A manifesto for psychological health and wellbeing
The Psychologist appeared at Latitude Festival in Suffolk for the third year running this summer, with two sessions. This one will be available as a podcast in the new year; what follows is an edited transcript.
Is it time for a revolution in how we think about mental health? Peter Kinderman, Professor of Clinical Psychology at the University of Liverpool and author of A Prescription for Psychiatry, rejects the ‘disease model’, which views emotional distress as a symptom of biological illness. Instead he argues that mental health problems are fundamentally social and psychological issues – the products of how we understand and respond to the world. Instead of thinking about diagnosing and treating 'abnormality', Peter argues we should replace ‘diagnoses’ with straightforward descriptions of our problems, and shift away from the use of medication towards psychological and social solutions.
In conversation will be Victoria Tischler, Professor of Arts and Health at the University of West London; and Dr Henrietta Bowden-Jones, a medical doctor and neuroscience researcher working as Consultant Psychiatrist in Additions, and the current President Elect of the Medical Women’s Federation. The panel will consider new and creative approaches to wellbeing. Should we rip up the manuals and move forward with a new manifesto?
HBJ: Through my work, I know that people can feel imprisoned by a diagnosis, by a term that is collectively negative in suffering. They feel so desperate at having understood that they have something wrong that is a known mental illness. This can leave people wanting to self-harm. It can leave people wishing they’d never been born. I’m not saying this lightly; it’s in feedback I’ve had from patients. So I’m particularly keen to hear from Peter on this.
In relation to art and science, there are many many ongoing projects and some of them I’m involved in deeply, like the Science Gallery in London. I’m a curator/advisor for a new exhibition called Hooked, which is all about addiction in art. And there are also Wellcome funded projects by Catriona Brodie and Vanessa Bartlett looking at how to portray the difficulties of addiction, through really high-quality art.
After these two wonderful presentations the three of us will comment on each other’s’contributions for a while, and then for the last 20 minutes we really want to hear your experiences, your thoughts, your questions. These Wellcome sessions are some of my absolute favourites here at Latitude … throughout the year I get emails from people who are part of the audience, wanting to connect, wanting to contribute, and I think that’s wonderful. You’re welcome to reach out to me on Twitter @artsciencedoc where you can also find a lot about what I think about pathological gambling, which is what I do during the week, with the NHS. I mean, that’s not what I do… you know what I mean.
So without further ado, I’d like to introduce Professor Victoria Tischler with our next topic.
VT: Good afternoon, thank you for inviting me to this session. I’ve got a brief few minutes to talk about my personal manifesto for mental health and wellbeing.
I’m a professor of arts and health, and I lead a dementia care centre, so most of my work focuses on using arts and creativity in dementia care. I feel very privileged to work in a job that I feel so passionate about. My mission is to really place art and creativity at the centre of mental healthcare. I’m going to explain why that is by presenting evidence from research that I’m involved with, and putting it in a wider context of why we should all have a right to be involved in arts and culture. And also, I’m going to issue up what I’m interested in, what I believe in, in the style of a manifesto, but also invite each and every one of you to join me by making a subtle change or a shift in each of your own lives in terms of improving your own health and wellbeing as well.
It’s not just me saying that being involved in arts and creativity is a good thing. I quote the relevant article from the United Nations Convention on Human Rights here so you see that it’s actually a human right to have access to cultural materials, to go to the theatre, to experience film, to go to art galleries, to go to museums. And I think that really gives it the appropriate kudos, the status that it deserves. It underpins why it’s not just a nice idea, or an add-on to mental healthcare, to have access to arts and culture. It’s a human right, and that’s the position I start from.
I underpin this belief with evidence from research that I’m involved with. So I wanted to start by highlighting some of the research findings that are coming out of the work on looking at creativity and mental health. My findings are very encouraging indeed. As I said, I work primarily in dementia care. But where there’s a critical mass of people coming through, new scholars who are looking at the evidence for music, creative writing, visual arts, theatre, dance, you name it, there’s really good scientific evidence which is coming out to show that these things are not just nice to do, and to experience, but they actually have real impact on our mental health. Just to give you some highlights, activities such as discussing visual arts and making art – and this is probably the modality that I’m most involved with – does a variety of things. Improvement in mood; it makes us feel better to be involved in these types of activities. It makes people more attentive, so that’s very important when people feel distracted, or they’re not able to concentrate. And these are things that are quite common symptoms that people with a variety of mental health problems may have. These activities improve communication, and when I say communication I don’t just mean social chit-chat, I mean meaningful conversation about meaningful things. So carers will come with people with mental illness to art sessions and talk about things that matter. Things from the past. Memories that are important to us. Values. Not just talking more, but talking about things that really are important in terms of being a human being, our connection to other people. Often people with mental health problems experience social isolation, they become detached from other people. And we know that being part of a group, communicating with others who are supportive, is very beneficial for mental health.
