Mis à jour le Mercredi, 5 Janvier 2022
Modern day mental health practice could be defined as the application of the four main schools of thoughts that dominate the field of psychology in the clinical setting, by abiding to strict criteria set out by packaged behavioural sets, diagnostically defined by names and categorised depending on the core nature of their specific characteristics in terms of behaviour, aetiology and epidemiology. While these four [biological, psychodynamic, cognitive-behavioural & systemic] main schools of thought have contributed to the development and ongoing evolution of the field of psychology, they also have downsides when applied to different types of psychological cases, with some being more efficient in treating particular disorders while others being hardly efficient and questionable. Applying and integrating these four schools of thoughts with new intuitive fact-based theories to explain psychological constructs and disorders are leading to major innovations in psychology; however with each field’s limitations controversies over the validity of their interpretations and the efficiency of their applied doctrines remain a constant topic of debate among scholars and clinicians.
One of the main controversies that surround modern day mental health practice is the medicalisation of psychological disorders, a tradition influenced by the field of medicine which contradicts an important founding philosophy of psychology, which was originally initiated to study the “mind”, not the physical characteristics of the brain as an organ. Furthermore, evidence suggests that psychological problems are not caused exclusively by organic factors. In anxiety, depression and/or schizophrenia, people with genetic vulnerability to the development of those psychological disorders only do so when exposed to particular stresses in their environment (Hankin & Abele, 2005). However, on the other side of the argument, evidence has also shown that deficiencies in genetics and neurobiological anatomy are linked to psychological difficulties and disorders, and hence nowadays, integrated approaches are used in a variety of assessments when treating patients affected by psychological disorders.
On the theme of medicalization, the debate over eating disorders has led to one of the major controversies within the field between advocates of the biomedical conceptualisation of eating disorders and the feminist position (Maine & Bunnell, 2010). The former sees an individual woman as a patient with a debilitating disease, in need of a cure to her illness; while the feminist position views eating disorders as a condition that is gender specific with the woman as a victim of socio-cultural pressures generated by a male-dominated society governed by a hedonistic economic reality focused on the pursuit of the thin ideal. There is an important distinction that should be made here for the benefit of patients since the feminist view may not fully comprehend that in the case of obesity and emaciation related to eating-disorders, the patients are at severe risk of medical complications such as growth retardation, osteoporosis, gastrointestinal bleeding, dehydration, electrolyte abnormalities and cardiac arrest [in chronic cases]. The social feminist constructivist perspective may be interpreting eating disorder as an image debate of “Fat” versus “Thin”. This may lead to the normalisation of obesity and destructive eating habits which in turn may result in further medical complications that involve surgical interventions. As for the feminists, it may be ethical to acknowledge that obesity & emaciation associated with eating disorders are major health issues that precede further complications such as diabetes, cancer and high blood pressure; and should not be confused with social stigma regarding image, but seen as a sign of poor-health and lifestyle that require attention and effort in providing patients with the medical and psychological help they need to adjust their patterns of life to a healthy one by adopting a culture synchronised with dietary & nutritional education. In an episode of the French show, Arrêt Sur Image, Sébastien Bohler, the chief editor for the magazine Cerveau & Psycho and doctor in neurology explained how in general, men tend to be attracted to females with particularly shaped hips, scientifically caracterised by the waist to hip ratio. It is a value obtained by dividing the wait circumference by the hip circumference, and the ideal waist-to-hip ratio is 0.7 in all cultures apparently (Singh and Singh, 2011) [this is not to be taken as ultimately applying to every single male because individuals with good reflective self-function, i.e. the ability to reflect on conscious and unconscious psychological states, and conflicting beliefs and desires, have the ability to rise above their basic biological instincts and change their internal working models, and consequently their behaviour].
Secondly, the medicalization of anxiety disorders as distinct medical & psychological conditions may seem less favourable to the biological model previously mentioned. A mass market of pharmacological products used in treatment has been favoured for being more convenient and less time consuming. This may lead to patients feeling disempowered and hopeless when being treated as victims of an uncontrollable illnesses requiring pharmacological treatment, while already being in a state of distress, shock, disbelief and/or confusion.
