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Main Debates on the Management of Mental Illness: 1990-2020. A Narrative Review

Authors:

Abstract

Introduction: Since the introduction of newer psychiatric treatment methods during the 20th century, debates about the effectiveness andappropriateness of such treatment have featured. Advocates among those who promote the sociological, biological, psychological and spiritual understandings of mental illness and its treatment have created tangible tensions with those supporting each position commonly indulging in fierce attacks on the others. Aims: The aim of this paper is to explore some of the principal treatment viewpoints that characterized the late 20th century (1990 onwards) and early 21st century (up till 2020). Ultimately, these debates guided contemporary practice towards a biopsychosocial-spiritual view of mental illness in a move towards holistic person-centered care, which nowadays is the advocated model in many health systems. Methods: The authors undertook a literature search in order to locate published debates on psychiatric treatment during the late 20th century (1990 onwards) and the early 21st century (up till 2020). Results: Debates emerging from 36 articles were identified and synthesized in a narrative review. Conclusions: Exploring the various debates that have characterized mental health care serves as a crucial reflective exercise on what needs to be considered when claiming that contemporary care is based on a holistic and person-centered approach. In this view, critical evaluation is needed so as to avoid repeating the coercive and inhumane mistakes of the past.
Introduction
Advances in psychopharmacology and psychological therapies have been signicant in improving the quality of
life for some of the individuals who were experiencing symptoms synonymous to a mental illness (Choo et al.,
2019). A multitude of clinical trials as well as convincing patient narratives have shown that mainstream psychiat-
ric treatment – mainly drugs such as antipsychotics, antidepressants, anxiolytics and mood stabilizers – conferred
a signicant benecial eect (see Reid, 2013; Leucht et al., 2012; Jamison, 1995). Medical guidelines, such as
those issued by the National Institute for Health and Care Excellence (NICE), recommend and guide the use of
Main Debates on the Management
of Mental Illness: 1990-2020.
A narrative review
Paulann GRECH 1 and Reuben GRECH 2
Introduction: Since the introduction of newer psychiatric treatment
methods during the 20th century, debates about the eectiveness and ap-
propriateness of such treatment have featured. Advocates among those who
promote the sociological, biological, psychological and spiritual under-
standings of mental illness and its treatment have created tangible tensions
with those supporting each position commonly indulging in erce attacks
on the others.
Aims: e aim of this paper is to explore some of the principal treatment
viewpoints that characterized the late 20th century (1990 onwards) and
early 21st century (up till 2020). Ultimately, these debates guided contem-
porary practice towards a biopsychosocial-spiritual view of mental illness
in a move towards holistic person-centered care, which nowadays is the
advocated model in many health systems.
Methods: e authors undertook a literature search in order to locate pub-
lished debates on psychiatric treatment during the late 20th century (1990
onwards) and the early 21st century (up till 2020).
Results: Debates emerging from 36 articles were identied and synthesized
in a narrative review.
Conclusions: Exploring the various debates that have characterized mental
health care serves as a crucial reective exercise on what needs to be con-
sidered when claiming that contemporary care is based on a holistic and
person-centered approach. In this view, critical evaluation is needed so as to
avoid repeating the coercive and inhumane mistakes of the past.
Keywords: psychiatric treatment, critical psychiatry, medical model,
individual-community model, person-centered approach
OPEN ACCESS
1 Department of Mental Health, Faculty of Health
Sciences, University of Malta, Msida, Malta
2 Medical Imaging Department, Mater Dei Hospi-
tal, Msida, Malta
Correspondence
Paulann Grech
Department of Mental Health, Faculty of Health
Sciences, University of Malta
Postal Address: Department of Mental Health,
Faculty of Health Sciences, Room 51, Block A,
Level 1, Mater Dei Hospital, Msida, Malta
Email: paulanngrech@gmail.com
History
Received: 31 July 2021
Accepted: 10 March 2022
Citation
Grech, P., & Grech, R. (2022). Main debates
on the management of mental illness: 1990-2020.
A narrative review.
