Psychiatry Needs a New Metaphor
By: Mad In America
Tags: Mental Health, Psychiatry

By Scott Hall

Metaphors are used extensively in medicine to simplify, communicate and synthesise complex and emotionally laden concepts into more palatable forms. Images of engaging in a ferocious battle with cancer or an immune system marching as a valiant army against disease convey predictability and reassurance. However, metaphors are deceptive, in that they imply detailed understanding of phenomena which have not been fully elucidated.

In this essay, I propose that the metaphor of “mental disease” is doing more harm than good. Rather than being a tool for communication, it has crossed the boundary from a metaphor to a theory that underpins much of what happens within public mental health services. This places psychiatrists in a position of dutiful compliance with what is essentially a fallacious model.

I put forward an alternative metaphor for psychiatry which is aligned with the less well-documented surgical model (as opposed to the traditional medical model) and is complementary to the concept of recovery. Injury (as opposed to disease) is approached in a pragmatic and personalised manner. Symptoms are recognised as forms of communication and coercive approaches are used in a truly proportional manner. Treatment follows ethical principles and normal human psychological processes rather than being directed toward an elusive disease.

I conclude by outlining a potential role for psychiatry in expediting change in the delivery of mental health care.

The Mental Disease Metaphor in Action

A key concept that psychiatry has bestowed on society is that of mental disease. Central to this concept is the identification of symptoms (or “psychopathology”) to support the existence of disease and the use of various forms of leverage/coercion to achieve “insight” (acknowledgment of having mental disease). I use the term “mental disease” as opposed to mental illness or disorder because the concept that has emerged within psychiatry is closer to the Oxford English Dictionary’s definition of disease:

“A disorder of structure or function in a human, animal, or plant, especially one that produces specific symptoms or that affects a specific location and is not simply a direct result of physical injury.”

The persistence of the mental disease metaphor suggests that it serves a purpose of some kind. A smoke-and-mirrors scenario exists whereby labeling a person with mental disease seemingly sanctions the following processes:

Selected forms of human suffering, behaviour and moral breaches are split off and described as “psychopathology.” This in turn can be attributed to defects in a person’s brain. This is synonymous with the concept of “mental illness,” which the Australian state of Victoria’s Mental Health Act defines as “a medical condition that is characterised by a significant disturbance of thought, mood, perception or memory.” Similar descriptors form part of mental health legislation elsewhere. Social causes are acknowledged as contributory, but it is implied that they act on an already diseased brain. Sometimes spurious links are made between mental disease and potential harms to satisfy legal criteria within mental health legislation. Society is largely absolved of blame because the person has a diseased or dysfunctional brain. Autonomy and individualism are celebrated as cornerstones of society but are coupled with an expectation of personal responsibility. Any change to this relationship would be deemed a challenge to the idea of free will, so we accept it as a given (“that’s just the way it is”). One possible exemption from personal responsibility is the concession that one has a mental disease. The cause of mental disease is purported to be complex, involving some sort of mix of genetic susceptibility, dysfunctional neurons and brain chemistry. We are told that scientists are working diligently to solve this conundrum but that for now, we must make do with what we have.

Scientific advances based on the concept of mental disease have been modest at best. Developments in fields such as psychopharmacology, psychology, neuroscience, and genetics have been more impressive but they do not appear to correlate with mental disease entities.

This has been partially acknowledged within the field of psychiatric research, in that traditional diagnostic classifications (e.g., DSM or ICD) are being challenged by alternative classification systems based on specific brain processes (e.g., the Research Domain Criteria). Evidence is conspicuously absent that a disease process akin to a form of cancer rears its head and causes aberrant cellular or chemical processes manifesting as schizophrenia, bipolar or personality disorder.

The mental disease metaphor unravels when you scratch the surface, yet it has persisted, perhaps because it gives the appearance of being a potentially solvable problem. It provides something to fight against and satisfies humanistic desires for order, equilibrium, and taxonomy. Finally, it serves to attribute causation to something other than society.

