The Critical Psychiatry Network
Friday, October 3, 2008
Dear Future Vision Coalition
Re: A New Vision for Mental Health
In broad terms the Critical Psychiatry Network welcomes this initiative. We believe that it is both timely and necessary. We agree that the discussion paper sets out accurately the political and policy contexts that make change necessary, with one exception. We agree, too, that these contexts indicate that radical change is necessary, not simple evolution of existing policy.
We support the four areas for change set out in the document, and agree that if progress were made in these area then the social and health inequalities experienced by those who have to use services, and their families, would be improved. We also believe that there would be significant improvements in the experiences of and satisfaction with care.
At the same time we recognize that some progress towards improving the experiences of those who use mental health services and their families has been made, and that it is important here to preserve and build on existing initiatives. Here we refer specifically to:
- Changes in the commissioning of mental health services that involve service users, carers and communities in the commissioning process, e.g. the individualization agenda.
- Specific policy initiatives such as Delivering Race Equality, particularly the importance attached in that policy to community engagement and development.
- New Ways of Working, which has attempted to rationalize the structure and modus operandi of clinical teams.
- Values based practice, and especially the importance of understanding the role of VBP in complementing evidence based medicine.
We are disappointed that the document appears to make no reference to these more progressive elements, and would argue that any future policy document should reflect this. We are also disappointed that the discussion document makes little or no reference to the mental health inequalities experienced by people from Black and Minority Ethnic Communities. We believe that their needs will require particularly close scrutiny in the future. This is because the imminent implementation of the 2007 amendment to the 1983 Mental Health Act has the potential to affect adversely the human rights of all people who use mental health services, but especially people from BME communities. We are thinking here of the move to compulsory treatment in the community. This is the missing context we refer to in our first paragraph. We believe that this should be included in any subsequent documents.
There are several issues raised by the document that cause concern, and which in our view require more careful thought.
- Whilst we agree that there should be a move away from a medical model of care, towards an ‘integrated’ model that stresses the broader determinants of well-being, such as social inclusion, the document is not clear how this should be achieved. If real progress is to be made here, we argue that it is necessary to broaden out the concept of the medical model to include what we would call scientific or technological psychiatry, particularly evidence based medicine (EBM). This clearly has an important role to play in many areas of medicine in helping to decide what interventions are effective, but there are significant differences between medicine and psychiatry. Recent work strongly suggests the notion of disease-specific interventions in psychiatry is flawed. There is no scientific basis for such beliefs. Indeed recent work in the evaluation of drug trials for antidepressants, and psychotherapeutic interventions for depression, strongly suggest that the non-specific factors (i.e. placebo effect for tablets, quality of therapeutic relationship in therapies) are the most powerful determinants of outcome. For this reason we would argue that if true progress is to be made in challenging the strength of the model, then less emphasis should be placed in mental health policy and clinical practice guidelines (such as service frameworks) on technological paradigms for evaluating ‘effectiveness’.
- It follows from the above that greater weight should be attached to non-technological approaches to evaluating ‘effectiveness’. There is already a substantial literature from service-user led research on what service users find helpful and effective. In addition, values-based practice has the potential to enable professional staff to understand the significance and importance of non-specific factors, such as the importance of meaning and understanding, the value of spiritual and cultural frameworks, in the recovery process. We argue, therefore that in future government mental health policy and clinical practice guidance documents should attach as much significance to the values-based evidence as technological (or EBM) evidence.
- While we agree with the importance attached to the shift from an ethos in which services do things to people, to a public health and prevention agenda, we are concerned that some of the proposals here are not clearly though through. For example, we are deeply suspicious about Layard’s proposal that the provision of cognitive therapy on a large scale can get people off benefits and back to work. We have already indicated that the evidence base for the effectiveness of cognitive therapy is deeply suspect2. Second, cognitive therapy pays little or no attention to the personal and contextual aspects of people’s lives that are important in understanding misery and unhappiness. We believe that the idea that people require cognitive therapy to get them back to work makes neither common nor moral sense. People require jobs, coupled with employment policies that make it easier for them to get out of the benefits trap. We would strongly argue that any future document should remove the reference to Layard and similar approaches.
- We are very concerned with the idea that screening should be an important part of future policy. Although we agree that it is important that people experiencing distress are able to access help and support at the earliest possible stage, we believe that screening for potential ‘disorder’ is not an acceptable way forward. In America the Texas Medical Algorithm Project has provided the basis for large-scale population screening with the intention of ‘treating’ prepsychotic people with neuroleptic medication. This is morally unacceptable for two reasons. First, it extends the scope of pharmaceutical company interests by opening up new markets for the marketing of their products. Secondly, it runs counter to plural notions of the diversity of human subjectivity. Is it justifiable to see children with early psychotic experiences as ‘ill’ and in need of treatment? Empirical research suggests not. Psychotic experiences in children are often self-limiting and settle without recourse to medication.
- We share the concerns made separately by one of our colleagues, David Abrahamson, that the needs of people with very severe levels of distress, especially severe and profound social withdrawal, should not be overlooked. Although we support the shift in emphasis from hospital and surgery to community, both for prevention and intervention, we think it is important to recognize that for many people, hospital will continues to be the main locus of care, especially for people with more severe problems. It is vital that future policy developments ensure that the ‘integrated’ model reaches out to these groups of people.
We offer these criticisms constructively, and in broad terms we welcome the document. We would be happy to contribute to the future development of this important initiative if this were helpful.
Philip Thomas Joanna Moncrieff
Co-chairs, Critical Psychiatry Network