from All in the Mind podcast.
Lynne Malcolm: Does mental illness really exist? There's no doubt that, worldwide, many people experience significant emotional distress. But are we using the best approach in mental health care?
Peter Kinderman: I'm angered by the way that people are treated. I'm angry at the way in which people are treated when they are detained, and legislation. I'm angry at the power imbalance between people who request help for their distress, and then the machinery of treatment that is applied to them. I'm angry at the system that just doesn't give us a set of alternatives. And I'm angry that our politicians haven't devised safe, pleasant, calming, restorative places where people can have a bed for the night, be kept safe, without being slotted into a hospital bed, told that they are ill, done the psychiatric workup and given the drugs.
When people are in huge distress they need somewhere to stay, and we don't give them alternatives, we don't give them choice, we give them 'back on the streets or hospital'. I'm frustrated. I think we should be doing things better and we absolutely, definitely can afford to do things better.
Lynne Malcolm: It's All in the Mind on RN, I'm Lynne Malcolm. Today, a controversial alternative view to the dominant approach to mental health care in western society.
Peter Kinderman is Professor of Clinical Psychology at the University of Liverpool, and former president of the British Psychological Society. I caught up with him when he was in Australia recently.
Peter, how significant are mental health issues across the world today, and what impact are they having on society?
Peter Kinderman: So, generally, wrapping up all of the things that are broadly in the area of mental health, hugely impactful. There was a report out in the UK just a couple of days ago that was talking about billions of pounds are lost to the UK economy, both in time lost for employees, lost productivity, turnover and so forth. Suicide is, according to at least some estimates, the most common cause of death for young men, men in their late teens, early 20s. It's the most common cause of death in women in the year after childbirth. Costs to major developed economies, both in terms of healthcare but more importantly in terms of lost productivity to the nation running in billions, and that's only if you go down the neoconservative route of counting it in dollars. If you talk about the tragedy of people's lives, both in simple terms, in terms of everyday sadness but also in terms of major threats to our well-being and our emotional health, it's an epidemic, it's hugely important to society.
Lynne Malcolm: And the mental distress is definitely on the rise?
Peter Kinderman: No, I'm not sure that you can say definitely. Certainly we are talking about it more and that's a good thing. Certainly people are more aware of the importance of mental health in their lives and in the lives of their children and in the lives of their loved ones than before. We are certainly more open about it. We are certainly more able to recognise the reality and the significance of our psychological well-being in everyday life rather than shoving it under the carpet. I'm not sure that that means that people are experiencing greater problems per head of population than they ever have done. I think there's a very good argument for suggesting that, if anything, people are probably slightly happier than they have been in the past. But I think we are aware of the hidden traumas in people's lives a lot more, and in a sense that's a good thing.
Lynne Malcolm: You argue, though, against the concept of mental illness. Would you go as far as to say that mental illness doesn't exist?
Peter Kinderman: I think if you say that mental illness doesn't exist, it sounds as if you are saying that the problems don't exist. And I like the fact that you've just introduced this segment by talking about the seriousness of the problems. I think they are vastly serious problems. It's my job to look at the problems that people experience and the impact of those problems on their lives.
No, what I'm arguing is that to suggest that the best metaphor to describe those issues is an illness metaphor or a disease metaphor or a disorder metaphor or a pathology metaphor is the wrong metaphor. It doesn't describe those very significant problems in an appropriate way. I think it's better to regard these terrible issues as terrible aspects of normal psychology and the lives of human beings as we live them, rather than to suggest that they are sort of alien pathologies. I think the fact that our young men are feeling hopeless about the future and are driven to take their own lives is a tragedy but I think it's a human tragedy of our societies and our families. I don't think it's an illness that is sweeping alien-like across our brains.
Lynne Malcolm: In some cases though…for example, in schizophrenia, is there no difference in the structure of the brain of someone with schizophrenia?
Peter Kinderman: I think there is very, very, very little evidence for any systematic, biological, causal mechanism in the major forms of mental illness that are described. So it is true that what we can see is that people who have been hearing voices for many years, there do seem to be differences between the functioning of my brain when I'm hearing voices or my brain when I'm paranoid and when I'm not paranoid, but it's very difficult to tell whether that is to do with the drugs that I take, whether it's to do with the fact that I hear voices all the time.
