The Medical Model, @TimeToChange and the Importance of Picking Your Battles

Yesterday on Twitter, I noticed various people piling onto Time To Change, the campaign to end stigma against people with mental health problems. The objection people were raising wasn’t about the need to end stigma, but about the fact that they use terms such as mental health and mental illness. Time To Change was accused of perpetuating the medical model, with all that entails in terms of depicting psychological distress in terms of illness.

Seriously, people. Pick your battles.

Let’s get something out of the way. Is the medical model “true” or “false”? A while back I heard a clinical psychologist on Twitter confidently asserting that bipolar disorder “doesn’t exist”. She was clear that she wasn’t suggesting that people don’t experience cyclical patterns of low and elevated mood, and she wasn’t suggesting that this pattern couldn’t be corrected with medication. But it’s the category of bipolar disorder that “doesn’t exist”.

Well, yes, in a sense that’s true. But psychological formulations, or occupational therapy assessments of strengths and needs, or whatever else way of explaining things you want to use, don’t “exist” either. They’re descriptive frameworks that may be more or less useful for different people and different circumstances.

Here’s an example (with details changed for confidentiality purposes). I was recently working with an anxious teenager who we’ll call Pete. After commencing medicaton he told me that he’d started separating his identity from his mental illness. He’d come to think of himself as “Pete, who has an anxiety disorder” rather than “anxious Pete”.

If one wanted to, you could unpick that statement philosophically, argue about whether it’s correct to say that he “has an anxiety disorder” and whether it’s technically correct that this could be separated from his sense of self. Or, you could accept that this way of viewing things was useful to him in terms of his recovery.

Obviously that’s not to say that the medical model is always useful everywhere. It clearly isn’t. I tend to be particularly cynical about the diagnostic category of “oppositional defiant disorder” because I’ve met very few cases in which that way of explaining things provides a clearer understanding of the problem. In many cases it’s a too-simplistic description that ignores the wider circumstances of why a child might be angry and defiant.

All the different models – medical, psychological, psychodynamic, systemic, social constructivist, humanistic – are essentially ways of seeing, not truths. It’s also important to recognise that they’re not necessarily in competition with each other. It’s entirely possible for somebody to have both a psychiatric diagnosis and a psychological formulations and find both (or neither) useful. You wouldn’t think it from certain noisy Internet arguments, but there are countless examples of psychiatrists, clinical psychologists, mental health nurses, occupational therapists, family therapists, psychodynamic therapists, and of course, people with lived experience engaged in peer-to-peer support, working together to complement rather than compete with their respective ways of seeing. In fact, I’d say it’s more the norm than the exception. There’s simply no need for a One True God of explanatory models.

So, going back to whether Time To Change are wrong to use terms like “mental health” and “mental illness”, I’d question whether that’s a battle that needs to be fought right now. Whatever anyone wants to call it, the important thing is that people shouldn’t be ashamed of it and shouldn’t be stigmatised for it. Campaigns like Time To Change aren’t the enemy and aren’t the people who need to change. People who sack people from their jobs and ostracise friends and family for having a mental health problem are the people who need to change.

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About Zarathustra

Trained as a nurse, currently working in Child and Adolescent Mental Health Services (CAMHS). Co-editing the Not So Big Society blog. May possibly be an incorporeal being called Phil Dore. All views expressed are in a personal capacity and not necessarily the views of my employer.

32 Responses to “The Medical Model, @TimeToChange and the Importance of Picking Your Battles”

  1. I don’t believe in CBT: it doesn’t exist.

    I mean sure, there’s lots of people who are trained on “CBT courses” and they administer a kind of therapy called “CBT” to patients in certain ways that have certain things in common. But that’s just a label for some behaviours. I choose to reject the label “CBT” and my point is, no-one can prove that CBT actually exists apart from the label.

    We need to move beyond the “CBTical model” and accept that every therapist and every patient is different etc etc. you get the point.

    • Personally I refuse to believe that the Sun exists.