While I am not implying that the concept has been contrived with sinister intent (e.g., as part of a government conspiracy), one would be forgiven for thinking this. When patients make such pointed observations, they are often told their opinion is delusional.

Proponents of the metaphor assert that disease models have been an effective banner for advances in medicine. For example, cancer (an umbrella term for a diverse range of diseases with a similarly diverse range of etiologies) has attracted iconic status with funds and public support flowing toward it. We frequently read headlines boasting of advances in medical science leading to increases in life expectancy for those who are diagnosed with various forms of cancer. It is not surprising that the field of mental health looks toward that of cancer and collectively thinks “we’d like a piece of that.”

However, many would argue that the degree of human suffering associated with cancer has not changed over the years. If anything, it has increased, along with the plethora of costly, complex, and heroic treatments being offered.

Moreover, the diseases that fall within the descriptor of cancer usually have well-defined pathologies and are universally caused by out-of-control cell replication. This is not the case with mental disease.

Mental Disease as the Foundation for Mental Healthcare

As a secondary effect of the metaphor, mental health services become implicated in a complex merry-go-round of causation that ultimately results in attribution of mental disease to individuals who behave or think in certain ways. They can be persuaded, leveraged or coerced to take “treatment” of varying kinds. For example, being spoken to, contained, or prescribed medication.

Psychiatric wards operate so-called “acute care models” and there are few long-term supported residential placements affording asylum in the true meaning of the word. They can become pressure cooker-like environments where a harsh version of the medical paradigm operates, subliminally communicating messages such as “take this (medication),” “behave this way” and “don’t say that” all delivered in a locked setting. So-called “restrictive interventions” involving seclusion (essentially being left alone for long periods in a small, locked room, often with no toilet), restraint (being tethered to a bed), and the injection of medication whilst being held down (usually by security guards) are not uncommon.

Emergency departments and hospital wards around the state also deliver restrictive interventions under the auspices of “duty of care” if patients do not comply with what is deemed to be in their best interests. While the practice of seclusion and restraint are recorded for patients subject to the Mental Health Act, restrictive interventions in other settings go largely unmonitored.

In community mental health settings we subliminally communicate: “I know life is unfair, but this is because you are categorically different (on account of having mental disease)… here is some support and treatment for your mental disease… now accept your place in society, find a niche or catch up with your mentally normal peers.”

Unsurprisingly, such demands or assertions are sometimes countered with a negative response. If treatments prove ineffective, people are often labelled “treatment resistant” and may be offered sympathy, “support,” or more complex (and sometimes harmful) medication regimens. If they do not cooperate with the process above, it may be implied that they are non-engaging, lacking insight or having impaired capacity. The merry-go-round may serve professionals (e.g., getting paid, deriving esteem), families (being partially absolved from blame), and society (splitting off and labelling “sick” members as such).

Unfortunately, it does not serve those labelled with mental disease well, although it is argued that they obtain certain primary and secondary gains such as sympathy, care, and financial support.

The mental disease metaphor lays an unstable foundation for the practice of mental health and many of its initiatives, movements and “brands.” The Early Intervention in Psychosis movement created a brand that conjures up images of intervening early and preventing a disease process in vulnerable young people. Forensic psychiatry purports to diagnose and treat similar disease processes that cause people to commit crimes.

Similar narratives have been created for other factions within mental health. The most widely publicised misuse of the mental disease metaphor has been by pharmaceutical companies, who have marketed drugs purporting to treat mental disease. We are all aware of the adverse consequences and huge financial gains that have accompanied this excursion.

It is possible that the metaphor has helped to attract healthcare resources toward mental health. It creates a depersonalised “enemy” against which we can put up a fight. I am consistently amazed by mental health workers who go above and beyond with the aim of helping those who are suffering. They are often taking a leap of faith and have confidence that the person will get better. For some, this faith is due to their belief in the concept of mental disease.

It is possible that a simplified model for considering human suffering may be necessary, or else we are left to embrace too much uncertainty which could overwhelm or evoke cynicism. The underlying fear may be of learned helplessness (i.e., that if things seem insurmountable, we may give up, lose faith and stop trying).

