Zero suicide: zero insight

A healthcare conference will take place shortly to discuss an aspiration to achieve zero suicide (1). Of course no one would deny that this is a worthy aim. The programme reminds us that:

The Prime Minister has announced £2 million in funding for the Zero Suicide Alliance (ZSA) over the next 2 years. The funding will help to reduce suicides across the NHS, with the aim of achieving zero inpatient suicides.

If a person with suicidal tendencies has been admitted to a mental health facility, wouldn’t we expect them to be protected from themselves? Close observation and the prevention of access to a means for carrying out suicide would surely be expected as a matter of course. That is why they have been admitted. Similarly, when someone is admitted for an appendectomy, we would expect the availability of a surgeon to carry it out. It is true that some suicidal people are extremely clever and determined. Although zero inpatient suicide is the expected target, there may be an occasional person who manage to achieve it despite the best of measures. A fund of two million spread across numerous mental health facilities might be a help but it is hardly a bonanza. Also, it does not address suicide outside mental health facilities.

As regards the prevention of suicide across the population as a whole (including people in prison), the logistics of prevention are far from obvious. According to the Samaritans: just under 6,000 people take their own lives every year. [This compares with just under 2000 killed in road traffic accidents and around 25,000 seriously injured in this way annually]. In order for suicide to be preventable, it must be predictable. The recommendations set out in the Government’s Five Year Forward View for Mental Health policy on suicide prevention and reduction makes: a commitment to reduce suicides by 10% nationally by 2020/21 (1). This 10% reduction certainly has greater chance of success than 100%. However, people must get the kind of help that they want. It has been reported that one quarter to one half of people who have already attempted suicide do not attend follow-up appointments (2). A major stumbling block to prevention is that in primary care, where most depressed mood with suicidal tendencies is diagnosed, approximately three quarters of suicide deaths are of individuals who are unknown to secondary care services (3). Of various interpretations for this figure, the following are credible (a) that people who are liable to kill themselves conceal this fact successfully from others (b) that they are not taken seriously when they draw attention to their state of mind (c) that they are taken seriously but an appropriate service is not available (or available quickly enough) (d) that the kind of help available is unwanted or ineffective. Perhaps greater priority should be given to researching these possibilities than to inpatient services that should, in any case, be preventing suicide as part of their regular functions.

(1) Health Care Conference: Towards zero suicide. (2018).

(2)  Miret, M., Ayuso-Mateos, J. L.,  Sanchez-Moreno, J., Vieta, E. (2013). Depressive disorders and suicide: Epidemiology and risk factors, and burden. Neuroscience and Biobehavioral Reviews, 37, pp. 2372-2374.

(3)  Hawton, K., Casanas, I., Comabella, C., Haw, C., Saunders, K. (2013) Risk factors for suicide in individuals with depression: A systematic review. Journal of Affective Disorders, 147, pp. 17-28.

Mental health and discrimination at work

According to Ruby Wax, (entertainer and mental health campaigner): If you become mentally ill, don’t – whatever you do – tell your boss (1). I know what she means but we need to take a closer look at what the Law says about discrimination at work. I am basing this post on what I have learned from offering therapy to people whose problems centre around work and also on some findings from research on the topic.

If you consider yourself to have a ‘mental health problem’, when can you accuse your employer of discrimination for not taking this into account? The Equality Act (2010) was designed to cover discrimination against a person for all kinds of reason, including having a disability. You might be surprised to learn how the Act defines a disability resulting from a ‘mental impairment’. The ‘impairment’ and the effect it has on normal daily activities must be present for a year or more. So if your ‘mental health’ has suffered from, say, a sudden bereavement or bullying colleagues, you must demonstrate three things: 1. the impairment is expected to last at least a year (unlikely for many kinds of stress) 2. the mental impairment must be labelled as such by a professional (i.e. getting a GP or a psychiatrist to stamp your official record with a stigmatised diagnosis) 3. Have an impairment that is not excluded from the Act. The excluded categories are chiefly the less desirable forms of ‘mental impairment’ such as an addiction to alcohol or nicotine, being a fire-setter, voyeur or exhibitionist, or having a tendency to abuse others sexually or physically. If you satisfy all three conditions, your employer is obliged to make reasonable adjustments to your working conditions. The charity MIND gives some examples of allowances made on grounds of ‘mental health’ (2).

I have not yet encountered a client who is aware of the Act or made use of it. ‘Mental health’ problems at work seem to invite one of two responses from an employer. The first is sympathetic, accommodating, and informal. This often depends on whether a manager has experienced something similar themselves. It helps if an employee’s skills are of particular value to the company. An employee might be able to use their health insurance policy (sometimes a company perk) to access therapy. If work becomes too stressful and affects ‘mental health’, the person may attempt to move departments, take unpaid leave, use up a holiday allowance instead of ‘going sick’, apply to work part-time, ask to spend more days working from home, or simply seek out a new employer. In other words, there is an attempt on both sides to accommodate to a difficult situation and smooth it over.

The second kind of response from an employer and employee is formal and legalistic, involving grievance procedures, Human Resources department, and Occupational Health. The people I see as clients (mostly in skilled jobs) are not inclined to view their ‘mental health problem’ as an enduring impediment to working normally and certainly do not wish to have a psychiatric label entered on their staff record. This is not because they shun the stigma of mental ill-health but because it is very likely, in practice, to harm their future career prospects. To be labelled (e.g. as a ‘depressive’) risks providing a spurious reason for future dismissal or is a handicap when being considered for promotion. A significant proportion of time in therapy is therefore spent discussing strategy and impression management, bearing in mind a client’s ultimate objectives. People are reluctant to pursue a grievance when they feel that they are being discriminated against unless they already have plans in place to change their job.

Research findings back up my own impressions. The Department of Work and Pensions has funded research into the impact of ‘mental health’ on employment. They are concerned because ‘mental ill health’ is given as the main reason for people being unable to work due to sickness (2). As in many areas of social life, the medicalisation of problems that have understandable causes and require pragmatic remedies gets in the way of devising sensible policies. As Irvine (3) states: What emerged from my studies was that some people did not talk about difficulties at work because they did not consider themselves to have a mental health problem at all. Rather they saw what they were experiencing as a perhaps intense but nevertheless ‘normal’ level of stress or emotional distress. There were also people who had talked to others in their workplace about difficulties of one type or another that they were experiencing in their home or work lives, but they did not express these in medicalised language, hence again did not disclose a ‘mental health condition’ as such. 

Consistent with my own experience, only a minority of Irvine’s respondents were aware of the Disability Discrimination Act (DDA, 2005): Very few felt that knowledge of the DDA would have made a difference to their employment outcomes . . . seeing any difficulties in carrying out their role as their own responsibility and not something their employer should be expected to accommodate. . . . people did not perceive their mental health issues as a ‘disability’ or even see themselves as being ‘ill’ in some cases. Irvine notes that this raises questions about the salience and applicability of disability employment legislation in the context of common mental health problems (3). 

Yet another example of the obfuscation caused by the mental health conspiracy.

1. Wax, R. (2015) Should you tell your boss about mental illness?

2. MIND (2014) We’ve got work to do.

3. Irvine, A. L.  (2015) Mental health and employment: Context, concepts and complexity. University of York Social Policy and Social Work. 


IAPT Manual, 2018: Newspeak confronts reality

The IAPT Manual, 2018:

The new IAPT Manual from NHS England (1) presents the Newspeak version of the expanding Improving Access to Psychological Therapies (IAPT) service. Duplicity is inevitable when non-medical interventions are forced to present themselves as medical. Otherwise, they would presumably not be funded as part of the National Health Service.

Medical terminology is apparent everywhere in the document. The focus is on ‘disorders’ (mainly ‘anxiety’ and ‘depression’) for people who suffer from these conditions. Evidence-based treatment must be administered at the appropriate dose. Adherence to protocols of NICE-recommended therapy is critical to good outcomes. Recovery in IAPT is defined in terms of caseness, in other words, whether a person scores above or below a threshold level of symptoms.

The chief (but not exclusive) IAPT therapy is CBT which is a psychological, not a medical approach. Consequently, there is a mismatch between the tasks and roles of a CBT therapist and the description of IAPT in this document. The impression given is also at variance with training curricula published elsewhere (2). The ‘stepped care’ method of providing the IAPT service means that the least intrusive/expensive intervention is provided first, and if this fails to resolve the problem, a person is referred up to increasingly intensive therapy provided by more highly skilled workers. I haven’t seen a description of the screening (triage) that is carried out on new referrals (or self-referrals) but it is presumably rather brief and based on an assessment of ‘symptoms’. In 2015-16, approximately one-third of new referrals (or self-referrals) were not accepted into the service and a further third who those who were accepted attended for only one session (3). What exactly is going on? Who is being rejected and why? What does one session of therapy amount to?

According to the IAPT Manual: A person-centred assessment completed by a trained clinician is a crucial part of the care pathway.  Presumably, this takes place some way up the path, not at the triage stage. Judging by the very detailed specification of what the assessment covers, I estimate that it would take at least two hours to complete, which makes me question whether the prescribed assessment is simply aspirational. Based on extensive experience as a CBT therapist, I have never known one client’s problem to be identical to another’s. Assessment and formulation are crucial. However, IAPT therapy is strictly railroaded into Adherence to protocols of NICE-recommended therapy, which is said to be critical to good outcomes (1). Do we really know that is true or is it part of the Newspeak? This protocol-driven approach is not even consistent with the published curriculum for High Intensity CBT therapists (2). This states that a trainee must demonstrate self-direction and originality in tackling and solving therapeutic problems and to practise as a scientist-practitioner. How many ‘original’ deviations is an IAPT therapist allowed?