European Journal of Mental Health, 17(1), 101–109.
https://doi.org/10.5708/EJMH/17.2022.1.9
REVIEW ARTICLE
ISSN1788-7119 (online)
© 2022 The Authors. Published by Semmelweis University Institute of Mental Health, Budapest ejmh.eu
European Journal of Mental Health
https://doi.org/10.5708/EJMH/17.2022.1.9
P. GRECH & R. GRECH Main Debates on the Management of Mental Illness
Eur. J. Ment. Health 2022, 17(1), 101–109 102
drugs and psychological therapies in most of the psychiatric conditions found in the DSM and ICD. Furthermore,
there seems to be a consensus on the move towards less restrictive community care, with hospitalization being left
as a last resort (WHO, 2018). Still psychiatric treatment has been characterized by a history of opposing views,
theories, debates and a confusing and non-conclusive ocean of clinical trials.
e aim of this paper is to explore some of the historical perceptions related to the treatment of symptoms
that mental illness causes. We have divided the paper into two parts – the rst segment (1) concerns opposing
views on the appropriateness and eectiveness of psychiatric treatment. e second section (2) explores some
contemporary alternative person-centered and holistic approaches in mental health. is paper includes debates
linked to the Medical Model as well as those that characterize the Individual-Community Model. e terms used
by the authors during the dierent debates shall reect those used by the particular source that is being cited
in that specic debate. However, the authors of this paper lean towards the Individual-Community Model as a
theoretical framework.
Methods
e authors undertook a literature search in order to locate published debates related to psychiatric treatment
that featured during the late 20th century (1990 onwards) and early 21st century (up till 2020). is was
an era characterized by the introduction of new psychiatric medication and methods of treatment – some
of which are still in use in contemporary psychiatry and mental health care. Key terms were identied by
carrying out focussed and expanded searches on the MeSH On Demand interface. e key terms used were
mental disorders, survivor movement, mental health treatment, mental illness management, psychiatric medication,
critical psychiatry, mental illness debates and mental health services. ese were then entered in selected databases,
namely e Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE and PsycINFO. We used
lters and limiters accordingly to limit the results in terms of relevance and the time limit of the search was
set to 1990–2020. e Critical Psychiatry Network article database was also searched manually to identify
additional sources. ese debates emerging from the nal 36 articles that were ltered from the results accord-
ing to set inclusion and exclusion criteria were then synthesized in a journey, which shall be presented in the
following section.
Results and Discussion
e Eectiveness of Psychiatric Drugs
A Crusade Against Drug Eectiveness
During the mid-late 20th century, the introduction of psychiatric drugs marked what is often considered
to be the new era for mental health. Bestowed with the title “pharmacological revolution”, it stood as a
remarkable technological achievement and played a role in downsizing psychiatric asylums. In his review of
the “psychiatric revolution”, Scull (2010) noted that the introduction of these new medications was not the
only factor responsible for the demise of the traditionally oppressive psychiatric system. Others such as scal
considerations and deliberate adjustments in state policy signicantly drove deinstitutionalization. Psychiatric
drugs, however, completely changed the practice of psychiatry as well as its status in society. Chlorpromazine
and similar antipsychotic drug types werethe rst onesto be introduced, providing psychiatry with a treat-
ment typethat was simple to administer although it was ultimately responsible foriatrogenic illness. e
phenothiazines lessened the severity of symptomatology andprovided relief for some patients. In this view,
these drugs received an eager welcome by professionals and patients especially when considering that before
their introduction, psychiatric treatment had merely consisted of social restraint. Quickly, these drugs became
a major source of prot for the industry notoriously termed “Big Pharma” which had discovered the benets
linked to the marketing of drugs that had the potential to change people’s moods (Scull, 2010). e intro-
duction of Prozac was another milestone in the revolution and such a successful one that it changed many
perspectives on mental disorder. However, the new drugs were not magical cures that provided a permanent
solution to psychiatric problems. Gradually, doctors and other reviewers raised critical stances which birthed
the emergence of widespread debates in the medical and social world.