      Okay, there’s a big yellow thing in the sky, and it heats us up, and it’s making me feel rather lethargic right now, but I reject the label “Sun”.

      • Ha, good one, Z. CBT is working wonders for my daughter, who needs no medication – but has Asperger’s Syndrome, the high-functioning side of the Autism spectrum. She’s learned time management, self-acceptance, and even how to look someone in the eye when speaking to them… I can’t say enough about Jenn Dugan, her therapist. I do, I do, I DO believe in CBT! (more comments way down the line). As for me, psychiatry and therapy are needed in my “toolbox,” as well as self-care. I am in recovery from bulimia because I treat it as an addiction and have used a 12-step approach!

    • CBT is quite effective, when used appropriately. There is no set disorder or label of someone for CBT. Rather, it’s a form of therapy that is used to address maladaptive cognitions that lead to particular behaviors. The thought process behind the therapy is to ultimately work on someone’s cognitions, which will then change their behaviors. Whether it’s an addiction or a mental diagnosis. I have seen it work very well, but I have also seen it not work. All cases should be taken situationally. When a therapist implements therapy, they should take into consideration their own clinical skills, the symptoms the client’s are experiencing, and what the client’s ultimate goals are. Sometimes CBT fits, and some times it doesn’t. It’s actually hard to disprove the effectiveness of CBT since their is substantial research on this form of therapy. Further more, it’s considered an “evidenced based practice”.

  2. It has been interesting to me as a non-clinician, to see just how much of this important wider debate has been characterised in terms of extremes. Both sides have at times adopted an ‘either or’ approach, but following the discussion more closely on, and off, Twitter it is apparent that there is a more moderate majority seeking balance and that they include psychologists, psychiatrists, patients and those with lived experience. It is, I would suggest, highly plausible that an individual with a mental health problem may indeed feel ill and perceive themselves as ill at various times, while at other times – particularly in stages of recovery – come to see the experiences as a part of their wider personal experiences. In other words, like so many other ideas and concepts represented in this debate illness and integrated experience aren’t mutually exclusive and that those who are so wedded to the ‘either or’ characterisation of the discussion are doing the moderate majority a great disservice.

  3. Yes Time for Change ARE a part of the problem, so are the ever corporate charities and projects which one way or another prop up the predominantly medical model of mental health with medical model descriptions of ‘illness’ and ‘disorder’ and these DO have primacy over all other models. Granted there is some competition but what saddens me the most is that service users preferred understanding of their distress gets lost (and no I don’t mind if people chose a medical construct for themselves).
    However I would agree there are bigger fish to fry right now; drastic cuts to services, inaccessible or short term support with fixed narrow treatment choices, the most punitive social security system we’ve ever seen where people now face the prospect of being with no income for months if they attempt to appeal which will mean starvation, homelessness, suicide for some and deterioration or re-admission for others approaching it, housing crisis with people being shoved anywhere in the country or into appalling conditions, loss of legal aid to stand up to any of this, increasingly difficult access to over stretched CAB’s, disabled people facing the prospect of going into a care home or having to cease working, kids lives denigrated by those who say they are “too expensive” to keep, and families needing ‘breakfast clubs’ for their kids because of poverty.

    Disability hate crime is UP, the current government is (mostly) responsible for this.
    Suicide in the recently discharged and those under Home Treatment is UP, the current government is (mostly) responsible for this.
    There is increasing societal derision and ‘horizontal oppression’ between the poor and poorer, working poor and non-employed poor, set up by and fuelled by the policies of a government hell bent on destroying the social fabric of this country including the welfare state and the NHS.
    They have expertly redefined the value of human life in the collective consciousness with the full weight of the media in their command, and business, corporations, charities are all at the trough one way or another.

    The reason to have a go at them is this – they do NOTHING to challenge any of this. They do nothing to challenge the most potent festering pile of fucking shitty fascist sadistic bastards overseeing this economic genocide. There lies the main orchestrating seat of discrimination and where in any of the glossy ads is this challenged?

