When today I recall the biblical story of David and Goliath, it appears to be a somewhat banal tale. For me, it lost its expressive power when I came to know Vikram Patel’s life history, his achievements, aims and finally the man himself. Born in Mumbai, India, he was a sickly child, but he took up the challenge of mental illness, which was reaping its harvest across the world. He decided to create a situation whereby the poorest and most deprived in every corner of the world could count on some form of help. What is most surprising is that he has realized his aims with remarkable consistency.
As his mother Bharati said, Vikram Patel always wanted to be a doctor. But seeing his physical condition, people would laugh at his dream. How could a seriously ill boy (he suffered chronic asthma and allergy) who might not even live long enough to graduate medical school become a doctor? But Vikram was nothing if not determined. When he was admitted for the MBBS, he went to do his internship in Goa, where his friend Gauri, today his wife, gave him a form to fill out to apply for the Rhodes Scholarship. He sent it and was selected for an interview along with 15 other people. The panel was comprised of several leading personalities and the selection process went on for four days. In the end, he was selected as one of three Rhodes Scholars from India in 1986 (Bhatt 2015).
After completing his MBBS at the University of Mumbai, he went on to study at the University of Oxford, then finished his training as a psychiatrist in London. Next, he moved with his wife to Harare, the capital of Zimbabwe, to begin a two-year research fellowship at the national university. His objective was to find evidence for the view, then widespread among anthropologically minded psychiatrists, that what appeared to be depression in poor countries was actually a response to deprivation and injustice—conditions stemming from colonization (Patel 1997). The remedy in such cases, he believed, was not clinical treatments, but social justice. Instead of evidence for this, however, he discovered something quite different. It turned out that mental illness, and depression in particular, affects people in developed and developing countries in very similar ways. Not only that, as the first Global Burden of Disease reported at that time, they are the single largest cause of disability worldwide. In the poorest countries as well as the richest, and at every socioeconomic level in between, mental disorders were the greatest thief of productive life. As Patel said in one interview, “Zimbabwe was an eye-opener. It set me on a course I have been on since then” (Jain 2015).
This course is to find out ways to help the mentally ill worldwide, regardless of where they live or their material circumstances. He accomplishes this goal through advocacy, research, and teaching. He does so with such determination that his efforts have been recognized by his inclusion in the TIME 100 list of the most influential people in the world in 2015 (Van Dahlen 2015). He has been awarded the Chalmers Medal from the Royal Society of Tropical Medicine & Hygiene (UK), the Sarnat International Prize (the National Academy of Medicine, USA), an OBE from the UK government, the Pardes Humanitarian Prize (the Brain & Behaviour Research Foundation, USA) and the Canada Gairdner Global Health Prize. He was elected a Fellow of the UK Academy of Medical Sciences, awarded an Honorary Doctorate from Georgetown University and awarded a Wellcome Trust Principal Research Fellowship.
Although Vikram Patel is a qualified psychiatrist, he rejects complicated psychiatric diagnostic categories which are unsuited to community contexts. He was a professor at the London School of Hygiene and Tropical Medicine, yet he somewhat feels uncomfortable in the academic world isolated in its ivory tower.
A brief profile does not give enough space to list all his achievements. However, some of them cannot be omitted. These certainly include writing and publishing in 2003 the book Where There Is No Psychiatrist, a mental health care manual primarily used in developing countries by non-specialist health workers and volunteers (Patel 2003).
On his request, the publisher entrusted the translation rights of his book on one condition—that they could use it as long as it was distributed free of charge. This book has since been translated into fifteen languages and helps spread the simple yet profound idea of mental health in over 70 countries of the world for all. A second, much-revised, edition was published in 2018 and, this time, the digital version of the book can be downloaded at no charge.
His work is firmly grounded in science, using epidemiology, social science research methods and randomized controlled trials. He has used them to create and test community treatment protocols for everything from depression to chronic schizophrenia in India. The product of this work includes over 300 scientific articles published in peer-reviewed journals.
