NYTimes Opinion: "Mental Illness isn't All in Your Head" - L. Pryor 2019

[James Morris-Lent]

https://www.nytimes.com/2019/03/15/opinion/preventing-mental-illness.html

This is an opinion piece that endorses the Biopsychosocial model for understanding mental/psychiatric illness.

We are primed to react negatively to "BPS" because it is used as an assertion to frame CFS and other 'MUS' as psychogenic/psychosomatic. I think this article is referring more to BPS as truism - people are affected by lots of different things and different frames of analysis can be helpful in understanding suffering.

You can read the quotes below to get a good idea of what the author has in mind.

Ultimately, I feel this article is well-meaning, but it seeks to address things that are beyond the scope of psychiatric/medical practice, and more into the realm of public health and social services - or just, you know, left up to a person living there own life as an individual with some level of agency. The implied paternalism is worrying. There is also the strong undertone of Freudian drivel.

Useful analyses of how the the medical system and social services can best interact to produce the best outcomes are surely welcome - but you probably want some reliable data for that, not just a nice truism.

If a diagnosis is a label, a formulation is more like a story. In a few sentences, a formulation gathers up all the biological, psychological and social factors that have led to a person becoming unwell and considers how these factors interconnect. In doing so, it provides clues to the pathway out of suffering.

Let’s consider an example of a formulation. The diagnosis “major depressive disorder” may not tell you much about a person, but consider a formulation for an individual, which might go something like this: “Forty-six-year-old single mother of two presents with a three-month history of depressive symptoms including low mood, insomnia and poor appetite (with weight loss). Her condition was precipitated by psychosocial stressors, including unstable housing and credit-card debt since the breakdown of her marriage eight months ago. This is on a background of an introverted and passive temperament and a childhood in which her parents encouraged dependency, and this was followed by a marriage in which her husband had complete control of finances. There is a strong family history of depression; her mother and maternal grandfather were hospitalized for this condition. Protective factors include a strong network of friends and a willingness to engage with therapy.”

In the hypothetical example above, treatment may not be limited to medication; it might include a suite of other interventions. Long-term psychotherapy to help build confidence and a sense of self-efficacy might be one element, as would other measures that on the face of it might not seem to be within the realm of psychiatric treatment. For example, it would make sense to provide assistance for obtaining safe and affordable housing if unstable living arrangements helped cause spiraling feelings of hopelessness. Similarly, helping the person find a course to learn budgeting skills or get a job might be beneficial.

 

[Jonathan Edwards]

Very simple really. A diagnosis is a label. A formulation is bullshit.

The author seems to miss the point that you need evidence to discover which psychosocial factors, if any, are relevant in an individual case, and by and large that evidence is not available.

 

[lansbergen]

Very simple really. A diagnosis is a label.

Yep

 

[shak8]

Why the incessant professional ($$ ?) need to rehash and reclassify all sorts of nonsense in the psychiatric field if not because psychiatry has limited efficacy. They are psychopharmacologists.

Oh what luxury to have debates with colleagues about this tripe when patients suffer from mistrust and neglect.

 

[rvallee]

https://www.nytimes.com/2019/03/15/opinion/preventing-mental-illness.html
This is an opinion piece that endorses the Biopsychosocial model for understanding mental/psychiatric illness.

We are primed to react negatively to "BPS" because it is used as an assertion to frame CFS and other 'MUS' as psychogenic/psychosomatic. I think this article is referring more to BPS as truism - people are affected by lots of different things and different frames of analysis can be helpful in understanding suffering.

You can read the quotes below to get a good idea of what the author has in mind.

Ultimately, I feel this article is well-meaning, but it seeks to address things that are beyond the scope of psychiatric/medical practice, and more into the realm of public health and social services - or just, you know, left up to a person living there own life as an individual with some level of agency. The implied paternalism is worrying. There is also the strong undertone of Freudian drivel.

Useful analyses of how the the medical system and social services can best interact to produce the best outcomes are surely welcome - but you probably want some reliable data for that, not just a nice truism.

The problem is with how it's used, which can't be detached from its underlying model. That basically seems to be the excuse used by people pushing the various PPS, MUS, CSS, functional models, etc. who say that it makes no such claims about psychological causes (then often say the opposite but whatever). In reality, plenty of people do just that and they can't wash their hands off it.

Same as Cochrane, basically saying they mean nothing by putting the ME review in the common mental disorders and that they are not responsible if people use it as a proxy for a purely psychological model. People do just that and they are responsible for its misuse when they make no effort whatsoever to correct this misuse, something that is evidently deliberate.

It's simply way too vague and open to interpretation, even more so than ME actually is so as a "better" explanation it just fails massively. BPS has no shape or form, you can use it to mean anything you want it to mean and even peers won't see the difference. We're seeing that very clearly with CBT as a treatment, where in the psychosocial model of ME it's not at all typical CBT but rather used as a tool to gaslight and convince patients to think themselves healthy.

I have no issues with pursuing this model. But do wait several decades until you have something objective and validated before attempting to put it into practice everywhere at once. All this will do is discredit the whole thing entirely.

 

[James Morris-Lent]

Very simple really. A diagnosis is a label. A formulation is bullshit.

The author seems to miss the point that you need evidence to discover which psychosocial factors, if any, are relevant in an individual case, and by and large that evidence is not available.

I would agree that this is the necessary mindset for doctors during clinical practice.

However, I think the idea of 'formulation' deserves more analysis outside of just that context. Particularly in our 'Information Age'. To me a 'formulation' is so vague it's basically an information vector of arbitrary dimension pertaining to a person. This already exists in some form - accumulated by companies that mine our data to ultimately feed algorithms that seek to modify our behavior in some way that they value.

If this approach can be used successfully to get us to buy more junk or spend more time on a platform, etc., it's not surprising that there would be interest in using it to modify health outcomes. That's not to say it would or even can be successful in terms of benefit to the patient or the greater good. But well-meaning people will be tempted to try because we can all see (with questionable accuracy) in ourselves or the people we know 'psychosocial factors' that influence health or well-being, and that we might like to think could be standardized and processed in some way to show the way to better outcomes. And, of course, insurers, employers, and governments will all be very interested in any sort of data they can (ab)use in order to achieve their ends.