International Journal o f Clinical and Health Psychology (2014) 14, 216-220

International Journal of Clinical and Health Psychology

w w w .elsevier.es/ijchp

THEORETICAL ARTICLE

The end of mental illness thinking?

Richard Pemberton3 *, Tony Wainwrightb <DCrossMark

ELSEVIER DOYMA

a University o f Brighton, United Kingdom b University o f Exeter, United Kingdom

Received 26 May 2014; accepted 15 June 2014 A vailable on lin e 9 July 2014

KEYWORDS A b s tra c t M ental he alth th e o ry and p ra ctice are in a s ta te o f sig nifica nt flu x . This th e o re t- Diagnosis; ic a l a rtic le places th e position taken by th e British Psychological Society Division o f C linical F o rm u la tio n ; Psychology (DCP) in th e c o n te x t o f c u rre n t p ra ctice and seeks to c ritic a lly exam ine some o f DSM-5; th e key fa cto rs th a t are d rivin g these transfo rm a tion s. The im petus fo r a co m p le te overhaul W e llb e in g ; o f existing th in k in g comes fro m th e m a n ife stly poor perform ance o f m e n ta l health services in T h e o re tic a l s tu d y w hich those w ith serious m e n ta l health problem s have reduced life expectancy. It advocates

using th e advances in our understanding o f th e psychological, social and physical mechanisms th a t underpin psychological w e llb e in g and m e n ta l distress, and re je c tin g th e disease m odel o f m e n ta l distress as p a rt o f an ou td a te d paradigm . Innovative research in genetics, neuroscience, psychological and social th e o ry provide th e p la tfo rm fo r changing th e w ay we con ceptualise, fo rm u la te and respond to psychological distress a t both co m m u n ity and in d iv id u a l levels. © 2014 Asociación Española de Psicologia Conductual. Published by Elsevier España, S.L. A ll rights reserved.

¿El f in d e p e n s a r e n e n fe rm e d a d m e n ta l?

Resumen La te o ría y la p rá ctica de la salud m e n ta l se encuentran en un m om ento de cam ­ bios significativos. El o b je tiv o de este a rtic u lo te ó ric o es m ostrar la posición adoptada por la British Psychological Society Division o f Clinical Psychology (DCP) en e l co n te x to de la p rá ctica a ctu a l, tra ta n d o de analizar de fo rm a c rític a algunos de los fa ctore s clave que im pulsan estos cambios. La necesidad de una revisión co m p le ta de los plan te am ie ntos actuales procede del m al fu n cio n a m ie n to de los servicios de salud m e n ta l en los que las personas con graves p ro b ­ lemas de salud m e n ta l han reducido la esperanza de vida. Se aboga por e l uso de los avances en los conocim ientos de los mecanismos psicológicos, sociales y físicos que sustentan e l b ie n ­ estar psicológico y la angustia m e n ta l, rechazando e l m odelo de enferm edad de la ésta como p a rte de un paradigm a ob soleto. Los avances de la investigación en ge nética, neurociencia,

* Corresponding author. University o f Brighton, Brighton, BN2 4AT, United Kingdom. E-mail address: [email protected] (R. Pemberton).

http://dx.doi.Org/10.1016/j.ijchp.2014.05.003 1697-2600/© 2014 Asociación Española de Psicologia Conductual. Published by Elsevier España, S.L. All rights reserved.

PALABRAS CLAVE D iagn óstico ; F o rm u la c ió n ; DSM-5; B ie n e sta r; E stud io te ó ric o

The end of mental illness thinking? 217

psicología y teoría social proporcionan la plataforma para cambiar la manera en que concep- tualizamos, formulamos y respondemos al sufrim iento psicológico, tanto a nivel comunitario como individual. ©2014 Asociación Española de Psicología Conductual. Publicado por Elsevier España, S.L. Todos los derechos reservados.