Vikram Patel is the co-founder and former director of the Centre for Global Mental Health, London School of Hygiene and Tropical Medicine (LSHTM). He was also the co-founder of the Centre for Control of Chronic Conditions at the Public Health Foundation of India, and co-founder of Sangath, an Indian NGO (where he continues to serve as a member of the Managing Committee) which has pioneered task-sharing experiments in the areas of child development, adolescent health, and mental health. Sangath won the MacArthur Foundation’s International Prize for Creative and Effective Institutions in 2008 and the WHO Public Health Champion of India award in 2016 and is now ranked amongst India’s leading public health research institutions. After serving as Professor and Wellcome Trust fellow at the London School of Hygiene & Tropical Medicine for a decade, he became the first Pershing Square Professor of Global Health at Harvard Medical School in 2017 where he launched the GlobalMentalHealth@Harvard initiative. He now splits his time between Boston and India.
He has served on three WHO Committees (Mental Health; Maternal, Child and Adolescent Health; Independent High Level Commission on Non-Communicable Diseases) and on four Government of India committees: the Mental Health Policy Group (which drafted India’s first national mental health policy), the National Rural Health Mission ASHA Mentoring Group, the National Human Rights Commission Core Committee on Health and the Technical Advisory Group of the Rashtriya Kishor Swasthya Karyakram (India’s national adolescent health program).
Professor Patel, as you are engaged in the area of mental health, the subject of both research and practice by a huge number of psychologists, I would like to start by asking you a few general questions about the subject. On many occasions, you have talked about how, from the perspective of primary healthcare workers, a lot of psychiatric categories do not make sense because they fail to reflect the reality of that field. Can we essentially toss our manuals like DSM or ICD into the shredder?
We need to design classifications which are meaningful to the people who use them and those who are classified as a result of them. In that sense, DSM and ICD are neither useful to the front line providers in primary health care, nor are they meaningful to most people who receive a diagnosis. We need to think of psychiatric classification as being pragmatic. At the level of the community and primary care, what really works are syndromes of distress, rather than the hundreds of different diagnostic categories that we have invented, which may be more useful for those working in a mental health specialist setting. The reason is that most psychiatric conditions are really dimensions, every individual with a psychiatric condition lying somewhere on a spectrum, and that when we classify people essentially, we are artificially or arbitrarily dividing the spectrum into binary categories. That is certainly useful for certain purposes. For example, it might be very useful for insurance purposes or for applying for welfare benefits. They can also sometimes be useful for treatment decisions, but often they are not very useful for people who are delivering psychological and social interventions or for those who receive the diagnoses. For example, such binary categories imply that those who are classified with a ‘disorder’ are different from other people who might also be experiencing very similar sort of experiences, but do not meet the arbitrary criteria of the diagnosis.
Is this also an effect of the medicalization of our life?
Yes, this is partly true, but it is important to know the history behind this. Up until the 1960s, it was very uncommon to have so many different diagnoses. We used to have very broad syndromes, like neurosis and psychosis, but in the 1970s there was a push in psychiatry to become more like its brethren in other medical specialties. These specialties were heavily influenced by diagnostic systems, which in turn were influenced by infectious diseases, where the diagnosis followed a causal agent. For example, you have tuberculosis that replaced a diagnosis of a cough—you could have many different infections causing a cough, but the diagnosis was not a cough, but TB or influenza, etc. However, because psychiatrists did not have any such causes, what they decided to do was to create diagnoses based on what they were observing in their clinics and hoped that this would, one day, through research using those diagnostic categories, help us to uncover a cause that was specific to those diagnostic categories. However, 40 years later we now know that that is not the case. To be fair, historically there was a good reason for applying these diagnostic categories. There was a genuine belief that the causes could be discovered by actually classifying people according to their clinically observed syndromes, because it was assumed that these syndromes would be very distinct from one another in terms of pathology. Today we know that’s not the case, and that is why we need to rethink how diagnoses are applied to the field of mental health. It’s very clear that the model that works so well for infectious diseases is not going to hold true for mental health problems.
Another general question. The World Health Organization estimates that more than 350 million people around the world are currently suffering from depression, which accounts for almost 5% of the population. Worldwide more than a third of people at some point in their lives meet all the diagnostic criteria for at least one mental disorder. These data suggest that there is a mental illness pandemic of unprecedented magnitude in the history of mankind. What is your explanation for these figures?
