After homo economicus, is homo biomedicus next?
A trained psychologist myself, I took great interest in today’s call of the British Psychological Society for a departure of the biomedical model of mental illness. And, to my delight, so did other colleagues – read a great blog post from Social Brain’s Emma Lindley here, where she writes that we might be right now witnessing a bona fide revolution that may change mental health services so radically, ‘they will be unrecognisable to the children of my generation.’ As Emma points out, the debate is as much driven by differing concepts of human nature as it is by politics, and the struggle for professional relevance and power. It is the latter aspect that I want to focus on in this blog post.
The RSA has long taken an interest in professions and their future (including this project in the early 2000s), and is currently managing an independent review of the Police Federation. Further international projects with other professions may follow soon.
Interestingly, even though Psychiatry is the younger term, it is the arguably the older science, and literally means ‘the medical treatment of the soul’, whereas Psychology means ‘study of the soul’. Psychology and, specifically, its subdomain Clinical Psychology, have always had a hard time standing up to their medical cousin. Part of the reason for that one can find in the etymology; isn’t medical treatment is just so much more tangible than mere study? Thus, in more than one hospital of the world (including one I interned in a long, long time ago), Psychologists have not been much more than overeducated sidekicks to doctors. This may change soon.
The main reason for this is that over the last decade, and particularly since 2008, Psychology has arrived in the scientific establishment. It did so by using a strategy applied by underdogs since the advent of mankind: collaboration. (And, of course, the emergence of discipline rockstars like Steven Pinker has helped.)
Not having enough leverage itself, Psychology entered functional marriages with up and coming disciplines like neuroscience and traditional ones like economics, a process that led to the creation of new interdisciplinary fields like behavioural science. A prominent victim of this process was homo economicus – the notion that humans are wholly rational and narrowly self-interested. Homo biomedicus (not an official term, my inadequate creation), the similarly reductionist paradigm underlying present day psychiatry that acknowledges only the physical side of human existence, but leaves aside the social and psychological aspects, may very well be next.
There are two reasons to be concerned about the potential revolution of mental health services given that professional battle lines are drawn:
Firstly, while for Psychology there was the possibility of a non-threatening complementary relationship in the mutual interest with economics or neuroscience, with Psychiatry it is different. Here the question is ‘who runs the show?’, or, if you will, one of professional hegemony. Still, one hopes that the critical voices on both sides steer the process away from the zero-sum-game it is in danger to become, which certainly would leave everyone worse off.
Secondly, the homo biomedicus model is not entirely wrong, just as the homo economicus model is not completely off the mark. The concept has its merit and adequate areas of application, and it will need to be taken into account when designing future services based on a richer, more complex understanding of man as Homo biopsychosocialis that is embedded in a capabilities-based approach. Throwing out the baby with the bath water would be just as wrong.
Josef Lentsch is Director of RSA International – follow him at @joseflentsch
Are we all mad? Or is it just the psychiatrists?
Today, the Division of Clinical Psychology has issued a statement that essentially says that our system for diagnosing mental illness is unreliable, lacks validity and is not fit for purpose. This follows a similar statement from the American National Institute for Mental Health last week in which it was announced that NIMH would not be using the new DSM-V (the prescribing manual for mental disorders) because of concerns about its validity and use value. These two announcements are of tremendous significance, and could herald the beginning of a bona fide revolution in how we respond to and treat mental illness.
I think that mental health services will change so radically within my lifetime that they will be unrecognisable to the children of my generation
For several years I’ve been saying, albeit tentatively, that I think that mental health services will change so radically within my lifetime that they will be unrecognisable to the children of my generation. I really hope these recent announcements are the beginning of that transformation.
Arguments about the revisions to the DSM have been simmering for a long time, and the new issue is already several years later in being published than expected. You could look at this as a predictable and relatively insignificant resurgence of the long held divisions between psychology (which assumes mental distress is caused by traumatic life events) and psychiatry (which treats mental illness like any other physical condition, and assumes causes are biological).