There is a p o w e rfu l m ovem ent in tra in , w hich is seeing old ideas in m ental health being replaced as new scien­ tific advances, including in epigenetics (Toyokawa, Uddin, Koenen, & Galea, 2012), neuroscience (fo r exam ple in child developm ent) (Riem e t a l., 2013) and psychological under­ standing o f cognitive mechanisms underlying m ental distress (Susan & Edward, 2011). M ental health is increasingly under­ stood as a public health issue (World Health Organisation, 2010) and research on incom e in e q u a lity has c le a rly shown th e lin k w ith expressions o f m ental distress (Wilkinson Et P ickett, 2010). This paper addresses one aspect o f this change, in w hich w e advocate abandoning th e o utdated 'd is ­ ease m o d e l’ o f m ental distress and th e developm ent o f new ways in w hich we can bring to g e th e r a ll th e elem ents o f a person’s experience in order to help them most e ffe c tiv e ly , and fo llo w s th e pub lica tio n by th e Division o f C linical Psy­ chology o f th e B ritish Psychological Society on classification o f behaviour (Awenat e t a l., 2013).

The United Kigdom context

Due to th e im p a ct o f a u ste rity on com m unities and ser­ vices across th e w hole o f th e Unted Kingdom, m ental health services are under severe stress and increased pressure. The governm ents program m e o f 'h e a lth service lib e ra tio n ’ (D epartm ent o f H ealth, 2010) has changed the way th a t services are funded. Power has shifted to doctors w orking in com m unity settings and away fro m centralised decision­ making. The people who use services have been p u t a t th e h e a rt o f policy making and every o th e r p a rt o f th e system is being to ld th a t th e re is to be " n o decision about me w ith o u t m e” . Budgets fo r social care have been d ra m a ti­ c a lly reduced and m ental health service funding has been c u rta ile d . The tra d itio n a l near monopoly o f th e N ational Health Service is being replaced by a much more m ixed econ­ omy o f providers. Many services are being p u t out to te n d e r and are s ta rtin g to be provided by N on-Governm ental Orga­ nisations (NGO’s) and p riva te fo r p ro fit companies. These changes have been highly p ro b le m a tic b u t also have resulted in significant challenges to historic patterns o f pra ctice and have brought forw ard new providers and new ways o f w o rk ­ ing. The governm ent agenda o f 'P a rity o f Esteem’ w hich is designed to increase e q u ity o f resources betw een m ental and physical health care services has h e lp fu lly highlighted th e very significant reduction in life expectancy fo r peo­ ple very serious m ental health d iffic u ltie s (Royal College o f Psychiatry, 2013).

There has been a consistent demand, by those who experience distress, fo r more psychologically based m ental

health care (Hicks e t a l., 2011). In England th is has resulted in a new program m e o f psychologically driven care. More people are now seen in th e im proving access to psychologi­ cal therapies program m e (IAPT) than are seen in secondary m ental health care (IAPT, 2012). This program m e has in large p a rt been lead by C linical Psychology. The program m e was in itia lly fo r people w ith a n xie ty and depression in th e com ­ m u n ity but has since developed a range o f service redesign arms in to the areas o f psychosis, long te rm physical con­ ditio n s, and m ental health services fo r ch ildren and young people.

The service user and recovery movements have been gaining p o litic a l strength and m a tu rity (Centre fo r M ental H ealth, 2003). Peer recovery w orkers and recovery colleges are becoming comm onplace. In th e la tte r you do not need to take on th e id e n tity o f a p a tie n t to receive support and guid­ ance to manage w hatever th e issue th a t is causing concern and distress. The w hole basis o f exp e rt professional p ractice and pow er is being questioned in new and challenging ways.

