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Mental Health the Medical Perspective: a Case Study

The aim of this assignment is to citically examine the medical model in relation to a client that I am working with, for reasons of confidentiality I have used a pseudo name: The medical perspectives in Mental Health. Background Alan is a 42 yr old white british male, he was diagnosed with schitzophrenia at the age of 21yrs. He is the eldest of two children, his sister resides with her husband and children nearby. Alan resides at home with his parents, who are in their early seventies. Alan has always complied with medication, and agreed to hospitalization when necessary, compulsory admission has not been required. Scitzophrenia is a devastating mental illneess, and probably the most distressing and disabling of the severe mental disorders. The first signs of schizophrenia typically emerge in adolescence or young adult. The effects of the illness are confusing and often shocking to families and friends. ” http://www. psychiatry24x7. com. schizophrenia retreived 19/01/06. Alan is seen by his psychiatrist, every six months, unless he is unwell, when he will be seen more frequently. He is reviewed through the Care program approach at hospital out-patients.

His key worker is a community psychiatric nurse, (CPN). The psychiatrist plays a central role in the diagnosis of a mental disorder. Diagnosis is made after a mental health examination. The role of the psychiatrist in the mental state examination serves two purposes: “A detailed history is taken to identify change and characteristic clusters indicative of a specific psychiatric disorder. Secondly the psychiatrist has to make a comparison of change against a diagnostic criteria to establish presence or not of a specific psychiatric disorder. ” (Holland, 2003, p. 938) After illiminating organic cause, by physical examination, the psychiatrist makes a diagnosis by classification of the symptoms. In todays psychiatry there are two systems used to more reliably identify a mental disorder. The International Classification of Disease, 10th revision, (ICD10), and the American Classification Diagnostic and Statistical Manual, 4th revision, (DSMIV). European psychiatry are guided by the former. The ICD10 catogarises schizophrenia under, F. 20. using the description of Kurt Schieder’s first rank symptoms, (1959).

These are ranked as A – D, other symptoms E-I have also been added. (p. 49, ICD10, WHO 1992,). For a diagnosis of Schitzophrenia the person must show at least one of the first rank symptoms A- D and at least two of the symptoms, E- I. Alan experiences; – Thought withdrawal, insertion and broadcasting, he beleives that someone or something is responsible for this. (First Rank symptom A). – Auditory Hallucinations, he hears a running commentary about him. (First Rank symptom C). These are also known as the positive symptoms of schitzophrenia.

Alan also experiences more than two of the symptoms E –I, he has thought disorder, anxiety,depression and poor motivation, referred to as negative symptoms. (Kingdom, cited Bailey, 2000) The ICD10, goes on to provide subsections for types of schizophrena, and notes; not everyone agrees with the sub-sections, due to the overlapping symptoms that can be present from one type to another. According to Alan’s medical notes and on asking him, he does not appear to have been diagnosed with a specific type of schizophrenia. Given the clusters of symptoms that e has experienced, at various times, it would be difficult to place Alan into one of the sub- sections. The medical model excepts that the schizoprenic brain has increased ventricles, (spaces in the brain), which leads to an imbalance of chemicals in the brain. Using their main tool pshycopharmoglogy, they prescribe drugs to correct this imbalance. (Leonard,2003). The pathology of the illness considers that the chemical which is imbalanced is dopamine. Drugs used to treat mental disorders are known as; neoroleptics or psychotropics, they target the chemical dopamine by blocking the neuroreceptors.

The drugs effect behaviour, psychological cognitive function and/or the sensory experience. They also effect other neurotransmitters in the brain, such as serotonan, a chemical associated with affective disorders, therefore, the same drugs are used to treat different diagnosises. (Barry,2002). Alan has been prescribed various psychotropic drugs to try and control the positive and negative symptoms of schizophrenia. His medical notes demonstrate that drugs have been introduced, decreased and increased on a number of occassions, with little effect of relieving the symptoms substancially over a long period of time.

Over the years in psychiatry drugs have evolved, Alan has been prescribed some of the older drugs, Chlorpromazine and Haloperidol, these are referred to as ‘typical’drugs. These drugs cause side-effects such as; pseudoparkinsonism, (uncontrolable shaking of limbs), and Akathisia, (an uncomfortable internal restlessness and anxiety). (Barry 2002). Further medication was prescribed to combat these side- effects. Following this Alan’s psychiatrist changed his medication to the newer ‘atypical’drugs olanzipane and risperidone.

Alan did not respond to this medication and after a deteration in his mental health he was admitted to hospital and agreed to try another ‘atypical drug’clozaril thearapy. Given the toxicity of clozaril it is not used as freely as other psychtropic medication. A complication of clozaril is the effect that it has on the white blood cells, if the deficiency becomes to great the drug can kill. (Barry 2002). To reduce the possibility of this the white cells are monitered through regular blood testing.

