Friday, November 1, 2013

Times of change and opportunity: Towards a psychological model of mental health and well-being

Notes for a speech given at: The International Psychology Conference, Dubai 1st November 2013. These are my NOTES for the speech, the speech as delivered may have been different (in particular, I did suggest that we needed to lead "a revolution" in our approach to these issues, which doesn't appear below).


Good morning, and thank you for inviting me.

It is a time of significant change in the field of mental health.

Over the past twenty years or so, we’ve seen a very positive and welcome growth of the user and survivor movements, some first signs of more responsible media coverage, and a rejection of the idea that we should be stupefied by shame and stigma into accepting the paternalism of earlier days – we are just starting to see the beginnings of transparency and democracy in mental health care.

The publication of DSM-5, the fifth edition of the American psychiatric diagnostic manual, has proved controversial, and has led many to question the creeping medicalisation of normal life, and to criticise the poor reliability, validity, utility and humanity of conventional psychiatric diagnosis.

At the same time, we have seen many commentators conclude that there is precious little reason to believe some of the more outrageous claims as to the effectiveness of many psychiatric drugs. We know that these drugs have very significant adverse effects, too. And there is even less reason to believe that these drugs are effective in the longer term – whatever their benefits in emergencies.

On the other hand, we have seen growing evidence of the effectiveness of evidence-based psychological therapies, helping people with a wide range of problems.

All this has led many to call for radical alternatives to traditional models of care.

I agree.

But I would argue that we do not need to develop new alternatives.
We already have robust and effective alternatives… we just need to use them.

The well-established ethos of the clinical psychologist as ‘scientist-practitioner’ means that we can offer evidence-based scientific models of mental health problems and well-being.

These integrate biological findings with the substantial evidence of the social determinants of health and well-being, mediated by psychological processes.

For example, colleagues and I found – in research conducted with the support of the BBC – that negative life events were substantial contributors to a person’s levels of depression and anxiety, but this was mediated by their level of rumination.

And, of course, because these models almost inevitably refer to psychological mechanisms mediating the effects of biological, social and circumstantial factors on mental health problems and wellbeing, they almost inevitably imply that psychological interventions – which affect these psychological mechanisms – can be effective.

In simple terms, if we were able to “turn off” our rumination, we’d be able to turn down at least some of our depression and anxiety.

These significant scientific and professional developments allow us to foresee a future beyond the 'disease model' of mental health and well-being.

The Roman emperor and philosopher, Marcus Aurelius (played by Richard Harris in the film “Gladiator”) once argued that we need always to bear in mind: “What is this, fundamentally? What is its nature and substance, its reason for being?” 

What, then, is the fundamental nature and substance of those psychological, emotional and behavioural problems that are the subject matter of our profession?

In my view, they are fundamentally social and psychological issues. They do have clear biological elements – we should not artificially separate our physical from our mental health. So psychologists, therapists and social workers must work closely alongside GPs, public health physicians and nurses. But mental well-being is fundamentally a psychological and social phenomenon, with medical aspects. It is not, fundamentally, a medical phenomenon with additional psychological and social elements.

Clinical psychology is a wonderful profession – I’m proud to be a clinical psychologist. But we have, I believe, been tempted down a medical route. We’ve tended to think in terms of “disorder”, in terms of “aetiology” in terms of “treatment” and in terms of “pathology” or “abnormality”. We conduct ‘randomised controlled trials’, we set up programmes such as the UK’s “IAPT” – improving access to psychological therapies programme – which is predicated on the notion of identifying people with recognised ‘mental disorders’, offering ‘treatment’ and assessing outcome on the basis of quite traditional medicalised criteria. We criticise this language, this way of thinking. But all too often, we use it.
  
We need to place people and human psychology central in our thinking. And we need to return to core principles – ethical, professional and scientific.

I went to a – slightly odd – meeting recently where a very senior psychiatrist said: “… we’ve got to remember, we’re paid to treat illnesses…” I simply disagree. That may be the core purpose of some professions, but not mine… and perhaps not medics’ either.

