Wednesday, 17 September 2008

Good enough

"Be ye therefore perfect, as your Father who is in heaven is perfect."
- Mat 5:48

Now that's a tough standard to live by, and no mistake. Charged by our Lord himself to "be perfect" is a lofty aspiration to strive towards. How achievable is perfection?

One issue in mental health is of illness, medical models and diagnosis framing a whole person's experiences (and potential health and social care) in a couple words.
Mental health is undoubtably about "health" so of course has to concern itself with illness and affording approriate care and treatment to our illest patients.
Mental health is also about mental wellbeing, about health in the broader sense.

The World Health Organisation define health as :
"Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."
The WHO also say a lot about mental health, but little of their assertions seem to filter through into healthcare provision.

My last post was about a patient who had no mental health problems in the recent past (but had self harmed when unable to cope in the more distant past) who presented with great mental health until his relationship ended which he said caused him to behave in a suicidal manner. He wasn't mentally ill, he was stressed/frazzled and wanted to show his partner what she had driven him to.

Letting him go and act as he wished to act provoked different views, from thoughts that this was great to allow his responsibility and autonomy to views that he had a personality disorder and needed care but had been inappropriately left with nothing. He was given offers of social care and CPN input and Consultant follow up, so did have some health and social care proffered but the discussion over at Mental Nurse around a comment "Isn’t this just pathologising behaviour?" is similar.

What's mental illness? At what stage do we say that problems aren't necessitating input from specialist professional services?

As a doctor the easy option is to treat illness, thus if someone doesn't have a psychiatric disorder I don't see them and they're discharged from the service. This would be overly harsh, since it then helps manage all formal psychiatric illness but doesn't help address psychological upset (rather than psychiatric illness).

If moving to help folk manage psychological upset then that opens up options for helping folk with relatively minor problems through to relatively serious ones and everything inbetween. Someone who really likes sex and spends more than they should on this, is that a mental illness? Should they be seen within mental health services to "get help" with this? If it's a choice they're making, is it an illness or a disorder? What if they don't like the impact it has but they like to keep doing it so their motivation for change is almost zero, so there's no enthusiasm for treatment?

Anger falls in to this. Often someone's angry but not mentally ill. Anger's just an emotion that's part of all of us, managing it is something we all have to do. Without formal psychiatric illness, is anger a mental illness? Should mental health services help people manage anger? If they don't get better, is it because mental health services haven't tried hard enough, or is it because we've got it wrong and the "treatment" hasn't not worked 'cause there's no "illness" to treat and we're just conceptualising it in this false fashion?

Personality disorder can fall in to this too. Some people will see it as a disorder. This can be helpful, folk can then receive support and care. This can be unhelpful. People with personality disorder (especially F60.31 emotionally unstable personality disorder, borderline type) can receive malign care. Such a person behaves in a fashion that causes concern. Rather than this being their choice (arising in someone who's not psychotic) it's seen to arise through mental disorder (personality disorder). To manage risk, the concern necessitates appropriate management, so compulsory admission and compulsory treatment follows. No better? Then better add in more medication. Doesn't work? Can't stop it, there's a mental illness there, it's causing risks, we need to be seen to be managing it, best keep on with the drugs. The evidence is that personality disorder can be improved through psychological work, if it's intense and there's a high motivation for change. Some work suggests that if motivation to change is sufficiently high, the person effects change without contact from formal mental health services, anyway (using their own resources and support networks).
What can mental health services do for folk with personality disorder? What should mental health services do for folk with personality disorder?

One problems of pathologising behaviour is then the follow on from this. It's not just a behaviour someone's chosen, it's pathology. So needs treatment. Admission, drugs, ECT, whatever. Not cured, well, more treatment, then. Still not improved? Then it's treatment resistant so needs even more drugs, at high dose, in combination. I like diagnosis, it guides care, but diagnosing something as an illness when it isn't can be really, really unhelpful.

In my corner I'm very keen on assessment that looks at all domains. Psychiatry is obviously a big part of it, but physical health and social stressors and the person's past life experience all contribute to what's going on in the here and now, why we're meeting up right this moment, this day, to look at this issue. As such I see diagnosis as important (so people get the right care) but equally there are those without formal psychiatric disorder who can still profit from mental health input.

This work then can help folk improve to a state where things perhaps aren't cured, aren't brilliant, but the person's coping and things are good enough. We may seek perfection but, within mental health services, it's a happy day when this is achieved. Usually we'll have to settle for helping make situations good enough.


mandy lifeboats appeal said...

Indeed Shrink

Maybe, and this is only me pondering a theory, the earlier someone is diagnosed with a PBD (who has PBD..isn't that a million dollar question to answer?) the more effective and appropriate the support could and should be.

The person I know has been in and out of MH and prison systems for years.

I do think there is a level of unwillingness on their part to alter those things about themselves that they acknowledge as problems for themselves.

