We are delighted today to be able to share the text and slides from the talk given by Phil Thomas at  Now We’re all Crazy- What’s Next? on Mon 8th July as part of Mad Pride Toronto 2013.

Phil Thomas sets out how the focus on technology -the technological or scientific paradigm – has both failed to provide evidence that validates and supports the hypotheses and assumptions upon which it is founded. Not surprisingly, it has also also largely failed those who struggle.

He shows how evidence indicates that the technology used by those who would treat us plays a surprisingly small role in healing:  the non-specific factors, as research calls them, like human relationship between the patient and profesional, and circumstances  play a much bigger role. In which case we need to ask ourselves yput all that time and effort and resources into making sure people comply with the technology when it plays such a small role and causes some so much pain?

In contrast with the typical six-weeks of randomized drug trails showing short term effects, epidemiological science is building  strong evidence from multi-year studies showing how factors like difficult early experiences are an important factor in shaping madness in later years; and how being unlucky enough to have genes that leave born into inequality and poverty increase our chances of experiencing those very same kinds of adversity that shape that madness.

He goes on to outline a handful of broad implications for psychiatry and psychology and “what’s next?”.

To paraphrase VS Ramachamdran paraphrasing Umberto Maturana: given that much complexity, and that many layers of complexity, surely anyone -let alone smart scientists- can see that we’re about as likely to find the singe intervention cure to mental illness by studying individual genes and synapses in a handful of human brains as we are likely to find the answer to Toronto ‘s gridlock by studying the spark plugs in Rob Ford’s car engine.

Diagnosis and the technological-only paradigm are a busted flush.

Psychiatry – and clinical psychology both -are in crisis and in need of new thinking and new approaches.

Phil Thomas was a guest speaker with Kwame McKenzie and Lana Frado at Now We’re all Crazy – What’s Next ? The event was presented by The Leadership Project and MadPride2013 Organizing Committee.
KH
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DSM-5 and the Crisis in Psychiatry

by Philip Thomas – Honorary Visiting Professor, Social Science and Humanities, University of Bradford

The publication of DSM-5 is a call to action for those concerned with the role of diagnosis in mental health care. It raises searching questions about the technological paradigm in psychiatry and clinical psychology, and concern about the rampant medicalisation of human difference and variation; as Marcia Angell (2011) puts it ‘It looks as though it will be harder and harder to be normal.’

In this talk I want to examine three themes that are evidence of the crisis facing psychiatry; the failure of the scientific or technological paradigm, the evidence linking madness and distress with childhood adversity, and the links between childhood adversity and income inequality.

I’ll end by outlining the implications of this for the future direction of mental health practice.

The Failure of the Technological Paradigm

Biological psychiatry has evolved into neuroscience, cognitive science, molecular genetics and evidence-based practice. This technological paradigm makes the following assumptions (Bracken et al: 2012):

• Madness arises from faulty mechanisms or processes involving specific abnormal       physiological or psychological events occurring in the individual’s brain/mind.
• These mechanisms can be modeled in causal terms independently of contexts.
• Technological interventions are specific and instrumental, and can be designed and studied independently of non-specific factors (relationships, contexts and values).

There are three main sources of evidence that this paradigm has failed; the lack of evidence for the validity of psychiatric diagnoses (assumptions one and two), and the evidence that non-specific factors (the placebo effect and quality of the therapeutic relationship) are more important for outcome than the specific factors (a particular drug or therapy, assumption three). The third is the mounting evidence of the seriously harmful consequences of psychiatric drugs on health and life expectancy.

The Problem of Validity

The DSM claims to be a scientific system of classification. In medicine validity concerns the extent to which a diagnosis is related to an underlying theory about the cause of a disease and whether there is evidence to support this relationship. In psychiatry this evidence is wanting. 

Since 1970 there have been four major articles about validity in the psychiatric literature written by leading psychiatrists; Robins and Guze (1970), Kendler (1980), Andreasen (1995) and Kendell and Jablensky (2003).

