The Needed Mental Health Paradigm Shift

Introduction

I’ve been annoyed at the state of western mental health care, especially the more I learn about Indigenous culture approaches to treating mental health, as well as my own experiences inside the western model. I believe the current dominant medical model has a purpose and might be useful – but it seems to also be doing a lot of harm without pushing for other alternatives – alternatives that may be more beneficial with less side effects.

I also wanted to tell you about the history of the civil rights movements, we owe a great debt in society to those who have had the passionate empathy and conviction to stand up to oppression against overwhelming odds. This history is important, especially for cis able bodied hetereosexual white men. I think that I will do this in another blog as I want to make this as concise as possible. This series of movements has lead us to where we are with the state of mental healthcare and the challenging of mental healthcare paradigms.

Earlier this year I found an issue of the Health and Human Rights Journal that just blew me away. It’s a heavy critique of current mental health practices and how they can not be scaled up to the level we need, and that we need proper alternatives to treating mental health support.

I’ll just post one quote from the overview to start – but i’ll come back to this journal issue a lot:

 We urgently need these conversations to address the inter-relatedness of human rights and to consider the real causes of mental distress. The pandemic sadly provides ample evidence of human rights failings that lead to unequal and unfair health outcomes. Discrimination, disempowerment, and social exclusion are producing excessive COVID-19 death rates in racial and ethnic minority populations across the world; the same patterns will be seen in the mental distress caused by the pandemic. Likewise, it is essential to develop an evidence base of the disastrous harms created by COVID-19 public health policies—political choices that have caused unimaginable suffering among society’s most marginal, including (but not limited to) the elderly, those who are homeless, people detained in prisons, and people living in psychiatric facilities and institutions and care homes. Technical solutions being proposed to these structural problems and policy harms—such as vaccines, telemedicine, and apps for well-being—are woefully inadequate.

EDITORIAL Reimagining the Mental Health Paradigm for Our Collective Well-Being

I’d like to thank @iwritecoolstuff for linking me some amazing resources on the next few subjects.

Critical Psychiatry

Originally coined anti-psychiatry during the mid-20th century. This was then refined to critical psychiatry. Critical psychiatry’s goal is to improve mental health and also to cast a light on some of the more dubious areas of this medical field. This is all taken from this outstanding freely available paper.
The critiques can be summarised as this:

  • Medical and Biological Model – Critics argue here that the idea that:
    • Mental health is a biological or physically detectable illness even though there have been no conclusive indications of evidence that any major categories of mental disorder – including schizophrenia, depression, anxiety, ADHD to be a neurological condition in this way. Most likely the differences that are found are likely attributable – to differences between controls and subjects, life experiences, social class, IQ, and the use of medications to treat illnesses. There is debate here about this – but it’s been going on for over 50 years. With both sides having valid points.
    • The connection between psychiatry and the medical field gives it more authority and allows them to exploit expert medical knowledge – it has become a professional enterprise. With a focus on the immutable truth using measurement and manipulation of the science to prove rigid hypotheses. A lot of psychiatric information has been socially constructed – through marketing. Different cultures have slowly fallen in line with the dominant pharmaceutical model with little improvements in mental health as a result.
    • Psychiatry is now an institution and developed out of managing troubling behavior or what they deemed to be ‘deviance’ at that time. It is predicated on maintaining a neurotypical ideal – making anyone outside the limits of what is considered normal take medication, and all of this happened alongside the growth of capitalism – an entire industry exists that seeks to contain or medicate those who are not able-bodied workers – while still providing a means for the system to make money
    • Seeking treatment assumes that you are ‘sick’ or ‘ill’ by default. You agree to treatment based on their rigid idea of what works. Power relations between psychiatrists and patients entrench long term passivity, impair investment into solutions, and can lead to dissatisfaction if the provided solution doesn’t work.
    • Psychiatry has made a lot of awful assumptions and been used as a means of social control. The alignment of mental health patients as ‘deviant’ allows for the dehumanisation and restraint of individuals, or even their involuntary incarceration. Medicalisation of the human experience has often had political implementations. Performance driven culture has made some question whether it’s the systems or the individuals who are actually at fault here.
  • Response to Mental Disorder – this section of critiques can be summarised as follows:
    • Drug treatment – the pharmaceutical industry has often over exaggerated the benefits of psychiatric medicines while downplaying their side effects. Critiques do not eschew drug treatment, but instead highlight issues with the current model.
    • Drugs as a ‘cure’ – at the moment drugs are focused on a ‘disease-centred’ model where the aim of medication is to restore the individual to a ‘healthy’ state. Rather than focusing on this approach, they argue that the focus should be a ‘drug-centred’ approach – where drugs are used to alleviate symptoms and through this altercation they bring about more ‘normal’ mental processes, emotion and behaviour. They say rather than focusing on the disease centred approach if we take an approach that because drugs are psychoactive – they themselves are the driver of change in mental processes, emotion and behaviour – this also allows more acknowledgement of their own side effects.
    • Placebo Effects – one of the biggest areas that medical model seems to be failing is in treating depression. In recent years when scientific analysis has been conducted on the effects of medications in treating depression, they often do not have a benefit higher than those who were given control medicine – meaning that it could be a placebo effect (where just taking something makes you believe that you are getting better so therefore you act as though you are better). Sometimes people can end up with further complications and long term dependency based on this effect.
    • Collaborative prescribing – the advice offered by critical psychiatry here is that when the patient and psychiatrist work under a drug-centred approach, the patient has more agency and it’s easier to explore reasons why they think medication should be used for them – you can more easily match patient desires to specific treatments tailored to their actual needs rather than trying to push them into defined existing categories. In this way – the role of a psychiatrist becomes more of a a repository of knowledge and evidence and helps explore the likely impact and limitations of drug treatment.