If the results for IAPT matched results that have been published in the journals I would be happy. The actual results do not match up. The IAPT Manual states that NICE recommends that a person should be offered up to 14-20 sessions depending on the presenting problem and the number of sessions should never be restricted arbitrarily.  We have now entered Never-Never land. The average number of sessions for people who began therapy was between three and six (3). The success rate (according to criteria that can be questioned) was as low as 38 percent for so-called post-traumatic stress disorder and 37% for so-called agoraphobia. A successful outcome for agoraphobia has been reported in the journals as close to 80% since the 1980s (4). The low success rate for PTSD is entirely understandable if therapy is as brief as three to six sessions.

The cost and effort involved in training psychological therapists is high. It is stated (5) that High intensity interventions are usually delivered by therapists who will have received several years of specific training and supervision in a particular therapeutic approach, and will usually have been trained in a recognised health care professional role (e.g. counsellor, nurse, psychologist, psychiatrist, social workers etc.) and may be registered with an appropriate professional body (e.g. BABCP, BACP, UKCP).  In other words, the training goes far beyond learning some recommended NICE protocols. The published curriculum for High Intensity IAPT training lasts one year and  combines academic study and supervised practise in a service context (2). Applicants have probably already acquired a variety of skills. If they already have a professional qualification it is unclear why they should be attracted to a job in IAPT. Having worked as a trainer myself, I know how difficult it is to cordinate all the necessary facilities in one locality (academic, supervisory, selection and assessment, practice placements, etc.). Since 2008-2011, when a number of courses were set up to provide training for High-Intensity therapists, many of them have since closed: 29% of all courses are no longer offering places (6). This may reflect the practical difficulties just mentioned and the fact that Universities find it much easier to offer straightforward classroom-based teaching.

Nevertheless, IAPT marches on regardless. At what point will the emperor’s new clothes be revealed for what they are?

1. NHS England (2018) The Improving Access to Psychological Therapies Manual.

2. Department of Health (2008). Improving Access to Psychological Therapies. Implementation Plan: Curriculum for high-intensity therapies workers.

3. IAPT (2016) IAPT Annual report, 2015-16.

4. Hofmann, S. G. & Spiegel, D. A. (1999) Panic control treatment and its applications. Journal of Psychotherapy Practice and Research, 8(1), 3-11.

5. NHS England (2015) Adult IAPT Workforce Census Report.

6. BABCP (2018) Accredited IAPT Training Courses.

Biomedical chimeras

The UK Department of Health and Social Care has funded King’s College, London, to develop a ‘bioresource’ of 40,000 people who have (or have been in the past) diagnosed with an anxiety or depressive disorder (1). These diagnoses apparently apply to one quarter to one third of the entire population. One purpose of the project is genetic profiling, presumably to help discover neuro pathways in the brain that could be modified by medication.

The sample of volunteers they wish to recruit, however large, is bound to be arbitrary and heterogeneous. There must be numerous people who could be or could have been given an anxiety or depression diagnosis who, for local and idiosyncratic reasons, were not, and a large number who should not have been so diagnosed due to the unreliability of diagnostic criteria. The sample is also biased by consisting only of volunteers. One previous attempt to find genetic characteristics associated with ‘major depression’ was unsuccessful (2). The authors stated that only a large sample comprising more than 50,000 subjects may be sufficiently powered to detect genes for depressive sumptoms. One reason for this negative result may be the fact that a questionnaire assessing ‘major depression’ is a hodgepodge of unrelated phenotypic behaviours. Another is that fact that ‘major depression’ (if it has any meaning at all) is almost certainly polygenic. If each gene contributes only a very small amount to ‘risk’, then it is only when a large number of randomly varying characteristics converge in a single individual that a genetic determination becomes evident.

The enthusiasm for investing in biomedical research into mental health seems unbounded. This project seems to be a fishing exercise, and seems entirely unjustifed when the target sample is one third of the entire ‘normal population’ who happen to have been subjected to an arbitrary diagnostic assessment.

1. Eley, T. (2018) Major new study to ‘serve the mental health community’. Interview with Professor Eley. The Psychologist, October, 2018, pp. 18-19.

2. Hek, K., Demirkan, A., Lahti, J. et al., (2013) A genome-wide association study of depressive symptoms. Biological Psychiatry. 73(7), 667-668.

Co-production: Who is co-producing what?

MIND recently commissioned a report from NEF (the New Economics Foundation) reviewing the evidence on co-production in ‘mental health’ (1). The NEF’s principles cannot be faulted. Co-production is about being equal partners in designing and delivering services, working in reciprocal relationships with professionals, and removing the distinction between professionals and recipients. They contrast this approach with the traditional one of ‘doing to’, in order to educate and cure them so that they conform to idealised norms and standards.

It is immediately apparent that MIND’s understanding of co-production is at odds with NEF’s principles. However, NEF concedes that the commissioned review helps to position the network of local Minds as market leaders of high quality, recovery focused, personalised services that individuals want to buy. MIND’s foreword refers to ensuring that millions more people are able to access the mental health services that will help them recover and stay well.    

To be cynical, this is rather like a tobacco company investing in e-cigarettes. A citizen who is a service user or buying a service is not engaged in co-production except in the sense that they are an essential element in the production process (as consumer). Of course, a citizen might wish to purchase the services of a professional and this reverse the power differential. The citizen is now in charge, and assuming that they have not been duped, they can end the relationship at will.

In the review, the NEF rows back on its principles somewhat when it refers to ‘doing with’ as a much deeper level of service user involvement that shifts power towards people. In case this is not entirely clear, it means that people’s voices must be heard, valued, debated. It would be foolish to deny that anything more than even a modest shift away from coercion would be welcome, and the evidence reviewed by NEF certainly supports the benefits of so doing. The review is a useful summary and describes 15 different projects. Benefits are seen in improved social networks, social inclusion, skills and employability, prevention, and addressing stigma.

However, what has this to do with ‘mental health’ except for reducing the need for services? According to MIND, one of their objectives is to increase access to services. We want to ensure that millions more people are able to access the mental health services that will help them recover and stay well. Recovery and staying well imply illness. If the outcomes of co-production are defined in this way (in the form of curing disorders as defined by WHO or the American Psychiatric Association), the citizen has already ceded power to the medical professional. The type of service that the citizen is invited to co-produce has already been ordained.  

The NEF’s conceptual framework is one of well-being, with an emphasis on autonomy, relatedness, and competence. Apparently, with the exception of the Richmond Fellowship and up2us, none of the projects used an explicit well-being framework in their evaluations. For MIND, and perhaps for other charitable organisations, the desired outcome is ‘improved mental health’. This latter concept is a convenient dustbin category that leaves power relationships pretty much the same as they have always been.

1. Slay, J. & Stephens, L. (2013). Co-production in mental health: A literature review. London: New Economics Foundation 


At last – the final solution for all mental health problems!

The solution is apparently simple and parsimonious and universally applicable.1

At first glance, the proposed new therapy has much in its favour. It seems to be a form of facilitated problem-solving. The therapist prompts a person to talk about their problem, to clarify their goals, and to expand their awareness of what might be causing it. It is suggested, very reasonably, that some kind of conflict is present at the centre of most problems. The focus is on self-determination, including a person’s freedom to choose the spacing of sessions and the duration of help.

All this can be simply laid out and it may represent an optimal way of conducting help. However, it is far from simple in practice. The method of levels is said to be a unified theoretical account and a single core psychological process. However, it is neither a theory nor a process. It is a pragmatic and principled means of persuasion. As such, it has much to recommend it.

Nor is the method theoreticallyparsimonious. It does not abandon the concepts of mental health, disorders, and symptoms. Presumably, the existence of a problem or a conflict can cause symptoms. However, how are symptoms fitted into the theory? They are not problems or conflicts as such. They are presumably elements in cognitive and behavioural processes. If so, why bother with concepts such as disorder and symptom? One reason for doing so is to compare this therapeutic approach with others. It is apparently better at reducing symptoms and distress. Shouldn’t the outcome of therapy be measured as the resolution of problems and conflicts? There are certainly better and worse ways of resolving things. These rest on pragmatic, ethical, social, and political criteria, not simply on the relief of distress.

Is this approach to ‘mental health’ universally applicable? Problem-solving and self-determination are certainly favoured concepts in our own society, and not without reason. However, not everyone in Western society endorses them. Across the world, there are likely to be an even greater variety of approaches to solving problems and conflicts. It cannot be assumed that everyone sees life as a matter of choosing a hierarchy of goals and finding an optimal way of resolving conflicts between them. In any case, many people are not free to choose their own goals. The problem may consist of all manner of constraints on self-determination, many of which lie outside the control of the person with a problem.

1. Mansell, W. (2018). Method of levels: Is it the most parsimonious psychological therapy available? Revista de Psicoterapia, 29 (110), 135-143.

The fantastic aim of preventing ‘mental health problems’

The Mental Health Foundation(MHF) believesthat mental health problems are preventable.1

What is a mental health problem? In a summary of ‘fundamental facts’, the MHF adopts the discourse of symptoms, disorders, and diseases.In an earlier MHF document3, an inquiry into the long-term future of mental health services, one would have expected to find a more considered answer to this question but it is not there. Based on a psychiatric epidemiological approach, it seems that almost 20% of the population are suffering from ‘common mental disorders’.2,4However, a ‘mental health problem’ is often understood in a looser sense than this, and the term could perhaps be applied to around half the population. Many ‘mental health professionals’ are also apparently sufferers.On these grounds, there is no clear divide between the mentally healthy and the unhealthy.

