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The Medicalization Of Mental Illness

Mark Dombeck, Ph.D.

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.

Mix of Mechanistic and Subjective approaches
Best Patient Attitude
Method of Intervention
Cognitive, Emotional, Behavioral and Social
Nature of Cure
External to the Patient
Internal to the Patient
Responsibility for Cure falls most on:
The Intervention (use of medicine or surgery which will correct the problem)
The patient's active practice and participation in the therapy relationship
Goal of Intervention
To cure existing disease
To cure existing disease, but also to prevent future disease and to promote growth
Solution Focus
Process focus
Crisis Management
Promotion of growth and learning

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.