Notes for a paper presented at 122nd Annual Convention of the American Psychological Association at Washington, DC, August 7-10, 2014.
It is a time of significant change in the field of mental health. 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. Reviews of the ineffectiveness and adverse effects of many psychiatric drugs as well as of the effectiveness of evidence-based psychological therapies have led many to call for alternatives to traditional models of care.
Psychological science also offers robust scientific models of mental health and well-being. These integrate biological findings with the substantial evidence of the social determinants of health and well-being, mediated by psychological processes.
We must move away from the ‘disease model’, which assumes that emotional distress is merely a symptom of biological illness, and instead embrace a psychological and social approach to mental health and well-being that recognises our essential and shared humanity.
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.
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.”
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.
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.
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.
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.
In my recent book, I outlined a possible Manifesto for the future of mental health services:
A spectre is haunting our mental health services.
The need for reform in mental health services is acute, severe and unavoidable. This demands nothing less than a manifesto for reform.
Article 1: services should be based on the premise that the origins of distress are largely social
The guiding idea underpinning mental health services needs to change from assuming that our role is to treat ‘disease’ to appreciating that our role is to help and support people who are distressed as a result of their life circumstances, and how they have made sense of and reacted to them.
Biological factors, social factors, circumstantial factors – our learning as human beings – all affect us; 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.
Article 2: services should replace ‘diagnoses’ with straightforward descriptions of problems
We must stop regarding people’s very real emotional distress as merely the symptom of diagnosable ‘illnesses’. A simple list of people’s problems (properly defined) would have greater scientific validity and would be more than sufficient as a basis for individual care planning and for the design and planning of services.
It’s entirely possible to imagine what this might look like in practice:
“Dear Dr Freud,
I would be grateful if you could offer an appointment to my client, [DEMOGRAPHIC INFORMATION (name, age, gender, address etc)] and offer advice and, if appropriate, assistance.
[NAME] reports that she experienced [CHILDHOOD EVENTS OF SIGNIFICANCE] in her childhood and more recently [RECENT EVENTS OF SIGNIFICANCE]. She reports that she [SPECIFY RESPONSE]. Now, she reports that she is experiencing [SPECIFIC PROBLEM #1], [SPECIFIC PROBLEM #2], [SPECIFIC PROBLEM #3].
We would appreciate your help and assistance.
Sincerely, Dr Jung”
Article 3: services should radically reduce use of medication, and use it pragmatically rather than presenting it as ‘treatment’
We should sharply reduce our reliance on medication to address emotional distress. Medication should be used sparingly and on the basis of what is needed in a particular situation – for example to help someone to sleep or to feel calmer. We should not look to medication to ‘cure’ or even ‘manage’ non-existent underlying ‘illnesses’.
Article 4: services should tailor help to each person’s unique and complex needs
Problems do not come in neat boxes. Services should be equipped to help with the full range of people’s social, personal and psychological needs, and to address both prevention and recovery.
We must offer services that help people to help themselves and each other rather than disempowering them: services that facilitate personal ‘agency’ in psychological jargon. That means involving a wide range of community workers and psychologists in multidisciplinary teams, and promoting psychosocial rather than medical solutions. Where individual therapy is needed, effective, formulation-based (and therefore individually tailored) psychological therapies should be available to all.
Article 5: services should offer care rather than coercion
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 also inappropriate to care for people in hospital wards; a different model of care is needed. As with other services, residential units should be based on a psychosocial rather than a medical model.
In those instances where compulsory detention was necessary, decisions should be based on the risks that individuals are thought to pose to themselves and others, together with their capacity to make decisions about their own care.
This approach is already the basis for the law in Scotland.
Article 6: mental health teams need to be radically different
Teams should be multidisciplinary, democratic and based on a psychosocial model. A psychosocial approach to service delivery would mean increased investment in the full range of professionals able to deliver these therapeutic services. Peer professionals, namely people with lived experience of mental health problems, will be particularly valuable, as will those skilled in practical issues such as finding employment or training.
In the multidisciplinary teams delivering these services, psychiatric colleagues will remain valuable colleagues. An ideal model for interdisciplinary working would see leadership of such teams determined by the skills and personal qualities of the individual members of the team, rather than by their profession. It would not be assumed that medical colleagues should have ‘clinical primacy’ or unquestioned authority.
Article 7: mental health services should be under local authority control
Mental health services should be based in local authorities, alongside other social, community-based, services. The thrust of the arguments in this book culminates in a simple message. The psychological, emotional and behavioural problems that are commonly referred to as mental health problems are fundamentally social and psychological issues. Psychologists, therapists and social workers must work closely alongside GPs, public health physicians, nurses and psychiatrists. But mental health and 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. It follows that the correct place for mental health care is within the social care system.
Article 8: we must establish the social prerequisites for genuine mental health and well-being
Our mental health and well-being are largely dependent on our social circumstances. To promote genuine mental health and well-being we need to protect and promote universal human rights, as enshrined in the United Nations’ Universal Declaration of Human Rights.
Because experiences of neglect, rejection and abuse are hugely important in the genesis of many problems, we need to redouble our efforts to protect children from emotional, physical or sexual abuse and neglect. Equally, we must protect both adults and children from bullying and discrimination: whether that is racism, homophobia, or discrimination based on sexuality, gender, disability or ‘mental health’ or any other characteristic.
We can all do more to combat discrimination and promote a more tolerant and accepting society. More generally, if we are serious about preventing mental health problems from developing, and about promoting genuine psychological well-being, we must work collectively to create a more humane society: to reduce or eliminate poverty, especially childhood poverty, and to reduce financial and social inequality.
We need to work harder to promote peace, social justice and equity, and ensure that citizens are properly fed, housed, and educated, and living in a sustainable natural ecosystem. We need to promote social mobility and social inclusion, encourage actions aimed at the common or collective good (for instance through practical support of local charitable activities), and reduce both corruption and materialistic greed. In a fair society, in a society that protects our mental health and well-being, we would ensure that everyone had a meaningful job or role in society and we would eliminate unhealthy organisational cultures at work.