A persistent social crisis which is not all in our heads

Alternatives to medical treatment for people with mental health issues need to get beyond the discussion phase towards policy and implementation, writes Jennifer Hough , who talks to practitioners about a national crisis

 

OME call themselves anti-psychiatry, some are part of the critical psychiatry movement, or promote the theory of “post psychiatry”. Others just know there has to be a better way.

Over the past 20 years, the voices of concerned mental health professionals, service users and academics have gained momentum in a bid to break down the medical model of psychiatry, and the damage they believe it is inflicting on people in distress.

Issues around overprescribing of medications, control and coercion, and the focus on labelling people’s emotions are the kind of debates critics of mainstream psychiatry demand be heard and tackled.

Some want psychiatry dismantled, others believe it can be a part of the way forward, but only if it embraces new ways of thinking, and places people and their individual experiences before longstanding medical views of distress.

The latest in a growing canon of books, blogs, research papers, lectures, and conferences railing against the mainstream is The Depression Delusion, Volume One, the Myth of the Chemical Brain Imbalance, a book by Limerick-based doctor and psychotherapist Terry Lynch. Set for release in September, it chronicles how the notion that a chemical imbalance in the brain is responsible for depression was started by pharmaceutical companies to market their pills, but was adopted widely by the psychiatric community.

Lynch, who has sat on several government-appointed mental health advisory groups, writes that psychiatry is unique in medicine in that none of its diagnoses have any scientifically established biology or pathology.

“Claims that depression and other psychiatric illnesses are biological are crucial to psychiatry’s identity and its unmerited position at the top of the mental health tree… after all, if biology isn’t central to the experiences that have become known as mental illness, what special expertise do psychiatrists really possess?” Lynch asks while the majority of medical practitioners are sincere people trying to do their best, a consequence of the medical model is that generations of people on medication have not been treated for the psychological and emotional components of their distress, reducing the potential for recovery.

Drug treatment

Lynch equates the scale of the problem to any of Ireland’s recent major social crises, such as institutional child sex abuse or the Magdalene Laundries.

“For 50 years, doctors have been telling people that antidepressants work by correcting brain chemicals that are out of balance. I know from many phonecalls and contacts I receive from people to this day, that this practice still goes on regularly in the privacy of the consultation room,” he says.

Lynch, a practicing psychotherapist, stresses he is not anti-medication, but believes it’s imperative that people be fully informed.

“It’s very clear that medications change how people feel, sometimes people feel better, sometimes they feel worse… There is a place for medication and it does help a lot of people, but I think doctors have a duty to tell people: we really don’t know how these work. Numbing is one of their more common effects.”

It’s a point SSRI expert David Healy has written about. “Their [SSRI anti-depressants] primary effect is to emotionally numb. Patients on them walk a tightrope as to whether this emotional effect is going to be beneficial or disastrous.”

Dr John Hillery, director of communications of the College of Psychiatrists of Ireland, says Lynch’s charges are “at odds” with what the college believes.

“I don’t believe the chemical imbalance theory is still widely believed in Ireland,” he says. “It’s not something that I would have told patients, I would have told people about the theories… and that there is a lot of evidence to show they [medications] help people. But they are not going to help everyone and should be part of a treatment package that includes talking therapies and other forms of support.”

Hillery says the college does not have an “official position” on the chemical imbalance theory.

“It is one of the theories behind depression, we talk about it when training people, and teaching the theories behind how medications work, but we do not teach people ‘this is what you tell patients’.”

Hillery, a practicing psychiatrist, said the most important thing for doctors, is to point out medications’ side effects, and that if they do not work, they should be stopped.

“Science that has produced theories [on medications]… beyond that we know they are very helpful for some people, but they should not be given without careful reflection. A lot of recommendations for treating depression now don’t put medications as first-line treatments, but one of the big problems in the public sector is getting access to other therapies for people.”

Lack of alternatives

Compounding matters in Ireland, and indeed globally, is the economic crisis has pushed so many people into despair; people who likely need social and psychological — not chemical — solutions.

An Irish Examiner investigation earlier this year found that almost 2.3m prescriptions were written for anxiety and depression drugs in 2012, enough to cover more than half the population. These figures only take the top five most frequently prescribed anti-depressants and anti-anxiety drugs under the General Medical Services (GMS) into consideration.

There has been an acknowledgement by the Government that alternatives to medication for people presenting to their GPs — who are the first port of call for more than 90% of mental health problems — are needed.

In 2013, the Counselling in Primary Care (CIPC) service was set up to offer free counseling sessions to medical card holders, but the need is far greater than what’s currently being offered.

Lara Kelly, spokesperson for Mental Health Reform, says the scheme was allocated a development budget of €3.8m, just one half of 1% of the mental health budget in 2014.

“The service is available to medical card holders only and has a limitation of eight counselling sessions for each individual accessing the service,” Kelly says. “We want to see it extended to meet the counselling needs of low to middle-income people with mild to moderate mental health difficulties and an increase in the number of sessions from eight to 20.”

Beyond Psychiatry

Those within the critical psychiatry movement, however, say a fundamental reimagining of how human distress is handled is needed — not just tweaks around a broken system.

Harry Gijbels, a lecturer of post-graduate psychiatric nursing at UCC, and Lydia Sapouna, a social work lecturer at UCC, in 2010 founded the Critical Voices Network of Ireland (CVNI), a grassroots movement that aims to redress the balance between patients and practitioners, and give a voice to people who have been silenced.

