International Journal of Integrated Care, 12 April 2006 - ISSN 1568-4156
Book review
Mental health at the crossroads: the promise of the psychosocial approach
Edited by Shulamit Ramon and Janet E Williams
Aldershot (GB): Ashgate Publising Limited, 2005, pp 235,
ISBN 0 7546 4191 0
Sjoerd Sytema, PhD, Sociologist and mental health services researcher

The 19 contributors of this book, most of them social scientists or mental health practitioners including a few psychiatrists, are united in their belief that a paradigm shift in mental health is needed. In short: the dominant bio-medical, diagnosis driven model should be replaced by the psychosocial approach, in which recovery, consumer involvement, emotional involvement of practitioners (‘hands-on’ approach) are central ingredients.

The book consists of four parts, each including a varying number of chapters, and 228 pages in total. In part one the conceptual framework of the psychosocial model is outlined. Like the anti-psychiatry movement dating back to 1960–1980, the authors criticize the biochemical model, as they call it, by denying the social context in the etiology and in the treatment of mental illness. The psychosocial model, which combines the psychological with the social, gives priority to the psychosocial context in interpreting and understanding mental reactions. The treatment will be directed towards changing this context by means of social work, psychotherapy or self-help groups. The medical model defines ‘health’ as the absence of disease or illness or symptoms, while the psychosocial approach sees it as an ability (to love and to work for example).

Part two describes the political context of mental health policy and service development in the UK, Australia and the USA in three different chapters. In the first chapter a case is presented (young man with a diagnosis of bi-polar depression in a crisis with mild aggressive behaviour, picked-up by the police, but refusing care) to illustrate the working of mental health in each of these countries in cases like this. This is very informative for the reader, as it shows how compulsory treatment (hospital as well as community) is legally and practically organised within these systems. The author criticizes the growing use of coercive interventions like the widespread community treatment orders (CTOs) in Australia which shows the power of psychiatry and which endangers the human rights of people with an identified mental illness.

Part three has four chapters organised around the theme: paradigm shift in psychiatry. The first chapter starts with the observation that within the American Psychiatric Association mental disorders are seen as neurobiological disorders. Although this has always been the dominant view, it tends now to be seen as a fact while previously it was a hypothesis among others. This development from hypothesis to fact is unjustified according to scientific proof. It simply is the most appropriate paradigm for psychiatry, according to the author, to gain more respect of the rest of medicine. The author puts against this the biopsychological approach, emphasising the continuum between normality and mental illness (instead of the neo-Kraepelinian absolute differentiation between normal and mentally ill) and the social context and individual experiences in understanding mental illness (instead of posing deviations in the brain as the sole cause).

In the second chapter de-institutionalisation (a direct result from the anti-psychiatric movement) is seen as the process that will inevitably lead to the paradigm shift. Community based services have to take into account all the resources (family, work, community) available for the individual patient, who will be no longer a passive receiver of care but an active mental health consumer in the search for recovery.

In part four of the book, including seven chapters, a number of experiences with the psychosocial model are described, such as self-help groups, informal caring, mental health promotion and spirituality. This part starts with a chapter about the place of recovery in mental health care, a concept which is used (although defined differently) in both the bio-medical and the psychosocial model, but originates from consumer/survivor movements in the US.

This book certainly is very welcome in giving a good overview of the theoretical and practical background of the so-called psychosocial model. But the question is whether there is a paradigm shift going on from the biomedical to the psychosocial model, as is the central proposition in the book. In my view a more realistic observation is that the psychosocial model is increasingly integrated into the biomedical model. Moreover, I don't think that it is very productive to pose the two models as conflicting rivals against one another. We can observe that consumers are increasingly involved in mental health care planning; many assertive community treatment teams do have a survivor as a team member for example.

From an integrative point of view, disease management is a prerequisite in the process of recovery for the severely mentally ill. This element, an exploration of the possibility of integrating the biomedical and the psychosocial model, is missing.