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.