You could regard it as being politically driven – in both the UK and US, the cost of mental illness is utterly unsustainable, and anyone who’s ever taken time to look at the figures will know that a majority of prison inmates have a history of mental illness. As Barack Obama put it rather starkly, it’s easier for a mentally ill person to buy a gun than to get proper treatment in the US. In the UK, the political narratives are spun separately, with few people joining the dots to see what’s really going on.
it’s easier for a mentally ill person to buy a gun than to get proper treatment in the US
On the one hand, mental illness is on the rise. It costs us £36 billion a year, in sickness absence, unemployment, not to mention treatment. The pharmaceutical industry produces more and more psychotropic medications, most of which are incredibly expensive, and all of which are developed on relatively limited understandings of how they work or why they work (if they work, which, frequently, they don’t). On the other hand, the voices of mental health service users are finally started to be heard, and the resounding message is that things need to be done differently. In support of that, both the critical psychology movement, and critical psychiatry movement have both been asking questions with increasing urgency. Running alongside are parallel problems around mental illness and employment; mental illness and education, and mental illness and social exclusion. All of this needs unpicking and exploring in a lot more detail.
This week is mental health awareness week, and the focus is on physical activity and its benefits for mental health. I’m fully in support of this, and a firm believer in the importance of physical health for mental health. But it strikes me that there are bigger and more important issues happening too.
My PhD thesis, Making sense of mental illness: The importance of Inclusive Dialogue, goes into some of these arguments in a lot more detail, some of which I hope to return to and develop in another blog post.
Communities: The omitted third dimension?
Here is an interesting Guardian piece on a transnational YouGov-Cambridge study. The research compared attitudes towards responsibilities of the state versus those of individuals in the UK, US, France and Germany.
To summarise, when it comes to the role of the state on issues like ‘a decent minimum income for all’ or ‘helping poor children get ahead’, British views are significantly more continental than atlantic. With the exception of company pay – on inequity of salaries, Britons are more liberal than Germans and French, if not as liberal as Americans – the results put the US on the individualist side, and UK, Germany and France broadly on the statist side; which highlights once again that the conversation on public services in the US is a very different one to this side of the pond.
What is just as interesting as the results, however, is the way the study is structured. It takes a classic two-dimensional approach: state versus individuals.
What about views on the responsibility of, and for, communities?
They are a pillar of social power just as much as the other two dimensions. And given fiscal pressures on both sides of the Atlantic, an increasing amount of challenges will need to be dealt with via this ‘third dimension’ (e.g., as my colleague Matthew Parsfield pointed out recently, in Mental Health, or as our CEO Matthew Taylor has argued, in Care).
But as so often, communities get left out of the equation – what statisticians would call an omitted variable. Arguably, without taking this third dimension into account, there is a lack of depth in the insights generated.
My hunch is that we would see a picture emerge that is more complex and informative than the binary US/Europe divide. But perhaps there is already some comparative data out there, maybe even longitudinal – might a reader point me in the right direction?
The RSA is well positioned to work across all three dimensions internationally, as we have strong Fellowships in all four countries (altogether we have Fellowships in 101 countries, the US being the largest one with almost 800 Fellows), as well as Fellow- and staff-led projects in the US and Germany. I will elaborate on these in my next blog posts.
Also, I am looking forward to the upcoming RSA Lecture with Tim Smit, CEO and Founder of the Eden Project, who asks the very question: ‘Where does responsibility for community lie’?
Communities: a solution to the ‘global mental health crisis’?
Mental health is a globally pressing issue. Conservative estimates suggest that 400 million people worldwide suffer from various mental illnesses, while the World Health Organisation predicts that by 2030 depression will be the world’s leading cause of the burden of disease, with mental health problems already exacting a greater toll than tuberculosis, cancer, or heart disease.
Yet look at this global picture more closely, and to some observers it appears as though this burden might not be spread evenly around the world. With recovery rates for schizophrenia and depression in the USA, UK, and other wealthy countries worse than those in Nigeria, India, and other developing nations, it looks as though the poor world is outperforming the rich when it comes to dealing with some mental disorders.
Theories as to why this may be abound. These range from the perhaps outdated and stereotypical idea that there is a greater tradition of family and community solidarity in economically developing nations, to the social anthropologist Tanya Luhrmann’s theory that a combination of greater stigma and “disgraceful” normative care practices in the West often mean that sufferers of devastating mental disorders like schizophrenia concurrently experience a range of other afflictions – ostracism, homelessness, poverty, substance addiction and a set of humiliating interpersonal experiences that she calls ‘social defeat’.