I cannot agree that there is a pandemic, and cannot say that things are getting worse, if only because we have no real knowledge about the prevalence of mental illness before the diagnostic system came into play, which is only 30 years ago. That said, I don’t think that it would be an overstatement to state that the burden of mental illness is very high. If you think of the full range of mental health problems—from problems to do with social communication in childhood, learning and behavior in adolescence, self-harm, use of harmful substances, feeling extremely miserable for extended periods of time, trauma through violent events, having sustained psychotic experiences—and you put them all together, it is hard to find anybody who actually has never experienced mental health problems at some time in their life. But to me this is part and parcel of the human experience. Our mental health is like our physical health. If I were to ask the question, how many people have ever had a physical health problem in their lives, would you be surprised if you heard the number 100%? Of course not, because everybody has a physical health problem, especially if you consider that physical health problems extend from, for example, a common cold all the way to lung cancer. In the same way, if you think of mental health problems as a spectrum, ranging from acute distress, for example because your wife has died after 30 years of marriage, all the way through to actually being depressed in a sustained way for months and months after she died, then almost everybody has had a mental health problem in their lives. Of course, this does not mean that everyone would have had a ‘diagnosis’ of a mental disorder! I think we should move away from numbers because they are misleading, and they can actually make us focus on the wrong issue, which is whether it’s 349, 350, or 351 million. Who cares about such numbers when these diagnoses are not really grounded in science? Where we really should be asking the question is, what proportion of humanity experiences difficulties with their mental health at some point in their lives? And if we asked that question, I think the answer is 100%.
What about the practice of over-diagnosis?
I agree, that’s a huge problem for me, and that is consequent on the fact that we think that every time our mental health is effected, it means we have a medical problem, and that requires us to see an M.D. or Ph.D. with specialist training and experience, and pay them significant amounts of money to get a diagnosis and, most often, a drug prescription. I completely reject that approach. What the dimensional approach to mental health tells us is that, as with physical health, a huge amount of that spectrum can be managed with appropriate changes that one individual can make to their own lives, through adequate information, hope and informal approaches of support and care and, as we have shown in our work, through community health workers who are able to deliver brief psychological and social interventions. For example, let me give you an analogy with heart disease. The majority of people with heart problems can actually manage their health through lifestyle change, and if they have a cardiovascular event, the majority of lives can be saved by a first responder being trained in CPR, so only a small proportion of people actually need to see a cardiologist or go through a cardiac procedure. We need to apply similar dimensional approaches to thinking about the prevention of mental health problems, the management of acute mental health distress, the front-line response to mental health problems and, finally, the specialist response to refractory and persistent mental health problems.
To some extent, your activities undermine traditional beliefs about the effectiveness of professional treatment, as through your research and practice you have proven that with the help of simple tips read in a book or given to them during a short online course, people without any qualifications can contribute to a significant improvement in the mental health of people suffering from serious disorders. Such results are also consistent with what Raj Persaud (1998) wrote in his book Staying Sane, showing that unskilled or novice healthcare professionals are often more effective than professionals. How do proponents of traditional, highly professional psychiatry and psychotherapy react to this?
I think that many of them react in the same way that physicians would react when they hear that a physician assistant or a nurse is able to manage the majority of physical health problems. However, it is extremely important not to see this as a debate about who is more effective. Instead, it is more useful to ask the questions—what are the skills are needed for particular kinds of problems, who is in the best position to offer these skills, and what does it take to achieve that degree of skill? For example, one would never ever question that the skills that are needed to manage an acute psychotic episode are quite different to the skills that are needed to help somebody who has lost a loved one and is suffering from acute bereavement to recover. To try and suggest that all of these are the same skills is a mistake, just as it is wrong to assume that all of these individuals need a biomedical approach. I think you need both psychosocial and biomedical approaches in the right proportion, tailored to the needs of the person.
As shown in the report you and your colleagues (2010) published in The Lancet, the efficacy of some of the forms of help you propose is astonishing. Doesn’t this directly explain the demand to simplify or at least review existing psychotherapeutic methods, whose effectiveness lags far behind what is achieved by non-professionals in developing countries?
