Friday,November1,2013

Times of change and opportunity: Towards a

psychological model of mental health and
well-being
Notes for a speech given at: The International Psychology Conference, Dubai 1st November
2013. These are my NOTES for the speech, the speech as delivered may have been different (in
particular, I did suggest that we needed to lead "a revolution" in our approach to these issues,
which doesn't appear below).

Good morning, and thank you for inviting me.

It is a time of significant change in the field of mental health.
Over the past twenty years or so, weve seen a very positive and welcome
growth of the user and survivor movements, some first signs of more
responsible media coverage, and a rejection of the idea that we should be
stupefied by shame and stigma into accepting the paternalism of earlier days
we are just starting to see the beginnings of transparency and democracy
in mental health care.
The publication of DSM-5, the fifth edition of the American psychiatric
diagnostic manual, has proved controversial, and has led many to question
the creeping medicalisation of normal life, and to criticise the poor reliability,
validity, utility and humanity of conventional psychiatric diagnosis.
At the same time, we have seen many commentators conclude that there is
precious little reason to believe some of the more outrageous claims as to the
effectiveness of many psychiatric drugs. We know that these drugs have very
significant adverse effects, too. And there is even less reason to believe that
these drugs are effective in the longer term whatever their benefits in
emergencies.
On the other hand, we have seen growing evidence of the effectiveness of
evidence-based psychological therapies, helping people with a wide range
of problems.
All this has led many to call for radical alternatives to traditional models of
care.
I agree.
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.
The well-established ethos of the clinical psychologist as scientist-practitioner
means that we can offer evidence-based scientific models of mental health
problems and well-being.

These integrate biological findings with the substantial evidence of the social
determinants of health and well-being, mediated by psychological
processes.
For example, colleagues and I found in research conducted with the
support of the BBC that negative life events were substantial contributors to
a persons levels of depression and anxiety, but this was mediated by their
level of rumination.
And, of course, because these models almost inevitably refer to
psychological mechanisms mediating the effects of biological, social and
circumstantial factors on mental health problems and wellbeing, they almost
inevitably imply that psychological interventions which affect these
psychological mechanisms can be effective.
In simple terms, if we were able to turn off our rumination, wed be able to
turn down at least some of our depression and anxiety.
These significant scientific and professional developments allow us to foresee
a future beyond the 'disease model' of mental health and well-being.
The Roman emperor and philosopher, Marcus Aurelius (played by Richard
Harris in the film Gladiator) once argued that we need always to bear in
mind: What is this, fundamentally? What is its nature and substance, its
reason for being?
What, then, is the fundamental nature and substance of those psychological,
emotional and behavioural problems that are the subject matter of our
profession?
In my view, they are fundamentally social and psychological issues. They do
have clear biological elements we should not artificially separate our
physical from our mental health. So psychologists, therapists and social
workers must work closely alongside GPs, public health physicians and nurses.
But mental well-being is fundamentally a psychological and social
phenomenon, with medical aspects. It is not, fundamentally, a medical
phenomenon with additional psychological and social elements.
Clinical psychology is a wonderful profession Im proud to be a clinical
psychologist. But we have, I believe, been tempted down a medical route.
Weve tended to think in terms of disorder, in terms of aetiology in terms
of treatment and in terms of pathology or abnormality. We conduct
randomised controlled trials, we set up programmes such as the UKs IAPT
improving access to psychological therapies programme which is
predicated on the notion of identifying people with recognised mental
disorders, offering treatment and assessing outcome on the basis of quite
traditional medicalised criteria. We criticise this language, this way of thinking.
But all too often, we use it.
We need to place people and human psychology central in our thinking.

And we need to return to core principles ethical, professional and scientific.