Last night, in his RSA lecture entitled ‘The Global Mental Health Crisis: What the rich world can learn from the poor’, Professor Vikram Patel of the London School of Hygiene and Tropical Medicine offered a slightly different perspective. Focussing on access to care, he gave examples of the relative ingenuity of mental health care practices in countries like India, where he has done extensive work.
There is, he said, no shortage of psychiatric professionals in wealthy Western nations; for example California alone has more psychiatrists than the whole of South Asia. Despite this, some 60% of people with mental illness symptoms in the USA do not access any form of psychiatric care. The UK, even with its free-of-charge National Health Service, only performs slightly better, with 40% of sufferers not seeking or receiving treatment. As explanations for this he pointed to the sometimes alienating, over-complicated professional culture of DSM-influenced approaches to mental illnesses in the West, and the remoteness of psychiatric practitioners to their patients in both lifestyle and outlook as reasons for people not knowing about or feeling they can access services.
By contrast, he presented a model of public health in India that, with limited resources in the form of professionals or pharmaceuticals, utilises lay community health workers to provide collaborative, locally appropriate community-based care. Specially trained lay workers operate under the direction of psychiatric professionals to provide outreach services, ‘psychiatric first aid’, and social interventions based in the home, in a Wellcome Trust-funded controlled trial, documented in a series of documentaries available online.
Back in the UK, the RSA is looking to draw upon a similar approach as part of its Connected Communities project, which seeks to explore ways of building resilient communities in which people’s wellbeing and life satisfaction benefit from social connections with their peers. Working with Nicky Forsythe of Positive Therapy, we shall shortly be launching an innovative Talk For Health peer support programme which will train key members of community networks as lay counsellors, giving them the confidence and knowledge to take the therapists’ skills of empathy, non-judgemental listening, and conversational support out of the doctors’ surgery and into the hands of the community. In Bristol, we’ve just launched an innovative tablet computer app called Social Mirror, which volunteer health champions will use to help people map their social networks and, where necessary, receive suggested social prescriptions. Simultaneously, we are working with Talk To Me London to launch an exciting pilot project in New Cross that seeks to encourage Londoners to engage in conversations with strangers, with participants identified by their ‘Talk To Me’ badges which show that they are friendly and willing to chat. The designers of the project promise that it will “be the most innovative, culture-changing campaign of our times”, so stay tuned for more on that.
With ever-increasing strains on public health and social care budgets, and worrying research that demonstrates links between social isolation and the risk of mental illness and death, it is hoped that we can learn much from Professor Patel and others in the ‘poor world’ who are demonstrating that innovative, ingenious social interventions can help manage the burden of mental illness by supporting connected communities. Keep checking this blog, follow #RSAConnected and @SocialMirrorApp on Twitter, or email matthew.parsfield@rsa.org.uk and ask to join the relevant email lists to keep updated with how this work progresses.
Stigma of mental illness? Alive and well
The stigma of mental illness is alive and well. Despite the fact that campaigns like Time to Change have been working hard to eliminate stigma and discrimination against people with mental health conditions, it seems that it’s still all too easy to casually slip into a culture of blame.
Image via guardian.co.uk
A short article in the Guardian published this morning reported the results of a study that indicated a link between being a child of parents with mental health problems and being at risk of harm. That such a link exists is troubling, and our response to this ought to emphasise the need for better provision of support where it is needed most.
Maev Kennedy’s piece starts with very much the wrong tone, with the sub-heading: “Report by Ofsted and Quality Care Commission reveals that 30% of adults with mental health problems have children.” This reads as though a shocking number of (by implication) irresponsible and dangerous parents with mental health problems have children, and really ought not to.
Kennedy doesn’t make a comparison with overall figures for having children. The stats are a little difficult to decipher, but my interpretation is that roughly 39% of couples across the population have children, so what is striking amongst people with mental health problems is that the proportion having children is significantly lower.
The case example Kennedy chooses to provide is that of a mother whose children “were only taken into care when their mother went into hospital” going on to describe a woman who had not showered for six months, rarely left the house and spent most days asleep. It sounds as though this woman was suffering from crippling depression, and was in desperate need of proper help and intervention, not for her children to be taken into care as soon as she began to show signs of distress.
