Why Parity of Esteem is Not Enough

This blog post was originally published at: http://www.huffingtonpost.co.uk/ed-pinkney/mental-health-parity-of-esteem_b_6183118.html

Mental health campaigners have been given cause for optimism recently thanks to increasing political discussion about underfunded mental health services. Whilst we can be thankful that such conversations are being entertained, there is cause to be wary of the rhetoric if we consider real implications to those at risk of mental health problems.

In 2011, the UK government published a mental health strategy which referred to the goal of giving “equal weight to both mental and physical health”. Others, including the Royal College of Psychiatrists, have talked about achieving “parity of esteem” between mental and physical health. These expressions may have captured public attention, but as an article published last week in the British Medical Journal pointed out, the phrasing is simple to the point of simplistic.

Any armchair philosopher can question the logic of the rhetoricians’ suggestion that the ‘mental’ is somehow distinct from the ‘physical’. To do so can be seen as uncharitable; pedantry that misses the point. Those using the expression would say that their aim is only to draw attention to the underfunding of mental health services; and with mental health services having been dangerously slashed, such efforts should be applauded and given full public support.

Having said that, while we engage in topical conversations about mental health, we must not allow ourselves to ignore symptoms of an underlying problem. Health services need to appreciate the deep interrelatedness of mental and physical health; at present they don’t, and the rhetoric doesn’t help.

The largest health burden facing the world this decade involves non-communicable diseases such as heart-disease, cancer, and diabetes. A better collective term is ‘stress-related disorders’, since they are all either caused by, or associated with, chronic stress (or lifestyle patterns related to chronic stress, such as smoking, unhealthy diets and alcohol consumption). Meanwhile, researchers are continuing to shed light on the gut-brain axis that shows how fundamental the links are between intestinal conditions and psychological health – and that’s before we get into comorbidity of mental and physical illness.

Modern medical science is increasingly revealing mental and physical health to not be separate yet interrelated domains, but rather two ways of viewing a single system. A health service that appreciated this wouldn’t encourage the idea that mental health services sit apart from other health services; it would do everything it could to strengthen pathways between the two, alongside a longer-term aim of embedding a consideration for mental health deep into every corner of the health service and every module of medical training.

Calling for mental health to be on an equal level with physical health doesn’t necessarily run counter to the aim of bringing mental and physical health services closer together. It can increase funding for mental health treatments. It can increase awareness of mental health at GP level. But it can also conjure up a combative image of mental and physical health as being in competition with one another, straining the already thin bonds between the two service areas. With a health system already under pressure, discord is the last thing needed.

That there should be wariness about bringing mental and physical health services closer together is understandable. The mind is a variable that’s hard to control for in medical studies. We just about manage to recognise its influence on the body with accounts of the placebo affect, but barely so. Going much further than this is scary; it draws us towards unchartered academic waters and requires us to traverse the borders between academic disciplines. Perhaps it also moves us towards a more preventative approach to health that might be seen as a threat to traditional institutional structures and finances.

In the field, it’s already being done. Encouragement can be taken from pragmatic examples like the use of cognitive-behavioural therapy in bowel disorders and social-prescribing in mental health (such as recommending forms of exercise for moderate depression). But these are still very much on the fringes. We need more of this kind of crossover at a strategic level; this whole-systems thinking that the World Health Organisation has been talking about, for 28 years already. We also need to look at alternative ways of categorising services.

The idea of dividing the mental and physical has deep roots, going back to Ancient Greece with Platonic ideas of conflicting poles and dichotomies. Perhaps the categorical thinking that gave rise to the ‘mind-body problem’ helped fuel Western progress and moved us ahead of the softer wholism of the East for half a millennia, but, right now, it threatens to stunt our health system.

So while the prospect of more funding for mental health services is a good thing, it’s no real victory if mental and physical services are not brought into unison. A health system that was in tune with medical science would have mental wellbeing at its core. But it would also see the body and mind as a single system. And, as with all systems, if you neglect one aspect then you affect the whole.