Understanding Depression: Opportunity rather than threat?

More openness is needed within the psychology professions about psychologists' and our families' experiences both of mental health difficulties and of services. Lived experience can be an asset in our work. We therefore applaud Dr Annie Hickox's openness in this regard (The threat is coming from inside the house, October). We condemn personal attacks on anyone who discusses such experience, via Twitter or elsewhere.

However, as the editors of the British Psychological Society's Division of Clinical Psychology's public information document Understanding Depression, we are concerned about Dr Hickox's suggestions that Understanding Depression contributes to barriers in being open about mental health difficulties (a) because it takes a stance of normalisation within what she calls 'the two perspectives of normalisation and illness' (p.30), (b) that this minimises people's difficulties and (c) that it equates to saying 'pull yourself up by your bootstraps' (p.31).

In Understanding Depression we acknowledge that depression can be severe and even 'life-threatening' (p.16). We also acknowledge that there is a debate about how best to understand depression and that 'calling it an illness is only one way of thinking about it, with advantages and disadvantages' (p.16). In terms of normalising, the stance in Understanding Depression is the same as in the DCP statement on psychologists with lived experience of mental health difficulties quoted favourably by Dr Hickox, namely that we need change so that people experiencing mental health difficulties 'are able to feel confident in receiving normalising, compassionate and accepting responses' (p.2, our italics).

Nowhere in Understanding Depression, of which one of the main editors was a psychologist with experience of severe depression, was there any suggestion to 'pull yourself up by your bootstraps' (Hickox, p.31) or have 'resilience training' (Hickox, p.30).

We are also concerned that The Psychologist published misleading messages about Understanding Depression, a document that was produced over several years, and drew on huge amounts of evidence and the input of many psychologists with specialist knowledge, and on lived experience.

- Dr Sue Holttum, CPsychol, AFBPsS
- Dr Gillian Bowden, MBE, AFBPsS
- Dr Rashmi Shankar, CPsychol
- Anne Cooke, CPsychol
- Professor Peter Kinderman 

In her recent article Annie Hickox writes about the very real barriers faced by people with lived experience of mental health problems who work in the mental health system, in 'talking openly with our colleagues about our struggles'. I agree that the current emphasis on 'resilience' is unlikely to encourage anyone to reveal vulnerabilities. However, Hickox's main concern is barriers or 'threats' she sees as coming from within her profession, likened to '….the creepy phone calls that come from the last place one would expect, the safety of one's own domain'. She locates these threats firmly in the views of some psychologists 'who appear to normalise mental illness and refute the widely accepted position that diagnosis and medication can have significant therapeutic value' and in '[a]dvocates of 'critical psychology'[who] consider diagnostic constructs to be invalid and also consider the term 'mental illness' to reflect a failed and outdated psychiatric paradigm.' As someone who has produced a fair number of critiques of psychiatric diagnosis and the concept of mental illness, I must take issue with these depictions and the threats they supposedly pose.

'Critical psychology' has questioned many of the assumptions, theories and practices of conventional psychology and, crucially, highlighted their links to the operation of power and to potentially harmful social and economic processes. This includes theory and practice about psychiatric diagnosis and so-called 'mental illness' where critiques and suggestions for alternatives have been produced not just by critical and mainstream psychologists but by many psychiatrists, service users/survivors, sociologists and philosophers.

Hickox claims that we 'appear to normalise mental illness'. This is doubly misleading. It takes for granted the very idea (mental illness) that is in dispute without engaging in any of the evidence and arguments we have put forward. It also links 'normalising' with 'minimising' – '…the current emphasis on resilience and/or normalisation of what for many is a paralysing illness can sound like 'pull yourself up by your bootstraps''. In fact, what critical psychologists and many others aim to do is convey the understandability and meaningfulness of those extreme and distressing mental states, emotions and behaviour that are so often labelled as symptoms of a medical type illness. This means highlighting their links not just with people's life experiences, but also with wider power-based social processes such as racism, misogyny, unrealistic social expectations, economic policies and so on.

There are many reasons in services and society why these links get obscured and why revealing them may be seen as threatening. If we have to use the word 'normal' then the message is not minimising but that, 'You are reacting normally to damaging circumstances.'

Hickox's claim that 'some psychologists refute the widely accepted position that diagnosis and medication can have significant therapeutic value' is also misleading. Many of us support a 'drug-based' rather than 'disorder based' approach to medication and know that it can be helpful (Moncrieff, 2020). But we also argue that too little attention is paid to the harms of psychiatric drugs, and that service users are often not given enough information to allow informed consent and even if they refuse, can be overuled. As for diagnosis, it's difficult to argue for the therapeutic value of a system which has amassed so much evidence against its validity that even its devisers concede its lack of scientific value. But diagnosis can serve many personal and social functions and some people find these helpful. Indeed diagnoses may be required to access some services and benefits.

It's ironic that Hickox should imply that questioning medicalisation and diagnosis is linked to 'shaming and silence' when evidence suggests that an unquestioned medical approach can make stigma and discrimination more likely (Read et al., 2013). It's also ironic that she should imply that these criticisms are a barrier to people telling others 'who [they] really are, rather than let[ting] them tell us who we are not'. Many service users feel that the diagnostic system imposes an identity they do not want, but haven't any way of resisting. As one woman put it, 'Service users who identify with their diagnosis – you have pretty much an entire mental health system that agrees and supports your perspective. Those of us who feel utterly hopeless and oppressed by diagnosis – where do we go? (cited in Johnstone et al., 2019, emphasis in original).

Hickox and those who criticise medicalisation seem to have the same goals – that people with experience of more and less extreme states of distress and troubling behaviour should have access to evidence-based knowledge and be able to make informed choices about how they make sense of their difficulties and the kind of help they receive. The value of their experiences should be openly welcomed by our profession. I'd hope that constructive questioning of medicalisation and diagnosis, whose problems are widely acknowledged, as well as suggestions for alternatives, would be seen as a necessity and not a threat to all of this.

- Mary Boyle  
Professor Emeritus of Clinical Psychology, 
University of East London

References
Johnstone, L., Boyle, M., Cromby, J. et al. (2019). Reflections on responses to the Power Threat Meaning Framework one year on. Clinical Psychology Forum 313 (January), 47-54.
Moncrieff, J. (2020). A Straight Talking Introduction to Psychiatric Drugs (2nd edn). PCCS Books.
Read, J., Haslam, N. & Magliano, L. (2013). Prejudice, stigma and 'schizophrenia': The role of biogenetic ideology. In J. Read & J. Dillon (Eds). Models of Madness: Psychological, Social and Biological Approaches to Psychosis. (2nd edn; pp 157-77). Routledge.

Illustration: Tim Sanders