You say you want a revolution: Recovery,biomedicine and muddling through

For those in the Australian mental health sector, it is hard to imagine a more important thesis than that proposed in the recent Debate piece (Wand, this issue): Wand suggests that pervasive habits of thinking, practice and power structure, arising from a dominant biomedical paradigm, may inadvertently exacerbate the mental health challenges faced by individuals and communities. Without rejecting the broad thrust of Wand’s position, the aim here is to advance this debate by adding some qualifications. It will be argued that framing the challenges of mental health as a simple clash of paradigms is neither accurate nor useful.

Seize the day

Wand’s thesis is not new, having been explored in the thousands of publications citing Engel’s call for biopsychosocial medicine or Seligman’s case for positive psychology. However, as Wand correctly notes, the rapid rise of the recovery theme in mental health worldwide brings new energy to the topic: Australian mental health services are now expected to provide recovery-oriented services.

Although the devil is in the detail, recovery seems to sit awkwardly with the biomedical approach to mental health. Recognised elements of recovery include connectedness, hope and optimism, identity, meaning in life and empowerment. Contrasted at least with the organic disease model of mental disorder, then, significant tensions might arise around the value of diagnoses, the aims of treatment and preferred types of intervention/support. Moreover, along with its elevation of lived experience, the recovery framework is less wedded to scientific positivism than are the major mental health disciplines. Finally, the recovery perspective, driven by consumers and with a strong social justice thread, has precursors in the antipsychiatry movement (Rissmiller and Rissmiller, 2006).

There are other signs of a move away from biomedicine. Within academic psychiatry, there are calls to redress the bio-psycho-social balance in the interest of the profession’s own sustainability (Bracken et al., 2012). The US National Institutes of Mental Health (NIMH) has rejected categorical mental disorder diagnoses as research targets (Insel et al., 2010). Patient preference and autonomy are elevated in international treatment guidelines (e.g. National Institute for Health and Care Excellence) andevidence-based practice recommendations (American Psychological Association). In Australia, the recent National Review of Mental Health Programmes and Services endorsed a recovery focus and argued that resources should be shifted from acute and chronic services towards prevention, participation and community-based whole-person efforts.

In sum, if Wand’s thesis were simply true, now would be a good time to push for paradigm change in mental health.

A dominant biomedical paradigm?

Wand suggests that extant biological reductionism, dubious/benefit ratios of psychotropic medications and questionable risk management practices constitute evidence of a dominant biomedical paradigm which is in turn inconsistent with the recovery theme. This characterisation seems to over-simplify the mental health domain in Australia.

First, significant public investment in resilience and prevention (e.g.headspace), and access to psychological therapies (Better Access), is not consistent with a pervasive biological reductionism. These explicitly biopsychosocial national programmes are supported by decades of multi-disciplinary biopsychosocial research, which has not only discredited ‘disease entity’ explanations of mental disorder (the easy bit) but has also begun to develop alternative multi-level and systemic models (the hard bit).

Second, although tensions can be identified between recovery and some aspects of biomedicine (above), recovery goals and clinical goals are widely viewed as complementary. In fact, the concept of serious mental illness underpins the recovery vision, and Australia’s framework for recovery-oriented mental health sees clinical services as one slice of the recovery pie. At the level of specific treatments, it is commonly argued that ‘personal recovery’ (e.g. subjective quality of life) and ‘clinical recovery’ (symptoms of disorder) are twin goals of intervention. By adopting this pluralistic stance, we can ask novel questions about which interventions might be superior against each outcome.

Finally, the very term ‘biomedical’ obscures important trends. For example, the National Institute of Mental Health (NIMH) Research Diagnostic Criteria project (Insel et al., 2010) is resolutely biological at the level of mechanism, but eschews medical diagnoses; clinical psychology tends to be medical (in the sense of accepting categorical diagnoses), but not biological (prioritising cognitive and behavioural mechanisms).

Biomedical biases

While the proposition of a monolithic biomedical paradigm is hard to defend (and arguably offensive to the legion of consumers, clinicians, educators, scientists and policy-makers who have problematised biomedicine), there are good grounds for staying alert to potential biases in the system. These possible biases are best understood and addressed in context, as exemplified by the current status of categorical mental disorder diagnoses.

Despite well-known problems with validity, stigma and misuse/reification, categorical diagnoses still play a significant role in mental health. A number of factors seem to explain this state of affairs, including the utility of a shared descriptive language (defining our terms), lack of an alternative dimensional nomenclature (better than nothing), accrued probabilistic meaning of some diagnoses (e.g. treatment outcome research), diagnoses’ appeal to some consumer groups (support/normalising), positioning for health/medical resources and so on.

The mental health domain is in fact characterised by a multiplicity of positions on diagnosis. Growing evidence for effectiveness of transdiagnostic treatments constitutes the green shoots of a world without diagnoses. In other areas, interesting hybrid positions are seen. For example, diagnoses are considered by many professionals as one descriptive component of a strengths-based biopsychosocial case formulation.

These issues have a critical developmental dimension – the barrier to change in some cases is simply insufficient work on an alternative approach. In research, attempts to understand the physiological basis of dimensional systems still rest heavily on the old façade of diagnoses. Evidence-based treatment guidelines, similarly, must rely primarily on randomised clinical trials of diagnostically defined groups. In other situations, as Wand implies, thoughtless conservatism or professional self-interest may need to be confronted.

In The Science of ‘Muddling Through’, Lindblom (1959) argued that complex public policy should target branches rather than roots – values are best clarified not in the abstract but in the daily nitty-gritty of measurable actions. Likewise, the utility or otherwise of categorical diagnoses is best addressed in the specific contexts in which they are used.

If you wanted easy, you should have studied rocket science

The theoretical foundation of psychopathology has been described as like biology’s before Darwin. The discipline straddles C.P. Snow’s two cultures, inviting tensions around human vs natural sciences, hermeneutic vs positivist methods and understanding vs explanation. Consequently, polarised schools of thought are common, marking psychopathology as an immature science in Kuhnian terms. Psychopathology, furthermore, is merely the scientific basis of the social practice of mental health, which also includes real-time imperatives, values conflicts and resource competition.

Future generations of mental health workers will be well prepared to handle these complexities if they are trained to tolerate ambiguity and doubt reductionism in all its forms. Constructive scepticism should extend, for example, to the invaluable recovery concept itself. Recognised challenges in implementing recovery include a new type of relationship between professionals and consumers, elevation of individual preferences over more collective/family priorities and the prioritisation of self-management (a challenging endeavour that demands intelligent support and resourcing).

Conclusion

Spurred by a welcome call for patient-centric services, Wand reminds us to be alert to the risk of biomedical biases in mental health. This paper sought to advance the debate by encouraging attention to context as we muddle through.