Monday, November 17, 2014

A Manifesto for the Reform of Mental Health and Well-being Services

A Manifesto for the Reform of Mental Health and Well-being Services

An extract from my book - A Prescription for Psychiatry: Why We Need a Whole New Approach to Mental Health and Wellbeing
Published 2014 by Palgrave Macmillan ISBN: 978–1–137–40869–3 

The need for reform in mental health services is acute, severe and unavoidable.
This demands nothing less than a manifesto for reform.

A spectre is haunting our mental health services. Recent scientific advances in understanding human psychology have revealed traditional ‘disease-model’ thinking about mental health to be profoundly flawed, and far-reaching changes are required in how we plan and commission services. Our present approach to helping people in acute emotional distress is severely hampered by old-fashioned and unscientific ideas about the nature and origins of mental health problems, and vulnerable people suffer as a result of inappropriate treatment. Radical remedies are required.

Taking its lead from physical health care, the current mental health care system currently ‘diagnoses’ our emotional, behavioural and psychological problems as ‘illnesses’, and is largely based on the idea that they arise primarily from brain abnormalities. The hope has been that eventually ‘biomarkers’ (physical signs) and biological causes (preferably genetic) will soon be found. This ‘disease model’ underpins too much of modern mental health care and has had profound and damaging effects.
It has led to inappropriate and harmful treatment. For many people, the only or main treatment currently offered is medication. Whilst useful for some people, recent research suggests that in general, the helpfulness of medication has been overestimated. Evidence is also accumulating that psychiatric medication can have dangerous adverse effects (side-effects) especially when taken long term.

It has prevented effective help and treatment. The disempowering idea that they are passive recipients of medical treatment for a disease has interfered with people’s ability to help and support themselves and each other. It has diverted resources away from effective sources of help such as listening and psychological therapy services, and practical help to improve life circumstances.

It has led to alienation between staff and service users. When people are experiencing huge distress and fear that their sanity, even their life, is threatened, empathy and compassion are central to any attempt to help. The ‘disease model’ locates problems within the individual and leads staff to see people’s behaviour and distress as irrational rather than as potentially understandable. This reduces professionals’ ability to listen, empathise and show compassion. Service users’ experiences are disregarded and their stories unheard. People often experience services as inhumane and avoid them. Only in mental health is there a ‘survivor movement’ – survivors not only of distress but specifically of the services supposedly established to help them.

It has necessitated widespread use of coercion. Mental health law has traditionally been based on the disease idea. Service users who see their problems differently and do not wish to take drugs have been seen as ‘lacking insight’ and have often been detained and administered drugs by force. Many thousands of people each year are detained in hospital and treated against their will. There is good reason to believe that these numbers could be reduced hugely if services adopted the approach outlined below.

It has diverted resources from efforts at prevention. The current approach to mental health care focusses attention almost exclusively on individual ‘pathology’ as the source of problems and as the focus for professional efforts. New knowledge about the role of life circumstances will lead to much more effective programmes of prevention, comparable to the effects on physical health of public health interventions such as the purification of drinking water.

The time has come for a wholesale reform of mental health services. We must move away from the ‘disease model’, which assumes that emotional distress is merely symptomatic of biological illness, and instead embrace a model of mental health and well-being that recognises our essential and shared humanity.

The Manifesto:
Article 1: services should be based on the premise that the origins of distress are largely social