    So next time I hear of a TTC volunteer relaying how they are not ‘allowed’ to speak of cuts/increasing widening inequality/injustice as a pressing contributory factor in failing mental health or ability to maintain their stability what do you suggest we say?

  4. This similarly can be compared to the argument about whether or not internet addiction or cybersex addictions exists. Regardless, it is a frame of reference, which, despite what I might personally think, or how I might deconstruct these concepts, my clients often come in self-identifying with one or the other. Shall I begin the dialogue with, “Well cybersex addiction doesn’t really exist. Now, tell me your most intimate thoughts…”

  5. I wanted to make a mention about “Anxious Pete” or “Pete has an anxiety disorder”. For me, it was initially helpful to sit there and pick apart the disorder and me. It made me feel a little better about the less flattering qualities. And it also allowed me to understand that I had some influence and those qualities weren’t just “me”.

    Later, it became a deliberate separation between bipolar disorder and me. The problem began when there were traits that I couldn’t really fit in either the “bipolar bin” or the “me bin”. And when I lost that cohesive self, it started to create other problems, like a crisis of self, unstable identity, etc.

    Here is the truth. The disorder is a large part of me. Even parts of me that I consider to be unaffected probably developed under the direct influence of bipolar disorder. My creative center became an outlet for symptoms in mediums of writing, music, and art.

    But, I wouldn’t use it to preface myself. That sparks the big debate of “Lulu has bipolar” vs. “Lulu is bipolar.” Either way is fine with me, because in reality, both are true.

  6. Reblogged this on Sunny With a Chance Of Armageddon and commented:
    Where do you stand? “Lulu is bipolar.” or “Lulu has bipolar.” The great debate has come to light again.

  7. Reblogged this on onbeingmindful and commented:
    Welcome back Lulu! Another great post full of wisdom. I’ve learned so much about the theories, frameworks, models, types of therapies etc the past two years of graduate school. So very true, work together, find what works, complementary rather then competition. Continue to fight the stigma!

  8. Alisdair Cameron 20 July 2013 at 4:45pm

    Worth noting that from what I recall, the Twitter dispute arose from TTC retweeting someone else, but modifying their tweet (i.e. doing an MT), and going out of their way to change the term “mental health problem” to “mental illness”.
    So, if anyone’s hung up on the terminology, it’s them.

  9. There are more facets to this conversation than there are scales on a fish. As a mental health blogger who has had her life severely impacted by mental illness, I prefer to identify as a person who LIVES WITH bipolar disorder and Asperger syndrome (which I do not identify as an illness, but it certainly makes my life DIFFERENT). I live with these entities that: are serious; have a high level of lethality; and severely impact my social life and employability. So I have difficulty moving these entities out of the “medical realm” and into something that bears a more….politically correct nomenclature. Thank you.

  10. victorianaomi 21 July 2013 at 3:04pm

    I find this discussion so interesting as I often reflect on mine and others’ use of language in discussing mental health. I choose the language I use very carefully. But in the context of this discussion it may be relevant to draw on the (quite extensive) research on what works and doesn’t work in challenging mental health stigma. The Time to Change’s primary task is to challenge stigma and so the way they do this and the language they use should be based on evidence about what works best. I’ve read a few studies suggesting that a biomedical frame for mental distress is the least effective in challenging stigma – the term ‘mental illness’ is most closely associated with a biomedical paradigm. Understanding the context for distress and the impact of stigma are the most effective as well as direct contact between people with and without lived experience. So I personally think that the broader and more inclusive we can keep the language we use in challenging stigma the better. So I totally get Z’s point about picking battles but I do wonder if use of language turns out to be quite a fundamental issue?