P. GRECH & R. GRECH Main Debates on the Management of Mental Illness
Eur. J. Ment. Health 2022, 17(1), 101–109 103
e eectiveness of psychotropic drugs has been one of the most controversial areas over the years. Figures
like Moncrie (2013a, 2013b), Healy (2016) and Breggin (2006) have presented research that contradicts the
promoted and evidenced eectiveness of commonly used drug types in psychiatry. Bracken (2012) stated that
the evidence that psychiatric drugs function through a placebo eect cannot be contradicted. e author cited
two meta-analyses, carried out by Turner and Kirsch, which have concluded that in 80% of the cases explored
through individual studies, the improvement seen was very much comparable to that experienced by participants
in placebo groups.
Double (2001) acknowledged that reviewing the literature about the eectiveness of psychiatric drugs re-
mains a complex task due to the vast number of studies, dierent methodologies, and the need to appraise
the quality of studies located. Several researchers have endeavored to undertake this process. Double (2001)
described how in 1974, Morris and Beck were amongst the rst to synthesize the data available by looking at
trials published over a 14-year period. eir results showed that in more than half the cases, antidepressants
were more eective than placebo. However, Bracken and omas (2004) theorized that the main mode of
antidepressants’ function is through the generation of hope. Since hope may be generated through alternative,
less invasive methods, the authors postulated that discourse in mental health should feature issues such as hope,
meaning, and values.
Kirsch (2011) reported that a signicant dierence between placebo and antidepressants is only witnessed
in very severe cases of depression. In 1995, Moncrie had also explored the eectiveness of the mood stabilizer
lithium and expressed dissatisfaction due to her observation that results obtained are neither clear nor signicantly
demonstrated:
Dierences between lithium and placebo treatment in several of the trials were probably attributable to
discontinuation of lithium increasing the likelihood of manic relapse in placebo treated subjects. In the largest
prospective trial, treatment conditions for the two groups were not comparable (Prien et al., 1973), and in
another prospective trial only a select group of subjects were considered and results were presented in a way
which impedes a proper understanding of the data. (Moncrie, 1995, p. 571)
In a later trial by Bowden et al. (2000), which is considered as the largest clinical trial in this area, there was
no signicant dierence in the participating individuals’ response rates to lithium and to a placebo. In addition
to the fact that the eectiveness of drugs has been placed under scrutiny, Evans (2004) also cautioned about
the inadequacy of the double-blind methodology that is used in many clinical trials. is is due to several
factors. For instance, participating individuals may note that the placebo tablets that they have been taking
taste dierently from the usual medication. Active medication may also be characterized by side eects that
distinguish it from a placebo. Treatment that is regularly used to manage psychosis has also been under scru-
tiny. In 1998, ornley and Adams explored the eectiveness of drugs used in the treatment of schizophrenia
over the past 50 years. A total of 2000 trials were included in the review. e ndings showed that the overall
quality of the studies was poor and this may have led to inaccurate overly positive results in relation to the
eectiveness of these drugs (ornley & Adams, 1998). omas and Bracken (1999) discussed how rather
than viewing drugs as the medical cure, it is advisable to talk and describe the experience of psychosis during
a dialogue with the person:
It is often assumed that in irrational states, such as psychosis, there are constraints on a persons ability to act
autonomously. is view may be used as justication by a psychiatrist to disregard the patient’s treatment prefer-
ences. But situations in which a person is irrational in all aspects of thought, will and action are rare. (p. 328)
In 2010, Irving Kirsch compiled his research around this area in a book called Antidepressants: e Emperor’s
New Drugs. His views were similar to that of other leading gures, and he outlined his concern that the drug
industry may be a culprit in promoting the pseudo-eectiveness of psychiatric drugs:
e drug eect seemed rather small to us, considering that these medications had been heralded as a revolution
in the treatment of depression – blockbuster drugs that have been prescribed to hundreds of millions of patients,
with annual sales totalling billions of pounds. (Kirsch, 2010, p.11)
is concern echoes the thoughts of critical psychiatrists in relation to the evidence base underlying the bio-
medical model. Notably, Kirsch did not shun the use of medical treatment as he realized that this may be of use
in particular cases.