The outcome of the long term effect of these drugs is not yet fully known. (Barry, 2002). Psychiatry does not go without critisim, Szass, (1997), best known as an anti – psychiatrist, challenges the concept of mental health as an illness. For an illness to be an illness it has to be classified as having three commonalities, cause – progression – and outcome. He argues that schizophrenia does not share any commonality, and that the reason a scitzophrenic patient becomes a patient is because those around him refuses to except a behaviour beyond the norm.

Laing, (1985), also supports this theory and informs the reader that psychiatry is the only medical model that does not have an exact pathology that is proven by labortory testing. Another school of thought suggests; individuals are treated for the side-effects of medication moreso than the original illness, (Illich, cited in Laing 1985). “They can end up fighting side effects …One drug to combat another…. Prehaps it is the medication that ends up disturbing mental behaviour, warping personalities or or conditions in to bigger problems. ( Hewitt, 2001, p. 72) Alan prosponed the decision to take clorazil due to the risk of toxicity. Since commencing treatment, the symptoms have reduced but not deminished, he still takes medication for side-effects, anxiety and depression. He continues to struggle with daily living. His anxiety levels are so intense, that this condition has preceeded the effects of schizophrenia, which has led to further isolation from society, he would like to engage in employment, paid or unpaid, however in his current frame of mind this is not a possibility.

Labour force 1995, reported that employment figures in mental health patients are much lower than any other disabled group. Only 21% of people with mental health problems are working or actively seeking work. (Webb&Tossell, 1999). Warnings on some medication advise that machinery must not be used, vechiles must not be driven, due to side-effects of drowsiness, alcohol should not be taken with a lot of psyhcotropic medication. All of these restrictions impact upon Alan’s ability to function in society. Secondry to this, Alan has to cope with the stigma attached to mental health disorders.

There is a stereo typical societal perception that individuals with mental health issues are more dangerous than others, regardless of research suggesting the opposite; Philo et al, (1993), published research to demonstrate that there is no evidence to suggest that a person with mental health issues is any more likely to harm than anyone else. Figures over the last 20 yrs demonstrate that there has been no increase in murder caused by someone with mental health problems,whilst the increase amongt the general polulation has more than doubled. Research shows that this discrimination within mental health does not stop with the lay person.

White, western people have better experience of the service than other ethnic groups. (Haddad & knapp, 2000). The Sainsbury Cenre for Mental Health, (SCMH), (2002), in it’s aim to influence national policy high lighted the inequalities experinced by Black and African Carribean communities. SCMH’s findings suggest that professional have a fear of some ethnic minority groups, due to individual size or skin colour. It is these stereotypical beliefs, cultural ignorance and racist views, that prejudice assessments and influences treatment, reponses therefore rely on heavy medication and restriction.

The consequences of which can be dentrimental, and have resulted in death, for people like David Bennett. In response to high profile cases, the Governement have produced various documentation to address issues of inequality. Delivering Race and Equality, (2003), set out to provide an action plan over 7yrs to improve mental health services for ethnic minority groups. The focus is on raising professional awarness around culture, ethnicity and racism. As the western world progresses towards a multi-cultural society, it is inevitable that more people from ethinic minorities will come in contact with mental health services.

Fernando, (1991), considers this to be of a special concern and warns that; “The white domination of black people promotes, and often imposes a cultural domination so that ways of thinking, family life patterns of mental health and mental health care that are identified as ‘European’in tradition ‘white’by racial origin, are seen as superior to others. ”(p. 198) Fernando, goes on to highlight the fact that many forms of human distress medicalised by western society are not medicalised by other societies, and notes that political forces dominates what is an illness and gives ultimate power to the psychiatry to treat.

Therefore suggesting that individual diagnosis can depend upon where you reside in the world. Rack, (1982), notes that western psychiatry has an important role in social control, whilst Asian psychiatry is largely concerned with spiritual development. Fenando states; “…medicine too is part of a culture and not a system with a life of its own outside the culture in which it lives. ” (P. 197) He advises that a reliable diagnosis is unlikely, unless the individual is interwiewed in their own language, as only a person with the same language knows what to look for.

If Racks theory is correct then services have a lot to achieve to gain full equality. According to research it is not only the diagnosis in mental health that globally differs, it is also the recovery rate. Research under taken by WHO, (1938, 1958, 1988, 1998), ## evidenced that only 33% of individuals diagnosed with schizoprenia in western soceity were successfully treated by drugs. A further pilot study by the same organisation, in the recovery of schizophrenia demonstrated that recovery rates in London and Washington, (33%, 34%), were immensly lower than in IBADIAN AND MAGA PERDESH, (86%,87%).

