That's
rather an extreme blog post title, but was inspired by the APA's (American
Psychiatric Association) recent
comment that "Many of the revisions in DSM-5 will help
psychiatry better resemble the rest of medicine". This alone would be
enough to send shivers down the spine of most psychology-minded mental health
practitioners, but it led me to thinking about where that might leave
psychology as a rather different knowledge-based approach to understanding and
treating mental health problems.
Specifically,
if the APA want to impose a medical model on mental health then what will our
doctors and physicians be learning about how to deal with their patients with
mental health problems? The incremental implications are immense. It is not
just that mental health is being aligned with medicine on such an explicit
basis in this way, this issue is compounded by the fact that medical training
still plays lip service to training doctors in psychological knowledge and, in
particular, to a psychological approach to mental health. So has medicine taken
the decision to align mental health diagnosis and treatment to fit the
constraints of current medical training (rather than vice versa)?
I
returned to a President's
column I wrote in 2002 about the state of psychology teaching in the UK
medical curriculum. The same points I made then seem to apply now. The
medical curriculum is not constructed in a way that provides an explicit slot
for psychology or psychological knowledge. Even though a recent manifesto for
the UK medical curriculum (Tomorrow’s
Doctors, 2009) makes it clear that medical students should be able to
“apply psychological principles, method and knowledge to medical practice”
(p15), there is probably no practical pressure for this to happen. Given that
the ‘Tomorrow’s Doctors’ document does advocate more behavioural and social
science teaching in the medical curriculum, I suspect that what happens in
practice is that a constrained slot for ‘non-core medical teaching’ gets split
up between psychology, social science and disciplines such as health economics.
If a medical programme decides to take more sociology (because there are
sociologists available on campus to teach it) – then there will be less
psychology.
The
second point I made then was related to the expectations of medical students.
This was illustrated by a QAA report for a well-respected medical school. This made
the point that:
“...there was a student perception that, in
Phase I, the theoretical content relating to the social and behavioural
sciences was too large. Particular concern was expressed about aspects of the
Health Psychology Module....a number of students suggested that the emphasis
placed upon theoretical aspects of these sciences in Phase I was onerous”
Well – death to
psychology! My own experience of teaching medical students is that they often have
a very skewed perception of science, and in particular, biological science.
Interestingly, the ‘Tomorrow’s Doctors’ document advises that medical students
should be able to ‘apply scientific method and approaches to medical research’
(p18). But in my experience medical students find it very difficult to
conceptualize scientific method unless it is subject matter relevant – i.e.
biology relevant. I have spent many hours trying to explain to medical students
that scientific method can be applied to psychological phenomena that are not
biology based – as long as certain principles of measurement and replicability
can be maintained.
But there has
been a more recent attempt to define a core curriculum for psychology in
undergraduate medical education. This was the report from the Behavioural
& Social Sciences Teaching in Medicine (BeSST) Psychology Steering Group
(2010) (which I believe to be an HEA Psychology Network group). I am sure
this report was conducted with the best of intentions, but I must admit I think
it’s core curriculum recommendations are bizarre, and entirely miss the point
of what psychology has to offer medicine! It is like someone has gone through a
first year Introduction to Psychology textbook and picked out interesting
things that might catch the eye of a medical student – piecemeal! For example, the
report claims that learning theory is important because it might be relevant to
“the acquisition and maintenance of a needle phobia in patients who need to
administer insulin” (p30). That is both pandering to the medical curriculum and
massively underselling psychology as a paradigmatic way of understanding and
changing behaviour!
Medical students need to understand that psychology is an entirely
different, and legitimate, method of knowledge acquisition and understanding in
biological science. Not all mental health problems are reducible to biological
diagnoses, biological explanations or medical interventions, and attempts by
the APA to shift our thinking in that direction are either delusional or self-promoting.
What is most disappointing from the point of view of the development of mental
health services is the impact that entrenched medically-based views such as
those of the APA will have on the already introverted medical curriculum.
Doctors do need to learn about medicine, but they also need to learn that
mental health needs to be understood in many ways – very many of which are not traditionally
biological in their aetiology or their cure.
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