This long read covers what we know about mental health, and why I think that distinguishing between those who are, and are not, mentally ill, is unhelpful.
I recently heard Saroj Datta give an update on the latest evidence regarding the interactions between genes and the environment in relation to mental health. Saroj was involved in the OU science course on mental health which takes a ‘biopsychosocial’ approach to the issue, and her talk demonstrated just how impossible it is to tease apart those elements: bio, psycho, and social (which is why they are combined into one word).
I already knew about ‘neuroplasticity‘: the fact that the way our brains connect up changes over the course of our lives depending on the experiences we have (this is the way that we learn, of course, but we often forget this and regard brains as static and unchanging). Saroj presented evidence that there is also flexibility on a genetic level. Whilst the set of genes in every cell in our body remains fixed, whether they are ‘switched on’ or ‘express themselves’ is not. Animal studies have shown, for example, that a glucocorticoid receptor gene tends to remain switched off, leading the animal to be fearful and anxious, unless the mother displays nurturing behaviours (due to not being anxious herself) in which case it is switched on, leading to pups who are calmer and less stressed. This research is in its early stages, and needs to be treated with caution when applied to humans of course.
Human research supports the genetic-envionmental interaction, finding that, for example, rates of depression are high when a particular allele of a gene is present and someone has experienced three or more stressful life events, but lower if just that allele, or just the life events, are present. It is the interaction between genes and environment that is vital. There have been similar findings in relation to childhood maltreatment. However, it is important to remember that some people were still depressed without those particular elements in the place (either that gene allele, those life events, or the two together): so this is not the whole picture. Also there is unlikely to be any one single gene involved in any element of human behaviour, but rather many.
Saroj suggested that such ‘epigenetic’ changes are potentially reversible and it has been suggested that this, and neuroplasticity, may explain why there are multiple different routes to repair and recovery.
My own interest has been mainly about the social end of the biopsychosocial composite, but it is vital to remember that this is as impossible to tease apart from the rest of it as the bio end is. The ways in which the society in which we live understands, and treats, people, is vital to the way in which we understand and treat ourselves. And one of the main things our society currently does is to split apart the biopsychosocial in a deeply problematic way when understanding issues of distress or ‘mental health’.
Why I don’t like the 1 in 4 statistic
It is important to say, before I start, that here I am absolutely not doubting the existence of severe distress, or the toll that it can take on people who are struggling and those around them. Rather I am questioning the way that we currently categorise and work with such experiences, and the role of wider culture in them (which so often gets missed).
What sparked this line of thinking, for me, was a series of adverts a few years back under the Time to Change campaign about mental health, which was put together by the Institute of Psychiatry, Mind, and several other mental health organisations, with the aim of ending mental health discrimination. The adverts featured celebrities such as Stephen Fry and Ruby Wax speaking openly about their own experiences of distress, and many quoted the ’1 in 4′ statistic. For example, the poster with Stephen Fry on it said: ’1 in 4 people, like me, have a mental health problem. Many more people have a problem with that.’ Ruby Wax’s said ’1 in 5 people have dandruff. 1 in 4 people have a mental health problem. I’ve had both.’
Clearly the statistic was intended to raise awareness of the commonality of mental health problems and to decrease the stigma of those experiencing them. However, I feared that it was in danger of doing quite the opposite.
The 1 in 4 figure is problematic anyway as it is not clear where the figure actually comes from. Of the few studies which have found something like this figure, some have been measuring families rather than individuals, mental health has been measured in various different ways, and it is unclear whether we are talking about, for example, 1 in 4 people at some point during their life, or 1 in 4 people in the last year, or 1 in 4 people at any given point in time.
However, for me, the bigger problem is the potential impact of the figure. 1 in 4 suggests that 75% of the population do not experience mental health problems. That is a substantial majority. The danger is that this situates people with mental health problems as ‘them’ (compared to ‘us’ who don’t have any such problems). As we know very well in psychology, the creation of any kind of ‘us and them‘ situation increases, rather than decreases, likelihood of discrimination.
Most of us will experience some form of abuse in childhood (if we include ‘bullying‘ by peers, which I think we definitely should); all of us will experience life events such as bereavement of a loved one in adulthood which tend to result in a period of high distress; not to mention the existential givens of life which we all struggle with. Given this, is ‘ill or well’ a useful model at all?
