As a professional working in the field I agree with the relevance of Ted's comments.
HMO's in the USA may require a continuing emphasis on specific diagnoses within the psychotic disorders, but I would argue that there is a slight swing away from diagnosis to a symptom or a syndrome approach.
Here the list of features Ted quotes are relevant. The only one that is problematic is the "loss of ego boundaries". This is linked to the sensitive but ill defined concept of the schizophrenias of Eugen Bleuler. Like psychoanalytic concepts, it led to many people being deprived of their liberty in state psychiatric mental hospitals in the USA. In the 60's there was an international scandal because the USA alone with the USSR was grossly "over-diagnosing" schizophrenia. The result was the revolution of DSM III which gives very narrow definitions of schizophrenia.
Three factors in the modern management of mental illness are contributing to a swing back to a broader syndromal approach. 1) a severe mental illness is rightly no longer considered as a reason for loss of liberty. Community care, although often deficient, can in principal help people outside hospital.
2) The growing emphasis on patients as customers and consumers with rights. They are demanding information about medication and about illness. A major problem in giving people advice sheets about psychoses are that the different subtypes are difficult to describe clearly and have either stigmatising names or are unintelligible, like "schizo-affective". An excellent young people's first onset psychosis project in Melbourne has devised an information sheet that acknowledges there may be many causes of a psychotic episode. The patient is invited to contribute their own opinions as to what factors were most important, and is more ready to accept that they had a problem of disengagement with reality.
3) Drug companies are pouring money into a new generation of drugs for psychosis (and also for depression) with much fewer unwanted side effects. These have come about thorugh the ability to differentiate between subtypes of the receptors for dopamine, serotonin, noradrenaline (norepinephrine) and histamine. The particular permutations of subreceptor combinations are numerous and complex but open up debate between clinican and client about what suits them best. Young schizophrenic men are now able to get oral medication which helps with their sleep as well as their paranoia. If they find they cannot masturbate enjoyably, they can assertively raise this question and try out another medication that is more comfortable for them. This has enormous effects on self-respect. These technical changes in the production of drugs by the big capitalist companies (now merging into world enterprises) are a qualitative change which is altering how doctors and patients think about concepts of illness. Customer- sensitive symptom-management is coming in, mechanical treatment by diagnosis is on the way out.
A corollary is that once some symptoms are better treated, the interaction with the patient involves psychologically sensitive counselling about how they are managing stresses across the board in their lives. The anecdotal account Ted gives contained many features which were not specifically diagnostic of psychosis in a narrow diagnostic sense but were relevant for the whole context in which the individuals might, with the right help, have a chance of re-orientating their lives.
Communication, problem solving, conflict management become part of the answer for people recovering from psychosis, as well as other disorders.
Where the paradigm has not yet shifted is, as Ted implies, the unshakeably individualistic frame of reference for mental illness under capitalism. It is still conceptualised as a disorder within the individual, from which the individual must themselves recover. However every mental illness manifests some sort of decompensation in the individuals functioning in social context. Mental illnesses are often accompanied with such powerful body language that they give a strong social message, that must have had evolutionary significance for the survival of the species. Mentally ill patients similarly are exquisitely sensitive to the emotional atmosphere around them even though they may be unpredictable about how they interact with it. The mentally ill individual may feel overwhelmed by an individual experience, often felt in a bodily way, but they actually exist in a social matrix. They have somehow got temporarily caught in an illness role which they cannot immediately get out of. This is *not* to argue that there are not a whole range of phenomena that occur in the individual and, when serious enough, need assistance as a definite illness. It is to say that illness itself is a social phenomenon and part of how the society as a whole functions or does not function in certain contexts.
Capitalist society has no social framework for containing mental illness except as the illness of individual workers whose labour power can no longer be productive.
At least however the emphasis on more client centred treatments opens the door to how the individual is functioning in relation to others. So paradoxically in that sense, it becomes less individualistic.
Needless to say I would argue the merit of psychological therapies that do not perpetuate the individualistic paradigm by concentrating on the relationship with one therapist, but teach psychosocial skills or give people insight into group psychodynamic experiences. The latter are probably too complicated to be suitable for people within the first couple of years of recovering from psychosis.
There is an international society for the psychological treatment of psychosis which is holding a conference in Norway in June.
Its web-site address is www.isps.org/
Its objectives are
- promote the appropriate use of psychotherapy and psychological treatments for
persons with schizophrenias and other psychoses
- promote the integration of psychological treatments in treatment plans and
comprehensive treatment for all persons with schizophrenias and other psychoses
- promote the appropriate use of psychological understanding and psychotherapeutic
approaches in all phases of the disorders including both early in the onset and in
longer lasting disorders
- promote research into individual, family, group psychological therapies, preventive measures and other psychosocial programmes for those with psychotic disorders
- support treatments that include individual, family, group and network approaches
and treatment methods that are derived from psychoanalysis, cognitive-behavioural,
systemic and psycho-educational approaches
- advance education, training and knowledge of mental health professionals in the
psychological therapies and psychosocial interventions in the treatment and
prevention of psychotic mental disorders for the public benefit regardless of race,
religion, gender or socio-economic status
Chris Burford
London