I've just spent a very stimulating and enlightening couple of weeks, first at the Rome Workshop in Experimental Psychopathology, and then at the University of Exeter - both times talking about experimental psychopathology. But these talks were not just about how to do experimental psychopathology, they were also about how many other researchers were simply not equipped to do experimental psychopathology, or simply had no idea about what this scientific paradigm was. And that has some very dramatic consequences for mental health funding, as well as our broader understanding of the mechanisms that contribute to mental health funding.

Let’s be quite clear about the main issue here. Most funding for mental health research goes to high profile, expensive, medically oriented research on the biological substrates of mental health problems. Why is that? Well, while psychologists learn about both biological mechanisms and psychological mechanisms, medics simply don’t learn about psychological mechanisms - in fact they tend to have no knowledge whatsoever of the inferential methodologies that allow psychologists to develop models of psychological processes - but rather sadly, there is a majority of those medics on the panels of most funding bodies for mental health research.

Is this important? Yes it is, because, I'm quite happy to assert that most common mental health problems are acquired through perfectly normal psychological mechanisms that involve attention, decision-making, learning, memory and other general cognitive processes - so the mechanisms are not in any way abnormal - only the outcomes of the process are abnormal - so why do we waste research time and taxpayers money trying to look for abnormal neurological mechanisms or medically aberrant signatures of psychopathology when they probably do not exist?

As an experimental psychologist studying learning in nonhuman animals I learnt a lot about inferential experimental methodologies that allowed us to infer cognitive processes in any organism – human or nonhuman. These are the same types of methodologies that are used to understand most human cognitive processes - such as memory, attention, decision-making and learning. What many researchers from a medical background do not grasp is that scientific method allows us to infer the nature and structure of psychological mechanisms without having to know anything about the biological underpinnings of these mechanisms. In fact, whatever medical or biological research does subsequently to psychologists elaborating these mechanisms will merely be to substantiate the infrastructure of these mechanisms – and indeed, as radical as it may seem, it will be very little more than that.

Experimental psychopathologists should have the lead on all research questions to do with the aetiology of mental health problems. Their research is cognitive, experimental, inferential, provides evidence for the causal relationships that underlie the acquisition of mental health problems, and allows the development of testable models of mental health problems – and it’s a hell of a lot cheaper than most other medically driven approaches!

I have recently been heard to say that experimental psychopathology needs a manifesto to enable it to compete with other explanatory approaches to mental health problems such as neuroscience and genetics – well, it does. We need this manifesto to prevent other disciplinary lobbies from monopolizing funding and – most importantly – from hijacking the way we explain mental health problems. Most mental health problems develop out of perfectly natural psychological processes – not medical problems. Understanding those processes in the normal, inferential way that psychologists do research will provide the basis for good mental health research.

As promised, here is another piece from the forthcoming second edition of Psychopathology. This time, here is a new section discussing mental health stigma, its causes, why it matters, and how we can eliminate it.

There are still attitudes within most societies that view symptoms of psychopathology as threatening and uncomfortable, and these attitudes frequently foster stigma and discrimination towards people with mental health problems. Such reactions are common when people are brave enough to admit they have a mental health problem, and they can often lead on to various forms of exclusion or discrimination – either within social circles or within the workplace. In the following sections we will look at (1) what mental health stigma is, (2) Who holds stigmatizing beliefs and attitudes?, (3) What causes stigma? (4) Why does stigma matter? And (5) How can we eliminate stigma?

What is mental health stigma?: Mental health stigma can be divided into two distinct types: social stigma is characterized by prejudicial attitudes and discriminating behaviour directed towards individuals with mental health problems as a result of the psychiatric label they have been given. In contrast, perceived stigma or self-stigma is the internalizing by the mental health sufferer of their perceptions of discrimination (Link, Cullen, Struening & Shrout, 1989), and perceived stigma can significantly affect feelings of shame and lead to poorer treatment outcomes (Perlick, Rosenheck, Clarkin, Sirey et al., 2001).