These papers rate five stars for aspiration but zero on delivery.

Robins and Guze’s (1970) highly influential paper on the validity of psychiatric diagnoses refers to laboratory studies, including biochemical, physiological, radiological and anatomical findings, as well as psychological tests, and family studies of the inheritance of psychiatric disorders. They assert that since psychiatric diagnoses like schizophrenia run in families, this indicates that they must have a biological basis. Despite this, fifty years of research has revealed no evidence of a genetic or biological basis for the condition. Forty years on from Robins and Guze, what empirical evidence is there that disordered brain function is causally related a psychiatric diagnosis like ‘schizophrenia’?

Kendler (1980) found that research had failed to establish the validity of schizophrenia as set out by Robins and Guze’s criteria.

Andreasen’s (1995) editorial in the American Journal of Psychiatry admitted that the long hoped-for laboratory tests anticipated by Robins and Guze had not materialised; ‘…we still lack definitive diagnostic tests equivalent to the measurement of blood sugar for diabetes or the ECG for myocardial infarction’ (Andreasen, 1995:161). She was writing at the mid-point of the ‘decade of the brain’, and was immersed in a range of neuroscientific studies using the latest brain imaging technologies to map the ‘broken brain’.

Anckarsäter (2010) used the Robins and Guze criteria for validity to assess meta-analyses and review papers for neurobiological markers and treatment effects in major psychiatric disorders. Apart from conditions like Huntington’s Chorea, which has an established basis in molecular genetics, and which is arguably a neurological condition, he found no laboratory marker to support the validity of any psychiatric diagnosis.

The literature abounds with studies claiming to find differences in the brains of those with a diagnosis of schizophrenia and those not so diagnosed, but subsequent studies either fail to confirm initial findings, or are inconclusive. Even the most recent NICE guidelines (2010, p. 22) on the treatment of schizophrenia (the UK clinical practice guidelines) acknowledge the lack of evidence for a biological basis for schizophrenia. Biological research has failed to reveal a point of discontinuity between people with the diagnosis of schizophrenia, and those without. Psychiatric diagnoses like schizophrenia simply do not carve nature at the joint. [SLIDE 5]

Kendell and Jablensky (2003) acknowledge that since Robins and Guze’s (1970) paper, the validation of the diagnosis of schizophrenia remains unresolved, either in terms of its symptom profile, or its genetic (and thus biological) basis. They describe an ‘… air of disenchantment…in the light of the failures of the revolutionary new nosology provided by DSM-III and its successors to lead to major insights into the aetiology of any of the main syndromes.’ (Kendell & Jablensky, 2003:7)

They conclude that psychiatry is two hundred years behind other branches of medicine because its diagnoses are not real diagnoses, simply syndromes or groups of symptoms that tend to occur together.

…most contemporary psychiatric disorders, even those such as schizophrenia that have a pedigree stretching back to the nineteenth century, cannot yet be described as valid disease categories.

(ibid:10)

The role of non-specific factors in therapeutic outcome

If there is no clear scientific basis for psychiatric diagnoses, it should come as no surprise to find a lack of evidence for the effectiveness of drugs and therapy. A recent paper in the British Journal of Psychiatry, co-authored by 29 members of the Royal College of Psychiatrists (Bracken et al, 2012) draws attention to the growing evidence from evidence-based medicine that fails to support the technological paradigm in psychiatry.

It highlights the importance of the human elements of care in helping people to recover from conditions like depression and schizophrenia.

We (Bracken et al, 2012) examined twelve meta-analyses of drug treatments and psychotherapy for depression. For drug treatment, differences in outcome between active drug and placebo groups are minimal (Andrews, 2001; Kirsch & Saperstein, 1998; Kirsch et al, 2008).