In 2013, Peter Breggin, another prominent gure in the eort to limit the abusive prescription of psycho-
tropic drugs, presented a guided system to psychiatric drug withdrawal in his book: Psychiatric Drug Withdrawal:
P. GRECH & R. GRECH Main Debates on the Management of Mental Illness
Eur. J. Ment. Health 2022, 17(1), 101–109 104
A Guide for Prescribers, erapists, Patients and eir Families. e aim of the book was to oer guidelines to
assist the prescriber and therapist in helping individuals to withdraw from psychiatric drugs. Breggin (2013)
elucidated how research revealed the danger of long-term exposure to psychiatric drugs due to their relation
to obesity, diabetes, heart disease, abnormal movements, and a detrimental eect on the quality of life. ese
dangers have led Breggin to advise that the best option in modern psychiatry is to encourage withdrawal from
psychiatric drugs.
Counter Arguments
Despite the convincing nature of these arguments, which indeed research supports, it is interesting to note that
the opposing side of the argument is similarly based on a multitude of studies which seemingly demonstrate the
eectiveness of the commonly used drug types in psychiatry (Kohler et al., 2014; Maher et al., 2011; Vieta et
al., 2010). Leading gures in this area, such as Leucht et al. (2012) have cautioned against the crusade opposing
psychiatric drugs due to the consequences that it can have on patients: “In this context, many psychiatric drugs
not only improve the acute episode but also prevent further episodes. Patients with severe, recurrent depression
might have 20 episodes in their lifetime, which could be reduced by medication to 10” (p. 103). ey argued
that controversy about medication eectiveness can result in patients who decide to discontinue their medication
– this can easily be a catalyst to suicide or relapse. ese researchers devoted considerable eort to proving the
eectiveness of psychiatric drugs through various randomized controlled trials and meta-analysis. One particular
study involved an overview of 94 meta-analyses in an attempt to demonstrate that the degree of psychiatric drug
eectiveness compares well to other drugs used in general medicine (Leucht et al., 2012). In an echo of Moncrie
and Cohen’s views (2009), it has to be said that whilst the consequence of stopping eective medication is
acknowledged, it may be equally harmful to mislead individuals into believing that psychiatric drugs are overly
eective or can provide a cure. In a chain of publications, Moncrie distinguished between a drug centered model
and a disease centered model (See Moncrie, 2013b; Moncrie, 2010; Moncrie, 2009). She described how the
drug centered model may be more empowering as it views psychiatric medication as an extrinsic substance that
mainly works through producing cognitive and emotional suppression:
e disease centred model is captured by the idea that drugs act by correcting or partially correcting an underlying
biological lesion, analogous to the way the action of most drugs in general medicine is understood. In contrast
the drug centred model suggests that drugs work by inducing their own abnormal brain states. (Moncrie,
2013b, p. 296)
is suppressed state may be benecial in certain circumstances, such as in acute psychotic states. However, in
an example brought by Moncrie and Cohen (2009), once the acute episode has been controlled, the person may
then decide to stop antipsychotic drug use and instead engage in alternative forms of maintenance treatments (p.
151). is is dierent and probably more benecial than adherence to the disease centered model which assumes
that psychiatric medication is physiologically corrective.
ese debates on treatment models raged throughout the process of deinstitutionalization that saw the down-
sizing of several psychiatric hospitals in the late 20th century. In Western industrialized nations, the number and
size of asylums had increased dramatically over the nineteenth century. ese were planned to be humaneplaces
where patients couldlive comfortably whilst receiving treatment,as opposed to the prison-like asylums of the
past – a push towards “moral care”. Despite these principles, these asylumsbecame overworked, non-therapeutic,
geographically isolated, and uncaring to patients (Wright, 1997). By the turn of the century, rising admissions
had resulted in severe congestion, posing several challenges for mental facilities. Funding was often withdrawn,
particularly during economic downturns and warfare. Patients were starved to death at asylums because of terrible
living circumstances, lack of cleanliness, overcrowding, ill-treatment, and abuse (Fakhoury & Priebe, 2007).
