Monday, February 12, 2018

Mental Health, Politics, and Social Justice

These are notes for a Public Lecture hosted by Chipping Barnet Labour Party on 12th February 2018. 

I first tried to join the Labour Party before my 16th birthday, and I think, even then, I called myself a socialist.
I’ve now been a clinical psychologist for 28 years.
I see these passions as intellectually, scientifically, and conceptually linked.
When it comes to mental health...

In ‘a prescription for psychiatry’ I argue that:

Mental health problems are fundamentally social and psychological issues...
That we should therefore replace ‘diagnoses’ with straightforward descriptions of our problems, radically reduce use of medication, and use it pragmatically rather than presenting it as a ‘cure’...

And that, instead, we need to understand how each one of us has learned to make sense of the world, and tailor help to our unique and complex needs. The well-established ethos of the clinical psychologist as ‘scientist– practitioner’ means that we can offer evidence-based scientific models of both mental health problems and wellbeing.

Fundamentally, in my opinion, our thoughts, our emotions, our behaviour and therefore our mental health, are largely dependent on our understanding of the world - our thoughts about ourselves, other people, the future, and the world. 

This understanding, of course, has itself been, and continues to be, shaped by our experiences. Things happen to us, we make sense of those events and respond to them, and there are consequences. We all differ in the ways we respond to events, and there are many reasons for those differences. There are as many different reasons for these different responses as there are people in the world. Biological factors, social factors, circumstantial factors – our learning as human beings – affect us as those external factors impact on the key psychological processes that help us build up our sense of who we are and the way the world works.

That perspective has implications for mental health services. To the extent that I think we can offer a MANIFESTO:

Mental health outcomes are getting worse in the United Kingdom. While other areas of medicine have seen significantly improvement, clinical outcomes in mental health have not improved and, according to some measures, have fallen over recent decades. Additionally, UK mental health disability rates have doubled over past 20 years, despite escalating psychiatric prescriptions.

The bio-medical approach to mental health care is dominant yet unsupported by the evidence. The biomedical approach rests upon scientifically unfounded claims for the biological causes of mental health problems and a selective and biased use of the evidence. This has led to excessive use of medication and coercive treatment; increased mental health stigma, and widespread misconceptions about the causes and most effective remedies for mental health problems.

The bio-medical approach has led to an excessive use of psychiatric drugs at great cost to the public purse. Approximately 18% of the adult population takes a psychiatric drug on any given day, with prescriptions of antidepressants doubling in the last decade. This costs the NHS around £800 million per year, with a large proportion being due to excessive, non-evidence based, and unnecessary long-term prescribing. 

Excessive long-term use of psychiatric drugs is causing significant harm. There is now clear evidence that psychiatric drugs do not cure mental health conditions but merely suppress symptoms. Like other psychoactive drugs, long-term use is associated with poor outcomes and can cause neurological damage. Withdrawal from psychiatric drugs can have severe long-lasting consequences, which often lead to disability.


Our services are fragmented, under-resourced and do not deliver what people want. Current mental health services fail to invest sufficiently in alternative yet more effective provision, including psychological therapies, psychosocial care as well as support in the community (rather than costly long-term hospitalization). Cost-effective psychosocial options are under-resourced, difficult to access and poorly integrated with other health and social care services.

Because of this, at least in my opinion, we need:

Appropriate funding of mental health and social care. Mental health care clearly requires adequate funding, but we should avoid the ‘more of the same approach’, which would merely see increasing funding for services with poor outcomes. Instead, we should prioritise investment in effective alternatives that will improve outcomes (including psychological therapies, psycho-social support and early intervention and primary prevention) and shift funding from ill-coordinated and fragmented bio-medical services to integrated and whole-person care.

We need the promotion of accurate, non-stigmatising, evidence-based approaches to mental health. Modern, scientific, accounts of the nature and origins of mental health problems reject both a diagnostic account of human distress and reductionist, bio-medical explanations. These accounts are, in fact, not only scientifically incorrect, they lead both to higher (not lower) levels of stigma and discrimination in the general public and to passivity and hopelessness in people using mental health services. We must therefore educate both members of the public and mental health professionals about the nature and origins – and resolution – of mental health problems. This includes greater understanding of psychosocial perspectives, leading to a greater appreciation of the ability of all of us, with appropriate help, to achieve greater positive mental health and a less passive, less patronising, relationship with professionals.

We need to have services that focus on people, not disorders. Such an approach would also emphasise fundamental human rights, most particularly personal autonomy (control over our own choices) and the protection of personal and family lives (things all too often threatened by current approaches) and would involve substantial transfers of power – from individual clinicians to teams, and from professionals to those of us who use their services. This will involve, therefore, genuine co-production, and leadership by users of services (defined both geographically and in terms of demographic factors) at all stages of service design, commissioning and management.