The common dichotomous understanding which I see amongst counselling clients, friends, and students alike when they are talking about their own – and other’s – experiences of distress and suffering is as follows:
I’m ill – I need help – it’s not my fault
I’m not ill – I don’t get help – it is my fault
People commonly feel, deeply and certainly, that these are the only two possible places to be: ill or not ill, and that the other aspects presented here follow from that. Not only is this a splitting up of the unsplittable biopsychosocial which I mentioned in the previous post. It also suggests that there are only two options: biology or choice (social doesn’t even come into it). Mental health problems are seen as an individual – frequently physiological – problem which requires treatment (commonly drugs, sometimes also therapy) to fix. However, if there is no evidence of such an individual problem (if no diagnostic label fits, for example, or if there is suspicion that they are not suffering enough) then the person cannot be ill and therefore any struggles must be their own fault.
This way of understandings things is problematic on all levels. It prevents many people with distress from admitting it because, if they do admit it, they will have to give up control, take on a victim/ill identity, and open themselves up to stigma and discrimination. Those who embrace diagnosis may be disempowered (due to the sense that they can’t help themselves and must require expert help). They may feel that they have to take certain treatments (often drugs) because of the common idea that mental health problems are biologically caused and must be biologically treated, despite the question marks which still exist over whether, and how, such drugs work and whether they are the most appropriate way of addressing such issues in all cases (not to mention the vested interest of ‘big pharma‘ in perpetuating this particular understanding). There is no room here for sociocultural explanations or for more complex involvement of personal agency.
Also, many people oscillate between the two positions as neither side really captures the complexities of human distress. This means that those who don’t identify as having a mental health problem are haunted by the fear that perhaps there is something terribly wrong with them which needs fixing (and hiding this fear, and any signs that they might be struggling, puts them under immense pressure). Those who do embrace a label such as ‘depression’ are often haunted by a huge sense of guilt that maybe they are not really ill and maybe this is all their fault and they are totally to blame (which massively exacerbates any suffering they were already experiencing).
This puts people in a horrendous double-bind when it comes to speaking about their own, inevitable, distress and struggles in life. If we openly disclose as ‘depressed’, for example, (as many people did on the recent ‘world mental health day‘) we run the risk of reinforcing this ill/well split such that those who do not embrace such an identity feel their struggles going unacknowledged and the pain of that invisibility. If we keep quiet about our distress, or resist such labels, then we can equally reinforce the ill/well split as we are read as ‘well’ by those around us.
We need to move to more biopsychosocial model of distress. We need to recognise that distress – in its various forms – happens for complex multiplicity of reasons, and that we can have a personal role in exacerbating and ameliorating it, but that acknowledging such a role does not mean that we are totally ‘to blame’ or ‘at fault’. We need to understand that we can all access support rather than it being something only for a certain few, and that different things work for different people at different times. We need to challenge either/or illness/wellness dichotomies and to consider other possible models and metaphors for distress.
Previously I said a lot about why people who are suffering might want to embrace a diagnosis of a mental health problem. After this, I will say more about why practitioners may be wedded to this way of working with distress. Here I will outline some problems with diagnosis in general.
As I mentioned, for people who are struggling, diagnosis is often seen as the only option other than seeing themselves as totally ‘to blame’ for their own distress. Also, it may be the only way to access support and community, and to be taken seriously by employers and others whose understanding they may need as they are struggling. Given that this is the world we currently live in, it is important for those who are critical of diagnosis not to impose that on others. Rather we might explore, with them, the potential losses and gains of taking on a diagnostic label (something explored in the Open University counselling module). Common losses which people express are that no label fits them perfectly, that – if they do embrace a label – they feel trapped by it (that this is all that they are are all that they’ll ever be), and that they are treated differently by other people.
Irving Yalom points out this problem with diagnosis, that it easily fixes people (the way that a kiln fixes a pot) and can prevent us from treating people as whole, complex human beings. Rather, it is easy for professionals to see people as a ‘bipolar’ for example, or as a ‘borderline personality disorder’ (assuming that that category is all that they are, and that this person will be the same as other people in that category). Actually there can be multiple diverse meanings for people who fall into the same category which it is vital to explore. Take agoraphobia, for example, which involves fear of being outside the home. This could be about a fear of social contact, a sense of shame about oneself, an oversensitivity to noise, a genuine concern around violent attack (racist or homophobic, for example), an inflated concern over the risk of crime, superstitious fear of an accident happening, worry over one’s own capacity for anger and violence with others, or many other things (and combinations of things).
