Trench Warfare in Mental Heath

The battle between biomedical vs psychological understandings of mental health has continued for over a century. But who really benefits? And does it cause more harm than good?

I’m going to argue that the debate needs to be scrapped entirely. Before I begin, I want to share a very short story about my father.

In WW2, my father fought against the Japanese. On one occasion, he was alone and out of ammo. An army of Japanese soldiers were coming up over the hill towards him. From his dug-out, he attacked them whatever he could lay his hands on – grenades, rocks, boxes. He knew this was the end, but he fought on to the bitter end.

Only, he didn’t. The incident never took place in the way he described it. It happened in 2009. On a general medical ward in Darlington, England. A 67 year-old man, dressed in a hospital gown, perched on the edge of his bed, face contorted with rage, hurling Quality Street at the man in the bed opposite, shouting “come on, you bastards!!”

Was he psychotic? Was this triggered by some past trauma? Did he have PTSD? Did he need anti-psychotic medication or therapy?

No. He was dehydrated and had a fever. Half a vat of saline drip and copious antibiotics later, and my father returned to tell the tale. Fortunately, we were all able to have a good laugh about it afterwards. And the rather bemused man opposite was grateful for the Quality Street.

My father’s brief episode underlines my frustration at a debate in mental health that refuses to die. Who is Right About Mental Health?

It is, on the surface at least, a debate of biomedical psychiatry versus critical psychology. For those not familiar with this debate, it can be summarised thus:

We are right. You lot are wrong.

There’s some extra detail, but that’s about the size of it.

I’m not going to argue for one side or the other. Neither am I going to summarise or critique the main points of each argument. That’s been done to death.

Rather, I’m going to argue why the debate itself is wrong, why everyone loses in the end, and why it needs to end. Then I’ll propose an alternative debate that, I believe, will be much more productive.

 

Everyone is Wrong

The psychological vs psychiatric debate has been going on for over a century. It goes way back to the early days of the asylums and the Retreat. It runs through the Enlightenment to the discovery of anti-psychotic medication and ECT. It includes the Anti-Psychiatrists like RD Laing and Postmodernists like Foucault. It has been enacted in the different flavours of the Mental Health Act, Care in the Community and on into the present day.

A hundred years of debate and no discernible progress.

Critics on both sides are quick to point out the excesses of the other. The dubious early use of ECT. The psychological underpinnings of torture techniques. The side-effects of psychiatric medication. The over-stated claims of effectiveness on both sides. And neither side has the cleanest of histories.

Over the years, mental health care has swung like a pendulum between the two, uncommitted. Neither this nor that. Going with the times. A hundred years of debate and no discernible progress. And still, folk are at each others throats about it.

The problem with the debate isn’t that people aren’t making valid points. They are. The problem is that it’s not a debate. It’s more akin to trench warfare. Each side sniping at the other, scoring points and claiming victories.

This can be seen in the ironically entitled “Maudsley Debates”, where professionals pit sides against each other and vote on who is the winner. It can be seen on social media, where professionals argue vociferously with each other. It can be seen in clinical practice, where professionals coerce people with lived experience to adopt a particular narrative of distress.

Proponents make ad hominem attacks on anyone who points out irregularities in their position. Allegations of “Conflict of Interest” are made against people from “the other side”. Formal complaints are thrown around like confetti.

Even worse, professionals publicly denigrate people with lived experience whose perspectives don’t fit their own narrative. It’s all quite unseemly and unprofessional.

It’s dogmatism. There is a collective refusal to learn from each other. Each side proposes theories and frameworks to counter the other side’s position. It’s all about outflanking the opponent.

No single wizzy framework can capture all the nuances of distress for everyone.

All this to establish their own position as the dominant concept of mental health. One Path for All. Everyone must walk on my path. Those people on a different path, they are heretics. It is a professional power struggle for control of the system.

But everyone is wrong. This is because there simply is no One Path. And nor can there be. No single wizzy framework can capture all the nuances of distress for everyone. Not the DSM or ICD, not the recently released Power Threat Meaning Framework.

