Why We Need to Abandon the
Disease-Model of Mental Health Care
The views
expressed are those of the author and are not necessarily those of Scientific American.
The original
English version of the DSM-5 as well as the French version of the DSM-IV-TR. (Credit:
F.RdeC via Wikimedia Commons)
The idea that
our more distressing emotions such as grief and anger can best be understood as
symptoms of physical illnesses is pervasive and seductive. But in my view it is
also a myth, and a harmful one. Our present approach to helping vulnerable
people in acute emotional distress is severely hampered by old-fashioned,
inhumane and fundamentally unscientific ideas about the nature and origins of
mental health problems. We need wholesale and radical change, not only in how
we understand mental health problems, but also in how we design and commission
mental health services.
Clarity without
diagnosis
Even mainstream
medical authorities have begun to question the creeping medicalization of normal life and criticize
the poor reliability, validity, utility and humanity of conventional
psychiatric diagnosis. It is important that we are able to define, identify and
measure the phenomena we are attempting to study and the problems for which
people seek help. But we obfuscate rather than help when we use the language of
medical disease to describe the understandable, human and indeed normal
response of people to traumatic or distressing circumstances. So there are
ethical and humanitarian reasons to be skeptical of traditional psychiatric
diagnosis. But there are scientific reasons too. It’s odd but hugely
significant that the reliability statistics for the American Psychiatric
Association’s influential DSM
franchise have been falling steadily over time. It is difficult reliably to
distinguish different “disorders”, but also difficult to identify specific biological etiological risk factors. Indeed, Thomas Insel, director of the
National Institute of Mental Health, recently suggested that traditional psychiatric diagnoses had outlived
their usefulness.
A Prescription
for Psychiatry, book cover.
Understanding
rather than etiology
It’s all too
easy to assume that mental health problems — especially the more severe ones
that attract diagnoses like bipolar disorder or schizophrenia — must be mystery
biological illnesses, random and essentially unconnected to a person’s life.
But when we start asking questions about this traditional disease-model way of
thinking, those assumptions start to crumble.
Some
neuroscientists have asserted that all emotional distress can ultimately be explained
in terms of the functioning of our neural synapses and their neurotransmitter
signalers. But this logic applies to all human behavior and every human emotion
and it doesn’t differentiate between distress — explained as a product of
chemical “imbalances” — and “normal” emotions. Moreover, while it is clear that
medication (like many other substances, including drugs and alcohol) has an effect on our neurotransmitters, and therefore on our emotions and
behavior, this is a long way from supporting the idea that distressing experiences are
caused by imbalances in those neurotransmitters.
Many people
continue to assume that serious problems such as hallucinations and delusional
beliefs are quintessentially biological in origin, but we now have considerable
evidence that traumatic childhood experiences (poverty, abuse,
etc.) are associated with later psychotic experiences. There is an almost
knee-jerk assumption that suicide, for instance, is a consequence of an
underlying illness, explicable only in biological terms. But this contrasts
with the observation that the recent economic recession has had a direct
impact on suicide rates, a rather dramatic (and sad) example of how social
factors impact on our mental health.
Neural activity
and chemical processes in the brain lie behind all human experiences, and it’s
undoubtedly helpful to understand more about how the human brain works.
However, this is very different from assuming that some of those experiences
(psychosis, low mood, anxiety, etc) should be classified as illnesses. The
human brain is not only a complex biological structure; it is also a
fantastically elegant learning engine. We learn as a result of the events that
happen to us, and there is increasing evidence that even severe mental health
problems are not merely the result simply of faulty genes or brain chemicals.
They are also a result of experience — a natural and normal response to the
terrible things that can happen to us and that shape our view of the world.
Stigma &
empathy
Traditionally,
the idea that mental health problems are illnesses like any other and that
therefore people should not be blamed or held responsible for their
difficulties has been seen as a powerful tool to reduce stigma and discrimination.
Unfortunately,
the emphasis on biological explanations for mental health problems may not help matters because it presents problems as a fundamental, heritable and immutable part of the individual. In contrast, a
more genuinely empathic approach would be to understand how we all respond
emotionally to life’s challenges.
But things are
changing. Over the past 20 years or so, we’ve seen a very positive and welcome
growth of the user and survivor movements, where people who have experienced
psychiatric care actively campaign for reform, and signs of more responsible
media coverage. We are just starting to see the beginnings of transparency and
democracy in mental health care. This has led to calls for radical alternatives
to traditional models of care, but I would argue that we do not need to develop
new alternatives.