The point about fixing people is supported by the famous Rosenhan study ‘on being sane in insane places‘ which was conducted in the 1970s. He got a group of people to present to psychiatrists. They didn’t wash for three days and said that they heard the word ‘thud’. All were admitted to hospital and all were diagnosed with schizophrenia (except one who presented to a private clinic who was diagnosed as manic depressive, which is telling about class and diagnosis). Once admitted, the people said that they were fine and didn’t report any further symptoms. Nonetheless they were kept in for weeks at least and their behaviours were still read as ill or disordered. For example, queuing up for lunch early because they were bored was labelled ‘oral acquisitive syndrome’ and making notes was labelled ‘compulsive writing behaviour’. Science writer, Lauren Slater, repeated the study in the early 2000s herself. She didn’t get admitted, but was diagnosed and medicated by everyone she presented to, reflecting shifts in understanding and treating mental health problems.
Clinical psychologist, Richard Bentall, has pointed out the incoherence of many diagnostic categories: It is possible for two people, categorised in the same way, to have completely different clusters of symptoms. Some symptoms which are generally seen as signs of mental illness, such as hearing voices, are experienced by many people and are not always viewed as problematic.
Also, there are issues with the cultural and historical specificity of diagnosis. The classic example of this is the fact that homosexuality was included as a disorder in the DSM until 1973 and in the ICD until 1992. Other consensual sexual behaviours which are considered ‘outside the norm’ (such as fetishes, sadomasochism and transvestism) are still listed despite lack of evidence linking them to distress and calls for them to be removed.
This raises the question of to what extent diagnosis of disorder represents individuals being in conflict with the norms of society rather than a genuine pathology. There are many other examples of this. For example, the ‘sexual dysfunctions‘ are categories for people who don’t have the amount, or type, of sex that they are expected to have by wider society. Categories of ‘premature ejaculation’ and ‘vaginismus’ suggest that ‘proper sex’ involves penile-vaginal penetration.
We might also think about what things are classified as addictions and what are not (in relation to what is socially acceptable), or what forms of self-harming are pathologised (cutting and burning oneself, but generally not smoking, drinking to excess, risky sports or driving, or cosmetic surgery).
Many have argued that the high levels of diagnosis of depression in women (and the greater likelihood that distressed men will be criminalised as ‘bad’ whilst women will be pathologised as ‘mad’) are related to cultural expectations around femininity and masculinity. Also, black and minority ethnic people are more likely than white people to be diagnosed with ‘severe’ mental health problems and to be hospitalised and treated with drugs, arguably due to the western norms inherent in the diagnostic categories, as well as experiences of racism and social injustice.
Going back to Rosenhan’s study we may regard the world that we currently live in as rather an ‘insane place’ (particularly given the current economic and ecological situation) and question what it means to respond ‘sanely’ to this.Winnicott famously said, of depression: ‘The capacity to become depressed, to have reactive depression, to mourn loss, is something that is not inborn nor is it an illness; it comes as an achievement of healthy emotional growth…the fact is that life itself is difficult…probably the greatest suffering in the human world is the suffering of normal or health or mature persons…this is not generally recognised.’ In recent goals for everybody to be ‘happy‘ there is a danger that we pathologise, even more, quite reasonable forms of distress.
Us and Them in Mental Health
Given the problems with diagnosis covered above, we might ask why practitioners continue to employ these, often without critical consideration, and to maintain a split between the ill and the well.
In her book, Users and Abusers of Psychiatry, Lucy Johnstone suggests that it is very tempting for mental health practitioners to treat clients or patients in an ‘us and them’ way because of how invested they are in the current system. There is the danger that, without such clear splits, their job security would be in danger. Also they would lose the sense of expertise and professional power that they have if, for example, there was a de-medicalising of distress or a de-professionalisation of support for people who were struggling. There is a danger, more widely, that those who have an investment in being seen as sane, in control, and professional require a comparison group of those who aren’t (and this may play out in mental health systems, in families and other groups, and in society at large).
