of the way that this article has provided that opportunity.

    1. Hi Huw,

      I agree with you that the functional/organic distinction is a false dichotomy. Sometimes there can be confusion, for example, I assessed a client who had been referred with depression, but subsequently ended up referring him to neurology with suspected Parkinson’s (neurologist agreed and made a diagnosis). However I have also seen the reverse, where an MDT dismissed a socially isolated person’s possible depression as purely being due to their Parkinson’s on the basis that they *did* have a diagnosis.

      I think the problem when Lucy and others suggest that it is demeaning to suggest that a person’s distress is biological when they have experienced abuse and trauma is complicated by several factors:

      i) No one is really suggesting this, other than the straw-men described by critical mental health authors

      ii) It can easily be misinterpreted to imply that conditions with definite biological involvement in terms of cause *are* demeaning. Lucy has clarified here that she doesn’t mean this, but its not an unreasonable mistake to make. Its a shame that she seems to think Vaughan is implying this himself, when he is merely criticising something which many of us could think was implied by critical mental health approaches, even if it is not intended.

      iii) If, as critical mental health authors seem to believe, there is absolutely no involvement of biology in conditions such as depression, and they are therefore entirely functional (i.e. 100% due to psychosocial factors) then it would perhaps be demeaning for people to suggest that they were 100% biological (which only the straw-men claim). Therefore, one could claim that in this case, claiming a condition was 100% biological could be demeaning when it in “reality” is not at all due to biology, whilst simultaneously claiming that it was not demeaning to have an obviously part biological condition such as a brain injury.

      I think (iii) sums up the views of authors in critical mental health, if I have understood them correctly. I can understand why they think this, but it relies on false-dichotomous thinking of functional vs organic, as well as straw-men that believe the opposite to what you (as a critical mental health thinker) believe. Its exhausting to think about here, let alone in academic writing or an MDT meeting with psychiatrists and nurses.

      We really need more balanced thinking for the good of our clients and colleagues.

      1. Hi Tom, looks like we are largely in agreement here. The one thing I will say in defence of Lucy and others who make similar claims is that the man is not made entirely of straw. It is not uncommon to see unhelpfully simplistic definitions of things like schizophrenia in some quite authoritative places. Jim van Os lists some good examples in his “schizophrenia does not exist” paper here: http://www.bmj.com/content/352/bmj.i375. My thought is that we are onto a hiding to nothing if we seek to counter such language as “schizophrenia is a brain disease” with an over-simplification in the other direction (“schizophrenia is a response to life events”). Critical psychology should bring out greater complexity, not close it down.

  12. Since my work was cited, I thought I should briefly respond. I think it’s perfectly valid to suggest that “mental health problems are fundamentally social and psychological issues” without in any sense demeaning people with neurological conditions or denying the role of biology.

    Notwithstanding the very small number of people with conditions such as 22q11.2 deletion syndrome and the somewhat larger number of people with brain injury, there is overwhelming evidence for the causal role of social factors in the origin of mental health problems for the vast majority of us (as outlined in Richard Bentall’s recent article in the Guardian newspaper). Moreover, there is equally overwhelming evidence for the effectiveness of psychosocial interventions for people who have developed mental health problems for whatever reasons. That alone would be sufficient to emphasise the fundamental role of psychological and social factors.
    But I think the misunderstanding is more profound. As I say in my book, reprising arguments made in my 2005 paper in the Harvard Review of Psychiatry, I believe that mental health problems are ‘fundamentally’ psychological issues, because, while both biological and neurological factors on the one hand, and social and circumstantial factors on the other, can be important in the origin of mental health problems, they do this through their effect on psychological processes. Of course biological insults such as 22q11.2 deletion syndrome or brain injury can indeed (the evidence suggests do) influence our mental health. But they have this effect through their impact on psychological processes.
    Mental health problems are “fundamentally social and psychological issues” because, while both biological and social factors impact on our mental health, the social factors are of fundamental importance, because psychosocial interventions are fundamental to our helping response, but more importantly because biological causal factors impact on our mental health because of the impact they have – must have – on psychological processes. None of these arguments demean people with neurological conditions or deny the role of biology. None of these arguments create a divide between one group of people and another. Quite the reverse, it emphasises how we are all making sense of the world, how we are all subject to the impact of social circumstances and biology. But, fundamentally, it emphasises how this is a human and psychological endeavour.

    1. I think my concern is with the use of the term ‘fundamentally’ which, if you’ll excuse the easy pun, leads to fundamentalism.

      With your reasoning, rabies – an infectious disease with intense emotional and behavioural symptoms – would be ‘fundamentally’ more social and psychological than Tourette’s syndrome – a psychiatric diagnosis defined largely by observation of brief actions. Or most brain tumours would be ‘fundamentally’ more social and psychological than DSM diagnosis narcolepsy. There are many many more examples in this vein which really don’t help us separate out ‘psychiatric’ from ‘physical’ – because the boundaries are, of course, largely artificial.

      In other words, I don’t think the idea of ‘fundamentally’ really helps us much. It just really serves to mark out ideology when what we really need are tools for helping people.

      For example, it doesn’t really help us to think of HIV as ‘fundamentally’ a viral infection issue or ‘fundamentally’ a social or behavioural issue. In terms of prevention, the single best intervention is education: very social and psychological – because we’re trying to stop the social transmission of the virus. For someone who is infected, antiretrovirals are the best individual intervention but thinking socially and psychologically is essential to maintain that person’s well-being and prevent further infections.

      It also depends strongly on context. What’s best thought of social and psychologically in one context and for one purpose may not be best thought of in this way in another. Malnutrition can be social, behavioural, political and / or biological depending on the context and what problems arise in helping people. Likewise, sometime the best intervention for depression is employment, sometimes it’s CBT, sometimes it’s an iodine supplement, sometimes its an end to an abusive relationship.