The first step towards a humane, scientific approach to care is to change the framework of understanding from a ‘disease model’ to a ‘psychosocial model’. 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.
We all differ in the ways we respond to events, and there are many reasons for those differences. Our thoughts, our emotions, our behaviour, and therefore our mental health, are largely dependent on our under- standing of the world, our thoughts about ourselves, other people, the future and the world. There are as many different reasons for these different responses as there are people in the world. 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. Some medical professionals and many members of the general public mistakenly believe that psychiatric diagnoses reflect real ‘illnesses’. However, research does not support this view. There is little evidence that mental health ‘diagnoses’ say anything useful about the causes of a problem or what is likely to help. Some people have found ‘diagnoses’ useful in providing a framework within which to understand their difficulties, and in accessing help and support. However, there are other, more scientifically valid and more helpful ways of reassuring people that their problems are recognised (in both senses of the word), understood, validated, explained (and explicable) and that some help is available. The approach described here outlines how this vital help and support can continue to be provided without the need to make the assumption that problems reflect underlying ‘illnesses’.
Some legal and other professionals mistakenly believe that diagnoses are needed in order to allow people to communicate efficiently with one another. However again diagnoses are misleading and unnecessary; a simple and direct list of a person’s actual experiences and problems provides more information and is of greater communicative value than a diagnostic label. Of course we need to research the nature, causes and remedies of problems. Again, ‘diagnoses’ are misleading here: rather than trying to investigate hypothetical ‘illnesses’, researchers would be better advised to study the nature and causes of specific, identified problems, and what can help.
Many medical professionals and policymakers mistakenly assume that we need to use diagnoses in order to allocate resources to those who need them. However we can see from how resources are successfully allocated in a vast swathe of other public services that this simply isn’t true.

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’.
In practical terms, we should aim for a massive reduction in the level of psychiatric prescription. There should be many fewer prescriptions, at lower doses, for much shorter periods. In essence, this means adopting a ‘drug-based’ approach in contrast to the more common ‘disease-based’ approach. We should respond to people’s specific symptoms, rather than make the mistake that we’re treating illnesses that can be identified by diagnosis. We need to listen to the person’s own experiences of which drugs have helped in the past and how they are finding those currently prescribed, and use what they say to guide our prescribing. Perhaps most importantly, we should only use psychiatric medication in the very short term (i.e., for a matter of days) in the vast majority of cases.

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.
All such therapies should 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 the diagnosis. Individual formulations should be used to put together an individualised package of care for each person’s unique set of problems. Using psychological therapies as part of a psychosocial, rather than biomedical, approach would significantly change the way clinical psychologists and others work.
Our psychiatric colleagues would play an important medical role within this overall psychosocial ethos. Their role would be analogous to those of general practitioners, public health physicians, and doctors who offer their expertise to athletes.

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. Residential social workers or nurses who have retrained in a psychosocial approach (and possibly with a more appropriate professional title) are likely to be best placed to lead such units. The nature of extreme distress means medical colleagues may well be valuable members of the team but again their role should be as consultants to the team, rather than automatically as leaders of the team.
The need for compulsory detention would be much reduced within this new approach. In those instances where compulsory detention was necessary, decisions would 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. The law in England and Wales permits the ‘responsible clinician’ (the person who is legally responsible for some- one’s care, traditionally a psychiatrist) 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. There would be different criteria governing to whom the law applies, different ways of assuring that people are offered care that is (in the words of the current law) ‘least restrictive’, with a psychosocial focus, new roles for new professions, and a greater focus on social justice and judicial oversight.

Article 6: mental health teams need to be radically different

Teams should be multidisciplinary, democratic and based on a psycho- social 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 deter- mined 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.
That doesn’t mean that we should design medical teams for psychiatry, and manage them out of hospital-based, NHS-based Trusts but, instead, housed in a building away from the hospital site as a gesture to being ‘community-based’. It means that we should locate the whole service in the community – put it entirely under local authority control. In the UK, we have the model of public health, recently transferred to local authority control, to build upon. Such services should be – and could then be – under democratic local governance.

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.

Adopting this approach would result in a transfer of mental health services from the health to social services management (including a shift from hospital to residential care); a substantial reduction in the prescription of medication; a shift of medical responsibility from psychiatry to GPs with commensurate reduction in psychiatrist numbers; and the training or retraining of a large number of current workers in mental health care in a psychosocial approach.

This would require much greater emphasis on, training in, and staffing of, psychosocial approaches, and would represent a very major revolution in mental health services and in psychiatric practice. It would challenge the central tenets of at least some traditionalist, biological psychiatrists and the implications could be significant as their power and authority is challenged.
Nevertheless these proposals would be entirely affordable, and may even liberate resources for greater investment in mental health and well-being. 

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