A psychological ethos and model
We need to develop and implement a new approach to understanding mental health problems. As I outlined in 'New Laws of Psychology',37
a psychological approach offers a coherent alternative. Our social circumstances, and our biology, influence our emotions, thoughts and behaviours - our mental health - through their effects on psychological processes. This psychological model of mental health and well-being proposes that our biology and our life circumstances both exert their influence through their effect on psychological processes. Of course, all mental health problems involve the brain, for the simple reason that all thoughts we ever have involve the neurological functioning of the brain. But that's not an explanation, merely a more detailed description (it's like explaining warfare in terms of muscular contractions in the fingers on the triggers). In statistical terms, variance in neurological processes seems to account for very little in terms of mental health - or indeed human behaviour in general. Most of the variability in people's problems appears to be explicable in terms of their experience rather than genetic or neurological malfunctions. Neurotransmitters such as serotonin and dopamine are associated with a variety of emotional problems. That's hugely unsurprising; reward mechanisms involve serotonin and dopamine ... but that's true for everyone.
Since the 1950s psychologists (and psychiatrists who understand cognitive psychology) have developed sophisticated and practically useful models of how people understand the world. In straightforward terms, people are born as natural learning engines, with highly complex but very receptive brains, ready to understand and then engage with the world. As a consequence of the events we experience in life, we develop mental models of the world, including the social world. We then use these mental models to guide our thoughts, emotions and behaviours.
Understanding things this way suggests that notions such as 'mental illness' and 'abnormal psychology' are old-fashioned, invalid and demeaning, that diagnostic categories such as 'depression' and 'schizophrenia' are unhelpful, and that the concept of mental illness is relatively meaningless. I am certainly not arguing that people are not distressed or that psychological problems do not exist. Many people clearly experience severe psychological distress. As I said above, in the UK, suicide is the most common cause of death in women in the year after the birth of their first child. We all have emotional problems from time to time, and there is a well-recognised statistic that one in four of us will, at some point in our lives, have difficulties severe enough to meet the criteria for a 'mental disorder'. The cost to the state from mental ill-health is estimated at over ?100 billion per year, and antidepressant drugs are among the most common - and most profitable - products of the major multinational pharmaceutical companies. But ideas of disease or illness are unhelpful. Even the concept of 'abnormal' psychology is unreasonable: we don't talk about 'abnormal chemistry 'or 'abnormal physics' - the same principles apply whatever value we ascribe to their effects. Instead, we know a lot about the key psychological and developmental processes that make us human, and we know how events in our lives, social circumstances and our biological make-up can affect those processes. Addressing well-being from that perspective is simultaneously radical and common-sense. Scientific research into the psychological processes we all use to understand the world and interact with other people offers a scientifically valid and more helpful approach than the idea of 'mental illnesses'. I will reinforce the World Health Organization's definition of health (that health is more than the absence of illness) and suggest that, rather than researching so-called mental illnesses, we should acknowledge that the concept of mental illness is probably misleading and unhelpful in the first place. Rather, an evidence-based approach to mental well-being - developing and applying our scientific understanding of the key psychological processes that underpin our humanity - offers great hope.
Like Pat Bracken, I believe that human distress is largely a social phenomenon . .. but I therefore conclude that the role of the psychiatrists within mental health services needs radically to change. In essence, we need to see psychiatry adopt an approach that is both more modest and more democratic. Like Nick Craddock, I believe that psychiatrists have very real and valuable specialist knowledge and skills ... and that these should be available to the democratic, team-based, multi-disciplinary services envisioned by Christine Vize. This approach would reverse the current dominance of psychiatric modes of thinking - the 'disease model' and the 'diagnose-treat' model - and place psychiatry in a more appropriate relationship with social and psychological models of care. Although such a change would be challenging both for psychiatrists and for psychologists (who would then be expected both to shoulder the burden of responsibility and to acknowledge the importance of social as well as psychological factors) it is worth spelling out - in detail - the practical consequences of such an approach.