I went to a slightly odd meeting recently where a very senior psychiatrist
said: weve got to remember, were paid to treat illnesses I simply
disagree.
That may be the core purpose of some professions, but not mine and
perhaps not medics either.
The World Health Organisation describes health as ... a state of complete
physical, mental and social well-being and not merely the absence of
disease or infirmity. The European Commission takes a step further, describing
mental health as: a resource which enables them to realise their intellectual
and emotional potential and to find and fulfil their roles in social, school and
working life. For societies, good mental health of citizens contributes to
prosperity, solidarity and social justice.
The European Commission, interestingly, also suggests that: the mental
condition of people is determined by a multiplicity of factors including
biological, individual, family, social, economic and environmental. They cite
the role of genetics, but also gender, personal experiences, social support,
social status and living conditions in our mental well-being.
I agree. In my view, good mental health is indeed: a resource which enables
them to realise their intellectual and emotional potential and to find and fulfill
their roles in social, school and working life. My role, my job, my profession, is
helping people fulfil their potential as human beings, not treating illnesses. In
fact, doctors medical practitioners, psychiatrists have always prized an
element of their profession that goes beyond merely treating the patient and
illness in front of them.
Im an unapologetic cognitive psychologist. And I recognise certain pretty
clear findings from psychological science. Our thoughts, our emotions, our
behavior 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.
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.
Of course, we must address the issue of biology.
Every thought I have involves a brain-based event. All learning involves
changes in associative networks, depolarisaion thresholds, synaptic
biomechanics, even gene expression.
My view is not an anti-brain, anti-psychiatry, model. But I believe that my brain
is a learning engine a biological system that is the servant of learning. I am
not the slave of my brain, my brain is the organ with which I learn. So of
course every thought involves brain-based activity. But this isnt the same as

biomedical reductionism. Our biology provides us with a fantastically elegant

learning engine. But we learn as a result of the events that happen to us - its
because of our development and our learning as human beings that we see
the world in the way that we do.
Everybody recognises that there are changes to the way that our brain
functions which affect our thinking, our moods, our behaviour. Most cultures in
the world are familiar with a range of chemicals cannabis, alcohol, even
caffeine that affect our psychological functioning because of the effects
they have on our brain.
And its perfectly reasonable to suggest that individual differences in people
even differences as a result of genetic differences will have measurable
influences on their behaviour and thinking in later life.
Theres nothing un-psychological and certainly nothing un-scientific about
understanding that biological factors can affect our psychological
functioning and thereby affect our moods, our thinking, our behaviour.
But I think theres a world of difference between acknowledging these
influences and accepting a disease model.
For two striking reasons.
First, I believe that the relative influence of biological factors is relatively small.
I need to clarify this.
Every thought I have ever had involves a biological event.
I have also been involved in supervising research that used fMRI technology
functional magnetic resonance imaging to study regional blood flow during
a self-referential task. We found that specific areas of the brain were
associated with self-referential thinking, and that these areas were more
active in people seeking help for depression.
When we think for example of ourselves, as opposed to thinking of another
person, its abundantly clear that specific neural pathways are involved.
Since thought involves neural signals in the brain, its hugely unsurprising that
thoughts of all kinds involves identifiable brain circuitry.
But identifying a pathway to a particular though process does not imply that
a pathological mechanism has been found.
Logically, quite the reverse seems a more parsimonious explanation if a
particular neural pathway is found to be associated both with emotional and
interpersonal difficulties and a key psychological process, it makes sense to
me to assume that this is an important scientific finding that applies to us all,
not just those of us unfortunate enough to have somebody attach an illness
label to our emotions.
This is not a style of thinking compatible with the disease model.

Because every thought must involve a neurological process, merely finding a

neurological correlate of emotional distress or psychological process isnt the
same as identifying a pathology or an illness. Quite the reverse.
In addition, my reading of the available literature suggests to me that the
influence of variance between people in biological terms has much less
influence on their subsequent emotional life than the variance between
people in social and circumstantial terms.
Just a couple of examples.
In my department at Liverpool, colleagues Ben Barr, David Taylor-Robinson
and Alex Scott-Samuel together with Martin McKee and David Stuckler
demonstrated that around 1000 more people killed themselves in the years
between 2008 and 2010 than would have been expected. They also found
that the English regions with the largest rises in unemployment had the largest
increases in suicides, particularly among men.
They conclude that the economic recession was the most likely cause.
Recession, economic insecurity, loosing your job clearly has a major impact.
Rather differently, Richard Bentall and John Read have analysed the impact
of childhood trauma abuse on the likelihood of developing psychosis. In a
number of studies, they have concluded that childhood abuse more than
doubles the risk that youll develop hallucinations or delusional beliefs in later
life.
It seems clear that social and circumstantial factors are significant.
There have been relatively few studies directly comparing the relative
contributions of biological and social variables, but reviews of the relative
contribution of negative life events and abnormalities of the serotonin
reuptake gene by Steven Reich and colleagues suggest that while life events
are associated with future depression, the same cant be said of serotonin
reuptake gene differences.
Its perhaps noteworthy that proponents of biological reductionism
occasionally make some peculiar suggestions suggesting to Bentall and
Read, for example, that genetic abnormalities might make kids vulnerable to
BOTH abuse and psychosis, but that the abuse wasnt really the cause. And,
of course, when the different alleles of the serotonin reuptake gene are found
to be less clearly related to depression than might be thought, well, were
told that new genetic breakthroughs are likely within months.
But, we must, as psychologists, remain clear-sighted as to HOW biological,
and, for that matter, social and circumstantial factors affect our mental
health and well-being.
And, again, the alternative to the disease model is already with us. Its
already part of our scientist-practitioner model, and already well-established
within psychological science.
Undergraduate psychology students are introduced to the ancient Greek