The Diagnostic and Statistical Manual version 5 (DSM-5) debate

The recent DCP co n trib u tio n to the debate concerning DSM-5 (Awenat e t a l., 2013) has been to release a s ta te m e n t calling fo r a very d iffe r e n t approach; one th a t does not deny the im portance o f biology and physical factors b u t w hich calls in to question th e e x te n t to which disease based models have led us up a conceptual and pra ctice blind alley. The in tro ­ duction to th e sta te m e n t says. 'The DCP is o f th e view th a t it is tim e ly and a p p ro p ria te to a ffirm pu b licly th a t th e cu rre n t classification system as ou tlin ed in DSM and the In te rn a tio n a l C lassification o f Diseases (ICD), in respect o f th e fu n c tio n a l p sychiatric diagnoses, has significant conceptual and e m p ir­ ica l lim ita tio n s , consequently th e re is a need fo r a paradigm s h ift in re la tio n to th e experiences th a t these diagnoses re fe r to , tow ards a conceptual system w hich is no longer based on a 'disease’ m o d e l’ .

The s ta te m e n t needs to be read in th e co n te x t o f th e DCP good p ra ctice guidance on th e use o f psychological fo rm u ­ la tio n (DCP, 2011). This guidance states th a t psychological fo rm u la tio n starts from the assumption th a t 'a t some level i t a ll makes sense’ . From th is perspective mood swings, hearing voices, having unusual beliefs can a ll be understood as psychological reactions to cu rre n t and past life e x p e ri­ ences and events. They can be rendered understandable in th e c o n te x t o f an in d iv id u a l’s p a rtic u la r life history and the personal meaning th a t th e y have constructed about i t and

218 R. Pemberton and T. Wainwright

w ithin th e ir cultural context. While this assumption in any individual case may turn out to need review, it provides a healthy starting point.

Illustrating the sea changes in thinking in this field, a recent paper (Forgeard e t al., 2011) records the discussions o f a distinguished group of American researchers and prac­ titioners (Aaron Beck, Richard Davidson, Fritz Henn, Steven Maier, Helen Mayberg, and Martin Seligman) concerning the current understanding of depression and how people who experience this condition can best be helped. One contrib­ utor, Steven Maier’s summed up the view: "We need to set rid o f our current categories because they do not inform us about the best way to tre a t people” .

They took to some degree as a starting point the US National Institute fo r Mental Health’s current Strategic Plan (Insel, 2008) which has laid down the challenge of bring­ ing together the current scientific understanding of brain and mind w ith practice, something it regards as sadly lack­ ing at present w ith the contemporary diagnostic framework. Forgeard et al. (2011) report th a t "d esp ite decades o f research on the etiology and trea tm en t o f depression, a significant proportion o f the population is affected by the disorder, fa ils to respond to treatm ent and is plagued by relapse” (p. 1). This fact, together w ith the relatively poor treatm ent success of any therapy, is referred to by Seligman (2011) as T h e d irty little secret of drugs and therapy’ (p. 45) is part of the recurring theme of the problem o f using the current classification system, rather than one which looks at how brains, minds and people (not forgetting people are social) work.

It is useful here to quote the NIMH 2008 strategic plan (Insel, 2008) to be clear what a fundamental change is being articulated:

” The urgency o f this cause cannot be over-stated. The President’s New Freedom Commission on Mental Health, which examined the need fo r reform o f the mental health care system, concluded th at the problems o f frag- m entation, access, and q ua lity o f mental health care were so great th a t nothing less than transform a­ tion would suffice. With several large-scale clinical trials completed by NIMH, we can add th a t fo r too many peo­ ple w ith mental disorders even the best o f current care is not good enough. To f u lly address these issues, we must continue to (a) discover the fundam ental knowledge about brain and behavior and (b) use such discover­ ies to develop b e tte r tools fo r diagnosis, preem ptive interventions, more e ffe ctive treatm ents, and improved strategies fo r delivering services fo r those who provide d irect m ental health care. These activities p oint toward NIMH’s u ltim a te goal, which is not m erely to reduce symptoms among persons w ith mental illness, but also to promote recovery among this population and tangibly improve th e ir q u a lity o f l i f e " (p. H i)".

