Our turbulent minds
The idea that our more distressing emotions are nothing more than the symptoms of physical illnesses, which can then be treated like any other medical disease, is pervasive and seductive. But it is also profoundly flawed, and our present approach to helping people in acute emotional distress is severely hampered by old-fashioned and incorrect ideas about the origins and nature of mental health problems.
We should stop thinking about 'abnormality', 'disorder' and 'illness', and instead offer humane and effective responses to what are understandable and normal psychological reactions. Because this is an approach which celebrates our shared humanity rather than relying on expert treatment of illnesses, I think that the best chance for real change lies in members of the public actively campaigning for better services to promote psychological wellbeing, for choice and for a choice which reflects a more appropriate understanding of our problems.
Mental health issues have been estimated as costing as much as $2,500 billion worldwide each year. In the UK, around 6,000 people take their own lives each year, and suicide is rapidly becoming the most common cause of death in young people. This is a large, complex, and important issue. It’s a matter of life and death, and it’s certainly ‘real’.
But, unfortunately, old-fashioned and unscientific ideas about the nature and origins of mental health problems remain common. Taking a lead from conventional medicine, our mental health care system applies ‘diagnoses’ to emotional, behavioural and psychological issues. And, when illnesses are diagnosed, people’s life experiences and their views on the origin of their problems are often seen as effectively irrelevant.
Failing to acknowledge the real problems
That means we do not have to harbour uncomfortable thoughts about the human costs of domestic abuse, rape, the sexual abuse of children, unemployment, poverty, inequality, war, loneliness and failure. All these troubling issues – the factors that can lead us to become distressed – can now be kept comfortably at arm’s length.
Conveniently for those with vested interests in the current system, the focus of attention moves to so-called ‘mental illnesses’. We now focus on looking for pathologies within the individual – whether genetic or biological abnormalities, or ‘thinking errors’. An expensive system develops to ‘treat’ these ‘illnesses’, with all the professional consequences. Multinational pharmaceutical companies step in to offer drugs – at a profit. In the UK, we spend over £800m each year on psychiatric drugs.
The ‘disease model’ also often strips professionals of their ability to empathise. Because the patient’s behaviour is seen as irrational, the product of an ‘illness’, even a ‘disease’, we stop trying to understand the human reasons why they might be feeling or acting the way they are. When people are distressed and feel that their sanity, even their life, is threatened, they need empathy and compassion more than ever. It is precisely then that we need to understand, rather than create divisions between ‘them and us’.
Illness and hospitals
Because our psychological health is seen as a matter of ‘illness’ and ‘disorder’, healthcare planners take a highly medical approach to care.
There is a shortage of non-medical alternatives, and the services that are available are often very stretched. Problems have to be quite serious to justify admission, and people are reluctant to enter residential units because of the pressurised and stressful atmosphere. There are worrying levels of violence against staff and service users, sexual harassment, and theft, with drug and alcohol problems being common. At the same time, people who could leave hospital if there were appropriate alternative specialist services are often detained for far too long; longer than would be the case if appropriate services were available in the community. And finally, in this maelstrom of stress, residential units are also plagued by boredom, a lack of purposeful activity, a lack of staff-resident interaction, and inadequate physical environments.
This is all wholly unacceptable. When we are so distressed we need residential care, we need a genuine ‘asylum’, a place of safety and calm, where we can resolve tension and stress and overcome trauma... not be exposed to abuse and assault.
This doesn’t mean rejecting the contributions of our medical, psychiatric, colleagues. A good analogy for this argument might be the role of medicine in pregnancy. Doctors from a wide variety of specialisms (general practitioners, obstetricians, paediatricians) all offer valuable care for pregnant women and babies. Pregnancy can sometimes have potentially serious medical complications, and we need medical science and professional care. But pregnancy, itself, is not an illness.
Similarly, when a multidisciplinary team offers care to a person in emotional distress, medical colleagues have much to offer. But that doesn’t mean that people are ‘ill’, and it certainly doesn’t mean that they necessarily have an underlying biological abnormality. In my opinion, this ‘disease model’ is scientifically incorrect, and contributes to the negative, punitive, controlling ethos that often prevails in services. It undermines genuine empathy and compassion; instead of seeing people’s difficulties as understandable and natural responses to the terrible things that have happened to them, the person is seen as having something wrong with them – an ‘illness’.
Addressing the biological
On a very technical level, much of the evidence used to support a biological model of ‘mental illness’ is open to challenge. Firstly, there is only very weak evidence for genetic causes of mental health problems. Many mental health problems appear to have high ‘heritability’ – they tend to ‘run in families. But, while this understandably implies that there are biological, genetically inherited characteristics at work, this is not the only mechanism for transmission down generations. Because rich people tend to have children who turn out themselves to be wealthy, car ownership is highly ‘heritable’; car ownership runs in families. Some important differences between people can be inherited without being biological.