And we need effective services that people actually want and need. The majority of people prescribed drugs would have preferred a different intervention. We need to commission and invest in services that people demand and would help them. These have to be effective, and therefore must particularly emphasise those psychosocial interventions of proven efficacy. Crucially, they should be the kinds of services that people choose – at present, many people want access to psychological therapies, but are offered only medication, and avoid other mental health services, leading to avoidable harm. Finally, because mental health problems are, in many cases, intimately connected to social and environmental causes, including abuse, bullying, poverty, insecure employment or insecure housing, mental health services must be more closely integrated with both physical health services (particularly community, GP, services) and local authority social and educational services. These services should prioritise prevention and early intervention, and work more closely with services such as housing, education and the criminal justice system.

This all has political implications.

The most powerful determinants of mental health are the events and circumstances of people’s lives. If we are to protect people’s mental health, we need wider social or even political change. This is often a neglected topic, but social and political changes are likely to make much more difference overall than anything individuals can do alone.

For example, the majority of people seeking help for experiences such as hearing voices or paranoid anxiety have experienced poverty. Addressing poverty is rightly the cornerstone of government, and few politicians suggest differently (although many of us fear that right-wing governments pay only lip-service to this aspiration, whilst presiding over policies that actually increase inequalities). With a very specific focus on mental health, however, measures to reduce or eliminate poverty, especially childhood poverty, would be hugely beneficial.

Absolute income is not the only important issue. Evidence shows that a major contribution to serious emotional distress is income inequality – the growing gap between the richest and poorest people in society. In their book ‘The Spirit Level’, sociologists Richard Wilkinson and Kate Pickett demonstrate that mental health problems are highest in those countries with the greatest gaps between rich and poor, and lowest in countries with smaller differences. This suggests that an effective way to reduce rates of mental health problems might be to reduce inequality in society.

Experiences of abuse in childhood are also hugely important – and again associated closely with experiences such as hearing voices and paranoia as well as self-injury, depressed mood and difficulties in maintaining intimate relationships. Rates of mental health problems would plummet if we found better ways of protecting children from abuse. This means working with teachers, social workers, community nurses, GPs and the police to identify and then respond to early warning signs that children might be exposed to sexual, physical or emotional abuse or neglect. It also means taking a serious look as a society at what we can do to bring down overall rates of abuse. Bullying – that is, peer-on-peer bullying in school and in leisure settings – is also important, and again here teachers and youth leaders could help...and thereby help prevent later mental health problems.

But... clear in that account is the reference to the social determinants of health and wellbeing. This is a question of why we behave as we do.

In my academic and professional role, we need to think a little about what CAUSE means.

The causal pathway that results in a particular phenomenon – hearing voices, depressed mood, anxiety – clearly involves our brain, our biology, neuroscience. Neurotransmitter activity and the depolarisation of neurones; chemical signalling, the expression of our genome and the biological functioning of the brain as an organ of the body.

I genuinely have never come across anyone who disagrees with that.

But perhaps what people really mean when they talk about ‘cause’ in the field of psychology or mental health is the explanation of INDIVIDUAL DIFFERENCES.

Am I different to you – has my trajectory in life been different to yours, or different to what it might have been – because of inherent differences, even biological, genetic, differences, or because we have been exposed to different life experiences, and learned different things from them?

In 1967 Martin Luther King Jr spoke to the American Psychological Association about links between racism, unemployment and living conditions. Now, in 2018, we can see continuing economic crisis and the impact of policies of austerity, right-wing populism and – most likely as a consequence – Brexit.

And these are not just economic or political matters; they are crucial psychological issues too. Quite literally, these are matters of life and death. Between 2008 and 2010, immediately following the most recent economic crisis – not yet the self-inflicted economic wounds of Brexit – there were 1000 more suicides in England and Wales than would be expected on purely historical trends, and many of those deaths can be attributed to rising unemployment.

Psychologists, whose professional role is the promotion of wellbeing and the prevention of distress, have a duty to speak out about those social, economic and political circumstances that impact on our clients and the general public, and to bring such evidence to politicians and policy makers.

For example, it’s clear that unemployment and exploitative employment practices – zero-hours contracts, insecure jobs, the ‘gig economy’ – are damaging to our wellbeing regardless of our age, gender, level of education, ethnicity or the part of the country in which we live. The longer someone remains unemployed, the worse the effect, and people do not adapt to unemployment. Their wellbeing is permanently reduced. In contrast, re-employment – finding a decent job if you are unemployed – leads to higher wellbeing.