And fu rthe r on:

"C urrently, the diagnosis o f mental disorders is based on clinical observation—identifying symptoms th a t tend to cluster together, determ ining when the symptoms appear, and determ ining w hether the symptoms resolve, recur, or become chronic. However, the way th a t men­ ta l disorders are defined in the present diagnostic

system does not incorporate current inform ation from integrative neuroscience research, and thus is not o p ti­ mal fo r making scientific gains through neuroscience approaches. It is d iffic u lt to deconstruct clusters o f com­ plex behaviors and a tte m p t to link these to underlying neurobiological systems. Many mental disorders may be considered as fa llin g along m u ltip le dimensions (e.g., cognition, mood, social interactions), w ith tra its that exist on a continuum ranging fro m normal to extrem e” (p. 9).

The need for a paradigm shift

The DCP call for a paradigm shift is not a denial of the embodied nature of human experience or the complex rela­ tionship between social, psychological and biological factors but instead calls for a system th at acknowledges the grow­ ing evidence o f psychosocial causal factors in many types of mental distress.

To speak of a paradigm shift could be seen as something of a cliché. However, we have used this term very deliberately as it does sum up the pivotal moment we find ourselves in; but the necessary change is not inevitable, and the form of change may or may not be the one we would envis­ age. Such is the nature of paradigms. In the very successful book on science Chalmers (2013) gives a very useful account o f the debates which surround the ideas of how science progresses and the meaning of scientific facts. The contem­ porary assumptions concerning mental distress-for example the serotonin d eficit theory of depression-are deeply rooted in the minds of mental health professionals. The idea th a t depression and other diagnoses are real things is simi­ larly strongly believed. This is similar, in our view, to the assumptions that the earth was the centre of the universe in pre-Copernican days. There was much to commend the ide a-th e sun rose in the morning and set at night and clearly w ent round the earth. Critiques o f these ways of reasoning, together w ith the vested interests in maintaining the cur­ rent views o f mental disorder (Goldacre, 2009, 2012) have shown how im portant the required change is. Our account is only one aspect-another example which Goldacre has been advocating is the Alltrials project (w w w .alltrials.net) aiming to provide at last an honest account o f the effectiveness of drug and other therapies.

A DCP project e ntitled 'Beyond psychiatric diagnosis’ aims to outline the first principles o f an evidence-based conceptual alternative to psychiatric diagnosis which w ill provide a more effective basis fo r reducing complexity by grouping similar types o f experience together. While biol­ ogy plays a mediating role in all human experiences, mental distress is not best understood as disease process, and this particular paradigm has comprehensively failed in the field of psychiatry. Rather than assuming th a t human thoughts, feelings and behaviours can be theorised in the same way as body parts, the p roject w ill draw on the large body of knowl­ edge about psychosocial causal factors in mental distress. It w ill describe the first steps towards identifying patterns and pathways which can be used to inform the co-construction of individual narratives and formulations based on personal meaning. This w ill provide a sounder and more productive basis fo r developing interventions, carrying out research,

The end of mental illness thinking? 219

planning services and empowering service users to make changes in th e ir lives. It w ill also have implications for social policy and issues o f social justice.

Another approach which may have m erit comes from so- called 'transdiagnostic’ models (Dudley, Kuyken, & Padesky, 2011). These argue th at we can begin to make sense of an individuals distress through an understanding o f underlying psychological mechanisms. Rather than starting w ith a set o f symptoms and trying to find a way in which they hang together, i t sets out to explore how a particular psychologi­ cal experience is mediated across many d iffe re n t diagnostic groups. Poletti and Sambataro (2013) fo r example, have looked a t how delusional ideas function from a cognitive and neuropsychological perspective in schizophrenia, bipolar disorder, m ajor depressive disorder and neurological disor­ ders stroke, and neurodegenerative diseases. Here there is a clear account o f an experience which can lead to con­ siderable distress and anxiety and an understanding of the underlying mechanisms and possible ways to help alleviate the problem.

