Psychiatric Treatment: the Question of Attitudes

Abstract

DESPITE advances in treating mental illness, differences of opinion about the value of existing treatments are deep and continue to attract public attention.Given the unreliability of diagnosis and the lack of specificity of most psychiatric treatments, such differences may seem inevitable. Yet, in everyday practice, when confronted with a patient, his symptoms or his problems, the psychiatrist has to choose from several possible treatments the one he thinks will work. In the absence of adequate knowledge, how does he embark on a particular treatment which may have to be continued for a long period?Since the care of the behaviourally disturbed person and responsibility for mental health has for social and historical reasons been largely assigned to the medically qualified psychiatrist, the greater reliance on a medical 'illness model' seems inevitable. In psychiatric hospitals or in community services, however, non-medical personnel, such as nurses and social workers, are not only expected to provide support for medically prescribed therapeutic regimes but they may also actively participate in treatment decisions. Although it is a common experience that attitudes to psychiatric treatment affect the communication between professional workers and their contacts with patients, this subject has not attracted the research interest it deserves. The available evidence, however, does suggest the existence of broad therapeutic preferences which in practice may result in adoption of relatively ineffective methods of treatment. This paper aims to review some of these findings and discuss their implications. THE PSYCHIATRIST Treatment OrientationStudies of psychiatrists' attitudes to treatment both in Britain and the United States have provided broadly comparable results, despite the socio-cultural and training differences between the two countries. By investigating psychiatrists in a London teaching hospital, Kreitman (1) was able to describe, like earlier American investigators (2), two distinct orientations, an 'analytical' and an 'organic' one; the former deriving mainly from psycho-analytic theory, stresses the importance of interpersonal relations in treatment while the latter concentrates more on the 'mental illness' aspect of psychiatric disorders and the use of physical treatments. These findings were largely supported by a subsequent study which used an empirically derived scale to measure attitudes to treatment and to professional roles within a psychiatric hospital (3). Although the sample studied was not an entirely representative one, Caine and Smail (3) were able to identify three 'psychologically distinct' attitudes to treatment indicating preferences for physical treatments, group therapy and individual psychotherapy. Their first attitude component was the best discriminator between an 'organic' and a 'psychological' treatment orientation. A further testing of a new sample of British hospital psychiatrists (4) has shown that they differ primarily in their acceptance or rejection of the 'organic' attitude to ...