Although asylum numbers continued to rise until the 1950s, the rst community-based solutions were proposed
and provisionally adopted as early as the 1920s and 1930s. Supportive housing as well as specialized teams
were among the community services that emerged. Although deinstitutionalization beneted the vast majority
of patients, it is not without aws. Some arguedthat it was a failed step in the right direction, claiming that
contemporary society suers from a “re-institutionalization” issue (Fakhoury & Priebe, 2007).  us, deinstitu-
tionalization left some homeless or without care (Eisenberg & Guttmacher, 2010), resulting in the formation of
“psychiatric communities” instead of a successful move towards “community psychiatry”.
P. GRECH & R. GRECH Main Debates on the Management of Mental Illness
Eur. J. Ment. Health 2022, 17(1), 101–109 105
Contemporary Alternative Approaches
e Psychosis Example
Dutch psychiatrist Marius Romme has been one of the early 21
st
century pioneers in developing alternative ap-
proaches which view symptoms characteristic of psychosis as meaningful, as phenomena that must be explored and
understood rather than suppressed or disguised. He posited that accepting and coping with auditory hallucinations
– a symptom that is often attributed to a state of psychosis – can enhance one’s quality of life in a better way than
simply ignoring the voices (Romme, 2009). Indeed, as a result of his empirical work, he concluded that struggling
against the voices only causes them to become stronger. In his publications, such as Accepting Voices (Romme &
Escher, 1993) and Making Sense of Voices (Romme & Escher, 2000), as well as others published in the journal
Mind, Romme described an innovative approach involving the extraction of meaning from psychosis. is may be
painful for some people due to the realization and facing of diculties. Professionals aim to facilitate this process
for the person and guide them by acknowledging that the individual’s explanatory framework may be dierent
from that of the professional’s as seen in the following service user narrative presented by Romme (2007):
Every time, when I was released from hospital and went back to normal life, there was this reduction of possibili-
ties in my life. Nearly ten years later, I was not interested in anything anymore. It took me quite a while to see
the relationship between my voices and my life, so I realized that when I was angry and did not express my anger
the voices became angry at me. (section 3-4)
is approach is synonymous with the Hearing Voices Network, originally founded by Marius Romme in the
Netherlands, which has been developed in other countries such as the UK. ese movements are concerned with
the normalization rather than the medicalization of the psychotic experience and are active in raising awareness
about alternative ways of coping: “So, accepting is not concretely accepting everything of the voices as they are
perceived, but is the beginning of looking dierently at them; normalising them; being with many others who
hear voices; creating hope and opening personal possibilities” (Romme, 2007, section 3).
e debate surrounding “medicalization” and “normalization” highlights two dierent concepts that manifest
during the management of mental illness. Medicalization is commonly associated with the medical model, having
the primary target of attaching a medical label to the presenting symptoms of mental illness and the provision of
medications to eliminate them. In this view, success is measured by the level of symptom reduction. Contrastingly,
normalization is concerned with ameliorating the individual’s quality of life, something not necessarily brought
about by the elimination of symptoms. Instead, the overarching philosophy is a focus on personal satisfaction
and quality of life. Rather than singling out the symptoms as “abnormalities” that need to be medicated, they are
viewed as normal variations within the human population that one can learn to manage and live with using various
ways. Whilst medication is not excluded from a “normalization” point of view, it is perceived as a means to enhance
quality of life rather than as a permanent end (solution) to a medical problem. On the plus side, normalization has
been considered as more enabling and a positive move towards humane care as well as the lessening of stigma by
increasing mental health awareness. However, it has also led to a rise in misdiagnoses, misperceptions and higher
prevalence rates as a result of people mischaracterizing typical feelings like sadness as depression (Frances, 2010).