The World Health Organisation describes health as “... a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. The European Commission takes a step further, describing mental health as: “a resource which enables them to realise their intellectual and emotional potential and to find and fulfil their roles in social, school and working life. For societies, good mental health of citizens contributes to prosperity, solidarity and social justice”.

The European Commission, interestingly, also suggests that: “the mental condition of people is determined by a multiplicity of factors including biological, individual, family, social, economic and environmental”. They cite the role of “genetics, but also gender, personal experiences, social support, social status and living conditions” in our mental well-being.

I agree. In my view, good mental health is indeed: “a resource which enables them to realise their intellectual and emotional potential and to find and fulfil their roles in social, school and working life”. My role, my job, my profession, is helping people fulfil their potential as human beings, not treating illnesses. In fact, doctors – medical practitioners, psychiatrists – have always prized an element of their profession that goes beyond merely treating the patient and illness in front of them.

I’m an unapologetic cognitive psychologist. And I recognise certain pretty clear findings from psychological science. Our thoughts, our emotions, our behaviour and therefore, our mental health are largely dependent on our understanding of the world, our thoughts about ourselves, other people, the future, and the world. Biological factors, social factors, circumstantial factors - our learning as human beings - affect us as those external factors impact on the key psychological processes that help us build up our sense of who we are and the way the world works.  

Of course, we must address the issue of biology.

Every thought I have involves a brain-based event. All learning involves changes in associative networks, depolarisaion thresholds, synaptic biomechanics, even gene expression.

My view is not an anti-brain, anti-psychiatry, model. But I believe that my brain is a learning engine – a biological system that is the servant of learning. I am not the slave of my brain, my brain is the organ with which I learn. So of course every thought involves brain-based activity. But this isn’t the same as biomedical reductionism. Our biology provides us with a fantastically elegant learning engine. But we learn as a result of the events that happen to us - it’s because of our development and our learning as human beings that we see the world in the way that we do.

Everybody recognises that there are changes to the way that our brain functions which affect our thinking, our moods, our behaviour. Most cultures in the world are familiar with a range of chemicals – cannabis, alcohol, even caffeine – that affect our psychological functioning because of the effects they have on our brain.

And it’s perfectly reasonable to suggest that individual differences in people – even differences as a result of genetic differences – will have measurable influences on their behaviour and thinking in later life.

There’s nothing un-psychological and certainly nothing un-scientific about understanding that biological factors can affect our psychological functioning… and thereby affect our moods, our thinking, our behaviour.

But I think there’s a world of difference between acknowledging these influences and accepting a ‘disease model’.

For two striking reasons.

First, I believe that the relative influence of biological factors is relatively small.
I need to clarify this.

Every thought I have ever had involves a biological event.

I have also been involved in supervising research that used fMRI technology – functional magnetic resonance imaging – to study regional blood flow during a self-referential task. We found that specific areas of the brain were associated with self-referential thinking, and that these areas were more active in people seeking help for depression.

When we think – for example – of ourselves, as opposed to thinking of another person, it’s abundantly clear that specific neural pathways are involved. Since thought involves neural signals in the brain, it’s hugely unsurprising that thoughts of all kinds involves identifiable brain circuitry.

But identifying a pathway to a particular though process does not imply that a pathological mechanism has been found.

Logically, quite the reverse seems a more parsimonious explanation – if a particular neural pathway is found to be associated both with emotional and interpersonal difficulties and a key psychological process, it makes sense to me to assume that this is an important scientific finding that applies to us all, not just those of us unfortunate enough to have somebody attach an ‘illness’ label to our emotions.

This is not a style of thinking compatible with the “disease model”.

Because every thought must involve a neurological process, merely finding a neurological correlate of emotional distress or psychological process isn’t the same as identifying a pathology or an ‘illness’. Quite the reverse.

In addition, my reading of the available literature suggests to me that the influence of variance between people in biological terms has much less influence on their subsequent emotional life than the variance between people in social and circumstantial terms.

Just a couple of examples.

