Depression? There’s no such thing ...
Leading psychiatrists are calling for a different approach to how we treat mental illnesses. One even says “there’s no such thing as depression”. Stephen Naysmith examines the issues
COMMONLY understood mental illnesses such as depression, schizophrenia and psychosis don’t exist – and telling patients they have them is “unethical, unscientific, unprofessional and inexcusable”, a leading clinical psychologist has said.
Dr Lucy Johnstone is one of a growing number of experts and clinicians in the field who believe the current system of diagnosis and treatment of mental illness is not working, and should change.
“There is no medical illness ‘depression’,” said Johnstone, a clinical psychologist, trainer, speaker and writer, and a longstanding critic of biomedical model psychiatry – which sees mental disorders as brain diseases which need treated with drugs.
“Neither are there conditions such as schizophrenia, or psychosis. Telling people they have borderline personality disorder is unethical, unscientific, unprofessional, inexcusable.
“Biomedical clinical psychiatry is an ideology and it is wrong for professionals to impose this on people.”
She is supported in this view, albeit a little less stridently, by Mary Boyle, emeritus professor of clinical psychology at the University of East London.
People have been told illnesses are the result of “faulty” brain chemistry, she says, but there is far more evidence for the role of other factors – such as poverty, neglect, abuse or some history of trauma.
“There is no evidence base for schizophrenia. Nobody has demonstrated a biochemical imbalance to explain it, for instance, despite much effort,” Boyle says. “But the money spent on looking unsuccessfully f or t hese t hings completely dwarfs that spent on researching the influence of people’s prior experiences.”
Drugs are presented by drug companies and by clinicians as a cure for prob- lems, but this is more marketing than science, she claims: “They have general effects and sometimes people find them helpful. But they are not cures, and in the longer term can have really serious side effects. People are not being told the truth about these drugs.”
While treatments, ser vices and resources are much discussed, discussion of the causes is minimal. “When we talk about physical health we almost always consider the causes. But we have an epidemic of distress among young people, even in loving families.
“One factor is the structures of society – normal working practices cause stress and pressure. Social norms are narrow and oppressive, but when we are talking about mental health, we rarely look at those causes.”
Those critical of the mainstream clinical approach to mental health believe there are two main reasons why it is not questioned. One is the influence of big pharma, the drug companies which have a clear vested interest in perpetuating the idea of mental health as a set of diagnosable conditions which can be treated with medication, and the psychiatrists who have spent careers training and working within this model.
The other reason may be that the alternative is expensive and politically challenging: understanding and addressing the trauma or other important experiences in the past lives of people who suffer mental health crisis – the events which lie behind their distress.
Johnstone and Boyle are the lead authors of a would-be revolutionary new document published by the clinical psychology division of the British Psychological Society.
The Power Threat Meaning Framework (PTMF) sets out an alternative to treating the symptoms exhibited by patients experiencing distress.
This approach is founded on the assumption that mental health conditions are always “threat responses”, feelings of distress, confusion, fear or despair or troubling behaviour arising from difficult life experiences.
One way or another, this is rooted in issues of power – more usually powerlessness: the power wielded by an abusive relative over a child, a bullying boss or co-worker, or the domestic violence from a partner, for example.
Under PTMF an individual would be urged to put together a personal narrative to help understand what has happened to them. What was the power dynamic, and what was the threat ( how did it affect you), what sense did you make of it, and what did you have to do to survive (“threat response” – currently commonly described as “symptoms”).
The PTMF identifies a range of “patterns” helpful in understanding the way trauma and other life experiences affect us all.
The document identifies seven patterns. One relates to behaviour or distress caused by trauma, neglect or rejection in childhood. Another deals with separation or identity confusion, a third to defeat, loss or “entrapment”.
Loosely, the first encompasses condi-
You might be depressed, but we wouldn’t say ‘you have depression’. The switch from ‘I’m sad and miserable’ to ‘I’ve got depression’ is absolutely toxic
tions such as ADHD, self-harm and anxiety, the second schizophrenia, psychosis and eating disorders, t he t hird depression.
But what is important is the light these patterns of reaction shed on someone’s current health, not the labels, which are often damaging, says Johnstone. “You might be depressed, but we wouldn’t say ‘you have depression’. The switch from ‘ I’m sad and miserable’ to ‘ I’ve got depression’ is absolutely toxic.”
Both authors acknowledge that people who are struggling may well want to seek out a diagnosis. Being diagnosed can be a gateway to services, or benefits. Refusing a label may be unwise.
“If you say ‘I haven’t got schizophrenia’ you could find yourself in a lot of trouble’,” Boyle says. “But you don’t have to be defined by it. People don’t have to accept what their GP tells them.”
These ideas, while challenging, are gaining currency. Boyle and Johnstone were recently in Glasgow, speaking to Scottish members of the British Psychological Society.
Consultant clinical psychologist Morag Slesser says they were well received: “We’re trying to get the message out there that there are other ways to make sense of mental health problems that can leave the sense of control with the person – rather than to medicalise symptoms and expect the doctor to fix them or you.”
Trisha Hall, of the Scottish Association of Social Work, is another enthusiast. Many social workers are unhappy at their twin role, she says, both assessing people with mental health issues for the risks they may pose, while also overburdened with paperwork for the relationship- based work they got into the profession to do.
“There is a risk of us colluding with a system that is increasingly biomedical,” she says. “We can no longer justify an approach with is based on people being risk assessed, diagnosed, offered a little package of treatment, and off you go.”
Alistair Brown is a mental health officer – a social worker with specialist training and experience in mental health, and a member of Mental Health Tribunal Scotland.
“There is considerable evidence that people with a psychiatric diagnosis are disproportionately adults who have experienced trauma, and children who have been in care, or have experiences such as extreme poverty, violence or sexual abuse in their background,” he says. “We are in danger of perpetuating something that is really not working for people.”