  11. Interesting blog post. Very opinionated, I guess that is the nature of the debate. I personally feel at one time, I could describe myself as ill – during a crisis. However, I do not feel there was any category to define what happened to me. I far prefer working with symptoms rather than diagnostic labels. For example: Hearing Voices, Negative thoughts, Mania, Depression, Dissociation, Agitation – but even some of these do not pin point with enough precision what is happening. For example Depression is a very broad term – whilst an element of my crisis could have been described as clinical depression, perhaps most helpful would have been terms such as withdrawn, severe low self esteem causing paranoia, loss of defense mechanisms. None of these broad diagnostic labels were helpful.
    I feel whilst we still use these huge broad terms, we still fail to help people understand and recover. I feel if we actually worked with symptoms instead of the medical model, that this in itself would help reduce stigma.

  12. I love these kinds of conversations. As someone who has depression for over 40 years I get amused by them. All these concepts and ideas come down to the number 1. Its one person one day at a time. Its like religion. All this time spent discussing stuff that really doesn’t matter. Trust me when you are in what I call “the hole”. Theories are something that never cross your mind.

  13. I have PDD-NOS and ADHD, but I don’t really care whether or not you want to call them mental illness. I’m more about making people aware of the conditions and how best to treat them or react to them…when the subject comes up.

  14. I taught for forty plus years and should have been more aware of my students and their way at looking at concepts. The problem was with thirty students in a class with a fifty minute period, it was impossible to address the situation. Interaction was discouraged and the reigning theory of the day was you taught, you were in the front of the room, the students sat in their cubicles and did not respond except to listen to you. I imagine in an average room I had every mental diagnosis that could exist. Labeling them would have been a waste but being aware would have been a good tool to engage them properly.

  15. I had better start by saying I am not a clinician of any kind. However, as a layperson, I found this is a very interesting post. I would agree that the attachment of a label for a particular pattern of symptoms may be more or less helpful to the person experiencing those symptoms. How effective this may be in the context of CBT I suspect would depend upon the extent to which the sufferer blames themself for their condition and its effect on their own life and that of others. In such a situation, I can see that the introduction of an external concept might be helpful in shifting any feelings of guilt away from the sufferer – effectively giving them a named enemy to fight against.

    That said, I do feel that people have a tendency to accept the first label they are offered, take the pills and stop looking for answers while they wait to feel better. If they are lucky, the first set of treatment may be spot on, but if they are not, the sufferer may have to fight twice as hard to get their clinician to look further than that initial diagnosis and if they are really unlucky, their initial treatment may exacerbate existing symptoms in the short term to such an extent that they are disinclined to persevere.

    There is still such tremendous stigma about otherness in general that wherever someone is seen to be not fitting in with ‘normal’ (or should that be statistically average) society, they are viewed as potentially hazardous. The UK has been trying to introduce increasingly politically correct legislation to combat human fear and improve conditions for those we consider ‘others’ for many years with limited success. I am not convinced that the terminology is what is holding us back, but rather a lack of openness, understanding and acknowledgement of what it is that frightens us. Without this soul-searching, I worry that any change will remain skin deep.

  16. Having worked in the health profession prior to my current job, I’d say a lot of the debate over using the term illness or whatnot is really idiotic. Maybe I’ll get a lot of heat for saying that but why is there such a big debate over the when there are more important things to be looked at. If you’ve got time to bitch and moan about the term itself, go donate some money to further research on it. Let’s find a solution or some sort of treatment form to treat people who are actually suffering from the condition itself. I’ve seen doctors jump for joy when something new is “diagnose-able.” Its like being handed a silver platter with new things to write on the prescription pads for drugs that hardly work considering how mental health is still fairly new. Like you said, there are bigger battles to be fought right now. Let’s start with those first and then we can worry bout the name or the term later. Now if it was something like the medical profession was calling mentally ill patients retards or something of that matter, then yeah, holy hell, let’s make a big deal of it. But this? come on now.

