Mental health is in the headlines again. In recent weeks, we have had the independent commission report on psychiatric care in England, which concluded that patients should not be treated miles away from their families; the Mental Health Taskforce report, which highlighted a rise in suicides; and the prime minister committing to improving mental health services.
But it was the BBC’s In the Mind series that reignited a longstanding debate about the nature and treatment of mental illness. Sometimes this has been caricatured as “psychiatry v psychology”, or equally unhelpfully “drugs v talking”, or “brain v mind”. But these are false distinctions, which don’t help in understanding mental disorders, don’t help mental health professionals, and most of all don’t help patients.
Sometimes these arguments arise from a confusion about what the different mental health professions do. All of us have been professionally trained to help people with psychological distress or mental illness, but we do so in different, albeit overlapping, ways.
Psychiatry is a medical speciality, like general practice, surgery or general medicine. We train for at least five years as a doctor and then do two further years of “foundation” jobs in hospitals before we can start to choose our speciality, in my case psychiatry. Like other areas of medicine, psychiatry builds its knowledge through the observation of unusual and distressing conditions. It uses a diagnostic system, which tries to identify clusters of thoughts, feelings and behaviours that seem to occur together. Some also research the social, psychological and physical causes of mental disorder, with a view to finding effective ways of helping. Psychiatrists usually work with people who have complex disorders, such as schizophrenia, autism or bipolar disorder.
Clinical psychologists have gained a psychology degree followed by three years’ doctorate clinical training. They use several models of psychological therapy to help patients. Psychology focuses on psychological mechanisms. Clinical psychologists work with the some of the same patient groups as psychiatrists, such as those with eating disorders or dementia.
A psychotherapist can come from any professional or graduate background. There are a number of different types of psychotherapy, all based on different theories of the mind. Different therapies suit different people – and different problems. Irrespective of one’s discipline, all mental health professionals share a common goal, which is to improve the lives of those with mental ill-health.
And so we come to modern psychiatry. While psychiatry is a medical speciality, we do not recognise the narrow biomedical approach that is sometimes suggested. This is a straw man. Psychiatrists are pragmatists who use the best approach for an individual patient, without being too constrained by any specific school of thought. As there is incontrovertible evidence that physical, psychological and social factors contribute to the development of mental health problems – in different degrees and mixtures according to the type of illness and the particular individual – it follows that treatments that psychiatrists use can be physically, psychologically or socially based, either singly or more often in combination.
Which brings me to one of these approaches – medication. Medications operate at the physical part of the overall picture. Some people do get better without medication, but there is a strong body of evidence suggesting that, for many people, medication reduces the risk of relapse and harmful behaviour, and enables them to live fuller lives. For example, worldwide data collected over several decades (so-called “meta-analyses”) shows that lithium reduces the number of hospitalisations, suicides and, indeed, deaths from all causes in people with bipolar disorder. Other meta-analyses point to the benefits of antipsychotics and antidepressants. Indeed, detailed analyses show that, as a whole, the medications used in psychiatry are no less effective than those used in other medical disciplines.
However, this isn’t a case of “either/or”. Most psychiatric disorders are multi-factorial. Understanding a soldier who returns from war with post-traumatic stress disorder depends on knowing something of the psychological impact of what he or she has seen or done, but also the social background from which they come, and some knowledge of the neurobiology of memory. Or consider depression. A meta-analysis of global data shows that combined treatment with psychotherapy and antidepressant medication is twice as effective as treatment with antidepressant medication or psychotherapy alone. Or consider psychosis and schizophrenia: the evidence-based Nice guidelines recommend “a full range of pharmacological, psychological, social, occupational and educational interventions” rather than any single type of intervention.
Speaking personally, I have carried out research into the biology of some mental disorders, but I am better known for my work on psychological treatments. My work on the outcomes of soldiers returning from combat is strongly influenced by social models of health and illness. So during my career I have drawn on the biological, psychological and social at different times and in different ways. Or to put it at its simplest, I am a psychiatrist.
The truth is that up and down the land psychiatrists, psychologists, social workers and other mental health professionals work together in multi-disciplinary teams for the benefits of patients. Yes, we have arguments, but tolerating uncertainty and different perspectives is one of the strengths of all the mental health professions, and there is as much debate within each profession as between them – perhaps even more so.
The book that first opened my eyes to the richness and diversity of psychiatry when I was a medical student was written by the late and much-missed Anthony Clare. It was called Psychiatry in Dissent. So some dissent is healthy, but we must never forget that there is no single solution to mental disorder, nor single approach to helping patients. We will always work in teams – because we are, to use a phrase borrowed from a rather more contentious argument, “better together”.