We already have robust and effective
alternatives. We just need to use them.
Therapy
Clinicians have
raised concerns about the relative benefits of psychiatric medication
and there is increasing evidence for the effectiveness of psychological
therapies such as cognitive behavioral therapy. Indeed, even for people with very
serious mental health problems, such as those leading to a diagnosis of
schizophrenia, and even for those choosing not to take medication, such
therapies have great promise.
We need to
place people and human psychology central in our thinking. Psychological
science offers robust scientific models of mental health and well-being, which
integrate biological findings with the substantial evidence of the social
determinants of health and well-being, mediated by psychological processes.
We must move
away from the disease model, which assumes that emotional distress is merely
symptomatic of biological illness, and instead embrace a model of mental health
and well-being that recognizes our essential and shared humanity. Our mental
health is largely dependent on our understanding of the world and our thoughts
about ourselves, other people, the future and the world. Biological factors,
social factors and circumstantial factors — our human experience — affect the
key psychological processes that help us build up our sense of who we are and
the way the world works.
A new approach
In my new book A Prescription for Psychiatry I offer a manifesto for mental health
and well-being. I argue that services should be based on the premise that the
origins of distress are largely social. The guiding idea underpinning mental
health services needs to change; from an assumption that our role is to treat
disease to an appreciation that our role is to help and support people who are
distressed as a result of their life circumstances.
This also means
we should replace traditional diagnoses with straightforward descriptions of
problems. We must stop regarding people’s very real emotional distress as
merely the symptom of diagnosable “illnesses”. A simple list of people’s
problems (properly defined) would have greater scientific validity and would be
more than sufficient as a basis for individual care planning and for the design
and planning of services. This does not mean rejecting rigor or the scientific
method — quite the opposite. While psychiatric diagnoses lack reliability,
validity and utility, there is no barrier to the operational definition of specific psychological phenomena, and it is equally possible to develop
coherent treatment plans from such a basis.
All this means
that we should turn from the diagnosis of illness and the pursuit of etiology
and instead identify and understand the causal mechanisms of operationally
defined psychological phenomena. Our health services should sharply reduce our
reliance on medication to address emotional distress. We should not look to
medication to “cure” or even “manage” non-existent underlying “illnesses”.
We must offer
services that help people to help themselves and each other rather than
disempowering them — services that facilitate “personal agency” in
psychological jargon. That means involving a wide range of community workers
and psychologists in multidisciplinary teams, and promoting psychosocial rather
than medical solutions. Where individual therapy is needed, effective,
formulation-based (and therefore individually tailored) psychological therapies
should be available to all. When people are in acute crisis, residential care
may be needed, but this should not be seen as a medical issue. Since a disease
model is inappropriate, it is also inappropriate to care for people in hospital
wards. A different model of care is needed.
Adopting this
approach would result in a fundamental shift from a medical to a psychosocial
focus. It would mean a move from hospital to residential social care and a
substantial reduction in the prescription of medication. And because
experiences of neglect, rejection and abuse are hugely important in the genesis
of many problems, we need to redouble our efforts to address the underlying
issues of abuse, discrimination and social inequity.
This is an
unequivocal call for a revolution in the way we conceptualize mental health and
in how we provide services for people in distress, but I believe it’s a
revolution that’s already underway.
About the
Author: Peter Kinderman is professor of Clinical Psychology at the University
of Liverpool, and is a
Chartered Clinical Psychologist. He is Head of the Institute of Psychology, Health and Society at the University of Liverpool. His
research interests are in psychological processes underpinning well-being and
mental health, and in particular psychotic phenomena such as delusions and
hallucinations. In 2000, he received the British Psychological Society's
Division of Clinical Psychology 'May Davidson Award', an annual award for outstanding
contributions to the field of clinical psychology, in the first ten years after
qualifying. He was twice elected Chair of the British Psychological
Society Division of Clinical Psychology; from 2004 to 2005, and again from
2010-2011. In that role, he worked with the UK Department of Health, the BBC,
the Health Professions Council, the European Union Fundamental Rights Agency
and the UK Office for National Statistics, amongst others. He has recently
launched a free, online, open-access course exploring our understanding of mental
health and well-being. Follow on Twitter @peterkinderman.
