Models and perspectives of care /biopsychosocial

Within this assignment the intention is to discuss the biological, psychological and social models and perspectives of care. This will be achieved through examining the influences of each model and their effects upon the practice of mental health care. Some historical information will be provided to give explanation of the background into the evolution of social and moral perspectives that have shaped mental health care practice throughout the ages.

” The history of mental illness has long been a process of trial and error

Guided by public attitudes and medical theory with each society

Developing its own responses. By tracking these developments, a deeper understanding of human interaction and acceptance of this disability can be gathered”. Wikipedia(2006).

Throughout the entire history of human kind, mental illness has always been perceived within the form of something “wrong.” The concept of mental illness during prehistoric, stone age times was a very mythical one. With the belief that mental disorders were of a magical, supernatural origin.

“Mental disease represented a breakdown of the magical-religious system and is mainly attributed to violation of a taboo, neglect of ritual obligations and demonic possessions” Mora,(1985).

People whose behaviour deviated from the majority of society would be considered to have an evil mind. Treatment during these times treatment would be conducted in the forms of spiritualistic ceremonies and crude forms of brain surgery, (trepanning) done by the Shaman. The motive for this would be to allow evil spirits to be released. It has been suggested that stone age cave dwellers may have treated behaviour disorders with this treatment of trepanation. (Sue et al,1990). It appears inevitable that they explained mental illness through a non-scientific cause, because they had not developed scientific techniques to provide a materialistic cause,

The supernatural concept of mental illness still existed through to ancient times of Egyptians following on to the Greek, Roman era. With the ancient Egyptians came the first signs of changes of the treatment of the mentally ill. Egyptians like the early stone age societies regarded mental illness as magical or religious in nature. Their society obsessed with life after death meant that the health of the mind or soul played an essential part in one’s overall health. . Egyptian society, with its fixation on the health of the soul, was the first major example of mental healthcare as a major priority for a society in history. It is believed that an ancient temple complex near modern Saqqara was a kind of mental hospital for the treatment of the mentally ill. Wikipedia, (2006).

According to Davison & Neale, (1997). The Greek philosophy of mental illness was a doctrine of demonology that an evil being, such as the devil dwells within an individual and controls their mind and body. However in contrast to this Hippocrates (460-355bc) believed in a biological cause of mental illness. His belief about the treatment of mental illness extended to a kind of brain pathology that was to be treated with proper diet, drink and abstinence from sexual activity (Davison & Neale, 1997). The Greek concept of mental illness was well spread through to the Roman Empire. Plato’s (428-348 B.C.) regarded mind as a cause of madness. He believed that the cause of mental illness is a person’s ignorance of a psyche (the force that kept the human being alive), which leads to the self-deception (Mora, 1985). Here, psychological viewpoint of mental illness was also presented. This era faced both mind and body as a cause of mental illness, but, unfortunately, both approaches could not be synthesized. So mind and body position went separately through this period.

During the era of the middle ages the Hippocratic viewpoint of mental illness was gaining prominence with the believed causes of mental illness to have a biological basis for example Constantinus Africanus (1020-1087) founder of the first medical school founded in Salerno, claimed melancholia was a result of an excess of bile causing an imbalance to the system of the body. (Mora, 1985). Later during the renaissance period (15th-16th century) there had been a period of witch-mania leading to the pope Innocent 8th sending monks to be the inquisitors of witches. From this the Malleus Maleficarun (1486) ” the witch’s hammer” was published serving as the instruction manual for the inquisitors (Romm & Friedman, 1994). The mentally ill were among the persecuted with witchcraft declared as the cause and possession of the devil. This witchcraft hysteria pushed the biological theories on mental illness backwards because of individuals fearing the punishment of the inquisition.

It wasn’t until the 18th century that a major shift from the supernatural explanation to clinical explanation of mental illness happened. This was through a complete rejection of witchcraft and various other scientific accomplishments in other areas. Legislation was created by the government to “deal” with what they considered as undesirables leading to the birth of “mad houses” for the purpose of detaining individuals. Acts such as, The Vagrancy Act (1744) and the Mad Houses Act (1744). From this, care for the mentally ill was based upon institution care which led to the large asylums used to house them using the medical model of treatment.