Absolutely. I think that the work my colleagues and I have done in global health over the last 15 years clearly demonstrates two things. Firstly, that non-specialist providers such as peer support workers, community health workers and lay counselors can be equipped with the necessary skills to help people with mental health problems recover, and secondly, that the contents of these interventions are relatively simple, brief and technically feasible to deliver in routine care settings. Secondly, what this evidence also shows is that there is a universally applicable scientific foundation to explain the nature of mental health problems, and therefore to also explain how specific psychosocial techniques that are addressing those mechanisms can help people recover. To me this is also very exciting. It shows that psychological reaction to adversity is a universal human response, that this follows very similar pathways, and therefore the kinds of techniques that we have developed in order to address them, no matter which tradition they emerge from, can be universally applicable. Diverse traditions of psychology, sociology and even spiritualism are often acting through similar pathways to help people recover. I should emphasize here that I am focusing mainly on mood and anxiety problems, which are a distinct group of conditions from psychoses. I think psychoses, on the other hand, are much more heavily determined by genetic and biological factors, and they are also much rarer conditions. There is no question in my mind that people with psychoses do benefit from medication as well as psychosocial approaches, but mood and anxiety problems, which are the biggest category of mental health problems, are to a large extent influenced by environmental factors. In that group of individuals, current evidence suggests that psychological and social interventions are far more likely to produce lasting benefit than pharmacological approaches.
In your public statements, you often stress that when you started your career as a psychiatrist, you were convinced that depression is a disease of Westerners. Today you admit that you were wrong, and that people in all cultures suffer from depression. However, I am curious if you perceive certain mental disorders that are present in one culture and not present or very rare in other cultures. Such cases are described by James Davies (2013) in his book Cracked: Why Psychiatry Is Doing More Harm Than Good, showing that some disorders which are alien in a given culture, such as eating disorders, appear in the East as a result of the cultural pressure exerted by Western civilization. He called this influence “psychiatric imperialism.” What is your view on psychiatric imperialism?
I think these are two completely separate issues. The influence of culture on our mental health is a global issue. I completely agree that culturally determined attitudes toward body shape are critically important environmental influences on dieting behaviors, and the emphasis on thinness is a major reason why eating disorders were so much commoner in European society. That said, as the world globalizes those attitudes are now finding their way into dieting behaviors in non-Western societies. Similarly, you also see other kinds of cultural factors operating in non-Western societies, which lead to mental health problems—for example, in India, there is a psychosomatic syndrome affecting young men characterized by severe anxiety about semen loss related to cultural attitudes about virility. I think the influence of culture on our mental health is a well-established and universal phenomenon. Psychiatric imperialism, on the other hand, is about the application of a biomedical psychiatry on cultures in which there is no history of psychiatry. Thus, it is considered that psychiatry is a product of Western culture, and it is imperialistic to apply it to non-Western cultures. I don’t agree with this at all. I think psychiatry is a discipline of medicine, and in the same kind of way that the other disciplines of medicine have been applied successfully around the world I believe that psychiatry can also be applied around the world. However, where I do have a problem with psychiatry is its failure to recognize that diagnostic categories do not travel across cultures, not only around the world, but even in European cultures, in particular the narrow pharmacological perspective of addressing mental health problems. There is a need for the reformation of psychiatry so that it is grounded much more in both neuroscience, in understanding how mental health is produced in the brain, and in epidemiological sciences, to understand how our social environment influences our mental health, and to apply these in a person-centered way. That is to say, there isn’t one size that fits all, and rather than single-mindedly follow a protocol that allocates a person into a diagnostic category which then leads to a treatment plan, we need to understand the context in which that person’s mental health problems are occurring, and provide interventions that are tailored to that person. To me, this is a universal need rather than occurring only in one culture or another. The application of the model of diagnosis that we talked about earlier is without thought to the person or the context, and I think that is a problem everywhere.
In his book The Mind Game: Witchdoctors and Psychiatrists, Erving Fuller Torrey (1972) was probably the first to attempt to convince the Western cultural community that the actions of witchdoctors and local healers in other cultures are the full-fledged equivalent of our psychiatry and psychotherapy. Your activity is done in places around the world where similar services are quite well-developed and available, and it could constitute a substitute or even an equivalent of professional psychiatric care. Do you see any opportunities for working with these people? Do witchdoctors come to people’s aid?