The views
expressed are those of the author and are not necessarily those of Scientific American.
The views
expressed are those of the author and are not necessarily those of Scientific American.
The original
English version of the DSM-5 as well as the French version of the DSM-IV-TR. (Credit:
F.RdeC via Wikimedia Commons)
The idea that
our more distressing emotions such as grief and anger can best be understood as
symptoms of physical illnesses is pervasive and seductive. But in my view it is
also a myth, and a harmful one. Our present approach to helping vulnerable
people in acute emotional distress is severely hampered by old-fashioned,
inhumane and fundamentally unscientific ideas about the nature and origins of
mental health problems. We need wholesale and radical change, not only in how
we understand mental health problems, but also in how we design and commission
mental health services.
Clarity without
diagnosis
Even mainstream
medical authorities have begun to question the creeping medicalization of normal life and criticize
the poor reliability, validity, utility and humanity of conventional
psychiatric diagnosis. It is important that we are able to define, identify and
measure the phenomena we are attempting to study and the problems for which
people seek help. But we obfuscate rather than help when we use the language of
medical disease to describe the understandable, human and indeed normal
response of people to traumatic or distressing circumstances. So there are
ethical and humanitarian reasons to be skeptical of traditional psychiatric
diagnosis. But there are scientific reasons too. It’s odd but hugely
significant that the reliability statistics for the American Psychiatric
Association’s influential DSM
franchise have been falling steadily over time. It is difficult reliably to
distinguish different “disorders”, but also difficult to identify specific biological etiological risk factors. Indeed, Thomas Insel, director of the
National Institute of Mental Health, recently suggested that traditional psychiatric diagnoses had outlived
their usefulness.
A Prescription
for Psychiatry, book cover.
Understanding
rather than etiology
It’s all too
easy to assume that mental health problems — especially the more severe ones
that attract diagnoses like bipolar disorder or schizophrenia — must be mystery
biological illnesses, random and essentially unconnected to a person’s life.
But when we start asking questions about this traditional disease-model way of
thinking, those assumptions start to crumble.
Some
neuroscientists have asserted that all emotional distress can ultimately be explained
in terms of the functioning of our neural synapses and their neurotransmitter
signalers. But this logic applies to all human behavior and every human emotion
and it doesn’t differentiate between distress — explained as a product of
chemical “imbalances” — and “normal” emotions. Moreover, while it is clear that
medication (like many other substances, including drugs and alcohol) has an effect on our neurotransmitters, and therefore on our emotions and
behavior, this is a long way from supporting the idea that distressing experiences are
caused by imbalances in those neurotransmitters.
Many people
continue to assume that serious problems such as hallucinations and delusional
beliefs are quintessentially biological in origin, but we now have considerable
evidence that traumatic childhood experiences (poverty, abuse,
etc.) are associated with later psychotic experiences. There is an almost
knee-jerk assumption that suicide, for instance, is a consequence of an
underlying illness, explicable only in biological terms. But this contrasts
with the observation that the recent economic recession has had a direct
impact on suicide rates, a rather dramatic (and sad) example of how social
factors impact on our mental health.
Neural activity
and chemical processes in the brain lie behind all human experiences, and it’s
undoubtedly helpful to understand more about how the human brain works.
However, this is very different from assuming that some of those experiences
(psychosis, low mood, anxiety, etc) should be classified as illnesses. The
human brain is not only a complex biological structure; it is also a
fantastically elegant learning engine. We learn as a result of the events that
happen to us, and there is increasing evidence that even severe mental health
problems are not merely the result simply of faulty genes or brain chemicals.
They are also a result of experience — a natural and normal response to the
terrible things that can happen to us and that shape our view of the world.
Stigma &
empathy
Traditionally,
the idea that mental health problems are illnesses like any other and that
therefore people should not be blamed or held responsible for their
difficulties has been seen as a powerful tool to reduce stigma and discrimination.
Unfortunately,
the emphasis on biological explanations for mental health problems may not help matters because it presents problems as a fundamental, heritable and immutable part of the individual. In contrast, a
more genuinely empathic approach would be to understand how we all respond
emotionally to life’s challenges.
But things are
changing. Over the past 20 years or so, we’ve seen a very positive and welcome
growth of the user and survivor movements, where people who have experienced
psychiatric care actively campaign for reform, and signs of more responsible
media coverage. We are just starting to see the beginnings of transparency and
democracy in mental health care. This has led to calls for radical alternatives
to traditional models of care, but I would argue that we do not need to develop
new alternatives.
