Recently Diabetes UK have been running an advertising campaign that sits uneasily with me and with a lot of my friends. In their posters they show images of people hugging their loved ones and crying, with slogans such as ‘If not for you then for your family’ and ‘so you and your family don’t suffer‘. The idea seems to be that people in high-risk groups should get tested early for diabetes so that they can do something about it before amputation, blindness, heart problems or other health implications mean that they become a burden on their loved ones.
My immediate reaction was to feel angry that this – otherwise excellent – charity was using guilt tactics to frighten people into action. I also disliked the implication that other people might have so much power over what somebody chooses to do with their own body.
However, I had to reflect that – when it comes to mental rather than physical health – I have used a somewhat similar argument myself. I am a great believer that we all need to build some form of self-care into our lives in order to be in an okay place emotionally and psychologically. It is when I don’t have a moment to myself that I get overwhelmed when stressful things happen, respond badly to conflict, or make mistakes at work. Similarly, clients who I work with in therapy are often constantly engaged with work, family and friends. When I encourage them to build in time for a ‘daily kindness’ to themselves, or for quiet reflection, the major block that they frequently come up against is all their obligations to other people in their lives. They don’t want to let down their managers and colleagues, their partners and parents.
For many of us the argument that we will feel better if we look after ourselves doesn’t get very far because we see self-care as being self-centred or as spoiling ourselves. When we’re depressed we don’t feel that we deserve this. Or perhaps it doesn’t fit the self-sacrificing image that we want to have of ourselves.
However, the realisation that we will be better for the other people in our lives is often the thing that helps us to make that first small shift towards building in some time for self-care. For example, we might notice that a small amount of self-care can leave us less exhausted, more able to hear other people, and better able to manage extra pressures. We might also see that we are a better role-model for others in our lives if we demonstrate that we are able to say ‘no’ to things or to prioritise looking after ourselves.
So how is this different to the Diabetes UK argument that people should take steps towards better physical health in order to be in a better place for their loved ones? I think it comes down to the complex tension that we all face that we are, at the same time, independent individuals, and unavoidably involved in interdependent relationships with the other people in our lives. There are a few elements of this that I want to tease out here, but I don’t think there are any easy answers. Rather I hope that this blog post might be a starting point for people who want to talk about such matters, and that it will set out some of the territory in a way that is helpful.
Guilt doesn’t work
The main difference that I can see between the Diabetes UK campaign and the conversations that I have with clients (and with myself!) is the direction of travel. With clients I encourage them to explore the implications – for themselves and for others – of the ways in which they are currently living their lives. I might suggest that they experiment – for example with building in a daily kindness or a little time to themselves into the day – and report back on what the experience is like, including what was difficult about it. I’d certainly explore what kinds of self-care they had found helpful – and not – in the past, and what it meant to them. And I would be open to the likelihood that this person would be different to me in terms of what counted as ‘self-care’ anyway, and how they experienced it.
What I’m saying is that it would be a collaborative conversation, and the client would be the expert on what works for them – not me. This is in contrast to campaigns that suggest that you are being bad for your loved ones. The implication of such campaigns seems to be that it is a relatively simple matter to get tested and to make the necessary lifestyle changes, and that recognising that we might be bad for our family is enough to make such changes happen.
These tactics are dangerous. Back in the 1980s scare tactics were frequently used in the ‘safe sex’ campaigns around condoms and HIV. As this Sigma report points out, the risk of using fear in this way is that people will come to associate condoms themselves with fear (rather than HIV) and will actually be less, rather than more, likely to engage in safer sex behaviours.
I imagine that the same is the case with guilt-based campaigns. At-risk people viewing these posters are likely to already have anxiety about their health. Adding guilt to this could easily lead to them feeling overwhelmed and even more worried about finding out whether they actually have diabetes. Similarly, making any potential lifestyle changes could become associated with feelings of guilt and fear of failure: it could easily feel safer to do nothing.
Personal meanings: We’re all sensible
Vitally, guilt and fear based campaigns fail to address the personal meanings behind people’s behaviours. Most of us have a fairly good idea these days about what constitutes healthy and less healthy behaviours. So when we do something less healthy (such as failing to build self-care, or physical activity, into our lives, or having unsafe sex) there are good reasons for this. If we just nag people – telling them that they should meditate, for example, or go to the gym, or put on a condom, then we are ignoring these reasons and giving them the message that they are faulty or deficient for struggling in this area (more guilt). This is what we often do to ourselves – of course – when we beat ourselves up for not exercising more, or eating less, or taking up yoga, or whatever, without trying to really understand why this might be difficult for us.
An alternative approach would be to assume that we – and others – are sensible people, so if we are doing something that seems irrational, we need to listen and explore more in order to understand how it makes sense. Perhaps a person has learnt that the only way to feel valuable is to work as much as possible, and that doesn’t leave space for self-care or exercise. Perhaps food has become such an important way of controlling a person’s emotions that the idea of eating more, or less, would be very threatening (taking this strategy away). Maybe someone has internalised the cultural messages that it is vital to be sexy, attractive and desirable, and they are willing to put themselves in risky situations if it validates this view of themselves.
