a coherent system

“… we’re tending to confuse mental distress … with mental illness”

Dr Stanley Kutcher, an expert in adolescent mental health and leader in mental health research in Canada

Our vision is of a simple system of service-based assessment and referral that doesn’t rely on an increasingly complex system of diagnostic labelling. It is a mental and emotional health care system that both removes a great deal of the burden from GPs and also recognises the need to resource new approaches such as street triage.

Service-based assessment and referral

What type of service does this person want and/or need? Service-based assessment – as outlined within the CPCAB model for example – can lead to faster and more appropriate client/patient referral and can also avoid the distress associated with repeated assessments. This, in turn, can lead to improved prescription or care-plan authorship and result in better healthcare. The key to service-based assessment is to distinguish between the different levels and types of mental and emotional distress and then to provide services to meet those different needs:

(A) Common life and lifestyle problems

(B) Common mental health problems including, for example, depression and anxiety

(C) Severe and complex mental health problems

(D) Psychosocial disabilities and naturally occurring cognitive variations

(E) Mental and emotional distress that has a proven bio-physical cause (as with dementia, for example)

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(A) Common life and lifestyle problems:

Common life problems such as bereavement or divorce can be quite emotionally overwhelming. Additionally, if a person isn’t coping and isn’t supported, these distressing life experiences may sometimes develop into common mental health problems. Both counsellors and life coaches are trained to work with these type of problems. Common lifestyle problems include smoking and obesity, with referral to a health coach.

(B) Common mental health problems including, for example, depression and anxiety:

A huge proportion of GP consultations involve people who don’t have a biophysical health problem and are wanting help with something entirely different – often distress arising from common life problems or common mental health problems. With all of these problems pharmaceutical treatments should be the option of last resort, regardless of patient/client expectations – yet five million people in the UK are currently taking antidepressants. Both counsellors and psychotherapists, for example, are trained to work with common mental health problems.

(C) Severe and complex mental health problems:

These includes those who have psychotic episodes – involving very distinct changes in their perceptions of reality – such as hearing and/or seeing things that are inaudible/invisible to others where this impacts negatively on emotions, thoughts, judgments and their ability to function. A person with this type of mental health problem would normally be referred to a psychiatric service.

(D) Psychosocial disabilities and naturally occurring cognitive variations:

This includes those on the autistic spectrum, those who have difficulties with standard ways of learning, and those diagnosed with ‘Attention Deficit/Hyperactivity Disorder’ (ADHD).

These all represent instances of neuro-diversity, rather than ‘illnesses’ which need to remedied and somehow cured, and thus pharmaceutical treatment is largely inappropriate. Here people need:

• Psychosocial support – and/or specialist-educational support – to help them lead lives that are as independent as possible.
• A society that values neuro-diversity.

(E) Mental and emotional distress that has a proven, main bio-physical cause (as with dementia, for example):

Despite decades of research there is a complete absence of biological markers for, or biogenetic causes of, mental health problems.

This excludes illnesses, such as dementia, which have pronounced mental and emotional effects but stem from a known bio-physical cause.

Developing services that don’t rely on an increasingly complex system of diagnostic labelling:

“The simplest answer to the question of ‘What do we do instead of diagnosing people?’ is ‘Stop diagnosing people’. … And the simplest current alternative is to ask people what their problems are, and start from there.”

Diagnostic labelling is often misleading because the labels are assumed to correspond to diseases that live independently of the patient, like types of bacteria. These labels describe, however, constellations of behaviour that can be related to any number of underlying conditions.

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Adverse life experiences such as prior physical and sexual abuse, racism, bullying and neglect are common on a psychiatric ward, and are understood by a great many patients to have played a significant role in the development of their problems. Moreover, often problems with housing, for instance, are understood by patients to be the trigger for a relapse. Thus many patients resist the attachment of misleading diagnostic labels and see their mental health difficulties as a natural response to adverse experience. Instead of asking people “what’s wrong with you?” – and then giving both “it” and them a label – we need to ask “what has happened to you?” Labelling can also be damaging to the interests of the patient/client in other ways that are difficult to contradict or escape.

Most psychiatric diagnosis is actually based on little scientific evidence – the disorders listed in the highly influential Diagnostic and Statistical Manual of Mental Disorders (DSM) have been arrived at by psychiatrists simply voting on what is, or is not, considered a disorder. It’s also worth noting that, whilst the first edition of the DSM (published in 1952) listed 106 categories of mental illness, the latest version (published in 2013) lists well over 600.

The question we need to ask is “Who does diagnostic labelling benefit – the patient/client or the mental health expert?”

“You can’t carry the world on yer shoulders, broad as they are.”


Removing the burden on GPs of patients who have non-biophysical ailments

More than a third of GP consultations are related to mental and emotional health, but GPs are not equipped for this because their training has centred primarily on bio-physical problems. GPs in England also say that almost a fifth (19%) of their time is taken up by social issues that are not principally about health.

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If every GP surgery had in place what might be called a GCP (General Counselling Practitioner), then the burden on GPs would be enormously reduced, leaving them more time to focus on patients who can best benefit from their attention. Each GCP would be an experienced and well-qualified counsellor and health coach, but their main role would be to psychosocially assess each person referred to them, with a view to making an appropriate non-medical prescription – e.g. for counselling, and/or changed housing conditions, and/or health and lifestyle coaching.


Developing new approaches such as street-triage

Many of those in need of help with mental and emotional health problems simply fall through the cracks. They will never make an appointment to see a GP or a counsellor – some may not even be registered with the NHS. Their only contact with the health service may well take place in hospital A&E departments. Their first contact with any public service is often with the police, out on the streets.

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Or they may call a help line, or else be found in care homes, or drug and alcohol rehab centres, or homeless shelters, or Salvation Army hostels, or in a variety of drop-in centres. To make matters even worse, some of the people concerned are very ill indeed and deeply traumatised. Welcome to the system’s dark underbelly where much is swept under the carpet or disappears down yawning cracks and where people with mental and emotional health problems are largely given inadequate help by those who, through no fault of their own, are not qualified to do any better. Proper organisation and resourcing of street triage would represent a step forward.

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