Mad in Ireland editorial: A radical shift in mental health practice is required

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It’s not new or controversial to say that psychiatry can no longer claim ownership over scientific knowledge regarding the nature of mental health and its treatment.

But finally, after years of not hearing – or perhaps not listening to this message, it finally appears to be sinking in.

Psychiatry in Ireland is feeling insecure and that’s a good thing because it means the winds of change are blowing. However, it also poses a risk as those seeking to maintain the outdated status quo are gearing up to do just that.

In October last year, a comprehensive pre-legislative scrutiny report by the Oireachtas Sub-Committee on Mental Health, called out the College of Psychiatrists of Ireland (CPI) for being at odds with other witnesses who came before the committee. The report observed that while there has been a culture shift, stigmatisation of mental health difficulties still exists, and mental health services often take a siloed approach which does not have a person-centred focus. It also noted the growing evidence-base and research available on moving away from an overly medicalised model of treatment.

In response to these well observed and reasonable assertions, then President of the CPI, Dr William Flannery told the CPI’s Winter Conference that the voice of psychiatry had been heard but “ignored and dismissed” by politicians and senior health management.

“The most recent and profoundly shocking example is the Oireachtas subcommittee on mental health report on the new Mental Health Act. The report gives an accurate example of what we said; of some of what we provided and presented to the committee. However, it clearly shows what this committee thought of us and then how they dismissed us,” he said.

It’s somewhat ironic to hear this from the CPI, who have long been ignoring the voices of service users who speak out about the harms suffered at the hands of mainstream psychiatry. How, then, does it feel when you are not listened to, not heard, “ignored and dismissed”?

Dr Flannery also stated that the College had undertaken to develop a position paper on governance for child psychiatry services, which, he said, would “need to be accompanied by a PR plan to get it implemented.”

Indeed, Dr Flannery said the CPI has engaged the services of a PR company, Gordon MRM, a leading PR and Media Relations Consultancy firm in Ireland. One can only imagine that the PR consultants will have advised that capturing the youth space was a sound strategic way to prolong the status quo for psychiatry, in a world that is increasingly moving towards a new paradigm in mental health. One where the biological framing of mental health is seen as a thing of the past and medications and diagnoses are less important than person-centred care with therapeutic interventions that get to the root cause of people’s distress.

That’s not to say that we don’t need a focus on youth mental health. As this week’s shocking – though not surprising, Mental Health Commission report into CAMHS has shown, reform in how we treat young people in crisis is urgently required.  It’s the type of focus and supports that we must be vigilant about.

As reported recently, young people are increasingly showing up at EDs in crisis.

The linked story quoted CPI’s Dr Mary Cannon who talked about not having enough beds in hospitals or medical teams to deal with the crisis. There was no mention about the root causes of young people’s distress and how best to support them.

This is in contrast to an article that appeared in the UK media, talking about an increase in referrals to youth mental health services. In this article, young people’s distress was put into context stating that it was linked to increasing social inequality, austerity and that online harm playing a role.

A similar phenomenon as reported in Australia also spoke about the pandemic exacerbated existing issues, such as loneliness and isolation, worry about the future, body image concerns often driven by social media, and difficulty seeking mental health help.

This chimes with a study from the UK highlighting the issues facing young people in crisis in an ED setting. 

The research found “significant association between suicidal crises and several Adverse Childhood Experiences” – specifically being exposed to ACEs relating to abuse, neglect, or violence or to variables relating to their parents, such as parents’ mental illness, criminality, and substance use.

The findings also emphasised the importance of early intervention, through implementation of effective programmes to reduce the number of ACEs to which children are exposed, and provision of support for those who may be exposed to multiple or parental ACEs.

The study once again demonstrates that children have not all of sudden developed brain disorders – this is what mainstream psychiatry believes mental illness essentially is, a biological brain disorder that requires medications, hospitals and medical teams to ‘fix it’.

If anything, we need more psychological services like Jigsaw and community based youth services to be the leaders in terms of children’s mental health. A study from Jigsaw found the factors strongly associated with presentations of psychological distress in young people included self-criticism, negative thoughts, physical health and eating and risky behaviour.

The paper talks about bullying, isolation, and difficult peer relationships and the need for youth mental health services to consider trauma-informed approaches when working with young people. In other words, we need to put young people’s mental health into context and considers mental health difficulties outside the “limitations of a purely predominantly biomedical understanding of mental health difficulties.”

