I aim to identify some of the mental health workforce's credibility issues in this article. This may inform your prevention and treatment strategy as a mental health consumer, or your practice if you work in mental health.

Mental health is the strongest determinant of quality of life at a later age. And, the pursuit of happiness predicts both positive emotions and less depressive symptoms. People who prioritize happiness are more psychologically able. In times of crises, some turn to the mental health system for support. But, how credible is the support available? Here are 10 categories of shortcomings that the mental health sector faces today:

 

1. Institutional credibility

 

Headspace's evaluations indicate it’s ineffective and they are evaluated better than many services out there. This isn’t academic, attendees who report that their mental health has not improved since using the service will trust the mental health system less, and with good reason.

 

2. Network credibility

 

There is an evidence base for the selecting a type of therapy (psychodynamic, cognitive-behavioural, etc) for a particular constellations of mental symptoms. If you work in mental health, have you ever made a referral on the basis of both symptomatology and theoretical orientation?

 

3. ‘Walk the talk’ credibility

 

Social workers, nurses, social workers medical doctors, and psychiatrists abuse substances and incur mental ill-health at among the highest rates of any occupation. For instance, the psychiatrist burnout rate is 40%. Mental health consumers may perceive clinicians as hypocritical or unwilling (...or too willing) to swallow their own medicine.

 

4. Academic credibility

 

Psychology is mired by error-riddled research and myth-ridden textbooks. Broadly, most published research is wrong. And, questionable research practices are common which bias the relevant evidence.

 

The difference between a well designed experiment and a poorly designed psychotherapy experiment is large. To quote the pseudonymous physician Scott Alexander:

 

‘Low-quality psychotherapy trials in general had a higher effect size (SMD = 0.74) than high-quality trials (SMD = 0.22), p < 0.001"...Effect sizes for the low quality trials are triple those for the high-quality trials.’

 

5. Credibility of treatments

 

Are treatments are becoming less effective over time? Cognitive behavioural therapy is a common treatment for various mental illnesses. It is the most researched psychotherapy. However, the more evidence piles up, the less effective that psychotherapy appears to be...the same goes for antidepressants.

 

Why are outdated treatments still used? Over the 19th and 20th Centuries, Austrian neurologist Sigmund Freud famously founded ‘psychoanalysis’. Psychoanalysis is a school of psychotherapy that together with other 'psychodynamic' psychotherapies focused on early experience on human behaviour and emotion. Freud's ideas challenged fundamental assumptions about human psychology. In particular, he suggested that our conscious mind is the just the tip of iceberg of our identities.

 

Today Freud is the subject of jokes and derision. Many of his testable ideas have been proven false.  'When tested, psychoanalysis was shown to be less effective than placebo.’  Yet, many psychologists and psychiatrists continue to practice psychoanalysis.

 

Psychology is a rather unsettled science. One estimate for the time after which half of the ‘knowledge’ in the field of psychology is overturned or superseded (it’s ‘half-life’) is at just 7.5 years. Interestingly, this time-span appears to be falling. That would suggest the field is becoming increasingly less reliable. The subfield of psychoanalysis bucks the trend. It has over double the parent field’s half-life. Why?

 

How do other subfields of psychology fair? Psychopharmacology is at the intersection of psychiatric drugs and brain chemistry. Knowledge in psychopharmacology is overturned at a rate higher than the rest of the field in general. Typically the ‘half life of knowledge’ argument aims discount psychology relative to ‘harder’ sciences like physics.

 

Psychological therapies are confusing and unnecessarily fragmented: According to The Handbook of Counseling Psychology:

 

‘Meta-analyses of psychotherapy studies have consistently demonstrated that there are no substantial differences in outcomes among treatments.’

 

Meta-analyses are a kind of research technique that quantitatively puts together many pieces of individual relevant research on a particular topic. There is 'little evidence to suggest that any one psychological therapy consistently outperforms any other for any specific psychological disorders.

 

This is sometimes called the 'Dodo bird verdict' after a scene/section in Alice in Wonderland where every competitor in a race was called a winner and is given prizes'. So, what is one to make of the best vetted clinical guidelines that indicate that particular therapies are more appropriate for particular mental conditions?

 

Guidelines are considered a higher order of evidence than a ‘handbook’ to some, and vice-versa for another. Could an expert or indeed an amateur credibly lead someone to conclude that all therapies are ‘equal’ or ‘different’ armed with either body of evidence? Could a similar case be made for say, antibiotics? Yes, or so the evidence suggests in the case of antibiotics, actually.

 

Finally, psychological therapies are administered haphazardly. Eclectically combining elements from different psychological therapies is inefficient. But, it happens. Clinicians should ‘integrate’ components of different psychotherapies using established formulae, if they want to ‘mix and match’. When I hear someone’s theoretical orientation is ‘psychodynamically informed’ or similar, for me that’s a red flag for eccelectisms.

 

6. Economic credibility

 

Therapists have a financial incentive to re-traumatise patients.

 

7. Social credibility

 

'The benefits of psychotherapy may be no better than the benefits of talking to a friend'.

 

8. Credibility of counsel

 

Mental health professionals offer their clients and the community general counsel and advice. But, if I was to ask a given mental health professional about the value of kindness or love of learning they would almost certainly indicate it’s worthwhile. Pop psychology is pervasive. And why not, people have been interested in psychology long before it was a science. But, misconceptions about psychology infiltrate mental health care practice.

 

Researchers who have reported on the character traits of people with high and low life satisfaction found something like this:

 

 

Meanwhile, research that separates their findings by gender looks different

 

Character strengths that predict life satisfaction

 

 

Would you receive nuanced, evidence-based advice when soliciting general counsel from your treatment provider?

 

9. Practitioner credibility

 

Consider the therapist factors that relate to a patient's success in therapy:

 

 

Are mental health services hiring based on the factors that predict a consumer’s success in therapy? Are they training for the right skills, and ignoring those that are irrelevant?

 

10. Diagnostic credibility

 

Imprecise measurement and lack of gold standards for validating diagnoses means that definitions tend to drift over time, even though, per the evidence, response to treatment does not vary across culture.

 

45% of Australians will experience mental illness over their lifetime. Whether that mental ill-health is transient, long-term or lifelong matters to the individual and for public health. To illustrate: experts suggests that those who have had 2 depressive episodes in recent years, or three episodes over their lifelong to get treated on an ongoing basis to prevent recurrent depression.

 

'At least 60% of individuals who have had one depressive episode will have another, 70% of individuals who have had two depressive episodes will have a third, and 90% of individuals with three episodes will have a fourth episode. '

- APA 

 

Without reliable diagnoses, how can one estimate their risk of relapse into depression?