Because of course the brain is an organ which…the functions of the brain, the thinking that is going on in the brain is visible in terms of the neurological activity of the brain. So if I am very frightened and you have a sophisticated test, you will see that fear, not only in my behaviour, not only in my reports, not only in my emotions but also in the functioning of my brain. Obviously there are parts of the brain associated with the fear response which are very active when I'm fearful.
So of course you will see paranoia, for instance, or you will see hallucinatory experiences in the functioning of the brain because everything that happens in our psychological world is happening in our brain. That's massively different from suggesting that those brain activities are the things that cause the problems in the first place.
For instance, if we look at the genetics, we do know that a very, very large number of genetic differences between people, possibly as many as 20,000, are associated broadly with very, very slight increases in the risk of people developing a very broad range of problems. And that would be problems that lumped together experiences like bipolar disorder, schizophrenia, ADHD, autism, all into very broad categories for which these genetic abnormalities seem to convey a very, very slight risk. I think that's a long, long way from saying we know that schizophrenia is a genetic illness. In fact we don't even know that schizophrenia hangs together as a concept, as a single unitary concept. Anyway, there are lots of different problems encompassed by that label, lots of different pathways, lots of different types of experiences that people have.
So I think it's true that our emotional lives are represented in the functioning of the brain, but that's not the same as disorders of the brain are known to cause problems in our emotional lives. I don't think that we should carve out things like feeling hopeless, performing repetitive behaviours to control our anxiety, hearing voices, being paranoid about the intentions of others as quintessentially diseases for which there are genetic causes. I honestly don't think the evidence supports that.
Lynne Malcolm: So you feel that in this biological approach, biological model, we are relying too much on the brain research and the studies that have been done on brains to fully explain the behaviour?
Peter Kinderman: I think we are relying too much on evidence which is really rather weak. I think we are relying too much also on a metaphor, the illness/disease/pathology metaphor which serves certain functions for us but doesn't actually help people very much. So, for instance, it means we can say what is the aetiology of depression, rather than why is our society making our young people feel so hopeless? It means that we can say 'what's wrong with him, can it be treated', rather than 'how do we have to change in order to help him?' It means that we can say 'come back when you're well', rather than 'how can we make this building a safe working environment?' And also we can say don't worry about it, I'm sure we will find some research that explains your son's illness in a few months' time, we just don't have it yet.
So I think the illness metaphor serves lots of functions for the people in power, it doesn't help people who are actually experiencing the problems a great deal. And by the way, you can take some drugs, and when the drugs don't work you can try some other drugs. And when those drugs don't work you can combine the drugs. And when the combined drugs are making you sick you can come off the drugs and feel terrible but that's because you are seriously ill. And then you can try some more drugs, and that doesn't really help people either, apart from the pharmaceutical companies.
Lynne Malcolm: So what is it that's driving this reliance on a disease model, as you call it?
Peter Kinderman: Well, I think it suits a lot of people with vested interests. I think it suits a lot of people in the healthcare world; leave it to us, we know best, we're in charge. I think it suits politicians in some ways because instead of addressing some of the structural weaknesses of society…and in Australia it seems obvious to me as a visitor that there is an ongoing slow motion genocide of Aboriginal communities, and rather than addressing that we look to how can we cure these mental illnesses. And so it serves a lot of people's interest to defer the issue somewhere else.
Also I think, slightly more benignly, medicine and scientific medicine is stunningly effective. I take a statin because we know quite a lot about heart disease, we know quite a lot about lipid functioning and so forth, and I put a lot of faith in biological medicine. So it's not unreasonable to say we've had enormous success applying biological medicine to a whole variety of disease entities, infectious disease being the most obvious. Let's apply that hugely successful science to mental health. I just don't think it's the right science to apply. I think we should apply psychological science rather than biomedical science to psychological health. So I think it's understandable, it's just I think we've gone a bit too far.
Lynne Malcolm: So what does this set of beliefs and attitudes mean for the treatment and support that is available?
