Mental health articles

OF mental health care and mentally ill


The D.S.M.-III definition speaks only of mental disorders, but the D.S.M.-IVincludes a note distancing the A.P.A. from the idea that any meaningful distinctioncan be drawn between disorders that are mental and those that are physical. Thus, byimplication, the current A.P.A. position suggests that mental and bodily disordersare fundamentally similar.

One of the main reasons for thinking that mental and bodily disorders should beconsidered together is that it is difficult to find any coherent criterion for deciding which disorders are bodily and which mental. One cannot simply divide diseasesinto those that have psychological and behavioural symptoms on the one hand andthose that have bodily symptoms on the other, as many diseases have bothpsychological and physical effects. People with Down Syndrome, for example,suffer from mental retardation, but also have a distinctive appearance and often haveheart problems. Epilepsy causes fitting but also mental confusion. Flu causes atemperature and makes our noses run, but it also makes us tired and irritable.Nor can diseases be split on the basis of whether they have physical orpsychological causes. Many, if not most, diseases will be affected by bothpsychological and physical causal factors. The risk that someone will developschizophrenia, for example, is increased by social stressors, and also by drug abuse,birth complications, and genetic factors. Many diseases that are generally consideredto be physically caused are made worse by stress, for example allergies and highblood pressure.

The D.S.M.-IV notes that there seems to be much that is “physical” in “mental”disorders, and much that is “mental” in “physical” disorders, but then it goes on tocondemn any attempt to distinguish mental and physical disorders as a“reductionistic anachronism of mind/body dualism”.12 Here the D.S.M. errs. Thephysicalist is simply committed to the claim that minds are made from physicalthings (neurones, whatever). It is quite compatible for a physicalist to also hold thatthe mental can be distinguished from the non-mental, for example by features suchas intentionality. If the mental and the non-mental are ultimately made from thesame stuff this no more implies that they cannot be distinguished than the fact thatchairs and tables are both physical implies that chairs and tables areindistinguishable. Physicalism itself does not imply that one account of disordershould encompass both mental and bodily disorders.

I suggest that the A.P.A. is right to think that mental and physical disordersshould be considered together, but wrong to think that this conclusion follows fromadopting physicalism about the mind. Rather the reason why it seems sensible toseek one unified account of disease is simply that attempts to find a clear-cutdistinction between bodily and mental disorders have failed.

It is often thought that if mental and bodily disorders are considered together,political implications follow. Generally speaking, in the 1970s, psychiatrists werekeen to consider mental and physical disorders as being similar, while psychologistspreferred to consider them quite distinct.13 The debate was seen as linked to thequestion of who should treat mental disorders. Tensions came to a head in acontroversy regarding the wording of the introduction to the D.S.M.-III. Originallythe introduction was going to contain the claim that mental disorders are a sub-set ofmedical disorders.14 When they heard about this, the American Psychological Association wrote and complained to the A.P.A., sought legal advice, and beganlobbying for the claim to be removed.15 The psychologists feared that any statementthat mental disorders are medical disorders might be taken to imply that onlypsychiatrists should treat mental disorders and that potentially this could lead toinsurance companies refusing to reimburse for treatment undertaken bypsychologists. The Presidents of the A.P.A. and American PsychologicalAssociation exchanged a flurry of strongly worded letters.16 Intheir defence thepsychologists pointed out that the etiology of many mental disorders is unknown andclaimed that “although there may be justification for considering mental disorders tobe health disorders there is no justification for any attempt to equate mentaldisorders with medical disorders”.17 That the debate was motivated by concerns overprofessional control is made clear by the request of the Chairman of the D.S.M.-IIIcommittee, Robert Spitzer, that the exchange between the Presidents of the twoassociations be made public to the A.P.A. membership because this would “beanother way of demonstrating our conviction that psychiatry is a specialty withinmedicine. It would also make clear to our profession that D.S.M-III helps psychiatrymove closer to the rest of medicine.”18 Eventually, however, the psychiatrists wereforced to back down and agreed not to include the offending sentence in the D.S.M.Unfortunately, the A.P.A. archives contain no documents that outline the reasons forthis decision.

