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Semantics instead of treatment

The move away from an ‘illness’ to ‘personal responsibility’ puts the onus on the patient to find the answers, so they can get themselves better, writes Ruth Hunt

THE demand for psychiatric services, including inpatient beds, is at an all-time high, but the capacity to treat such inpatients has not kept up, with some regions in the UK faring worse than others, the Royal College of Psychiatrists report from 2019 found.

This has resulted in the threshold for getting admitted increasing, leaving service-users who are unwell, including some people with a serious mental illness such as depression not meeting the threshold for admission.

These service-users might be offered therapeutic tools through Improving Access to Psychological Therapies (IAPT) and receive, for example, Cognitive Behavioural Therapy (CBT) or they might try to find a therapist, on a private basis, who can help them deal with their symptoms.

The pandemic has exacerbated these problems in accessing NHS help, with private psychologists and therapists more able to bend and shape their practices such as moving counselling online.

Therefore, a document from the British Psychological Society (BPS) on the core values and approaches taken to deal with depression would have been welcome – not just for patients but also for members dealing with these unprecedented times.

This explains the strength of the negative feelings when Understanding Depression was published by the BPS.

A large chunk of the report focused on what depression is or is not – going over old ground yet again. The first key takeaway claim states: “Depression is best thought of as an experience, rather than a disease.” To clarify this position, they add: “We experience depression, just as we experience anxiety, anger or even love or joy.”
 
It says depression is comparable with normal human emotions rather than an illness. The emphasis then turns towards the patient to ask why they are not coping with this “experience.”

This move away from an “illness” to “personal responsibility” has already seeped into mental health care with the ever-expanding recovery industry, CBT and mindfulness — where the onus is on the patient to find the answers so they can get themselves better.

For service-users this undermines and invalidates their lived experience of devastating prolonged bouts of illness, which can bulldoze through their relationships and careers, causing physical health problems and even, for some, shorten their life expectancy.

Such a position also poses a triple threat, with caregivers less inclined to treat the illness as a potentially life-threatening and serious condition as well as those who work in public or private bodies and the government who ultimately decide on what services and initiatives to invest in.

It is this last “threat” that seems to be the most important – with the report clearly aimed to sway the minds of those in powerful positions. Yet, in the real world, professionals work well together in the best interests of their patient.

Adam, 43, is a practising psychologist who has left the BPS due to this report. He said: “In clinical practice, most of us enjoy collaborative and collegial relationships with our mental health and medical colleagues and this is not reflected in the Understanding Depression document nor by its authors’ public statements.”

His concern is that in the past five years or so, the BPS has drifted in a direction which appears anti-psychiatry, anti-medicine and anti-diagnosis: “I would even say that it appears to be anti-science and has damaged our identity as a scientist-practitioner profession. I believe that it is a small but vocal group who appear to have been given a very privileged voice by the BPS.

“They do not represent the wider membership,” Adam said, “with the majority of the profession not feeling listened to or served well by the ideological bias and dogmatic presentation that is now particularly visible on social media.”

It was not simply the contents of the report that caused concern but how it was delivered. For example, in a key section of Understanding Depression when they are trying to break down the notion that depression is an illness, they argue: “For many people, depression is unlikely to be the result of an underlying biological disease process or a chemical imbalance in the brain or nervous system. Even if there are changes in the brain when people are depressed these are often consequences not primary causes. After all, all mental states have physiological and biochemical elements…The discovery of physical changes tells us nothing about causality or even the best ways for helping.”

These arguments are discussed as if they were established facts.  Author and professor in discourse analysis Dariusz Galasinki said after examining the report what he strongly objected to was how the authors’ view was constructed as the truth: “The authors say they will only argue that depression is best thought of as experience or a set of experiences, rather than as a disease. But it is hardly an argument if you have already decided, is it? If you want to argue then argue, but don’t cheat by simply saying in the first sentence that depression is an experience.”

Similarities are noticeable between this report and the earlier report Understanding Psychosis regarding the language, such as the dropping in of the pronoun “we” or use of “some of us.”

“This is a common political tactic of aligning oneself with the audience, as if the audience and the speaker/writer spoke with one voice,” Galasinki said, “and the important question is: Do they?”

Galasinki was also concerned at the normalisation of depression and the lack of balance throughout the report. Despite the report being called Understanding Depression, the executive summary contains no mention of antidepressant treatment, yet the authors claim it is a “major” report.

The focus is instead on formulation, which is defined as the process of making sense of a person's difficulties in the context of their relationships, social circumstances, life events, and the sense that they have made of them

Although Galasinki values the role formulation can have in mental healthcare, there is more than one approach. “You cannot simply forget there are many and many people who take antidepressants and swear they save their lives. Wouldn’t it be much better to tell those people if the meds help you, take them, just make sure you understand what you take, what it means and how you will get off them?”

As Galasinki indicated the language and messaging of Understanding Depression is similar to a recent report, Understanding Psychosis, where they claim: “The problems we think of as ‘psychosis’ – hearing voices, believing things that others find strange, or appearing out of touch with reality – can be understood in the same way as other psychological problems such as anxiety or shyness.”

Both of these reports are unpinned by the Power Threat Meaning Framework, a report released in January 2018 which argued that “there are, and have always been, alternatives to diagnosis on an individual, one-to-one basis, such as problem descriptions and formulations.”

Many BPS members were deeply concerned regarding the contents of these reports, and some have decided to leave the organisation, with Understanding Depression being the last straw. Others have made it clear that the arguments made in the report don’t match their clinical practice and do nothing to advance the understanding of such a complex condition.

Mary, 46, who is a practising psychologist, said she disagreed with the suggestion that depression as a mood state and depression as a disorder were considered as essentially the same. “Depression (or sadness) as a mood state – such as grief, will come and go. Depression as a clinical disorder does not go away.

“The report doesn’t help us ‘understand’ depression or why 50 per cent of people have their first episode as a young person, before the age of 18.”

It has also come under heavy criticism from service users. Cassie, 30, who has suffered from depression on and off since she was a teenager, found Understanding Depression patronising because of the language used and persistent use of inverted commas to effectively belittle lived experience. “Its superior language and selective use of science to underpin its biased narrative wasn’t balanced.”

Psychiatrists today do ask “what happened” acknowledging the impact of events and experiences, such as early trauma, as part of a full biopsychosocial approach. However, that is not to say everything in psychiatry is working well.

There is no doubt psychiatry has become more biological in its perspective over the last 30 years, and under time-pressed and under-resourced services there has been and still is a tendency to focus on medication.

Those attacking psychiatry as a whole use these problematic areas as a way in to mount their attacks. Taking all that into account, it’s hard not to view Understanding Depression as anything other than another tool in the vitriolic power struggle by those in the anti-psychiatry camp to gain legitimacy and access to lucrative contracts and services.

One of the authors of the report, Peter Kinderman, revealed its main goal with a tweet that said: “The purpose of our report was to challenge vested interests.”

Challenging vested interests, through political and ideological statements, does nothing to help service users like Paul, 32. He said: “The publication of Understanding Depression means the polarised state of therapy will continue. That doesn’t help someone like me who was not just knocked back from NHS services but also from finding a compatible therapist.”

Ruth F Hunt is a freelance journalist and the author of The Single Feather (Pilrig Press)

Dariusz Galasinki is an author and professor in discursive analysis, his latest book Discursive Constructions of the Suicidal Process (Bloomsbury) is out now.

Some names have been changed to protect confidentiality.

 

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