In relation to social stigma, studies have suggested that stigmatising attitudes towards people with mental health problems are widespread and commonly held (Crisp, Gelder, Rix, Meltzer et al., 2000; Bryne, 1997; Heginbotham, 1998). In a survey of over 1700 adults in the UK, Crisp et al. (2000) found that (1) the most commonly held belief was that people with mental health problems were dangerous – especially those with schizophrenia, alcoholism and drug dependence, (2) people believed that some mental health problems such as eating disorders and substance abuse were self inflicted, and (3) respondents believed that people with mental health problems were generally hard to talk to. People tended to hold these negative beliefs regardless of their age, regardless of what knowledge they had of mental health problems, and regardless of whether they knew someone who had a mental health problem. More recent studies of attitudes to individuals with a diagnosis of schizophrenia or major depression convey similar findings. In both cases, a significant proportion of members of the public considered that people with mental health problems such as depression or schizophrenia were unpredictable, dangerous and they would be less likely to employ someone with a mental health problem (Wang & Lai, 2008; Reavley & Jorm, 2011).

Who holds stigmatizing beliefs about mental health problems?: Perhaps surprisingly,  stigmatizing beliefs about individuals with mental health problems are held by a broad range of individuals within society, regardless of whether they know someone with a mental health problem, have a family member with a mental health problem, or have a good knowledge and experience of mental health problems (Crisp et al., 2000; Moses, 2010; Wallace, 2010). For example, Moses (2010) found that stigma directed at adolescents with mental health problems came from family members, peers, and teachers. 46% of these adolescents described experiencing stigmatization by family members in the form of unwarranted assumptions (e.g. the sufferer was being manipulative), distrust, avoidance, pity and gossip, 62% experienced stigma from peers which often led to friendship losses and social rejection (Connolly, Geller, Marton & Kutcher (1992), and 35% reported stigma perpetrated by teachers and school staff, who expressed fear, dislike, avoidance, and under-estimation of abilities. Mental health stigma is even widespread in the medical profession, at least in part because it is given a low priority during the training of physicians and GPs (Wallace, 2010).

What factors cause stigma?: The social stigma associated with mental health problems almost certainly has multiple causes. We’ve seen in the section on historical perspectives that throughout history people with mental health problems have been treated differently, excluded and even brutalized. This treatment may come from the misguided views that people with mental health problems may be more violent or unpredictable than people without such problems, or somehow just “different”, but none of these beliefs has any basis in fact (e.g. Swanson, Holzer, Ganju & Jono, 1990). Similarly, early beliefs about the causes of mental health problems, such as demonic or spirit possession, were ‘explanations’ that would almost certainly give rise to reactions of caution, fear and discrimination. Even the medical model of mental health problems is itself an unwitting source of stigmatizing beliefs. First, the medical model implies that mental health problems are on a par with physical illnesses and may result from medical or physical dysfunction in some way (when many may not be simply reducible to biological or medical causes). This itself implies that people with mental health problems are in some way ‘different’ from ‘normally’ functioning individuals. Secondly, the medical model implies diagnosis, and diagnosis implies a label that is applied to a ‘patient’. That label may well be associated with undesirable attributes (e.g. ‘mad’ people cannot function properly in society, or can sometimes be violent), and this again will perpetuate the view that people with mental health problems are different and should be treated with caution.

            We will discuss ways in which stigma can be addressed below, but it must also be acknowledged here that the media regularly play a role in perpetuating stigmatizing stereotypes of people with mental health problems. The popular press is a branch of the media that is frequently criticized for perpetuating these stereotypes. Blame can also be levelled at the entertainment media. For example, cinematic depictions of schizophrenia are often stereotypic and characterized by misinformation about symptoms, causes and treatment. In an analysis of English-language movies released between 1990-2010 that depicted at least one character with schizophrenia, Owen (2012) found that most schizophrenic characters displayed violent behaviour, one-third of these violent characters engaged in homicidal behaviour, and a quarter committed suicide. This suggests that negative portrayals of schizophrenia in contemporary movies are common and are sure to reinforce biased beliefs and stigmatizing attitudes towards people with mental health problems. While the media may be getting better at increasing their portrayal of anti-stigmatising material over recent years, studies suggest that there has been no proportional decrease in the news media’s publication of stigmatising articles, suggesting that the media is still a significant source of stigma-relevant misinformation (Thornicroft, Goulden, Shefer, Rhydderch et al., 2013).

