Discussion and Questions on Mental Illness
1. Is there such a thing as a mental illness? If so, what is it? If not, what are the
phenomena that some people call mental illnesses?
2. How can we properly distinguish biological from social influences on behaviors?
3. What is the difference between “mind” and “brain”?
Since some time in the Middle Ages, there have been asylums. At other times, and in
many places since then, people with mental illness were either left to wander or were
locked up at home. During the Enlightenment in the 18th century, people began to
recognize that asylums could be therapeutic. This recognition led to the birth of
psychiatry.
4. How could an institution have a therapeutic effect?
During that time, people recognized a difference between “nerves” and “madness.”
“Nerves” was considered to be a physical problem, nonhereditary, and treatable by
physicians. It had a positive prognosis. “Madness” was considered characterological,
hereditary, and untreatable. It had a negative prognosis. These were essentially the early
diagnostic categories – what we now think of as incurable, psychoses, or serious and
persistent vs. curable, neuroses, or “other” mental illnesses.
From these differences, people began to systematically look for a connection between
brain structures. This reasoning from finings upon autopsy back to signs and symptoms
before death is called the clinical-pathological model, and it was the first biological
psychiatry. It lead to the discovery that what we now call neurosyphilis is a brain
disease, and for the first time, people recognized that mental illness is brain disease. This
related to the medicalization of psychiatry. Physicians had to learn to deal with families
and to deal with patients who had psychiatric illnesses. They could send patients to the
asylums where psychiatrists were in charge, and they could treat the ones who had
medical conditions that manifest themselves through psychiatric symptoms.
The clinical-pathological model also led to the distinction between psychiatric illness and
neurological illness.
5. What is the difference between psychiatric illness and neurological illness?
A related idea is the term functional illness, which is a presumed psychiatric illness
without an identifiable brain lesion. It is a presumed problem of brain function without
an identifiable problem of brain structure.
The focus of the first biological psychiatry on brain structure instead of on the person to
whom the brain belonged killed the first biological psychiatry. Also, because of the
limitations of technology at the time, after the discovery of neurosyphilis, there were no
other major discoveries of structural pathologies related to psychiatric symptoms. In fact,
Nissl wrongly concluded that there was no connection between brain structure and mental
illness.
Kraepelin began to track the different illnesses and to categorize them according to their
outcomes. This shifted the focus away from hypotheses about causes—of which there
were many— to ideas about natural history and prognosis. This is a significant shift
toward a modern scientific approach. It is a study of phenomena instead of an exercise in
hypothesizing.
The death of biological psychiatric led to an increase in institutional care, and this
parallels a development in social work. Both psychiatry and social work came to believe
that moral instruction would lead to improved functioning. Implicit in that was the idea
that the pathology was somehow within the person’s character.
Psychotherapy entered medicine through the use of medical hypnosis. Medical
practitioners discovered that talking—the use of hypnosis—could influence illnesses.
Freud was an early practitioner of hypnosis, but he essentially abandoned it for
psychoanalysis. Psychoanalysis was a radical rejection of biological psychiatry. It was
built on a variety of assumptions and untestable hypotheses about psychological
processes. It allowed psychiatrists to carve out a market niche, though, and to treat
patients that were not being treated elsewhere. In the first half of the 20th Century, there
were essentially two psychiatric treatments: institutional care and psychoanalysis. From
the early days of psychoanalysis through World War II, a number of social workers left
traditional social work to do psychotherapy.
6. What happened to medical treatment of psychiatric illness?
7. How did psychoanalysis create illness?
8. Why did social workers get into psychotherapy?
Following World War II, psychiatrists and clinical social workers focused on
psychological explanations and interventions while traditional social workers focused on
social explanations and interventions. This era saw some interesting divergence within
the professions. For example, Frieda Fromm-Reichman, whi was connected with the
Mental Research Institute, aka the Palo Alto Group developed the theory of the
schizophrenogenic mother, which led to family systems theory. Karl Menninger of the
Menninger Clinic decided that mental illness was a matter of degree, not kind.
9. What are the adverse consequences of these ideas?
Electroconvlusive therapy was discovered and was found to be an effective treatment for
some mental illnesses, yet it was, and still is adamantly opposed by some groups,
especially the analysts.
10. What was the analysts’ philosophical objection to ECT?
During the 1950s, Thorazine was found to be an effective treatment for some illnesses.
This was the start of the second biological psychiatry.
Today there are several models of psychiatry: the biological model, the medical model,
the biopsychosocial model, and the social and community model. Although people often
confuse these models, and in some ways they can overlap, there are significant
differences: biological – pathology is in brain structures; medical – discrete diagnostic
entities; biopsychosocial – illness is socially caused; social and community – because
illness was caused by the community, it could be healed with a therapeutic community.
There is also the mental health model, which is concerned with distress, and there is the
mental illness model, which is concerned with disease.
11. What evidence supports the biological model of mental illness? What evidence
undermines it?
12. What are the implications of the difference between a mental illness model and a
mental health model?
13. What are the implications for our society and for your practice of the tendency for
people to psychologize distress?
14. How would we properly draw boundaries around what is and what is not mental
illness?
15. Is personality disorder a mental illness?
16. Is under-diagnosis or over-diagnosis more ethical?
17. What treatments should we use?
18. What does a social worker have to offer a person who has a mental illness?
19. What are the major themes psychiatrists have struggled with in the evolution of
the profession? How do these themes influence the practice of social work today?
Based on A History of Psychiatry by Edward Shorter