The foundation of the paradigm shift in how we now view mental health, or as I prefer to consider to consider my field, emotional distress, is one where the problem is increasingly located in the individual as a disorder, rather than in the environment that the individual finds themselves.
The inception of this paradigm in thinking began with the publication of the third version of The Diagnostic and Statistical Manual of Mental Disorders (DSM-III) produced by the American Psychiatric Association (APA) which had a specific focus on meeting the needs of a wider clinical audience in the field of mental health. It was never specifically intended as a guide to clinical treatment and despite the introduction of specific clinical categories, there was an assumption that prior clinical wisdom across the field would endure, however, in practice it was the clinical categories that took precedence.
In no other field of medicine – which is the direction that mental health has taken – is symptomatology clustered together as it becomes fundamentally unreliable and invalid in understanding what may bring about a syndrome, condition, or as the DSM prefers to refer to it – a disorder.
For example, how mental health disorders are clustered is based on symptoms and were this to be replicated in the field of physical medicine, we would have groupings of ‘fever disorders’, ‘limp disorders’ or ‘headache disorders’ – an idea that would be absurd and yet is the basis for psychiatric classification.
The reality is that there is no consensus in psychiatry about what exactly causes ‘disorders’ and yet the list of disorders continues to grow with every revision of the DSM and with it more and more ‘disorders’ become both labels and terms of abuse in popular culture – after all the problem is now firmly located in the individual. We have seen an explosion of disorders from around 106 in the 1970’s through to 365 in the latest incarnation of the DSM (DSM-V)! And, not only has the number of disorders increased exponentially, but in parallel so too has the bar been lowered at which point a patient qualifies for having a particular disorder.
In clinical practice we now see the normalisation of these disorders with patients using disorder terminology to ‘self diagnose’ so rather than presenting for therapy with a statement such as ‘I notice that I feel very shy in social situations’, we are increasingly presented with statements such as ‘I have social phobia’. The problem with this is that it can serve to eradicate curiosity around why a person may feel shy in certain situations and inherently positions them as ‘wrong’ rather than suggesting a position of openness towards how this may be adaptive behaviour learnt during childhood.
The profession of psychotherapy is increasingly under pressure to comply with this new world of diagnostic criteria in that the language has been adopted by general practice in medicine, public health and by insurance companies. The latter meaning effectively that patients cannot get psychotherapy sessions reimbursed without a patient meeting the criteria for a disorder.
Arguably what has underpinned this shift in the field of mental health is how the sector has responded to meeting the needs of the economy, rather than those of the sufferers. The focus of public mental health and overarching classification system for psychiatry has shifted from being patient centred to being directly linked to economic productivity.
An example o this is how in the UK, The NHS’ mental health initiative ‘Improving Access to Psychological Therapies’, now renamed Talking Therapies for Anxiety and Depression has its foundations in getting people back into work. Whilst there is nothing intrinsically wrong with a drive to enable people to return to the workplace, in many instances it is a normal human response to environmental stressors that lead a person to feel anxiety or depression. This is the crux of the schism – are mental health disorders located in the individual and therefore indicative of a failing or are they responses to the external environment?
Suffering has been turned into a commodity
The problem is located in the individual rather than seen as an adaptation to past or present environment. This eliminates both a capacity for curiosity as to cause and blame – a person simply has a disorder. From a macro systemic perspective governments can provide a health service that treats’ the problem in the individual rather than consider how societal issues lead directly to emotional suffering – mental health problems.
Secondly, the industry that benefits from the drive towards specific disorders located in the individual is the pharmaceutical industry, which, despite there being little to no evidence of increased efficacy in psycho-pharmacological treatments over the past 40 odd years, This question pervades all types of emotional suffering and the past well-trodden path of linking emotional suffering with a broader and deeper developmental, social and economic narrative is being cast aside in favour of a diagnostic super-highway with disorders based on symptoms and neat psycho-pharmacological solutions. Essentially the invitation is to disconnect the threat response from the threat; to increasingly shift away from asking ‘what’s happened to you?’ to simply ‘what’s wrong with you?’
Mark Vahrmeyer, UKCP Registered, BHP Co-founder is an integrative psychotherapist with a wide range of clinical experience from both the public and private sectors. He currently sees both individuals and couples, primarily for ongoing psychotherapy. Mark is available at the Lewes and Brighton & Hove Practices.
Further reading by Mark Vahrmeyer