Why does stigma matter?: Stigma embraces both prejudicial attitudes and discriminating behaviour towards individuals with mental health problems, and the social effects of this include exclusion, poor social support, poorer subjective quality of life, and low self-esteem (Livingston & Boyd, 2010). As well as it’s affect on the quality of daily living, stigma also has a detrimental affect on treatment outcomes, and so hinders efficient and effective recovery from mental health problems (Perlick, Rosenheck, Clarkin, Sirey et al., 2001). In particular, self-stigma is correlated with poorer vocational outcomes (employment success) and increased social isolation (Yanos, Roe & Lysaker, 2010). These factors alone represent significant reasons for attempting to eradicate mental health stigma and ensure that social inclusion is facilitated and recovery can be efficiently achieved.

How can we eliminate stigma?: We now have a good knowledge of what mental health stigma is and how it affects sufferers, both in terms of their role in society and their route to recovery. It is not surprising, then, that attention has most recently turned to developing ways in which stigma and discrimination can be reduced. As we have already described, people tend to hold these negative beliefs about mental health problems regardless of their age, regardless of what knowledge they have of mental health problems, and regardless of whether they know someone who has a mental health problem. The fact that such negative attitudes appear to be so entrenched suggests that campaigns to change these beliefs will have to be multifaceted, will have to do more than just impart knowledge about mental health problems, and will need to challenge existing negative stereotypes especially as they are portrayed in the general media (Pinfold, Toulmin, Thornicroft, Huxley et al., 2003). In the UK, the “Time to Change” campaign is one of the biggest programmes attempting to address mental health stigma and is supported by both charities and mental health service providers (http://www.time-to-change.org.uk). This programme provides blogs, videos, TV advertisments, and promotional events to help raise awareness of mental health stigma and the detrimental affect this has on mental health sufferers. However, raising awareness of mental health problems simply by providing information about these problems may not be a simple solution – especially since individuals who are most knowledgeable about mental health problems (e.g. psychiatrists, mental health nurses) regularly hold strong stigmatizing beliefs about mental health themselves! (Schlosberg, 1993; Caldwell & Jorm, 2001). As a consequence, attention has turned towards some methods identified in the social psychology literature for improving inter-group relations and reducing prejudice (Brown, 2010). These methods aim to promote events encouraging mass participation social contact between individuals with and without mental health problems and to facilitate positive intergroup contact and disclosure of mental health problems (one example is the “Time to Change” Roadshow, which sets up events in prominent town centre locations with high footfall). Analysis of these kinds of inter-group events suggests that they (1) improve attitudes towards people with mental health problems, (2) increase future willingness to disclose mental health problems, and (3) promote behaviours associated with anti-stigma engagement (Evans-Lacko, London, Japhet, Rusch et al., 2012; Thornicroft, Brohan, Kassam & Lewis-Holmes, 2008). A fuller evidence-based evaluation of the Time to Change initiative can be found in a special issue dedicated to this topic in the British Journal of Psychiatry (British Journal of Psychiatry, Vol. 202, Issue s55, April 2013).

For those of you that would like to test your own knowledge of mental health problems, Time to Change provides you with a quiz to assess your own awareness of mental health problems.

Summary: Hopefully, this section has introduced you to the complex nature of mental health stigma and the effects it has on both the daily lives and recovery of individuals suffering from mental health problems. We have discussed how mental health stigma manifests itself, the effect it has on social inclusion, self-esteem, quality of life and recovery. We ended by describing the development of multifaceted programmes to combat mental health stigma and discrimination.