philosopher Epictitus, and his ethos that it isnt events that upset us, but our
interpretation of those events.
That fits with my own findings that psychological processes mediate the
impact of biological, social and circumstantial factors on mental health.
And more generally, it supports the notion that 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. Biological factors, social factors, circumstantial factors our learning as human beings - affect us because 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.
In this view of the world, of human nature, there is no real need to invoke the
idea of abnormality or disease, even of diagnosis people are just making
sense of their world; developing complex, shifting, emotionally-laden
frameworks of understanding of the world. This is why psychologists tend to be
sceptical of diagnoses.
Our science is robust and substantiable. And our therapies even when
appraised using the standards of biological medicine are demonstrably
effective.
So... what are the implications for the system of care?
This is perhaps not the forum to outline the failings of modern psychiatry. But it
seems clear that were dealing with a slightly dysfunctional family. On the one
hand, biological psychiatrists such as Guze author of Biological psychiatry:
is there any other kind? and the Nobel Prize-winning Eric Kandel suggest that
biological functioning is the final common pathway for mental disorder and,
indeed, therapy.
And our own Nick Craddock argues in his manifesto or wake up call for British
psychiatry that there has been a creeping devaluation of medicine in
psychiatry. There is, Craddock and colleagues argue: a very real risk that
as the understanding of complex human diseases steadily increases, recent
moves away from biomedical approaches to psychiatric illness will further
marginalize patients and that Psychiatry is a medical specialty. We
believe that psychiatry should behave like other medical specialties. This is a
precise recapitulation of a medical model of psychiatry. Craddock and
colleagues are also refreshingly clear in their professional or political
aspirations British psychiatry faces an identity crisis. A major contributory
factor has been the recent trend to downgrade the importance of the core
aspects of medical care.
Craddock and colleagues confidently expect that molecular biology and
neuroscience will help us understand the pathogenesis of mental health
problems, therefore confirm the value of biomedical explanations of illness
and confirm the value of a medical psychiatric profession. On the other
hand, Pat Bracken and colleagues in the same forum as Nick Craddock
argue the opposite: that Psychiatry is not neurology; it is not a medicine of

the brain.
Although mental health problems undoubtedly have a biological dimension,
in their very nature they reach beyond the brain to involve social, cultural and
psychological dimensions. These cannot always be grasped through the
epistemology of biomedicine. And, of course, a phrase often repeated in
relation to the developments of DSM-5 is that such approaches represent
the creeping medicalization of normal life.
Two pretty much diametrically opposed perspectives.
Does this matter?
It probably does.
I receive a fair number of unsolicited letters. One read: "... Rather than
engaging with the patients on the ward, the staff instead shepherded them
around like sheep with bullying commands, threats of jabs (injections), and
removal to an acute ward elsewhere in the hospital, if they did not cooperate. The staff also stressed medication rather than engagement as a
way of controlling the patients. And the staff closeted themselves in the ward
office, instead of being out and about on the corridors and in the vestibule
where they should have been. The staff wrote daily reports on each patient
on the hospitals Intranet system; these reports were depended upon by the
consultant psychiatrists for their diagnoses and medication prescriptions, but
were patently fabricated and false, because the staff had never engaged or
observed properly the patient they were writing about in their reports. The
psychiatrists themselves were rarely seen on the ward, and only consulted
with their patients once a week."
And I quote in aid Professor Sir Robin Murray, writing as Chair of the recent
Schizophrenia Commission; the message that comes through loud and
clear is that people are being badly let down by the system in every area of
their lives.
So whats needed?
Well First.
1. Get the message right drop the disease model and adopt a
psychosocial model.
I realise this is didactic, that Im telling people how to think. But didactic
messages from medicine have been commonplace for years! (a very senior
psychiatrist once, quite pleasantly, stated that his medical education made
him entirely competent to do all the jobs of everyone in his team, including
clinical psychologists, nurses and social workers, but that they, of course,
couldnt do his!).
So drop the disease model and accept that these are psychosocial issues.
On twitter, a colleague suggested I was proposing a psychobiosocial
model.
I quite like that.