The means by which the authors of the inquiry into future services sought clarity (when it suited them) was to fall back on the more restrictive concept of ‘mental illness’. Although they had reservations about ‘medicalisation’, they assumed that there will still be people who are diagnosed as having a mental illness in 20-30 years time. These are people who will require care and treatment. They may be right about the needs of a relatively small group of people often described as having ‘severe mental illness’ but this group cannot be equated with everyone who is thought to have a ‘mental health problem’.

According to an attitude survey conducted on a random sample of the UK population in 2010,the general public agree that there are different classes of mental health problem. The authors of this survey sought respondents’ opinions about possible candidates for a ‘mental illness’. It turned out that 68% ‘agreed strongly’ that ‘schizophrenia’ was a mental illness whereas the proportion that regarded ‘stress’, ‘grief’, and ‘drug addiction’ as mental illnesses was around 20%. Stress and grief are presumably seen as ‘mental health problems’ (or simply as life’s hardships) rather than illnesses. The authors of the survey did not seek an opinion on typical ‘mental health problems’ but were content to define the latter as conditions for which an individual would be seen by healthcare staff. On these grounds, it follows that the prevalence of mental health problems will increase as a more and more service providers find employment.

I suggest that concepts of mental illness and psychiatric disorder should be abandoned.It is not of course possible to define away peoples’ problems but there exists a variety of non-medical approaches for their resolution. There is no need for the great majority of them to come within the remit of a ‘health service’.

At present, people commonly consult health care professionals, especially general practitioners (GPs), when they experience some form of distress. Eighty three per cent of the sample in the attitude survey said they would consult a GP about a mental health problem. For instance, it is quite common for someone experiencing stress at work (sufficient to impair performance) to get ‘signed off’ for weeks or even months. With this system, an employer can feel reasonably confident that a gatekeeper is applying control over potential malingering without necessarily knowing what the health problem is or how it is diagnosed. The blurry, somewhat meaningless, terminology of mental health performs a euphemistic function, somewhat similar to other circumstances or motives that are best left un-explicated (such as ‘waste matter’, ‘dodgy’, or ‘the departed’). The GP simply writes ‘stress’ in the case notes.

It is probably just as well that most GPs have little or no training in psychiatry and are not inclined to assign a considered diagnosis. To name something as a problem or disorder implies a judgement (by self or an agent of society) that something is amiss. Most people want to be seen as problem-free and therefore would prefer not to publicly advertise the existence of a problem. There seems to be an advantage in ‘keeping up appearances’, hoping any problem will eventually be resolved, as often happens. This is not a sign of denial but indicates an acceptance and toleration of problems, an attitude of live-and-let-live. Life is not expected to proceed without a hitch and some people are not gifted with the temperament, abilities, or inclination to choose a path in life that avoids the kind of situation that creates problems.

The contrary point of view is to nail a problem down and eliminate it. I accept that this approach may at times be necessary whether or not a problem is medicalised. However, the path of regarding ‘mental health problems’ as serious and burdensome leads to unrealistic expectations that can never be met by ‘mental health services’. The MHF states that mental health problems cost the UK economy an estimated £70-100 billion each year. This figure is around six times the amount the UK government pays annually to the EU for membership and is therefore a very large sum. For comparison, total NHS annual spending on mental health is somewhat over 10 billion.

The medicalisation of life’s problems encourages a steady expansion in the number mental health professionals who are needed to deal with them. On current prevalence figures, society will soon approach a state in which a person is either a service provider or a service user. The latter are viewed as unfortunates who need to be cared for. The MHF report inquiring into the future remarks that: One-to-one human contact, a smile and kind words have a timeless benefit to people with mental health problems. How nice, thoughtful, and caring that is. The remark implies a ‘holier than thou’ attitude, a sense that anyone with a problem deserves our pity.

The future of mental health envisaged by this MHF report would require that all problems be clearly labelled. Services will build service user’s capacity to self-manage their conditions. They will know these conditions by the label they are given. Their self-management will be guided by research that points them in the right direction. Future mental health services can be based on proven and effective service delivery mechanisms. A key element . . . will be an effective computerised system for sharing patient information both within the NHS and across boundaries with other organisations.

A consequence of having this kind of information system in place would be the ability to identify who it is that belongs to the ‘blessed’ and who to the ‘blemished’. Those unfortunate enough to be in the latter group could be quickly identified and tracked across different settings.

Out of interest, I examined my own computerised medical records held by my general practice. It stated that 18 years ago I had had a ‘mild depressive episode’. Of what use is that information without a context to give it meaning? In years leading up to that period my partner and my mother had both died from long drawn out illnesses (cancer and dementia) and I myself had been misdiagnosed for a serious medical condition requiring surgery that everyone thought, including myself, was terminal. My state of mind was not ‘mild’, nor was it simply a ‘depressive episode’. How are we supposed to characterise complex life situations as ‘mental conditions’? Casual and de-contextualised labelling can be socially damaging, especially when a ‘condition’ has undesirable connotations such as a ‘personality disorder’. In view of the risks of labelling, I am often consulted (as a therapist) by individuals who wish to pay privately. They do not want to leave any official trace of having done so. This is not driven by the shame or stigma of ‘mental illness’ but by a common sense appreciation of the tendency to pigeonhole people, and the reality that a problem can affect a person’s social functioning in a way they might not wish to advertise publicly.

The authors of the MHF inquiry state that we take patient confidentiality seriously, not least because of the immense stigma that still surrounds a diagnosis of mental illness. However, this same stigma can also apply to a ‘mental health problem’. It is hard to credit assurances that digitally stored information is secure, especially as any individual can find their own record easily and share it, as I have done. Sharing ‘across settings’ enormously magnifies the likelihood of illegitimate access. It is also illusory to suppose that problems can be cleansed of any negative connotation by calling them ‘conditions’ or ‘illnesses’ from which anyone might happen to suffer. A problem is a problem because it implies a failing (by self or others) or a failure to meet a standard of some kind. There is no gain from having it medicalised, and the concept of ‘prevention’, in a medical sense, is inappropriate. The existence of problems is an inevitable feature of life. Problems are preferably resolved, not ‘treated’. This outcome can be achieved in a variety of non-medical ways and settings.7

  1. Mental Health Foundation (2015). Prevention review: Landscape
  2. Mental Health Foundation (2013). Starting today: The future of mental health services. Final inquiry report.
  3. Mental Health Foundation (2016). Fundamental facts about mental health.
  4. Steel, Z., et al., (2014). The global prevalence of common mental disorders: A systematic review and meta-analysis 1980-3013. Int. J. Epidemiol. 43(2) 476-493.
  5. Rao, A. S. et al. (2016). Psychological wellbeing and resilience: Resetting the
  6. Research Report JN 207028. (2010). Attitudes to mental illness.
  7. Hallam, R. (2018). Abolition of the concept of mental illness: Rethinking the nature of our woes. London: Routledge.

Addiction to medicalisation

The intention to include “gaming disorder” in the draft revision of the WHO 11th International Classification of Diseases has created quite a furore from punters, the games industry, and commentators. Apparently, 1%-6% of adolescents and young people may be “afflicted” by gaming addiction.

According to a BBC report1, Dr Richard Graham of the Nightingale Hospital (a private clinic) welcomed the decision (I wonder why). However, he added that “he would have sympathy for those who do not think the condition should be medicalised” (I wonder why). According to an article in the New York Times2, quoting a therapist, “It’s going to untie our hands in terms of treatment, in that we’ll be able to treat and get reimbursed.” The cost of treatment? According to a figure quoted on BBC Radio 4 News (18/06/18) it’s £350 per hour. So it’s winners all round.

Three hundred and fifty pounds is a lot of money, getting close to the amount for surgery, although a lot of that fee could be taken up with the cost of hiring a room in Harley Street. Perhaps we will soon see a Journal of Gaming Disorders; conferences and workshops will be advertised; self-help manuals for worried parents will be published, the possibilities are endless. The signs and symptoms will be carefully defined and redefined in new editions of manuals of mental diseases. Different subgroups will be identified, some which will be found to show unusual activity in certain centres of the brain, corresponding to evidence found in gamblers and people with substance abuse.

Can playing games all day long become a problem? Of course it can. Is it a disease? Of course not.

  1. Gaming addiction classified as disorder by WHO (2018)
  2. Video game addiction tries to move from basement to doctor’s office (2018)

A chip off the old block

A child who has ‘made it’ in the world might want to forget the parents who no longer match its self-image, even demonstrating a blind spot about its heredity.

There is, however, nothing secretive about the fact that clinical psychology was born out of an alliance of convenience with an older and more established profession. As Hans Eysenck stated it in 1950: That a strong, respected and highly competent profession of psychiatry is essential for the growth and flourishing of clinical psychology appears obvious: it is perhaps no less true to say that the existence of well trained, competent, and friendly clinical psychologists can be of the utmost value to psychiatrists.1

There has been a substantial redrawing of the boundaries since 1950, with new alliances, antagonism as well as cooperation, and new power structures to deal with. Applied psychologists have now decided to march under the banner of ‘evidence-based practice’, confident that ‘the facts’ will win out in its competition with other professions. American psychologists have looked on with admiration at the UK government’s decision to invest in a psychological therapy service provided by the NHS (IAPT), while in their own country they seem to be losing the battle against the promotion of psychotropic drugs on an overwhelming scale.According to market researchers, the global depression drug market alone will reach $16.8 billion by 2020.3

Gaudiano and Miller2 view the current situation facing the advocates of a psychosocial approach as serious and challenging. It appears to them that in the global market place, ‘evidence-based’ and sound ‘value-for-money’ psychosocial interventions are losing out. What they fail to fully recognise is their own allegiance to a concept of mental illness that sets the rules of the game. They are chips off the old block. They refer to the over-medicalizing of mental health problems and define medicalization as the practice of defining and treating non-medical problems as if they were such conditions. But in the same article, they endorse the idea of improving public attitudes about mental illness, mention recovered patients relapsing after treatment, and note the importance of reducing the burden of mental illness at a population level.