DSM-5 is at the binders and being prepared for release in May, but I can report that a new Task Force has already begun its preliminary work on its successor, DSM-6.

While the most recent changes to the DSM have been extensively discussed and researched, many of the revisions have been received critically, and the APA has moved rapidly to stymy criticism of DSM-5 by convening a new Task Force that has already reported on some further significant changes to mental health diagnostic criteria that will refine and elaborate on the changes in DSM-5.

The APA has recently confirmed that "Many of the revisions in DSM-5 will help psychiatry better resemble the rest of medicine", but now the aim of DSM-6 is to align psychiatric diagnosis with car maintenance. This will move diagnosis and treatment away from airy-fairy, psychological concepts such as ‘recovery’ to the more practical notion of fixing something that is clearly broken. Pursuing the ‘car maintenance’ analogy, DSM-6 will recommend that everyone should have an annual “road test” to ensure that their mental health is fit for purpose. Failing the test (e.g. by reporting the experience of at least one negative emotion in the previous 12 months) will require compulsory medication for a period to be determined by a panel of experts recruited from salesmen within the pharmaceutical industry.

Other new changes within DSM-6 include:

1.         An increased number and range of prodromal risk factors for mental health problems. These include dementia compulsio – forgetting whether you’ve locked the door and returning to check; risum cacoethes – uncontrollable inappropriate giggling fits – a known risk factor for a number of diagnosable disorders such as delirium, mania and bipolar disorder; anxietatem dentalis - feeling anxious when reading magazines you’ve previously encountered in your dentist’s waiting room, a precursor for a range of irrational fears.

2.         Nose-picking disorder is recognized as a new independent disorder category, along with Gluttony (formerly known as Binge Eating Disorder), and Jealousy (a former sub-type of Borderline Personality Disorder).

3.         The ‘scorn exclusion’ has been removed from the diagnosis of Antisocial Personality Disorder. This allows scorn (or contempt) to be included as a contributor to a diagnosis of Antisocial Personality Disorder.

4.         All criteria for major Depression have been removed and replaced by the single cardinal feature of ‘low mood’. This will allow GPs and physicians to prescribe antidepressants on the basis of an immediate diagnosis rather than – as before – a financial inducement from a pharmaceutical industry rep.

5.         DSM Criticism syndrome is a new psychosis sub-type characterized by delusional beliefs that DSM is not a necessary requirement for helping people to recover from mental health problems and merely provides labels that stigmatize sufferers. People diagnosed with this disorder should not be approached directly because of their revisionist and anti-establishment views. The APA has set a target date of 2020 for the total eradication of this particularly virulent illness.

You can find a much fuller summary of the recommendations for DSM-6 here. When published, DSM-6 is expected to cost in the region of $45,000 a copy.

First published 27/08/2012 at http://grahamdavey.blogspot.co.uk

“Normal science does not aim at novelty but at clearing up the status quo. It discovers what it expects to discover.” – Thomas Kuhn.

I was struck by this quote from Thomas Kuhn last week when reading a Guardian blog about the influential philosopher of science. It’s a simple statement suggesting that so-called ‘normal science’ isn’t going to break any new ground, isn’t going to change the way we think about something, but probably will reinforce established ideas, and – perhaps even more importantly – will entrench what scientists think are the important questions that need answering. Filling in the gaps to clear up the status quo is probably a job that 95% of scientists are happy to do. It grows the CV, satisfies your Dean of School, gets you tenure and pays the mortgage.

But when I first read that quote, I actually misread it. I thought it said “Normal science does not aim at novelty but aims to maintain the status quo”! I suspect that when it boils down to it, there is not much difference between my misreading of the quote and what Kuhn had actually meant. Once scientists establish a paradigm in a particular area this has the effect of  (1) framing the questions to be asked, (2) defining the procedures to answer them, and (3) mainstreams the models, theories and constructs within which new facts should be assimilated. I suspect that once a paradigm is established, even those agencies and instruments that provide the infrastructure for research contribute to entrenching the status quo. Funding bodies and journals are good examples. Both tend to map on to very clearly defined areas of research, and at times when more papers are being submitted to scientific journals than ever before, demand management tends to lead to journal scope shrinkage in such a way that traditional research topics are highlighted more and more, and new knowledge from other disciplinary approaches is less likely to fertilize research in a particular area.