I wouldn’t call them witch doctors. I call them traditional medical practitioners or traditional healers. I certainly see that in some cultural contexts they play a very important role, particularly for chronic conditions, which included not only mental illness but also a range of other conditions, from allergic disorders to diabetes, etc. I do believe that biomedicine is not the only or dominant form of health care that is required, especially as most of these chronic conditions are a product of interaction with an environment. I see the role of other therapeutic traditions as being very relevant, but just as with biomedicine, there is also a risk of abuse in these other traditions of practice. Most of these traditional systems operate without any scrutiny, monitoring, or quality control, and almost entirely in the private sector. Some of their practices can be very abusive, such as chaining, whipping and branding, and many blame the person of their family for the sickness. I think that one should not romanticize and valorize these alternative systems simply because they have come from another culture. There is a danger of the “happy native” concept that has pervaded anthropology for a long time which postulates that the so-called natives are happy with the living in their jungle and wearing no clothes and the so-called Western way of life is always a destructive or malevolent force. I think that is also a fundamentally racist concept, and was at the heart of the rationale which European nations used to systematically abuse its colonized peoples. I think we have to be very careful about that kind of thinking and the history behind it. It is a very fine line between that and the idea that all traditional medicine is beautiful and wonderful, because I have seen traditional medicine as being anything but beautiful and wonderful.
In the places your help reaches, mental illness is often confused with possession or spells. Doesn’t that make it more difficult to diagnose people with mental illness, the difference between their expectations of how to deal with them and what they expect in reality?
I don’t think there is any one mental illness. It’s rare for people with mood and anxiety problems to think they’re being possessed, and most people really see their experiences as a result of social suffering, which of course is exactly what epidemiology also teaches us. Possession states are mostly associated with extreme anxiety or psychosis, and in those situations, it is important to remember that the possession belief is very much rooted in the fact that the spirit and the mind have always been seen as being interconnected in most societies of the world, including Europe. It was only after the Enlightenment, which separated religion from medicine, and the emergence of biomedicine about 150 years ago that spiritual matters become the realm of the church, and medicine became the realm of the biomedical practitioner. But in most parts of the world, of course, that association of spirit and the mind continues to this day. Indeed, you can also see this in the west—for example, if you go to any of the evangelical churches in Europe or North America you will see a lot of intermingling of spirit and mind, and witness many people coming for spiritual healing who might also be considered as suffering from a mental health problem. I think this is a very rich expression of how people understand their mental health problems and the kind of help they seek, and as long as the practice is not going to be harmful to the person, either economically or because of the loss of dignity or autonomy, I think all of these alternative forms of healing are acceptable as the person may ultimately benefit from.
I got to know the problem of possession quite well in my country in the middle of Europe. Poland is one of the leaders in exorcisms in the world. But let’s return to the developing world. Leo Igwe, the Nigerian human right advocate and humanist, told me about how people accused of witchcraft, including children, are persecuted in Africa. What does the stigmatization of mentally ill people look like, when its roots are perceived are being in possession or spell? Is it different than in the West?
I have read about women being labeled as witches in India as well, but most often these labels of are not to do with mental illness but rather with misfortunes that are happening in the community, and then blaming a particular individual for being a witch. Here, the link with mental illness is much weaker, it’s much more to do with misfortune and other social factors, such as those related to gender. For example, in India someone is often accused of witchcraft if in a particular family three children have died one after the other, leading to the conviction that there is some kind of bad spell or evil spirit in the house. I think the stigma associated with mental illness has to a large extent been the result of the way people with mental illness have been treated, and that could be either in traditional healer shrines, where they might be chained or whipped, or over the last hundred years in most countries through asylum psychiatry. If you think about the way people with serious mental illness are treated, that they are taken away by the police, incarcerated, and no longer treated with dignity, but as some kind of sub-human creature. They are put into hospitals where they are naked, raped, and given ECT as punishment for “bad behaviour.” If this is what passes for mental health care, then it is no surprise at all that people don’t want to seek mental health care and be stigmatized with a psychiatric label. People mock and joke about mental illness, because over hundreds of years we have done exactly that as part of our societal and professional response to people with mental illness.
