Beware of medical solutions to human problems

The Anex
Illegal Drugs and Mental Health Conference
Melbourne, 3-4 September, 2007

Beware of Medical Solutions to Human Problems
David Webb

Hello everybody …

I’d like to draw your attention to one of the most important issues facing Australian society.  No, not illegal drugs, serious though this is.  No, not mental health, serious though this is also.  Nor is it the two of these in combination, which is also very serious and has its own special complications as we will hear over the next two days.

No, the issue that concerns me is the excessive medicalisation of what it is to be human that we find throughout Australian society today.  Sometimes called ‘disease-mongering’ or selling sickness, I think it is best described as the medical colonisation of the human spirit. Almost every aspect of the human experience is being reduced to our biology alone, with particular emphasis these days on the biochemistry of the brain.  By reducing us all to little more than biochemical robots, we are all diminished by this colonisation, both individually and collectively.

It is useful to look at how and why this medical colonisation of everyday life arises and my fear is that this conference is going to be an example of it.  So I want to alert you to some of the hazards we are likely to encounter over the next couple of days.

First, I’d like someone to count how many times we hear the term “dual diagnosis” over the next two days.  This language is a prime example of how a medical bias seeps into our language and into our thinking.  It immediately assumes a medical perspective, putting the discussion in a medical framework.  Then, if we make the mistake of uncritically accepting this assumption, it automatically follows that diagnosis indicates the presence of illness which in turn requires treatment.  Before we know it, the whole conversation is reduced to narrow and shallow medical ways of thinking.

I heard on the radio last week another small but I think revealing illustration of how the medical colonisation of addiction is taking place.  Professor Jon Currie, who is a neurologist at St Vincents here in Melbourne and I believe is speaking here tomorrow, was being asked about the current hot news story on AFL football players and drugs.  Professor Currie said, almost as an aside, that “we know that addiction is a medical problem”.  Although I’ve got very used to such sweeping statements over the years, they still make me cross.  No, Professor Currie, we do not know that addiction is a medical problem.  What we do know about addiction is that it is a complex interaction of medical, psychological, social, and I would also include spiritual, factors.

Long ago when I used to work in the computer industry, where technologies are changing all the time, we had a saying that if the only tool you have is a hammer then everything looks like a nail.  The overwhelmingly dominant influence in mental health today is the medical hammer of psychiatry which sees only illness, diagnosis and treatment.  It is hardly surprising then that the term “dual diagnosis” was invented.  But please – beware of the assumptions in this language and how they can limit and contaminate the important discussions we are having here today and tomorrow.

The medical colonisation of mental health is already very advanced.  There is already a widespread myth in the community that so-called mental illness is an illness just like physical illness even though there is no good scientific evidence to justify this assertion.  Hand in hand with this myth comes another that these alleged illnesses are due to chemical imbalances of the brain, which also has no scientific justification.  And then, even worse, following these myths comes the dangerous one that psychiatric medications correct this chemical imbalance.

Where do these myths come from?  Well, I saw them last week on the website of Victoria’s Mental Health Branch.  We hear them regularly from big and very expensive public relations campaigns – the best example we have in Australia is not the marketing of the pharmaceutical company industry, shocking though this is, but the $100 million dollars of public funds being spent by beyondblue to further advance the medical colonisation of mental health.

What’s particularly galling is that when people like me and my many colleagues around the world call for a more holistic approach to mental health, our arguments are dismissed as not “evidence based”.  This is galling because modern psychiatry fails to meet its own medical standards for what constitutes valid evidence, but this is the standard used to silence us.

Please also beware – be alert and alarmed – whenever you hear this phrase, “evidence based”, as it is one of the primary weapons used by the medical colonisation to silence everyone but the doctors.  Although the medical standards for what constitutes valid evidence are appropriate for things like drug trials and testing new surgical procedures, they are inappropriate – indeed they’re utterly useless – for many other kinds of knowledge that are needed for good mental health policy.  Whenever you hear this phrase, please ask yourself three questions: whose evidence, what criteria are they using, and in particular, what other evidence is being excluded by these criteria?

The most serious consequence of medical colonisation is that it blinds us to many important aspects of what we’re grappling with as we struggle to make sense of madness and drug abuse.  My PhD research into suicide exposed what for me is perhaps the most serious example of this.  Another of the prevailing myths in mental health, touted by organisations like beyondblue to the point that it is now generally believed throughout the community, is that depression is the major cause of suicide.

First of all, even if you believe that depression is a genuine medical illness, it is not a terminal illness.  Suicide is a conscious, deliberate, cognitive, psychological decision that usually also includes social, relational, cultural and/or spiritual factors, as well as, perhaps, biological factors.  But more than this, if we accept the assertion that depression is the cause, when in fact it is just a correlate, then we will never look deeper for why so many people are making this choice.  This blindness to what might really be happening for a person, whether it’s suicidal feelings, other so-called mental health issues, or substance abuse, is the greatest danger of the medical colonisation of the human spirit.

There’s an old tale that illustrates this problem – I first heard it told as a Sufi tale but this has been contested.  A man is walking through his village and sees his neighbour searching on the ground for something.  He asks, “Neighbour, what have you lost”, to which the neighbour replies, his keys.  The man gets down to help his neighbour but after some time without finding them he asks, “Neighbour, where did you last have your keys”, to which he replies, inside his house.  “So why are you searching out here”, he asks.  “Because the light is much better out here”, he replies.

The bright light of medical science, wonderful though it is for illuminating many problems, will not reveal anything where there is nothing to be found.  At best, the brain contains some of what we need to know to understand mental health, though it will only ever be – at best – just one part of what we need to know and understand.

What is needed, in both mental health and in drug and alcohol services, is a holistic approach that considers all domains of the human experience and draws upon all the many different ways of knowing and understanding what it is to be human.  The closest we have to this at the moment is known as the biopsychosocial approach, though we somehow need to also squeeze into this already clumsy term the lived experience, or phenomenology, of madness and also the spiritual dimension.

Although this is well understood by many, including, I suspect, many people in this room, the trend in mental health in recent decades has been in exactly the opposite direction.  This is not just the view of dissenting voices such as mine.  In 2005, the then President of the American Psychiatric Association, Steven S. Sharfstein, acknowledged this trend when he observed that, “we must examine the fact that as a profession, we haveallowed the biopsychosocial model to become the bio-bio-biomodel”.

The bio-bio-biomodel that he speaks of is the medical colonisation I’ve been talking about.  It represents the biggest obstacle to meaningful progress on the issues that we are meeting to discuss here today and tomorrow.  It is a bigger obstacle than the lack of funding and other resources that we regularly hear so many complaints about.  One way to recognise where the real power and influence lies is to “follow the money”.  Staggering amounts are spent on the bio-bio-biomodel.  Even if we shifted just some of this money to research, policy and practice that could help people in ways that brain science will never be able to, then we will have taken a giant step forward in the issues that have brought us together here today.

I urge all of you who believe in a genuine biopsychosocial approach – plus a few extra necessary bits to make it truly holisitic – to resist a medical takeover of drug and alcohol services under the phoney jargon of “dual diagnosis” and to fight for truly human solutions for human problems.

I’ll finish by repeating what I once said at meeting of the Ministerial Advisory Committee on Mental Health – though to deaf ears at the time, I’m afraid.  From my personal experience of both mental health and drug and alcohol services, and now also through my PhD research, I still say that our mental health system has very much more to learn from our drug and alcohol sector than the other way around.  These days I’d add that I now also look to the drug and alcohol sector for some hope and guidance for the radical reforms we so desperately need in our mental health system.

Thank you