In my department at Liverpool, colleagues Ben Barr, David Taylor-Robinson and Alex Scott-Samuel together with Martin McKee and David Stuckler demonstrated that around 1000 more people killed themselves in the years between 2008 and 2010 than would have been expected. They also found that the English regions with the largest rises in unemployment had the largest increases in suicides, particularly among men.

They conclude that the economic recession was the most likely cause.
Recession, economic insecurity, loosing your job clearly has a major impact.

Rather differently, Richard Bentall and John Read have analysed the impact of childhood trauma – abuse – on the likelihood of developing psychosis. In a number of studies, they have concluded that childhood abuse more than doubles the risk that you’ll develop hallucinations or delusional beliefs in later life.

It seems clear that social and circumstantial factors are significant.

There have been relatively few studies directly comparing the relative contributions of biological and social variables, but reviews of the relative contribution of negative life events and abnormalities of the serotonin reuptake gene by Steven Reich and colleagues suggest that while life events are associated with future depression, the same can’t be said of serotonin reuptake gene differences.

It’s perhaps noteworthy that proponents of biological reductionism occasionally make some peculiar suggestions – suggesting to Bentall and Read, for example, that genetic abnormalities might make kids vulnerable to BOTH abuse and psychosis, but that the abuse wasn’t really the cause. And, of course, when the different alleles of the serotonin reuptake gene are found to be less clearly related to depression than might be thought, well, we’re told that new genetic breakthroughs are likely “within months”.

But, we must, as psychologists, remain clear-sighted as to HOW biological, and, for that matter, social and circumstantial factors affect our mental health and well-being.

And, again, the alternative to the ‘disease model’ is already with us. It’s already part of our scientist-practitioner model, and already well-established within psychological science.

Undergraduate psychology students are introduced to the ancient Greek philosopher Epictitus, and his ethos that “it isn’t events that upset us, but our interpretation of those events”.

That fits with my own findings that psychological processes mediate the impact of biological, social and circumstantial factors on mental health.

And more generally, it supports the notion that our thoughts, our emotions, our behaviour and therefore, our mental health are largely dependent on our understanding of the world, our thoughts about ourselves, other people, the future, and the world. Biological factors, social factors, circumstantial factors - our learning as human beings - affect us because those external factors impact on the key psychological processes that help us build up our sense of who we are and the way the world works. 

In this view of the world, of human nature, there is no real need to invoke the idea of abnormality or disease, even of diagnosis – people are just making sense of their world; developing complex, shifting, emotionally-laden frameworks of understanding of the world. This is why psychologists tend to be sceptical of diagnoses.

Our science is robust and substantiable. And our therapies – even when appraised using the standards of biological medicine – are demonstrably effective.

So... what are the implications for the system of care?

This is perhaps not the forum to outline the failings of modern psychiatry. But it seems clear that we’re dealing with a slightly dysfunctional family. On the one hand, biological psychiatrists such as Guze – author of “Biological psychiatry: is there any other kind?” and the Nobel Prize-winning Eric Kandel suggest that biological functioning is the ‘final common pathway’ for mental disorder and, indeed, therapy.

And our own Nick Craddock argues in his manifesto or ‘wake up call for British psychiatry’ that there has been a “creeping devaluation of medicine” in psychiatry. There is, Craddock and colleagues argue: “… a very real risk that as the understanding of complex human diseases steadily increases, recent moves away from biomedical approaches to psychiatric illness will further marginalise patients…” and that “…Psychiatry is a medical specialty. We believe that psychiatry should behave like other medical specialties”. This is a precise recapitulation of a medical model of psychiatry. Craddock and colleagues are also refreshingly clear in their professional or political aspirations – “British psychiatry faces an identity crisis. A major contributory factor has been the recent trend to downgrade the importance of the core aspects of medical care”.

Craddock and colleagues confidently expect that molecular biology and neuroscience will help us understand the ‘pathogenesis’ of mental health problems, therefore confirm the value of ‘biomedical explanations of illness’ and confirm the value of a medical psychiatric profession. On the other hand, Pat Bracken and colleagues – in the same forum as Nick Craddock – argue the opposite: that “…Psychiatry is not neurology; it is not a medicine of the brain. Although mental health problems undoubtedly have a biological dimension, in their very nature they reach beyond the brain to involve social, cultural and psychological dimensions. These cannot always be grasped through the epistemology of biomedicine”. And, of course, a phrase often repeated in relation to the developments of DSM-5 is that such approaches represent “the creeping medicalization of normal life”.

