The Irish Times
Mon, 11 Oct 2010 20:35 CDT
According to Prof Ivor Browne, treatment of mental illness can not - and should not - be undertaken without the effort of the patient, and the power of change and recovery being firmly placed in their hands
The world is a sea of troubles and we have to adapt to these as best we can. People use all kinds of ways to manage. Some are better than others, while some are counterproductive and land us in difficulty. Mental illness is seen as a disease caused by either a disturbance in our biochemistry or by genetic influences - but this is a myth.
This view of mental illness arises from a reductionist scientific concept, where the disturbance of the whole person is seen as caused by something wrong with the parts. It's derived historically from Galileo's statement that, to make scientific progress, we must concentrate on things we can measure. But this is only half the story and it breaks down when applied to living creatures such as ourselves.
When a new whole emerges, this is a completely new reality, quite distinct from the parts that make it up. It's not explainable by simply analysing the parts. Once the new reality, for example of a person, emerges, the causal direction reverses. The new whole takes control over its parts - thus we have to take control of our behaviour, cells and biochemistry, and not the other way around.
This is why, in dealing with emotional problems, there is no therapy the psychiatrist or therapist can apply to the person to bring about real change. The person has to do the work of changing themselves, with the support and guidance of a therapist.
This concept of "self-organisation" is synonymous with what it is to be alive. Anything that diminishes our state of self-organisation lessens our control over and management of our health and will be a step towards sickness.
Because of the mechanistic attitudes that have accompanied advances in science and technology, the western mind has fallen prey to the illusion that there is a remedy for every ill; we expect to be able to avail of these without any effort or suffering on our part.
When a person comes to a doctor or therapist with symptoms that indicate depression or anxiety, they expect the doctor to do something to relieve them.
Certainly doctors can relieve symptoms, but without the natural healing power of the body and a functioning immune system, medicine and doctors are largely helpless.
In dealing with psychiatric illness, there is no treatment you can apply to a person that will bring about real change in them. The person has to undertake the work himself and this involves pain and suffering.
Many psychiatrists seem to have missed this point entirely. They think that, by giving tranquillisers or ECT and temporarily relieving symptoms, something has been achieved, whereas in fact no real change has taken place and, sooner or later, the person will slip back to where they were.
The issue here is not the giving of a drug; many of the psychoactive drugs can be the only way of making initial contact with a person who is psychotic, anxious or depressed so that therapy can begin. The question is whether they are given as treatment, or as an aid to working in a relationship with the person. It is not the drug - it is the message that accompanies it that is really damaging.
Typically, if a person is "clinically" depressed, he is told that whenever he feels depression descending on him he must contact his psychiatrist and start medication - the message is that there is nothing the person himself can do.
This is lethal. It is because of this that many people see themselves as ill and helpless and move, imperceptibly, into a state of chronic ill health. No drug can teach what you need to know to manage your life or have a personal identity.
There are two main kinds of problems we deal with as therapists. On the one hand, there are those who have been traumatised through loss, unresolved grief, physical trauma, accidents, sexual abuse and so on. Typically, when these things happen, particularly if it's early in life, the person freezes the situation and builds a wall of defence around the trauma.
In my experience, such persons are nearly always diagnosed as suffering from "clinical" depression, bipolar and so on. In these situations, the only way for healing to take place is for the person to open up the trauma and fully experience it so that it can become simply a memory. Then they will no longer be troubled by it.
On the other hand, there are those who have failed to reach adult maturity - these are the various developmental syndromes such as psychosis, schizophrenia, eating disorders and so on.
I feel the sort of therapeutic interventions that could give these individuals a foothold towards health would be, firstly, the establishment of a personal therapeutic relationship.
Secondly, where there are a lot of psychotic symptoms and fixed delusional thinking, it may be necessary to give anti-psychotic medication on a temporary basis to enable contact to be established and the therapeutic relationship to develop.
This would, thirdly, clear the way for a therapeutic education programme to help the person understand the nature of psychotic thinking, of illness behaviour and symptoms such as hallucinations and delusions.
Fourthly, I would propose to help them undertake the work to move from a "child" to an "adult" position, from dependence to independence. It is not a question of helping the person reshape a development that has been damaged so much as helping them reach adult independence in the first place.
The fifth and final point is the development of skills for living. The current psychiatric view of what constitutes psychotherapy is too narrow, and needs to address the deficits in social behaviour and vocational skills many patients may have developed in the course of their illness.
If this rehabilitative task is not undertaken, such patients are likely to be a millstone around the neck of the psychiatric service, causing management and economic problems far in excess of that which their numbers would suggest. This is the yawning gap in our services.
What we urgently require is a new form of asylum, a therapeutic community that provides a warm, loving, human context within which a person can grow, develop a healthy lifestyle, learn to work and manage themselves. It is then that the problem of so-called "psychiatric illness" ceases to be relevant.
Prof Ivor Browne is professor emeritus of psychiatry at UCD