Kennedy’s piece finishes with the damning line, “although an estimated 30% of adults who experience mental health problems have children, there is no national obligation to notify relevant authorities or collect information on how they are coping.” This almost makes it sound as though having a mental health problem is akin to being a paedophile, and that some sort of national register should exist to monitor the parenting abilities of anyone who experiences difficulties with their mental health.
My guess is that the piece was written quickly and that its author probably did not intend to produce an article that exhibits stigma and has a tone of judgement and blame. However, it is this type of subtle stigma that perpetuates damaging stereotypes and allows marginalisation and othering of people with mental illnesses to continue.
Mental health and spirituality
Mind published an interesting blog post on their website today, in which a woman with bipolar disorder describes the importance of her spirituality in staying well. The spirituality she describes is explicitly non-religious.
It’s interesting to contrast her experience with the recent finding that people who are ‘spiritual but not religious’ are more likely to experience mental health difficulties than those who belong to a religion.
Mark Vernon’s piece discussing this is well worth reading. It occurs me to that the writer of Mind’s blog post is absolutely right in saying that giving due attention to spiritual needs is long overdue.
It’s important to make a couple of points about the framing of this issue. Firstly, that ‘spirituality’ can be more than merely ‘new age’ and secondly, that it doesn’t always have to be juxtaposed with religion. Indeed, the Social Brain Centre is in the early stages of exploring how spirituality might be reconceived based on new understandings of human nature, and there will be more about that here soon…
Does ‘dual diagnosis’ have a place in a recovery agenda?
Having a ‘dual diagnosis’ means that someone who has mental health problems also has problems with one or more drugs, including alcohol. In my years as a substance misuse practitioner I would frequently work with individuals where underlying and undiagnosed mental health issues would have a significant impact on problematic drug and alcohol use.
The continuing issue in my experience was that mental health services would frequently be unprepared or seemingly unable to work with individuals that presented with substance misuse issues. This would create a huge gulf in service delivery with many being unable to access appropriate support to meet their needs. The relationship between dual diagnosis: substance misuse and dealing with mental health issues a research report published in 2009 aimed at addressing some of the finer issues relating to ‘dual diagnosis’, and although there has been an improvement in the relationship between drug and mental health services, red tape and referral processes can still often prove to be a block to treatment.
In February 2011 the government released a paper entitled No health without mental health. The paper outlines the government’s strategy and action plan for improving mental health and well-being stating;
“This Government recognises that our mental health is central to our quality of life, central to our economic success and interdependent with our success in improving education, training and employment outcomes and tackling some of the persistent problems that scar our society, from homelessness, violence and abuse, to drug use and crime.”
Unfortunately the paper does not detail the specific issues relating to ‘dual diagnosis’ and how this strategy can shape and improve service delivery for individuals accessing drug and alcohol treatment.
In 2011 I was involved in an eight week pilot, which enabled those accessing services and exhibiting potential mental health problems the opportunity to be seen and assessed in the treatment centre by a clinical psychiatrist. This allowed for immediate referrals to be made to GP’s and mental health services for treatment, the initial results were positive and fundamental to the successful completion of treatment for many individuals over that period.
So how does this relate to a ‘Recovery Agenda’? The ineffective treatment of mental health problems relating to people accessing drug treatment services could jeopardise the potential for meaningful recovery. If the ideal vision is for treatment is to be but a small part of the recovery journey, then surely a more integrated service focused on ‘dual diagnosis’ will be required in the future. The tagline for the above mentioned government paper is ‘Delivering better mental health outcomes for people of all ages’ maybe that should include ‘all backgrounds’ to achieve real success in improving mental health for all.
Mental health, hidden wealth… of cabbies?
Filed under: Education Matters, Fellowship, Social Brain
One of the unwritten conventions of working at the RSA is that, if a Fellow calls, you try your best to answer. So far, this has felt like anything but a burden, and has led to fascinating discussions and an emerging set of ideas for education projects, all which aim to engage Fellows at every stage.