With all of this in mind, is it wise to let the CPI capture the youth mental health space as it is planning? When very clearly the research shows that we need to find ways to help young people navigate life and their distressing emotions, not to pathologise and medicate them, storing up their problems for another day.

Internationally, there is a tipping point occurring in respect of how we view mental health. It’s happening in academic circles and the media, and it’s backed by the World Health Organisation and the UN both of whom have in the strongest terms called for governments to move away from a biomedical understanding of mental health, and services that medicate people over understanding and treating the root causes of distress. Perhaps the CPI could critically reflect on why they are not been heard or listened to? Is it something to do with being stuck in the old ‘flat world’ paradigm and a reluctance to embrace the broader – so much more effective – paradigm of hope, self determination, equity and recovery, as possible. 

There is a recognition now that antidepressants and other drugs can be harmful and should not be used long term or as first line treatments. 

The concept of tapering off psychiatric drugs has been studied and talked about in academic circles for years. In the UK, the media has highlighted the problem and the National Institute for Health and Care Excellence, NICE has addressed the issue.

The issue is not one the CPI has ever addressed, therefore people in a mental health services in Ireland – all teams are lead by consultant psychiatrist, will very likely not get any information about how to taper, or indeed the known harms and side effects associated with psychiatric drugs.  Indeed, the CPI admitted in 2015 to still teaching the long debunked chemical imbalance theory of depression to its students. Journalists who do ask questions about these issues are likely told – perhaps by PR consultants – that if they publish anything negative about psychiatric drugs, people could stop taking their medications, hence steering them away from any coverage. This kind of what can only be called paternalism at best, media manipulation at worst, that happened very publicly, very recently in Poland.

This constant denial of new research and reality is not unique to psychiatry in Ireland but is a global phenomenon. It is worrying, however, that instead of seeking to reform, the CPI is reverting to tactics used by harmful industries such as alcohol and tobacco to try and maintain their status in a changing world. Resorting to PR tactics is exactly what the tobacco industry did in the 1950s when news began to emerge that smoking was bad for your health. Its PR offensive created doubt for decades about clear scientific evidence about the harms of smoking.

Globally, psychiatry and the pharmaceutical industry are closely linked and have also been using PR tactics for decades to market their drugs, often changing the names and apparent mechanism of drugs and how they work to suit whatever mental health diagnosis is in vogue.

As Robert Whitaker, Mad in America’s founder, has noted:

“the psychiatric community long ago knew that the low-serotonin story of depression hadn’t panned out, yet the American Psychiatric Association, pharmaceutical companies, and scientific advisory councils told the public otherwise, and this created a societal belief in that false story…In essence, a marketing story was substituted for a scientific one.” 

What does all of this mean? 

It means that – as pointed out by a group of eminent psychiatrists some years ago: “The evidence base is telling us that we need a radical shift in our understanding of what is at the heart (and perhaps soul) of mental health practice.”

Unfortunately we have in the past given psychiatry so much power that we can’t actually run mental health services in Ireland without them being in charge. We know there are many good psychiatrists out there who are moving with the times and who understand their role in a new paradigm but until the CPI begins to reform, sadly our mental health services will not change.

It is also regrettable that the Irish media is very much in thrall to Irish psychiatry. This is not to be overly critical, but perhaps a call to action – there are many other voices in the realm of mental health that can be contacted for comment when a story emerges, and there are many questions to be asked about the current state of our mental health services, as run by psychiatry. 

At the very least, the question must be posed – as pointed out in a recent blog post by Mike Watts – why are mental health professionals so reluctant to change and to collaborate with courageous, highly motivated people who are willing to explore non-medical routes to recovery? And why can the CPI not acknowledge the swathes of undisputed research that shows people’s distress is very much rooted in their lives and experiences, and begin to reform its training and service delivery to take account of this? 

The media must challenge psychiatry when it tries to stifle debate using extreme cases and stereotypes about dangerous people who require hospitalisation. If someone is that dangerous, we have the Gardai to protect us.

Irish psychiatry cannot be allowed to continue to stifle debate with fear mongering and denial. We need robust debate and intense scrutiny on practices that are increasingly deemed outdated – and harmful.  We need to encourage alternative ways of thinking and embrace what the research is screaming at us: psychiatry is no longer working.

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