Thursday, 21 July 2016

A Prescription for Psychiatry

In today's post, Peter Kinderman introduces his new book ‘A Prescription for Psychiatry: Why We Need a Whole New Approach to Mental Health and Wellbeing’, which is published by Palgrave Macmillan.

I am professor of Clinical Psychology at the University of Liverpool and President-Elect of the British Psychological Society. My research interests are in psychological processes underpinning wellbeing and mental health. I have published widely on the role of psychological factors as mediators between biological, social and circumstantial factors in mental health and wellbeing. I have been awarded (with colleagues) a total of over £6 million in research grant funding (from the Medical Research Council, the Economic and Social Research Council, the Wellcome Trust, the NHS Forensic Mental Health Research and Development Programme, the European Commission and others). My most recent grant, awarded in 2015, was for a total of over £1m from the Economic and Social Research Council (ESRC), to lead a three-year evidence synthesis programme for the ‘What Works Centre for Wellbeing’, exploring the effectiveness of policies aimed at improving community wellbeing. You can follow me on Twitter as @peterkinderman.

My most recent book, A Prescription for Psychiatry, offers a radical new ‘manifesto’ for mental health and well-being. It argues 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 an assumption that our role is to treat ‘disease’ to an appreciation 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. This does not mean rejecting rigour or the scientific method – quite the reverse. While psychiatric diagnoses lack reliability, validity and utility, there is no barrier to the operational definition of specific psychological phenomena, and it is equally possible to develop coherent treatment plans from such a basis.

All this means that we should turn from the diagnosis of illness and the pursuit of aetiology and instead identify and understand the causal mechanisms of operationally defined psychological phenomena. 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 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 it’s a revolution that’s already underway.

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