Activities also stimulate this idea of flow, which some of you may be familiar with – synchronicity between the physical and the mental self. When you’re doing something and you’re so engrossed in what you’re doing that you’re not aware of anything else around you. You often hear athletes talk about this, where we’re trying to be the best we can be, and creative activities are able to get us in that zone of being in a state of optimising our performance: that is very good for our mental health.
And what I also know about people being involved in art is that it’s about identity. I’ve done a lot of work in forensic hospitals, and that brings it across in a place where people have mental health problems, and they’ve also committed in some cases very serious criminal acts. For these people, they can’t go to art galleries and museums, they’ve been detained, but I remember a patient from a forensic hospital, and he showed me his artwork – he’d done an A-level in Art, and was a very talented artist. He said, ‘I’m an artist, I’m not a patient’, and for him that made a big transition from being someone in the seat of mental healthcare, almost feeling like he didn’t have an identity, to having a really strong identity as an artist, and from there he could actually see a future, and not only is it a path to recovery from mental problems but also potentially a future career.
I also think that there’s a lot of negativity around mental illness, and when you look at the condition that I deal with most of all, dementia, it’s the most feared condition, people are really frightened of dementia. People often talk about it as a fate worse than death, almost a living death. I think that arts and creativity gives people hope, it’s quite positive. To give an example: I devised a pop-up art installation recently which was inspired by artwork made by people with dementia. Around that, we built a café, and people could come in, and we showcased the wonderful creative work made by people with dementia. The public were very shocked that people with dementia were able to be creative, and to produce these aesthetic artefacts that were really beautiful and thought-provoking. We also had singing, we had dancing, we had artists working with the public, and all of this was under research evidence about dementia but in a joyful way, to get people talking about a serious mental health condition.
So just to give you some other examples of things I’m involved with, a lot of my work involves taking people with serious mental health problems into art galleries. The image you can see on the left here is me working with a group of people with dementia in Nottingham Contemporary, a gallery that is very committed to working with people with a variety of mental health problems. I also put artists into care homes. I think artists have a really key role to play in the mental health workforce. Artists are trained in a very flexible, responsive way. They’re not worried about health and safety concerns that a lot of us healthcare professionals are. They’re able to work very flexibly, and a lot of people, as you may be aware, are worried about the quality of care in dementia, there’s been some abuses in dementia care. So I think that by putting artists in, you can really change that culture of care and provide a really interesting experience for people who perhaps can’t rely on verbal communication as we can.
The image I’m showing you here on the right, it’s by a Mexican artist called Martin Ramirez, who went to the US in the 1930s, and he didn’t speak, he had a breakdown in an asylum in California and started to create incredible artworks using very basic materials. This man has been seen as a master creative in the field of finer art. His work commands six-figure sums, is seen at Frieze, in the top art shows, and this from all from a humble fisherman who ended up in an asylum… so there are lots of opportunities for people to be recognised for their creative talents, and not just for having mental health problems.
So I’m committed to providing opportunities for people with mental health problems to get involved in creative activities, to showcase their work, to celebrate the creative mastery that people have, and to share that, and to create a dialogue about mental health problems. I’m really interested by inspiring students to come and work with me in this area. Mental illness is still stigmatised; a lot of people don’t want to work with people who have mental health problems, so I see my work as showing people it can be really interesting and stimulating to work in this field, and making a case for creativity. It’s not just enough to say, ‘this is a good idea’, we need to provide the evidence for people who make decisions about mental healthcare, and who pay for services.
I’d like to finish with a call to action; this is something I did, and I’d like you all to consider what you might do. This is me performing on stage with a dance company called Candoco. I’m not a dancer, this is a Wellcome-funded project about hysteria. Myself and the choreographer have devised a piece about the EU referendum result. It’s called Brexit Means Brexit, and I was given the opportunity to perform on stage. It was terrifying, but for me it was incredibly cathartic and powerful, so I’d like you to think about one thing you could do to improve your own lives, in terms of creative opportunities for you or people around you. Thank you.
