Professionals across the Western world, from a range of disciplines, earn their livings by offering services to reduce the misery and suffering of the people who seek their help. Do these paid helpers represent a fundamental force for healing, facilitating the recovery journeys of people with mental health problems, or are they a substantial part of the problem by maintaining our modestly effective and often damaging system?
A discomforting question
Earlier in the year I attended an excellent conference hosted by the Psychosis Research Unit in Manchester (UK) titled, ‘Challenging the Stigma of Psychosis: Advances in Theory, Research & Practice‘. A range of speakers – professionals and people with lived experience of mental health problems – delivered informative presentations describing the stigma endured by many people experiencing psychiatric difficulties and the potential ways to eradicate it. However, for me, the most memorable (albeit discomforting) moment of the day was not in relation to something a presenter said, but a question asked from the floor.
The eloquent Rai Waddingham (an internationally-renowned trainer) had delivered a powerful account of her own experiences within the UK’s psychiatric system where, despite the worthy intentions of many of the staff, the central ‘you are ill’ message she heard from professionals only reinforced her longstanding view of herself as an inherently defective ‘monster’. In the aftermath of her talk, a young woman sitting towards the rear of the conference room raised her hand and asked, ‘Do we really need mental health professionals?’
As a vocal critic of traditional psychiatry, I’ve recognised for many years how viewing a mental health problem as an ‘illness like any other’ is unhelpful and often damaging, quashing hope, encouraging passivity, increasing stigma and leading to the gross overuse of neurotoxic medication. As such, I’ve long been convinced that our society would respond more effectively to human suffering without the contribution of biological psychiatrists. But the young woman’s question was framed in much broader terms, suggesting all mental health professionals might be culpable.
The question triggered a sequence of disturbing thoughts within me. I worked for 33 years as a psychiatric professional (nurse and clinical psychologist) within the NHS mental health services and devoted countless hours to talking therapy, offering thousands of distressed people structured ways of overcoming their emotional and behavioural difficulties. Was this dominant chunk of my working life ineffective, or even damaging? Would the cash-strapped services have been wiser to invest only in lay people with the appropriate personal qualities (compassion, genuineness, open mindedness) to support those suffering distress and overwhelm rather than on relatively expensive professionals?
My uneasiness deepened as I brought to mind the raft of evidence casting doubt on the superior healing qualities of an expert psychological therapist: all brands of psychotherapy achieve broadly similar outcomes (suggesting that it may not be the therapy per se that is the active ingredient) (1)(2); the quality of the relationship between the service-user and helper is the most potent predictor of outcome (and you don’t need to be a professional expert to develop a positive rapport with someone) (3)(4); untrained amateurs can achieve therapeutic outcomes similar to highly-trained professionals (5); and – in many ways the most dispiriting bit of evidence – my personal recollections that many of the service users I worked with did not seem to realise prominent improvements in their mental health.
We also know that psychiatric professionals are the most potent source of stigma for the people they are commissioned to support (6). And (at least in the UK) one can only begin to imagine the benefits of freeing the helpers from the suffocating constraints of the risk-averse National Health Service, where mental health professionals are often compelled to prioritise the reams of paperwork to protect themselves and the organisation from future censure rather than providing human support to someone suffering emotional pain and overwhelm (7).
The Soteria approach to acute psychosis – as pioneered by Loren Mosher (8) – deployed non-professional staff and the outcomes were at least as effective as expensive (and often traumatising) acute psychiatric units. Peer support, where people with lived experience of mental health problems offer timely help to those currently in crises, represents an acceptable and hugely beneficial way of responding to those in the midst of mental turmoil and overwhelm. And service users themselves can provide excellent guidance about the kinds of services they find most helpful.
Furthermore, it is increasingly recognised that one of the most potent ways of countering human suffering is to address the fundamental societal ills (discrimination, homelessness, deprivation, disempowerment and intra-family abuse) that spawn the mental health problems of the future. These radical shifts depend on political will rather than the contributions of psychiatric experts.
So do we really need mental health professionals?
In a perfect world, there would be no need to pay people to help those suffering emotional pain. In a Utopian society the primary generators of mental health problems – discrimination, homelessness, poverty, intra-family abuse, unemployment, and violence – would be eradicated. All of us would feel empowered and recognise our worthwhile contributions to our communities. On the occasions of feeling distressed or overwhelmed, we would rely on the nurture of our comprehensive social networks, friends and family instinctively rallying to provide the necessary support.
Alas, such an ideal is not going to be realised anytime soon; perhaps the human race will require several thousand more years of evolution to recognise the universal benefits of such an egalitarian society. So in the meantime I believe we will require people in formal helping roles, supporting and enabling those who are suffering and overwhelmed.
What do we mean by ‘professional’?