Peter Kinderman: Well, in my opinion I think what we need to do is to start understanding the psychological issues from a human, psychological, social perspective. I think we need to start using the word 'we' an awful lot. So instead of 'why do they get depression', we need to ask 'why do we feel hopeless?' You know, nuclear weapons being developed in North Korea, and you think why is it that we feel hopeless and pessimistic about the future. So I think we need to start asking questions of why, and to ask what is it that makes us happy, what is it that gives us contentment in life, what is it that gives us a sense of hope and optimism for the future, rather than 'can we find the treatment for depression'. For people who've got serious problems I think we need to be very cautious before applying disease labels to their problems, and I think we need to describe their particular problems in clear, even scientific language and use that as a mechanism for communication and in order to give them themselves hope.
I think we need to sit down with them and talk to them about the things that have happened in their lives, how they've made sense of those things, and then piece that together to see if we can form a plan for recovery. And that is subtly but vitally different from correctly diagnosing their illness and then getting them the right treatment. And I think, yes, we need to pull away a little bit from assuming that there is a drug that would cure their problems, and to be very cautious about that.
Lynne Malcolm: One example I think that you've talked about is ADHD, hyperactivity attention disorder is an example of a diagnosis that you have concerns about.
Peter Kinderman: Yes, I have grave concerns about it. I think that several things have gone wrong in the area of ADHD. I think the first thing is instead of seeing that as an educational and social issue that does involve our medical colleagues but primarily it's an educational and social issue, an issue of child development. It's seen as an illness that the child might or might not have and that we need to then treat, and I am wary of that as a response.
I think we all differ in terms of the way that we engage with learning, the way that we are able to control our emotions, the way that we are able to sustain attention and so forth, but that's somewhat different from 'some of us have illnesses'. But then I think that there is an explosion of the use of that diagnosis. And it's different in different cultures, it's different in different segments of society, it's used differentially for different people coming from different socio-economic or cultural backgrounds, and it is used differently in different countries, and that makes me very suspicious of it as a medical concept. It looks much more like a social concept. It looks a lot like a label that you give to kids that aren't fitting in with the schooling system that we give them. And we don't give them a terribly good schooling system.
We need to think about how we shape the school day and shape the individual educational experience to each child's needs. So instead of giving them Ritalin in order to cure the ADHD so that they can fit in with the educational system, how about changing the educational systems so they don't have to do that?
So I think there are lots of ways where if we stop thinking about ADHD as this illness for which we need to diagnose the kids and then treat them for it, but instead think how might a kid who was nearly a year younger than their classmates and comes from a particular socio-economic background have difficulty fitting into the education system. If we start thinking about it as a psychological phenomenon and not an illness to be diagnosed, I think we would come up with very different solutions to the kids' needs. None of that is saying that the kids don't have problems, it's just saying that they are different sorts of problems than symptoms of illnesses.
Lynne Malcolm: You're with All in the Mind on RN, I'm Lynne Malcolm. I'm with Professor Peter Kinderman from the University of Liverpool in the UK.
He's calling for society to abandon what he calls the 'disease model' of mental health care, which he says is ineffective and lacks humanity. Peter Kinderman argues that services should be based on the premise that the origins of mental and emotional distress are largely social. For example, some of his colleagues conducted a study analysing the impact of the economic recession on suicide rates in Britain.
Peter Kinderman: This was public health colleagues David Taylor-Robinson, Ben Barr, Alex Scott-Samuel and others who are public health researchers in Liverpool. And yes, they looked at whether there was an impact of the global economic recession on both mental health issues, reported mental health issues, interestingly also on prescription rates for antidepressants, and particularly on suicide rates. It's not an individual case series analysis looking at individual people's lives, it is a public health analysis looking to see whether the broad trends in statistics can be explained statistically in particular ways.
And what they found was very clear, that when there are spikes in economic recession, particularly when there were spikes in unemployment, you get spikes in suicide attempts. More common for men than women, and there might be something about how in our very gendered society employment roles might be particularly significant for men.
It's interesting, I went up to a semirural community in Australia a few days ago and they were talking about impact on mining and industrial communities, and again, identifying patterns of self-harm and suicide in men whose economic future is threatened. And yes, Ben and others found that when people are laid off as a result of economic recessions, you see consequential rise in suicide attempts. You also see rise in people reporting serious mental health problems as well.