Professionals who provide ‘psychosocial interventions’ are in business too, but when they share a medical inheritance, they constrain the defining characteristics of the ‘market’ of their potential consumers. By adopting the trope of health, illness, treatment, and cure, psychosocial means whatever their competitors want it to mean, and what their competitors have already persuaded the consumer to believe it should mean.

According to Gaudiano and Miller: This tendency within psychology to fail to put forward a unified front has left room for other professions to wage aggressive media campaigns to change public thinking in ways that argue against psychology and ultimately do a disservice to consumers and their families.

What would doing a service to consumers (and their families) actually amount to? Not, in my view, sharing the mythology of mental illness.


  1. Eysenck, H J (1950) Function and training of the clinical psychologist. Journal of Mental Science, 96, 710-725. Cited by Burton, M and Kagan, C in British clinical psychology in historical perspective: The genesis of a profession,(1983, unpublished).
  2. Gaudiano, B A and Miller, I W (2013). The evidence-based practice of psychotherapy: Facing the challenges that lie ahead. Clinical Psychology Review, 33, 813-824.
  3. Market Research Store.  

Could do better!

The role of the Parliamentary and Health Service Ombudsman is to handle complaints that have not been satisfactorily resolved by the NHS itself. On 19th March 2018 it issued a report giving illustrative examples with lessons for how mental health services could do better: It is our role to ensure NHS organisations learn from these mistakes and take the necessary steps to prevent those mistakes from happening again. That a problem exists is suggested by the fact that: In 2016-17 there were 14,106 complaints made to NHS mental health trusts, with around 65% being upheld or partly upheld by the local organisation.

How many times in the past have we heard this kind of tut-tutting? How many new five year plans, reorganisations, revisions to legislation, and other ‘worthy’ initiatives have there been since a new Mental Health Act was introduced in 1959?  Are the concerns serious or is it just a pretence? As stated: According to The King’s Fund, 40% of mental health trusts in England received a real terms decrease in their operating income in 2015-16.  More recently, The King’s Fund found that, despite 85% of mental health trusts receiving increases to their income in 2016-17, funding for acute and specialist physical healthcare continued to grow more quickly, increasing the gap in funding between physical and mental health services. Furthermore, there has been a 13% reduction in mental health nurses between 2009 and 2017, with inpatient care losing nearly 25%. Almost 10% of all posts in specialist mental health services in England are vacant. 

Who should we charge with doing better?


Maintaining momentum: driving improvements in mental health care. Parliamentary and health service ombudsman. 19 March 2018, HC906.

IAPT for physical health conditions: the way forward?

NHS news on the 14 May 2018is certainly arresting. It announced early results from a Cambridgeshire and Peterborough trial of an IAPT service “to integrate mental and physical treatments.” For people with diabetes, cardiovascular or respiratory illnesses there was a three-quarters reduction in inpatient hospital attendance and a two-thirds drop in Accident and Emergency admissions. This is a truly astonishing result, although I could not find a report of the study online citing the evidence to back it up. There is currently a plan to place “3,000 mental health therapists” into GP surgeries “to offer combined mind and body care to patients.” It is claimed that one in three of the more than 16 million people in England diagnosed with a long-term physical health condition experience a mental health problem. It is pointed out that depression and anxiety are also commonly experienced in people with medically unexplained symptoms. The new initiative is seen as a win-win deal: benefit to patients and a saving of tax-payers’ money.2,3  Fifteen new sites for integrated physical/mental IAPT services have been announced.4

The sceptic in me asks what combining or integrating IAPT treatment with physical health care amounts to in practice. Having worked in a general practice centre in the 1970s and spent seven years working closely with hospital physicians in the 1980s, I am totally convinced of the value of this kind of work. The NHS proposal to expand this integrated approach using IAPT therapists is a kind of catch-up exercise. Numerous mental health professionals and counsellors have been working in physical health care settings for decades. There must be at least a couple of dozen academic journals, national or international, reporting on research and practice in this field.

The way the proposed service is being sold is not encouraging. The problem is seen as one of co-morbidity: “Two thirds of people with a long term physical health condition also have a co-morbid mental health problem, mostly anxiety and depression. In addition, up to 70% of people with medically unexplained symptoms also have depression and/or anxiety disorders. These common mental health disorders are detectable and treatable.”

Co-morbidity is a non-starter as a foundation for this kind of work. It provides absolutely no insight into the way physical, psychological, and social factors interact. It is of course true that accurate medical diagnosis is essential. In one area I am familiar with (vestibular dysfunction) the relationship with psychosocial factors is complex, and knowledge of a range of disorders is essential. This means that any therapist “treating anxiety or depression” would need to have a significant grasp of relevant medical conditions and the physical treatments/rehabilitation in common use.

It is stated that the ‘competency framework’ will be based on the one outlined by two academic clinical psychologists, Anthony Roth and Stephen Pilling.This framework presupposes the level of competence expected of a clinical psychologist (i.e. someone with a psychology undergraduate degree and a three year applied doctorate). The assumption of these authors seems to be that IAPT therapists would be offering manualised treatments that have been validated in randomised control trials. This is a rather optimistic assumption. As they say: “Many clients present with co-existing conditions, and although this is well-recognised in clinical practice, there is little research examining the most effective packages of treatment for this group. As such, determining the treatment pathways most likely to address their needs will rely on clinical judgment (based on careful engagement, assessment and formulation).” They point out “that a traditional mental health perspective may not be the most useful way of formulating their difficulties” and “foregrounding functioning over symptom change may make sense.” Their competency framework identifies seven domains but “not all of these competences are needed to carry out a psychologically-informed intervention, particularly because these interventions will usually be conducted by individuals without an in-depth training in psychological therapy.” This is really an admission that IAPT therapists will be a cheaper and, quite probably, an insufficiently sophisticated workforce. Their view is that “the framework is intended to accommodate a range of clinicians – from non-specialist healthcare workers who will be implementing psychological interventions as part of their clinical practice to practitioners implementing psychological therapies. It would be unrealistic (and indeed unnecessary) for the former group to acquire competence across all domains of the framework.” By contrast, they seem to be suggesting that at a higher level of competence, it would be necessary “to create a tailored formulation of the individual’s difficulties and to feedback the results of a treatment plan . . . Psychological treatments cannot be delivered in a ‘cook book’ manner. 

The integration of physical health care with a psychosocial perspective is welcome. Only time will tell whether this NHS initiative is the best way to take it forward.


1. NHS England News. Mental health “game-changer” care leads to 75 per cent reduction in hospital admissions

2. The Improving Access to Psychological Therapies (IAPT) Pathway for people with long-term physical health conditions and medically unexplained symptoms.

3. NHS England. Long Term Conditions and Medically Unexplained Symptoms. Available from: 

4. NHS England. Wave two Integrated IAPT sites. Available from:

5. Roth, A. D. and Pilling, S. A competence framework for psychological interventions with people with persistent physical health conditions. Available from:

The new NICE Guidelines on ‘Depression’.

NICE, the National Institute for Health and Care Excellence, is about to publish new guidelines on the ‘treatment of depression’. A consultation paper on the proposals has already been sent out. Publication, intended for January 2018, has been postponed following criticism by service-user organisations and politicians1,2. The controversy this update has generated illustrates very well the philosophy that currently drives ‘mental health thinking’ in the UK. Critics have raised serious concerns about the new proposals but they have not moved away from the position of medicalising depressed mood as an illness or disease.

I have found at least one partial exception to this generalisation. The Tavistock Institute3 has described a middle way between disorder and understandable adversity: Depression is a term that covers a multitude of human problems. For most sufferers, the difficulties express themselves in a different way . . . Whereas an infectious illness starts at a definable point and has a course limited to weeks and months, depression is different; increasingly we have come to recognise that depression is not best thought of as an acute illness but as a long term condition . . . It is thus more appropriate here, and in fact in the majority of cases, to understand the depression as part of what a person is, part of their personality . . . The depression, in this sense, is an authentic expression of their lives and its contents, and the negative thoughts and feelings need to be seen and respected as very important meaningful communications.

It is rather surprising that in 2018 we have to be reminded to take seriously what people say. The Tavistock Institute maintains that people referred to them will have a number of in-depth consultations to understand the nature of their difficulties. This need for assessment could hardly be challenged. Understanding the nature of a person’s complaints is likely to require a minimum of one to two hours of sensitive and open-ended interviewing. Moreover, initial impressions will probably have to be revised subsequently.

Despite nodding assent to the meaningfulness of ‘depressed mood’, the Tavistock Institute still describes ‘depression’ as a condition which needs to be managed, much like diabetes or asthma and that some briefer therapies may sometimes help with certain symptoms. Consequently, it seems happy to sit on the fence.

Detection of so-called depression according to NICE guidelines (CG90).

The guidelines suggest two questions to alert a worker to the presence of ’depression’: During the last month, have you often been bothered by feeling down, depressed or hopeless? and During the last month, have you often been bothered by having little interest or pleasure in doing things? If a person answers ‘yes’ to either question, it is recommended that a mental health assessment be performed by a competent person. Presumably, this has the purpose of distinguishing ‘ordinary woefulness’ from a ‘medical condition’. NICE assumes that the assessor would often be a GP. But how many GPs have the time to perform this function? Many people say they cannot even name their own GP. They see whoever happens to be available at the time of their appointment, which lasts minutes rather than hours.