HBJ: Victoria, thank you so much. I think one of the things I’d like to touch on later during our discussion is resilience and prevention, because I do believe that sometimes in many of the people I see who have problems, life took over, routines took over, there was very little time, if any, for flow or any even discussion of flow by the time someone tried to look after a house, do their job, look after the kids… I think in many circumstances anxiety and depression could have been avoided if time had been carved out somehow, and maybe also if knowledge had been delivered in terms of how one might spend one’s time in order to improve peace and serenity. And one of the saddest things I have found is that sometimes, some of the people I treat can’t remember ever having had a happy day, ever. They started life being neglected, abused, beaten, you name it. Life just got worse and worse, until it was either addiction or mental illness. With those people, how do we give them that knowledge. At what level do we do it – before they get ill? Would it be through schools? Give me a thought about that.
VT: I’m not an idealist in thinking that everyone can become an artist, but what I do know is that giving people the opportunity to partake in some kind of creative activity is cathartic, at any point, even in people with advanced dementia, who you might think are not capable of sitting for five minutes, are able to engage in some way. So I think it’s about making a small change, not putting a canvas in front of somebody who’s got all kinds of problems, but just finding something that resonates with them, finding a small opportunity for them to experience pleasure and joy, which then might motivate them to make an additional change.
HBJ: Thank you, we’ll pick that up in a moment. I’d like to introduce Peter Kinderman now.
PK: Thank you very much. So, my name is Peter Kinderman, I’m a professor of clinical psychology at the University of Liverpool. My basic manifesto is that we should see mental health problems as fundamentally social and psychological issues with some medical components, rather than as fundamentally medical illnesses with some social and psychological aspects.
For me then, we all have emotions, we all have thoughts, we all have ambitions and disappointments. We all need in our lives a sense of meaning and purpose. We are all dependent on the presence and absence of relationships around us. We all try to make sense of the world on the basis of our experiences and this shapes our mental health and wellbeing. We are all different, we all have different personal vulnerabilities, we all experience different challenges and adversities in our lives, and we’ve all learned to respond to the influence of people around us in different ways to respond to those adversities. Inevitably, this means that we are different in terms of our mental wellbeing. Some of us are generally happy and rational most of the time, some of us have very serious problems indeed, but hope we have joy in our futures. And of course all possible variants and permutations of experience are also present. So for me then, mental health and wellbeing are key to understanding how we think, feel and behave, not the accurate or supposedly accurate diagnosis of pathologies, illnesses or disorders. It’s not, in my opinion, the case that ‘one in four’ of us meets the criteria for a mental illness, whatever that might mean, but we don’t need to diagnose their pathologies, we don’t need to look at the pain and suffering in people’s lives and decide that this is the result of a disorder inherent in their personality or their brains or their being. Instead, all we need to do is understand our psychological wellbeing.
For me this means we need to move away from the disease model. We need to move away from a model that assumes that emotional distress is merely symptomatic of biological illness. Instead, we need to embrace a model of mental health and wellbeing that recognises our shared and essential humanity. Mental health is, in my opinion, dependent on our understanding of the world, and our thoughts about ourselves and other people, the future and the world around us. For me, biological factors, the social environment in which we live – and contrary to Margaret Thatcher I do believe that there is such a thing as society – and of course the events that happen to us are experienced as human beings and the way that we learn from it are all important in that they shape the way that we have learned to engage with and respond to the world. They build up our sense of who we are, and the way that the world works.
It’s for these reasons that I believe that we should regard our mental health as a social and psychological issue. That means that we should replace the practice of diagnosis with straightforward, and I would say, in fact, scientific descriptions of our problems, we should radically reduce the use of medication, and we should use it pragmatically rather than seeing it as a cure for an underlying disorder or dysfunction of the person. Instead, what we need to do is understand how each one of us has learned to make sense of the world, a process that clinical psychologists refer to as formulation, and offer care rather than coercion. And finally, I think we need to put this into a genuine manifesto: I think our mental health and our wellbeing are matters of social justice. This is a genuine photograph of the streets of Mumbai, where individuals are sleeping rough, and behind them you see the billboard: ‘There is only one way to live. The Trump way.’ A genuine photograph that is also indicative of the nonsense of which we live.