Two pretty much diametrically opposed perspectives. 

Does this matter? 
It probably does.
  
I receive a fair number of unsolicited letters. One read: "... Rather than engaging with the patients on the ward, the staff instead shepherded them around like sheep with bullying commands, threats of ‘jabs’ (injections), and removal to an acute ward elsewhere in the hospital, if they did not co-operate. The staff also stressed medication rather than engagement as a way of controlling the patients. And the staff closeted themselves in the ward office, instead of being out and about on the corridors and in the vestibule where they should have been. The staff wrote daily reports on each patient on the hospital’s Intranet system; these reports were depended upon by the consultant psychiatrists for their diagnoses and medication prescriptions, but were patently fabricated and false, because the staff had never engaged or observed properly the patient they were writing about in their reports. The psychiatrists themselves were rarely seen on the ward, and only consulted with their patients once a week."

And I quote in aid Professor Sir Robin Murray, writing as Chair of the recent ‘Schizophrenia Commission’; “the message that comes through loud and clear is that people are being badly let down by the system in every area of their lives.”
  
So… what’s needed?

Well… First….

1. Get the message right – drop the ‘disease model’ and adopt a psychosocial model.

I realise this is didactic, that I’m telling people how to think. But didactic messages from medicine have been commonplace for years! (a very senior psychiatrist once, quite pleasantly, stated that his medical education made him entirely competent to do all the jobs of everyone in his team, including clinical psychologists, nurses and social workers, but that they, of course, couldn’t do his!).

So… drop the ‘disease model’ and accept that these are psychosocial issues.

On twitter, a colleague suggested I was proposing a ‘psychobiosocial model’.

I quite like that.

Then...

2. Stop diagnosing non-existent illnesses – a simple list of people’s problems (properly defined) would be more than sufficient as a basis for individual care planning and for the design and planning of services.

And….

3. Recognise our role lies in supporting well-being, not treating illnesses. For my psychiatric, medical, colleagues, this is a perfectly respectable medical role (think of the role of General Practitioners and public health physicians, think of medical care in pregnancy and the role of someone like the medical advisor to the Manchester United Football Club squad).

4. Fourthly … and perhaps more radically…. Stop pushing the drugs (or at least slow down). They just simply don’t offer an effective and safe solution…. And here I would appeal to the work of medical colleagues such as Dr Joanna Moncrieff and others.

Of course, pharmaceuticals alter our mood, cognition and, therefore, our behaviour. But –very briefly to summarise Jo Moncrief’s ‘drug-centred’ rather than ‘disease-centred’ model – this merely explains that drugs alter brain chemistry… there’s simply no convincing evidence that they are re-establishing neurotransmitter balance or addressing pathologies.

Instead….

5. Offer psychosocial services that aim for recovery and personal agency on the part of the client. That means working with a wide range of community workers such as social workers, social pedagogues, and psychologists in multidisciplinary teams, and promoting social rather than medical solutions in the first instance.

Of course, of course, there should be one-to-one psychotherapy. But we should be doing what we’ve always wanted to do - which is offering more fully holistic services. We should be linking with Jobcentre Plus employment advisers who are delivering what are effectively wellbeing interventions for people. We should be working with the education services. And we should be working with the physical health services. We should be working with employers, there’s plenty of evidence that interventions aimed at improving people’s wellbeing, not curing their mental illnesses but improving people’s wellbeing is productive for employers. We should be working with community services and the wider civil society. 

In each case, scientifically elegant analyses of psychological processes leading to interventions. 

All such interventions should all be evidence-based and delivered by qualified, competent professionals. Decisions about what therapy or therapies should be offered to whom should be based on a person’s specific problems and on the best evidence for the effectiveness of the intervention, not on diagnosis, and individual formulations should be used to put together an individualised package of care suitable for addressing each person’s unique set of problems.