NICE acknowledges that a comprehensive assessment should not be a simple symptom count (i.e. obtained from a questionnaire or standard set of questions). They advise taking into account functional impairment, psychiatric history, interpersonal relationships, living conditions, social isolation, and suicidal intent. This kind of assessment would certainly take some time. If actually carried out, one would expect that depressed mood severe enough to lead to suicide would be picked up at the primary care level. In fact, three quarters of people who intend to end or take their own life have been invisible to the secondary health care system.4 Their suicidal intent has not been detected earlier.

A thorough assessment should be able to identify obvious psychosocial causes of depressed mood but what should a GP or mental health assessor do about them? It is recommended that: Psychological and psychosocial interventions should be based on the relevant treatment manual(s), which should guide the structure and duration of the intervention. Are these manuals flexible enough to take account of job loss, marital breakdown, debt, street crime, bullying, bereavement, and innumerable other possible kinds of adversity? Recommendations for manualised treatment resemble a prescription for a medication e.g. For all people with depression having individual CBT, the duration of treatment should typically be in the range of 16 to 20 sessions over 3 to 4 months. In a non-manualised therapy, it makes sense to give a person time to reflect on making changes, time to collect relevant self-observations, and time to put change into practice at their own pace according to their actual opportunities to do so. The spacing of sessions is part of therapy decision-making and should not be dictated by considerations of an ‘adequate dose of psychological input’ as if two sessions were twice the strength of one session. The idea that therapy should be a certain length, with a predetermined spacing of sessions, is foreign to how most therapists work.

Is ‘depression’ a meaningful concept?

‘Feeling depressed’ is a common enough complaint. It refers to a state that varies from being mild and temporary to one with a range of behavioural and bodily effects that can be severe and life-threatening. The fact that similar words are used to describe this state along a continuum of severity is no guarantee that they are the expression of a unitary ‘illness’ or ‘disease’. In fact, psychiatrists distinguish several types of ‘depression’. The NICE guidelines are intended for major depressive disorder, dysthymia, sub-threshold depression and sub-threshold depressive symptoms. This is quite a large collection of possible states of mind. At present, psychiatry cannot cite a set of biomedical markers that would justify the concept of ‘depression’ as a disease. The belief that ‘major depression’ has any credibility as a meaningful medical concept is simply one example of the rhetoric of medicalisation. If it is the case that depressed mood has a variety of different causes (as in my experience seems to be the case), generic guidelines for its ‘treatment’ have little role to play.

We should also be wary of pathological explanations of ‘depression’ when analogous behaviour has been widely observed in animals, especially in those genera with dominance hierarchies, such as the primates. Part of this behavioural pattern is ‘giving in’ (i.e. conceding social defeat) and this may be accompanied by responses that solicit resources from others (e.g. begging, crying, agitation, self-harm, and helplessness). This pattern resembles the deferential, submissive, and often ineffectual behaviour of many people who describe themselves as depressed. This ethological perspective points us to psychosocial elicitors not a disease pathology.

As already noted, the NICE guidelines are broadly aimed at a group of people who would satisfy criteria for ‘major depressive disorder’ (MDD), a diagnosis supplied by the American Psychiatric Association.5 If MDD was actually a disease, one would expect to find (1) a cluster of signs and symptoms that can be reliably observed, and (2) an explanation of the cluster in terms of causal pathways discoverable within the body that are in some way distinct from the somatic correlates of everyday (‘non-clinical’) depressed mood. The criteria for MDD specify that a person must report one of two core symptoms and at least four of seven secondary symptoms. Some of these secondary symptoms are binary (e.g. insomnia or hypersomnia) and so the list effectively increases to 20. In 3703 individuals diagnosed according to these criteria, Fried and Nesse6 identified 1030 unique symptom profiles, of which 83.9% were endorsed by five or fewer people. If the medical syndrome that supposedly links all these symptoms together is a fiction, a unitary concept of depression might as well be dispensed with altogether7.

NICE recommendations for ‘treatment’

NICE was set up to analyse the evidence for various medical interventions. Primarily, the evidence consists of the results of randomised control trials, a method of research that was originally introduced into the field of medicine. While the method certainly has its uses, the design of these experiments and the conclusions that can be drawn from them often suffer from a variety of limitations. (These would require a more extended discussion).

NICE recommends a stepped approach to ‘treatment’. In other words, it advises beginning with advice, self-help, or computerised therapy, and then stepping up to a more intense form of psychological therapy, medication, or electro-convulsive therapy whenever whatever has already been tried fails. The rationale for this slow but steady approach makes some sense but given the slowness with which the referral system can operate, leading to lengthy delays before an appointment is offered, it is quite likely that a crisis situation will have become worse by the time help is available. The time-window in which something can be done quickly and effectively is often fairly short. In practice, GPs are quick to prescribe medication for ‘mild depression’ even though this is not the recommendation of either NICE or the World Health Organisation.

When ‘depression’ is persistent, or low intensity methods have failed, there is a recommendation to try either antidepressant medication (typically a SSRI) or a ‘high intensity’ psychological therapy (typically CBT). For ‘moderate to severe depression’ it is suggested that medication and psychological therapy could be combined. In the case of CBT, the advice is 16 to 20 sessions over 3 to 4 months, with bi-weekly sessions initially moving on to weekly, and then to follow-up sessions over the next 3-6 months.

As noted earlier, therapy is seen as analogous to a drug regime for which the method of delivery is prescribed in advance. It is stated that: There is little evidence to guide prescribing in relation to depression subtypes or personal characteristics. Do not routinely vary the treatment strategies for depression described in this guideline either by depression subtype (for example, atypical depression or seasonal depression) or by personal characteristics (for example, sex or ethnicity) as there is no convincing evidence to support such action. This really equates to saying that therapists do not possess the skills to make strategic decisions in therapy based on their formulation of a person’s problem according to their observations of a person’s personality and circumstances. These conclusions of NICE are based on a mindless approach to the evaluation and interpretation of research into therapeutic processes, chiefly randomised control studies.

Therapist competence is of course an issue that needs to be addressed. NICE advises monitoring and evaluating treatment adherence and practitioner competence. In the case of group-based CBT, it is stated that this should be delivered by two trained and competent practitioners. At the present time, it would be premature to say that therapist competence can be reliably assessed.8 Sampling by means of audio- or video-recording is expensive in terms of time and is rarely performed in routine practice. Monitoring by asking a client to complete a feedback form after each session is, in my opinion, insulting to the client and corrosive of the relationship. In any case, this is not a measure of therapist competence. Research has shown that even when agreement on ratings of therapist competence can be agreed, the relationship of these ratings to a successful outcome of therapy is weak or non-existent9. Therapist competence is still an area of research that is in its infancy.

A major failing of the NICE guidelines is that they make no mention of the potential contribution of the voluntary sector. There is a reference to befriending but this is viewed as an ‘adjunct‘ to treatment and should be limited to ‘trained volunteers’. This caution gives the impression that government departments and their advisors are fearful of allowing citizens to make any attempt to solve their own problems.

The New Savoy Conference discussing the anticipated NICE guidelines.

The New Savoy Partnership is a consortium of organisations that promotes freely available psychological therapy on the NHS. It held a conference on 27th April, 2018, to discuss the anticipated revised NICE guidelines on ‘depression’. Some of the speaker’s contributions are accessible on the Net. 10 Of chief interest here is the presentation of Jeremy Clarke, chair of the New Savoy Partnership and an expert advisor on the NICE guidelines committee. In response to earlier lobbying and previous NICE recommendations, the Government has strongly promoted and funded a new service, Improving Access to Psychological Therapies (IAPT), initially directed towards the ‘treatment’ of ‘depression and anxiety’. Clarke’s enthusiasm for IAPT, despite the very large number of people who have made use of it, has been tempered by population indicators of worsening ‘mental health’ since it was introduced. Rates of prescribing for anti-depressant medication have been rising, as have rates for suicide and self-harm. He also points that that there is a large difference in ‘recovery’ rates for ‘depression’ in IAPT between the least and most economically deprived areas of the country (35% vs 55%). He notes that the wellbeing of the personnel delivering the NHS service for ‘depression’ has deteriorated to the point of threatening staff retention and acceptable levels of job stress.

All of this calls into question government policies for tackling the problems of people who are currently diagnosed as ‘depressed’. Clarke does not take the next logical step of critiquing the medicalisation of personal and social problems and calling for non-medical answers to their resolution.


  1. Early day motion 980 – NICE guidelines on depression in adults.
  2. The current draft guideline on the Recognition and Management of Depression in Adults is not fit for purpose.
  3. The Tavistock’s view of depression and what the draft NICE guidelines may be missing (2017).
  4. Hawton. K., Casañas I Comabella, C., Haw, C. & Saunders, K. (2013) Risk factors for suicide in individuals with depression: A systematic review. Journal of Affective Disorders, 147, pp.17–28
  5. DSM-5 (2013) Diagnostic and Statistical Manual of Mental Disorders (DSM–5). Arlington, VA, American Psychiatric Association.
  6. Fried, E. I. & Nesse, R. M. (2015) Depression is not a consistent syndrome: An investigation of unique symptom patterns in the STAR*D study. Journal of Affective Disorders. 172, pp.96-102.
  7. Fried, E. I. (2016) Depression – more than the sum of its symptoms, The Psychologist. 29(1), pp.42-43.
  8. Schmidt, I. D, Strunk, D. R., DeRubeis, R. J, Conklin, L. R. & Braun, J. D. (2018) Revisiting how we assess therapist competence in cognitive therapy. Cognitive Therapy and Research (online, March, 2018).
  9. Webb, C. A., DeRubeis, R. J. & Barber, J. P. (2010). Therapist’s adherence/competence and treatment outcome: A meta-analysis. Journal of Consulting and Clinical Psychology, 78, 200-211.
  10. New Savoy Partnership, news, 30 April, 2018.

