Five years ago, when I worked as a clinical psychologist within the UK’s psychiatric system, a senior colleague urged me to be patient. After hearing me – again – express my frustrations at the speed of change, and the stubborn endurance of bio-medical approaches to human suffering, he would urge me to aim for modest, incremental improvements in the existing system, to not expect too much too quickly, and to strive for ‘evolution not revolution.’
But how realistic is it to expect that the biological skew of Western psychiatry can be sustainably changed one small step at a time?
During the last decade of my career in psychiatric services I experienced mounting recognition that a paradigm shift – something akin to a revolution – would be necessary if, as a society, we were to meaningfully promote or restore positive mental health to our fellow citizens. Further reflection has highlighted four reasons for my pessimism about the potential for organic change to the existing system:
- The degree of change required
Despite the emphatic discrediting of the bio-medical, ‘illness like any other,’ approach to mental health problems, the routine discourse heard throughout mainstream psychiatric services continues to be dominated by assumptions of brain diseases and chemical cures. A fly on the wall of a typical inpatient unit or community mental health team anywhere across the Western world would witness professionals wrangling about correct diagnoses and corresponding medication combinations. Where pockets of more enlightened psycho-social practice exist, they are typically viewed as optional add-ons, supplementary to the core biological treatments.
The distance yet to travel to realise a more appropriate response to human misery and overwhelm is vast and daunting. Meanwhile, numerous people who seek help from psychiatry are experiencing interventions that are of limited benefit and often damaging. Given these circumstances, the adoption of an evolutionary approach to change is difficult to justify on both practical and moral grounds.
- Vested interests
Two powerful institutions benefit hugely from the current ‘diagnose and medicate’ approach to mental health problems and will use their considerable muscle to quash attempts to promote sustainable change.
The misdemeanours of the pharmaceutical industry have been well documented. The concept of brain disorders that demand indefinite medication is such a lucrative one that drug companies will stoop to any depths to maintain the biochemical imbalance myth: sponsoring bogus brain diseases (for example, suggesting that social phobia is synonymous with being ‘allergic to people’ ); bribing doctors to promote ineffective drugs for unapproved uses ; influencing the stance of service-user organisations through their funding ; and speaking directly to the general public through media advertising .
The psychiatric profession is the second major stakeholder who would be terminally damaged by a paradigm shift away from bio-medical approaches to mental health. The power, status, and remuneration of consultant psychiatrists are dependent upon the perception that their medical expertise is central to the treatment of mental health problems, in the same way, that other specialists (such as oncology, gynaecology, neurology) rely on the overarching skills of their medical practitioners.
Unsurprisingly, given what is at stake, the psychiatric profession’s substantial power continues to be deployed to counteract any effort to shift the tone of mental health services away from bio-medical dominance. One widely used strategy is to neutralise alternative approaches by removing their more radical elements so that what remains appears different from the dominant orthodoxy only in the degree of emphasis  – what might be referred to as the, ‘we’re already doing this’ approach. For example, some years ago I recall a psychiatrist claiming his was already a recovery-orientated service on the basis that it strove to cure people of their mental illnesses.
Given these vested interests, innovators espousing alternative approaches to mental health are likely to be ignored, discredited or neutralised.
- The general public’s liking of simplistic explanations
When faced with complexity, human beings are drawn to explanations that require minimal effort. Bio-medical accounts of mental health problems offer such a seductively simple message. If a person is acting bizarrely, hearing voices and overly suspicious, biological psychiatry can label him as suffering from ‘schizophrenia,’ suggesting the presence of an underlying brain abnormality. Similarly, withdrawal, despair and a lack of enjoyment of life can conveniently lead to a diagnosis of ‘depression’ and the implication that the person’s malfunctioning neurons are somehow causative of the presentation.
Over the last three decades, many of the so-called ‘public education’ initiatives around the issue of mental health have promoted these kinds of lazy – and spurious – explanations . Similarly, current ‘mental health first aid’ courses adopt an illness approach to human suffering , while celebrities like Stephen Fry and Ruby Wax continue to espouse ‘broken brain’ explanations for their personal struggles .