So there are a number of psychosocial interventions that we should pursue in addition to standard one-to-one therapies.

6. Where individual therapy is needed, recognise that there are many effective, evidence-based, psychological therapies available.

When I was first qualified as a clinical psychologist, I was told that to talk to a service user experiencing psychosis was “unethical”, as talking about their problems would make them worse. We now have evidence-based psychological therapies recommended for a wide range of so-called ‘disorders’ and – in my area of speciality, such evidence-based approaches are recommended for all – 100% of people experiencing psychotic phenomena such as hallucinations and delusions.

But this again returns to the language and thinking style of medicine – diagnosis, treatment, outcome. We need to accept that a focus on social determinants of well-being means that we are discussing what is effectively a social and psychological phenomenon, with medical aspects, not a medical phenomenon with social correlates

And this means…

7. In the multidisciplinary teams delivering these services, medical psychiatric colleagues should remain valuable colleagues. An ideal model for interdisciplinary working would see leadership of such teams determined by the personal qualities of the individual members of the team. It would not be assumed that ‘clinical primacy’ would inevitably put our medical colleagues in a position of unquestioned authority – people should regard themselves as consultants TO the team, not leaders OF the team.

This does have implications. It could mean a much greater reliance on GPs and other primary care colleagues as opposed to what are not ‘traditional’ psychiatrists. We might see joint working between GPs and community teams, with GPs offering the medical input when needed – as opposed to seeing psychiatrists serving this role.

And that might not only be beneficial for the service user, but could see a massive cost saving for the NHS, if this fed through to a commensurate reduction in our dependence on highly expensive psychiatrists.

And this principle could apply in residential care, too…

8. When people are in crisis, residential care may be needed, but this should not be seen as a medical issue. Since a ‘disease-model’ is inappropriate, it is inappropriate to care for people in hospital wards; a different model of care is needed. Residential units, again, should be based on social, not medical, models. Residential social workers or nurses may well be the most appropriate people to be in charge of such units. The nature of extreme distress means medical colleagues may well be valuable members of the team but again they should be consultants TO the ward, not having sapiential authority OVER the team.

As part of the process of accessing these residential units…

9. When the powers of the Mental Health Act are needed, the decisions should be based on the risks posed to self and others, but also on the person’s capacity to make decisions about their own care. This approach is the basis for the law in Scotland, and the law in England and Wales permits the ‘responsible clinician’ to be a psychologist, nurse, or social worker. This should be routine. When we reject a ‘disease-model’ of care and adopt a ‘human-centred’ model, the law relating to mental health could change significantly; with different legal criteria, different ways of assuring that people are offered ‘least restrictive alternatives’, with a psychosocial focus, new roles for new professions, and a greater focus on social justice and judicial oversight.

But all this would – in my vision – need one final… or first… step.

10…. Base yourselves in local authority services, alongside other social, community-based, services.

That doesn’t mean “design medical teams for psychiatry, manage them out of hospital-based, NHS-based Trusts but put them in a building away from the hospital site”, it means locate the whole service in community services – put the service entirely under local authority control. In the UK, we have the model of public health (transferred to local authority control) to build upon. This should – and could then be – under democratic local governance. I recognise that some local authorities – especially, perhaps, in developing countries, may not yet be robust enough for the task, but this should be the vision and aspiration, rather than aiming for a medical model.

Adopting this approach would result in much lower reliance on medical interventions, and a much greater reliance on social and psychological interventions. We would – we may as well be honest – need fewer psychiatrists. As we see a move towards community-based social services, we would look to primary care (General Practice - GP) colleagues for much of the necessary medical consultation and input; linking psychological care to the wider well-being of patients in the community. We would, in contrast, require much greater emphasis on, training in, and staffing of, psychosocial approaches. What I’m proposing would be a very major revolution in psychiatric practice. It would challenge the central tenets of at least some traditionalist, biological, psychiatrists – and the knock-on implications for social psychiatrists (who might otherwise share Pat Bracken’s views and therefore otherwise be sympathetic) could be equally significant as their power and authority is challenged.

