On Open Dialogue Part 2: Why do we need a new approach?

(Click here for an overview of all my Open Dialogue posts)

The problems with the current ‘illness-centred’ approach

The Schizophrenia Commission report paints a disturbing view of the current state of UK mental healthcare. The report describes how people and families affected by mental distress commonly experience difficulties such as a widespread fragmentation of mental health services,  lack of involvement of families, poor continuity of care with professionals, anti-therapeutic inpatient wards, and little access to psychological interventions.

Let us consider the possible journey of a person seeking professional help for severe mental distress in the UK today. Like Eleanor Longden, a young woman who started hearing voices at college, they are likely to consult their GP, who will in turn refer them to a psychiatrist. Miss Longden, who overcame her difficulties to become a respected psychologist, describes her own seeking of help through this route as a “fatal mistake”.

There is an immediate power imbalance between a patient and psychiatrist. In the eyes of both parties, the psychiatrist is the expert, in whom the solution lies. For this to be the case, the mental distress is reduced to a problem in a person’s head. This is how medical students and trainee psychiatrists are taught to see psychiatric illnesses. The biopsychosocial paradigm is cited (acknowledging that there are biological, psychological, and social factors at play), but Dr Steven Sharfstein, the former President of the American Psychiatric Association admits that “…we have allowed the bio-psycho-social model to become the bio-bio-bio model”. As Yakeley et al note, there has been a subsequent marginalisation of psychosocial approaches – psychiatry is in practice ‘dominated by the biological field in its greater efforts to yield ‘objective’ empirical findings than its more ‘woolly’ psychological or social counterparts.’

Biological factors have come to be seen as causative. This is despite a lack of strong evidence for any biological cause of mental illness (excluding dementia), or for the reductionist ‘chemical imbalance’ theories that continue to be propagated to students and patients. In other words, the mental distress is pathologised – viewed as an illness, rather than, as many people who have personal experience of this describe it, an understandable reaction to circumstances.

Emotional ‘no-man’s land’

This pathologisation can be understood in many ways, but one of the most important factors is the avoidance of difficult emotions in medicine and mental health.

50 years ago, psychotherapist Michael Balint wrote that the emotional problems in patients occupy ‘a kind of no-man’s-land: they are the province of neither the physician nor the psychiatrist’

Balint was critical of what he called ‘illness-centred medicine’, where the doctor was an ‘objective’ observer, using tests to diagnose and treat discrete illnesses without involving the patient as a person. He also spoke about a doctor’s unconscious desire to ‘convert’ the patient to his faith in medicine – his ‘apostolic function’. As an alternative, Balint advocated ‘patient-centred medicine’, where the doctor was interested in the patient as a person, worked to establish a collaborative relationship with them, and acknowledged the links between emotions and physical symptoms.

Yakeley et al lament that emotion, or ‘affective subjectivity’, remains neglected in psychiatry today, in exchange for objectivity. They argue that subjectivity within medicine and psychiatry ‘is seen as a limitation or hindrance to the accuracy and effectiveness of the task in hand’. The question remains, however, as to the limitations of ‘objectivity’ in understanding our minds.

‘If we knew all we could do about the brain of a bat,

we would still have no idea what it was like to be a bat’

– Thomas Nagel

Big eared Townsend Bat

Our Illness-centred medicine

Returning to our hypothetical consultation, the psychiatrist enters the meeting with an agenda. He is trained to identify symptoms of illness and use these to arrive at a diagnosis. He will ask questions to gather the information he wants, which often does not match what the patient wishes to express. The patient becomes an object, a repository of signs and symptoms to be classified. Their problems are intellectualised and reduced to a label within a diagnostic systems –  systems that lack validity.

A diagnosis in turn leads to a particular ‘care pathway’, a sort of recipe of ‘evidence based’ treatments. In psychosis, this is almost invariably antipsychotic medication. However, as with many psychiatric medications, the evidence of antipsychotic effectiveness is less clear than the manufacturers and psychiatrist advocates would have us believe.

Cochrane reviews are internationally respected analyses of all available evidence on a topic. The Cochrane review on Risperidone, a commonly used antipsychotic contains the following passage:

“There is no clear difference between risperidone and placebo….these data are very difficult to trust… People with schizophrenia or their advocates may want to lobby regulatory authorities to insist on better studies being available before wide release of a compound with the subsequent beguiling advertising.”

As well as some poor evidence of effectiveness, there is growing evidence of harm from antipsychotic use. The significant and common side effects of antipsychotics (such as sedation, weight gain, and diabetes) are fairly well known, but there is emerging evidence that their use leads to worse long term outcomes with psychosis. In 2013, Wunderink et al showed that patients who had no antipsychotic medication or a low dose for a first episode of psychosis were enjoying a better social outcome after seven years than patients who received usual treatment. Also, the brain shrinkage that was originally attributed to ‘schizophrenia’ itself, has now been shown to probably be caused by the antipsychotics the patients were taken (Andreasen, 2011).

The wrong road?

Social psychiatrists Priebe et al note how 30 years of expensive research by biologically orientated academics has failed to yield clinical relevance, and call for a change in direction, rather than ‘more of the same’. Open Dialogue is one alternative road to take. But rather than a novel modern idea, taking a social approach to mental distress is (of course) based in generations of wisdom.

Thomas Kuhn, author of ‘The Structure of Scientific Revolutions’ (1962), used this duck-rabbit optical illusion to demonstrate how a paradigm shift can lead one to see the same information in a radically different way

Click for Part 3: It takes a village

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3 thoughts on “On Open Dialogue Part 2: Why do we need a new approach?

  1. Pingback: On Open Dialogue Part 1: Introduction | Mandala

  2. Pingback: On Open Dialogue Part 4: Our origins in dialogue | Mandala

  3. Pingback: On Open Dialogue Part 1: Introduction | Mandala

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