Those organisations whose responsibility it is to commission mental health care in the UK today have mostly adopted some version of a stepped care model that has been recommended by the National Institute for Clinical Excellence.46 This means organising people and designating them appropriate treatments based on diagnoses. Depending on severity and nature of the ‘condition’, people are recommended self-help resources, CBT (or a low-intensity stripped-down version) and/or different forms of psychotropic medication. The focus is on choice as well as appropriate care, and the DSM remains at the centre of this care because its allotted disorders relate to given pathways of treatment.1
There are now over 50 million prescriptions for antidepressants written, and as many as one in six adults are prescribed monthly antidepressants in some parts of the UK.40 However, despite the supposedly robust evidence base that attests to the efficacy of many forms of psychotropic medications, there are a number of key problems with both the premises underlying these approaches and the evidence itself. With regard to medication it as not been demonstrated that many psychological disorders are caused by an imbalance in serotonin or any other brain chemicals implicated in their causes.1 Indeed, there is little evidence that drugs exert effects that return ‘disordered brains’ to ‘normal’, that is, that they have an antidepressant effect or an antischizophrenic effect. Rather it appears that if medications work (and sometimes they are experienced as beneficial), then they do so by placing people into drug-induced states with uncertain pharmacological impacts. Antidepressants as a form of sedation are an often useful form of anaesthetic to people’s difficulties.1,2,36 However, antidepressants ‘fix’ depression no better than a painkiller fixes a root canal.
Furthermore, the supporting research is problematic. There is a long history of inadequate controls, an excess reliance on selected individuals and use of abstract numerical measurements with diagnostic inventories that have little clinical meaning. Most bruisingly, there is a bias towards selective publishing and reporting of success stories, while the dozens of trials that show them as having, for most, little more potency than sugar pills are withheld.1,40 A recent review of five studies of early psychosis found that those treated without medication fared better than those on medication.9
In the debates on what constitute appropriate, patient-centred approaches to mental distress, psychological therapies are often constructed as the humane side of psy practices. Here the corrupting activities of big pharma, and the often debilitating side effects and the frustrations of the inappropriateness of a biochemical agent masking underlying psychological disturbance, are replaced with a sensitive, appropriate and ethical approach to distress.
However, psychological therapies are also problematic. Waldegrave47 notes that therapy typically refers to the healing and problem-solving discourses that the helping professions carry out, where professionals focus on interpersonal experiences that are typically framed through individual or family dynamics. Through non-specific processes of clarification, support and empathy,2 the experience of this kind of therapy can be comforting. Yet comparisons of qualified practitioners with amateurs with no specific training suggest few meaningful difference in effectiveness (regardless of how they were measured).6,48 Moreover, psychotherapy can foster the illusion that misery is an internal failure requiring expert cor- rection.2 For the many whose distress links to violence, addiction, poverty, poor housing and/or unemployment, these models of therapy can at best be understood as making those in poverty feel a little better and at worst as a practice which silences the voices of the poor.47 Look, we know that a lot of you reading this won’t be practicing like that. But quite a few people do. Indeed the lack of inequalities imagination in the psy professions is worrying.48,49
As with much of the pharmacological research, research on the effectiveness of psychotherapies is prone to long-held biases towards selective publication and reporting. Also at play here are inadequate controls and excessive reliance on selected individuals that conceal that there are large numbers of people for whom therapy has been unsuccessful.1 Again there are abstract numerical measurements with preset diagnostic inventories with little personal or clinical meaning and practices which inherently steer the client into the therapeutic model. Both parties expect improvement and that improvement is normal, and to expect or to admit anything else is an admission of personal inadequacy.1
But as well as this, counselling has come to be seen as the answer to almost every type of personal and social problem—boredom, loneliness, overexcitement, rejection, unattractiveness, workplace change, marital infidelity—and in 2010 nearly 20% of British people had consulted a counsellor and nearly half knew someone who had.1 Paul Moloney suggests that a key problem with therapies like CBT is that the focus on thoughts and feelings, without a meaningful focus on the social lives that frame them, is like studying a snowstorm paperweight without reference to whether it had been shaken.