"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.