So our mental health and wellbeing are matters of social justice, because experience of neglect, and rejection, and abuse, are hugely important in the genesis of many mental health problems. We need to redouble our effects to protect children and adults from emotional, physical and sexual abuse and neglect. More generally, I think if we’re serious about preventing mental health problems, and developing and promoting general psychological wellbeing, we should be work collectively to create a more humane society, to reduce or eliminate poverty, especially childhood poverty, and reduce financial and social inequality. And I plead, indeed, as everyone does these days it seems – this is a report by Dainius Pūras, the United Nations special rapporteur on the human rights of people to physical and mental health access. This is the argument of the special rapporteur of the United Nations rather than myself, but I would like to fully engage myself with what he’s saying. And his quote is that ‘The crisis in mental health should be managed not as a crisis of individual conditions, but as a crisis of social obstacles which hinder individual rights. Mental health policies should address the power imbalance rather than the chemical imbalance, targeting social determinants and abandon the predominant medical model that seeks to cure individuals by targeting disorders.’ Thank you.
HBJ: Thank you Peter, very much. At this point, according to the organisers of the festival, we need to stand up and have a fist-fight! But instead, we will have a gentle conversation. I am fascinated to hear his perspective and want to understand it a little bit better, because indeed, I may agree with you. Although right now, it’s hard for me to do so, but I’m happy to shift position somewhat.
It might be helpful for some of the younger people in the audience, the psychologists and psychiatrists come from a different let’s say, educational and academic formation. As a psychiatrist, having gone through medical school and having worked in lots of medical specialties I then chose psychiatry, but the issue here is very much about the medical model, as you mention. The fact that the Royal College of Psychiatrists in the last year, with Simon Wessely as President at the helm, has had a quite high profile in trying to reach a parity of esteem, really, trying to achieve a status for mental illness that is on a par with other illnesses. So, in a way, he’s trying to do the opposite from what you are saying. But he may not be, it may be that I’m not understanding. The reasons why he’s pushing for that, or why the Royal College of Psychiatrists is pushing for higher profile for mental illness as an illness, is that by doing so, it may receive more status, more funding, more, let’s say, attribution in terms of suffering, in terms of quality of life. I also could totally see your point.
PK: I think that the general principle is that the degree of emphasis that we place on the distress that falls into the area generally referred to as mental health is too little. We don’t pay enough attention to mental health and wellbeing and more investment is needed to address this problem, so I completely agree with that. So for instance, children growing up in poverty in Britain are five times more likely to take their lives in adulthood than children with wealthy parents, and suicide is the most common cause of death in young men between 16-35. The idea that we should have a paltry, both NHS and social response to those needs, is of course a nonsense. I would absolutely agree that bearing in mind the amount of distress, the amount of suffering, and indeed if you want to go down a financial route the number of days lost to ill-health, the amount of impact on lost productivity, all of these data would suggest we need to invest much more heavily, absolutely, I completely agree. But that doesn’t mean that it therefore follows that if you have a child that grows up to hear the disembodied voice of her abuser, who continues to talk to her in the form of auditory hallucinations, that what you say to her is that although it’s possible to understand this as a psychological response to the experiences that you’ve had as a child, for the purposes of our initial argument, that you will call this a disorder. It doesn’t make any sense to say to veterans that return from armed conflict, traumatised by what they have experienced, and left with paltry social and healthcare services, that because the state is refusing to invest in care appropriately to your needs, therefore we will tell you that you suffer from a disorder. Of course, there is a phenomenon called post-traumatic stress: if you have watched babies’ arms being blown into the air as you advance with the forward forces into Mosul, then you will be traumatised by your experience. The idea that this means you have a disorder… the disorder is that you’re feeling something for your fellow human being, that is not a disorder. Yes, we should invest in mental healthcare. Yes, we should invest in the social wellbeing of our children. Yes, we should see people being given care commensurate of their distress and their needs that they have, but no, that doesn’t mean to say that the only way we can win that argument is to falsely claim that they have something wrong with them.
HBJ: Peter, thank you. I have one more question before we move to Victoria and then open things up. Do you believe that diagnostic manuals that we have been using to diagnose these kinds of illnesses – indeed post-traumatic stress is there – there are very clear guidelines for treatment. Do you believe that we should get rid of those?