Then...
2. Stop diagnosing non-existent illnesses a simple list of peoples problems
(properly defined) would be more than sufficient as a basis for individual care
planning and for the design and planning of services.
And.
3. Recognise our role lies in supporting well-being, not treating illnesses. For my
psychiatric, medical, colleagues, this is a perfectly respectable medical role
(think of the role of General Practitioners and public health physicians, think of
medical care in pregnancy and the role of someone like the medical advisor
to the Manchester United Football Club squad).
4. Fourthly and perhaps more radically. Stop pushing the drugs (or at
least slow down). They just simply dont offer an effective and safe solution.
And here I would appeal to the work of medical colleagues such as Dr
Joanna Moncrieff and others.
Of course, pharmaceuticals alter our mood, cognition and, therefore, our
behaviour. But very briefly to summarise Jo Moncriefs drug-centred rather
than disease-centred model this merely explains that drugs alter brain
chemistry theres simply no convincing evidence that they are reestablishing neurotransmitter balance or addressing pathologies.
Instead.
5. Offer psychosocial services that aim for recovery and personal agency on
the part of the client. That means working with a wide range of community
workers such as social workers, social pedagogues, and psychologists in
multidisciplinary teams, and promoting social rather than medical solutions in
the first instance.
Of course, of course, there should be one-to-one psychotherapy. But we
should be doing what weve always wanted to do - which is offering more
fully holistic services. We should be linking with Jobcentre Plus employment
advisers who are delivering what are effectively wellbeing interventions for
people. We should be working with the education services. And we should be
working with the physical health services. We should be working with
employers, theres plenty of evidence that interventions aimed at improving
peoples wellbeing, not curing their mental illnesses but improving peoples
wellbeing is productive for employers. We should be working with community
services and the wider civil society.
In each case, scientifically elegant analyses of psychological processes
leading to interventions.
All such interventions should all be evidence-based and delivered by
qualified, competent professionals. Decisions about what therapy or
therapies should be offered to whom should be based on a persons specific
problems and on the best evidence for the effectiveness of the intervention,
not on diagnosis, and individual formulations should be used to put together

an individualized package of care suitable for addressing each persons

unique set of problems.
So there are a number of psychosocial interventions that we should pursue in
addition to standard one-to-one therapies.
6. Where individual therapy is needed, recognise that there are many
effective, evidence-based, psychological therapies available.
When I was first qualified as a clinical psychologist, I was told that to talk to a
service user experiencing psychosis was unethical, as talking about their
problems would make them worse. We now have evidence-based
psychological therapies recommended for a wide range of so-called
disorders and in my area of speciality, such evidence-based approaches
are recommended for all 100% of people experiencing psychotic
phenomena such as hallucinations and delusions.
But this again returns to the language and thinking style of medicine
diagnosis, treatment, outcome. We need to accept that a focus on social
determinants of well-being means that we are discussing what is effectively a
social and psychological phenomenon, with medical aspects, not a medical
phenomenon with social correlates
And this means
7. In the multidisciplinary teams delivering these services, medical psychiatric
colleagues should remain valuable colleagues. An ideal model for
interdisciplinary working would see leadership of such teams determined by
the personal qualities of the individual members of the team. It would not be
assumed that clinical primacy would inevitably put our medical colleagues
in a position of unquestioned authority people should regard themselves as
consultants TO the team, not leaders OF the team.
This does have implications. It could mean a much greater reliance on GPs
and other primary care colleagues as opposed to what are not traditional
psychiatrists. We might see joint working between GPs and community teams,
with GPs offering the medical input when needed as opposed to seeing
psychiatrists serving this role.
And that might not only be beneficial for the service user, but could see a
massive cost saving for the NHS, if this fed through to a commensurate
reduction in our dependence on highly expensive psychiatrists.
And this principle could apply in residential care, too
8. When people are in crisis, residential care may be needed, but this should
not be seen as a medical issue. Since a disease-model is inappropriate, it is
inappropriate to care for people in hospital wards; a different model of care
is needed. Residential units, again, should be based on social, not medical,
models. Residential social workers or nurses may well be the most appropriate
people to be in charge of such units. The nature of extreme distress means

