The Medicalization Of Mental Illness

The other day I was flipping around the channels on my television
when I came across a sign of the times. A major pharmaceutical company
was advertising one of their medicines for use as a treatment for a
psychological disorder. Now, normally this wouldn't catch my eye at
all. Pharmacy companies have been doing this sort of thing for a while
now. What grabbed my attention was the fact that the medicine (Paxil I
think) was being hawked for use against that most common of all mental
disorders - Social Anxiety. Social anxiety, it seemed, had been
declared a Medical Disorder and there was now a drug with which to
treat it.

Now, it's not hard to accept that medicines can
impact anxiety. We've known for years that drugs can take away people's
anxiety and fear. Any shy boy or girl drinking for courage at a social
gathering can tell you that. Anti-anxiety medicines like Valium and
Xanax have been available for years, as have Buspar and beta blockers.

What
is sobering is that, even though we have hard-won, elegant and well
supported scientific theories that explain anxiety in biological,
psychological and social terms; even though we have excellent
psychological treatments for anxiety with high "cure" rates; even
though fair minded scientists know darn well that the data do not
support an exclusively medical model of the nature of anxiety; it still
seems that a few well-coordinated and beautifully slick advertising
campaigns will be more able to shape public perception of how anxiety
should be treated than all of this psychological science. I cannot
avoid drawing the following conclusion: As a society we are moving ever
closer towards an exclusively medicalized vision of mental illness.
With the TV telling me that social anxiety is a medical disorder, how
likely am I to ask about alternative non-medical treatments?

The Medical Model vs. The Psychological Model

For
those of you who don't know this - the different doctoral level
professions that deal in the treatment of mental illness (medicine and
clinical psychology) have very different models of the causes and
proper ways to treat mental illness. Medicine has one way of looking at
things, and Psychology has a different one. I attempt to lay out some
of the key differences below. In the process I've had to paint a
stereotyped and a bit caricatured picture of both medicine and
psychology. I hope both parties will forgive me my license.

I've perhaps used some confusing terms in my table. Let me explain in English.

Medicine
takes a mechanistic approach to illness. This means that the physician
tends to view a patient in a detached way, as a body with a problem,
much like an actual mechanic might try to figure out what was wrong
with a car. The physician's goal is to understand the nature of the
body's problem so that this problem can be addressed and fixed. The
physician determines a diagnosis based upon her analysis of symptoms.
Her prescription is designed to fix the diagnosed problem. Nowhere in
this chain of events is the physician encouraged to be particularly
interested in the experience of the person behind the problem.

In
the medical model, the prescription (almost always a biological or
body-focused intervention such as medicine, or surgery) is the active
ingredient that will solve the patient's problem. The physician is the
authority in the doctor patient relationship. The patient's role is to
accept what the physician has prescribed and to minimally meet the
demands of the prescription. It doesn't matter if the patient
understands why the treatment should work or not. So long as the
patient minimally complies with the prescribed treatment regime, the
treatment should be able to do its corrective work. The subjective
experience of the patient is not really relevant to this process.

Where
the medical model tends to rely on cures that are external to the
patient (like medicine), the psychological model tries to cure by
getting the patient to use internal resources they already possess in a
different way. Because the patient (and not a pill) will be doing the
work, psychotherapists must act in fundamentally different ways towards
patients than physicians would. Psychotherapists are interested in
forming a relationship with the patient and in using this relationship
to help along the process of change. In working to foster this process
of change, psychotherapists become more like motivational guides than
white coated authorities. Their goal is to actively involve and
motivate their patients to make the specified changes that will improve
the patients' functioning. Good patients become active partners in the
process of change; the psychotherapist and the patient work together
collaboratively over time to solve the patient's problems.

The Continuing Need For Both Models

The
models I've outlined above are inseparably tied to the ways that the
medical and psychotherapy professions operate. Therefore, when an
advertisement sells a medicine as a solution to a mental health
disorder, part of what is being sold is also the correctness of the
medical model. The failure of this advertisement to even mention
psychotherapy or counseling as an important adjunct treatment
(understandable as this is in a commercial advertisement) makes an even
stronger (if unstated) claim: that the psychological model is
irrelevant.

The reality is that the psychological model is far
from irrelevant. There are real strengths and weaknesses to both
models; Both are 'correct' but also incomplete at the same time. Where
medicine excels at crisis management and biological manipulation,
psychology excels at behavior change and growth. Despite their
incompatibilities, these two models need each other desperately.
Without the other model present as a balancing force, any one of these
models would ignore vital facets of the human condition.

One Reason Why Medicine Is Becoming So Dominant

The medical model has become more prominent, in part, because medicine sells products
and psychotherapists do not. There are powerful pharmaceutical
companies behind the medical model who make billions of dollars each
year selling their medicines. These companies have the money to spend
on research and development of new drugs, and they also have the money
to spend on advertising.

Psychotherapists don't sell anything
except their services. They are a disorganized bunch made up of
multiple different professional groups. They use different therapy
approaches, only some of which have actually been researched and found
to work well. As a group, therapists have difficulty agreeing upon
anything more than that psychotherapy is important.

There is no
real business or professional interest behind therapists who would fund
the costs of even a modest advertising campaign. A few years ago, the
APA piloted an advertising campaign that would have helped to educate
the public about what psychologists do. Despite a reasonable public
reception in the markets that it did run in (so I understand) the
psychologist members of the state associations who needed to pay for
half of the fees associated with the media buys were unwilling or
unable to come up with the cash needed to launch the campaign. As far
as I am aware, the project never really got off the ground.

You
can't fault the pharmacy companies for promoting their products. Their
products work (mostly), they help people and they make money for the
shareholders. Of course they're going to advertise their stuff. They
want to sell as much of it as possible. As much as I'd like to see them
co-promote the benefits of psychotherapy when they talk about social
anxiety, I suppose that this is too much to ask them for.

The
responsibility to keep the good news about psychotherapy alive, then,
falls back upon psychotherapists (psychologists, social workers,
counselors, etc.) and those who have benefited from psychotherapy. The
writing is on the TV. Without some strong advocacy program to promote
the benefits of therapy, I think we will see a further decline on the
part of public knowledge and confidence in therapy.

We know
therapy works. We even know what sorts of therapy work and when they
are best applied. We have a good product. But a good product without
public awareness is not a good business proposition. It remains to all
of us invested in the psychotherapy enterprise to find a way to
advertise.