Yesterday I met with RSA Fellow Sarah Bickerstaffe. An Associate at Improving Care, she is also carrying out research on social impact bonds in the mental health sector, and has recently set up a social enterprise to deliver Mental Health First Aid training. Imported from Australia, this two day programme trains people to identify and support people with mental health issues – from spotting panic attacks, to simple ways to talk to people who may be suicidal, to having more subtle conversations. Freed from an initial DoH programme, a new Community Interest Company is now thriving, with an interesting franchise model that encourages its instructors to innovate , whilst assuring quality in an atmosphere of high trust. Sarah has written about her work here.
Unsurprisingly, mental health first aid has taken off mainly in the public and voluntary sectors so far, for instance in the criminal justice and health sectors. There are also discrete courses for young people that could link well with the Modern Baccalaureate (which RSA is developing a partnership with).
Sarah is keen to develop new approaches to attract the private sector. There should be a strong business case for this, although the evidence on effectiveness is not quite mature yet. Although all kinds of businesses would benefit from this, as mental health is a common issue across any workforce, there are certain industries who encounter mental health issues more frequently, so might benefit from bespoke training. Nightclub bouncers, for instance, or bus drivers.
My first choice for a mental health first aid trial would be to run the course for cabbies. Sensible regulation during the last ten years, especially in London, has made the taxi industry far less shadowy. My local cab offices are staffed and their cabs driven by polite men, usually first generation immigrants, often highly educated. Their presence on our roads, and especially when waiting in their offices on our main shopping streets, discourages crime and anti-social behaviour. RSA’s project on how taxi drivers can change habits to promote fuel efficiency shows a capacity and appetite for a different kind of ‘Knowledge’.
Cab drivers could probably do with some general first aid training (In Germany, everyone has to pass a first aid qualification to get a driving licence), but might benefit in particular from mental health first aid training. Given their role in fuelling the night-time economy, they are likely to confront mental health emergencies, often drug and alcohol-related, sometimes leading to violence. Could there be a business case for cab drivers participating in mental health first aid training? Sometimes of course, as my favourite movie taxi scene shows below (rated 15) , it’s the driver himself who needs help. But beyond the specifics of mental health first aid, are there other ways to turn cab drivers into our fourth emergency service?
Inclusive Dialogue: The Way Forward in Anti-Stigma Education?
Yesterday saw the publication of a new article of mine in the Journal of Public Mental Health. It’s titled ‘Inclusive Dialogue: The Way Forward in Anti-Stigma Education?’ Inclusive Dialogue is an educational technique I developed during my PhD research, and the article discusses the impact it had on the young people taking part. As you need subscriber access to view the full PDF, I’ll use this blog post to give you a flavour of the piece.
Reducing the stigma of mental illness is a major public health issue. Historically, the anti-stigma agenda has been largely controlled by those holding most power in the field – predominantly psychiatrists. This has led to anti-stigma initiatives drawing primarily on a biomedical model, emphasising similarity between mental and physical illness, stressing that mental illness can happen to anyone and that it should be treated with medication. However, there is a growing body of evidence that the biomedical approach to reducing stigma is not only ineffective, but can actually increase the very phenomenon it aims to ameliorate.
My work on inclusive dialogue aimed to develop a viable alternative approach to education about mental illness. The inclusive dialogue process consisted of a series of discussion workshops with a group of seven young people aged 14-15. The aim was to encourage participants to share and explore understandings relating to mental illness. I intentionally avoided being didactic, but rather set out to give young people opportunities to share and explore their own existing ideas and to reflect on their responses to stimulus material.
I intentionally avoided being didactic, but rather set out to give young people opportunities to share and explore their own existing ideas and to reflect on their responses to stimulus material.
I used a number of springboard techniques from which to launch conversations, including the use of photo-vignettes, a narrative building exercise, language audit, media-based activities and exploration of first-hand narratives of mental illness.
All of the activities aimed to foreground personal experiences of mental illness rather than to consider the concept in the abstract, or purely in terms of diagnostic categories. The young people taking part were encouraged to take an active role, bringing their own experiences and understandings to the discussion.
The approach was informed by the principles of constructivist education. The aim of constructivist education is personal autonomy – to enable young people to be governed by themselves, and to think logically about any subject or issue, drawing on their own resources to form both understandings and opinions. Inclusive dialogue represents an attempt to apply this philosophy to the delivery of education about mental illness, guided by two broad aims. First, to enable young people to look at the issue from a number of different perspectives, and second, to equip them with the resources to construct open and positive positions towards other who are experiencing or have experienced mental illness.
