The Mental Health Care System Needs Urgent Care Itself

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Whatever level of public awareness exists about mental health, it’s probably safe to say that awareness about the system of mental health care is considerably worse. Maybe there’s a belief that the bureaucrats and well-meaning health professionals will muddle though.

Think again, say the authors of a new book, Mental Health in Crisis, whose title banishes any hope that the current system is acceptable.  In a sheet prepared for UK Mental Health Awareness Week (13-19 May), the picture they paint is stark and unsparing:

The mental health care system is in crisis. This year, one in four people will experience a mental health problem. Over the course of their life almost one in two will suffer from psychological problems. Almost 6,000 people will die from suicide this year – more than three times the number of deaths due to traffic accidents. Untreated mental health problems cost the British economy £94 billion each year, a sum comparable to the annual state budget for education.

In December 2018, a consortium of 150 user-led organisations, allies and individual campaigners, led by the National Survivor User Network, concluded that the UK government refuses to accord people with mental health diagnoses full human rights. In the same year, the presidents of all British psychological bodies concluded that mental health care has been structurally underfunded. Evidence strongly suggests that the diagnostic system is unscientific and flawed, that many treatments are not effective and that vested interests exert a disproportionate and disturbing influence on how the mental health system operates.

Their book, part of the SAGE Swift series of short volumes at the nexus of solid current scholarship and urgent social needs, came out this week. The authors are three eminent researchers — Joel Vos, researcher at the Metanoia Institute and leader of the Professional Doctorate in Existential Psychotherapy and Counselling at the London New School of Psychotherapy and Counselling; Ron Roberts, a chartered psychologist and Associate Fellow of the British Psychological Society; and James Davies, reader in social anthropology and mental health at the University of Roehampton and co-founder of the Council for Evidence-based Psychiatry. A contribution to the book was made by the group Psychologists for Social Change (formerly known as Psychologists Against Austerity), who apply psychology to policy and political action.

We talked to Vos about the crises and what the practical expectations are from the new book. Due to a tight window for conversation we weren’t able to address his personally fascinating, if clearly tangential, personal experiences like being present at the fall of the Berlin Wall or organizing the charity Punk4Mental Health. Our Q&A appears below three more bullet points the authors address in their sheet for Mental Health Awareness Week.

• Why do so many people suffer from mental health problems?

Most psychological difficulties are related to the events and circumstances of one’s life. We live in a world of multiple crises which adversely affect our well-being– these include financial uncertainty, benefit cuts, and discrimination. Research shows that several groups are structurally more likely to suffer from mental health problems. These include women, those with low socio-economic status, black and Asian minority ethnicity (BAME), lesbian gay bisexual transgender queer and intersex (LGBTQI), and people who are disabled or living with a chronic or life-threatening physical condition. Given such stressful circumstances and the added effects of our current political and environmental crises it would be unusual if people did not experience mental health difficulties: these need to be considered as normal responses to abnormal situations.

• How does the care system help people?

Though much has improved since the days when individuals were shunted off to asylums, and many practitioners do offer excellent care, much remains to be done. The pharmaceutical industry continues to exert an unhealthy influence, not only in the pricing of drugs but in lobbying for new psychiatric diagnoses which can be targeted with industry products. With this comes a lack of transparency: more than half of the existing mental health budget is unaccounted for, and freedom of information requests from the British Medical Association are returned unanswered.

• What can be done?

An overhaul of the system is urgently needed. The British Psychological Society has argued for a complete overhaul of the diagnostic system with service users and mental health advocates given a larger voice in policy-making. Mental health difficulties need to be seen not as problems confined to the feelings and thoughts of individuals, but as issues which may require far reaching social change. Finally, the authors call for urgent investigation and political scrutiny of the corruption, cronyism and fraud in mental health care.

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Could you tell me a little bit about your own journey as a mental health professional and in particular, as a critic of the mental health care system?

