Mental Health Care Reform Needed Now

A paradigm shift, dramatic practice change and revolution of mental health care is required: URGENTLY!

We must radically re think our approach to mental health care. It is not enough to drag along partially paying lip service to the relevance of alternatives while the overwhelming majority of people in mental health care receive nothing more than a brief periodic medication review and a medication only approach to their treatment. This is utterly inadequate, unscientific, misleading and ineffective. We must move forward. We cannot allow this sham prevail any longer. The real tragedy is that we know a great deal about how to move things on. There are several things lacking: a poorly informed or hampered political leadership who continually re boot to a medical led approach. A profound lack of knowledge or motivation amongst the leaders in our health and mental health services about the limits of the current system and what’s required to change it. A profound lack of resources properly allocated and structured to deliver the intensive comprehensive variety of psycho social interventions needed. The following are some key points that must start to shape how we deliver mental health care:

1. There are no diseases or illnesses. Depression is not a disease or illness. Schizophrenia is not a disease or illness. These are categories that are invented to describe sets of experiences, behaviours, psychological and emotional phenomenon. These categories are neither valid nor reliable. There is no underlying biological neurochemical imbalance, or biomarker that has ever been discovered for any of the major categories of disorder or diagnosis that have been described
a. This does not mean these categories don’t point to extreme difficulties, problems, suffering in the minds and hearts, thoughts and emotions, behaviours, lives, relationships and the histories of people seeking mental health care. These difficulties do exist and must be addressed meaningfully
b. This does not mean we cannot acknowledge the immense suffering that occurs or understand this suffering credibly in a non stigmatising way. We do not need a fabricated medical diagnosis to operate effectively in a non stigmatising way

2. Diagnoses don’t help, they harm. Diagnoses increase stigma, they don’t decrease it. Understanding on the other hand is a powerful, therapeutic, transformative and pragmatically helpful exercise and endeavour. Giving a diagnosis (while sometimes seemingly reassuring) does none of these things; a diagnosis in and of itself does not offer understanding or explanation. Telling someone they ‘have depression’ tells them nothing about how they came to experience what they are experiencing that is labelled depression. How do we know you have depression? because you have a loss of motivation , anhedonia, etc. What does it mean that you experience loss of motivation, anhedonia etc? That’s because you have depression. The ‘diagnosis’ doesn’t tell us anything more about the difficulties already described. A diagnosis is supposed to tell us what the underlying problem is, but mental health diagnoses do not do this. Dr Terry Lynch’s book ‘Depression Delusion’ presents a fantastic description of the difficulties as this relates to depression (http://www.recoveryourmentalhealth.com/my-next-book-depression-delusion-volume-one-the-myth-of-the-brain-chemical-imbalance-publication-date-02-sept-2015/) Does this mean that people don’t get depressed? Not at all, of course they do, its simply inaccurate to call it an illness akin to a physical illness.

3. Formulation is a helpful, useful, pragmatic, sophisticated and flexible means of collaboratively understanding a persons difficulties that leads to solutions, interventions, therapeutic direction, support and other mechanisms of helping and addressing difficulties. Lucy Johnston has done a remarkable job making the case for this approach to mental health care. We should base services on a collaborative formulation of mental health difficulties and not on a diagnosis of a fabricated ‘illness’ model of mental health difficulties (https://www.canterbury.ac.uk/social-and-applied-sciences/salomons-centre-for-applied-psychology/docs/resources/DCP-Guidelines-for-Formulation.pdf)

4. All problems are ultimately understandable, and some never will be. With time, care and patience, almost all mental health difficulties can be understood in some way that is useful. Some never will be, but this is a minority, and does not automatically prove the existence of some underlying brain pathology that must be treated medically. Having spent many years with hundreds of people suffering serious and severe mental health problems (including psychosis, mania, depression etc) it strikes me that with some time and effort understanding of how a persons problems have developed and how the create suffering is almost always possible.