Similar findings emerge for psychotherapy. Advocates of CBT argue that it is effective because it specifically rectifies faulty cognitions that are believed to cause depression. Several studies have shown that most of these ‘specific’ elements can be dispensed with without adversely affecting outcome (e.g. Jacobson et al, 1996; Longmore & Worrell, 2007). There is overwhelming evidence that non-specific factors such as the quality of the therapeutic alliance have greater influence on outcome than specific therapeutic elements (Wampold, 2001; Castonguay & Beutler, 2005; Stiles et al, 2008).

The same holds for recovery from schizophrenia. At face value most RCTs suggest that neuroleptics are superior to placebo in the short-term management of the condition.

However, as Joanna Moncrieff (2008) points out, most of these studies last only a few weeks, whereas most episodes of schizophrenia last for years. She identified only three studies since 1967 that followed up acutely psychotic patients for a minimum of one year (May et al, 1981; Rappoport et al, 1978; Schooler et al, 1967). All three found that although active treatment groups improved more rapidly than placebo groups in the early weeks, a year later these differences disappeared.

There is growing evidence that people with the diagnosis of schizophrenia, who avoid long-term treatment with neuroleptics, have better outcomes (Bola & Mosher, 2003; Lehtinen et al, 2000).  The most recent evidence from Martin Harrow’s long-term follow-up studies of people with the diagnosis in Chicago show that a substantial proportion have better clinical and social outcomes if they remain off neureolptic medication (Harrow et al, 2007) These benefits persist at twenty years (Harrow et al, 2012). This is vitally important given the evidence that the long-term use of neuroleptics raises the risk of cardiovascular disease and diabetes (Casey et al. 2011), and reduces life expectancy (on average 16 years or more, Wildgust et al 2010; Chang et al 2011).

Madness and childhood adversity

You may conclude from this that I am anti-science; not at all. I am opposed to scientism, the belief that science is ultimately capable of answering all human problems. Epidemiological science is making an important contribution to understanding madness.

John Read and colleagues (2005) have reviewed the relationship between trauma, psychosis and schizophrenia. They found clear evidence of a link between childhood abuse and schizophrenia in the scientific studies they reviewed, and a particularly strong relationship between childhood abuse and hearing voices across diagnostic boundaries.

They also found a strong relationship between abuse and delusional beliefs. Some studies indicated that the content of delusions and voices in people with a history of childhood sexual abuse was related to the abuse, with references to ‘evil’ or ‘the devil’. They (Read et al, 2009) also identified eleven epidemiological studies that investigated the relationship between psychosis and childhood adversity in the general population. Ten found significant associations between childhood ill-treatment and psychosis. The evidence indicates that the relationship between psychosis, schizophrenia and childhood abuse and neglect is at least as strong as it is for more common psychiatric conditions. Large-scale population studies suggest that the link may be a causal one – that the more severe and persistent the abuse, and the more varied it is, the stronger the relationship with adult psychosis.

Similar relationships exists for the experience of racism, racial attacks and discrimination experienced by member of BME communities (Karlsen et al, 2005; Janssen et al, 2003).

Childhood adversity and income inequality

 Wilkinson and Pickett’s (2009) book The Spirit Level ambitiously argues that differences in social status closely related to income permeate society like an invisible, odourless gas, influencing the physical, emotional  and psychological wellbeing of all family members, especially children.  Income inequality has a profound and corrosive influence on the quality of family, community and social relationships. Societies with high levels of income inequality have lower levels of trust and mutuality (or lower social capital).

If we take death rates as an index of health, life expectancy is closely related to income.  People with higher incomes live longer, and are healthier and happier than the poor, a relationship that holds across more affluent countries.

• This relationship is also reflected in the prevalence of a wide range of health and social problems.
• The greater the extent of income inequality, the wider the gap between the rich and the poor in a society,
• The higher the levels of poor health, poor mental health, and a wide range of social problems such as teenage pregnancy, crime and homicide.
• People report lower levels of trust in societies marked by high levels of inequality

This relationship is also reflected in the prevalence of a wide range of health and social problems. There are higher levels of poor health, poor mental health, and a wide range of social problems such as teenage pregnancy, crime and homicide in less equal countries.