The medical model is based on biological (physical) theory with the aim to find medical treatments for diagnosed symptoms and syndromes and it treats the body as a very complex mechanism. It attempts to offer physical pathological explanations of mental illness through: biochemical, endocrine, genetic, trauma, infection, diet and toxic causes. Mental illness is regarded as being “ill” and requiring medical treatment and intervention. According to Davison & Neale, (1997). An important contribution to the biological aetiology was Louis pasters establishment of the germ theory of disease. Which claims that disease is caused by infection of the body by minute organisms. This theory provides an excellent basis to develop the aetiology of specific mental disorders due to viral diseases. The changes in physical pathology are believed to result in symptomatic changes of mood, behaviour, perception and thoughts that characterise the medical diagnosis of mental illnesses. Psychiatry uses the tool of the Diagnostic and Statistical Manual of Mental Disorders- Fourth Edition (American Psychiatric Association, 1994) (DSM4). To make diagnoses. It lists over 200 mental health conditions and the criteria required for each one in making the diagnosis

Treatments for mental illness through the medical model is based upon reliving of symptoms through medical interventions and providing a cure. These medical interventions would be delivered through medical settings and involve treatments such as: E.C.T. and medication. These treatments are aimed to “cure” the symptoms and behaviour associated with mental illness. The medication aims to combat the chemical imbalance that the medical model has attributed to the cause of most mental illnesses. Schizophrenia is one of the most commonly diagnosed severe mental illnesses. Drug treatment is used with anti-psychotic medication. Anti-psychotic drugs are believed to work by changing the activity of chemicals that transmit messages in the brain. The chemical they work on is dopamine. All antipsychotic drugs can cause side effects but these can be different for each patient.

The Mental Health Act (1983) defines individuals suffering with mental illness as patients. The Act “deals” with people who have a mental disorder, it contains the effect of detention and covers the interests of a person’s health and safety. When the law says this is for your own good. This act supports the medical model by determining that treatment is needed for the person’s disorder implying the same basic philosophy of the medical model of diagnosis, treatment ,and cure.

The social model examines our relationship and the environment. It was developed in response to the medical model and the impact it had upon disabled individuals’ lives. According to Light .R (2006), the origins of the ‘social model’ can be traced to an essay by a disabled Briton, a critical condition, written by Paul Hunt and published in 1966. In this paper, Hunt argued that because people with impairments are viewed as ‘unfortunate, useless, different, oppressed and sick’ they pose a direct challenge to commonly held Western values. This analysis led Hunt to the view that disabled people encounter ‘prejudice which expresses itself in discrimination and oppression.’ Ten-years later, the Union of the Physically Impaired against Segregation (UPIAS) developed Paul Hunt’s work further, leading to the UPIAS assertion, in 1976, that disability was:

“‘The disadvantage or restriction of activity caused by a contemporary social organisation which takes little or no account of people who have physical impairments and thus excludes them from participation in the mainstream of social activities.” UPIAS(1976).

.The social model of disability provides a different perspective, it does not concern with how “bad” a persons impairment is. It establishes that society erects barriers that prevent disabled people, thus restricting their opportunities. The philosophy of the social model is to rid society of these barriers, rather than relying on curing the impaired person. . The social models’ primary focus is being on family and group relationships. It considers the social class, risk , vulnerability increase. Early life experiences, peer group, education and sexual experiences are also considered important. The social model of care aims to give other reasons for impairment (mental illness), in that it is not just biological ect. It gives explanation through the environmental factors of life.

The social models philosophy is that disability is caused by the society in which we live and is not the ‘fault’ of an individual disabled person, or an inevitable consequence of their limitations. A simple example is that of a wheelchair user who has a mobility impairment. He is not actually disabled in an environment where he can use public transport and gain full access to buildings and their facilities in the same way that someone without his impairment would do. The social model of disability has fundamentally changed the way in which disability is regarded and has had a major impact on anti-discriminatory legislation. However, some disabled people and academics are involved in a re-evaluation of the social model and they argue that the time has come to move beyond this basic position.

The Psychological model is based upon the academic field of psychology. It attempts to explain mental illness through study of the human mind and behaviour. Psychology applies knowledge from the field of study to aspects of human activity, including the problems of individuals’ daily lives and the treatment of mental illness. Psychology’s’ primary concern is the interaction of mental processes and behaviour and not simply the biological of neutral processes themselves. In 1879 Wilhelm Wundt (also known as the father of Psychology) founded a laboratory at the Leipzig University in Germany specifically to focus on the study of psychology. William James later published his 1890 book, Principles of Psychology which laid many of the foundations for the sorts of questions that psychologists would focus on for years to come. The psychological model of care is primarily broken down into three areas of theory.