PK: Yes. Absolutely. And one of the interesting things that I thought you were going to ask me whether that I thought they were invalid and unreliable. And I thought that would be a very easy win, because the people who wrote them say that they are invalid and unreliable. They say that there is no scientific evidence to support, for instance, the idea that the symptoms described that form the syndrome of schizophrenia actually coalesce in nature. They don’t find that the joints of nature are carved in the way that the manuals say. There’s no particular evidence that any one treatment regime follows from the diagnostic label. In fact the way in which most decent psychiatrists care for their clients is by looking at the particular circumstances of their case, the particular circumstances of their background, the nature of the exact experiences that they’re having. When you suggest to psychiatrists that treatment incidence with antipsychotic medication naturally follows from the diagnosis, they’re shocked.
In fact, even the proponents of diagnosis, say, despite the fact that these ideas are invalid and unreliable, it is necessary that we continue to use them. It might be necessary for professional psychiatrists, but it’s not necessary for clients. One final thing, in 1972, homosexuality was on a par with paedophilia, it was a mental disorder. The interesting thing about that vote, is that while about that while around 6000 members of the American Psychiatric Association voted to suggest that homosexuality was not a mental illness, 3500 voted to suggest that it was.
HBJ: A very good point and I’m glad you raised its shortcomings, and the fact that as society evolves, and our understanding of human nature evolves, then we are now on edition 11 of the manual because things are changing. Thank you very much, and we could carry on all night. Victoria, one very specific question for you. Who, in the UK, is doing good work in relation to promoting creativity and the arts for the people who most need it, and who might not be able to go and get it themselves?
VT: I couldn’t pick one in particular, there are lots and lots of good projects. What I think I would say is that it’s very patchy, it often depends on where you live, it depends on the attitudes of the decision-makers within organisations. What I would like to see is a much more joined-up approach, and coming from above. I’m involved in an All Party Parliamentary Group for arts and mental health so there is recognition at a government level that we need to embed arts and creativity into healthcare, but I think we’re a long way off. I was at a conference in Bristol a couple of weeks ago and there was a delegation from Finland where they’ve had an artist in government for 40 years. That, to me, that’s progress, that’s what we want, that’s the ambition. There’s lots of really good projects happening but the evidence base, again, isn’t fully developed yet.
HBJ: Something I made a note of last night and was thinking about during today’s session: we have to resist the very easy governmental position of, ‘there is no evidence base, therefore we shall not go ahead and fund this project’. Actually, the wellbeing of patients can be measured in many other ways, I think. Although eventually I’m sure that the right evidence base will be reached, I do get the feeling that not enough projects may be funded using, maybe even within hospitals rather than at a national level, this kind of approach. Certainly, when I started to try and get funding to get some cameras, cheap cameras even, to my pathological gamblers so they could record their experiences of being homeless and a pathological gambler, I was quite unsuccessful, because I kept being asked what the evidence base was. I had no idea, I just knew that it’d be a good, special thing to do. In the end, a photographer I knew did a session with them, and some of the things they came back with, the images and the narratives say ‘this was the first time anyone has believed in me, has trusted me with an object that I looked after and I used to express my innermost emotion, when I don’t have the words to do so’.
VT: Arts and culture isn’t harmful, I think it’s beneficial for everyone. It doesn’t need to be prescribed, people just need to have the opportunity. One thing I’d say in response to what you guys were talking about; I’ve worked in mental health for 20 years and what I know is that people’s mental health is complicated, it’s multifaceted, often the problems go back to when people were born, or even before they were born, and in a heavily metric society where we want quick fixes, psychiatry and mental health is suddenly led by a medical model, psychiatry at the helm, and we have CBT and cognitive behavioural therapies as a tool, the talking therapy of choice, it’s a quick fix… some would say it’s about getting people back into being economically viable as quickly as possible. How do you address problems that go back to childhood, or beforehand? Multiple adversities that people have often experienced… these things take a long time to unravel, and I think our politicians do not have the time or the will to get involved in something that’s so complicated, that’s so long-term, so expensive, potentially. So I think that’s why often we go for these quick fixes which are pharmacological or CBT.