The variable out come appeared to be talking methods and a positve out look from the onset. People were advised that they would get better rather than being told there future would depend upon medication. Colman, (2004), suggests; “Most psychiatic doctors appear to be wedded to the idea that they must treat everyone with medication and that it is only through the use of medication that people recover. The evidence for ths view appears to be based on research carried out using moneys supplied by pharmacutical industry. ”(p. 4). Colman’s view does not stand alone, Klass, (1975), advises that drug treatment is encouraged by the profit they make for their producers, who also provide the drugs to treat the side-effects. Large profits from the industry is used to provide research and advertise what they view as successful intervention for mental disorders. (cited Pilgrim&Rogers, 1987). In relation to Alan’s drug therapy and the side-effects of anxiety, I have spoken to his treatment team regarding alternative therapy such as; Anxiety Management.

The response was that he had this previously and is unable to sustain self help techniques. My view was that this was a funding issue, psychosocial therapy costs more than drug therapy. (Pilgrim&Rogers, 1987). It appears to come secondary to drug therapy in the view of the medical model. “ Whilst it is generally conceded by most commenters on psychiatry that it is now electic… The bias towards physical treatment is still strong. ” (p. 121. Baruch&treacher,1978, Roman,1985, Bushfield 1986, cited Pilgrim&Rogers, 1987).

Alan has spoke with me regarding the conscequences of stopping treatment to combat the side-effects. Pilgrim & Rogers, (1987), amongst others acknowledge that individuals may stop complying with medication if the side effects from the drugs become intolerable and they are not listened to. “ treating psychiatrists do not take their complaints about ‘side-effects’, or their concerns about the debilitating effects of the drugs, seriously. Instead, doctors tend to be concerned only with the effectiveness of the drugs in symptom reduction (assessed by them, not the patients themselves)’. p. 125 ) If Alan chose not to comply to medication, experienced a deteriation in his mental health and refused voluntary admission to hospital he could be detained under the Mental Health Act 1983. (MHA). The mental state examination would be under took by a doctor who was not exculded under s12 of the act (MHA1983,cited Jones, 2004). In good practise Alan should be assessed by his psychiatrist and his own general Practitioner. Thus meeting the requirements of s 12 [2], (MHA1983). Both doctors must examine the patient within five days of each other (s12,[1],MHA1983).

As Alan is known to the clinical team, and has a specific diagnosis, admission for traetment (s3 MHA, 1983, cited Jones 2004), would possibly be the proposed section. (Code of Practise, 1999, ch5). Laing, (1985), Szass, (1997), claims that psychiatry is used to police society and not to treat the individual. Psychiatrists have been given the power to lock people up and treat them against their will, they have more power than a judge, and hospital wards provide a prison for the unconvicted individuals who do not meet societal norms.

The approved social worker,(ASW), also has a powerful role under the 1983 Act and does make the ultimate decision as to whether treatment in hospital is the most appropriate form of treatment. (s13[2],MHA1983). As a social worker under taking the duty of an ASW, (albiet as a shadow), I have been faced with dilema’s whereby the role and duty of an ASW conflict with my social work values, instead of promoting rights and autonomy I am restricting them. I am managing this by addressing the issues in debriefing following the ssessments, in supervision, and by challenging other professional’s practise when necessary. For example, on one assessment, nursing staff had observed a patient as being withdrawn because he chose not to watch television in the communial lounge. During interview, the patient advised that he was a Johava witness and was oppossed to violence which was all that was on the particular channel viewed in the lounge. On addressing this with staff, it was clear that cultural or religous needs this had not been taken in to consideration.

If Alan was formally admitted to hospital his psychiatrist does have the power to treat him against his wish. (part IV, MHA1983). This could include invasive treatment such as ECT, which Alan is oppossed to. I am therefore proposing Alan prepares an advanced directive, which will be incorporated in his careplan. Although, this does not over ride the clinical desicion his treatment team will need to take his views and wishes in to consideraton. MHA —————– Alan is supported by his family they have a good insight in to his illness, his father has recently been diagnosed with Alziemen’s disease.

My current concern is that his mother is a carer for two family members. The largest proportion of community care is carried out by unpaid family members, who often miss out on employment and become isloated. (Webb&Tossell, 1999). To ensure that Mrs A, is able to continue in her role, her needs also must be met. I have therefore requested an updated assessment under The Carer’s (recognition and service) Act 1995. Mrs. A’s wellbeing is paramount in preventing deteriation of the home situation which would inevitabley impact upon Alan’s mental health. Mrs.