Diazepam (Valium) or other benzodiazepines that are highly addictive have also been prescribed for years to treat anxiety disorders. The long term side effects have been trivialised along with the arrogant act of medicalizing fear and courage (Breggin, 1991). Critics of the medicalization of experiences argue that if patients are helped in understanding that panic attacks develop from the misrepresentation of bodily sensations and hyperventilation, this knowledge along with their own courage may strengthen them to take control of their fear. Research has also shown how patients who are educated in cognitive-behaviour techniques learn to use problem-solving and develop other skills (e.g. social – help them build meaningful lasting relationships while letting go of psychosocial burdens) that they lack to reappraise situations that may formerly have brought distress.
The tragic death of one of the most talented vocalists on the planet, Chris Cornell, has sent a shock throughout the arts world and reports have revealed that the gifted artist was on Lorazepam [a benzodiazepine medication sold under the name Ativan used in the treatment of anxiety disorders], the substance is known to heighten the risk of suicide in those suffering from depression, while a recent investigation (Bushnell et al., 2017) has also shown no meaningful clinical benefit from the addition of benzodiazepines during treatment initiation.
To prevent such tragedies from affecting the human race, more emphasis could be placed on “the mind” with clear guidance on the “thinking styles” (cognitive scripts) to adopt in the protection of the individual organism’s own psyche (mind). Simple foundations based on psychological logic should be propagated educationally to help people understand their uniqueness as organisms while protecting their psyche [mind] from the influence/control of external environmental factors that are beyond their control [e.g. biased negativity, uninformed prejudicial comments of meaningless acquaintances, etc]; acknowledging the fact that as long as an individual organism is within the boundaries of the law, he is allowed to live the life of his choice, and external factors would only affect one’s psyche if attention is given to them; and selectively ignoring parts of the environment is also an acquired skill vital in maintaining sanity, stability and psychological health, along with the ability to select experiences that are positive & progressive to the organism [while discarding negative ones] in the context and theme of their chosen individual lifestyles.
This would also shift the focus to the individual’s mind, courage & abilities to handle the world while maintaining a stable sense of self and resilience; and not turn them into biological organisms that are having their neurochemistry savagely altered by powerful chemical substances that are known to affect individuals differently with dangerous & sometimes fatal outcomes.
« Les meilleurs meurent souvent de leur propre main juste pour s’échapper, et ceux qui restent ne peuvent jamais vraiment comprendre pourquoi quelqu’un voudrait s’éloigner d’eux. »
– Charles Bukowski
« The best often die by their own hand just to get away, and those left behind can never quite understand why anybody would ever want to get away from them. »
As mentioned above, similar therapies oriented towards changing the “thinking styles” of patients to build a resilient psyche, could also be provided to sufferers of post-traumatic stress disorder who would benefit of a non-pharmacological and empowering intervention to manage and take control of recurrent intrusive and distressing memories – it may be useful to study fear, distress and courage as normal psychological processes happening on a dimensional scale on a normal continuum from one individual to another where those on the extreme ends of the scales may be considered for psychological interventions.
Similarly, antidepressant medication used to treat depression remains controversial due to its questionable efficacy and side-effects. The high level of effectiveness of SSRIs reported in academic journals was greatly due to only trials with positive results of antidepressants being published while those where antidepressants were found to be no more effective than placebos being rejected. The effects of TCAs and SSRIs have also been found to be negligible in mild to moderate depression but effective in severe depression in meta-analyses (Fournier et al., 2010). The negative side-effects of antidepressants are known to be risky and dangerous where symptoms such as loss of sexual desire and impotence, weight gain, nausea, sedation or activation, and dizziness are known to be some of the more disturbing ones, with effects varying with types of antidepressants – for depressed pregnant women, health risks may affect their offspring. Dangerous antidepressants such as MAOIs are only prescribed to patients who can follow strict dietary patterns that exclude foods with thyramine (e.g. cheese) to prevent risks of high blood pressure and hypertensive crises. Although meta-analyses suggest benefits may outweigh the risks, an increased risk of suicide has also been noted among patients under 25 (Bridge et al., 2007).
Electroconvulsive therapy has also sparked a major controversy as a primitive, dangerous and non-scientific practice for the brevity of its effect and negative side-effects on memory (Read & Bentall, 2010). A thorough review of studies on the effectiveness of ECT and its side-effects [retrograde and anterograde amnesia] revealed it to be effective for a brief duration in treating severe depression [in cases that are unresponsive to psychological treatment] and questionably only supported by psychiatrists with a vested interest in proving ECT’s effectiveness. ECT has also been associated with a slight but significant risk of death, and a qualitative study of patients’ negative experiences concluded that for some ECT leads to fear, shame and humiliation, and reinforces experiences of worthlessness and helplessness associated with depression.