The working methods you promote are designed for areas of the globe inhabited by people deprived of access to professional mental health services. Nevertheless, in developed countries a large part of the population (estimated to be as much as half) also does not have access to such services. In your opinion, could the methods you have developed also be applied in Europe and North America?
Yes, absolutely, and in fact I am already involved in such efforts. With colleagues in Canada and the USA, we are now applying the same methods of brief, technique focused, psychological therapies to be delivered by front line workers such as community health workers and nurses. There is a huge potential to reform the architecture of mental health care, so that for the majority of people with mental health problems their first level of care is not in a hospital, a clinic or a mental health professional setting but either in their own homes or in primary health care, with treatments that are brief and seek to empower that person to be able to learn the skills and techniques and to give themselves time and space to recover, rather than medicalize them, apply meaningless diagnostic categories and reduce them to patients passively taking a prescription.
For some time now I have been interested in the possibilities offered by computer-assisted therapy and the use of AI in psychotherapy. Achievements to date in this area seem promising—inexpensive help readily available in even the most remote places in the world, as long as there is an Internet connection. Does your program of help for the most needy and poorest people in the world account for these possibilities? What prospects do you see for them?
I have a very different view of digital technologies. I think most people who are distressed don’t want to sit with a computer to get better. Remember that 15 years ago, there was much excitement around the digital revolution offering the potential of apps based on psychotherapy which people could use themselves so that we could actually remove the need for a therapist completely. We now know, 10 or 15 years later, that none of the thousands of apps which were developed have actually been successful or commercially viable. Companies will say they had a million people accessing the app, but then they will never tell you how many people actually completed more than one session because those numbers are very dismal. What we do know now is that the vast majority of people do not want to sit with an app alone, and now the field is moving toward blended approaches, recognizing the need for a skilled person who can use an app, where appropriate, to support recovery. The person doesn’t have to be an M.D. or Ph.D., but somebody who can assist you with their knowledge to help you recover. The digital world is then something that you use as a support for that, rather than a replacement of the skilled provider. One example of the way I use digital applications in my work is to build a platform for training providers to learn psychological treatments, so we can address the barrier of the old-fashioned face-to-face training and supervision, which is one of the major reasons why none of these brief evidence-based treatments have gone to scale. Another example is using digital platforms for supporting the quality of the care that is delivered and for providing supervision. Such provider and health system facing apps, combined with patients facing apps, is perhaps something I would feel very excited about, but just simply giving a patient an app with AI makes me very pessimistic. The latter may help a handful of people who are very motivated and fairly adept at using such digital offerings, but for the majority of people with mental health problems, I see them using these apps only as a supplement to skilled providers.
Although you are a scholar educated at Western universities, you enjoy the capacity to look at mental health, psychiatry and psychology from a perspective quite different from that of most of the readers of this book, and it would be a waste not to use it to paint a more detailed picture of our field. Looking at psychology through the eyes of someone who tries to use its findings to help mentally ill people in the poorest regions of the world, which of its achievements do you consider to be particularly significant and beneficial?
I think psychology is probably the most important science of all, when it comes to understanding mental health and mental illness. It is certainly a lot more scientifically grounded than psychiatry is. In fact, most of the ideas that we are talking about right now have a rich and long history in psychological science. For example, the dimensional model of understanding mental health, such as concerning with cognition and different emotional states, has a very rich history in psychology, and it is psychiatry that took these ideas and created biomedical categories out of them. I think of social and psychological sciences as the fundamental foundations of mental health science, alongside neuroscience, and it is clinical psychiatry that in many ways is out of step. I would suggest that practitioners of psychology should follow the original thinking that lay at the heart of psychological science, rather than trying to ape the psychiatric practice of mental health. Among its greatest contributions are the understanding of cognitive and behavioral foundations of mental health, the interpersonal dynamics through which mental health is produced and the understanding of how our social environment affects the brain, particularly in the early years of life. Such discoveries, and many other aspects of psychology, form the essential science of mental health, alongside functional neuroscience. For me, actually one of the real disappointments these days is the desire expressed by some psychologists to be psychiatrists. While I do appreciate that to a large extent this desire is driven by commercial interest, but I still find it amazing, and even amusing, that there are some psychologists who want prescribing powers despite the fact that the most powerful mental health interventions that we have today, the ones that are most acceptable to consumers, the ones that have the least side effects and that have the most sustainable long-term effects, are actually those that are derived from principles of psychological and social interventions.