Although, when left to their own devices, the general public lean towards psychosocial factors (bereavement, trauma, environmental stress) as the primary causes of mental health problems , the bio-medical, ‘illness-like-any-other’ accounts can be seductive. These simplistic explanations negate the need to further question our own roles and responsibilities for the prevalence of human suffering; labelling people as ‘mentally ill’ conveniently avoids reflection about the contributions of families, work colleagues, neighbours and fellow citizens via processes such as scapegoating, discrimination and victimisation. Consequently, piecemeal advocates of alternative approaches, scattered across the existing psychiatric system, are unlikely to harness the widespread support of the general public necessary to realise the desired radical change in the way we address mental health problems.
- The lack of political will
A fundamental and sustainable shift away from bio-medical approaches to human suffering will not be achieved solely by changes to psychiatric provision; whole-system transformation to the legal and political domains will also be required.
Mental health legislation across the Western world constitutes a form of legalised discrimination, denying people with mental health problems fundamental civil liberties afforded to all other citizens . Yet, it is rare to hear high-profile politicians advocating for reform; their silence is in stark contrast to campaigns to change laws that perpetuate sexual and racial discrimination. It seems that these legal generators of misconceptions – portraying psychiatric service users as people with internal defects that render them inherently risky – will remain immune to change for decades to come unless there is an injection of revolutionary energy that allows the rejection of laws (such as the UK’s Mental Health Act) to be seen as part of the ‘last great civil rights movement’ .
Furthermore, the current ‘illness-like-any-other’ approach, in locating the cause of mental health problems in the brains of individual sufferers, gets our politicians off the hook. If it is assumed that diseased brains are primarily responsible for human misery and overwhelm the well-documented contributions of societal ills, then homelessness, poverty, intra-family violence, high-crime neighbourhoods, unemployment, and discrimination can all be conveniently ignored by the government of the day.
Taking all of the above into account, it seems unrealistic – even naïve – to expect that radical change away from bio-medical approaches to human suffering can be achieved organically, one step at a time, by innovative practitioners embedded within the existing psychiatric system. A hefty dose of revolutionary energy is needed to ignite the system from its current self-serving inertia. But how can such a catalyst be developed?
What follows are my reflections on the kind of forces that might be necessary to start, and maintain, a fundamental shift away from the current ‘illness like any other’ approach to mental health problems. Such a transformation will require multi-level changes to the Western world that stretch far beyond a redesign of existing psychiatric provision. Consistent with this premise, I will structure my proposed changes under two broad headings: legal and political.
Legal: fundamental revision to mental health legislation
Mental health laws across the Western world represent legalised discrimination against people suffering with emotional distress and overwhelm (12)(13). By sanctioning incarceration of law-abiding citizens without trial and non-consensual drug administration, mental health legislation rides roughshod over two fundamental human rights afforded the rest of the population.
In the UK, the justification for coercion under the auspices of the Mental Health Act is based on two dubious assumptions: the presence of a ‘mental disorder’ and the conclusion that the individual presents a risk to self or others. A formal psychiatric diagnosis is typically seen as broadly indicative of a mental disorder, despite the construct being virtually meaningless, providing scant information about both the course of a mental health problem and the interventions likely to be beneficial (14). Likewise, even the most comprehensive of risk assessments (for suicide and homicide) are only marginally better than guesswork and are unlikely to reduce the number of high-profile incidents (15)(16)(17).
In addition to legitimising discrimination, the implicit assumption within the legislation that people with mental health challenges are risky perpetuates the ‘psycho-killer’ myth and the associated sensationalist media headlines. Furthermore, the fact that sectioning requires no formal assessment of decision-making capacity implies that all people with mental health problems are inherently defective, an assumption that leads to more stigma, less proactivity, more hopelessness and overuse of medication (18).
It is unrealistic to expect a radical change in the way we respond to human suffering while all professionals operate within the discriminatory infrastructure of mental health legislation. What we urgently require is a collective scream of disapproval from mainstream psychiatric personnel – social workers, psychiatric nurses, psychologists, and psychiatrists – comparable to the reaction we would expect if the legislative framework underpinning their day-to-day work was blatantly racist or sexist.