There are so many factors influencing our mental and emotional health. It’s frankly disingenuous to tie your colours to just one mast, at the expense of all others.

For sure, some medics specialise in the biological factors behind mental health and ill health. But the number of medics who would honestly propose that all human experience can be reduced to bio-chemical structures is vanishingly small.

The biomedical model of psychiatry simply does not exist. It is a straw man, held up by critical psychologists to beat with a stick in order prove their alternative point of view.

Likewise, I don’t think that there are many clinical psychologists who would seriously argue that the inner workings of the brain have absolutely no bearing on how we think and feel.

So why the hell are we still having a century-old argument about two things that JUST DON’T EXIST?

 

Everyone Loses

I say “everyone loses”, but that’s not the case. Some people get paid serious money to perpetuate this debate. They gain status, authority and power. They get to publish books and do powerpoint presentations to important people. They have a zillion followers on Twitter.

Others, meanwhile, are at the debate’s mercy, caught in the cross fire. It is a cruel irony that the very people who are the subject of the debate – ie. those with lived experience – are the ones most negatively affected by the debate.

Many people with lived experience will see the relative merits of both perspectives. They may have benefited from, or been harmed by, psychiatric and/or psychological interventions. As a result, they may find themselves more aligned to one view than the other. Or they may just despise everyone, which is understandable.

It is a cruel irony that the very people who are the subject of the debate – ie. those with lived experience – are the ones most negatively affected by the debate.

And yet people with lived experience are largely excluded from the debate. Those professionals who agree with them may co-opt them onto their team. Those who disagree will dismiss their experiences as “anecdotal evidence”.

People with lived experience may be invited by one side or the other to do a (short) powerpoint presentation or write a blog. But the purpose isn’t to include them in the debate or to learn from their experiences. It’s to weaponise their experiences against the other side.

Crucially, people with lived experience don’t get to lead the debate. They don’t get to frame it and set the direction it should take. They only get to participate in it, on someone else’s terms.

Entrenched positions only enhance the lives of those within the trenches. Lucrative contracts, key-note presentations to fee-paying audiences, journal articles and sponsored blogs. The battle is their purpose, their livelihood. Without it, what are they? But are they pushing people under a bus to keep it?

 

Just Pack It In

No understanding of mental health and ill health can hold water unless it considers all the factors that contribute to mental health and ill health. This includes biological, neurological, chemical, psychological, social and environmental (and other) factors. Lots of paths.

The good news is that there are tonnes of people out there who know a great deal about each of these things. Collectively, they could create a model that incorporates many paths.

The bad news is that many of them are too busy throwing rocks at each other to realise that coming together might be kind of a good idea.

Lobbing rocks at each other just exacerbates the problem.

But understanding these factors alone is insufficient. We must also consider the long-term impact of childhood and adult trauma. We need to pay attention to stigma, discrimination, social isolation, debt and poverty.

And even then, we’re still nowhere close to a unified model. There’s still the elephant in the room. The maltreatment, abuse of power and poor quality of service that all sides of the mental health system inflict upon it’s patients every day.

Lobbing rocks at each other does nothing to address this. If anything, it exacerbates the problem.

People are being gaslighted by professionals in promotion of their own cause. This is happening on social media and in clinical practice. People are being told, “you only accept a diagnosis so that you can adopt a sick role”. “There’s no such thing as mental illness”. “Your diagnosis has no validity”. “You’re not suicidal, if you were, you’d have killed yourself”.

And these are professionals and allies advocating a “more compassionate” approach to mental health. No. Pack it in.

Professional groups are at war over who has the most power and influence. But in truth, they’re only focused on retaining the greatest power and influence for themselves. This in itself disempowers the very people they all say they are trying to empower.

The entrenchment needs to end. It sustains the structural power imbalance that is inherent right across mental health services.