But that’s probably being somewhat dismissive. Modern biological science has given us remarkable, important and useful insights into the genetics of these phenomena. But the picture is clearly much more complex than merely saying that, for example, schizophrenia is a genetic disease.
In the case of mental health problems, it’s highly likely that a very large number of genetic variants all conspire to offer generally increased or decreased risks of a wide variety of problems. Genetic factors play a role in all human phenomena, including our mental health, It does seem clear that there are a very large number of genetic factors that increase the one’s general vulnerability to or likelihood of experiencing mental health problems – psychosis (hearing voices or experiencing paranoia), mood swings, social communication and difficulties in concentration.
Even when researchers find clear evidence of biological factors associated with mental health problems, this is a long way from concluding that such problems constitute ‘illnesses’ or that such biological ‘abnormalities’ are necessarily biological causes. We know, for example, that the hippocampus – an area of the brain – is specifically involved in memory. It’s fascinating that taxi-drivers’ hippocampi physically change as they develop their ‘mental maps’ of London. That is a physical change in the brain as a result of environmental factors. It would be ludicrous to suggest that the changes in the brain, in the hippocampus, are unrelated to the taxi-driver learning more about the physical geography of London, but it’s equally ludicrous to suggest that the changes in the hippocampus have ‘caused’ changes in the taxi-driver’s behaviour. Brain studies in mental health are vitally important as we struggle to understand ourselves better. But we have to be careful how we interpret them, and in particular not to use misleading biologically reductionist arguments.
This is important, because there is evidence that the ‘disease model’ itself is associated with stigma and discrimination. People in receipt of mental health care experience high levels of stigma and discrimination. Many people assume that promoting a biological understanding of mental health problems will reduce stigma – because it implies that the person is not responsible for their problems. So traditional attempts to reduce negative attitudes towards people with mental health problems have – of course – used the ‘disease model’, biomedical approach, and have tried to make the case that ‘mental illness is an illness like any other’.
On the whole, these have had only limited success. And that’s not really surprising. Biological, especially genetic explanations, suggest that people experience difficulties because their genetic blueprint, their DNA, is faulty. If we say that a particular trait is both undesirable, and part of the most fundamental, heritable, and immutable genome of the individual, we are clearly associating that person fundamentally with the undesirability. We may well feel some sympathy with someone who is ‘ill’, but locating an undesirable social phenomenon within the essential nature of a person is also very stigmatising.
Psychological models themselves can be stigmatising, of course - they can still focus attention on what goes on inside people’s heads, rather than on what has happened to them. We can blame ‘thinking errors’ or – worse, and unscientifically – still blame the person’s character or personality. But I repudiate that too.
Explaining things either in terms of biology or a person’s innate disposition tends to lead to greater discrimination, and so a non-medical approach – one that stresses how our psychology is shaped by the events that happen to us, the experiences that we have, and how we learn to respond to them – is likely to be the most effective and humane. It also, happily, is more accurate and scientific.
Despite the importance of social factors in the development of mental health problems, routine mental health care in practice still relies on the attempted treatment of illnesses assumed to reside, physically, in the body and more specifically the brain, as opposed to helping people to address these social challenges.
But those social factors are powerful. Colleagues of mine at the University of Liverpool recently conducted an elegant analysis of the impact of the economic recession on suicide rates. They concluded that around a thousand people had taken their own lives as a result of the recent financial crisis and recessions.
There’s also good evidence that inequalities, both economic and social, are particularly important. Looking across successful, industrialised nations (the ‘G20’ nations), the greater the difference between the rich and poor, the worse a nation performs on a series of measures such as physical health, obesity, substance misuse, education, crime and violence, and (of course) mental health.
The economic mismanagement of our economy really is a matter of life and death.
A psychological ethos and model
Our social circumstances, the things that happen to us, and our biology, influence our emotions, thoughts and behaviours – our mental health – through their effects on psychological processes.
Of course, all mental health problems involve the brain. But that’s not necessarily an explanation. What is more interesting is how much differences between us, in terms of biological risk factors or in terms of the different life experiences we’ve had, account for our different mental health experiences.
The evidence convinces me that variance between us in terms of our neurological processes seems to account for very little in terms of the observable differences between us in our mental health – or indeed human behaviour in general. Most of the variability in people’s problems appears to be explicable in terms of our very different experiences, and how we respond to them, rather than genetic or neurological malfunctions.
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 earlier, 6,000 people take their lives every year in the UK, and their hopelessness and despair is very real indeed.
But ideas of disease or illness are unhelpful. 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.