This led me to thinking about my own research area, which is clinical psychology and psychopathology. Can we clinical psychology researchers convince ourselves that we are doing anything other than trying to clear up the status quo in a paradigmatic approach that hasn’t been seriously questioned for over half a century – and in which we might want to question it’s genuine achievements? Let’s just take a quick look at some relevant points:

1.         DSM still rules the way that much clinical psychology research is conducted. The launch of DSM-5 in 2013 will merely re-establish the dominance of diagnostic categories within clinical psychology research. There are some who struggle to champion transdiagnostic approaches, but they are doing this against a trend in which clinical psychology and psychiatry journals are becoming more and more reliant on diagnostic criteria for inclusion of papers. Journal of Anxiety Disorders is just one example of a journal whose scope has recently shrunk from publishing papers on anxiety to publishing papers on anxiety only in diagnosed populations. DSM-I was published in 1952 – sixty years on it has become even more entrenched as a basis for doing clinical psychology research. No paradigm shift there then!

This doesn’t represent a conspiracy between DSM and journals to consolidate DSM as the basis for clinical psychology research – it merely reflects the fact that scientific journals follow established trends rather than create new spaces within which new concatenations of knowledge can emerge. Journals will by nature be a significant conservative element in the progress of science.

2.         There is a growing isolation in much of clinical psychology research – driven in part by the shrinking scope of clinical research journals and the adherence of many of them to DSM criteria for publication. This fosters a growing isolation from core psychological knowledge, and because of this, clinical psychology research runs the risk of re-inventing the wheel – and probably re-inventing it badly. Some years ago I expressed my doubts about the value of many clinical constructs that had become the focus of research across a range of mental health problems (Davey,2003). Many of these constructs have been developed from clinical experience and relate to individual disorders or even individual symptoms, but I’m convinced that a majority of them simply fudge a range of different psychological processes, most of which have already been researched in the core psychological literature. I'm an experimental psychologist by training who just happens to have become interested in clinical psychology research, so I was lucky enough to be able to bring some rather different approaches to this research than those who were born and brought up in the clinical psychology way of doing things. What must not happen is for clinical psychology research to become even more insular and even more entrenched in reinventing even more wheels - or the wheels on the bus really will just keep going round and round and round!

3.         OK I'm going to be deliberately provocative here – clinical neuroscience and imaging technology costs a lot of money - so its role needs to be enshrined and ring-fenced in the fabric of psychological knowledge endeavor, doesn’t it? Does it? If that’s the case – then we’re in for a long period of paradigm stagnation. Imaging technology is the Mars Rover of cognitive science while the rest of us are using telescopes - or that's the way it seems. There are some clinical funding bodies I simply wouldn't apply to for experimental psychopathology research – ‘cos if it ain’t imaging it ain't gonna get funded - yet where does the contribution of imaging lay in the bigger knowledge picture within clinical psychology? There may well be a well thought out view somewhere out there that has placed the theoretical relevance of imaging into the fabric of clinical psychology knowledge (advice welcome on this)! There is often a view taken that whatever imaging studies throw up must be taken into account by studies undertaken at other levels of explanation - but that is an argument that is not just true of imaging, it's true of any objective and robust scientific methodology.

Certainly - identifying brain locations and networks for clinical phenomena may not be the way to go - there is growing support for psychological constructionist views of emotion for instance, suggesting that emotions do not have either a signature brain location or a dedicated neural signature at all (e.g. Lindquist,Wager, Kober, Bliss-Moreau & Barrett, 2012). There are some very good reviews of the role of brain functions in psychological disorders -but I'm not sure what they tell us other than the fact that brain function underlies psychological disorders – as it does everything! For me, more understanding of psychological disorders can be gleaned from studying individual experience, developmental and cognitive processes, and social and cultural processes than basic brain function. Brain images are a bit like the snapshot of the family on the beach - The photo doesn't tell you very much about how the family got there or how they chose the beach or how they're going to get home.