I studied clinical psychology in the Netherlands, but I studied philosophy as well. So from the outset I’ve tried to look at mental health and psychology from a more philosophical perspective.  I was inspired by all the great models that exist in psychology, but I started to see that many unwarranted assumptions lie behind the established ideas and policies, all of which were questioned during my education. I really enjoyed having a conversation between psychology and philosophy at the same time.

As I pursued my PhD work with cancer patients and my therapeutic practice with immigrants and students, I saw that a lot of the traditional mental health models didn’t really apply. In many of our clients and research participants what explained mental health issues was not solely what was going on inside the patients themselves. There was a need to understand their life experiences, the life events they faced, their physical health and their socio-economic situation.

I want to be clear that for some people, the traditional models may apply fairly well. — but that’s not very often the case. And I think it’s important that we do not assume that one size fits all.

I noticed that that there’s a certain tension in the book between this dealing with the individual as an individual, as you were just talking about, but then also dealing with the individual as a sort of a component in an ecosystem.

We started the book with a chapter on what I call the “crisis in the community,” where traditionally mental health is seen as an individual problem, as the individual has an issue. When an individual is experiencing signs of depression, yes, then that may have to do with their individual make up, how they were brought up, as well as their own psychological patterns and habits. But it also has to do with the socio-economic context and their interaction with health professionals where they may be subject to labeling and power dynamics, etc. So what you see is that mental health, someone’s psychological well-being, results from a complex interaction between different factors, that in any one case may combine in unique ways.

What were your and your co-authors’ intentions in presenting this in a book, especially as a SAGE Swift, which is a different sort of book? What were you hoping to achieve?

To some extent, what we write in this book is not revolutionary, but from a certain perspective it is. There are many critical voices in the field, notably amongst health professionals – people who work in mental health services here in the UK, and who really feel all the struggles. And because the standard mental health model doesn’t always work, many researchers, therapists, and services users, have experienced these struggles. So, we give words to what many people may have already been experiencing for a long time.  

However, beyond the experiences of those who are directly involved in the system there is a lack of understanding about what precisely is going on, and what precisely is lacking, and the empirical evidence to explain this. We looked the academic research out there, made it accessible, and presented it in a broad overview, for a broad audience. We also wanted this to be available for health professionals, particularly for trainees and students who are starting out, so that they can readily access what is out there in a concise and digestible format.

There’s not enough discussion from this more critical and more complex perspective. So our main aim is to make people aware of the complexity and the crisis that is happening in the field of mental health. We also wanted to show that they don’t have to automatically accept the system or accept care as it is and to know that alternatives are possible.

The book is focused on the provision of mental health care and not on, say, changes to the DSM. In fact, you call for a complete overhaul of the British system. So who will pay attention to this cry?

Well, this is always a big question, indeed. Because of course, we’re ambitious and hopeful. Yes, it’s a big wish indeed to say that it’s the whole system, and all the existing powers in this field, needs to be overhauled and needs to be changed. And this includes critically thinking about diagnoses like the DSM, and how we assess our clients, and how do justice to the complexity of their suffering. I guess that’s a very big claim. But asking for a complete overhaul is the only possibly conclusion following from our reviews in this book.

And yes, the question is, as well, which proposals will policy makers really read and to what extent will this directly change the system. One of the things that we know from our experience, because we, as authors, are in a field, where we are often interviewed, and have roles in advocacy groups, etc. is that there is a lack of knowledge amongst politicians, and policy makers. This is also one of the points that we are describing in this book, about the organizational crisis in mental health care service. Many politicians are not actually aware of the wider system, of what’s going on, because as policymakers they come from an economic or political background, and simply don’t know anything about mental health, even though they may be a minister of mental health, for instance. So to an extent, this book is also meant for policymakers and for politicians. We intend to send this book to Members of Parliament, and we’ve already been speaking with them. Unfortunately, at this moment, they’re extremely busy with things like Brexit, which seems to take over everything, as you may imagine.