As I said earlier, we know that issues such as poverty, deprivation, social isolation, childhood abuse (of various forms) all affect us emotionally and psychologically. Mental health problems are strongly linked to inequalities and violence, including gender based inequalities and gender based violence, and to those threats that people, especially those in vulnerable situations such as poverty or social exclusion, face when their basic needs are not met and their rights are not protected.
People respond psychologically to these abuses. Poverty and social deprivation, and sexual, emotional, or physical abuse lead to fear, disillusionment, hopelessness, and learned helplessness – to a belief that others are likely to be malevolent, and that there is little or nothing that one can do to improve or change one’s lot in life and so there is little point in trying. It should not be surprising when people experiencing such negative events become depressed or anxious, paranoid or hopeless.
Since the 1950s we 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.
A fully psychological approach to mental health would suggest that our beliefs, emotions and behaviours – including our mental health – are the product of the way we think about the world, our thoughts about ourselves, other people, the world and the future. And it would acknowledge that thoughts are, in turn, the product of a process of learning.
And I should say, of course, that not everybody who experiences mental health problems is the survivor of abuse or poverty. Merely navigating the normal processes of life – relationships, adolescence, learning how to manage our own complex and turbulent thoughts… which don't always behave as the should – set bear-traps to catch us out if we’re unawares. Life, for each of us, is a complex challenge.
So these problems aren’t best thought of as disorders or illnesses. They are the human consequences of how each of us – for all those complex reasons that make us who we are – have made sense of and responded to the events and challenges in our lives. Even the concept of ‘abnormal’ psychology is unreasonable: we don’t talk about ‘abnormal chemistry ‘or ‘abnormal physics’ – the science describing how our minds work describes us all, not the ‘normal’ and ‘abnormal’.
Once we reject the notion of disease, but embrace the ideas of understanding and care, the shape of services would be very different.
Imagine there’s no diagnosis, it’s easy if you try
The ‘disease model’ approach to mental health care naturally relies on diagnosis. But the dominant diagnostic framework in mental health is unreliable, invalid and even bizarre. Committees of experts – with vested interests – fail to agree on diagnostic criteria. Statistical analyses fail to identify clusters of symptoms that correspond to the putative ‘disorders’. In fact, the abject failure of diagnostic approaches has led the enormously wealthy and enormously influential American National Institute of Mental Health to declare that its strategy ‘cannot succeed’ if it uses the diagnostic categories enshrined in the influential ‘Diagnostic and Statistical Manual’ of the American Psychiatric Association and there is widespread opposition from a wide group of professional and service user-led groups.
Psychiatric diagnostic labels have huge implications – they affect access to healthcare, legal issues, and employment rights, and they lead to discrimination and stigma. They are ‘sticky’; although psychiatric diagnoses are intended to be descriptive summaries of a person’s particular problems, they tend to be applied to the person (not the problems) and they tend to linger on over time (not disappearing when the original problems disappear or change).
But we have alternatives. They are nothing extraordinary. It’s merely the application of science – we identify the observed phenomena, describe them clearly, and relate our observations to our knowledge of relevant science. This means identifying social anxiety – a perfectly understandable human phenomenon – rather than diagnosing social anxiety disorder. If people are plagued by intrusive thoughts and compulsive behaviour, that can perfectly easily described in common-sense language. And we can all recognise post-traumatic stress. It adds very little to add ‘disorder’ to post traumatic stress, to make post traumatic stress disorder… except to imply that there’s something wrong with the person… and of course that you need a medical expert.
New models of care
In the vision of mental health care that I am proposing, 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. In these places, our medical, psychiatric colleagues would still play a valuable role, but the ethos of care in such places 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 when compulsion is needed, 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.
The drugs work… but not in that way
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. In episodes of acute distress, people may 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 the psychiatrist Jo Moncrieff) be very brief, targeted and practical. Medication should be used to help people through difficult times, not to ‘treat’ putative ‘illnesses’.
Medication – of course – alters our brain chemistry and affects our moods, our thinking, our behaviour. That’s really unsurprising, but falls a long way short of treating underlying pathological processes or – and this is a widely used phrase – correcting chemical imbalances.
One example. Very recently, we saw media coverage of the use of ketamine, a recreational drug and battlefield anaesthetic, to help people who are seriously depressed, but for whom all other approaches had failed. An expert commented that; “…low dose intravenous ketamine [has] a dramatic and rapid effect… The effect peaks at one day and can persist for a couple of weeks”. I really am not surprised that a combat anaesthetic and recreational drug has a powerful, even positive, effect on our mood. Isn't that why people use it on the streets? And I would be genuinely pleased if ketamine helped people who were severely depressed and for whom nothing else gives relief. But again… isn’t that why people take street drugs? While perhaps welcome, I do not believe that this equates to effective treatment for an illness.