But the point I’m trying to make is that if certain ways of doing research require significant financial investment over long periods of time (like imaging technology), then this too will contribute to paradigm stagnation.

4.         When tails begin to wag dogs you know that as a researcher you have begun to lose control over what research you can do and how you might be allowed to do it. Many researchers are aware that to get funding for their research – however ‘blue skies’ it might be – we now have to provide an applied impact story. How will our research have an impact on society? Within clinical psychology research this always seems to have been a reality. Much of clinical psychology research is driven by the need to develop interventions and to help vulnerable people in distress – which is a laudable pursuit. But does this represent the best way to do science? There is a real problem when it comes to fudging understanding and practice. There appears to be a diminishing distinction in clinical psychology between practice journals and psychopathology journals, which is odd because helping people and understanding their problems are quite different things – certainly from a scientific endeavour point of view. Inventing an intervention out of theoretical thin air and then giving it the facade of scientific integrity by testing to see if it is effective in a controlled empirical trial is not good science – but I could name what I think are quite a few popular interventions that have evolved this way – EMDR and mindfulness are just two of them (I expect there will be others who will argue that these interventions didn't come out of a theoretical void, but we still don't really know how they work when they do work). At the end of the day, to put the research focus on ‘what works in practice’ takes the emphasis away from understanding what it is that needs to be changed, and in clinical psychology it almost certainly sets research priorities within establishment views of mental health.

5.         My final point is a rather general one about achievement in clinical psychology research. We would like to believe that the last 40 years has seen significant advances in our development of interventions for mental health problems. To be sure, we’ve seen the establishment of CBT as the psychological intervention of choice for a whole range of mental health problems, and we are now experiencing the fourth wave of these therapies. This has been followed up with the IAPT initiative, in which psychological therapies are being made more accessible to individuals with common mental health problems.  The past 40 years has also seen the development and introduction of second-generation antidepressants such as SSRIs. Both CBT and SSRIs are usually highlighted as state-of-the-art interventions in clinical psychology textbooks, and are hailed by clinical psychology and psychiatry respectively as significant advances in mental health science. But are they? RCTs and meta-analyses regularly show that CBT and SSRIs are superior to treatment as usual, wait-list controls, or placebos – but when you look at recovery rates, their impact is still far from stunning. I am aware that this last point is not one that I can claim reflects a genuinely balanced evidential view, but a meta-analysis we have just completed of cognitive therapy for generalized anxiety disorder (GAD) suggests that recovery rates are around 57% at follow-up. Which means that 43% of those in cognitive therapy interventions for GAD do not reach basic recovery levels at the end of the treatment programme. Reviews of IAPT programmes for depression suggest no real advantage for IAPT interventions based on quality of life and functioning measures (McPherson,Evans & Richardson, 2009). In a review article by Craske, Liao, Brown & Vervliet (2012) that is about to be published in Journal of Experimental Psychopathology, they note that even exposure therapy for anxiety disorders achieves clinically significant improvement in only 51% of patients at follow-up. I found it difficult to find studies that provided either recovery rates or measures of clinically significant improvement for SSRIs, but Arroll et al (2005) report that only 56-60% of patients in primary care responded well to SSRIs compared to 42-47% for placebos.

I may be over-cynical, but it seems that the best that our state-of-the-art clinical psychology and psychopharmacological research has been able to achieve is a recovery rate of around 50-60% for common mental health problems - compared with placebo and spontaneous remission rates of between 30-45%. Intervention journals are full of research papers describing new ‘tweaks’ to these ways of helping people with mental health problems, but are tweaks within the existing paradigms ever going to be significant? Is it time for a paradigm shift in the way we research mental health?