A Manifesto for the Future of Mental Health Care by Peter Kinderman
Peter Kinderman, author of A Prescription for Psychiatry, discusses the current state of mental health care.
The idea that our more distressing emotions can best be understood as symptoms of physical illnesses is a pervasive, seductive but harmful myth. It means that our present approach to helping vulnerable people in acute emotional distress is severely hampered by old-fashioned, inhumane and fundamentally unscientific ideas about the nature and origins of mental health problems. In ‘a prescription for psychiatry’ I explain why we need wholesale and radical change in how we understand mental health problems and in how we design and commission mental health services.
It’s all too easy to assume mental health problems must be mystery biological illnesses, random and essentially unconnected to a person’s life. But when we start asking questions about this traditional ‘disease-model’ way of thinking, those assumptions start to crumble. While it obviously serves the purposes of pharmaceutical companies, ready with their chemical pseudo-solutions, the evidence doesn’t support this view.
Some neuroscientists have asserted that all emotional distress can ultimately be explained in terms of the functioning of our neural synapses and their neurotransmitter signallers. But this logic applies to all human behaviour and every human emotion – falling in love, declaring war, solving Fermat’s last theorem. It clearly doesn’t differentiate between distress – explained as a product of chemical ‘imbalances’ - and ‘normal’ emotions.
It is helpful to understand more about how the human brain works, but bio-reductionist accounts of mental health problems seem rather unhelpful. It’s obvious that neural activity and chemical processes in the brain lie behind all human experiences, but this is very different from assuming that some of those embodied experiences should be classified as illnesses. Our biology provides us with a fantastically elegant learning engine. But we learn as a result of the events that happen to us - it’s because of our development and our learning as human beings that we see the world in the way that we do.
Critics of traditional psychiatric thinking have begun to question the creeping medicalisation of normal life, and to criticise the poor reliability, validity, utility and humanity of conventional psychiatric diagnosis.
Over the past twenty years or so, we’ve seen a very positive and welcome growth of the user and survivor movements, some first signs of more responsible media coverage, and a rejection of the idea that we should be stupefied by shame and stigma into accepting the paternalism of earlier days – we are just starting to see the beginnings of transparency and democracy in mental health care.
Reviews of the ineffectiveness and adverse effects of many psychiatric drugs as well as of the effectiveness of evidence-based psychological therapies have led many to call for alternatives to traditional models of care.
All this has led many to call for radical alternatives to traditional models of care. I agree. But I would argue that we do not need to develop new alternatives. We already have robust and effective alternatives... we just need to use them.
We need to place people and human psychology central in our thinking. And we need to return to core principles – ethical, professional and scientific. Psychological science offers robust scientific models of mental health and well-being. These integrate biological findings with the substantial evidence of the social determinants of health and well-being, mediated by psychological processes.
We must move away from the ‘disease-model’, which assumes that emotional distress is merely symptomatic of biological illness, and instead embrace a model of mental health and well-being that recognises our essential and shared humanity. Our mental health is largely dependent on our understanding of the world, our thoughts about ourselves, other people, the future, and the world. Biological factors, social factors, circumstantial factors - our learning as human beings - affect us as those external factors impact on the key psychological processes that help us build up our sense of who we are and the way the world works. This is diametrically opposed to the traditional ‘disease-model’ of mental illness.
In my new book - A Prescription for Psychiatry – I offer a radical new ‘manifesto’ for mental health and well-being. I argue that services should be based on the premise that the origins of distress are largely social. The guiding idea underpinning mental health services needs to change from assuming that our role is to treat ‘disease’ to appreciating that our role is to help and support people who are distressed as a result of their life circumstances, and how they have made sense of and reacted to them.
This also means we should replace ‘diagnoses’ with straightforward descriptions of problems. We must stop regarding people’s very real emotional distress as merely the symptom of diagnosable ‘illnesses’. A simple list of people’s problems (properly defined) would have greater scientific validity and would be more than sufficient as a basis for individual care planning and for the design and planning of services.
I believe that our health services should sharply reduce our reliance on medication to address emotional distress. We should not look to medication to ‘cure’ or even ‘manage’ non-existent underlying ‘illnesses’. We must offer services that help people to help themselves and each other rather than disempowering them: services that facilitate personal ‘agency’ in psychological jargon. That means involving a wide range of community workers and psychologists in multidisciplinary teams, and promoting psychosocial rather than medical solutions. Where individual therapy is needed, effective, formulation-based (and therefore individually tailored) psychological therapies should be available to all. When people are in acute crisis, residential care may be needed, but this should not be seen as a medical issue. Since a ‘disease model’ is inappropriate, it is also inappropriate to care for people in hospital wards; a different model of care is needed.
Adopting this approach would result in a fundamental shift from a medical to a psychosocial focus. It would see a move from hospital to residential social care and a substantial reduction in the prescription of medication. And because experiences of neglect, rejection and abuse are hugely important in the genesis of many problems, we need to redouble our efforts to address the address underlying issues of abuse, discrimination and social inequity. This is an unequivocal call for a revolution in the way we conceptualise mental health and in how we provide services for people in distress. But I believe it’s a revolution that’s already underway.
Peter Kinderman is Professor of Clinical Psychology at the University of Liverpool, UK. His research activity and clinical work concentrate on understanding and helping people with serious and enduring mental health problems, and on how psychological science can assist public policy in health and social care.