Perhaps it’s also a pressure from patients. They expect a psychologist will prescribe them something.
I actually don’t think so at all, because if you look at the literature about people’s choices about what kind of care they receive when they’re offered a choice, there is an overwhelming preference for psychological and social interventions, especially when they are dealing with mood and anxiety disorders.
What therapeutic methods have proven themselves in the difficult conditions you work in?
I think that the most effective ones in the psychological realm are to do with behavioral activation, which is relatively simple technique to teach both the provider and the patient. Examples include behavioral activation that is primarily used for depression and exposure which is used for anxiety. Motivation enhancement is a very effective technique for promoting healthy behaviors. Problem-solving is a very effective technique for helping young people, especially for executive decision-making and emotional regulation. Another set of approaches which come outside the narrow domain of clinical psychology are focused on social work practices, for example enabling people to nurture social relationships through befriending interventions or supporting people with severe mental disorders to be included in mainstream spaces, such as in school, the workplace, the family environment or the neighborhood.
Which methods have proven themselves to be utterly useless or even dangerous?
The one approach that I think is the most dangerous and useless is the incarceration of people with mental illness. It damages everyone concerned, but most of all the person with mental illness, because it robs them of their freedom and their autonomy. Typically, when they are incarcerated against their will, whether in hospital, at home or in a prison, they are robbed of most or all of their fundamental human rights. But this practice also robs the providers and the mental health professions of their dignity and respect. And so I think the one practice that I would like to see forever ended is the incarceration and involuntary treatment of people with mental health problems. Then there are a whole range of psychiatric practices that are not evidence based, such as long term psychoanalytical therapy or regression therapy, which have no scientific basis. Typically, such practices are offered only by private practitioners, who have completed a course somewhere and charge huge amounts of money. To me, these are people who are preying on vulnerable people with mental health problems, and I think we should reject this kind of charlatan practice. Part of the problem is that mental health care systems are so weak everywhere that it offers a much larger space for charlatans with no scientific base to establish a foothold. You would never see this, for example, in cancer therapeutics, and that really is a reflection of how weak evidence based mental health care is in most parts of the world.
One of the very important issues in contemporary clinical psychology is the gap between science and psychotherapy. By that, I don’t mean pseudo-therapy, which has nothing to do with science, but those modalities that are commonly considered evidence-based. In one study (Jonsson et al. 2014), it was found that only 3% of all studies on the effectiveness of psychotherapy included monitoring of negative side effects. In another, it turned out that most of the research is conducted by researchers who do not declare a conflict of interest (Lieb et al. 2016). Yet another meta-analysis showed that only 7% of all studies contain convincing evidence confirming the effectiveness of psychotherapy (Dragioti et al. 2017). The picture that emerges from these and many other works is not very optimistic. What are your views on this subject?
I share the concerns that a lot of the science in both psychotherapy and pharmacotherapy has been produced by people with a vested interest, which they often don’t disclose, and often these findings are not replicated, and this is a real problem in our field. It goes back to what I’ve mentioned earlier about the fact that there is weak evidence based science in most mental health practice today, and that allows fertile ground for people to step in and offer all kinds of therapies, because they are likely to say there is no evidence base to even back up what the formal system is providing. This is where, I think, what global mental health is doing is really exciting, because it is not using branded therapies. Instead, it is generating evidence on the utility and effectiveness of simple techniques that can be used by ordinary people to help themselves or other ordinary people who are going through mental health problems. It is de-professionalizing psychological science and making it available to people in a democratic way. You also probably know that most people who claim they are psychotherapists don’t actually practice evidence-based psychological therapy, but practice an eclectic mix of whatever they think is needed. This is probably the reason why community health workers probably do better than psychotherapists, because they stick to the simple approaches they have been taught to deliver.
Today everybody is talking loudly about the crisis in psychology. And I don’t mean only the replication crisis. It’s a much wider issue. In your opinion, which areas of psychology have we neglected? What should we focus on so that our field does not merely remain an exciting hobby allowing us to describe our behaviors and motivations in ever finer detail, but rather helps to solve the most present problems of humanity?