Second, 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 finally, to promote genuine mental health and wellbeing, we need to protect and promote universal human rights, as enshrined in the United Nations’ Universal Declaration of Human Rights. Because experiences of neglect, rejection and abuse are hugely important in the genesis of many problems, we need to redouble our efforts to protect children from emotional, physical or sexual abuse and neglect. Equally, we must protect both adults and children from bullying and discrimination: whether that is racism, homophobia, or discrimination based on sexuality, gender, disability or ‘mental health’ or any other characteristic. We can all do more to combat discrimination and promote a more tolerant and accepting society.
Disagreements within psychiatry
None of this is a ‘guild dispute’ – a fight between psychologists and psychiatrists.
Sadly, many psychologists use diagnostic labels and fail to question the ‘disease model’ or the widespread use of psychiatric medication. Equally, many psychiatrists reject these views.
Over the past few years we have seen very different visions for the future of psychiatry – from within the profession. Professor Nick Craddock, and 36 colleagues, in an editorial in the British Journal of Psychiatry, argued that psychiatry needs to re-establish itself as a branch of medicine, re-establish mental ill-health as a medical concept, re-establish the biological and neurological basis of ‘real’ mental illness and re-establish the authority and status of the psychiatric, medical consultant.
In contrast, Professor Pat Bracken, and 28 psychiatry colleagues, again writing in an editorial in the British Journal of Psychiatry, argued almost exactly the opposite. They suggested that the vast majority of mental health problems, including those traditionally seen as symptoms of serious ‘illnesses’ such as ‘schizophrenia’ should instead be understood from the perspective of social psychiatry – as normal, human, responses to difficult social circumstances. They argued, therefore, for a social, psychosocial, empathic response.
Obviously, I strongly orientate to this more social ethos. But my point is that this is debate and even a dispute within psychiatry rather than between psychology and psychiatry. I clearly can’t claim everybody agrees with me. But I do know that my allies come from both my profession and from my psychiatry colleagues.
My allies also come from other places. To mark World Health Day 2017, the United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Dainius Pūras reflected on the fact that our health is not only dependent on our astounding – and very welcome – scientific and professional developments, is also a matter of social justice. More specifically talking about our mental health, Mr Pūras commented that depression, in particular, ‘… is strongly linked to early childhood adversities, including toxic stress and sexual, physical and emotional child abuse, as well as to inequalities and violence, including gender based inequalities and gender based violence, and many other adverse conditions which people, especially those in vulnerable situations such as poverty or social exclusion, face when their basic needs are not met and their rights are not protected.’
He went further, arguing – as I do – that: ‘... a reductive neurobiological paradigm causes more harm than good, undermines the right to health, and must be abandoned…. There is a need of a shift in investments in mental health, from focusing on "chemical imbalances" to focusing on "power imbalances" and inequalities.’
Obviously, I agree.
A prescription for mental health and wellbeing
Drawing this all together, my prescription for our mental health and well-being services could be summarised as:
Mental health problems are fundamentally social and psychological issues. We should therefore replace ‘diagnoses’ with straightforward descriptions of our problems, radically reduce use of medication, and use it pragmatically rather than presenting it as a ‘cure’.
Instead, we need to understand how each one of us has learned to make sense of the world, and tailor help to our unique and complex needs.
We need to offer care rather than coercion, to fight for social justice, equity and fundamental human rights, and to establish the social prerequisites for genuine mental health and wellbeing.
Finally… a few years ago some colleagues and I were discussing how we might spread these ideas outside of academic and professional ivory towers. We thought about two successful (or at least engaging) campaigns… ‘some people are gay, get used to it’ and ‘there’s probably no god, now stop worrying and enjoy your life’.
And I can do no better than the words of the campaigner and activist Jacqui Dillon, who rejected the disease-model approach by saying…
‘Don't ask what’s wrong with me, ask what’s happened to me’.
Kinderman, P. (2014). A prescription for psychiatry. London: Palgrave Macmillan.
Wilkinson, R. & Pickett, K. (2009). The Spirit Level: Why More Equal Societies Almost Always Do Better. London: Allen Lane.
Davies, J. (2013). Cracked: Why psychiatry is doing more harm than good. London: Icon Press.
Moncrieff, J. (2007). The myth of the chemical cure. Palgrave Macmillan.
Cooke, A. (Ed). (2014). Understanding Psychosis and Schizophrenia: Why people sometimes hear voices believe things that others find strange, or appear out of touch with reality, and what can help. A report by the British Psychological Society Division of Clinical Psychology. Available from www.understandingpsychosis.net
Davies, J. (Ed). (2017). The Sedated Society: The Causes and Harms of our Psychiatric Drug Epidemic. London: Springer.
United Nations (2017). Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. Available from http://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=21480&LangID=E
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