At the end of the inclusive dialogue process, I interviewed the young people who had taken part to find out how they felt it had affected them. The young people reported that as a result of taking part they had become more confident and comfortable in being able to talk about mental illness. They discovered a number of things that they had not previously appreciated, including that there can be positive aspects to having mental illness, and that having a mental illness does not necessarily mean a person will have a substandard life.
They felt they would be less scared if faced with a friend or family member experiencing mental illness and that they would have the resources to know how to respond. They also reported increases in knowledge and understanding, along with having more resources to be able to empathise with the experience of mental illness. Most importantly, they seemed to enjoy the process, as this comment from a member of the group demonstrates:
“The best thing I did in school all year was that thing you did with us where we had to choose a picture and decide on what the person would be like and stuff, if they had a mental health problem.”
My work was encouraging, in that it showed inclusive dialogue has the potential to be a viable alternative to biomedically-based anti-stigma work, and that it can help to shift young people to being more open, empathic and supportive towards others with experience of mental illness. Given that mental health issues are an unavoidable feature of the landscape of the social worlds young people inhabit, the need to promote greater understanding of mental illness in society becomes ever more pertinent. The study I conducted adds to the body of evidence that there is a place for education about mental illness in adolescents’ lives and I would be delighted to see more teachers broaching the subject with their pupils.
In pursuit of happiness
‘Happiness’ is a concept that I seem to be increasingly encountering. It is the subject of a piece of work that my colleagues in Arts and Society are involved with in collaboration with the Happy Museum Project, an initiative that is encouraging UK museums to support transition to well-being and sustainability in our society.
The Happy Museum Project was born from psychological research suggesting that happiness and well-being are not related to material wealth. On the contrary, an emphasis on material wealth has led to a focus on the short term, causing the majority to feel pressure to “keep up” and leading to more unhappiness. Key to a sustainable notion of well-being, according to the Happy Museum Project, is what they call ‘support learning for resilience’, which encourages learning that is curiosity driven, engaging, informal and fun and can build resilience, creativity and resourcefulness.
Of course this is not a wholly new concept. We’re becoming increasingly familiar with research that shows that over a certain comfort threshold, increased wealth doesn’t correlate with general satisfaction, take Bhutan’s Gross National Happiness index, for example, which was developed in the 1970s. Now the UK government has started to focus on the notion of happiness, with the announcement of the National Wellbeing Project in 2010, which will see them attempt to measure how happy Britons are and use the results to shape government policy.
One area where happiness does not seem to have been a central consideration however is in education. Take the new Ofsted framework, which requires inspectors to place emphasis on behaviour, safety and teaching but makes no mention of emotional wellbeing, sociability and support. The aim here may have been to concentrate on the essentials and perhaps the more quantifiable elements, but this only reinforces the lack of regard with which these qualities are held.
Plans for performance related pay for teachers could be taken as another example of overlooking the importance of happiness. Not only is this measure likely to increase pressure on teachers, making them less happy, but their performance is likely to be measured solely on academic results, as it must be, and not well-being. This is not to say that the two will always be unrelated. For example it seems obvious that if a child is taught in a way that is exciting, fun, collaborative and supportive then they will not only be happier but will be more engaged and therefore attain better results. But this policy risks increasing pressure on students to achieve academically, leading to more teaching to the test and so risking children’s well-being.
Additionally some proponents of performance related pay for teachers base their arguments on economics; a good teacher = a good education (good grades) = a good job = more money. Not only in the current climate is this not necessarily the case, as there are not enough good jobs for high achieving students, but if money doesn’t make us happy then we shouldn’t be thinking only about education in these terms.
So I come back to the Happy Museum Project’s central tenet – our culture must focus on the long-term and sustainable benefits of its actions. Whilst achieving good academic results may lead to happiness in the short term, it can no longer guarantee a child’s future well-being in the face of unemployment, recessions and climate change, although perhaps it can help. My point is not to belittle academic achievement, but to emphasise that like so many things, we just cannot be sure. What we can be sure of is that having confidence, emotional stability and resilience, will help this generation of students to survive this uncertainty and to cope better, if not always be happy.
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