The Survivor Researcher Network (SRN)

The National Survivor User Network (NSUN), a charity, is currently hosting a survivor researcher network (SRN) comprised of prominent academics and service user consultants who have been active in researching on or collaborating with service users. It also aims to foster the development of service user-led studies. Quite understandably, it is helpful to form a network of this kind for all sorts of reasons. My aim here is to comment some of its objectives as set out in a document (SRN, 2018).

Although the authors of the document admit there is no agreed terminology for people who experience (or have experienced) ‘mental distress’, they use the word ‘survivor’ in two ways, namely, survivors of the experience of distress and survivors of the mental health system and societal oppression. Presumably, this refers to oppression occasioned by a state of distress rather than all forms of oppression.

Some survivors have become activists who have sought to challenge a psychiatric system based on a biomedical model of distress. According to the SRN document, survivors can make a claim to possess different forms of knowledge based on their experiences. Researchers in the network have studied the effects upon an individual of being treated or coerced within current mental health services. Their reason for doing so is presumably to strengthen their case for what is, essentially, a political and cultural campaign. However, it is worth pointing out that the objectives of this campaign are also shared by people who have never identified themselves as ‘distressed’ or ‘survivors’.

The phrase different forms of knowledge presumably refers to knowledge gained by direct experience of distress and survival of a system viewed as oppressive. In this sense, it is a type of knowledge (first-hand experience), rather than a form of knowledge that would be considered new by philosophers of science. In response to this direct experience, survivors have experimented with ways of dealing with distress that represent alternatives to the present mental health system. As such, this aim is also shared by many non-survivors, mental health professionals, and social theorists. One problem linking the political campaign with being a ‘survivor of distress’ is that the term ‘distress’ is often used as a euphemism for ‘mental ill-health’. If the aim is to propose alternatives to the present mental health system, it would seem preferable to remove all reference to mental health. The political campaign could then become more inclusive and be seen to cover all kinds of social problems.

It therefore is difficult to understand why the SRN wishes to establish an independent discipline in its own right. The fragmentation of efforts (within social science and, more generally, in campaigns that challenge oppression) does not sound very appealing. Its purpose may, of course, be designed to define a voice within the highly competitive chorus of researchers who seek funds. The authors of the document are keenly aware that their funding has often come through collaboration with the kind of services they would like to overthrow. It is acknowledged that service users in this environment often perform a tokenistic function, in effect having little real power over research questions and methods.

One of the aims of SRN is to broaden mental health research. As already noted, this might best be achieved by abandoning the concept of mental health. Another aim is to promote experiential evidence as fundamental for the knowledge base on mental health, human rights and social justice. It cannot be gainsaid that the experience of oppression provides a fundamental impetus for fighting it, but human rights and social justice must draw on other forms of argumentation as well. Experience doesn’t seem to be more fundamental than other ways of approaching the subject. In this regard, the SRN document questions the idea that academia is the only place for ‘valid’ forms of knowledge production. This is undoubtedly true but a rather surprising position to be taken by a document, six of whose nine authors are either academics (including professors) or have strong academic links. The SRN wishes to lobby funding bodies for the commissioning of studies which reflect the research priorities of people with lived experience of mental distress and are user-led. The sad reality is that funding bodies are weighted down by academics who support research done by other academics. In practice, there is nothing to prevent the SRN conducting research on whatever subject it likes. The constraints are money, time, and certain skills of logical reasoning and methodology. Perhaps the resources for research are best sought through voluntary efforts, public appeals, or wealthy benefactors.


SRN (2018) Survivor Research Network Manifesto. Available from:


Statutory regulation of practitioner psychologists

The UK Department of Health recently sent out a consultation document called Promoting professionalism, reforming regulation (DoH, 2017), and invited interested parties to complete a questionnaire to comment on proposed changes to regulatory procedures for all the health professions. It has yet to publish its recommendations. This blog explores what statutory regulation can achieve, if anything, and discusses responses to the document from psychology, psychotherapy, and counselling organisations. Like many policy initiatives, its first aim is to save money. Present practices are said to be “slow, expensive, complicated, reactive, overly adversarial and confusing for patients.” One proposal is to reduce the present large number of regulators to three or four. It is stated that: “efficiencies begin to accrue when a regulatory body has a registrant base of between 100,000 and 200,000.” Most counsellors and psychotherapists are not regulated by statute but there are moves afoot to include them.

One significant proposal (with dangerous consequences if abused) is to give regulators greater autonomy by allowing them to set more of their own operating procedures. The powers of a regulator are severe. For instance, a strike-off could result in the loss of a person’s livelihood. The document fails to mention the near certainty that a small number of complaints will be malicious allegations. It seems to be assumed that regulators could not possibly make mistakes. The expense of an appeal against a sanction is so high as to render it unavailable. In an adversarial system in which the regulator has deep pockets, the chances of reversing a judgement are small.

The primary purpose of statutory regulation is to protect the public from harm and to give a client/patient the opportunity to complain when they feel badly served. There are three aspects to this; one aim could be to prevent harm before it occurs, the second is to determine whether harm has in fact occurred, and the third is to sanction those who cause it. A register ensures that a person with a designated professional title is properly qualified. For practitioner psychologists, their regulator, the Health and Care Professions Council (HCPC), also monitors the updating of skills. It is a criminal offence to advertise services using certain designated titles without being registered. If a complaint is made, the registrant’s ethical behaviour and fitness to practise are investigated. If there is a case to answer, a list of allegations is made public, leading eventually to a prosecution by HCPC and a tribunal in which rival legal teams battle over the evidence, each attempting to win over a panel of three individuals who are paid partners of the HCPC and advised by their lawyer. The panel then issues a sanction, strike-off, or no-case-to-answer, as it sees fit.

The claim that this kind of regulation protects the public is surely illusory. It has never been difficult to establish whether or not a professional is properly accredited. In any case, it is only the use of a designated title that is controlled by law. A professional (or unqualified person) can represent him or herself with a non-designated title and they commonly do. When Mark Russell, a qualified podiatrist who felt that his skills were being offered by others under different titles, raised this matter with the HCPC, they failed to address it. He de-registered himself in protest (Russell, n.d). Despite attempts to remove advertising referring to his designated title, he was successfully prosecuted by the HCPC. After a protracted legal process, he learned from a prosecution barrister that the term “with intent to deceive, either expressly or by implication” was an integral and essential part of the charge against him. It was pointed out that he could have used, “Formerly registered podiatrist or Previously known as a podiatrist” without infringing the legislation. Consequently, it is possible for a so-called “guilty” practitioner to make it clear they are not registered and carry on as before. (Of course, whether guilty or innocent, a reputation might be fatally damaged, destroying the possibility of further employment).

It is surely incumbent upon service providers and clients to adopt the principle of ‘buyer beware’, just as it is when employing a builder, by checking qualifications and reputation. A system of registration is no guarantee of competence unless the latter is also assessed. A regulator with over 100,000 registrants would not have the resources to be able to give this assurance. Rather oddly, the document argues that the introduction of a licensing regime should be investigated. “Language change should be adopted to align with a licensing process, similar to the Driver and Vehicle Licensing Authority.” Presumably, a practitioner would have to flash their licence whenever they saw a new client.

Moreover, the monitoring of a registrant’s continuing professional development (CPD) is no assurance of fitness to practice. It is only necessary to sleep through a workshop and collect the certificate at the end. There is no way to ensure that an incompetent practitioner has learned anything from their CPD. The HCPC states that: “It is important that you meet our standards and are able to practise lawfully, safely and effectively. However, we do not dictate how you should meet our standards.” Many of the standards, such as understanding the power imbalance between therapist and client or knowing the limits of one’s own practice, cannot be met except by peer supervision, which is not monitored.

The consultation document declares that: “Regulators need to be independent of government, the professionals themselves, employers, educators and all the other interest groups involved in healthcare.” While this statement is manifestly inconsistent with reality, it also makes no sense when considered in conjunction with a proposal in the document to widen the role of regulators in the interests of employers and professional bodies. Regulators also have their own vested interests, which is to ensure that they sanction enough registrants to justify their own existence.

Independence is sought because: “The UK’s model of professional regulation has its roots in a system of self-regulation in which professionals themselves were largely responsible for policing their own conduct, performance and behaviour. This system lacked independence and transparency.” While there may be risks of this nature, no professional body is likely to want to have amongst its members a person who is incompetent, unethical, or likely to do something to tarnish its reputation. Furthermore, actual practice is the best teacher of what is right or can go wrong, what temptations exist, and how to avoid common hazards. These are widely written about in the professional literature. It is usually required that a practitioner should be supervised by someone with equal or greater experience. Without traditional methods of professional oversight, it is difficult to see what the lay members of a regulatory body and their judicial panels could contribute. As it is, they rely on professional experts at tribunals (and in other capacities with respect to qualifications and competence). Unfortunately, expert witnesses at tribunals receive a digested version of the ‘facts’, and they have no contact with someone, such as a defendant’s supervisor, who might be able to provide insight into the alleged problematic conduct. The invited expert might not share a relevant specialisation and may lack the knowledge to comment sensibly (e.g. a psychoanalyst offering an opinion on CBT methods of working). A panel may, in any case, ignore the expert and form its own clinical opinion. It is not obvious that this process is ‘transparent’ or ‘independent’.