They also cover psychotherapy, but I believe this is better covered by the next topic.

Critical Psychology

Critical psychology’s aim is to look into the limitations of mainstream non-pharmaceutical approaches to mental health treatment. The goal of critical psychology is to put the focus back on psychologists who usually see the world in psychologist/non-psychologist terms. Most of this comes from this paper, but I have gathered more examples – there are also some responses to critiques of critical psychology in the paper.

Some common questions/issues that have been raised are:

  • how does evolutionary psychology confirm differences between men and women – are they actually biologically unchangeable?
  • psychoanalytic psychology pathologizes gay and lesbian people during “normal” development stages
  • faulty concepts of intelligence testing seem to reinforce essential differences between ethnic groups
  • organizational psychology seems to make companies more efficient by crushing dissent
  • that schools of thought on psychological approaches seem to be trying to compete with one another rather than compliment one another – e.g. Cognitive Behavioural Therapy, Acceptance and Commitment Therapy, Dialectical Behaviour Therapy. Psychologists will often specialise into these methods rather than using a vast tool kit.
  • that a lot of psychology practice seems to be burdened by political motivations either external or internal within organisations that undermine actual treatment responses.
  • societal factors such as racism, LGBTQIA+ identification are ignored
  • an over emphasis on individual personality rather than social factors
  • that academic psychology is often grounded in bad assumptions, and faulty methodology and yet is taken as a strictly scientific practice
  • that the emphasis of negative consequences of mental health perpetuates stigmatisation in media and causes some harm through pathologizing this way
  • that psychology comes from mainly western academic sources of information and that psychology often excludes interest groups including those with the neurodivergent differences they are investigating
  • academic psychology has not sufficiently considered Indigenous, or non-western approaches, this has caused replication problems in a lot of social psychology
  • that people with lived experience are excluded from helping others manage their conditions, once they are able to, due to stigmatisation

Why is this important ?

The current model is failing a lot, it’s causing misdiagnosis issues, and loading people up with medications that might have a net negative effect on their mental or physical health. Some of the science for these (especially in Autism treatment) is not at a level where conclusive results can be shown, and yet they are prescribing based on this science.

Mental health issues instantly treat you as though you have a deficit when in fact these are generally just neurodivergent differences. Negative symptoms should be managed but the focus on only the deficit model leads to much more stigmatisation and might have a pygmalion effect for those being diagnosed – meaning that the negative attributions associated with diagnosis become a self fulfilling prophecy.

Gatekeeping scientifically proven alternative treatments due to the dominant lobbying, special interest groups, and societal belief in the medical model is occuring at all levels – but especially at government levels where they can make changes to support. This means that treatment options are being reduced and people who can help are being excluded from mainstream acceptance.