They believe although Irish psychiatry promotes an image of change, it’s still very embedded in the traditional model of thinking.

“People’s struggles, distress and despair are still very much framed in biomedical terms without looking at a broader picture of people’s lives,” says Sapouna.

Gijbels says psychiatry has engaged with the service user movement and talks about change, but contends that what’s happening is just “lip service”.

“Psychiatrists talk the talk a lot because they feel they have to, but with very little substantial change. We have seen no change in the services. It’s still the very traditional way of thinking.”

He pointed to the new €15m mental health unit at Cork University Hospital (CUH) as an example. “This is very much the old way of thinking — you are ill so you need to be in hospital.”

Recovery

A Vision For Change (AVFC), the national blueprint for modernising the mental health services, calls for the implementation of the recovery concept. The idea emerged in mental health in the 1980s and grew from the publication of personal stories and research studies that showed people diagnosed with severe mental health problems could recover and lead meaningful lives.

The recovery ethos requires new knowledge, skills and approach and is seen as a challenge to professionals working within traditional services, according to Mental Health Reform.

“We talk about recovery as a paradigmatic shift, but what’s happening is just tinkering at the edges, without major changes,” Gijbels continues. “There is a national project, Advancing Recovery in Ireland, and a number of mental health services are trying to implement change, but again there is no real big change. Recovery is not about models or systems… it’s supposed to be about giving people hope, opportunities, control, but that’s not happening and psychiatry remains firmly in charge.”

Lynch devotes a chapter of his book to telling the stories of nine people he has treated and who have recovered from their mental health problems.

All, he says, were told they had a chemical brain imbalance that needed long-term treatment with medication. In each of the cases, the person either never took the medications in the first place, or came off them during the course of his work with them.

Lynch says he’s not suggesting everyone who comes to him makes such a recovery, but uses the examples to point out what’s possible when the right emotional and psychological supports are in place.

“I’m not saying it’s easy, it’s very difficult because there are very few supports for it, but surely if recovery can happen, that’s what we should be aiming for.”

Hillery of the College of Psychiatrists says the college is pushing the “bio/psycho/social model” and the recovery concept, and teaches trainee psychiatrists to look beyond the medical model. “I would hope people are being told they can recover, and can eventually get off medications… some can get off them, but others will need to remain on them.

“One of biggest frustrations we have is a lack of access to other therapies for people who can’t pay.”

Systemic change

In an article published in 2012 in the Irish Journal of Psychological Medicine, Dr Pat Bracken, consultant psychiatrist and clinical director of mental health services in West Cork, wrote that one of the most important questions facing psychiatry is its relationship to the emerging international service user movement — groups like the Hearing Voices Network, Mad Pride, and Mindfreedom International.

“As it becomes more organised and influential this movement is starting to play a major role in shaping the sort of questions that are being asked about mental health services and their priorities,” he wrote.

“Yet there is limited reflection in our profession about how we, as doctors, might engage positively with it. It seems that while we are comfortable working with individuals and organisations who accept the medical framing of mental problems, we are less willing to contemplate working with critical service users.”

Sapouna says: “Naming something as recovery is not change… the college [ICP] can say, ‘we have a group, we are talking’, but the power imbalances need to change and they are far from changing,” she says.

“One indicator of real change would be to see peer-led services. We constantly get calls and emails from people, and the families of people, who are experiencing difficulties, they are despairing for other services, asking us what other ways there are… we need to develop other structures outside mainstream services,” she says.

“For example, people in crisis need a safe place where they can be supported and nurtured, an acute unit is not necessarily the best place for someone in crisis.”

Sapouna points to a unique service in rural Cork, Slí Eile, a housing and support facility, with a farm, for people looking to get away from the revolving doors of the psychiatric system.

“We need crisis homes, more places like Slí Eile… places where people who are in a bad place can find a sense of hope and meaning.

Gijbels says it’s about giving people choices.

“Society need to find ways of understanding how life affects people, we talk about impact of the recession, but at the same time, I don’t think distress has been framed in a different way… effectively you need to seek advice from your GP, at the moment there’s no one else to go to,” reinforcing the notion that people have a medical, rather than a social, problem.

“Drugs will take the pressure off but they won’t fix what’s wrong,” Gijbels says.

“I can understand why GPs prescribe them, they only have 10 minutes with people and want to alleviate their suffering. Some people will get a counsellor, but it’s still a very individual approach… the idea that people’s problems are within them rather than social problems, faults in structures, systems and the lives that we lead.”

Ultimately, says Sapouna, it’s about a more democratic process that allows people to lead the way.

For any of this to happen, political will is needed.

As pointed out by Mental Health Reform in its report in June, A Vision for Change, Nine Years On, in 2012, the current government took a decision not to appoint an Independent Monitoring Group (IMG) to oversee implementation of the strategy. The cost of having an IMG — there were six, from 2006 to 2011 — is negligible as experts appointed, such as Terry Lynch and John Hillery, do not get paid.

Hillery says the move was “disappointing” as the final IMG recommended the Mental Health Commission take over monitoring, and it became a statutory requirement.

Lynch says he’d like to see an independent public inquiry into what’s gone wrong in the past, and how to fix it. “It may need to be international… it should be officially funded and involve a range of people and groups, including mental health service users, with special emphasis on the input of people who have fully recovered from diagnoses such as bipolar disorder, schizophrenia and depression. Psychiatry should have an input but should not be controlling it. It’s widely recognised that we are going through a major mental health crisis, this is a huge societal issue that needs to be tackled properly.”

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