With respect to practitioner psychologists, the HCPC could not (and should not) function without the close collaboration of the British Psychological Society (BPS). A lay body cannot know what qualifications are required or what changes need to be made in the light of innovation and change in a profession’s knowledge and practice. It monitors CPD but how can it judge what is relevant? Any proposal to produce a better system of protection for the public would require a considerable increase in resources. It is entirely inconsistent with the idea of comparing registration with a ‘driving license’, where, presumably, decisions could be made by consulting the equivalent of the Highway Code.

The adversarial approach to fitness-to-practise is focused on only a small minority of registrants who have “a case to answer” while leaving the majority unsupported. For this reason, the document argues that regulators should support the professional practice of their registrants before problems occur. A regulator that supports registrants, identifies problems early on, and intervenes to prevent harm, can no longer be considered independent. These are the function of a professional body, manager, or supervisor. Unfortunately, professional organisations and managers seem to have been only too willing to offload their responsibilities onto a regulator, knowing that professional support is costly and time-consuming.

The consultation document states that: “In future we expect the professional regulators to work in partnership with employers and higher education providers to ensure that the recruitment, education and training systems they assure and operate are delivering the right people, that they are teaching the right things (through both the formal and informal curricula) and that behavioural problems identified early in a professional’s career are properly addressed.” It is entirely beyond my understanding how a group of lay people, lawyers, with some paid-for professional advisors of their own choosing could undertake such a huge task. In any case, their chief business has been to investigate complaints and sanction registrants. A regulator’s efficiency is measured in terms of operating cost per registrant. The consultation document states that for the HCPC, 59% is consumed by the expense of fitness-to-practise procedures and 9% is devoted to education and training.

The response of professional organisations to the document, as far as this can be determined from evidence gathered through a web search, has been mixed, with doubts expressed about giving regulators more powers without proper oversight. The response of Action Against Medical Accidents (AvMA ) illustrates the difference between a failure to adhere to fundamental standards of care (which have objective criteria of proof) and psychological practice in which it is more a question of resolving differences between parties (complaints) about whether the approach taken was justified or not. There is rarely a hard and fast interpretation of a violation of a psychologist’s code of practice. It is not surprising that different tribunal panels come up with different interpretations of what are merely generalisations about good practice, not codified rules.

On the whole, the views of therapy organisations that are not currently subject to statutory regulation seem to be more open-ended and thoughtful. The UK Council for Psychotherapy referred to a sensible grouping of regulatory bodies and preferred informal resolution of a complaint, avoiding where possible adversarial and costly hearings, and removal from a register. Similarly, the British Association for Counselling and Psychotherapy stressed the monitoring of supervision arrangements, a recognition of levels of experience, and remediation of low-level, low risk misconduct through advice. Like the British Psychoanalytic Council (BPC), it favoured a conciliatory approach involving peer review with an emphasis on training and improving professional skills. This is, presumably, the kind of ‘self-policing’ that politicians have objected to. The British Association of Behavioural and Cognitive Psychotherapy firmly believed that statutory regulation of psychotherapy “could have a huge impact on public safety” without arguing its reasons for saying so.

BABCP drew a clear separation between the role of regulators and specific professional bodies, noting that some therapists do not have a professional affiliation. The lack of any clear professional role description must apply to a large number of health and social care workers, making any system of protected titles impossible to implement. The BPS was worried that there is a loophole in allowing psychologists with non-designated titles to practice without statutory regulation, especially when they work autonomously without supervision. This assumes that acquiring a designated title is a guarantee of anything, for which no evidence was produced.

Perhaps the most remarkable feature of all the responses to the DoH document is the fact that they make no reference whatsoever to empirical evidence. What proportion of registrants are unethical or incompetent, and what kind of offences do they commit? What is the evidence that registration ensures public safety? What can we learn by reviewing the circumstances surrounding bad practice so that we can devise ways of minimising it? This evidence is easily accessible from the transcripts kept by the HCPC of all their tribunal proceedings, but it does not seem to have been mined. The flag of public protection through statutory regulation is waved without bothering to make an empirical case to support it. Therapy researchers have reported that up to ten per cent of clients, and sometimes more, score lower on tests of psychological wellbeing at the termination of therapy than they did at the beginning. Is this explicable? Does it indicate lack of training, incompetence, or unknown and unpreventable factors?

From the HCPC annual report for 2016-17, we learn that 0.64% of registrants from all professions had a case investigation. A total of 143 cases concerning practitioner psychologists were investigated, representing 6.2% of all HCPC cases. (This compares with social workers who made up 54.3% of all cases investigated). Ninety six cases came from the public, 19 from employers, 17 were self-referred, and there were 11 others. Of only 20 taken to tribunal, nine were found to be not well founded. Five registrants had conditions imposed on their practice, three were suspended, and one was struck off (two were removed by consent). There are 22,604 psychology registrants and so the strike off rate is infinitesimally small, as is the percentage for other sanctions. The proportion of unfounded complaints is also unacceptably high, given that it may have taken several years to obtain this acquittal.

Many HCPC cases involved disciplinary and procedural matters rather than direct harm to clients. These can include illegible writing, failure to keep or sign records, mislaying records, and so forth. As an illustration, two separate allegations against a psychologist were framed as seeing a client outside normal clinic hours and seeing a client at home. If this practice is deemed to be harmful, innumerable independent practitioners working from home in the evening would have to confine themselves to daytime appointments (when most clients are working themselves). In fact, many allegations constitute a form of innuendo. In another example, a social worker working for a drug and alcohol charity was cautioned for three years for texting a service user at the weekend when the charity was closed (Community Care, 2017). She also disclosed personal information, although the content of the message was not “inappropriate.”

I conclude that the aim of protecting the public from harm through statutory regulation has not yet shown itself to be worth the money expended on it. Support for it is based on slogans and rhetoric. Of course, we would all like to raise ethical standards and the competence of professionals but this requires serious thought about alternative methods.

Community Care (2017).
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HCPC (2018) Annual report 2016-17.
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Russell (n.d) Health and Care Professions Council (HCPC) – A grand deception.
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The launch of the Power, Threat, Meaning Framework

I have been receiving emails from Time to Change telling me it’s O.K. to talk about mental health wherever I am. That’s a relief because I want to give a brief response to the launch of the Power, Threat, Meaning Framework (PTMF) which I attended in January 2018 in London. It’s the result of several years work by a team of mainly academic clinical psychologists with the added input of some service-user consultants.

The framework is set out as an alternative to psychiatric diagnosis. This sounds straightforward enough until one asks ‘alternative’ in what sense? The PTMF certainly does a good job of reviewing the social causes of what the authors have grouped together (by default) as “mental health problems”. No one could object to attempts to understand why people get to be diagnosed in the first place. The PTMF is therefore something that policy makers should take seriously. However, as regards diagnosis in the sense of labeling someone with a disorder, the PTMF doesn’t seem to question the fact that a large segment of the population can be labelled as distressed, troubled, or as troubling others. It also proposes general descriptive patterns that could serve to categorise this group. This is not, therefore, an alternative to the practice of diagnosing per se. It seems to follow that the PTMF doesn’t see an alternative to a societal need for a group of professional experts to administer to the distressed. It is even suggested that the replacement for medicalising practices could be located in local authorities where, presumably, psychologists would take the lead role rather than psychiatrists. I hesitate to support replacing target-driven NHS managers with the whims of town hall councillors and bureaucratic local government officials. Social workers have to operate from this base and their public image is not great despite the hard work they put in to support poor, helpless, or dependent individuals. It seems likely that the ‘distressed and troubled’ would become another class of unfortunates – too poor to afford private health insurance that covers psychotherapy or specialist treatment centres. The NHS does at least attempt to provide a uniform and universal coverage that is free to those who satisfy criteria of sufficient need. In any case, psychiatry is not forced to adopt the biomedical model even though it is difficult to conceive how this particular leopard could change its spots.

For all its focus on power, the PTMF still seems to be advocating a system of the powerful dispensing to the relatively powerless. The constant reference to ‘distress’ evokes an image of a person who needs to be cared for, who is perhaps, depressed, anxious, or traumatised. The sufferer is encouraged to reflect on their personal history and what they actually did to confront adversity and build a new narrative. It emphasises the meaning that a person has given to experiences of surviving abuse and trauma, and to focus on their personal narrative of resistance and coping. The PTMF offers a set of general principles to help them in this self-analysis but given that each person has a unique biography, generalities can only go so far. The framework could be enlightening but it doesn’t tell you what to do when up against it. In fact, a person might not become ‘distressed’ but turn to alcohol, substance abuse, violence, crime, or bitter resentment. However much a person self-reflects or benefits from a consciousness-raising group, in the final analysis, a narrative has to lead to practical action. It may be necessary to challenge past personal accounting and make a decision to change. As one questioner in the audience asked: doesn’t the PTMF framework leave the person as a passive victim of adversity?

I was hoping to hear something about the formulation of the problems of single individuals but the PTMF is rather silent on this topic, even suggesting that a formulation could represent the imposition of an unwanted analysis by an expert. This downplays the collaborative and dialogical nature of formulation. If a person refuses to engage in dialogue, they are unhelpable until they change their mind about this. He or she might turn to religion or numbing medication instead. Of course, not all forms of distress require psychological expertise, especially when wrongs need to be righted by taking legal action or by conducting a political campaign. For people who are willing to engage in therapy, I believe that mental health professionals have much to contribute in solving a number of common problems. For instance, despite their somewhat narrow theoretical base and implicit support of medicalisation, clinical psychologists have produced many useful ideas and methods that are disseminated widely in the media and through self-help books. The latter are read by people who not necessarily aware of their academic origin. It is rather disappointing to see in the PTMF document that successful therapy is attributed to the ‘relationship’, as if professionals have some kind of inspirational power to make people better. Instead of this top-down position, professionals could work in partnership with or in support of voluntary and community initiatives for solving problems. As an alternative to ‘diagnosing and treating’, more power could be given to people who know their problem from the inside, encouraging them to generate their own solutions. The role of government could be to fund and support groups of people with a similar kind of problem. However, this is not the direction in which current mental health policy is heading.