5. Medications may help some people some of the time, but they do not cure mental illnesses, have many drawbacks, and offer many people little or nothing in the way of help. Joanna Moncrief in her book ‘The Myth of the Chemical Cure’ presents a brilliant, evidenced based critique of the evidence for and against the use of psychiatric drugs. Her description of a drug model of prescribing, allows for the reality that medications help some people some of the time, without relying on a disease or illness model of mental health (https://www.youtube.com/watch?v=IV1S5zw096U)

6. Psychological, interpersonal and social difficulties including trauma and poverty are a primary cause of much of the mental health problems that people experience, far more so than genetic or biological factors. This should point to a preponderance of psychological, social, and psychotherapeutic interventions in our mental health services, with a minimal reliance on medication and hospitalisation. The opposite is currently true. It is very likely you will be offered a medication only approach if you attend a mental health service. It is very unlikely you will have adequate access to professional psychological care, professional psychotherapy, advanced/professional social care or structured evidenced based psychosocial interventions, groups, programs or therapies

7. It is not dangerous to question the use of medications in addressing mental health problems; it is dangerous to massively over rely on them and use a medication only approach to mental health care, as is currently the case. It is dangerous to suddenly stop taking some medications so only do so under medical supervision

8. A credible alternative movement has been developing for many years, with key critiques of the current ‘disease model’ or ‘illness model’ paradigm coming from both within the ranks of the medical profession and psychiatry and outside from journalists, service users, psychologists and others. We are very lucky to have one such critic in our country, Terry Lynch, GP (author of the fantastic book ‘Depression Delusion’). This movement (often unfortunately called the anti-psychiatry movement) which voices criticism of the current model and offers an alternative road forward has been articulated clearly in many ways. Most recently in an excellent review of the issues by Professor Peter Kinderman of Liverpool University in his book ‘A Prescription for Psychiatry’. But historically by many other highly credible leaders in the field e.g. Joanna Moncreif ‘The Myth of the Chemical Cure’, Robert Whitaker ‘Anatomy of an Epidemic’, Richard Bentall ‘Madness Explained’ and Peter Breggin ‘Toxic Psychiatry’. For anyone seeking a genuine reform of mental health care, this body of thoughtful, evidenced based critiques and understandings should be reviewed and acted upon. A movement called the International Critical Psychiatry Network has been established and is promoting a campaign to abolish psychiatric diagnostic systems such as ICD and DSM (CAPSID). The call for reform is coming from both within and outside of Psychiatry. http://www.criticalpsychiatry.net/wp-content/uploads/2011/05/CAPSID12.pdf

In his book, Professor Kinderman offers a prescription for mental health services. I am summarising, paraphrasing and quoting the central elements below. We should adapt these recommendations without delay.

1. Get the message right. We need to change our whole framework of understanding from a ‘disease model’ to a ‘psychosocial model’

2. Drop the language of disorder, symptom and illness. We must stop regarding peoples very real emotional distress as merely symptoms of a diagnosable illness

3. Be careful with medication. We should sharply reduce or reliance on medication to address emotional distress. We should rely on a ‘drug based’ approach to medication use and not a ‘disease based’ approach, as articulated by Joanna Moncreif

4. Offer holistic psychosocial services. Services should be equipped to address the full range of peoples’ social, personal and psychological problems and also address prevention

5. Offer non-medical residential care

6. Establish democratic multidisciplinary teams that can be lead by members of all disciplines, and are not automatically led by a Psychiatrist thereby automatically frontloading the disease model in considering how mental health problems are conceptualised

7. Plan for mental health and well-being alongside other social, rather than medical, services

The messages in Professor Kindermans manifesto are vital and we should listen and take it seriously. A change must happen sooner rather than later. A massive increase in funding for non medical, psychological and psychosocial interventions and for staff who are expert in the delivery of these interventions is required if we are to move beyond the current paradigm. A significant political and managerial change in ethos is required. It seems likely that until voters start to demand these things from their political representatives the change process will be allowed languish. While some changes have been made, we are a very long way from a genuine and substantive reform of our mental health services.

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Mental Health Care Reform Needed Now

The Role of Trauma in Mental Health: The issue cannot be ignored any longer

There is no doubt that trauma is a major contributor, and likely cause of the mental suffering of many people who are given diagnoses for mental illnesses. This has recently been established and articulated by people like John Read. You can see him talk about it here http://youtu.be/Y6do5bkUEys

What is most impressive about this issue is the extent to which childhood adversity and trauma is associated with future mental health difficulties. The relevance of trauma vastly outweighs the relevance of biological or genetic factors. And yet the overwhelming majority of interventions people receive are designed to ‘treat’ biological ‘illnesses’. Medications will not address early traumatic experiences. Psychotherapists and psychologists have known this through the therapeutic process for decades. As a psychologist it has become abundantly clear that early experiences shape profoundly the quality and nature of our health and mental health. This has always been evident even looking back in time through the lense of sometimes hazy memory. Listening to people’s stories over the last two decades (almost) has left me in no doubt. However, it is encouraging to see research establishing this reality in a different and very solid way. No longer is this just the opinion of some psychologists and therapists. John Read points out that trauma, particularly cumulative or multiple trauma (the various forms of child abuse for example) multiplies the risk of developing psychosis many many times over. If trauma was somehow magically erased from our society the incidence of psychosis would reduce by about one third. This is a massively important public health concern. The Advese Childhood Experience Scale research has also established firmly the role of early trauma in all sorts of negative health outcomes both physical and mental. The US centre for disease control now views early trauma as a major public health issue.