To return to the paper I talked about earlier:

One of the aims of this special section is to identify alternative mental health approaches to the reductionist biomedical paradigm that has contributed to the exclusion, neglect, coercion, and abuse of people with intellectual, cognitive, and psychosocial disabilities, and those who deviate from prevailing cultural, social, and political norms. In our call for papers, we wrote that the status quo, preoccupied with excessive biomedical interventions, including psychotropic medications and non-consensual measures, is no longer defensible.

EDITORIAL Reimagining the Mental Health Paradigm for Our Collective Well-Being

What might a new paradigm look like?

This is harder to answer for me alone, the reason for that is that a new model needs to be designed with a far more inclusive approach – and diversity of opinion must be a key component of any new paradigm. While there is an alternative that is widely regarded – the social model of disability – out of which the neurodivergent movement has grown, it seems like a common ground between these approaches is needed – both have extreme proponents which sometimes exclude the other model and it is my personal belief that the more integrative approach is key. The medical model can work in some cases (I will personally vouch for stimulants and the science here for treating ADHD focus and inattention issues has been consistently verified and replicated well beyond a placebo effect).

The main suggestion here is that we should no longer look to binary approaches for a new paradigm. Binary thinking (ie this is wrong/this is right) often fails to account for individual variances in mental health treatment – I don’t think there will ever be a solution that is applicable to all people. Instead we will need input from all groups of people to develop and cater specifically to them as individuals, taking special care of intersectional problems – race, sexuality, socioeconomic status etc.

I will link the full Health and Human Rights journal at the end, and you can see how we may develop more effective treatment models incorporating the vast resources of ethnic cultures and creating a new system focused on centreing human rights as the priority.

Why does the model actually need to change?

This is best addressed in this pull quote from the summary article from the Health and Human Rights journal:

Given the anticipated need for mental health support, there is no possible way that dominant models can cope with, let alone address, the demand. The pandemic is providing a profound illustration of interconnected determinants of mental health: the impact of loss of freedoms, for example, on people having to stay at home when that home may be violent; the impact of loss of employment on people who are already poor, living on minimum wages without health insurance and perhaps in crowded homes; the impact of risk exposure to COVID-19 on health workers and other “essential workers” who are from minority groups and suffer discrimination in the workplace and are given no option but to work; the loss of access to nutrition for the school children whose most nutritious meal was provided by their school.

EDITORIAL REIMAGINING THE MENTAL HEALTH PARADIGM FOR OUR COLLECTIVE WELL-BEING

The bolded quote is the part that keeps me awake at night – there are already massive deficits in the current systems with estimates that nearly every health system in the western world is failing to correctly treat and diagnose mental health issues with a gap of over 50% in most places.

I know from my own research conducted into just ADHD as a single condition that these deficits are occurring here.

What are the biggest challenges here?

These challenges are actually best identified in another article within the same journal – this one is on a human rights based approach to mental health crisis management.

The greatest limitations to establishing supports that uphold human rights for individuals in mental health crisis lie with the vested interests that hold most power within existing mental health systems. The two most prominent are the pharmaceutical industry and the mainstream medical establishment, which is still largely centered around hospital-based services. Half a century ago, antipsychotic medications were heralded by policy makers as miracle cures that would enable those deemed in need of being separated from society to leave psychiatric institutions. The ensuing deinstitutionalization failed largely from lack of adequate community-based alternatives. In the meantime, the efficacy of psychotropic medications has been shown to be equivocal, adverse, even lethal, outcomes (such as dependency, metabolic disease, and suicidality) are not uncommon. Despite this, the pharmaceutical industry and its lobbyists have shaped public policy for decades. Psychiatrists and other mental health professionals are key players in this status quo, and their incentives are skewed toward a focus on short-term evidence of medication effectiveness and away from long-term well-being, recovery, and human rights.

Crisis Response as a Human Rights Flashpoint: Critical Elements of Community Support for Individuals Experiencing Significant Emotional Distress

Why did I want to write about this?