Laying Foundations for an Alternative Metaphor

Is it possible or even necessary to challenge a concept that is so ingrained within society? And to what can we change it? Sudden paradigm shifts tend to occur at times of war, revolution or natural disaster.

Many consumers of mental health services are socially, financially and educationally disadvantaged, such that they find it difficult to integrate within mainstream society. The 10–25 year reduction in life expectancy is a widely publicised statistic but it is often attributed to mental disease rather than social and medication-related causes.

Policies such as abolishing private education, expanding social housing and introducing inheritance tax would arguably provide a more efficient means of closing the gap but in the current climate of populism, society does not seem to have an appetite for social engineering approaches.

A more evolutionary (but inherently slower) approach may involve providing and promoting an alternative metaphor. From a strategic perspective, if an alternative metaphor is to promote change it should incorporate key elements of the existing metaphor but with subtle modifications (specifically, in the role of coercion and the use of symptoms as a proxy for disease).

In an alternative model, symptoms could be acknowledged as simultaneously being indicators of illness as well as forms of communication. Similarly, coercion could be seen as a “necessary evil” which is humanised and minimised by judicious application of the concept of proportionality. These ideas are elaborated further below.

Coercion and Proportionality

I often experience the mental health system as excessively coercive and inflexible. If this perception arises within someone working in a senior role, I struggle to imagine what it feels like to be a consumer receiving coercive treatment. In the state of Victoria, the rates of community coercion are amongst the highest in the western world, as are the rates of the use of restrictive interventions in hospital settings.

I believe that there will be a role in mental health services for coercion and temporary deprivation of liberty for the foreseeable future, but the current system encourages these approaches as a first port of call for severely distressed people. Frontline workers are often placed in a position of brinkmanship where restrictive interventions are used preemptively because of a reciprocal sense of fear (i.e., staff fear patients, and patients fear the system).

Frameworks to incorporate proportionality exist within most mental health legislation, but the inclusion of mental disease as a key criterion serves to dilute it. In practice, proportional use of coercion could facilitate a move away from the principle of community coercion (community treatment orders) and whole-population approaches (which by definition seek out new “cases”). Determination of a person’s capacity to make important decisions is a more equitable test to sanction deprivation of liberty than the current process of determining presence or absence of mental disease.

Symptoms as forms of communication

Phenomena that psychiatry labels “symptoms” are also forms of communication. They allow people to convey the uncommunicable and, if received appropriately by a recipient, facilitate the discharge of emotion. The act of compassionate listening and giving of medication that I observe between patients and nurses daily is just one example of this interplay.

This process does not always follow the idealised, harmonious dynamic outlined in the nurse/patient example above. We often see discharge of anger toward the self and others in hospital or within relationships and families (what is now termed “family violence”).

Mental disease is possibly a modern-day correlate for what would have previously been labelled “bad” or “evil.” Bad and evil necessitate punishment, forgiveness or religious explanations whereas mental disease requires treatment. Interestingly, society seems to be clear that family violence, paedophilia and drug use are bad (or evil), hence there is little appetite for including these social phenomena within the mental disease metaphor.

Expressed opinions, regardless of whether they are labelled delusions, overvalued ideas, hallucinations, or cognitive distortions, are always associated with emotion or affect. There are a variety of techniques, procedures, and behavioural technologies that allow discharge of bad feeling into a therapeutic relationship without causing undue harm.

Sadly, these are rarely incorporated into service design, models of care, or the built environment within mental health care settings. Most mental health personnel and teams are not trained or experienced in these approaches. They are often overworked or exist within high-pressure, protocol-driven environments; hence, their work involves internalising others’ trauma, contributing to so-called “burnout.”

A Surgical Metaphor for Psychiatry

I have outlined personal observations of social, anthropological and psychological processes that occur in clinical settings and assert that they fall within a spectrum of normal behaviour in people who are under acute or chronic strain. If nothing else, psychiatric research has demonstrated that people are neurologically diverse and there is significant overlap between diagnostic entities. It would follow that there is similar variation in behavior and internal experience in response to injury.