That is part of my frustration at the story, which is that this story about can we find a biological cause of depression, a lot of money and a lot of effort is put into trying to find biological markers of depression, biological causes of depression, genetic risk factors for depression, that the evidence of the social causes is staring us in the face. It is obvious. If you lay off 100 people because the company goes bust, then you will see suicide attempts as a consequence. We simply know that, we don't have to wait for some fancy new evidence coming around the corner, we know that.
So we have very clear evidence that social factors lead to mental health problems, we know that childhood abuse, we know that peer-on-peer bullying in schools, we know that violence between domestic partners, usually men are beating up their wives of course, we know that these things cause mental health problems. We know that the war impacts on both civilians and on veterans. We know those things to be true. Maybe there's some biological elements, maybe some people are slightly more vulnerable than others, I don't doubt that that's true, but we simply see the evidence of the social causes every day. And yet, little bit like Harry Potter in the wizardry world, the Muggles seem to be almost wilfully ignorant of those massive causes of psychological distress.
Lynne Malcolm: So what do you believe are the most significant factors that determine the differences in the mental health of individuals as a result of the social factors?
Peter Kinderman: When you look at surveys of well-being, you find that commonly the three factors that impact…that contribute most strongly to your well-being are your physical health, relationships, and a sense of meaning and purpose in life. So I think that bad things happen to people in the context of bad relationships.
Another take on it would be the work coming out of people who do cognitive behavioural therapies. This would be the stuff that people like Aaron Beck talks about which is thoughts about self world, other people and futures, so how you think about yourself, how you think about other people, how you think about the world, and how you think about the future. And again, it's about a bad things happening to people in the context of bad relationships, but what that teaches us about the world. So if every day the people around you are telling you that you are a worthless person, if they are behaving as if your input has no merit, if they are indicating to you in words and deeds that you are somebody to be devalued, the danger is that you will pick that up and devalue yourself. And if our political leaders basically signal to us that our contribution is to be ignored, then maybe we feel as if our contribution is ignorable.
So I think as a psychologist it's not just a sociological thing that is the impact of the man's fist on your face causes you to be depressed, it's more about what that tells you about who you are. So I fear for children being bullied at school and their peers telling them that they are a bad person and the teachers doing nothing about it and how that kid develops a sense of who they are that will give them great vulnerability in future lives.
Lynne Malcolm: There seems to be an increase in the number of teenagers and young people who are experiencing issues with anxiety. Do you think this is the case and why is this?
Peter Kinderman: I am unsure. I can think of arguments both ways. So the negative arguments would be that we live in very uncertain times. So if you are in your late teens and you are thinking 'what sort of life am I going to have', then being saddled with debt, not having secure employment, worrying about the nature of the world in which you are entering into as an adult, that can be extremely destabilising for your sense of who you are and where you are going.
Social media can…I mean, I think on the whole social media is a good thing, but you've got cyber bullying, you've got the exposure, stored forever representations of the negative things that people say about you, relentless pressure, judging especially young people in terms of league tables and scores and numerical ratings of their aptitude and success. So I can think of lots of reasons for arguing that life is quite tough for young people.
As a father and actually as a grandfather I see reasons to be hopeful. And in that context you can tell a story where some of the mental health stories for young people are quite hopeful in that people are willing to talk about themselves and their friends' emotional lives in a way that wasn't true for my parents, for instance. It's becoming true for people like me but it's a little bit more true for my children. So I think that there are people in their late teens and early 20s who are much more happy than I would have been when I was of that age, saying, yes, I was really in a dark place and I ended up cutting myself but I've moved on from that. And the fact that we can talk about that means that we see it more. It looks like it's an epidemic, but I can tell a story which is little bit more hopeful than that. And I think if we were able to build on that and encourage young people to be open about their mental health and the emotional climate in which they live and respond to them appropriately, then that would be good. The fear is that if these young people are emboldened to talk about their mental health and then we'd tell them all that they've got a brain disease for which they need to take powerful drugs, maybe we will put the key back in the lock again and that wouldn't be so good.
Lynne Malcolm: Peter Kinderman from the University of Liverpool. His alternative vision for mental health care involves a shift away from the assumption that we need to treat a disease. It focusses more on supporting people who are distressed as a result of their life circumstances.