Psychologist Rufus May advocates a similar approach to Romme’s; May’s main focus is to introduce alternatives
to medical labeling and management of psychiatric symptoms, particularly, psychosis. In the documentary e
Doctor who Hears Voices, produced by Regan (2008), May provided an overview of the “voice dialogue technique
that can be used to engage in a therapeutic relationship with a person who is experiencing auditory command
hallucinations. He explained that “supporting people in a force-free way through their spiritual and emotional
crises takes resources. Not more resources, just a dierent emphasis in how they are used.” (May, 2008, paragraph
11). Such symptoms would normally probably merit an admission to a psychiatric hospital were a mainstream
approach to be applied:
In terms of care for psychosis, force is at the centre of the state’s approach to treatment. Neuroleptic drug
treatment (under the pseudonym anti-psychotic medication) is presented as the treatment of choice for people
with unusual beliefs, behaviours or experiences; Treatment of choice for those who have no choice. Most rst
admissions to psychiatric hospitals are characterised by a ‘try this medication or if you don’t we’ll have to force
you to take it’ approach. Maybe we should rename mental health services ‘psychiatric drugging services’! (May,
2005, paragraph 18)
Earlier in the 20th century, this phenomenon of medical force had been explored in depth by Parsons (1951)
in his book “e Social System”. His main claim was that social control is present in all social relations – this also
P. GRECH & R. GRECH Main Debates on the Management of Mental Illness
Eur. J. Ment. Health 2022, 17(1), 101–109 106
applies to the doctor-patient relationship during which the doctor acts as an agent of control. In this relationship,
the patient assumes the “sick role” and is expected to follow the doctor’s guidance to recover. is becomes even
more accentuated when an illness is more severe and the individual needs to rely on the doctor’s expertise to a higher
degree. Since the faking or mismanagement of illnesses can be detrimental to society, the doctor has been given the
societal power to be in control of this “deviance” (sickness) and has a duty to assist the patient to return to normal-
ity. However, the move towards the 21st century brought with it greater access to information, especially through
the virtual world. is has led to individuals who are more knowledgeable and who are ready to challenge medical
authority, viewing the doctor-patient relationship as a “provider-consumer alliance” rather than as a sacred bond.
Other leading gures in this area include Sandra Escher (see Escher et al., 2003) who has worked with Marius
Romme to produce various publications, Patricia Deegan (see Deegan, 2007), Tamsin Knight (See Knight, 2013)
and Peter Lehmann (see Stastny & Lehmann, 2007).
e Recovery Movement and the Person-Centered Approach
Bracken (2012) noted that these controversial approaches may bring about changes in the way that psychiatrists
and other professionals are trained since it seems as if the only skill needed to engage with those experiencing
mental health challenges is the willingness to listen and to respect the individual. One of the most powerful
contemporary movements, which may be viewed as lying midway between the critical psychiatry model and
conventional psychiatry one is the Recovery Model. Warner (2010) explained that this refers to a focus on self-
determination, empowerment, and interpersonal support – a focus on collaboration rather than adherence and
compliance. Lieberman et al. (2008) added that educational programs, as well as structures such as user-run
services and peer support, are important concepts in the recovery model, which constitutes a bio-psycho-social-
spiritual model of care. As stated by Deegan (1996):
e recovery model is rooted in the simple yet profound realization that people who have been diagnosed with a
mental illness are human beings. ose of us who have been diagnosed are not objects to be acted upon. We are
fully human subjects who can act and in acting, change our situation. We are human beings, and we can speak
for ourselves. We have a voice and can learn to use it. We have the right to be heard and listened to. We can
become self-determining. We can take a stand toward what is distressing to us and need not be passive victims of
an illness. We can become experts in our own journey of recovery. (p. 92)
Ultimately, this is the spirit within the contemporary move towards a person-centered approach, which focuses
on oering care that is personalized, coordinated and enabling whilst treating those seeking care (and their loved
ones) as individuals and as equal partners (e Health Foundation, 2014). In the 1940s, Carl R. Rogers pioneered
the “person-centered approach” in the United States through his realization that the practitioners attitudes were