Medicalization has also led to controversy over the diagnosis of schizophrenia, a condition classified as a disease by the World Health Organization and ranked second only to cardiovascular diseases in terms of overall disease burden internationally (Murray & Lopez, 1996). Diagnosis is believed to be part of best practice in the patient’s “best” interest, however a strongly presented viewpoint by Thomas Szasz (2010) qualified diagnosis as an act of oppression as it may pave way for involuntary hospitalisation; where a deviant, maladjusted or poorly educated person may be subjected to “control” processes that they are not fully aware of – this has been proposed as a “possible” explanation for the greater rates of schizophrenia among ethnic minorities (particularly Africans in the US & those of low-SES groups). This view has also been supported by many who argue that schizophrenia as a distinct category may not be a fully valid diagnostic, but a fabrication constructed that may stigmatise disadvantaged or poorly educated people – while this may be positive in shaping “unacceptable behaviour” and protect citizens & society, some people with moderate symptoms may also be forcefully hospitalised. Thus, nowadays, schizophrenia is not a single definite disorder anymore, but one among others, as it has been revised and turned into a spectrum, known as the schizoid spectrum [with other related disorders]. In the treatment of schizophrenia, medicalisation has also led to the evaluation of psychotherapy as a possibly ineffective treatment (Lehman & Steinwachs, 1998). Freud & others in his discipline acknowledged the treatment of psychosis as problematic with psychotherapy as psychotic individuals tend not to develop transference [interpretation of their hidden feelings, defences & anxiety] to the analyst – unlike neurotic patients. For personality disorders, addictions and other severe mental health problems medicalisation has led to the development of alternative methods of treatment that unlike the traditional authoritarian & hierarchically organised inpatient mental health settings, are run in a more democratic line where service users are encouraged to take an active role in their rehabilitation rather than simply being passive recipients of treatment.
Therapeutic communities have turned out to be effective in the long-term treatment of difficult patients with severe personality disorders with the outcome being more positive with longer treatments. These therapeutic communities are believed to lead to improvements in mental health and interpersonal functioning. For drug misuse issues, the assumption that clinicians make over users attempt to quit being due to conscious guidance & coherent plans should be revised as no evidence suggests so, and more evidence argue that unconscious processes, classical and operant conditioning, erratic impulses, and highly specific environmental cues affect the development and cessation of drug use (West, 2006). According to West, interventions should not stimulate adolescents to think of what ‘stage’ they are in or be matched to a stage, but maximum tolerable pressure should be put on the young person to cease drug use – which contradicts the stages of change model (DiClemente, 2003; Prochaska et al., 1992) where 30 days are allocated to stages [pre-contemplation, contemplation, action & maintenance] based on no evidence. While concepts such as harm reduction programmes with needle exchange, safe injection sites, and the provisions of free tests of quality of MDMA sold at raves remain controversial, some believe they prevent mortality and morbidity (Marlatt & Witkiewitz, 2010), while others argue they send the message that hard drug use [such as heroin] may be acceptable.
The second major controversy in modern day mental health practice remains the “Person or Context” debate where many in the field still question the validity of focusing on context as it shifts attention from the individualistic characteristics of the patient, and whether the focus should shift depending on the disorder and the patient’s age. For example in the treatment of childhood disorders, if difficulties are assumed to be individual ‘psychiatric’ illnesses the risk of focus being solely on the child and not on broader social environment may lead to medical treatments and individual therapy without addressing important risk factors for those of such young age who are influenced by their social environment, e.g. teacher, school and wider social context. This may not be the case for some adults who value a sense of autonomy more than being influenced by wider social contexts that they have no connection to, interest in or affinity for. In contrast, to the autonomic adult, treatment cases of other childhood behaviour disorders such as oppositional defiant disorder and conduct disorders may be particularly problematic, since the major risk factors that should be addressed are social: through interventions such as parent training, family therapy, multisystemic therapy and treatment foster care. For ADHD, the bold emphasis on medication is dangerous as the effects are limited to only 3 years (Swanson & Volkow, 2009), while growth and cardiovascular functioning may be affected that may lead to somatic complaints such as loss of appetite, headaches, insomnia and tics, which are present in 5-12% of cases (Breggin, 2001; Paykina et al., 2007; Rapport & Moffitt, 2002).