• The same relationship emerges for self-reported experiences of conflict in childhood.
• Children in more equal societies feel safer and that they can trust their peers. They experience lower levels of bullying and harassment.

The same relationship emerges for self-reported experiences of conflict in childhood. Children in fairer societies feel safer and that they can trust their peers. They experience lower levels of bullying and harassment.

This is just one of a range of differences between more equal and less equal societies as measured by the level of income inequality. Overall this suggests that the fairness of a society influences childhood experience.

The World Mental Health Study Consortium compared the prevalence and severity of mental illnesses internationally. There is a strong relationship between the proportion of people who developed mental illness in the preceding twelve months and inequality. For more equal countries like Japan, Germany and Spain, less than 10% of the population had experienced mental ill health in the previous twelve months. In less equal countries the rates were over twice as high, over 20% in the UK and 25% in the USA. These figures include rates of anxiety, and depression, as well as an index of serious mental illness.

How does the child adversity described by Read and colleagues compare with that described by Wilkinson and Pickett? Studies of childhood adversity in psychosis tend to consider a single type of abuse, usually sexual. However, Felitti et al (1998) studied the long-term impact of abuse and family dysfunction in childhood on health and mortality, in 8,500 US residents. 52% of respondents experienced more than one category of adverse childhood exposure, 6.2% reported more than four exposures. Experiences of childhood adversity clustered The impact of these adverse childhood experiences on adult health status was cumulative. Green et al (2010) carried out a community study of 9282 US residents (slide 19). They examined  four broad categories of childhood adversity, childhood loss, parental maladjustment maltreatment (physical abuse, sexual abuse and neglect), and other (life-threatening childhood illness, extreme childhood family socio-economic adversity). They found that individual experiences of childhood adversity clustered. Children who experience adversity commonly experience more than one, and often three of four together. Cumulative childhood experiences of adversity strongly predicts adult mental disorder, but not diagnosis.

Implications for the future

A chasm has opened up between technological psychiatry and the lives of those who suffer madness and distress, and who find themselves using mental health services. The unsubstantiated theories of contemporary psychiatry are remote from lives ravaged by adversity, suffering and injustice.

Many experts by experience and survivors have been saying this for many years, but growing numbers of carers and professionals, including psychiatrists, are in agreement.

Psychiatric theories shun the social, economic, political and cultural contexts in which madness occurs, but it is clear that decontextualised psychiatry is in crisis. It is out of touch and remote from the concerns of most people. It is increasingly difficult to see the relevance of an uber-scientific psychiatry, especially one that claims to be able to unlock the neurobiology of early trauma and adversity and develop new drugs to treat it.

The crisis demands a radical reframing and reorganisation of help and support for people who experience madness and distress.

1. Clinical practice must prioritise caring and respectful engagement with personal narratives of suffering, not diagnosis. Narrative psychiatry (Lewis, 2011, Thomas & Longden, 2013) is one way of achieving this.
2. There must be a greater focus on engagement with communities in mental health work, through for example, community development (refs). Mental health services must be much more closely aligned with primary care and NGOs involved in community work.
3. It is vitally important that those who plan and commission mental health services, and those who deliver them, recognise the explicitly political nature of madness, and facilitate the reorganisation of services and systems of care in ways that challenge the economic impacts of inequality on health and wellbeing.
4. Governments must recognise that there is nothing to be gained by wasting large sums of money on the futile search for the neuroscientific basis of madness. Funding should instead be directed to work that helps us to minimise the harmful effects of psychiatric drugs on people’s lives, for example by understanding why it is so difficult for people to come off them.
5. The education and training of all practitioners in the field, including psychiatrists, must reflect these priorities.
6. There can be no justification for the statutory involvement of psychiatrists and mental health professionals in the civil processes of detention and forced medication under mental health legislation. 

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