    • A lot of money IS being wasted, like Time for Change to the tune of 20 million – I’d rather see that money go to cheap vital services like informal advocacy/user-led services/peer support.
      The terms DO hurt people – ask those deemed to be PD how they feel about being excluded because of their very diagnosis, and those suffering physical consequences because of antipyschotics

  17. I agree with the main point of your argument but may I suggest that it must be recognised the extent to which a diagnosis has (albeit unintended) consequences of a severe social and physiological nature. Tell psychiatrists that they are only using a working model – I’m afraid they will, in the main, come back at you with a defensive statement on schizophrenia being a genetic disorder and on depression being a chemical imbalance in the brain, all in defense of serious over-prescribing of what are very toxic and frankly almost useless medications . All these labels and assumptions (and medicating) have serious repercussions for sufferers, thankfully an enlightened group of psychiatrists, psychologists etc, in partnership with service users, are opening up the debate (see Moncrieff, Bracken, et al and the recent Maudsley debate). Thanks for stimulating post btw :)

  18. Your last sentence sums it up, perfectly.

    I openly and publicly admitted to having a mental illness this May. I’ve fought the stigma for twenty-nine years and came to the personal understanding that if I didn’t find the courage, maybe others wouldn’t find it either. There was nothing self-serving in taking that step forward, it was a painful decision. Stigma can only be adequately expressed by those that have experienced it, no matter what condition or experience one suffers with; it’s personal. It perpetuates fear in those unwilling to acknowledge it for what it is: an ignorance and a failure at accepting the differences created by environment and genetics.

  19. Well said! Even when advances in Medicine determine the genetic defects causing diseases of the “mind”, we will still require a rich and diverse set of paradigms in order to improve the lives of those who seek assistance.

  20. I’m always fighting labels, but at the same time, I’m very open about living with manic depression, anxiety, and PTSD, as well as being a survivor of sexual abuse. My husband’s church? Let’s say a few of the members wish I’d “keep my big blog shut,” but I have had so much support over the years from family and friends, it’s a tribute to them that I am even alive.

    Pick your battles, YES!!! I have mental disorders, I have chemical imbalances, I am mentally ILL. The funny part is the people who know the least about mental illness are the ones most squeamish with the term. They move away like it’s contagious.

    I’m proud to call myself a survivor of incest, not a victim. I’m proud of the work I have done in partnership with several great therapists and two great psychiatrists – hell, even the LOUSY one I had years back (that one ended up with a hospital stay) taught me things, like don’t simply take the psychiatrist’s advice – advocate, ask questions.

    GREAT post, and congrats on being “Freshly Pressed,” because that’s where I found you.

    Sincerely, Amy Barlow Liberatore, Madison, WI AKa “Sharp Little Pencil,”

  21. I agree strongly with your point that while some individuals with mental health challenges do like identify with terms used by the medical model, others find it very useful to separate themselves like Pete in your example. I’ve had clients who fall into both categories. I think the important thing for clinicians is to explore how the client perceives and identifies their own experiences.

  22. thanks for the post! I really appreciated a small point you made about not being embarrassed about mental heath issues. I loved the line, “People who sack people from their jobs and ostracise friends and family for having a mental health problem are the people who need to change.”

  23. I find it shocking that people with mental or brain complaints aren’t the ones among us who are the most happy to be alive. Do you know how close you are to being stereotyped as organ donors, trapped in hospitals, worsened and then have your family lied to that you are dead because you’re “brain dead.” And that you now best serve society as an organ donor? Get off your complaining bench… There are thousands of people who are not dead, yet gutted for their organs. So yes, you have two reasons to be pleasant and grateful rather than complain in this day and age: 1) You’re still alive, 2) you don’t want some doctor noticing you as unhappy and feeling stigmatized. He has a solution that will make you feel worthwhile–NOT! (organdonorptsd.wordpress.com)

  24. Thank you for writing this! I have a very close friend with manic depression, and the medical model has helped her frame the issue for a lot of loved ones, so I totally agree with you- we should not be fighting against that right now, but focusing on how all framing models can work together to increase understanding and reduce stigma.

    http://stepstochangetheworld.wordpress.com/

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