Example...they ranted on and on about not getting psychological therapies (to look at issues and behaviours) and when they finally got an appointment they refused to go. I had 2 views on this 1) They opted out of taking personal responsiblity (or even the shared responsiblity) 2) Perhaps 15 years down the line trying to address what have become intrinsic parts of a person's nature is a bit too late.

I do think when it comes to cracking behavioural nuts (scuse politically incorrect pun) sooner rather than later would be more beneficial all round.

I have empathy for the person I know because they were severly brutalised as a child. However, I find it overwhelming (to the point of running and hiding in the wardrobe) dealing with the shifts. In fact..when there is no support (apart from, as you put, the constant upping of meds) coming forth from MH services...I get swamped to point of drowning and I have to make a decision about self maintenance for me.

Good posting :>)

Paul said...


You make the case that there is a difference between 'psychiatric illness' and constructs like personality disorder or anger. But i'm still unclear on how you are using these different terms.

Can you offer your definition of mental illness and mental disorder?

For instance, the now abandoned mental health act definition was quite tautological - something like "a mental disorder is a disorder of the mind" or something similar...

Can you do better?

My own view is that we should move beyond terms such as illness and disorder and should just talk about 'need for care'. Need for care is essentially determined by answers to questions such as;

1. Is this person experiencing (or going to experience) high levels of distress or disability and do they want (and need) our help?

and / or

2. Is this person's capacity to make important decisions about their lives impaired in any way?

I'm not saying anything new here but I don't see why we need terms such as illness and disorder when we make decisions based solely on distress and impaired capacity. If someone is referred who is neither distressed or incapable then psychiatry should leave them alone in my view!

Cheers Paul

Tainted_Halo said...

I must agree with Paul. MH intervention is initiated by functional distress and irrational behaviour. It is not invoked by 'voices' or 'mood swings' until those symptoms impede function (including safety/harm) to such a degree as quality of life is compromised beyond that which 'normal' social and personal supports cannot alleviate.

I'd also be happy to abandon the term 'mental illness' and all it's diagnostic labels. As anecdotal evidence I see too many misdiagnoses so the purpose and function of a DSM is made redundant. I also find it pointless to suggest diagnoses informs treatment - as the same illness can present in many different ways.
I've long advocated for a simplified symptomatic treatment method and skip the whole diagnostic labeling process.
Symptom clusters may vary the treatment slightly but in medication and psychological therapies the selection criteria and evaluation is informed by the presentation or absence of symptoms - not a diagnostic label.

As for pathologising behaviour - it all comes from somewhere - even the choice to behave badly originates in a pathological premis as we all act compulsively in the context of who we are. How else can we be who we are if not by being who we are?

Paul said...

Just to add to Tainted Halo's thoughts a little.

We definitely need to draw a distinction between irrational behaviour and impaired decision making capacity. The reason I say this is that people must retain the right to make unwise decisions (as per the Mental Capacity Act 2005), which we might consider irrational.

Furthermore, I'm not sure risk to self or others is required as an additional justification for psychiatric intervention. That is, I think this issue is dealt with sufficiently by the requirement for impaired capacity.

That is, if someone states they are thinking about harming themselves or others (or indeed fully intend to), then their capacity to make this decision ought to be tested. If found wanting, then efforts should be made to increase capacity.

If capacity is preserved and intact (as per the gent in Lake Cocytus's 'Death' post), then it ought to be viewed as a matter of personal choice re self-harm / suicide and a criminal justice matter re harm to others.

The massive problem with the governments proposed legislation around 'personality disorder' is that it somehow implies that individuals classified with 'Dangerous and Severe PD' lack capacity for their actions (almost by definition it seems). Whether psychopathy entails impaired capacity is unclear to me (although I am not aware of research into this). Certainly I can think of many individuals meeting criteria for psychopathy who seem perfectly capable to me...

Sorry if this sounds harsh and uncaring but do we really want a paternalistic society where a capable individual loses their sovereign rights over their body, or where a capable individual who chooses to engage in crime and violence is medicated rather than punished?

For a great set of papers looking at the clash between the mental health act/bill and the mental capacity act see the following link.

Paul said...

Sorry, that last link failed to appear properly. Try the following:

Must learn how to use html...

Tainted_Halo said...

it somehow implies that individuals classified with 'Dangerous and Severe PD' lack capacity for their actions
This is also true however for suicide.
As with DSPD, there is a presumption of incapacity by nature of the decision made, measured by the nature and extent of outcomes of those decisions - rather than by the function of decision making being impaired.
In effect - the Capacity Act allows for a person to make irrational or simply bad decisions without recourse (which we always had) - except where we, the state/people/profession, don't like the (potential) outcome.
The C~ Act serves to protect those who are incapacitated - but by default empowers those who have capacity and wish to use it for bad decisions.
Since suicide is no longer a criminal offence - tho assisted suicide is - I'm waiting on the first euthanasia test case as a result of this law.
I'm also interested to see C~ Act vs MH Act when someone is detained for suicidal ideation yet is determined to have capacity.
Bit of a double standard.

frontierpsychiatist said...