PK: I completely agree. Of course roll on the day that we have a government in the UK that leans on some of the Norwegian social policies, and roll on the day we have a society in the UK that loves its children… if you work from home occasionally as I do, you’ll turn on the TV, and you’ll see adverts for child-free holidays, as if the best thing you can do is to spend your money to avoid interacting with young people. There are lots of ways in which the UK can be a quite horrible country and we need to move away from that.
One thing about quick fix is that I think there’s another element to this, in that I think there’s a slightly nasty coalition between what the government wants to do, what professionals want to do, and what the person wants, because the idea of absolving yourself from responsibility by saying ‘it was not me, it was my brain’ is a very tempting thing. But it’s obviously completely ludicrous… there’s lots of things where we could conspire, that the individual themselves would be quite right to have an externalising rationale for their distress, but we also, not only as a society but as individuals take responsibility for our own mental health and wellbeing and understand ourselves, where it has come from. I agree with you about CBT being a quick fix, but quite a lot of people want to go to their doctor and get the quick-fix.
HBJ: Peter, I have a slightly controversial question; I’m going to ask it and then we’ll open it to the floor. Should I tear up my prescription pad?
PK: No, you shouldn’t tear up your prescription pad. I think in the vision for mental healthcare that I have in the future, I’d actually like to retain medical professionals as part of the team. You hinted earlier that psychiatrists and psychologists have been trained from different backgrounds, and although I did quite a lot of biochemistry when I was an undergraduate I don’t have the professional knowledge to understand, to keep pace with, to be quite honest, the developments and the changes with drug policy. And in the team of people looking after my daughter, I would quite like to have a medical professional. My point is, I don’t think that medical professional should see herself as treating the underlying illness giving rise to these problems. And my best example of that: my daughter is heavily pregnant and she’s about to give birth, and her life, in fact, is dependent on medics. So medical expertise is valuable to help us. The drugs that you can prescribe are valuable, of course, but my daughter is not ill. She doesn’t have a disorder or pathology called ‘pregnancy’. She has a life experience which is a fulfilling and wonderful one, for which medical support is valuable and necessary. And I think that as we learn to deal with our experiences in our lives, I think our medical colleagues can play a part in the solution.
HBJ: Only psychiatrists should tear up their prescription pads?
PK: No no no, psychiatrists must be the ones who retain the medical expertise, otherwise you’ll have people like me being able to prescribe drugs and I wouldn’t be as excellent at it. The difference is not whether you prescribe or don’t prescribe, or whether you’re involved in care, but whether you think you’re treating an underlying illness, or whether you’re using your medical expertise and knowledge to help a person, understand the things that have happened to them, and how that’s led them to respond to the challenges in the way that they have, and use your expertise to help them, and not cure them of an underlying pathology.
HBJ: Brilliant, I knew we’d get on in the end, and that everything would be fine. Now, thank you for that. I’d like to open the floor to questions, but let’s start with Victoria. Has anyone got any questions for Victoria?
Audience member 1: It’s brilliant to hear a professional saying we’ve got to get away from CBT as a treatment, there’s nothing to address the deeper needs, it’s good to hear this.
VT: One of the many benefits of using arts and creativity is that it doesn’t rely on verbal communication. You’re able to communicate without having to speak, and with things like CBT, you need this kind of dialogue. I’d argue that being creative is a very powerful way of communicating very difficult, painful experiences, in a way that doesn’t involve talking and, clearly, for someone with dementia speech may be very difficult so it gives another way. It gives them agency.
Audience member 2: I deliver a lot of mental health courses for Mind. The doctors give people a prescription, and they’ve found it’s not helping. The number of people having positive relationships, exercise. Seeing what we can do to help people rather than going into their background. Some people think this is opening a can of worms, and just want to work on the future. They’ve been to counselling, CBT, and they’ve come out of that and said they just want to move forward. They hear, ‘time’s up, time to go’, and they’ve been left open wounded, being pushed out of the door. Going on a long-term course brings up a lot of different things, such as their relationships, what they eat, how they exercise, lots of basic things like that. Going back to basics has helped a lot more …
PK: There’s lots things in what you’ve said, including the importance of basics, physical health, exercise, relationships, community, not necessarily even going down the route of any sort of talking treatments, I kind of concur with that. One of the concerns about CBT is that, it’s a quick-fix intervention… Often, it’s seen that the alternative to this quick-fix form of therapy is long-term psychological therapy. This is surely based on another problem, that is ‘you’ve got a problem that needs to be put right, therefore you need to uncover what the problem is, we need to go into therapy, it hasn’t worked with CBT so you need to go deeper’; it might be, but you never know why it’s happened, you’ll never know what’s caused it… you should possibly avoid people who say that they can uncover the secret hidden trauma in your childhood because maybe it never happened. Maybe, I don’t know? But what are you going to do now? And then you rebuild their life, that’s not right for everybody, but it’s equally not right for everybody to say you’ve got to get to the root of their underlying problem. Again, there’s the element of pathologising that, you can pathologise them psychologically. Jay Watts has written about this recently in The Independent about problems with the mental health first aid approach.