 

Parallel Paths

In an alternate nightmare universe, my dad may have been fighting the Japanese in his own living room, throwing ornaments at my mam. In this universe, he might have been admitted under section to the local mental health ward.

Instead of fluids and antibiotics, he may have received intra-muscular anti-psychotic injections. Knowing my dad, there’d be an almighty and violent fight with the nursing staff. Going down quietly was never his style.

A psychologist might argue that he’s traumatised. A psychiatrist that he is delusional. A social worker might suggest that he’s struggling with being newly retired. The nurses may want to put him on an intensive care ward, for safety. And they’d all be wrong.

Thing is, entrenched views of professionals would do nothing to help him. Would a psychological or psychiatric approach to my dad’s situation been more helpful than antibiotics and fluids?

It would only be through collaboration and shared learning that someone would note that he was dehydrated, had kidney failure and a fever. Maybe this sounds far-fetched. Maybe you’re thinking “nah, that’d never happen.”

This zombie of a debate has held progress in mental health care back for decades.

People are still admitted to psychiatric wards with delirium and confusion caused by urinary tract infections.

People are being diagnosed with personality disorder when they are actually on the autistic spectrum.

People are being denied a diagnosis by someone who thought it would be too stigmatising. This delayed them getting the right support and treatment.

People are getting the wrong treatment because of diagnostic overshadowing.

I could go on. But these things don’t happen because one side got it wrong. They happen because this zombie of a debate has held progress in mental health care back for decades. I’m still hearing the exact same arguments today as I was when I was a student nurse in the 1990’s.

We are all complicit. It’s not enough to say #notallprofessionals. It’s not ok to claim that “I don’t do that”. If we are not ending the debate, we are continuing in the debate.

It’s fine to critique. But we need to cross-fertilise. To enrich each others perspectives, instead of knocking them down.

This is the inevitable side-effect of a system where the people in it all believe that they are right and everyone else is wrong. Patients are struggling to be heard above the noise and power dynamics.

Is it too big an ask that professionals and their allies stop shouting and start listening? Not just to each other, but to the people in our “care”? I don’t mean consultation exercises, “user-voice” sub-groups or one-off events with flip charts and post it notes. They’re all crap and we need to pack that in too.

I mean being actually led by people with lived experience. Seats at the table. Employing them throughout organisations, paying them actual wages.

Designing research studies with their concerns at the heart of the question.

Conducting experience-based design of services. Exploring what would be an ideal service response for someone. And then designing every aspect of that service to consistently deliver that response.

Seriously, it’s 2018 and many wards still don’t give new patients a basic welcome pack. Many community teams still won’t accept emails from patients. Jesus. Come on.

Redesigning services from the bottom up to make compassion an inevitability, not a chance encounter.

Having patients design and deliver training to staff, managers and students. And not one off things. Core training.

Taking complaints seriously and not making out that professionals are the victims. What’s that all about anyway? Pack that in as well.

These issues, and many others, are all important things that we need to address. But we’re not. And part of the reason we are not is that so much energy is being expended on giving the other side a kicking.

But imagine how much more time and energy we’d have if we quit sniping at each other. We could then actively listen to, and be guided by, the experiences of all those who make use of mental health services. Not just the ones whose experiences corollate with our favourite narrative.

We need to stop forcing people with lived experience onto our chosen path. We need to get on theirs.

 

Declaration of Conflict of Interest

No one paid me to say this.

I don’t have an imminent book to publish or a powerpoint presentation for which to sell tickets.

At the time of writing, I don’t do adverts on this site and make no money based on the number of visitors I get.

I qualified as a Registered Mental Health Nurse in 1995 and escaped in 2004 to go into public health. I remained there until redundancy in 2015. Since then, I’ve been a freelance trainer.

You can, if you like, book me to do some training to People about Things. I’m told I’m quite good at it. If you’re interested, check out the Training button at the top. Or not. Your call.

I think that covers everything.

Oh, yeah, I’m not a scientologist.