In such a vision…. Where are psychologists and what is our role?. Well… In my view, good mental health is indeed: “a resource which enables them to realise their intellectual and emotional potential and to find and fulfil their roles in social, school and working life”. My role, my job, your profession, is helping people fulfil their potential as human beings, not treating illnesses.

I believe that our thoughts, our emotions, our behaviour and therefore, our mental health is largely dependent on our understanding of the world, our thoughts about ourselves, other people, the future, and the world. Biological factors, social factors, circumstantial factors - our learning as human beings - affect us as those external factors impact on the key psychological processes that help us build up our sense of who we are and the way the world works. 

It naturally follows that psychologists should play a central role. We should offer leadership – with colleagues such as Pat Bracken, Phil Thomas, Jo Moncrieff and Sami Timimi; psychiatrists proud of their profession and expert medical practitioners who nevertheless share these points of view.

But most importantly, we should lead in the process of change. I invite you to think about how we might work to make this kind of vision a reality.

Some steps might appear hugely ambitious – I am recommending that local authorities, not hospital Trusts, are the right home for psychiatry. You might think that the opposition to that might be overwhelming. And you might think that it would be impossible to achieve.

But we’ve recently seen public health services transferred from NHS responsibility to local authority management – a wholesale transfer, in my opinion placing public health where it should be – and under democratic control – and, significantly, meaning that local authorities now employ doctors and deliver clinical services. I believe psychiatry should follow them. So… perhaps this relies on the political and managerial activity of local Health and Well-Being Boards and the management teams of Trusts… but it’s certainly not impossible.

And we’ve seen some public and influential psychiatrists recently arguing that it’s dangerous to abandon the current diagnostic tools – despite their acknowledged and admitted flaws – because we have no proven alternative. The argument – the incorrect argument – is that the critics of diagnosis would need to develop a new technology of classification, which would then need to be counter-tested against diagnosis, before we could take the dangerous – in their view – step of abandoning the ‘disease-model’ approach.

Not true. It’s forgivable for people with no perspective other than a ‘disease-model’, ‘diagnosis-treat’ approach to look within medicine and see… diagnosis and nothing more. But I am – we, as clinical psychologists, are – applied scientists.  

We use the basic principles of applied science. The Oxford English Dictionary defines the scientific method as: "a method or procedure that has characterized natural science since the 17th century, consisting in systematic observation, measurement, and experiment, and the formulation, testing, and modification of hypotheses."

So we use operational definitions of relevant concepts. We develop hypotheses. And we collect data. We don’t need to meet the challenge of a new technological alternative to diagnosis and the “disease model”. We’ve had it since the 17th century.

So it is time for change.

It is time to remember – and act up to – out core purpose as psychologists.

Psychological health and well-being is “... a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”…. and “a resource which enables citizens to realise their intellectual and emotional potential and to find and fulfil their roles in social, school and working life”.

Our thoughts, our emotions, our behaviour and therefore, our mental health are largely dependent on our understanding of the world, our thoughts about ourselves, other people, the future, and the world. Biological factors, social factors, circumstantial factors - our learning as human beings - affect us because those external factors impact on the key psychological processes that help us build up our sense of who we are and the way the world works. 

Our particular role is to use the well-tested tools of science to understand this process and to intervene to help people improve their lives.

Change is needed, but it’s also a return to our core purpose as a profession.

Thank you.





16 comments:

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  2. nice article...

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  3. Plenty of food for thought. Cant help thinking you have a fight on your hands though.
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  6. I had CBT therapy.. I have severe asthma with other illnesses.. now am at the underground there are 30 steps to climb lift out of order. What should I do..?

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  10. Very thought provoking and well established basis for the role of psychology in mental well being.

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  12. I appreciated Peter's fine work and his proposal for new concept on mental healthcare and well-being approach. The paradox here is that, like all illness has to be scaled on merits and causes. After a patient holistic assessment, the doctor or whoever is the assessor has to determine the area that trigger the illness, it could be biological, social, economical, environmental and psychological. I believed that treatment should be targeted on that area not using one model for all patients.

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  13. Very well written and informative article. I think more psychologists need this perspective.

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