Furthermore, the organisations representing psychiatric professionals possess a moral and clinical responsibility to oppose discriminatory mental health laws. For example, the formal bodies and trade unions that advocate for mental health practitioners might usefully consider supporting a ‘conscientious objection’ clause whereby their members can legitimately – and without fear of censor – opt out of colluding with the fundamentally unfair ‘sectioning’ process. Collectives of social workers and psychiatric nurses could be particularly potent in this regard, given their relatively high numbers and central role in its day-to-day implementation.
Political: make the economic case for radical reform
Money is the primary driver underpinning Western societies, with income generation, the rate of taxation and level of government spending typically determining whether proposed changes are desirable and sustainable. As such, to be viable, a revolution in the way our nations respond to human suffering would need to make economic sense. The seductive financial implications of radical reform must be made explicit, without fear of disturbing the sensibilities of the vested interests – traditional psychiatry and the drug companies – that act to maintain the status quo.
Some commentators argue that rejection of the ubiquitous capitalist system is necessary to improve the mental health of our citizens meaningfully. Such arguments are not without merit. Consumerism and the pursuit of profit undoubtedly contribute to the power differentials and social inequalities that are to some extent responsible for the emergence of mental health problems [for example, (19)(20)]. It is, however, unrealistic to expect a wholesale rejection of capitalism by the Western world in the foreseeable future. Nor am I convinced that these generators of human suffering would not arise in other political systems.
The economic advantages of a paradigm shift away from bio-medical approaches to mental health must be spelled out and widely promoted if radical change is to be achieved. The main elements of such a proposal might include:
A) The phasing out of acute, hospital-based inpatient units
Re-locating safe spaces away from (hugely expensive) inpatient hospital units to community-based respite houses, where criteria guiding staff recruitment would focus mainly on personal qualities and lived experience of mental health problems rather than a designated professional qualification, would markedly reduce expenditure. There is already plenty of research evidence to support the argument that non-medical units can provide an effective service, at significantly less cost, for people overwhelmed by psychotic experiences – for example, the Soteria approach (21).
B) Shifting the lead role for mental health away from physical health providers
In the United Kingdom, this would involve the withdrawal of lead responsibility for mental health away from the cash-strapped National Health Service (allowing it to concentrate on physical health problems) and redirection of funding towards an expanded 3rd sector and charitable organisations. Not only would this transition save money, but the culture of the new environment would be more enabling, less stigmatising and free from the suffocating risk aversion so characteristic of traditional services.
C) Phasing out psychiatry posts
The considerable savings from a system that no longer requires the employment of psychiatrists should be highlighted. As of April 2016, there were almost 9,000 medical psychiatry posts in the UK, with about half of these at consultant level (22)(23). Realistically, attrition would be a gradual process but could start immediately by shedding the significant number of consultant psychiatry posts that are currently vacant and covered by – extremely expensive – locums. The compensatory requirement for an expansion of General Practitioners to attend to the physical health needs of those struggling with emotional problems would not hugely detract from these savings.
D) Drastic reduction in the drug budget
The grotesque overuse of psychotropic drugs by traditional psychiatry has been widely documented, reporting year-on-year increases in consumption. Community prescribing of antidepressants and antipsychotics in 2014 for England alone reached 57.1 million and 10.5 million respectively (and these figures exclude inpatient hospital settings) (24). In the USA, the amount spent annually on these drugs has recently been estimated to be $11 billion for antidepressants and a staggering $15 billion for antipsychotics (25). A much more cautious, and shorter-term, use of medication would save a vast amount of money that could be redeployed towards prevention and the promotion of mental wellbeing (for example, the funding of projects to support socially disadvantaged families).
If we are to achieve the desired paradigm shift away from the bio-medical approach, these economic arguments – delivered in a detailed and comprehensive way – should be at the forefront of the fight for more appropriate responses to human suffering. Professor Peter Kinderman has offered one recent, worthy attempt at such an analysis in his book, A Prescription for Psychiatry (26).
This article originally appeared on http://www.talesfromthemadhouse.com/blog/
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(26) Kinderman, P. (2014). A Prescription for Psychiatry: Why we need a whole new approach to mental health and wellbeing. pp. 175 – 185. Palgrave – MacMillan