Every assessment of every persons in mental health care should now include a comprehensive review of early trauma. All mental health professionals should be highly trained in working therapeutically with trauma. Currently this is not the case, very few disciplines have any comprehensive understanding of early developmental processes and the impact of trauma on our development. I include psychologists in this group, although the problem is less so in this group. Most mental health professionals are poorly equipped to assess, understand and facilitate healing from early trauma, despite the enormous role it plays in so many peoples mental health difficulties. There is a wealth of information to facilitate this healing drawing from PTSD literature and psychological interventions ranging from exposure therapy, to psychodynamic and psychoanalytic theoretical and therapeutic understandings to the work of people like Peter Levine. Looking at things from a problem specific angle, like paranoia or depression, we also find a great deal can be done to help psychologically and psychotherapeuctically. So why is this not the driving force of interventions for those people who present to mental health services? Primarily because clinicians are not looking at people who have been hurt, wounded, abused and traumatised, they are looking at illnesses. Looking at people as if they are illnesses obscures the lived experience and reality of people’s developmental pathway towards the mental health difficulty.

In short, mental health services need to become at least in part, sophisticated and expert trauma healing services. The evidence is overwhelming. We must adapt to this understanding.

 

 

 

The Role of Trauma in Mental Health: The issue cannot be ignored any longer

Mental Health: An urgent need for reform

Mental health has never been more in need of reform and investment. This blog will reflect on the developments occurring around the world that could and should be applied in Ireland and elsewhere.

The first and primary issue requiring reform in mental health is conceptual and philosophical. It would be easier if a particular type of therapy, a number of psychologists or something concrete were ‘the’ central need for reform. These things are indeed also required and will be reflected upon in future posts. However firstly a thought on philosophy. It is the ground from which all else grows. If the philosophy is flawed, all mental health care that follows from it is also flawed. The current system is based on a disease or illness model of mental health. This presupposes the existence of discrete biological diseases or illnesses that can be diagnosed and treated. This is the most fundamental problem with modern mental health care. There are no biologically based illnesses, there are no diseases. This of course doesn’t mean that people don’t suffer or experience low mood, terrifying paranoid ideas, extreme anxiety etc. It simply means these things are not accurately thought of as illnesses.

The first thing we as a society need to do is rethink psychological distress, emotional pain, mental anguish and events that seem extreme and hard to understand. All things can be understood with sufficient time and patience. We must dispose of the disease model and drop the language of medical intervention to stop ourselves repeating the same errors.

Why do we need to make this change? So what if we call depression an illness? The problem with this frame of reference is the likelihood that a medication only approach follows and a cessation of thinking. We don’t need to understand why the person is depressed anymore. It’s sufficient to say they are depressed, because depression is an illness. But this is flawed. Why a person becomes depressed is extremely important. This understanding has enormous consequence for how we might consider helping. An example. Someone has lost their job, lost their marriage, and has a history of childhood abuse. They become deeply depressed and meet criteria for the illness ‘major depressive disorder’. Do we really believe that the problem is a chemical imbalance in their brain that needs to be addressed by medication? Of course not. Help with these specific problems is most likely to benefit this person. The help that might help may be different for different people; psychotherapy, behavioural therapy, social support, occupational therapy, lifestyle changes, exercise, peer support etc. There are many things that might help. Including medication. The fact that a psychoactive substance might help is not the issue. People have always used chemicals to alter how they feel sometimes very effectively. However this does not prove the disease model, and the medications can come with risks, dependency, side effects that all should be understood. Drugs also don’t help many people and even harm some. And they certainly don’t address the underlying difficulties. So back to the point. Why change? Why not use an illness model? Because it stops us thinking about what might be helpful and points inaccurately to a non existing disease that obfuscates the nature of anyone individuals depression.

We should without hesitation switch to a collaborative formulation model which allows for the development of an idiosyncratically based understanding of each persons depression or anxiety or schizophrenia. This shared understanding points to problems and possible solutions. This may at times point to drugs, but almost always won’t, certainly not in the long term and certainly not as a stand alone approach to treat illnesses.

 

 

 

Mental Health: An urgent need for reform