It is important to define what we mean by a mental health professional, as the term can be interpreted in different ways. The expression might refer to anyone who receives payment for routinely offering help to those experiencing emotional pain and suffering. In this respect, a peer support worker, for example, who accepts a regular salary immediately morphs into a mental health professional. It does not seem unreasonable to me – on ethical or practical grounds – that those devoting time to the stressful, and often challenging, role of supporting people through periods of heightened distress and overwhelm receive payment for their efforts.
However, when the need for mental health professionals is questioned, I suspect that a very different kind of employee is in mind, one who has achieved membership of a traditional occupation (psychiatrist, psychologist, psychiatric nurse, occupational therapist or psychiatric social worker). The recognised experts in these fields seem rather different animals to helpers without these formal qualifications and, I believe, it is the value of these specialists that is increasingly disputed.
While there clearly are benefits for service users of a workforce comprising mainly of qualified professionals – particularly around accountability and the requirement to maintain explicitly stated standards – the price for this is often destructive power imbalances and a suffocating level of risk aversion. More importantly, to gain membership of one of the traditional professions requires assimilation of a body of knowledge that is different from, and in many respects incompatible with, that of the others. Thus, within mental health services the outcome can be a competitive environment where each professional group expresses self-serving dogma, jockeying for position within over-regulated organisations like the National Health Services and Local Authorities.
So what is the optimal skill set?
So perhaps the central question is not so much whether we need paid helpers – which clearly we do – but deciding the optimal content, and underlying values, of the learning environment to which aspiring professionals are exposed. Given the contested nature of the mental health field, this is a far from a straightforward task. My own view is that the core, mainstay of an ideal service should provide people suffering distress and overwhelm with routine access to fellow humans who possess the appropriate personal skills (empathy, compassion, genuineness and open-mindedness) and who operate within a philosophical framework characterised by hope and the expectation that all service users can find their own idiosyncratic solutions to the problems that life has inflicted upon them and thereby achieve a worthwhile existence.
Supplementary to this core provision, a menu of change (or coping) options should be available for service users to opt into if they so wish. These secondary approaches would require personnel with the appropriate skills to offer: psychological formulations to enable people to make sense of the contributory factors to both the development and maintenance of their distress; strategies for self-soothing and arousal reduction, such as mindfulness and relaxation; short-term medication options, accompanied by balanced information about their drug-centred mode of action (i.e. creating abnormal brain states) and side effects, as well as describing potential benefits; and a range of evidence-based talking therapies.
Ensuring sustained delivery of these skills
It is one thing to list the optimal skills and values to support service users, but a far more difficult challenge to ensure that provision adheres to these requirements and does not default back to an unhelpful ‘illness like any other’, techno-medicalised approach to human suffering.
In order to ensure the appropriate skills development – and skills maintenance – for this proposed new type of professional, the mental health system would require several key elements. Firstly, with regards to the UK, the lead providers of the service would be largely independent of the National Health Service and Local Authority, thereby freeing them from the bureaucratic constraints and unhelpful cultures of these organisations. Third-sector providers (social enterprises, community groups, co-operatives, charitable bodies) that can nurture and sustain the desired ethos would be central to the new model, aided by the use of non-hospital settings Perhaps there is something to learn from the way that the hospice movement in the UK maintains its distinctive philosophy to providing high quality, end-of-life support, and drawing significantly on charitable donations and input from volunteers.
Secondly, all personnel employed in the core service will benefit from having undertaken a ‘generic mental health’ qualification, incorporating the appropriate skills and values. Such a course could usefully be overseen and delivered by an expansion of the existing recovery and well-being academies that centrally involve people with lived experience of mental health problems in the production and delivery of the curriculum. Importantly, an essential criterion for a significant proportion of the core workforce would be personal experience of seeking help from psychiatric services.
Thirdly, inspirational and high-quality leadership, at every level, would be essential to maintain the underpinning values of the service, in tandem with comprehensive support networks for the helpers to counter burnout and ideological drift.
So returning to the original question, ‘Do we really need mental health professionals?’, the gist of my response would be, ‘Yes, but in a radically different form to the current incumbents’.
- Styles, Shapiro & Elliott (1986). ‘Are all psychotherapies equivalent?’ American Psychologist 41(2), 165 – 180.
- Epstein (2006). ). ‘Psychotherapy as Religion: the civil divine in America’. Reno NV, University of Nevada Press.
- Bergin & Garfield (1994). Handbook of Psychotherapy & Behaviour Change (multiple editions)
- Norcross [Ed] (2011). ‘Psychotherapy relationships that work’. 2nd edition. New York. Oxford University Press.
- Moloney, 2006: ‘The trouble with psychotherapy’ Clinical Psychology Forum, 162, 29-33.