Seligman (2014) takes this further, and in a discussion of transdiagnostic models uses the example of smallpox to show th a t before Jenner discovered th at there was an infective agent, it was simply a description o f symptoms. Afterwards there was a mechanism-the germ theory. He makes the point th a t this was a landmark change-and led to a paradigm shift in understanding infectious diseases and th e ir treatm ent. He goes on to say about mental health diagnostic systems however:

"T h e underlying processes are therein called "transdiagnostic.” Transdiagnostic o f what? "Transdiagnostic” assumes th a t the disorders have a re a lity th a t is illu m in ated by these processes. But this puts the cart before the horse. In a post-Jenner world, what is real are the underlying processes and what are mere way stations (fictions?) are the "d iso rd e rs.” "C om orbid” smacks o f ju s t the same anachronism. Two diagnostic categories, mere congeries o f symptoms, are "co m o rb id ” i f they share the same underlying process. But i f i t is the underlying process th a t is real, and the "d isorde rs” convenient way stations to the process, "co m o rb id ” vanishes into thin a ir ” (p. 2).

What then is the way forward?

Kinderman (2013) has cogently argued th at we need aban­ don the disease model and adopt a psychosocial model in its place. He argues th a t we need to stop diagnosing non­ existent illness. In the place o f diagnosis we need to base planning fo r individuals and services on a simple list of peo­ p le ’s difficulties and to recognize our primary role lies in supporting th e ir wellbeing. Despite its many lim itations the positive psychology movement (Seligman, 2011) is correct in its assertion th a t we have been overly preoccupied w ith deficits and deficiencies and th at we need to approach psy­ chologically distress by building on peoples strengths. We need to significantly reduce our ever-increasing reliance on psychotropic medication and instead o ffe r redesigned psychosocial services than aim fo r recovery and personal agency.

From yet another perspective the World Health Organisa­ tion International Study o f Schizophrenia (ISOS) on recovery among people given a diagnosis o f schizophrenia is also instructive (Hopper, Harrison, Janea, & Sartorius, 2007; Mason, Harrison, Croudace, Glazebrook, & Medley, 1997; Mason, Harrison, Glazebrook, & Medley, 1996). This research found, contrary to expectations, much better recovery rates in less developed (by which you could perhaps read less prescribing and western psychiatric approaches) than in so called 'advanced’ countries. This work has never been satis­ fa cto rily absorbed by the mental health system in the United Kigdom but it provides another strong evidence-based chal­ lenge to the contemporary approaches.

Whitaker (2010), a science journalist has made a study o f the impact o f the way we currently provide services, and extensively quotes from the ISOS studies: He provides chap­ te r and verse th a t in the United States, and probably also in the United Kingdom there is a mental health epidem ic-a public health problem largely caused by the system we have in place. He also describes some services th a t seem to making real progress in putting some innovative and ground­ breaking ideas into practice. One o f these is based in West­ ern Lapland and is called Open Dialogue and it has recently been introduced in the UK (Open Dialogue, 2014). This approach draws on a number o f theoretical models, includ­ ing systemic fam ily therapy, dialogical theory and social constructionism and has echoes of some very early work on crisis intervention in the United Kingdom (Scott, 1973).

Conclusions

Mental Health theory and practice is at a crossroads. The language and categories we use to to describe psycholog­ ical distress are changing and as evidenced by the furore over DSM-5 are being challenged from all sides. The complex interplay between the physical, the psychological, the social and cultural is always likely to be controversial and prone to change. We however have argued th at it is tim e th at the cur­ rent disease-based systems are replaced. We advocate using the advances in our understanding of the psychological, social and physical mechanisms that underpin psychological wellbeing and mental distress to change the way we respond a t a community an individual level. These new insights need to be incorporated into practice and research. Central to the way we move forward w ill be the role and power of people experiencing mental health difficulties. As McKnight (1995) says "Revolutions begin when people who are defined as problems achieve the power to redefine the problem” (p. 16). We need to be careful th at we don’ t ju st replace dis­ ease based frameworks w ith overly restrictive psychological ones. Success w ill include social inclusion in the local com­ munity, friendships w ithin and outside of the mental health system, and purpose in life.

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