      One of my frustrations with critical mental health approaches is not that they apply social and psychological approaches to mental health, but that they don’t apply these when there’s the perception of a ‘biological’ illness. The blinkers come on and the thought stops here. But guess what the social determinants of brain injury, epilepsy, HIV and other ‘biological’ causes of poor mental health are? Poverty, abuse, gender… you get the picture. Does that mean a job will cure your brain injury? No. Will a job help your recovery? Yes. Will a job prevent brain injuries? On a population level, on average, yes. Different problems, different models.

      Perhaps we can move away from fundamentalism and just start thinking about what can help. I genuinely think that ideology is not the solution in mental health, it’s the problem.

      Practically speaking, one of the massive biases of mental health is that we’ve had far greater attention in recent decades on bio aspects and not enough on social and psychological aspects. So let’s work on better developing the social and psychological aspects. Making claims about the ‘fundamental’ nature of mental health I suspect just misdirects us.

      1. I agree: “…one of the massive biases of mental health is that we’ve had far greater attention in recent decades on bio aspects and not enough on social and psychological aspects. So let’s work on better developing the social and psychological aspects”.
        And if the word ‘fundamental’ is misleading, i apologise. But I’d still return to the argument I made in my 2005 paper – “that disruption or dysfunction in psychological processes is a final common pathway in the development of mental disorder. … The model proposes that biological and social factors, together with a person’s individual experiences, lead to mental disorder through their conjoint effects on those psychological processes”.
        Maybe ‘essentially’ would be a better word – fewer connotations, perhaps.

  13. I shall speak out of turn, as I am not a psychologist, but I am interested in how you all speak/write. I have 3 observations and a plea.

    1. The original post raises the ‘language’ issues raised by the critical approach, and yet, does not really respond to it. As you talk about about Huntington’s disease or dementia, you avoid, really, talking about all of these things. Are they all diseases, problems, difficulties, disorders? To be honest, I have problems with all of them and perhaps this is part of the problem. What do we call all those people (it is inevitably ‘those’, isn’t it), is important. I would like you to declare your hand.

    2. But I also have a problem with the other side of the argument (with which I have more sympathy as it reflects more on disease as something socially invoked). If I, a man, lie in bed crying, unable to move, with my partner and children scornfully looking at me (I wrote a book on men’s depression – I heard so many of such stories), do I really care whether you call what I have a disorder, illness, disease or, simply, F33. I don’t, I really, really, don’t.

    I also doubt very much that the scornful look from the children comes from a label or two. Its source is hugely complex. And it is beyond optimistic to think that if you change one word, two, or 200 diagnostic labels for some others, it will change reality. Linguistics has produced a library and a half of research why it is impossible.

    3. And now I will probably offend everybody – I am sorry. I suspect that (checking it is not impossible) both camps speak one language, or as some linguists would say, use one discourse. And it is within this discourse you battle out your differences. Yes, they are important differences, no doubt, but they are still only the surface of talking about ‘those people’. That’s my hunch at least.

    4. I end with a plea. How about sometimes thinking of little things? Like what do I say here, in this encounter with this person. Person, utterance, interaction, here and now, and then reflecting on them. I wish sometimes I read such a heated debate about the little things. This comment is probably mostly out of place, for which I am sorry.

  14. Long before language…. there was one study suggesting our brains instantly, instinctively and completely unconsciously – in millieseconds – reacts to the symptomatic behaviors of mental illness as accompanying infectious diseases. A logical precaution in evolutionary times. A weakened immune system and poor hygiene may be other issues. I would bet language is post hoc, epiphenomenal and a symptom of these deeper automatic responses and not causal of ppl staying away.

  15. After reading all of the comments, despite some of the “guild-like” tendencies displayed here and there, I am heartened that people are for the most part willing to debate these important issues respectfully and with an eye towards common ground. I did want to point out a couple of things, however.

    The argument is made at some point that it is demeaning to label someone as having a mental illness when they have suffered from abuse, since it erroneously assumes others would fare better. Except research unequivocally shows that others under the same circumstances, without the genetic predisposition (eg no short allele in the serotonin transporter gene) DO fare better.

    I am also surprised at the seeming over-focus on trauma as a causal agent alluded to in some of the comments, especially regarding schizophrenia. Let’s not forget that just a few decades ago Schizophrenia was solely blamed on terrible mothers, who many times had done nothing but care for their child the best way they knew and were certainly not abusive. The neurobiological understanding of schizophrenia has come a long way, and twin studies have confirmed it has one of the highest rates of estimated genetic contribution among the different psychiatric disorders. Even among anxiety disorders there is plenty of evidence that non traumatic factors can increase your risk (such as overprotective parenting!) There was an interesting piece on the Atlantic about this not too long ago. So one must be careful of not becoming TOO trauma focused lest you provide treatment just as inappropriate as say medication for social isolation.

    Finally a neurobiological understanding is in no way inherently demeaning. I have bipolar disorder. It is in good measure genetic, but there are also clear risk factors I had growing up. It is unfortunate in the sense of the suffering it has caused me and my family, but at the same time I’m tremendously grateful that the diagnosis exists which along with research on effective treatments can guide my self care, and allow me to live a much higher quality life than others would have just a few decades back. As such the label simply gives valuable information and as Dariusz mentions above, I could care less what they call it. Positive results are, after all, the essence of any successful mental health model and as long as both psychosocial and biological aspects are considered I could also care less what you call it 😉

    Thanks Vaughan for a thought provoking post, and thanks to all the commenters for a lively debate.

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