Another interesting argument comes from the Scottish psychiatrist and psychoanalyst R. D. Laing (2009) in the 1960s and 1970s who opposed the view that schizophrenia was a genetically based medical condition requiring treatment with antipsychotic medication. His dimensional approach led him to view schizophrenia as a ‘sane reaction to an insane situation’ where the contents of psychotic symptoms were simply viewed as psychological responses to complex, confusing, conflicting and powerful parental injunctions that left no scope for more rational and adaptive modes of expression. Thus, Laing proposed that the treatment involved creating a context where insight into the complex family process [e.g. poor housing, low SES, deviant parents with drug problems, over-involved family members who maintain the patient’s stress, alcohol problems, sexual deviance, incest, lack of financial stability, poor educational motivation, poor emotional education, lack of problem solving skills, lack of sophistication, poor nutrition, restricted finances, etc] of patients with schizophrenia and psychotic response to these could be facilitated. The context here seems partially important in the case where the patient’s delusions and hallucinations are linked, where their interpretation would be the client’s response to conflicting parental injunctions. The experience of psychosis and recovery was a process where the individual could emerge stronger with new and valuable insights regarding the solutions to their problems. However, this has not been supported by any evidence or subsequent research. In contrast, strong scientific evidence points to the importance of a more client-centred individual approach focussed solely on the patient with defective inherited neurobiological factors as major focus for the role they play in schizophrenia, and antipsychotic medication for the reduction of symptoms in two-thirds of psychotic patients affected (Ritsner & Gottesman, 2011; Tandon et al., 2010). Research has supported the hypothesis that suggests the family does affect the psychotic process and that psychotherapy has a place in the management of psychosis, for example personal trauma, including child abuse increases the risk of psychosis, and stressful life events including those within the family can precipitate an episode of psychosis, and high levels of family criticism, hostility and emotional over-involvement increase the risk of relapse (Bebbington & Kuipers, 2008; Hooley, 2007; Shelvin et al., 2008). So for those with a strong sense of family, and heavily involved peers, family therapy delays relapse in troubled families characterized by “extreme” levels of expressed emotion; and cognitive behaviour therapy which stresses the idea that psychotic symptoms are understandable and on a continuum with normal experience can help patients control these psychotic symptoms (Tandon et al., 2010), with solutions to rebuild their lives, their own identity and manage their social circle intelligently by differentiating types of relationship and expectations.
The third and last controversy to be addressed is the ongoing debate in clinical psychology over the categorisation of psychological disorders where many have been arguing over a dimensional outlook on psychological conditions that offers more precision in diagnosis along with a more scientific approach. In the case of childhood behaviour disorders with regard to scientific approaches, there is an ongoing debate over whether they should be viewed and classified in categorical or dimensional terms. While DSM are based on rigid categories, most empirical studies support the view of a dimensional outlook. Furthermore, factor analytic studies consistently show that common childhood difficulties belong to two dimensions of internalizing and externalizing behaviour, which are normally distributed within the population (Achenbach, 2009). Young children diagnosed with oppositional defiant disorder (ODD), conduct disorder and ADHD are part of a subgroup of cases with extreme externalizing behavioural problems, while those with anxiety or depressive disorders have extreme internalizing behaviour problems (Carr, 2006a). By the same dimensional approach, children diagnosed with intellectual disability fall at the lower end of the continuum of intelligence, a trait also normally distributed within the population (Carr et al., 2007). The dimensional approach is not only more scientific, but also has a less stigmatizing and rational approach to human uniqueness. The dimensional approach has also enhanced the movement critical of qualifying psychological deficiencies as ‘real psychiatric illnesses’, conditions such as ADHD, conduct disorder and other DSM diagnoses. Questions have been raised over whether they are invalid fabrications or spurious social constructions (Kutchins & Kirk, 1999). Those who trust the evidence of the dimensionality of childhood disorders argue that they may simply be traits distributed normally among the population where some cases fall on the extreme ends of certain traits, while those who point to the interests of pharmaceutical industries’ financial motives argue that they are spurious social constructions. The latter seems unethical but is a part of the decadent and immoral economic reality that we have allowed to exist. As parents, health and educational professionals, it is clear that the pharmaceutical industry and governments may all gain from conceptualising children’s psychological difficulties as ‘real psychiatric illnesses’. Some schools or uncaring parents may prefer children to receive a diagnosis of ADHD with stimulant therapy as they may have difficulty meeting their needs for intellectual stimulation, nurturance and clear limit-setting; thus these children in their care become more aggressive and disruptive.