* Behavioural : inappropriate behaviour learned from negative life experiences, Behavioural Therapies/approaches focus on the need to re-learn more adaptive and appropriate patterns.

* Cognitive: perception and interpretation of the world.

* Psychoanalytical: Fixation at one of life’s earlier stages.

Behaviorism is the psychological theory of the study of behavior. It rejects the ides that internal mental states such as beliefs, desires, or goals can be studied scientifically. Behaviorism was the dominant model in psychology for much of the 20th century, largely because of the creation and successful application of conditioning theories as scientific models of behavior.

Cognitive psychology studies cognition, the mental processes underlying behavior. It uses information processing as a framework for understanding the mind. Perception, learning, problem solving, memory, attention, language and emotion are all well researched areas. Cognitive psychology is associated with a school of thought known as cognitivism, whose adherents argue for an information processing model of mental function, informed by positivism and experimental psychology.

Psychoanalytical Sigmund Freud, who was trained as a neurologist and had no formal training in experimental psychology, had invented and applied a method of psychotherapy known as psychoanalysis. Freud’s understanding of the mind was largely based on interpretive methods and introspection, but was particularly focused on resolving mental distress and psychopathology. Freud’s theories became very well-known, probably because they tackled subjects such as sexuality and repression as general aspects of psychological development. These were largely considered taboo subjects at the time, and Freud provided a catalyst for them to be openly discussed in polite society. Although Freud’s theories are of virtually no interest today in psychology departments, his application of psychology to clinical work has been very influential.

Psychotherapy treatments involve a range of techniques which use dialogue and communication and are intended to improve the mental health of the individual. Most forms of psychotherapy use spoken conversation, though some also use various other forms of communication such as writing, art work or touch. Commonly psychotherapy involves a therapist and client. Therapy addresses specific forms of diagnosable mental illness, or everyday problems in meeting personal goals. Treatment of more everyday problems is referred to as counseling but the term is used interchangeably with psychotherapy. Psychotherapeutic interventions are often designed to treat the client in the medical model, although not all psychotherapeutic approaches follow the model of “illness/cure”. Some practitioners, such as humanistic schools, see themselves in an educational or helper role.

Through the evolution of mental health care practice it has been made apparent that the three separate models of medical, social and psychological approaches of care are not each in their own right complimentary to the holistic needs of individuals suffering with diagnoses of mental illness. Pressure from such groups as the Anti- Psychiatry movement are helping to change attitudes and perceptions about mental health. Critics of psychiatry generally do not dispute the notion that some people have emotional or psychological problems, or that some psychotherapies do not work for a given problem.

They do usually disagree with psychiatry on the source of these problems; the appropriateness of characterizing these problems as illness and on what the proper management options are For instance, a primary concern of anti-psychiatry is that an individual’s degree of adherence to communally, or majority, held values may be used to determine that person’s level of mental health. Other organisations such as : Mind Freedom International and World Network of Users and Survivors of Psychiatry maintain that psychiatrists exaggerate the evidence of medication and minimize the evidence of adverse drug reaction. An article published through the anti-psychiatry movement stated that:

“Psychiatry should be abolished as a medical specialty because medical school education is not needed nor even helpful for doing counselling or so-called psychotherapy, because the perception of mental illness as a biological entity is mistaken, because psychiatry’s “treatments” other than counselling or psychotherapy (primarily drugs and electroshock) hurt rather than help people, because nonpsychiatric physicians are better able than psychiatrists to treat real brain disease, and because nonpsychiatric physicians’ acceptance of psychiatry as a medical specialty is a poor reflection on the medical profession as a whole” Stevens.L (2006).

The medical profession does not have a precise understanding of why some individuals develop a psychiatric disorder and some do not. Some have developed a general theory to explain the causes of these disorders and their course over time called the stress vulnerability model. This theory was originally introduced as a means to explain some of the underlying causes of schizophrenia by Zubin & Spring, (1977).This model aims to serve as a guide to professionals to attempt to ensure that individuals with psychiatric disorders have the best possible outcome. The stress vulnerability model has three critical factors that are responsible for the development of a psychiatric disorder and its course over time: biological vulnerability, stress and protective factors. Thus Psychiatric disorders have a biological basis, but environmental factors can influence their course over time. The stress-vulnerability model points out that a positive outcome of a psychiatric disorder is more likely if environmental stress is minimized or managed well, medication is taken as prescribed, and alcohol and drug abuse are avoided.