Psychologists have also mounted parallel attacks on psychiatrists. In theintroduction to his 1960 Handbook of Abnormal Psychology, Hans Eysenck arguesthat psychologists, not psychiatrists, should treat the majority of mental disorders.

Eysenck claims that psychiatry should be divided into two: a medical part “dealingwith the effects of tumours, lesions, infections, and other physical conditions”, and abehavioural part under which would fall most neurotic disorders as well as some ormost of the functional psychoses. He accepts that physicians should be left to dealwith the medical part, but when it comes to the treatment of the behaviouraldisorders he claims that “psychology is the fundamental science, and rationalmethods of treatment have to be based on a thorough knowledge of modernpsychological theory”

Whether mental and physical disorders are fundamentally similar or dissimilar isalso often thought to have implications for patients. Being mentally ill is stigmatisedin a way that being physically ill is not, and the mentally ill are often denied benefitsthat are granted to physically ill people. As a consequence, patient support groupsfor the mentally ill are often moved to argue that “mental illness is illness like anyother”, and that thus psychiatric patients should be treated like other patients.Claiming that mental disorders are biologically based and describing them as “brain disorders” play an important role in the rhetoric used by such groups. For example,in 1999 Senators Domenici and Wellstone proposed a bill that would require U.S.medical insurance coverage for some mental illnesses to be equal to that granted forother medical disorders. The senators reasoned that “severe mental illnesses arebiologically based illnesses and should be treated like any other medical illness”

Similarly, The National Alliance for the Mentally Ill, one of the best known U.S.mental health charities, states, “Just as diabetes is a disorder of the pancreas, mentalillnesses are brain disorders…”

Other patient groups have found their interests to be better served by arguing thatmental and physical disorders are quite distinct. Often this strategy is employed bypatients who suffer from disorders that are borderline between being considered asmental or as physical disorders and that can reasonably be claimed to have strongphysical components. Such patients tend to argue that they are significantly unlikepsychiatric patients and thus should not be treated like them. For example, TheNational Association of Councils of Stutterers appealed to Robert Spitzer when theyfound out that stuttering was to be included in D.S.M-III, and asked that stutteringbe removed, because they wished to avoid the stigma attached to suffering from amental illness.22 They argued that stuttering probably has a neurological basis and isthus not a mental disorder. They lost the argument, and stuttering became disordernumber 307.00. More recently, some patients with Chronic Fatigue Syndrome andsome transsexuals have been campaigning for their conditions to be recognised asphysical as opposed to mental disorders.

These arguments put forward by professional groups and patient support groupsare invalid. Even if someone doesn’t suffer from a medical disorder it might beappropriate for them to see a psychiatrist. Healthy people visit doctors forimmunisations. There is no reason why they shouldn’t visit psychiatrists for helpwith problems in living. Equally, mental disorders might be a sub-set of medicaldisorders and it still be the case that psychologists are the best people to treat them.

Psychologists already play a lead role in treating certain medical disorders, forexample those incurable disorders where the only possible treatment is CognitiveBehavioural Therapy aimed at helping patients adapt to a new way of life.The arguments put forward by patient support groups are also dubious. Patientswith prototypical physical conditions are considered eligible for medical insurancepayments and other benefits primarily because their conditions are thought to beinvoluntary and disabling. Thus, when considering whether other patients should begranted the same benefits, what is relevant is whether their conditions are alsodisabling and involuntary, not the general degree of similarity between theircondition and prototypical physical disorders.

With these preliminary issues dealt with, I shall shortly move on to consideraccounts of disease. First, however, it is worth briefly summarising the discussion sofar. I have explained that I will be using the terms “disease” and “disorder” throughout to refer to all injuries, disabilities, and diseases in the narrow sense. Thisusage is in line with that of much of the philosophical and medical literature ondisease. I shall be looking for an account of disease that encompasses both mentaland physical diseases. This seems the most reasonable path to take as it is plausiblethat mental and physical disorders cannot be cleanly distinguished. The claim thatphysical and mental disorders should be considered together has often been taken toimply that psychiatrists should treat mental disorders and that psychiatric patientsshould be granted the same benefits as patients with prototypically physicalconditions. Neither of these conclusions necessarily follows.

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