I began thinking about this post whilst I was reading Mary Midgley’s Wickedness (Midgley, 1984). Here, in a chapter considering Freud’s proposition of the “death wish” (Thantos) as a core behavioural motivation she discusses the medical model, and its imposed limitations on Freud’s thinking.
“It is striking how subtly at this point the medical model deepens the limitations of the individualistic political one. A doctor is expected to treat his or her clients as patients, not agents, to isolate them to some extent in social vacuum.” (p164, Chapter 8, (Midgley, 1984), emphasis mine).
So the role of medical models as an isolating influence on individuals was very much in my mind when I was talking with a friend, who unfortunately has a family member currently unwell in hospital. This friend was expressing frustration at the manner in which the family had been cut off from discussion relating to care for their relative and had been offered little information that might inform decision making.
Sadly this is an example of bad medical practice and it made me reflect on my own clinical training and experience. Lectures and reading at medical school had emphasised the importance of a holistic approach to the person presenting for medical care. It is not always practiced routinely unfortunately and I believe that Midgley is right in her appraisal that doctors seek to reduce the individual and isolate them from their environment, an effort to simplify the problem perhaps?
Evidence around social networks and mental health (not comprehensive, just my own recent reading)
We are social beings and define our identities partially through our positions within social networks. Richness and variety of social contact seem important for mental wellbeing, this is reflected in a limited body of literature assessing the impact of social network placement, and connection, on emotional wellbeing.
Within family networks there is a wealth of evidence demonstrating the interrelatedness of the mental health of constituent members. A recent publication in the American Journal of Psychiatry saw Apter-Levy and colleagues measuring levels of Oxytocin in family members over time with mothers with brief and prolonged episodes of postnatal depression (Apter-Levy, Feldman, & Vakart, 2013).
The quality of social networks around individuals with a diagnosis of Schizoaffective disorder compared with those with diabetes was assessed by Nettelbladt and colleagues (Nettelbladt, Svensson, Serin, & Öjehagen, 1995). Those with a diagnosis of Schizoaffective disorder experienced, subjectively, less overall social contact and derived less quality from these relationships. Interestingly the spouses of participants were also interviewed and those married to participants with a diagnosis of Schizoaffective disorder felt less provided with information than those married to participants with diabetes.
Finally an analysis of social networks amongst an ageing population by Cornwell and Laumann found association between social network connectivity and both physical and mental wellbeing – although direction of association, endogeneity, can not fully be accounted for (Cornwell & Laumann, 2013).
A clinical case example
My thinking about the role of social networks in psychiatry came again to a head when I was reading a case report in this week’s New England Journal of Medicine (Cabot et al., 2013).
The presented case was a 40 year old woman presenting with abdominal pain, weight loss, rectal bleeding and a feared diagnosis of some form of cancer. Primary care records revealed a number of previous presentations with fears of possible underlying cancer in the past and also several self-referrals for specialist oncology assessment against the advice of her primary care physician.
Ultimately this woman received a combination of Sertraline (antidepressant, related in class to Fluoxetine, Prozac), Gabapentin (anticonvulsant with anti-anxiety properties and mood stabilising properties), Quetiapine (antipsychotic) and Clonazepam (benzodiazepine anxiolytic) at varying times during her assessment.
She received psychological assessment and treatment which led ultimately, reportedly in conjunction with medication, to a reduction in time spent on rumination in relation to her health from 8 hours per day to only 1 hour per day.
The thrust of the case report was on highlighting the interdisciplinary work between psychiatry, gastroenterology and primary care in case management. The closing statement in relation to psychological therapy was
“Hypochondriasis is a chronic condition and despite this patient’s gains, her family conflicts raise her risk of recurrence.”
A number of features were described in relation to the woman’s personal social history. Her relationship with her mother was strained, she developed worsening of symptoms following the birth of her first child, her divorce, second marriage and loss of a second pregnancy through miscarriage. There is no indication of assessment being given to the nature, or origins, of these reportedly strained family dynamics.
I would like to suggest this is an oversight by the clinical team. I believe that we, in mental health care, can not afford to treat the client in isolation from their social environment. We need to consider the support, or absence of support, available to clients through their family members and social networks. We are not privy to all the details in this case so it is difficult to pass detailed comment, however I believe that the outcomes, particularly given the conclusion statement relating to family conflict, could be improved with adequate provision of a systems based therapy.
In my own practice I have tried, in a number of cases, to involve family members directly in consultations. The response to this is interesting; some families have met the suggestion openly and have welcomed the involvement, others have not. In the cases where the suggestion of involvement was rejected I was left with the sense that the idea of involving people other than the “patient” in a “medical” consultation was too alien to their experience to be met with comfort. Again I think this is a limitation and that we should try to make moves to normalise the involvement of families, or friends, in mental health assessments rather than ignoring, isolating or at worst, directly challenging their involvement in the client’s care.
Thanks to those who have begun following this blog, I hope it is of some value. I have to admit I’ve moved from initial ambivalence, or even fear, at writing it, to quite looking forward to it each week. We’ll see how long I keep going for. Please comment below, it would be really interesting if this could become something more of a dialogue and I would welcome agreement, disagreement or outright argument.
Apter-Levy, Y., Feldman, M., & Vakart, A. (2013). Impact of maternal depression across the first 6 years of life on the child’s mental health, social engagement, and empathy: the moderating role of oxytocin. American Journal of Psychiatry
Cabot, R. C., Rosenberg, E. S., Harris, N. L., Shepard, J.-A. O., Cort, A. M., Ebeling, S. H., et al. (2013). Case 33-2013. N Engl J Med, 369(17), 1639–1647. doi:10.1056/NEJMcpc1215968
Cornwell, B., & Laumann, E. O. (2013). The Health Benefits of Network Growth: New Evidence from a National Survey of Older Adults. Social Science & Medicine.
Midgley, M. (1984). Wickedness. Routledge Classics.
Nettelbladt, P., Svensson, C., Serin, U., & Öjehagen, A. (1995). The social network of patients with schizoaffective disorder as compared to patients with diabetes and to healthy individuals. Social science & medicine (1982), 41(6), 901–907.