5 thoughts on “Trench Warfare in Mental Heath

  • 26th September 2018 at 11:54 pm
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    I don’t quite see it like that- its not a two way argument is it- its not as simple as one person believes this and one believes that- and were having an argument about it- its not an argument its a begging or a plea, to one person, who holds all the cards, and all the power,- i don’t call that a conversation,- or an argument- i call that a dictatorial reality- where one sides got all the power abusing the other side- and the other sides begging them- not conversing with them- to cease- or change their way- so they and others like them don’t have to even have a conversation- that they cant really have, when its dictatorial like it is- anyway- its a one way street – a conversation can only happen when the playing field is even- and when you take the compulsory out of the equation- cause without taking that out of it- its a bully- and a victim- and since when could bullies converse with the people their beating up- they don’t converse t they dictate and tell you- assault you like bullies do- “you don’t tell them”- and that’s exactly what their gonna tell you when they’ve got you locked up in a bin- we tell you. you don’t tell us. Feels more like pleading,bleeding, or a hemorrhaging, than a conversation. Take away that power to force drug people- and the conversation we think we might be having- is over- the argument we think were having- “is over”– no more war. when its up to an individual- and not to one person or entity- law- and when people can choose the care they prefer- or not choose a care- we can have a conversation- cause until then its not a conversation- sorry mate- i get what your saying and where your coming from- i just cant call it a conversation or an argument- when its all one sided.

    • 27th September 2018 at 8:46 am
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      Hi John, thank you for taking the time to comment. You’re right to highlight the huge power imbalance in mental health – especially between those delivering the services and those on the receiving end. The debate we need to have is one where people experiencing mental health problems are directing professionals in what they find most useful, and not being told from on high what their problem is or what they must do.

      Of course, professional infighting isn’t the only problem – there are many others. But I think that when groups of mental health professionals are vying with each other for their own status and power, they are not focused on creating the level playing field that you rightly say is where we need to get to.

  • 27th September 2018 at 8:03 am
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    This is absolutely brilliant Thankyou! I agree with all of it and it reflects what many of us think when watching these psychiatry versus psychology debates. Anyway, everyone knows that both are wrong and the social model of mental health is the one true system that everyone must follow!! Honestly!?

  • 27th September 2018 at 8:55 am
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    Hi Mark, many thanks for commenting. You’re right, all the polar opposite debates distract us from recognising that there are many different perspectives on mental health, all with something useful to contribute. And of course, everyone lives in a society beset with discrimination, inequality and injustice – especially people experiencing mental health problems. So the social model is a must for everyone! 🙂

    Cheers!

    Tony

  • 9th January 2019 at 3:59 pm
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    Dear Tony,
    I respect your view, seeing this as a complex role playing of positions rather than an actual debate. I like this piece. However, I don’t agree with all of it – just most of it!
    Firstly, I can’t see this as a role play with two players (psychiatry and psychology). It is a role play with at least three players, probably more. Many people lump ‘psychosocial’ together, but in many ways, socio perspectives about mental health are more separate from ‘psycho’ than ‘psycho’ often is from ‘bio’. I expect that, from a working involvement in public health, you get exactly what I mean. And I think it is also worth exploring the idea that psychology is not actually one kind of discipline, but several competing ones. Importantly, there are psychological perspectives that see experience as driven from the inside of a person outwards, and others that see it the other way around. Put representatives of these in the same room and soon it becomes apparent they don’t agree on much at all. We should also not forget the reciprocal nature of the law and psychiatry in this. Neither can stand on their own to defend their position, each can only be explained by the other.
    So I think the way you describe the ‘trench warfare’ aspect is exactly right – this is seldom conducted as a debate but more as an angry role play between ideological positions. In fact, neither bio, psycho or social perspectives can be evidenced because they are not features of nature but of the divisions within the patterns of thought that we use (and as you say, it goes back way longer than 100 years – these are inherited from all kinds of places). What you recognise is that a single ideology cannot work and I agree. I would not have said that the different sides are making valid points. I think they are making points that mostly gain validity through their own ideological position and sound credible because of their professional power. In my opinion, tired though I get of repeating myself, it is also worth saying that contemporary biological science does not support many of the cornerstone claims of psychiatry, and that many pieces of seminal psychological research have been shown to be unrepeatable. Modern science has taken a big lurch with new understandings that match up to our long hunch that humans are not divisible into bio psycho and social elements, and so statements like ‘mental illness is probably genetic’ is pure nonsense now. And the world is falling over itself to deny that it ever said that there was ever any such thing as a chemical imbalance… except if you see your doctor, who is probably still a believer, and that is worth mentioning too, I feel.