Mental health care practice has now evolved into a mixture of the three models of care and is referred to as the biopsychosocial approach. The biopsychosocial approaches to treatment are broadly speaking holistic. Biological psychological and social factors are all incorporated into individual patient assessment. The biopsychosocial model of medicine is a way of looking at the mind and body of a patient as two important systems that are interlinked. The biopsychosocial model is also a technical term for the popular concept of the mind-body connection. This is in contrast to the traditional biomedical model of medicine. The biopsychosocial model draws a distinction between the actual pathological processes that cause ‘disease’, and the patient’s perception of their health and the effects on it, called the illness. As well as a separate existence of disease and illness, the biopsychosocial model states that the workings of the body can affect the mind, and the workings of the mind can affect the body. Gilbert.P (2002) stated that:

“At its best the biopsychosocial approach is holistic but is also more than that. The biopsychosocial approach addresses the complexity of interactions between different domains of functioning and argues that it is the interaction of domains that illuminate important processes.”Gilbert, P (2002).

Government policies and guidelines dictating the standards of care for the mentally ill now give consideration to the biopsychosocial approach to care. The National Service Framework for mental health was launched in 1999 and sets out how mental health services will be planned, delivered and monitored. The NSF lists seven standards that set targets for the mental health care of adults aged up to 65. These standards span five areas: health promotion and stigma, primary care and access to specialist services, needs of those with severe and enduring mental illness, carers’ needs, and suicide reduction are also considered. Mental health care is delivered according to these standards with assessments and needs of the individual being assessed through a collaborative approach of Effective Care Co-ordination. (ECC). ECC assesses individuals needs through the biopsychosocial philosophy ie: medical assessment, social needs and or psychological interventions.All mental health service users have a range of needs which no one treatment service or agency can meet alone, this system of ECC allows a service user access to the most relevant response. Hopefully providing the individual the necessary tenets of care they require.

References:

1. Davison, G.C. & Neale, J.M. (1997). Abnormal psychology (7th ed.). New York, NY: John Wiley &Sons, Inc.

2. Department of Health. National Service Framework, Mental Health. The Stationary Office1999

3. Diagnostic and Statistical Manual of Mental Disorders, Fourth edition.Copyright 2000 American Psychiatric Association.

4. Gilbert,P.( 2002).Clinical Psychology. Understanding the biopsychosocial approach: Conceptualisation. Kingsway Hospital, Derby.

5. Hasler,F(1993) Developments in the Disabled Peoples Movement Disabling barriers, enabling environments. In J.Swain et al.(Eds).

6. Light, R .(2006)Disability Awareness in Action.The Inernational Disability & human rights network. http://www.daa.org.uk/social_model.html.

7. Mora, G. (1985). History of psychiatry. In H.I. Kaplan & B.J. Sadock (eds.), Comprehensive text book of psychiatry .(pp. 2034-2054). Baltimore, M.D.: Williams & Wilkins.

8. Mental Health act1983.http://www.dh.gov.uk/PublicationsAndStatistics/Legislation.

9. Romm, S. & Friedman, R.S. (Ed.). (1994, September). History of psychiatry. The psychiatric clinics of north America.

10. Stevens,L.Why psychiatry Should be abolished as a medical speciality. http://antipsychiatry.org/abolish.htm. September 12th 2006 13.47.

11. Sue, D., Sue, D. & Sue, S. (1990). Understanding abnormal behavior (3rd ed.). Boston, MA: Houghton Mifflin

12. The 1832 Madhouse Act and the Metropolitan Commission in Lunacy from 1832http://www.mdx.ac.uk/www/study/3_06.htm

13. Wikipedia, History of mental illness, http://en.wikipedia.org/wiki/History_of_mental_illness . ( Sep. 19, 2006, 08:54 GMT).

14. UPIAS, http://jarmin.com/demos/course/awareness/091.html, September 12th 2006 11.05

15. Zubin, J. & Spring, B. (1977). Vulnerability: A new view of schizophrenia. Journal of Abnormal Psychology, 86, 103-126.