Prevention beyond the 'disease model'
Advances in the psychological understanding of mental health and well-being allow us to foresee a future beyond the 'disease model'. First, it's important to address the root causes of distress. The ethos of mental health that I'd like to see does place the person at the centre of their universe, and emphasises our individual agency, but it does not imply that people (or their thinking) can be blamed for their distress. The way that people make sense of what happens to them plays an important role and is often a useful focus when we are trying to help someone. However, the most powerful determinants of mental health are the events and circumstances of people's lives. If we are to protect people's mental health, we need wider social or even political change. This is often a neglected topic, but social and political changes are likely to make much more difference overall than anything individuals can do alone.
For example, many people diagnosed with 'psychosis' have experienced poverty. Addressing poverty is rightly the cornerstone of government, and few politicians suggest differently (although many of us fear that right-wing governments pay only lip-service to this aspiration, whilst presiding over policies that actually increase inequalities). With a very specific focus on mental health, however, measures to reduce or eliminate poverty, especially childhood poverty, would be hugely beneficial. However absolute income is not the only important issue. Evidence shows that a major contribution to serious emotional distress is income inequality - the growing gap between the richest and poorest people in society. In their book 'The Spirit Level', sociologists Richard Wilkinson and Kate Pickett demonstrate that mental health problems are highest in those countries with the greatest gaps between rich and poor, and lowest in countries with smaller differences.8 This suggests that an effective way to reduce rates of mental health problems might be to reduce inequality in society.
Experiences of abuse in childhood are also hugely important. Rates of mental health problems would plummet if we found better ways of protecting children from abuse. This means working with teachers, social workers, community nurses, GPs and the police to identify and then respond to early warning signs that children might be exposed to sexual, physical or emotional abuse or neglect. It also means taking a serious look as a society at what we can do to bring down overall rates of abuse. Bullying - that is, peer-on-peer bullying in school and in leisure settings - is also important, and again here teachers and youth leaders could help ... and thereby help prevent later mental health problems.
In that context, we also know that experiences of discrimination are important - people who have been subjected to racism, homophobia and sexual discrimination are put at risk by these experiences. Society - and important agents in society - can help. We can help to make societies less discriminatory. On the other side of this equation, we can perhaps think of ways in which community leaders could help make communities more trusting, more open to help one another - more 'prosocial' in psychological jargon.
And finally, many recreational drugs are associated with mental health problems. Alcohol is unquestionably the most serious substance-related public health issue, but cannabis and other more traditional 'drugs' have been associated with mental health problems in general and psychosis in particular. This certainly doesn't mean that we need a stronger clamp- down on drugs - the so-called 'war on drugs' does not appear to have been won, and many people argue that de-criminalising the possession and use of drugs would be an important positive step towards protecting people's health.
To conclude, the most effective way of reducing rates of mental health problems in our country would be to focus on the social causes of distress. This involves all of us, not just mental health professionals. Politicians in particular have a very important role to play in passing legislation that could protect our health, strengthen our community and prevent mental health problems.
So a new ethos for mental health - moving away from the 'disease model' - would embrace social change. But we must also address the issue of biology. Every thought I have involves a brain-based event. All learning involves changes in associative networks, depolarisation thresholds, synaptic biomechanics, even gene expression. My view is not anti-brain or anti-psychiatry. 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.
This approach contrasts with the approach taken by biological psychiatry. I mentioned psychiatrists Eric Kandel and Samuel Guze earlier. They and their colleagues argue that all psychological concepts will disappear from the psychiatric lexicon as we understand the neural basis of behaviour. Their logic is that any changes in our thinking or behaviour - whether that means learning during childhood, the impact of life experiences or even therapy - reflect physical changes in the neural associative networks. So, they argue, when we understand the physical changes that happen in the brain - the changed 'excitation thresholds', the new synapses etc. - we will understand human behaviour. On one level, this analysis is obviously true. Any learning must involve biological changes in the brain at the molecular and synaptic level. But such an argument is intellectually trivial. All learning - all human behaviour - is dependent on the functioning of the brain. But merely invoking 'the brain' doesn't explain the learning satisfactorily, at least not for me. Of course, a well-functioning brain is necessary for all human activities. But it doesn't really explain why I do one thing in one situation (whereas somebody else behaves differently) or why I behave differently in other situations. To understand that, we need to ask whether such differences between people are best explained by differences in their biology.
Everybody recognises that there are changes in our brains that can affect our thinking, our moods and our behaviour. All over the world people use a range of chemicals - cannabis, alcohol, even caffeine - that affect our psychological functioning because of the effects they have on our brain. Individual differences between people, including genetic differences, naturally affect our behaviour and thinking. 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 reasons.
Firstly, I believe that the relative influence of biological factors is comparatively small. To be slightly more precise, my reading of the available literature suggests to me that the influence of biological variance between people has much less influence on their subsequent emotional life than the variance in their social circumstances.
In my department at Liverpool University, colleagues Ben Barr, David Taylor-Robinson, Alex Scott-Samuel, 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.9 Recession, economic insecurity, losing your job clearly has a major impact. On a different but related note, my colleagues 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. The social circumstances of our lives are very significant.
There have been relatively few studies directly comparing the relative contributions of biological and social variables. One attempt was made by Steven Reich and colleagues, who found that life events were much more predictive of future depression than a biological variable that scientists had thought might be important, namely differences in genes that affect a brain chemical called serotonin. It's perhaps noteworthy that proponents of biological reductionism occasionally make some peculiar suggestions, such as the response to research by Bentall and Read, referred to earlier, which suggested that genetic abnormalities might make children vulnerable to BOTH abuse and psychosis, but that the abuse wasn't really the cause.10 And, of course, when serotonin reuptake genes are found to be less clearly related to depression than might be thought, well, the media 'spin' is that new genetic breakthroughs are likely 'within months'.