Volume 7 Issue 10 October, 2017
Psychiatry is an evolving science, though faced by the criticisms of antipsychiatry movement in the past that psychiatry is not a science and there cannot be any psychiatric disorders. Thomas Szasz in his controversial article of 1960 mentioned any disorder with psychological symptoms have pure biological origin and involve brain dysfunction. A decade later George Engel convincingly gave a holistic approach to the etiopathology of psychiatric disorders that more or less masked the antipsychiatry movement. This model is called ‘Biopsychosocial model’, which considers biological, psychological and social factors as precipitating, predisposing, perpetuating and protective factors in various combinations in the causation of psychiatric disorders. Thus it was widely accepted and became popular compared to other narrow pathways of care like psychodynamic model, cognitive behavioral model, interpersonal model etc.
Psychiatry however was integrated into the medical model of care even before antipsychiatry movement. The last 5 to 6 decades have seen rapid advancement in the management of psychiatric disorders- both psychological and pharmacological. Cognitive behavioural therapy and interpersonal therapy in general continue to be the most useful therapies even today. There have been innumerous medications approved and available. Social and vocational rehabilitation involve the key social therapies. All these components form the comprehensive management under biopsychosocial model. We further have Mental Health Act, guiding us through the patient care and an action plan through ‘National Mental Health Program’. Thus we are much comfortable today in managing patients. Yet this doesn’t appear to be the final answer. Mental morbidity continues to be in the rising trend!
Maslow in 1954 explained his ‘Hierarchical needs’ that includes the biological needs, safety needs, love and belongingness needs, esteem needs and self-actualization needs to be satisfied in that order, for an individual to evolve mentally. In short it is the ‘Roti-Kapda-Makaan’ proverb of India. That is, whatever the mental illness is, the recovery starts with having basic necessities first. This appears to be an ideal situation for every individual irrespective of the psychiatric disorders. However, as far as psychiatry is concerned, the most recent advancement in the pathways to care appears to be on the lines of this good old Maslow’s theory. William Anthony in 1993 explained the ‘Recovery model’ of care. This model essentially imposes responsibility of mental illness and recovery from illness on the patient himself and assists him throughout the process. This involves meeting the essential needs of the patient from the step one which may include helping with finances, shelter and food.
This happens through case management, where a case manager is the key contact to the patient (client). This model is also known as client centered approach. The case manager works through the recovery goals of the client. Recovery here is not the cure. It is a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness. All the needs such as food, shelter, financial assistance, job, medication, counseling/psychotherapy etc are provided as needed through the mediation of a case manager to facilitate the process of recovery. It is also a collaborative approach including patient in the decision making process rather than being paternalistic. Thus recovery is a resilience that the patient is expected to develop eventually. The government funds the entire care pathway.
This approach is currently followed in countries like UK, USA, South Africa, Australia, New Zealand and Canada. This appears to be the best answer for care of the mentally ill. However an interesting point here is that even Recovery model has no robust positive evidence base. Further, there is no significant positive change in the mental morbidity in those countries, with more than a decade of implementation of this model. Yet it is an approach believed to deliver the best. But it is not feasible to be implemented in all countries. Further the predominantly medical model of care in countries like India cannot be said to be a failure. All pathways to care have definitely been beneficial. There is no best answer yet. Considering that Psychiatry is a complex and evolving science, it is time for contemporary psychiatrists to think beyond recovery.
Dr Anil Kumar M Nagaraj, Specialist pathway Psychiatry Registrar, North Western Area Mental Health Services Melbourne