A number of reasons. Firstly, I was misdiagnosed for 37 years in the current model. I now have diagnoses that actually make sense to me, and explain behaviour. When I got diagnosed finally with Autism and ADHD, I was able to better educate myself on these conditions. Reading books by authors with Autism

The problem here though, is that initially I relied on available scientific information, and with ADHD – I spent 6 years trying to cure it as the model of deficit makes you believe you are morally defective for having anything wrong with you. When I started actually connecting with #ADHDTwitter and #TeamADHD – I began to understand myself far better, and actually find strategies that worked for me based on others experience.

Connecting with Neurodivergent people on Twitter actually meant I figured out that I had Autism as well as ADHD, and my diagnosis confirmed this. I’ve been able to quickly develop coping strategies for the more negative side effects – and my anxiety while present at times – is manageable because I understand where the feelings come from.

I also would never have realised I might have Autism due to the common misconceptions that occur about Autism due to it’s representation in media (newspapers, film, and TV). All of these are stereotyped and not accurate of the diverse experiences of Autism, and the male bias in these conditions is being proven to have been bad science as we are realising more about “feminine” presentations of Autism.

I was in Dialectical Behavioural Therapy for my critical mental health support after experiencing Autistic Burnout, but I was bad at therapy. I would often come out of sessions with more anxiety than I went in with. Having Aphantasia (no visual mind’s eye) makes things like meditation and visualisation impossible for me. Yet that is what a lot of this psychology focuses on.

Peer support was the main thing to get me through this, these people I talked to had no qualifications, they were simply self-advocates who spoke up, and talking to them privately via direct message allowed me to share my traumatic concerns in a safe space where I knew I wouldn’t be judged for questionable actions in my past as a result of not having being treated correctly. They also just listened to me and said stuff sucked and they could relate while offering their own also traumatic experiences – this reduced my terrible isolation that I had for thinking I was the only one who had done these things, or had these things happen to them.

Will this solution work for everyone? No – it would be arrogance to assume that one size fits all. But meaningful peer support with absolutely random people did more for me than any of the medical model or deficit model has done. I now work to build a substantial toolkit of resources to help other people. I share any information I can find on ADHD or Autism, as I know these areas personally – I definitely do not feel comfortable speaking to concerns outside of these diagnoses.

It makes me question why people without these conditions think they are the authority on them – when they don’t fundamentally know what it’s like to live with neurodivergent brains. Half my recent life has been deprogramming societal views on ADHD and Autism that have been hypothesised and proven by bad science with no actual stakeholder input. This has finally given me a coherent sense of self. My whole life I’ve known I was a certain person, but the expectations of society tried to change me into something I am not.

Further Reading

I would highly recommend doctors, mental health workers, politicians, researchers, and anyone else who has an interest in mental health treatment and solutions to read the following journal from start to finish. It contains a lot of excellent critique on the current issues within mental health care – and we need a diverse approach going forward if we have any hope of dealing with a crisis that will be as large as climate change, as well as being impacted by that.

If you have limited time, I would highly recommend to look at the section on peer support in crisis management. The paper basically confirmed what I believe helped me the most last year. It can be found here:

Published by roryreckons

I am an ADHD/Autism Coach as well as ADHD/Autism/OCD/CPTSD advocate and independent ADHD/Autism researcher. I am an ADHD/Autism Coach who trained through the ADD Coaching Academy. I write mainly about ADHD/Autism/OCD/Mental health issues, but will also discuss morality, abolition, and current affairs occasionally.

3 thoughts on “The Needed Mental Health Paradigm Shift

  1. Thanks for the research and digging up the resources, I will certainly have a look at them. It’s weird to see how much this still echoes critiques that literally existed in the 70s (last thing I randomly found and read), but let me check if anything is new 😀

    I personally relate totally to what you say about peer support from random strangers — whether on the internet, or say on airplanes or in weird attics. There are many more random strangers who saved my life at various points than there has been useful input from any sort of “system” (frankly I’m glad I didn’t insist on getting it from there, though I wasted some money on therapists who did not understand neurodivergence, much less economic, migration or queer realities).

    These latter realities are often far more relevant to mental health than personality-based psychological theory (or sometimes biomedical factors) in my opinion and experience, and I’m glad to see that serious discussion around this exists … somewhere — too niche, it should be front and center.

    Liked by 1 person

  2. I’m curious about these Indigenous culture methods that you mention. Do you have any links to them, or to other methods of mental health care that aren’t the white Western psychiatric model?

    Like

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