While some fight over psychiatry, others are forging better ways ahead

Getting everyone to take part is the first step. R L Johnson

The subject of mental health and illness often raises philosophical and ethical issues and fundamental questions revolve around the definition of mental illness – how are health and illness defined, who makes these decisions and if treatment can be imposed against the will of an individual?

The 1960s saw the emergence of figures in the anti-psychiatry movement, such as RD Laing, who challenged the power of psychiatry and the psychiatric profession. Such critics attacked psychiatry - and still do - as a “pseudo-science” that can’t provide empirical evidence to support the claims made for the consistency of diagnosis and efficacy of medication.

The general response of the psychiatric profession, particularly in the US, has been to retreat into more detailed outlines and categorisations of mental disorders.

Against this background, mental health services are under huge financial pressure. And the concern is that services concentrate far too much on the management of symptoms with medication rather than a wider consideration of the causes and impact of mental distress.

But are there other ways of working that can give us more positive stories?

Open Dialogue is an approach that has been pioneered in Finland. Initial studies have shown that on three key measures of success in acute psychiatric care - rates of hospital admission during a first episode, repeated hospital admissions and the use of medication - this radical approach has had positive effects. The film-maker Daniel Mackler wrote down his powerful impressions at the Keropudas Hospital in Finland where it begun 30 years ago:

The first people I saw when I arrived at the hospital were several — maybe six or eight — very troubled looking, middle-aged or elderly men and women shuffling around outside the hospital entrance and inside the hospital lobby looking quite drugged, and some seeming to be experiencing serious long-term neurological side-effects from anti-psychotic drugs.

… Some of them had been around since the 1970s — back when Western Lapland, I have since been told, was getting some of the worst outcomes for schizophrenia in Europe … when everyone with issues labelled as psychotic was getting heavily medicated. These folks I met were the people who didn’t recover — and hadn’t been able to integrate living in the community. These were the people labelled as “failures” of a failing and quite traditional psychiatric system.

… These people were actually no reflection whatsoever on the success of Open Dialogue, but instead reflected the horror of the previous system.

The success of Open Dialogue has seen it or other similar approaches adopted in a number of other countries including Sweden. It involves psychiatrists, mental health nurses, social workers and the individual who is experiencing acute mental distress and their families, who are all fully involved in any decisions.

It’s most effectively used during first episodes of a psychotic illness such as schizophrenia. As soon as possible, the person in crisis, their family and the professionals meet to discuss the situation. There are no separate meetings where professionals “assess the case” – any discussions and decisions, including those about medication or hospitalisation, are held with everyone there.

At the heart of this is a shift away from a focus on symptoms, such as auditory hallucinations, to supporting the person through the crisis they’re experiencing. It’s an attempt to break down the isolation that people in acute distress feel and recognises that a psychotic episode is a bewildering, frightening experience, not only for an individual but also for those closest to them.

In addition, it acknowledges that interventions by mental health professionals – particularly compulsory hospitalisation or the use of medication – can add to these feelings of fear, social isolation and dislocation. And also that the process of recovery is also based on the involvement of the person at the centre of the crisis.

Its underlying principles are surely ones that all those involved in mental health services – service-users, carers, mental health activists, policy makers or professionals from any discipline – would surely accept.

And versions of them can be found in professional codes of ethics and a range policy documents. But while the fight over mental illness, how it is defined and a lack of budget rages, whether these principles are put into practice is another thing.