Martin Luther King said: ‘There are some things in our society, some things in our world, to which we should never be adjusted.’ Another Nobel Prize winner, Albert Camus (distinctive in that he occupied himself during the Nazi occupation of France editing the clandestine newspaper of the Resistance) wrote in his private notebook in May 1937: ‘Psychology is action, not thinking about oneself.’

Psychologists study why people behave as they do. We are therefore uniquely placed to help understand and address some of the most pressing problems facing humankind. Our expertise brings with it an ethical duty to follow the lead of Camus and King and speak out about those issues that demand a voice. We should be clear that human beings are products of our society. We should explore and explain, using our distinctive science, the mechanisms by which the events and circumstances of people’s lives can lead to psychological problems.

So... what do we do?

Well, I’m here at a political event, so I’ll focus on that.
But clinical psychologists are – nearly all – employed in the NHS, so it’s worth just mentioning the contractual expectations on us from our employers – the NHS Trusts, the Secretary of State for Health and Social Care, and, ultimately, citizens.

A genuinely psychosocial approach to service delivery would mean increased investment in the full range of professionals able to deliver therapeutic services that address people’s genuine problems and their root causes. The service would offer help with a spectrum of psychological difficulties rather than only those deemed ‘mental health problems’.

There would be a major emphasis on prevention. We need to be able to address such issues as divorce, marital difficulties, unemployment, stresses at work, financial difficulties, illnesses in family members, crime (both as a victim and as a perpetrator, when caught up in the criminal justice system), assaults, bullying, and childhood abuse.

Clearly, we need to offer psychological therapies, because we know that the way that people make sense of and respond to events is important, and the opportunity to talk through what has happened and how it has affected us is vital. But we also need to offer much more practical responses. As my colleague Anne Cooke put it: ‘It’s no good just mopping the floor and leaving the tap running’.

So mental health and well-being services should need to work with the criminal justice agencies to ensure both protection and justice – investigating and preventing assaults. Because marital separation is a major source of emotional stress, we should ensure that there is sufficient support for people going through separation or marital difficulties, such as mediation services, support for single parents, and practical, legal and emotional support for people in difficulty in their relationships.

Because unemployment is a major source of distress, we should aim for full employment, and certainly do what we can to protect people from the emotional and economic impact of unemployment.

Many jobs are themselves sources of stress, however. We should aim to ensure equitable and supportive employment practices, including employee relations, a living wage, decent terms and conditions and appropriate employee representation. We should engage with employers to address workplace stresses and offer people who are out of work practical, as well as emotional support.

Services such as Citizens Advice, debt counselling agencies and Victim Support are vital to help people in financial difficulties, victims of crime and people dealing with a range of other traumatic life events. We should ensure that any mental health and well-being services are fully integrated with other social services that support families and parents in difficulty.
It also means working with teachers and educational psychologists in schools, and it means supporting a network of children’s services. We should not only offer emotional support, and counsel people in financial difficulties, we should also offer people practical help and financial advice. We should support people in negotiations with benefits agencies to ensure people have the financial support that they deserve, and we should be prepared to engage with financial systems (such as ‘pay-day loan’ companies) that conspire to keep people indebted. Recreational street drugs can prove a threat to people’s mental health and well-being, and so we should ensure that mental health services have intimate links to services that help people who have problems with drug use.

Clearly, providing these services properly will entail significant change. Many of these issues are currently largely ignored, and most are ill-coordinated. Apologists for the present systems will argue that all these services are currently part of the care offered to clients. The experiences of those who have passed through the system would tend to suggest otherwise.

Our mental health and well-being are largely dependent on our social circumstances. To promote genuine mental health and well-being we need to protect and promote universal human rights, as enshrined in the United Nations’ Universal Declaration of Human Rights. Because experiences of neglect, rejection and abuse are hugely important in the genesis of many problems, we need to redouble our efforts to protect children from emotional, physical or sexual abuse and neglect. Equally, we must protect both adults and children from bullying and discrimination: whether that is racism, homophobia, or discrimination based on sexuality, gender, disability or ‘mental health’ or any other characteristic. We can all do more to combat discrimination and promote a more tolerant and accepting society.
More generally, if we are serious about preventing mental health problems from developing, and about promoting genuine psychological well-being, we must work collectively to create a more humane society: to reduce or eliminate poverty, especially childhood poverty, and to reduce financial and social inequality. We need to work harder to promote peace, social justice and equity, and ensure that citizens are properly fed, housed, and educated, and living in a sustainable natural ecosystem. We need to promote social mobility and social inclusion, encourage actions aimed at the common or collective good (for instance through practical support of local charitable activities), and reduce both corruption and materialistic greed. In a fair society, in a society that protects our mental health and well-being, we would ensure that everyone had a meaningful job or role in society and we would eliminate unhealthy organisational cultures at work.