In the case of schizophrenia, a dimensional approach has also led to the schizotypy construct as a dimensional alternative to the prevailing categorical conceptualization of schizophrenia (Lenzenweger, 2010). In contrast to the categorical view based on Kraepelin’s (1899) work and used in the DSM which sees schizophrenia as a discrete diagnostic category, this one proposes that anomalous sensory experiences, odd beliefs and disorganized thinking exist in extreme forms of schizophrenia as hallucinations, delusions and thought disorder, but these are simply on continuum with normal experience [i.e. it is present in all ‘normal’ people but peaks in abnormal ones] – a position originally advocated by Bleuler (1911). Research measures have provided support for the dimensional construct of schizotypy (Lenzenweger, 2010) where the continuum may be composed of sub-dimensions; from normal to psychotic experiences. Schizotypy is heritable; and patients with high schizotypy scores but who are not psychotic show attentional, eye-movement and other neuropsychological abnormalities associated with schizophrenia. Further, the dimensional approach has also led to the distinction between schizophrenia and split personality where 40% in the UK equated split or multiple personality with schizophrenia – as popular culture often does. It is clear that schizophrenia does not refer to such characteristics.
The closest equivalent to split personality is a condition known as dissociative identity disorder (DID), where the central feature is the apparent existence of two or more distinct personalities within the same individual, with only one being evident at a time. Each personality (or alter) is distinct with its own memories, behaviour and interpersonal style. In most cases, the host personality is unaware of the existence of alters and these vary in knowledge of each other. Evidence suggests that the capacity to dissociate is normally distributed within the population and an attribute many use to manage their own lives and network. Those with high degree of this trait may cope by dissociating their consciousness from the experience of trauma (such as child abuse, extreme graphic violence, etc) in early childhood by entering a trance-like state. This dissociative habit is negatively reinforced (strengthened) as an effective distress-reducing coping strategy over repeated traumas in early childhood as it brings relief from distress during trauma exposure. Eventually a sufficient number of experiences become dissociated to constitute a separate personality that may be activated in later life at times of stress or trauma through suggestion in hypnotic psychotherapeutic situations. Treatment often simply involves helping clients integrate the multiple personalities into a single personality and develop non-dissociative strategies for dealing with stress [e.g. argument with work colleagues, new manager, divorce, adolescents leaving home for studies, partner with alcohol problems, over-involved family members, etc] – this helps them deal with tough situations by facing them with problem-solving abilities and skills to come out with a firm resolution and have their views understood. Core symptoms of multiple personality disorder are not treated with psychotropic medication unlike schizophrenia but involves psychological education for patients to learn the skill of mentalizing [understand their own state of mind and that of others].
Finally, with personality disorders, the dimensional approach has led to the trait theory in conceptualizing important aspects of behaviour and experience from a limited number of dimensions. Any given trait is believed to be normally distributed in the population, for example, introversion – extraversion, most people show a moderate level of the trait, however those who exhibit extremely low or high levels [extremes] would have the sort of difficulties attributed in the DSM. So, normal people only differ from the abnormal in the degree to which they show particular traits. The trait theory has become dominated by the five-factor theory (McCrae & Costa, 2008) in recent years. This model includes the dimensions: neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. There is evidence for the heritability of all of factors within the Five Factor Model except agreeableness which seems to be predominantly determined by one’s environment (Costa & Widiger, 1994). Thomas Widiger has proposed that the five-factor model may be used as an alternative system for describing personality disorders (Widiger & Mullins-Sweatt, 2010). Widiger also argues that trait theory offers a more scientifically useful approach to assessment with good psychometric properties embraced by its questionnaires (De Raad & Perugini, 2002) – they are reliable and valid, and have population norms. Compared to categorical classification systems, trait models offer a more parsimonious way of describing patients with rigid dysfunctional behaviour patterns which in turn offers a more parsimonious way to conceptualize the development of effective treatments.
The major controversies in modern day mental health practice seem to revolve around the precision and the validity of constructs as psychological illnesses, and since they may stigmatise those who suffer from them, the constant research into better and more modern interpretations and explanations of their characteristics and treatment seem bound to revolutionise the field of psychology, as the movement takes a more dimensional approach; with a new generation of psychologists applying the rules with an open mind and a creative outlook on new perspectives and methods – the field of psychology looks set on a positively progressive course.
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