Peter Kinderman: What we need to do is we need to change the thinking and change the language, think about our mental well-being as part of what it is to be alive, see it as part of our psychological and emotional lives, part of a concept of well-being rather than a separate part of our life predicated by illness. I think we need to describe our psychological issues in everyday but also scientifically valid language. We need to talk about self-harm, we need to talk about relationship difficulties, we need to talk about finding that our self-esteem is very variable and not use pejorative and unpleasant and unscientific labels like 'borderline personality disorder'.
We need to talk about hearing voices or possibly, if you like, auditory hallucinations. We need to talk about paranoid fears rather than schizophrenia. We need to talk about distress, hopelessness and low mood and tiredness and an inability to feel pleasure rather than 'major depressive disorder'. And we need to talk about intrusive thoughts and repetitive behaviours the rather than 'I have OCD'. We need to talk about the trauma of conflict rather than 'this is a man with PTSD'. So I think we need to describe people's problems using the scientific language of psychology and the everyday language of human life rather than medicalised diagnostic terms. We need to stop assuming that those things that we are describing are the consequences of underlying illnesses.
We then need to radically reduce our reliance on medication, and when we use it we need to understand what the medication is actually doing in our brains. I think we should use medication more sparingly, we shouldn't reach to it as a first resort. And instead…yes, I'm a psychologist, so I think that we can use some of our understanding of how the events in our lives and the way we make sense of it impact on our emotional well-being to plan ways of therapy or intervention or a community help that will enable people to recover from these problems.
I hesitate a little bit because I think the answer to my dilemma is not to say, look, it's fine, everything is cosy, let's bang a tambourine and sing a song together and somehow the community will help. I think I deserve, I think I'm entitled to realistic, sensible and scientifically well tested help, but I think those forms of help are available. I think we should stop seeing ourselves, however, as treating illnesses, and see ourselves as people who can use our training and expertise and academic knowledge to help our fellow human beings who are in great distress.
Lynne Malcolm: That potentially is more trouble and it requires a huge amount of effort. How optimistic are you that the changes that are most appropriate will happen?
Peter Kinderman: So it does require effort. I think one of the stories of mental health is troublesome people who might cost us a lot of money are put in hospital. But you know, damn it, it does cost a lot of money, but I think that protecting my children's mental health, given the stresses on them and the things that might happen to them and protecting their friends against the consequences of bullying and so forth, if it costs money, it costs money.
I'm speaking now in Australia and I come from the UK, we are both residents of massively wealthy countries. We can afford to send satellites up into space, we can afford to build gravitational wave detection devices, we can afford nuclear submarines that cruise under the oceans tipped with weapons of mass murder. We can afford these things, of course we can afford to sit down with kids who have been bullied at schools and then sit down with the head teachers and plan a way of eliminating bullying and helping those kids. So yes, it takes a bit of effort. We should do it. It takes a bit of money. We've got loads of money. And it's the right civilised way to do it. I think that the next steps actually is citizens demanding from politicians that we are offered the sorts of services that we need.
Lynne Malcolm: So you are also really referring to changes at a societal level to reduce the likelihood or risk of people developing difficulties.
Peter Kinderman: Yes. I mean, we are sitting in a world, in a time when we are talking about Harvey Weinstein being accused of sexual attacks on women, and where the President of the United States boasted about his ability to assault women and get away with it. Okay? We are not living in a world where women are going, I wonder why that sad, poor woman developed that rather bizarre illness called borderline personality disorder? We are living in a place where young women are being attacked by a powerful white men. So yes, it requires societal change, but that's the thing that we need to be focusing on.
And when we are looking at young people…I'm not suggesting that every young person in Australia is being physically assaulted, but I think we need to think about whether or not we are bringing up children in a community which loves them and honours them and offers them a positive and hopeful vision for the future. And that's a subtly different message from are we ensuring that we identify the early signs of depression and treating it properly. So yes, I'm suggesting a more political, a more social and interventional mental health, focused a little bit more on social justice.
Lynne Malcolm: Peter Kinderman, Professor of Clinical Psychology at the University of Liverpool and former president of the British Psychological Society. He was in Australia for the recent Big Anxiety Festival.
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Thanks to producer Diane Dean and sound engineer Judy Rapley. I'm Lynne Malcolm. Bye, till next time.