I think what psychology should be doing is returning to its roots of attempting to understand and study the dimensions of mental health and personality. I consider, for example, the whole area of neuro-cognition and psychopathology as fundamental psychological science. These are the areas that we should be focusing on, and trying to understand how our social worlds are influencing our psychological state, and furthermore connecting this with the growing and exciting developments in circuit and network neuroscience. I think we should stop thinking about diagnostic categories and revert to the original, historic scientific foundations of psychological science. We should embrace exciting new fields, such as cognitive and network neuroscience. Digital tools will also play a role, but the digital tools of the future will not treat diagnoses such as depression or ADHD, but help people learn and master techniques to deal with impairments or difficulties in dimensions of psychological function. For example, in the case of ADHD, tools which can help children improve their attention span, and reduce their impulsiveness. That’s where psychology should be heading.
Readers interested in psychology rarely read about global mental health problems. You have achieved a lot in this field. Which of these achievements are you most proud of and why?
It is really disappointing that few people in psychology talk about global mental health, because most of global mental health is about psychology. It is necessary for counseling and clinical psychology to recognize how influential they are to the way the world is beginning to understand and respond to mental health problems. I think the most exciting things emerging from global mental health are the deconstruction of diagnostic categories into dimensions of psychological function or experience, and also the application of deconstructed complex psychological therapies into specific elements or techniques that can be used to help people with different forms of mental health problems recover.
What problems are you trying to solve and what questions are you trying to find answers to these days?
Firstly, early child development. I am engaged in programs to try and characterize the development of very young children using dimensions of neuro-cognition, rather than trying to classify them into diagnostic categories. The second area is working with adolescents, and again, moving away from diagnostic approaches to study and address difficulties in emotional regulation which lead to impulsive acts and behaviors such as self-harm. The techniques that can be used are based on the principles of problem-solving, to help young people pause before they act impulsively and be able to identify and deal with stresses in their everyday lives. The third is to disseminate evidence based psychological treatments using digital platforms for training front line workers, to complete competency assessments and to master their delivery.
What other questions in global mental health that you would like to be able to answer in the next few years?
I think one of the other very important areas that I am passionate about, and which I am increasingly seeing myself drawn into, is how to end coercion in mental health care. How do we actually empower people with the most acute mental health problems to be supported in decision making in their own interest, rather than to substitute decision making to others. I would like to see all forms of coercion and violence in mental health care completely eliminated, and to me that is an aspiration and a moral mission. Another area which I am also very interested in is to begin to better understand how poverty and deprivation affect our mental health, so that we can interrupt the pathways between living in conditions of adversity and suffering the mental health consequences of these adversities. In that way we can build capabilities in people who are very disadvantaged to lead lives that are more fulfilling and rewarding, even if we can’t necessarily change the upstream social and structure determinants of poor mental health.
What is your biggest dream related to what you do?
I would love to live in a world where we can all truly value our mental health in a way we value our physical health. To do that, we have to abandon the idea that mental health is about diseases, disorders and specialists, and recognize that mental health is something that accompanies each of us at every single point in our lives, as long as we are alive, whether we are awake or asleep. Also to value our mental health is to be conscious of it, to be able to talk about it freely and comfortably, and be empowered with the knowledge and tools to care for it. This is the world that I really envision and aspire to.
This book will mainly be read by psychologists. What message would you like to convey to them?
My message is, became a practitioner of a person’s mental health, not their mental illness.
Is there anything I haven’t asked you about during this conversation that you would like to mention?
I want to reiterate one more point and that is that all mental health problems, without exception, have a social dimension, and I think we must address the social world that the person occupies, as much as their internal mental experiences. I think that only then can we have a truly person-centered approach to mental health, with a long-lasting impact. The problem in the field of psychology is that it has focused entirely on the inner world, and assumed that the outer social world is the realm of another discipline, for example, social work. But I think that is a mistake. It is a limitation of psychology not to also be able to at least understand and acknowledge this, and assist the person to re-order their social world as much as possible, because to ignore the social world is to ignore much of the picture.