Even these are oversimplifications, and there are likely to be many things going on for all of us in our relationships with food, time alone, physical activity, work, sex, and so on.
The danger with guilt and fear-based campaigns – and when we nag, berate or criticise ourselves and our loved ones – is that we make it less, rather than more, likely that people will be able to kindly, and gently, explore these individual meanings and the very personal fears and desires behind them. Without such understanding I doubt that lasting change is possible, and a continual pattern of trying and failing will likely make things worse rather than better.
Sidebar: Physical and mental health
I realise that I’ve been writing here about physical and mental health – running together things like depression and diabetes. I think that this might be useful because the kinds of underlying behaviours that we are talking about impact on both our physical and mental health, e.g. physical activity, food, sleep, work, self-care, etc.
Also, as we’ve seen, physical and mental health are pretty inextricably linked. Our past experiences, the messages we’ve taken on board, and related feelings like guilt, worry, fear, irritation, and envy are interwoven with our physical health in many ways: from how we feel when we get sick, to our reaction to various potential ‘health behaviours’, to our immune function and likelihood of having accidents.
Of course, in all cases, there are also likely genetic factors and other physiological – and external – aspects involved that we have little or no control over. But the parts that campaigns like the diabetes one, and counsellors working with depression, are trying to address are the parts that we can do something about ourselves – in addition to any medical treatments. Also, of course, whether or not we access screenings, treatments, etc. is an aspect of that controllable part.
However, it is worth also remembering how much of our physical and mental health is out of our control. We can easily spend our whole lives having a go at our partner who smokes, and our kid who goes motorcycling, only to be the one who is struck down by totally unanticipated accident, chronic condition, or period of despair. Perhaps part of our desire to believe that we – and others – are responsible for our health comes from the existential anxiety we all have about the inevitability of sickness, suffering and death.
Useful conversations: What can we offer? What do we expect?
It seems like what I’ve concluded here is that it’s good for us to decide – ourselves – to address our physical/psychological health in whatever ways we can, but that it is definitely not so good (indeed perhaps even counterproductive) to tell somebody else that they need to do so. This is where my discomfort with the diabetes advert comes in: it is not inviting somebody into a conversation about what they would like to do with their body, rather it is telling them what to do (or else!)
However, questions then come to my mind about what we do when other people in our lives don’t address their health – in whatever way – and that does have serious implications for us.
What about the colleague whose difficulties with stress get in the way of our joint projects? Or the partner whose risky behaviours have implications for our own safety? The friend whose aggression has alienated all their other friends, leaving us the only person to pick up the pieces each time they get in trouble? Or the housemate who goes out all night and is therefore never around to help with the chores and is too tired and run down to have a conversation about it
On the one hand whatever a person does can be viewed as sensible if we are willing to really listen and try to understand. On the other hand, what do we do if the person isn’t up for listening and trying to understand themselves? Or if they’ve done so and still continue with some behaviour that feels difficult to us. Should we accept any behaviour, even if it leaves us resentful and angry? Surely that isn’t very helpful either?
A tentative suggestion here is that it might be useful to communicate about the kind of relationship that you have and how that might shift if it there is such a tension.
We tend to take for granted what it means to be a colleague, partner, friend, housemate, child, parent, sibling, etc. and what responsibilities come with that. But none of this is set in stone. It is often the assumptions that are the problem here. We might assume, for example, that if our parent became sick they would come and live with us for the rest of their lives. Then we might feel like we should be very involved in any decisions that they make about their health. However, this may not be in their plans at all, and/or there may be many other possibilities that we could explore together.
Of course we can’t always know how we will feel in the future – especially if a mental and/or physical health crisis happens – but it might be worth having some conversations about what you think you could offer to people in your life under various circumstances.
Certainly if we get married it is worth discussing what ‘in sickness and in health’ means to each person. For example, does it mean ‘in sickness and in health provided that I know you’ve done as much as you can to stay healthy’, or ‘in sickness and in health physically but I know I really can’t cope with serious mental illness because of my own history’, or ‘in sickness and in health as long as our relationship could adapt that I’d still get my needs for socialising/sex met if you got ill’, or ‘in sickness and health as long as we cultivate a good group of friends who’ll be there to support us too’.
Also, of course, these things are likely to have different meanings for each person, so it may well be that what the other person has to offer is not the same as what we could offer ourselves. It might be that one of us can promise that we’ll be great in an emotional crisis but are likely to struggle with anything involving blood, whilst the other can confess that they really struggle with sudden changes but can be very patient with long-term conditions involving gradual shifts.
And, of course, it is only in marriage that the ‘sickness and health’ discussions come up at all. Perhaps it would be a good idea to open up such conversations with other people in our lives, despite there being less obvious contexts for doing so.
I suppose that what I’m reaching for here is something that respects both our own – and the other person’s – freedom whilst recognising the ways in which we are inevitably bound together and impact on one another. I’m trying to capture the ways in which we have some control over our physical/mental health whilst recognising all of the ways in which it is out of our control. I’m seeking to respect each person’s choices – both around their own bodies and feelings – and around the limits that there might be on what they can offer.