Christina Richards presents a further reason why it may be difficult for practitioners to shift away from an ‘us and them’ approach to distress. She argues that underlying a resistance to change might be a sense of: ‘“I have been doing things this way for years and will continue to do so as this way must be right (because if I have been doing it wrong for all these years look at all the pain I’ve caused/ time I’ve wasted/ good I could have done)”. It boils down to: “I can’t act in the future, because that proves I could have done so in the past”.’
This way of thinking can keep people very stuck on both sides of the ‘us and them’. For practitioners it prevents critical exploration of their current ways of understanding and practising, and substantial revision of diagnostic manuals, etc. which have been used for so long. For clients or patients it makes it difficult to change in ways that might alleviate suffering because changing is seen as acknowledging that one could have changed previously (this is especially difficult because taking personal agency is seen as putting a person on the ‘not ill’ and ‘all my fault’ side of the dichotomy explored in my second post). The more time passes, the harder it can be to step away from the way you have been doing and seeing things. There is a kind of tyranny of consistency which would be helpfully addressed by a model which embraced the fact that people change over time and that it is okay to revise and adapt the way we used to see things or admit that we were wrong in the past.
Richards quotes the great sage, Esme Weatherwax, who said that ‘Sin … is when you treat people as things. Including yourself. That’s what sin is.’ Whilst, of course, we require some kind of language to describe, and make sense of, our experiences of distress, we need to be cautious of ways of understanding that function to trap people and to concretise things rather than enabling them to move. We also need to be alert to understandings which assume that the biopsycho can be disconnected from the social such that it is only the individual who is seen as disordered or malfunctioning, rather than wider systems, and only target treatment at the individual (rather than the family, the school, the organisation, the media, or wider culture, for example). The social aspect is something that I will explore further now.
Self-monitoring Culture and Distress
A friend of mine recently posted a cartoon on Facebook which had Sigmund Freud saying ‘before you diagnose yourself with depression or low self-esteem, first make sure that you are not, in fact, surrounded by assholes’. I responded that I thought this said something rather profound about mental health at the moment. Could it in fact be said that a key aspect of many experiences of suffering is the problem of being ‘surrounded by assholes’ or – to be more generous – being surrounded by damaging cultural messages perpetuated by those around us?
When I first started counselling I became very aware that virtually everybody I saw was convinced that there was something wrong with them that needed fixing, mostly based on the fact that – when they looked around themselves – nobody else seemed to be struggling the way they were. Conversations with close friends, and self-reflection, suggest that this is an extremely common feeling: that everybody else is managing fine so there must be something wrong with me. Of course, when I asked clients how they thought they appeared to other people they recognised that they generally put on a ‘happy, managing everything fine mask’ which probably gave off the impression that they weren’t struggling either.
It strikes me that many experiences of depression, anxiety and other common mental health problems have a strong element of self-scrutiny and comparison to others in them (whilst, of course, I am wary of proposing any universal explanation because these experiences mean many different things to different people and at different times). Michel Foucault used Jeremy Bentham’s Panopticon to explain how people self-police in contemporary society. In the Panopticon prison there is a tower in the middle and cells all around an outer circle, such that a guard in the centre could – at any time – be looking into your cell. Because of this, prisoners begin to monitor their own behaviour rather than having to have huge numbers of guards. This idea has been linked to the high degree of surveillance that we now have, meaning that we could – most of the time – be being watched or recorded.
Foucault suggested that contemporary culture worked in this way more broadly. People are encouraged to scrutinise and judge themselves at all times, with advocations to self-improve, to work on themselves, and to present a positive and successful self to the world. This is linked to consumerism which is all about seeing ourselves as lacking and needing something to fill that lack. Advertising, and many other forms of media, create fears (e.g. we might look bad, be out of date, or be a failure) and then offer products to allay those fears (e.g. beauty products, the latest fashion, recipes for success in various arenas).
Within such a culture it is no wonder that people would be particularly driven to constant self-scrutiny, comparison to others, and presentation of themselves as happy, satisfied and successful (even when they may not be any of these things). This shores up the ‘us and them’ that I wrote about in my second post. Rather than distress and suffering being an inevitable part of everyday life, it is seen as a problematic lack which must be addressed, and is probably outside of the power of the person who is suffering to address.