[Nonetheless], there are also some policymakers and politicians who are more naive or uninformed, I think. And these people we can try to help by making them aware of the effect of bigger powers and bigger systems in a way that that they may not have been aware of.

So speaking of people being uninformed, the book notes that medical models create hopes of ‘cures’ for mental health problems even though available data provides little support for this. But a cure sounds very attractive to me as a policymaker. How do you explain to people that this is a process and not a pill?

Yes, yes. So, there is a difference between what people call ‘cure’and what they call ‘recovery.’ The idea behind there being a cure, is that you have a well-defined disorder or first specific symptom, such as depression, as defined by DSM, and by a cure, you would say, ‘Well, before I started, the person was examined and received such a diagnosis, and now at some later point the person doesn’t have it anymore.’ What you would call that it would be a cure. However, the question is, what is the diagnosis which this cure focuses at? The diagnosis can sometimes be questionable, due to all the powers and influences from policy-makers and lobbyists as we describe in the book.   

But also, when you really ask, what is it that people want to get out of therapy or any other type of mental health care? Is that the cure of a diagnosis? What countless studies tell, is that when you ask people what they need, what they want to achieve from mental health care, they say they want to learn how to live a meaningful, satisfying life, despite the mental health problems that they may be experiencing in their life situation. This often has to do with the opportunities and skills in their social context, and not merely with intrapersonal processes.

And these are actually things where therapy can be extremely effective. This is what has been called ‘recovery’. I’m personally not very happy with this term, because it sounds like recovery from an addiction, but recovery is much more about being able to live a realistic life that is satisfying and meaningful.

This may actually be what an economist or politician is seeking: giving individuals the ability to work again, to participate in a full way in society, for people to be constructive and helpful citizens, in a sense. So by actually focusing on this wider definition of mental health and not only focusing on the psychiatric diagnosis, politicians and policymakers can be more effective in improving the mental health care system and society in general.

I’m going to use the term wider focus in a slightly different context right now. The book is UK centric, which makes perfect sense. But I noticed in the existential crisis section, you address the global, or at least the western nature of the problem. So, are you offering this prescription, if you will, for the British system alone, or do you think that what you’re writing in general should be or could be applied elsewhere?

A lot of the research we’re citing is not solely based on the UK, but of course we primarily focus on the UK as a case study. But we’ve also showed in the book, how, for instance, Improve Access to Psychological Therapies, or IAPT, this new system in the UK, has been exported to other countries as well, and how that’s been used as a model.

There’s also the research and work concerning neocolonialism with respect to mental health, appearing in the book, explaining how the western model, particularly British model, is being used as a modern form of globalization, particularly in Africa and Southeast Asia. So where this British Western model is being taken up, this more humanistic or more inclusive model of mental health that we are promoting, offers a wider approach. But it doesn’t only apply to individual problems and individualistic types of countries; it could apply in collectivist countries where mental health and the concepts and perception of mental health issues is seen much more from a collectivist perspective.

Do you think there’s a greater incidence of mental health problems now? Then at other times in history, or is it just a question of awareness itself?

Yeah, well, this is very difficult to say. For instance, we’ve already described how things have changed with regard to diagnosis – that there’s been an exponential increase in the numbers of diagnoses. In the past, we didn’t look at people as having ADHD or autism; they would say, ‘Well, they just have a behavioral disorder,’ or  ‘That’s  just the culture. ’ or in fact we were more accepting of individual differences.  So it’s always difficult to really compare in terms of actual numbers. Can we say that is because norms have changed or whether people really have more problems? But there is this other issue — is the suffering of people real? l think that that is the question that lies behind your question and there the answer is for sure.  Though we must understand that suffering is embedded in the social, organizational and political contexts in which we live.

That’s what we’re really trying to say in a book — let’s do justice to the real cause of suffering and not just impose our diagnostic models or what we think should be cured. Acknowledge the real cause of the suffering and try to help people not miss that.

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