A recognises the signs and symptoms when Alans mental health starts to deteriate, which in turn has historially prevented admission to hospital. Research from All Saints Hospital Birmingham evidenced that 59% of relatives recognise early warning signs one month before relapse and 75% two weeks before relapse. (cited Howe, 1998). Mrs. A feels that she is coping at present with the assistance of her support worker she is able to off load. She accesses carer’s groups which she finds helpful. If the situation becomes to much the family have agreed to access further support for Mr. A. nder The Community Care and National Health Service Act 1990. Alan receives support from the day centre where he is involved with Art therapy and other activities. He attends the Fountain club, (a mind project), where he has access to support through group therapy, and attends respite two days a month. Alan finds these resourses useful in helping him to live with not only schizophrena but also the side-effects of his medication. He is offered support and advise that is not from a medical perspective. The family also consider that alternative therapy is as important to them, as to Alan. Mrs.

A considers that Alan and the family’s needs have been better met since a holistic approach has been under taken, as social and pshcological factors are adressed, aswell as the pathology of the illness. Howe, ( 1998), acknowleges that this has been a general failure in the medical model. I have not progressed with my original task regarding accomodation because I feel that Alan has enough going on in his life at present, in coming to terms with his father’s illness. Although his CPN, considers that this would be in his best interest, the family do not want it and I am not convinced it is what Alan wants either.

Szass, (1997), refers to how the mentally ill pateint is considered to be incompetant where as the medically ill pateint is considered to be competant. If Alan did not have a mental disorder, residing at home would not be an issue for anyone, other than the family. I will continue to project my view wtih the CPN and in supervision. In conclusion to this assignment I would agree that all those who work with in this area have far to go in developing services. My role amongst this will be to challenge oppression, by raising awarness as I have done in practise, and to promote an holistic approach towards assessment.

I am of the view that medication does help certian individuals, and their life has improved with medication. However in my view this should be minimal to releive distress and enhanced with other socialogical and pyshcological intervention. Although relapse cannot be illiminated, research and literature referenced throughout this assignment suggests that there is a high colleration between staying well and receiving a combination of services. Drawing from my previous managerial experience I have know doubt that the constraints on budgets will effect resources, which will inevitable effect the services individauls receive.

Pilgrim&Rogers, (1987), acknowledge that the limitation of resourses and the cost to them, which is not measurable in comparison to physical treatment has been a factor that has prevented psychological and social models from competeing against the medical model. Undoubtabley this will need to change to allow individuals a successful chance of recovery. Authors referred to who opposs psychiatry and its role do have a fair arguement, in that drug treatment and legislation polices society, however no realistic alternative is provided.

In my view the way forward is through raising public and professional awareness and de-stigmatising mental disorder. Word count 3297 References Barry, P. (2003). Mental Health and Mental Illness. (7th ed). Philidelphia.. Lippincott. Colman, R. (2004). Recovery an Alien Concept. (2nd Ed). Fife. P. P press. Delivering Race and Equality, (2003) The Sainsbury Centre for Mental Health, breaking the Circles of Fear, breifing 17. A review of the relationship between mental health services and African Caribbean communities. London. Fernando, S. (1991). Menatal Health Race and Culture.

London. Mind publications in association with Macmillon. Hewitt, P. (2001). So You Think Your Mad, 7 Practical Steps to Mental Health. Ppppppppppp Handsell Publishing. Howe, G. (1998). Getting in to the System, Living with Severe Mental Illness. London. Jessica Kingsley publishers Ltd. Jones, R. (2004). Mental Health Act Mannual. (9th Ed). London. Sweet &Maxwell Ltd. Laing, R. D. , (1985). Wisdom, Madness and Folly. Making sense of psychiatry. Basingstoke. Paper Mac. Leonard, B. E. (2003). Fundementals of Psychopharmocology. (3rd ed). Wiley. Pilgrim, D. ,and Rogers, A. (1987). A sociology of Mental Health and Illness. (2nd Ed). Pppppppppppp. Open University Press. Professor, Kingdom, (2000). D. Edited by Bailey D. 2000, At the Core of Mnetal Health. Key issuese for practitioners managers and mental heealth managers, Rack, P. (1982). Race Culture and Mental Disorder. forwarded by G. Morris. London. Routledge. Szass, T. (1997). Insanity. The Idea and it’s Consequenses. Syrcuse. University Press. WHO, (1992). The ICD10, Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidlines. Geneva.

World Health Organisation. Webb. R. , & Tossell, D. , (1999). Social Issues for Carers Towards Posive Practice. (2nd ed) London. Arnold. Haddad, P. , & Knapp, M. , (2000). Health Professional’s views of services for schizophrenia – fragmentation and Inequality. Psychiatric Bulletin (24), p 47 – 50. http://www. psychiatry24x7. com. schizophrenia retreived 19/01/06. NICE, (2003). Recommends newer antipsychotic drugs as one of the first line options for schizophenia. Press release. retrieved 19/01/06. Webb site: http://www. nice. org. uk/page. aspx? 0=32928

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