We can also see good arguments for change at the level of commissioners and policy-makers.

Psychosocial codes, which are already part of both the World Health Organisation’s ICD-10 and the American Psychiatric Association’s DSM-5, incorporate descriptive information regarding adverse life experiences and living environments, but are almost never used or reported in clinical practice or academic publications. These quasi-diagnostic codes document issues such as; neglect, abandonment, and other maltreatment, homelessness, poverty, discrimination, negative life events in childhood, including trauma, problems related to family upbringing, and housing and economic problems.

Preliminary data – from North London, as it happens – suggests that such codes – which clearly apply in the vast majority of cases – are recorded in as few as 7% of occasions. 93% of people simply do not have the root causes of their problems recorded. And ignoring these social determinants of mental health problems can only serve to locate the blame NOT in those unacceptable social circumstances, but – unjustly – in the individual.

Broadening routine data capture within UK National Health Service records could establish more inclusive, social, systemic, and psychologically comprehensive patterns of difficulties, which could target information regarding established social determinants of mental health problems, such as inequality, poverty, and trauma. Imagine if it were as serious to fail to document extreme poverty as it would be for a clinician to fail to identify severe depression.


As I look at the world – at the world at large as well as at the world of mental health – I see people making sense of the things that have happened to them.

We’re using that miracle of evolution – the human brain – to learn, on a deep an implicational level, from the events, the circumstances, the context of our lives.

If we’re told we’re worthless, stupid, ugly, or merely pawns to be used – by abusers or oligarchs – then we’ll learn from that... and the consequences are obvious.

So, for me, a humane, right-based, intelligent, psychological position on mental health is – sorry – a social-determinist approach... and that brings me back to my political views.
Maybe I’ve taken the wrong course in life.
Perhaps I should not have trained to be a clinical psychologist.
Perhaps I should have stood for political office.
Maybe it’s not too late.


Saturday, August 19, 2017

The British Psychological Society and the UK Association of Clinical Psychologists

I’ve recently become a grandfather for the second time. Sophia has joined my family. And my family is better and stronger and happier for her arrival.

Over recent months, UK clinical psychologists have come to the conclusion that the time has come – in order better to promote the principles they value, the best interests of the NHS, their clients and their profession – to establish a new professional body, the ‘Association of Clinical Psychologists’. In my view, this is a positive move. There are many reasons to hope that such a new organisation will l be successful. And I strongly believe that the British Psychological Society should actively work with this new group; actively negotiating a division of responsibilities and discussing robust mechanisms of joint working.

My position, outlined in writing and presented at an Extraordinary General Meeting of the Division of Clinical Psychology in York on 5th June, is that there was a powerful argument for the establishment of a new body. I argued that the BPS as it is currently constituted is too big and disparate to be cohesive and effective, and clinical psychology needs either very radical, very rapid reform of the Society (which now seems highly unlikely) or its own organisation. I likened this to the birth of a granddaughter; a new and welcome member of a family, rather than a rival or alternative. I suggested that the birth of a new professional body for clinical psychologists, working with, but independent of, the existing BPS, was rather like the relationship between the Royal College of Obstetricians and Gynaecologists and the Royal College of Physicians (or indeed the British Medical Association). I pointed out that, if the activities demanded by the clinical psychologists was indeed the remit of the British Psychological Society, then we should simply get on with business, but that has proved difficult for many years, and I am sadly not optimistic. Alternatively, if these activities (as we have repeatedly been told) lie outside (‘ultra vires’) the Society’s responsibilities, then both parties should logically be happy for a new organisation to take on these duties.

Now that a decision to establish a new organization for clinical psychologists has been taken, I repeat my position that I think the BPS should work with it, even actively negotiate a division of responsibilities. Unfortunately, my colleagues on the British Psychological Society Board of Trustees disagreed. Their collective position was that the Society needed to press forwards with one message; that the Society (and only the Society) was the natural home for psychology and psychologists. This ‘one Society’ message was, and is, in significant contrast to my message of ‘we need to discuss respective areas of responsibility’. Hence, my position as a Trustee became untenable.

My position has really not changed. I am more than proud of the work I have done with and for the Society over the years. We have had major successes, and I think we have worked hard and effectively to take forwards the promotion of the effectiveness and utility of the science and practice of psychology and psychologists, pure and applied.

I remain proud to remain a Member of the British Psychological Society, and I am confident that we will continue to be successful in promoting the Society’s charitable objects. I do now, however, think that the time has come for a new, more dynamic, professional body for clinical psychologists. I very strongly hope – and believe – that the existing BPS and any new body will rapidly learn to work together on issues of mutual interest and learn to divide up areas of responsibility rather than compete fruitlessly. I shall work actively to that end… just not as a Trustee of the British Psychological Society.