Mainstream Narratives: A Person-Centered Paradigm of Care Is Gaining Favor in the Global North

As the history of psychiatry reveals, the “management” of mental illness has gone through numerous phases, with one paradigm of care after another failing the test of time. A narrative review of published debates on this subject from 1990 to 2020 concludes that the biomedical model, which became the dominant paradigm of care following the publication of DSM-III in 1980, is giving way to a “person-centered, biopsychosocial spiritual model.”

The authors, Paulann Grech and Reuben Grech, faculty at the Department of Mental Health at the University of Malta, in an article published in the European Journal of Mental Health, write that this shift is occurring even though “a paucity seems to exist in the empirical evidence-base related to a number of these [alternative] approaches, especially when compared to mainstream treatment options such as pharmacotherapy and psychotherapy.”

Through a literature search, the authors found 36 articles that highlight the ongoing debate between what they characterized as the biomedical model and the “individual-community.” They wrote:

“This journey through the history of ‘modern’ psychiatric treatment highlights the multifaceted characteristics of mental health and its illnesses, with explanations and treatments lying on a spectrum that features social explanations, biological ones, psychological understandings, and spiritual beliefs. In view of all these considerations, selecting appropriate treatment options depends on feasibility and meaningfulness and not simply on effectiveness and availability. Conclusively, whilst many service providers and health carers claim that their practice stands based on a holistic and person-centered approach, this may not always be the case. This is where the debates and theories that have been explored in the paper may serve as a reflective exercise on the historical debates on mental health care, in a bid to facilitate a critical evaluation of contemporary practice.”

In their paper, the authors tell how the arrival of chlorpromazine into asylum medicine in the 1950s, and introduction of other psychiatric drugs, kicked off what is remembered today as a “psychopharmacological revolution.” The introduction of these drugs is understood to have played a role in the downsizing of psychiatric asylums, and “completely changed the practice of psychiatry as well as its status in society.”

However, a counter-narrative to this story of progress is present in the literature, according to Grech and Grech. Historian Andrew Scull has told of factors other than the introduction of chlorpromazine that led to deinstitutionalization and “the demise of the traditionally oppressive psychiatric system.” Such factors included fiscal considerations and adjustments in state policy.

Since the arrival of Prozac, a fierce debate has emerged over the effectiveness of psychiatric drugs. A “multitude of clinical trials” have concluded that they provide a “significant beneficial effect,” the authors write. This “evidence-base” is the foundation for a “medical model” that attaches a “medical label to the presenting symptoms of mental illness and the provision of medications to eliminate them. In this view, success is measured by the level of symptom reduction.”

The criticism of that model begins with a challenge to claims of the drugs’ “effectiveness.” Kirsch, Healy, Moncrieff, Breggin, and others have noted that in the clinical trials of antidepressants, there is little benefit in the drug group over placebo. The quality of psychiatric trials is poor, positive results from industry-funded trials are exaggerated, and the drugs, rather serve as a cure, could be understood to induce their own “abnormal brain states.” Critics argue that the drugs should be used more as tools in periods of crisis, rather than as maintenance drugs, and that forms of care that focus on “personal satisfaction and quality of life” should be embraced.

The authors point to the work of Dutch psychiatrist Marius Romme as one of the “pioneers” in the development of alternatives to the medical model. He reconceptualized “psychosis as meaningful, a phenomena that must be explored and understood rather than suppressed or disguised.” His work led to the formation of the Hearing Voices Network.

Romme wrote:

“So, accepting voices is not accepting everything as they are perceived, but is the beginning of looking differently at them; normalizing them; being with many others who hear voices; creating hope and opening personal possibilities.”

The Hearing Voices Network can be understood to belong to a “recovery model” that is fundamentally different from the medical model. In the latter, “the patient assumes the ‘sick role’ and is expected to follow the doctor’s guidance to recover.” The recovery model focuses on “self-determination, empowerment, and interpersonal support—a focus on collaboration rather than adherence and compliance.”

The authors quote Pat Deegan on this point:

“The recovery model is rooted in the simple yet profound realization that people who have been diagnosed with a mental illness are human beings. Those of us who have been diagnosed are not objects to be acted upon. We are fully human subjects who can act and in acting, change our situation. We are human beings, and we can speak for ourselves. We have a voice and can learn to use it. We have the right to be heard and listened to. We can become self-determining. We can take a stand toward what is distressing to us and need not be passive victims of an illness. We can become experts in our own journey of recovery.”

During the past 30 years, the authors conclude, “the person-centered movement [has] continued to spread over the globe and has now become one of the leading approaches to mental health treatment, particularly in Europe. This approach, and the rise of the recovery movement, provided alternatives to the Medical Model, leading the way to a more humane management of mental illness.”

 

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Grech, P. & Grech, R. (2022). Main Debates on the Management of Mental Illness: 1990-2020. A narrative review. European Journal of Mental Health, 17(1), 101-109. (Link)