Mental health - Britain’s biggest social problem?
Mental pain is as real as physical pain. But while nearly everyone who is physically ill gets treatment, two in three of those who are mentally ill don’t. Roughly a third of families in the UK currently include someone who is mentally ill. And it’s the same pattern in the USA and in other European countries. Mental illness is the biggest health problem of any rich country, with at least a third of the population expected to experience mental illness at some point in their lives.
In America, more people commit suicide than are killed in road accidents. Worldwide, as many people die from suicide as from homicide and warfare combined. In the U.K., mental illness gives rise to nearly half of all absences from work through sickness. It also accounts for nearly half of the people on disability benefit. In short, the scale of mental illness is mind-boggling.
While the rhetoric continues to be focussed on raising awareness, the reality is a chronic lack of funding to pay for services. No economically advanced country spends more than 1% of national income on mental health, and most spend less than 0.5%. No country spends more than 13% of its health budget on mental health, and most spend much less.
If you were wondering which country spends 13%, well, that’s Britain. And that’s because of the expansion of psychological services via the Improving Access to Psychological Therapies programme. Whatever you think of the limits of that programme, it has massively increased the number of people receiving evidence-based treatments. The prestigious scientific journal Nature has described it as a world beating system. It is now widely considered to be the benchmark of best practice, globally.
The architects of IAPT (Clarke and Layard) know it has its limits too. They regard it as still a far from perfect system. They also rail against what they call the continued scandalous lack of treatment. The primary reason for this, is what they call ‘the technology lag’ - too few people know how good psychological treatments are. And by that they mean not just those who use services, but those who lobby for them, comment on them in the media, as well as those who make policy, funding or commissioning decisions. Too many people still think mental illness is untreatable and do not realise that, with proper help, most people can recover.
And we can be absolutely categorical about this - it has been established in hundreds of randomised controlled clinical trials. Mental health treatments are subject to exactly the same tests used to test any medical treatment. And they have success rates just as high as the majority of treatments for physical illnesses. The reality is we now have a range of tried and tested treatments at our disposal for the most common mental health problems.
Do you know what they are? If someone comes to your practice reporting symptoms of Obsessive Compulsive Disorder or social phobia, do you know what the evidence suggests is the best way to help them? Do you know what NICE (the body that provides clinical guidance to the NHS) recommends?
Mental illness requires expert help. Too few clinical trainings are informed by research. Subsequently, too few therapists have a working knowledge of what the evidence currently tells us. Our continuing professional development doesn't usually help much either - dominated as it is by new techniques, which make improbable claims, unsupported up by data. Our professional bodies don’t do enough in this area either, and often ‘spin’ research in a positive way or a way which goes beyond what those who led the study have concluded.
And it’s partly for this reason that when Clarke and Layard were proposing IAPT, they did not turn to the members of BACP and UKCP to help with delivery. Despite the massive expansion of work for mental health specialists, they took the seemingly extraordinary decision not to ask the standing army of tens of thousands of BACP and UKCP trained members to play any meaningful part in that.
Yes, there are some general principles that work well for a range of clinical problems and which cut across different types of treatment approach. Yes, the ‘common factors’ that occur in most therapy are routinely found to be an active factor in treatment success. But they work alongside treatment protocols, not on their own. And there are many specific problems for which research shows that a particular type of therapy works and for which others don’t (Obsessive Compulsive Disorder and Body Dysmorphic Disorder, being just two examples).
Indeed, some therapeutic interventions make the situation worse. Let’s look at a quick example. People used to be offered psychological debriefing a day or two after a serious traumatic event, such as a road traffic accident. Seems like a common-sense, humane response, right? Well, research has since shown that this type of intervention is unhelpful and actually slows down natural recovery. What is needed is for people to be back home, in familiar surroundings, with loved ones, and to wait to see if any symptoms still persist, two or three months after the event.
There are lots of interventions in public life which are well-intended but which don't work. In the US, a programme called ‘Scared Straight’ took groups of young people to visit prisons, in an effort to turn them away from a life of crime. Twenty years later, the kids said the programme had helped keep them out of trouble. But the research showed that, compared with the control group, more of them had actually broken the law. Similar results were found in all seven of the other ‘Scared Straight’ projects that were evaluated.
And closer to home, Clarke and Layard describe a study in which a group of therapists were independently assessed for their skill before taking part in a trial of a parenting intervention. The hypothesis was that more skilled therapists would deliver better outcomes. What they didn’t expect to find was that the least effective therapists actually had a negative effect on treatment outcomes - they made things worse.
If therapists and counsellors want to be taken more seriously, they need to take research and evidence more seriously. The problems therapists are being asked to deal with are serious. The effects on life expectancy of psychological problems are deeply serious: depression reduces your length of life as much as smoking does (and not mainly because of suicide).
Mental illness is painful in its own right. But increasingly, the physical effects of mental illness are now know too. In a recent Canadian study, depressed people were at least 50% more likely to develop heart disease, stroke, lung disease, asthma, or arthritis.
We know from another fascinating experiment that when flu injections were given to a group of people, those who were psychologically distressed developed the fewest antibodies. That’s a finding from over 20 years ago, but has never been more relevant today, during a global pandemic.
Yet too many therapists sell their services on the basis of providing a ‘safe space’ for people to talk. Fewer than two hundred people search the internet for a ‘safe space’ each month. Meanwhile, more than 200,000 people search for ‘help with depression’. It’s also the minimum people expect when they come to therapy - of course the space will be safe, but what will happen in that space and how will I be helped?
The truth is, we don't just offer a safe or confidential space to support clients. We offer relief from intense distress and we change lives for the better: nearly three-quarters of people who have therapy are better off than those who don’t. We are too diffident about what we do. Too few of us are willing to talk about recovery or relief. Given the scale of the mental health need right now, the underemployment of therapists is absurd (the most recent estimate of earnings amongst members of the largest professional body is £10,000 per annum).
In rich countries, the burden of mental illness is bigger than that of cardiovascular disease or cancer. In those same countries, over 90% of people with diabetes are in treatment. But most people with mental illnesses are not. Mental health is a huge humanitarian issue. Our work is critical. As Clarke and Layard say, global warming aside, there is no other major problem which is currently so neglected or so important. Mental health is the biggest social problem in the UK today.
If any of this is relevant to your practice, or you feel there is more you need to know, why not begin by clicking on one of our short, evidence-based, affordable video workshops?