The difficulties that are traditionally thought of as 'mental health' issues are in truth primarily social and psychological problems. Of course, there are physical, biological aspects to them. That's true for all human experiences. But we need to understand that we're trying to respond to social and psychological problems, not treating diseases. And we therefore need a profound change in how we try to help people. We need to move away from a state of affairs where the default response to distress is medical care, whether in the community or in hospital. We need to stop diagnosing 'mental illnesses' and we need to stop prescribing drug treatments. Instead, we need to offer social and psychological interventions. Happily, these can be very effective. Even when people need residential care for very serious crises, there is no reason that this needs to be in hospital; non-medical residential crisis centres which provide social care and support are likely to be much more helpful. That means that a formal transfer of responsibilities of mental health care to local authorities (as has recently happened with public health and is very common across Europe, with a strong tradition of city governance) would be appropriate. This would represent a return to an approach which was common in the past, before distress began to be medicalised in the 19th and 20th centuries. But all that would mean profound changes for the professions of psychiatry and nursing in particular. It would be financially affordable for the nation, but might be challenging for powerful and well-paid professionals. However, the bitter pill I'm prescribing is necessary to cure the grievous sickness of the current system.
Services planned on the basis of a psychosocial model, would offer a very radical alternative. Instead of seeing care for people with mental health problems as a specialist branch of medicine, with links to social care, we would see such support as essentially part of social provision, with specialist input from our medical colleagues. In such a world, people would default to a psychosocial explanatory model, and the disease model of mental disorder would be redundant. That would, at least in my opinion (but substantiated by considerable evidence) lead to more empathy, more compassion, more understanding of people's needs both by professionals and in wider society, and put a stop to stripping people of their sense of agency - their ability to help themselves. People's problems would be understood as just that - problems, and diagnoses would be largely replaced by formulations. For people in extreme distress, places of safety would still be needed to replace the niche filled at present by in-patient wards. However these should be seen as places of safety, not medical treatment units, should therefore be led by social workers, or possibly psychologists, rather than doctors or nurses, and physically designed as homely, welcoming houses rather than 'wards'. On those units, our medical, psychiatric colleagues would still play a valuable role, but would act as consultants to the care team on specifically medical issues, not necessarily leaders of those teams. The ethos of care on such units would be based on recovery, not treatment or cure, and be firmly based on a psychosocial formulation of the problems facing each service user. Good quality, humane, care, and taking seriously the person's own views about their difficulties and needs rather than insisting that they see themselves as 'ill' and accept medication, would minimise the need for compulsion. When compulsion is needed, however, the legal criteria should be based on the principle that people should only be subject to coercion when they are unable to make the relevant decisions for themselves - a capacity- based approach.
For the majority of us, though, mental health care is already community based. In the vision of care proposed here, reconfiguring services as psychosocial rather than medical would transform care. Links to other community-based services such as primary care (GP) and public health services are strong and should remain so. Interestingly, public health services are already based in local authorities. As with in-patient care, medical psychiatrists would be valued to consultants to community mental health teams rather than necessarily leading them. Their ethos would shift from a medical to a psychosocial one, and shift from medical dominance to a model whereby medical colleagues offer consultancy on primarily medical issues (for example the prescription of drugs) to those psychosocial teams.
There should be a very significantly reduced emphasis on drugs. In particular, long-term drug use should be avoided. Where medication is used (sparingly, and short term) it is important that high-quality (and that emphasis is important) medical and pharmaceutical advice is available. Most especially, we must see a significant increase in the range, quality and availability of a wide range of psychosocial interventions - both practical help and psychological therapies. However, the emphasis should be on care and support rather than 'treatment'. This is obviously true in community settings - where it is frankly appalling that people seeking help for social and personal issues are diagnosed with illnesses and given drugs - but is also true in residential settings. In episodes of acute distress, a few people would benefit from very short-term prescription for medication (mainly to help them feel calmer if they are deeply distressed and agitated, or to help them through the depths of despair and 'depression') but three key points follow. First, such use of medication should (following the advice of Jo Moncrieff) be very brief, targeted and practical. Second, following from that, medication should be used to help people through difficult times, not to 'treat' putative 'illnesses'. And finally . .. there are very real effective alternatives to medication. Many problems resolve from crisis-point to a more manageable state if people are simply offered high quality, genuine care and support. Psychological therapies such as cognitive behavioural therapy (CBT) can be effective for very many people with a wide range of problems, even when those are serious. And non-medical whole-service alternatives such as the Soteria approach38 appear extremely effective.