The point you make is about the medication again, about the effects of this medication. One of the many ways in which you can assess the effectiveness of this medication, such as Prozac, is to look at the Profile of Mood States, a very quick questionnaire. In The Journal of Fashion Marketing and Management, there’s a paper that I co-authored where we invited women to choose outfits, clothing outfits, from their most hated to most liked… this partly depends on body shape and self-confidence and so forth, and then we asked them to rate their moods when wearing these clothes. The difference between wearing an outfit that you hate most, and love most – the difference in emotional quality between your experience of wearing those two outfits – is greater than the effect size of treatment over a two-week period with Prozac. So there are lots of things you can do to improve your mood. Going for a dance with someone you love is probably a really good idea and it’s probably more effective than Prozac. Problem is, not many of us dance, and many of us don’t have people who love them!
Audience member 3: My question is regarding the arts. I heard you talking about politicians and government and the schools to change arts and bring creativity into our everyday practice. But surely, if it can start at home, surely we want our children to be involved in these kinds of things, we want this change to be efficient and productive as possible, so surely we need to look at ourselves rather than looking outwardly, we want to engage our society, which I agree with, I agree that society is a real thing, we want creativity in society, it’s real, this connection between creativity and having an outlet of some description. Surely the best way to do that is through ourselves, not saying ‘you do it’, every day, ourselves do something creative and varied, just like eating fruit and vegetables.
VT: And that’s why in my call-to-action, I invited you all to do something creative for yourselves or for other people. I agree with you, it should start with oneself. I think you should lead by example. I think that being a parent is the toughest job ever, and that responsibility should start at home. And if I could just say something in defence of psychiatrists and mental health professionals, they’re not evil people, it’s a stressful job, and I taught medical professionals for many years, and the stress and the burden of care is huge. One thing we need to think about is how do we care for the people who care for others. So I don’t want to get into attacking professionals; it’s everyone’s responsibility and I think your point brings that home, it should start with oneself.
HBJ: Thank you Victoria. One thing I’d like to mention is severity. I only ever see patients who have already been through psychological treatment, and haven’t got better, and things have really broken down often, because they have tried everything, so medication is a last resort, fitting in quite well with what has been said. Two questions – one there then one there.
Audience member 4: One quick comment to start with. It’s great to hear a psychologist putting social inequality on the map: the study you quoted on children who grew up in poverty and violence being more likely to develop a mental health problem. My second point is about the word ‘mental health’. Do you know the most common form of insult is still ‘mental’? There are a lot of agencies who define mental health as mental health. I think we should also use the term ‘emotional wellbeing’.
Audience member 5: Yeah, I think it’s a really good idea, taking away from medicalising mental health and wellbeing, I just wonder how you can do that. We’ve got such a big way of working with mental health that’s so trapped at the moment. If you just take depression, people go to the doctors, and the GP has ten minutes, hardly any time, all they do is reach for their prescription. I’ve heard recently that prescriptions are sub-therapeutic doses of medication, so if a young person goes on anti-depressants, nothing else, and they’re sub-therapeutic, so they don’t work, and then they think, ‘well my depression must be really bad, I’m on these tablets and I’m not getting any better’. What about introducing something like a book, I’m thinking of Phillipa Perry’s How to Stay Sane. You know how you have nurses who check up on asthma? You have to go to a regular asthma check-up. Well, how about a regular wellbeing check-up? How about taking it out of that ‘pharma’? I also wonder about the pharmaceutical companies, they’re making a bomb.