medical colleagues may well be valuable members of the team but again
they should be consultants TO the ward, not having sapiential authority OVER
the team.
As part of the process of accessing these residential units
9. When the powers of the Mental Health Act are needed, the decisions
should be based on the risks posed to self and others, but also on the persons
capacity to make decisions about their own care. This approach is the basis
for the law in Scotland, and the law in England and Wales permits the
responsible clinician to be a psychologist, nurse, or social worker. This should
be routine. When we reject a disease-model of care and adopt a humancentred model, the law relating to mental health could change significantly;
with different legal criteria, different ways of assuring that people are offered
least restrictive alternatives, with a psychosocial focus, new roles for new
professions, and a greater focus on social justice and judicial oversight.
But all this would in my vision need one final or first step.
10. Base yourselves in local authority services, alongside other social,
community-based, services.
That doesnt mean design medical teams for psychiatry, manage them out
of hospital-based, NHS-based Trusts but put them in a building away from the
hospital site, it means locate the whole service in community services put
the service entirely under local authority control. In the UK, we have the
model of public health (transferred to local authority control) to build upon.
This should and could then be under democratic local governance. I
recognise that some local authorities especially, perhaps, in developing
countries, may not yet be robust enough for the task, but this should be the
vision and aspiration, rather than aiming for a medical model.
Adopting this approach would result in much lower reliance on medical
interventions, and a much greater reliance on social and psychological
interventions. We would we may as well be honest need fewer
psychiatrists.
As we see a move towards community-based social services, we would look
to primary care (General Practice - GP) colleagues for much of the necessary
medical consultation and input; linking psychological care to the wider
wellbeing of patients in the community. We would, in contrast, require much
greater emphasis on, training in, and staffing of, psychosocial approaches.
What Im proposing would be a very major revolution in psychiatric practice.
It would challenge the central tenets of at least some traditionalist, biological,
psychiatrists and the knock-on implications for social psychiatrists (who
might otherwise share Pat Brackens views and therefore otherwise be
sympathetic) could be equally significant as their power and authority is
challenged.

In such a vision. Where are psychologists and what is our role?. Well In my
view, good mental health is indeed: a resource which enables them to
realize their intellectual and emotional potential and to find and fulfil their
roles in social, school and working life. My role, my job, your profession, is
helping people fulfill their potential as human beings, not treating illnesses.
I believe that our thoughts, our emotions, our behaviour and therefore, our
mental health is largely dependent on our understanding of the world, our
thoughts about ourselves, other people, the future, and 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.
It naturally follows that psychologists should play a central role. We should
offer leadership with colleagues such as Pat Bracken, Phil Thomas, Jo
Moncrieff and Sami Timimi; psychiatrists proud of their profession and expert
medical practitioners who nevertheless share these points of view.
But most importantly, we should lead in the process of change. I invite you to
think about how we might work to make this kind of vision a reality.
Some steps might appear hugely ambitious I am recommending that local
authorities, not hospital Trusts, are the right home for psychiatry. You might
think that the opposition to that might be overwhelming. And you might think
that it would be impossible to achieve.
But weve recently seen public health services transferred from NHS
responsibility to local authority management a wholesale transfer, in my
opinion placing public health where it should be and under democratic
control and, significantly, meaning that local authorities now employ
doctors and deliver clinical services. I believe psychiatry should follow them.
So perhaps this relies on the political and managerial activity of local Health
and Well-Being Boards and the management teams of Trusts but its
certainly not impossible. And weve seen some public and influential
psychiatrists recently arguing that its dangerous to abandon the current
diagnostic tools despite their acknowledged and admitted flaws because
we have no proven alternative.
The argument the incorrect argument is that the critics of diagnosis would
need to develop a new technology of classification, which would then need
to be counter-tested against diagnosis, before we could take the dangerous
in their view step of abandoning the disease-model approach.
Not true. Its forgivable for people with no perspective other than a diseasemodel, diagnosis-treat approach to look within medicine and see
diagnosis and nothing more. But I am we, as clinical psychologists, are
applied scientists.
We use the basic principles of applied science. The Oxford English Dictionary
defines the scientific method as: "a method or procedure that has
characterized natural science since the 17th century, consisting in systematic
observation, measurement, and experiment, and the formulation, testing,

and modification of hypotheses."

So we use operational definitions of relevant concepts. We develop
hypotheses.
And we collect data. We dont need to meet the challenge of a new
technological alternative to diagnosis and the disease model. Weve had it
since the 17th century.
So it is time for change.
It is time to remember and act up to out core purpose as psychologists.
Psychological health and well-being is ... a state of complete physical,
mental and social well-being and not merely the absence of disease or
infirmity. and a resource which enables citizens to realise their intellectual
and emotional potential and to find and fulfil their roles in social, school and
working life.
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. Biological factors, social
factors, circumstantial factors - our learning as human beings - affect us
because 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.
Our particular role is to use the well-tested tools of science to understand this
process and to intervene to help people improve their lives. Change is
needed, but its also a return to our core purpose as a profession.
Thank you.
Peter Kinderman