A surgical metaphor for psychiatry embraces the idea of illness behaviour being a response to adversity, damage, or disruption in “normal” people (i.e., an injury) without the assumption that symptoms are part of a chronic disease process. Injuries can be induced suddenly (acute) or may be historic in nature (having formed into a scar or a walled-off collection). Very severe injuries may require life-saving approaches in the acute phase, but once stabilised, an adaptive process can begin.

Prevention of future injuries could become the responsibility of government and society through public health initiatives, rather than mental health services employing surveillance and monitoring of individuals.

Assessment would involve determining the nature, degree, and etiology of the injury and offering treatments in a proportional manner. Treatment may involve short-term approaches to the injury (consistent with suturing and healing by primary intention). Some injuries could be acknowledged as being too severe to be “closed.” Leaving a wound open, providing supportive treatment and waiting for a scar tissue framework to form may be the preferred approach (similar to healing by secondary intention).

The surgical metaphor has the potential to be a sophisticated endeavor that could harness technology, resources, and social buy-in. We could make it abundantly clear that we are in the business of suturing up, draining, and supporting psychological wounds rather than retreating to the paradigm of treating or preventing mental disease.

On a systemic level, we could acknowledge that much of our work is directed towards the psychological injuries caused or maintained by social inequity and trauma rather than being due to a dehumanised disease process.

Redefining the Role of Psychiatry Within Mental Health Services

My own experience as a psychiatrist has been of negotiating an often-unwanted obligation to uphold the mental disease metaphor as a valid theory. It remains at the core of psychiatric training and, in common with other forms professional training, concepts are instilled through a process akin to religious indoctrination.

The internal and interpersonal conflict that arises when explaining behaviour as a manifestation or “relapse” of mental disease can be tempered by conceding its metaphorical nature. Most psychiatrists are trained in proportional approaches to treatment and alternative theories for understanding our patients, but the mental disease metaphor is often prioritised. Clinical approaches comprising time-limited medication use, tailored psychotherapies and care planning systems can be delivered with precision and fidelity without interpreting symptoms as a proxy for mental disease.

Most psychiatrists can identify with the feelings of frustration that arise when the most appropriate or least restrictive forms of treatment cannot be provided in a personalised, proportional, and coordinated manner due to a lack of resources. Most are aware that the costs of treatment per patient may be equivalent or less than the unit cost attributed to treatments in other areas of medicine. These are uncomfortable comparisons to draw, but they reinforce the need to demand parity between mental and physical health when it comes to allocation of healthcare resources.

The rush toward developing specialist services based on the mental disease metaphor should be reconsidered. Such a tendency toward splitting off and specialization may be based on mimicry of other medical specialties, but may also be due to dissatisfaction with the underlying theory of mental disease.

Whole-population approaches that identify “cases” under the banner of mental disease (or the potential for developing it) may do more harm than good. For example, the rapid expansion of early intervention services may be creating “cases” of mental disease which would otherwise abate or resolve spontaneously. We need to get the basic elements of mental health care and theories that underpin it right before creating subspecialties and yet more “centers of excellence.”

Mental disease is a powerful metaphor which, for all its faults, has allowed psychiatry to exist within the prevailing model of healthcare delivery. However, it is not serving our consumers well. Medicine has a great deal to offer the field of mental health, and, in particular, those individuals for whom distress, patterns of thought, and behaviour have become engrained, persistent, or have subsumed one’s identity. It is the systematic, scientific approach, as well as the compassion and safety offered by healthcare systems, that are beneficial-not the concept of mental disease.

Psychiatrists are in positions of leadership within mental health services and hence in a unique position to bring about change.

I am aware that this opinion piece may do no more than reiterate the approach that many psychiatrists adopt in their day-to-day work. However, the extensive use of metaphor in psychiatry is not clearly articulated in most training curricula, nor is it openly acknowledged within the profession or in public-facing forums.

If nothing else, writing this piece has allowed some clarity in my own mind that a surgical metaphor for psychiatry is a more pragmatic, realistic, and honest one than that of mental disease. It is consistent with the concept of recovery, and conveys humility in the face of complexity.