The evidence‐based group‐level symptom‐reduction model as the organizing principle for mental health care: time for change?

Abstract

The content and organization of mental health care have been heavily influenced by the view that mental difficulties come as diagnosable disorders that can be treated by specialist practitioners who apply evidence-based practice (EBP) guidelines of symptom reduction at the group level. However, the EBP symptom-reduction model is under pressure, as it may be disconnected from what patients need, ignores evidence of the trans-syndromal nature of mental difficulties, overestimates the contribution of the technical aspects of treatment compared to the relational and ritual components of care, and underestimates the lack of EBP group-to-individual generalizability. A growing body of knowledge indicates that mental illnesses are seldom "cured" and are better framed as vulnerabilities. Important gains in well-being can be achieved when individuals learn to live with mental vulnerabilities through a slow process of strengthening resilience in the social and existential domains. In this paper, we examine what a mental health service would look like if the above factors were taken into account. The mental health service of the 21st century may be best conceived of as a small-scale healing community fostering connectedness and strengthening resilience in learning to live with mental vulnerability, complemented by a limited number of regional facilities. Peer support, organized at the level of a recovery college, may form the backbone of the community. Treatments should be aimed at trans-syndromal symptom reduction, tailored to serve the higher-order process of existential recovery and social participation, and applied by professionals who have been trained to collaborate, embrace idiography and maximize effects mediated by therapeutic relationship and the healing effects of ritualized care interactions. Finally, integration with a public mental health system of e-communities providing information, peer and citizen support and a range of user-rated self-management tools may help bridge the gap between the high prevalence of common mental disorder and the relatively low capacity of any mental health service.

Priorities and preferences for school-based mental health services in India: a multi-stakeholder study with adolescents, parents, school staff, and mental health providers

“…Adolescent respondents preferred a warm, relatable, empathic, and non-judgmental counsellor who ensured confidentiality, and provided a safe and private space for adolescents to share their problems. This is consistent with a large body of international research demonstrating the primary importance paid by young people (and service users more generally) to 'non-specific' relational aspects of mental health care (Butler, 2007;Persson et al 2016;Van Os et al 2019). Relatedly, studies from high-income countries have shown that face-to-face therapy may be preferred by adolescents over pure self-help and remotely delivered formats (Farrand et al 2006;Bradford & Rickwood, 2014).…”

The Italian ICD-11 field trial: clinical utility of diagnostic guidelines for schizophrenia and related disorders

“…Although being positive, clinicians considered the guidelines less useful for treatment selection, assessment of patients' prognosis, communication with other health professionals and education of patients and their relatives about their condition. This finding is in line with the field trials carried out for the development of ICD-10, DSM-IV, and DSM-5 [3] and could be due to the fact that many psychiatric treatments are trans-nosographic and are not guided only by patients' diagnosis [21,44]. Nevertheless, clinicians' ratings on the usefulness of the ICD-11 diagnostic guidelines for treatment selection, prognosis, and communicating with patients and families were substantially higher compared to those reported by clinicians using the ICD-10, the DSM-IV or the DSM-5 [3].…”

Internet-delivered cognitive-behavioral therapy for significant others of treatment-refusing problem gamblers: A randomized wait-list controlled trial.

“…Over the years, there have been many debates about what outcomes we should focus on. Some have questioned the symptom-reduction model, and argued that the focus should be on transsyndromal symptom reduction such as resilience and social participation (Os, Guloksuz, Vijn, Hafkenscheid, & Delespaul, 2019).…”