I feel that I must take Paul to task on his assertion that psychiatric treatment should be based on 'need for care'.

Psychiatry diagnoses are very open to criticism, not least from me. However they serve some useful purposes:

- they enable effective communication between professionals.

- they help avoid unacceptable variations in diagnostic practice.

- they allow more accurate discussion of treatment and prognosis.

They are also at least an attempt to define what constitutes a mental illness. Beyond the obvious one about the lack of validity, my major problem with ICD-10 and DSM-IV is that they are too broad in what they permit to come under the psychiatric diagnostic umbrella.

However if you simply define psychiatric illness according to distress, then you not only become bogged down by subjectivity, but literally anything can become a psychiatic illness. I mental health professionals owe it to society not to encourage this more than we have already.

Also you should be careful about capacity. If you wish to define anyone without full capacity as having a mental illness, you will also leave the doors wide open - not least to a lot of children.

Tainted_Halo said...

If I might jump in before Paul - Having a diagnosis does not make it a problem. Nor does it clearly indicate to what extent and course of action is required.
A broken bone is a broken bone - but different treatments exist depending on the many variable factors.
What remains the same in mental and in physical health care is - how far does this condition impede the person?
Even DSM recognised it's shortcomings and developed into 5-axis comprehensive summary to include a GAF.
This is the major indication of any need for intervention and support - not simply that they have a psychoses. Plenty of people cope fine without medications or well meaning interventions from MH services.
GAF is where it's heading - or should be and ought be the primary indicator for service involvement instead of psychiatrists jumping for the fisrst available Axis I diagnoses to justify interventions.
Axis I II & III diagnostics are useful in indicating the types of possible treatments and do indeed provide a shorthand communication - but sometimes that's used as a throw away line rather than a treatment-informative one.
I'd much rather see GAF used to indicate need for intervention first and then take time over the rest.

frontierpsychiatist said...

We should not be too reductionist about this, since clearly neither the ‘diagnosis only’ or the ‘distress only’ approach alone represents a model of eligibility for psychiatric treatment. My concern about your substantial leaning towards the ‘distress model’ of caseness, is that 'distress' is not a mental illness and as a symptom is extremely prevalent in society.

Recognising people as having a mental health problem is difficult because, with no laboratory tests or robust aetiology, we are forced to rely on aggregates of symptoms rather than actual diseases. However although you or I might recognise symptoms of mental imbalance in ourselves, in someone whom we might recognise as suitable for treatment of mental illness an important threshold must be crossed.

That this ‘surpassed threshold’ must cause some distress in order for someone to be eligible for our attention is very sensible, but this does not work both ways. In practise we look at anyone who comes to us and is distressed, but although we can quibble over whether this is necessary, it isn’t sufficient.

In characterising anyone who presents to mental health services ‘distressed’ as acceptable for treatment by mental health services we seek to medicalize what is an essential part of every day experience. Furthermore we would seek to take away from people something that, the overcoming of which, may lead to a vital source of resilience for life’s vicissitudes?

(as an aside it’s interesting that in your comment you are both doubting the use of the medical model by stating your reservations about the utility of proffering a psychiatric diagnosis to a patient, but at once genuflecting to it by comparing psychiatric classifications to other more solid medical diagnoses such as broken legs....)

Tainted_Halo said...

My genuflecting (with both hands on the keyboard) was more in this case to identify that a condition is not just a condition but has a gradient factor to it's severity. I was actually supporting the existence of Axis I diagnoses but suggesting this alone was not sufficient to impose mental health care. I posted the Q on mentalnurse site more fully.

I think the differentiation for me comes with the profession rather than the patient.
You seem to hold that nurses psychiatrists and the rest all deal with the same level of disorder. I disagree and believe that distress at any level is a MH issue and sometimes that only requires brief generalist (in the context of MH professionals) intervention. This is what MH nurses; OT; SW and even Lifestyle Support Workers deal with often without supervision or referral to another as it does not always require a psychiatric diagnoses.

I prefer a process that generic workers (which MH nurses are initally trained in) assess and triage and refer as required - rather than sending the patient to a specialist in the first instance when only perhaps 5% of the issues are psychiatric and amenable to or requiring medical specialist treatment.
You've only to read back on some of Shrinks's referrals and assessments to realise how he often gets 'social' and 'totally normal understandable reaction' issues to offer "a cure" - which is sometimes totally ridiculous (clinically and economically) - and more often these seem like sending for Gordon Ramsey to help you make eggs on toast.

Paul said...

Hi Frontier, rather than clogging up Lake Cocytus's comments section I've responded to you in detail over at mine.