We already have robust and effective
alternatives. We just need to use them.
Therapy
Clinicians have
raised concerns about the relative benefits of psychiatric medication
and there is increasing evidence for the effectiveness of psychological
therapies such as cognitive behavioral therapy. Indeed, even for people with very
serious mental health problems, such as those leading to a diagnosis of
schizophrenia, and even for those choosing not to take medication, such
therapies have great promise.
We need to
place people and human psychology central in our thinking. Psychological
science offers robust scientific models of mental health and well-being, which
integrate biological findings with the substantial evidence of the social
determinants of health and well-being, mediated by psychological processes.
We must move
away from the disease model, which assumes that emotional distress is merely
symptomatic of biological illness, and instead embrace a model of mental health
and well-being that recognizes our essential and shared humanity. Our mental
health is largely dependent on our understanding of the world and our thoughts
about ourselves, other people, the future and the world. Biological factors,
social factors and circumstantial factors — our human experience — affect the
key psychological processes that help us build up our sense of who we are and
the way the world works.
A new approach
In my new book A Prescription for Psychiatry I offer a manifesto for mental health
and well-being. I argue that services should be based on the premise that the
origins of distress are largely social. The guiding idea underpinning mental
health services needs to change; from an assumption that our role is to treat
disease to an appreciation that our role is to help and support people who are
distressed as a result of their life circumstances.
This also means
we should replace traditional diagnoses with straightforward descriptions of
problems. We must stop regarding people’s very real emotional distress as
merely the symptom of diagnosable “illnesses”. A simple list of people’s
problems (properly defined) would have greater scientific validity and would be
more than sufficient as a basis for individual care planning and for the design
and planning of services. This does not mean rejecting rigor or the scientific
method — quite the opposite. While psychiatric diagnoses lack reliability,
validity and utility, there is no barrier to the operational definition of specific psychological phenomena, and it is equally possible to develop
coherent treatment plans from such a basis.
All this means
that we should turn from the diagnosis of illness and the pursuit of etiology
and instead identify and understand the causal mechanisms of operationally
defined psychological phenomena. Our health services should sharply reduce our
reliance on medication to address emotional distress. We should not look to
medication to “cure” or even “manage” non-existent underlying “illnesses”.
We must offer
services that help people to help themselves and each other rather than
disempowering them — services that facilitate “personal agency” in
psychological jargon. That means involving a wide range of community workers
and psychologists in multidisciplinary teams, and promoting psychosocial rather
than medical solutions. Where individual therapy is needed, effective,
formulation-based (and therefore individually tailored) psychological therapies
should be available to all. When people are in acute crisis, residential care
may be needed, but this should not be seen as a medical issue. Since a disease
model is inappropriate, it is also inappropriate to care for people in hospital
wards. A different model of care is needed.
Adopting this
approach would result in a fundamental shift from a medical to a psychosocial
focus. It would mean a move from hospital to residential social care and a
substantial reduction in the prescription of medication. And because
experiences of neglect, rejection and abuse are hugely important in the genesis
of many problems, we need to redouble our efforts to address the underlying
issues of abuse, discrimination and social inequity.
This is an
unequivocal call for a revolution in the way we conceptualize mental health and
in how we provide services for people in distress, but I believe it’s a
revolution that’s already underway.
About the
Author: Peter Kinderman is professor of Clinical Psychology at the University
of Liverpool, and is a
Chartered Clinical Psychologist. He is Head of the Institute of Psychology, Health and Society at the University of Liverpool. His
research interests are in psychological processes underpinning well-being and
mental health, and in particular psychotic phenomena such as delusions and
hallucinations. In 2000, he received the British Psychological Society's
Division of Clinical Psychology 'May Davidson Award', an annual award for outstanding
contributions to the field of clinical psychology, in the first ten years after
qualifying. He was twice elected Chair of the British Psychological
Society Division of Clinical Psychology; from 2004 to 2005, and again from
2010-2011. In that role, he worked with the UK Department of Health, the BBC,
the Health Professions Council, the European Union Fundamental Rights Agency
and the UK Office for National Statistics, amongst others. He has recently
launched a free, online, open-access course exploring our understanding of mental
health and well-being. Follow on Twitter @peterkinderman.