    All of this is why I cannot agree with you about the Power Threat Meaning Framework, because it begins from the same position. Most of what you write under the heading of ‘just pack it in’ is very carefully put forward in that document. I know, because I was a critical reader for it and I would not have been happy to see my name on it if I was not very satisfied about that (and other things too). It is explicit about this. It is certainly not a blow struck by psychologists at psychiatrists and any psychologist that tries to wield it like that is making a fool of themselves. It should be almost as unpopular with psychologists as it is with psychiatrists. Neither is it reducible to being largely just about ‘formulation’ instead of diagnosis, but that probably requires a separate discussion. Every profession within MH has its very identity to lose from the Power Threat Meaning Framework, which is probably why seething anger has been expressed about it from every side, including from psychologists. At the launch day there was a lot going on… but one of the things we were supposed to workshop was what it would mean for our profession. I would say that simple answer we came to almost straight away is that it didn’t mean anything for our profession. It doesn’t recognise the professions, and nor should it.

    It is true that professionals frequently (and revoltingly) discount the lived experiences of people. It is also true that, caught in the same ideological traps, people with lived experiences (and their carers) revoltingly discount each other. And many professionals have experiences of mental health problems, too. And some people with mental heath problems decide to become professionals. I generally don’t bother to go to professional conferences anymore. They are often so unscholarly as to be a joke, and since I don’t particularly enjoy meeting doctors or nurses or psychologists socially I really can’t think why I should go. I’m sure you and I could swap some good stories about this. And you are right, they often use people with lived-experience as a currency for their own self-aggrandisement – its Orwellian, some of it. I’ve seen service-users trotted out as performing monkeys as recently as last year – I stand by that statement, it was sick. But I’ve seen back-stabbing and ‘my story is better than yours’ and power-plays and gross invalidation at survivor-led conferences too. So I completely agree with you that personal power and structural power is the only way to really understand the lack of progress and raging arguments that are going on. And that is why I find the Power Threat Meaning Framework such a useful explanatory framework – one which the authors hope will be discussed and changed and worked upon, not seen as a gauntlet and a definitive statement. The fact that it has had an awful first year since publication, with authors being trolled, foolish blogs and angry rants everywhere, professional snubs and painful betrayals – and no-one wanting to endorse it, makes me more positively disposed to it than ever. If any of the miserable grasping f****rs actually liked it, then I’d be worried.

    The one exception is that I reserve a little more patience for service-users who are dismayed that with the PTMF they would find it very hard to call upon the State for financial help. That is a temporary problem and it may be not quite as simple as that, but that doesn’t make it less real. It also does not invalidate the PTMF, however. It doesn’t give them the right to make personal attacks either, but I do know what it is to feel desperate and being paranoid about the way that the powerful can use almost anything to justify aggressive othering of the vulnerable is just common-sense these days.

    Finally, I don’t think ‘on the autistic spectrum’ is an explanation that resolves controversy – it just ushers in another version of the same problems!

    From a fellow student nurse of the 1990’s… the very best to you, Happy New Year.

    Thank you once again for this very stimulating piece. So… just to summarise the waffle… my reason for responding is that, although I didn’t write a single word of the Power Threat Meaning Framework, I think it is the framework you are looking for to further articulate this gross trench warfare and lack of understanding about power… and I felt you were discounting that in your piece.

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