HBJ: I’m going to let Peter answer all of that, but firstly I’d like to say if any of you see a GP for an issue related to anxiety or depression or anything to do with mental illness, make sure you ask for a review. Medication needs to be titrated, it’s not the lowest available dose for the population, it is awful, and I spend my whole life fighting for people who could have been saved from being really unwell if within primary care, they’d been invited back for a review. Has this medication caused side effects, if so, and you’ve stopped taking it, let’s try a new one. Or, it’s not causing side effects, you’re taking it, but you’re not well enough because actually you’re on the minimum dose. This happens all the time, thank you for raising that.
PK: It’s a real challenge. For the past 140 years, we’ve thought of our emotional distress as a potential illness, so we’ve regarded it as something to do with the healthcare system. I actually think that attitude is changing, so that we’ve moved from a very biomedical model to a biopsychosocial model, I think we need to move to a psychosocialbio model, or even a psychosocial model and move further in that direction. At the same time, we’ve seen a very welcome increase in the number of people who say, ‘in this modern society, the amount of money and resources that we have, the amount of distress that I see in my children’s behaviour is unacceptable, we should be doing something about it’… it didn’t happen in the past, we just accepted misery to be part of everyday life. We’ve also moved towards a more secular understanding. My view is that we’ve seen less prevalence of suffering, which is good, we’ve seen more willingness to do something, which is good, we’ve seen less reliance on religion, which is good, but we’ve filled it with still trying to cram people’s complex personal social lives into a biomedical understanding of their distress.
I think it’s really hard… what I’m extremely positive about in the UK context, is the development of regional mayors, with the responsibility for health and wellbeing. What you’re seeing is better integrated planning for social, even educational services, local authority services, charitable sectors, in locales with the health service planning. So rather than the NHS being organised over there, and local authority services over there, and charities somewhere else, we’re seeing regional planning for wellbeing. I sit on Liverpool’s health and wellbeing board, and we’re moving towards integrated planning, and I think that’s the way. The final point is, ‘how do we get from here to there?’ well, obviously, it’ll happen when citizens stand up for their rights and they say, ‘with regard to my daughter’s medication, why the hell was she not given a review, why did you not answer those questions?’. ‘When the World Health Organisation includes extreme poverty as a diagnostic category, why the hell do you not diagnose this with the same alacrity as you diagnose major depressive episodes?’
HBJ: Thank you Peter, I’m going to stop you here. Very passionate. We have time for one more question for Victoria.
Audience member 6: My partner’s a physician. I’m half Argentine and half English, and for the past five years have been living in Argentina. We both have an artistic background, and we both support different, very varied issues, from environmental issues to old people’s homes, to illiterate women, to rape victims, to everything, and we just go and volunteer and see what’s going on in art, that can help. It’s so wonderful to hear everything you said, I thought it was fantastic. What I wanted to ask in particular that one of the things that I noticed, having come back from Argentina as a developing country, coming back to London after five years, something I noticed that really alarmed me was the arts is very inaccessible. People don’t have time, they’re very stressed, and I felt it happening to me. I wanted to ask you, have you seen in all of your situations that a lack of time has been one of the biggest problems, people saying they don’t have the time to create art as a byproduct of being human?
VT: What you say, and your attitude, is what I love as an artist, so thank you! It’s like anything: you have to schedule it in. I have scheduled my yoga classes in like an appointment, and I honour that appointment, otherwise everything else would take over. Why shouldn’t an artistic activity, as a human right, not be part of your schedule? That would be what I would advocate.
HBJ: On that note, I suggest we all take up running, because that’s what I do five times a week to keep sane and keep well! Anything else?
PK: There’s a guide to exercise and well-being which is well-supported in many NHS Trusts and many local bodies so, Google ‘Five ways to wellbeing’.
HBJ: Thank you all.
- Thanks to Latitude Festival and Wellcome Trust for hosting us, and to Kate Brennan for transcription.
- A podcast of this session will be available via the Latitude website in the new year. In the meantime, find more from Professor Peter Kinderman (including his public lecture 'Our turbulent minds') and Professor Victoria Tischler in our archive.
- A transcript of our other session at this year’s festival, Professor Steve Reicher on ‘The rules of unruliness’, will be available (along with a podcast version) at the end of September.
- Read the transcripts of our sessions in previous years; Professor Sarah-Jayne Blakemore on teenagers debunked; and Professor Elizabeth Stokoe on how to talk so people listen.
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