Perhaps the major challenge for mental health practitioners, counsellors and psychotherapists is the danger that our work can perpetuate this perception: creating new diagnoses and categories and offering an ever-increasing menu of products to fix these (at a price). Even the one-to-one therapy situation is at risk of exacerbating this sense that people are wrong and need fixing, given that one person (the client) is encouraged to express their distress to another person (the therapist) who is generally fairly quiet and certainly not expressing any of their own problems. This is not to say that therapists and counsellors should be inappropriately burdening clients with all their difficulties. But we need to find ways to challenge the idea that the client’s struggles mean that there is something wrong with them, and the perception (which most clients have, even when they are therapists themselves) that the therapist has no struggles, or deals with them all perfectly.
Existential therapy includes the idea, not only that all people will inevitably suffer, but also that all responses to this suffering are sensible so long as we properly understand the person who is responding in this way. This, to me, is a very useful counter to the common assumption of something being ‘wrong’ and the person being flawed and lacking in some way if they do not respond in ways that are deemed culturally acceptable.
Alternatives: Care and compassion for all
Above I have argued for a complex understanding of suffering and distress which is very cautious of applying diagnostic criteria and of dividing people into ‘ill and well’ ‘us and them’ boxes. Perhaps a better model of distress is of a continuum which we all go up and down during our lives, and where we are not fixed at any given point. I’ve also emphasised the importance of not splitting up the bio, psycho, and social in our understandings of distress, and suggested that we must not neglect the social aspect of the biopsychosocial because societal ways of understanding people (which we internalise and which, no doubt, are represented on a neurological level) are involved in our difficulties. This is particularly the case in the way in which we are encouraged into self-monitoring, and in the way in which individuals who are in conflict with societal norms tend to be pathologised as disordered individuals.
If we resist the temptation to ‘us and them’ thinking then perhaps we can make more of a connection with people when they are distressed (rather than attempting to distance ourselves from them in ways that maintain them as ‘them’ and protect us from any sense that we might experience similar things ourselves). Then we might be able to ask questions such as ‘what works for me when I am distressed?’ which may lead to more helpful responses when others are struggling (although, of course, we must be cautious of assuming that everybody works in the same way that we do – perhaps the question is more like ‘given everything that I know about this person, what might they be needing right now?’) We might reflect, for example, on times when we’ve been under chronic stress or when a crisis has occurred in our lives.
Broadly speaking, when we reflect on what is unhelpful when we are distressed we might come up with things like: taking away the aspects which makes the person what they are (things that they regard as central to their identity such as work or relationships), removing people’s sense of personal freedom and choice, and regarding them as inexplicable or baffling, for example questioning why they can’t just stop feeling, or responding, in the way that they are doing. On the other side, we might find that what helps when we’re distressed is not being overloaded with anything else, being treated kindly and patiently and being around those we feel safest with, being reassured that we are still free (but perhaps we don’t have to make lots of decisions right now), and feeling that we are understood and that our response is a perfectly explicable way of responding to this situation (which involves somebody taking the time to understand what it means to us).
The vital role of compassion (from others and towards oneself) has been emphasised by many recently, and is part of the reason, perhaps, why various forms of mindfulness-based therapies are suddenly so popular (as they often encourage practices of self-care and compassion). Compassionate treatment of self and others is, perhaps, an opposite to the judging-comparing-monitoring mode which is so culturally encouraged at present. Rather than fearing that we are lacking, pretending that we aren’t, and trying to prove that we are better than others, we accept that everyone is imperfect, are open about our struggles, and move away from a competitive way of relating with others.
Vitally, an alternative compassionate, or self-caring, form of working with distress does not present this as something that is necessary just for people who are struggling (reinforcing that ‘us and them’). Rather it is seen as something everybody needs to engage in to counter those omnipresent self-monitoring messages (which affect us all) and to address the struggles and distress which we all experience.
Find Out More
- Many of the ideas in these posts are explored, in more detail, in Understanding Counselling and Psychotherapy.
- A very accessible book that covers may of these areas is Richard Bentall’s Doctoring the Mind.