The PTMF would clearly like to replace the concept of mental illness but there is a risk that an alternative might attempt to explain everything in life that presents itself as a problem. This is clearly too ambitious and impractical. In any case, problems may have little in common. Would the approach to dealing with a gambling habit, an episode of panic, domestic violence, a cleaning ritual, or a distorted body image share much in the way of general principles? Perhaps each type of problem requires a different framework. From a social policy perspective, there are decisions to be made about the extent to which a person is made personally responsible and accountable, how far changes in legislation would help, and, as noted earlier, what could be done at the level of social provisions and the support of community action.

In brief, the PTMF does not seem to acknowledge the role of professional helping in systems of social control, in the sense of returning the ‘distressed’ to ‘normality’. The influence of power in society is also viewed in mostly negative terms. Social control can operate positively by encouraging and rewarding virtuous behaviour, by providing education, training, and hopefully inspiring and creating opportunities for positive ends. This is not to underestimate the role of negative power in producing adversity, threat, trauma, and abuse. The latter undoubtedly account for a very large proportion of people who end up in current mental health services. However, as some in the service user resistance movement have pointed out, the activities of helping professionals (and not solely medical ones) can also amount to a form of negative social control. It would be helpful for any radical employment of an alternative framework to diagnosis to address the role it would play in processes of social control.

What is the concept of mental health?

This is a simple question but the answer is far from clear. If the question refers to mental ill-health (rather than health), most people would probably take it to mean being stressed, anxious, depressed, or to be suffering from a ‘psychiatric disorder’. Logically, to be mentally healthy should mean the opposite of being mentally unhealthy, which would signify the absence of any psychological problem. However, if we look to the World Health Organization as our authority, their definition of ‘health’ is wider than this: health is ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. Many researchers have bought into this dual meaning and have investigated the relationship between the two aspects of health, firstly, the degree to which a person is disordered (from having no disorder to being diagnosable with a physical or mental disorder), and secondly, the degree to which a person enjoys a state of well-being (from ‘languishing’ at the bottom end of the scale to a feeling that life is going swimmingly at the top). According to the WHO definition, you would have to score highly on both dimensions to be positively mentally healthy. The definition doesn’t seem to allow for being happily mad or sanely unhappy.

Another feature of the WHO definition is that it could be taken to imply that ‘languishing’ is a state of poor mental health. If well-being is integral to health, it follows that a lack of it is unhealthy. In reality, there must be hundreds of ways in which a person can languish in a sub-optimal state of well-being: being chronically unemployable, losing religious faith, having few friends, getting old, etc. These are not connected with a state of health in a strictly medical sense. In fact, when responding to these circumstances, it is probably not a good policy to think of them as examples of mental ill-health. If mental means ‘to do with the mind’, there is no reason to believe that a person who is languishing has lost the capacity to use their mind or that their brain is diseased. That would be to go down the path of responding to languishing by allowing oneself to fall into the sick-role. The person would not be demonstrably ‘sick’ but might be encouraged to take a brain tonic. The pharmaceutical industry has, of course, devised many kinds of brain tonic. Although these medicinal products might take the edge off languishing, it seems far preferable to tackle low well-being in other ways.

How then should we promote ‘positive mental health’? In the 1950s, the US Joint Commission on Mental Illness and Health employed a social scientist, Marie Jahoda, to investigate the matter. When answering this question, she did not consider a concept of mental disorder to be relevant. She came up with a number of alternative suggestions that did not equate positive mental health with freedom from disorder. Her own definition was multi-layered and did justice to the complexity of the topic. Subsequent research on well-being has, instead, contented itself with self-report scales that measure ‘happiness’, ‘life satisfaction’ or ‘quality of life’. Some measures are as simple as asking a person to rate their life on a scale from 1 to 10. Well-being scores have been of considerable interest to economists, who have sought alternatives to assessing the progress of a country in terms of its Gross Domestic Product, a purely monetary indicator. They have been struck by the fact that people’s rated satisfaction with life hasn’t changed much (if at all) over the last fifty years despite considerable improvements in average income, possession of luxury goods, and the provision of greater social welfare. If being mentally healthy means the same as being satisfied with life, it seems we are not making much progress in advancing it.

The best judge of whether someone is ‘mentally healthy’ is probably a person him or herself. It is difficult to get away from a subjective judgment. However, a problem with a subjective scale is that it seems to depend on unknown and shifting reference points that could be quite different for each person. It is likely that how satisfied you are depends on how well you consider yourself to be doing (or expect to be doing) with respect to your peers or other people in general. For instance, most people in the West have access to running water, and so access to it no longer enters into a judgment of life satisfaction. This might not have been the case when some people had to travel a long distance to use a well while others had piped water. Similarly, to take a more contemporary example, if a woman earns less than a man for doing the same job, she might, understandably, feel dissatisfied, and this might possibly influence her rating of satisfaction, well-being, or even mental health. The relative basis for subjective judgments also has other implications. It means that if one section of the population gets very much richer relative to the rest (as has happened in the USA), the majority will become more dissatisfied even though their general wealth has stayed the same or improved. This would be so if they use the richest as their reference point to make comparisons. The upshot of all that I have been saying is that subjective ratings of positive mental health have extremely complex causes. I think it is safe to assume that these causes have little to do with health or medicine (except, of course, in particular cases, when life satisfaction could be affected by physical ill-health.)

So in answer to the question of ‘what is mental health’, I would advocate being much clearer and more single-minded about a definition of health. By and large, we have a pretty clear idea of what a physical health problem is. In most countries, physical and mental health services employ different professionals who occupy different premises. Textbooks of medicine rarely mention ‘psychiatric disorder’ apart from discussing the effects of head injury or the known diseases of the central nervous system. A person does not normally go to a physician to check up on their ‘mental health’. Let’s adopt a far stricter definition of a disorder of the body and stop talking about ‘mental health’ altogether. As Thomas Szasz pointed out many years ago, the mind is not the kind of thing that can be disordered in a physical sense. To live unwisely to one’s own detriment is not a mental disorder. If we followed his advice, we might cease to confuse remediable social and personal circumstances with remediable bodily disorders.

Marie Jahoda. Current concepts of positive mental health. New York, Basic Books, 1958

The mental health conspiracy

Why a new blog on mental health? I have spent my career working as a mental health professional and have been disappointed that the public understanding of what is at stake has changed so little. Governments attempt to grapple with rising evidence of “mental ill-health” but do so with the primitive idea that the problem is one of “health”. Mental health professionals, the pharmaceutical industry, and mental health charities would all have a great deal to lose by dropping the idea that “mental disorder” is a meaningful concept. It seems like a conspiracy and it is time for a radical reappraisal.

From this standpoint, it should be clear that this blog is not a source of “impartial truth” about the facts of mental health, as if all that is needed is a discerning commentator to lay it all out in a few easily digested words. Mental health mythology cannot be answered by scientists in white coats.

Put simply, life is unavoidably messy and its tragic aspect cannot be whitewashed over. I am not so simple-minded as to believe that people do not, for good or bad reasons, become extremely distressed, act strangely, anti-socially, or feel compelled to act in ways they would prefer not to. People can have real problems but these are not merely an individual matter, as if “mental health policy” should be directed towards providing services to cure or assist them. That would ignore the fact that problems arise in certain kinds of circumstance, under the influence of social norms, cultural beliefs, and government legislation. If the messiness of life is to be addressed at all, it is necessary to abandon a simple “health” mindset.

For each person there will always be a gap between what is desired and what is achievable. When this gap has negative consequences it is not helpful to sweep them up into a big heap called “mental ill-health”. Most people resolve the gap without ever thinking that their suffering is due to a health problem. This is not to argue that we can just ignore calls from people who report difficulties, problems, suffering, and wish for this to be resolved or contained within tolerable limits. The conspiracy of mental health limits the way we approach this task and also serves the function, in many cases, of letting society or the individual off the hook. The   umbrella of health hides the fact these problems may have entirely different causes. For this reason, greater imagination is needed rather than more services or resources. It doesn’t rule out science and medicine as having something to offer. It is simply to argue that “mental ill-health” is not primarily a scientific or medical issue.

The idea of mental health at an individual level can mystify the nature of problems and encourage a person to think of him or herself as “ill”. This can happen without any deliberate intention (on the part of society or a person) to deceive. It is to fall in with a way of construing problems that has been with us for a couple of millennia, ever since some version of a “mental health theory” has been promulgated. The State willingly colludes, accepting that “mental ill-health” is an affliction that has little to do with its own laws, policies, or prevailing social conditions. The “sufferer” who seeks help is placed in the position of a supplicant, who is assisted by a process of ‘caring’ or ‘curing’, metaphors that would be appropriate if a person was really experiencing a physical illness or disability affecting the functioning of their body. The State now sees itself has having a duty to provide a “mental health service” premised on the existence of ‘disorders’, the need for ‘medical treatment’, and support for ‘sufferers’. The World Health Organisation believes that people around the world are experiencing an epidemic of mental disorder.

The blogs on this site discuss various aspects of the mental health conspiracy. They are not intended to promote a particular answer to any particular problem that a person might happen to have. This website is not offering a service. There are many sites that document how people have dealt with their own issues or have linked up with others to do so, and these are not too difficult to find.

The purpose of these blogs is to encourage democratic debate – so please comment. Anything that seems completely irrelevant or is insulting will be removed as soon as possible.

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