just as crucial as his skills (Kirschenbaum, 2020). In this view, therapeutic interactions are potentiallysuccessful if
the practitioner is able toreally embrace the client in the moment, enter the client’s frame of reference, and express
an empathetic acceptance to the patient.Rogers used the phrase “client-centered” to dene his approach to thera-
peutic interactionsas a result of his intensive attention on the client’s inner experience. His book “Client-Centered
erapy” (Rogers, 1951)bore a signicant impact on the helping professions. In one of hiswritings, he statedthat
when a practitionerconveysunconditional positive regardand empathic understanding to the extent that the
client feelsthe professional’s genuineness, the “necessary and sucient circumstances for therapeutic personality
change” are present (Rogers, 1957, p. 95). Although Rogers used the term “client-centered”, “person-centered” was
considered by othersasa better phraseto characterize the therapeutic connection, which is, after all, a relationship
between two people and not just one (Kirschenbaum, 2020). After Rogers’ death in 1987, theperson-centered
movement continued to spread over the globe andhas now become one of the leading approaches to mental
health treatmentin some countries, particularly in Europe.is approach, and the rise of the recovery movement,
provided alternatives to the Medical Model, leading the way to a more humane management of mental illness.
Strengths and Limitations
Whilst quality assurance eorts were employed during the design stage of this narrative account, a number of
strengths and limitations characterized the process. e main strengths identied entail the robustness of the search
strategy for locating literature on the topic, the critical evaluation of the resulting documents, and the inclusion
P. GRECH & R. GRECH Main Debates on the Management of Mental Illness
Eur. J. Ment. Health 2022, 17(1), 101–109 107
of debates emerging from dierent professional and philosophical viewpoints. Although search keywords were
selected to target a wide range of potential articles emerging from dierent disciplines, it is acknowledged that other
potentially important keywords may have been invariably omitted. Finally, whilst the 30-year time span selected was
a vital period in the development of contemporary mental health services, important changes that took place during
the 1950’s could have added further perspective to the debates.
Conclusion, Implications and Future Directions
On reection, it appears as if the alternative approaches to biomedical psychiatry that have just been described
may add an interesting tangent to the range of psychiatric services and treatment options available in the 21st
century. However, a paucity seems to exist in the empirical evidence-base related to a number of these approaches,
especially when compared to mainstream treatment options such as pharmacotherapy and psychotherapy. is
journey through the history of “modern” psychiatric treatment highlights the multifaceted characteristics of mental
health and its illnesses, with explanations and treatments lying on a spectrum that features social explanations,
biological ones, psychological understandings, and spiritual beliefs. In view of all these considerations, selecting
appropriate treatment options depends on feasibility and meaningfulness and not simply on eectiveness and
availability. Conclusively, whilst many service providers and health carers claim that their practice stands based on
a holistic and person-centered approach, this may not always be the case. is is where the debates and theories
that have been explored in the paper may serve as a reective exercise on the historical debates on mental health
care, in a bid to facilitate a critical evaluation of contemporary practice.
Funding
ere were no funding sources for this work.
Author contributions
Paulann Grech: conceptualization, design, methodology, investigation, project administration, data management,
formal analysis, interpretation, writing original draft, writing review and editing.
Reuben Grech: conceptualization, design, methodology, investigation, formal analysis, interpretation, writing
original draft, writing review and editing.
All authors gave nal approval of the version to be published and agreed to be accountable for all aspects of the
work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately
investigated and resolved.
Declaration of interest statement
e authors have no conicts of interest to disclose.
Ethical statement
is manuscript is the authors’ original work.
Human participants have been not involved in this study.
No ethical approvement, informed consent or data handling policy was needed.
ORCID
Paulann GRECH https://orcid.org/0000-0001-5485-0893
Reuben GRECH https://orcid.org/0000-0002-3518-5880
P. GRECH & R. GRECH Main Debates on the Management of Mental Illness
Eur. J. Ment. Health 2022, 17(1), 101–109 108
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