I’ve experienced mental health struggles for most of my life. For me, like many of us, that means that I’ve had a high level of self-critical background noise a lot of the time: thoughts that I’ve done something terribly wrong, or that I will do, or that there’s something wrong with me. It often manifests as a low, heavy mood: a kind of grey fog over everything that makes it difficult to see things clearly, to make decisions, or to appreciate the beauty of the world around me. At its worst, it has tipped into extreme self-loathing and the urgent wish to eradicate the ‘bad’ parts of me in order to make myself acceptable.

Despite these experiences I’ve always been reluctant to label myself with the terms that might seem obvious when you read this description. I’ve probably ticked the boxes for several of the recognised ‘psychiatric disorders’ in my time, but I don’t feel comfortable identifying as a person with depression, as mentally ill, or as having a psychological problem. Equally I don’t feel comfortable identifying as sane, mentally well, or psychologically healthy. As with so much in life, I feel that the binary – in this case between ‘mad’ and ‘sane’ – is actually part of the problem.

The mad/sane binary

The mad/sane binary is present in all of the mainstream messages that we receive about mental health. For example, high profile campaigns to end mental health discrimination have often centred around one, apparently game-changing, statistic: 1 in 4 people have a mental health problem. Celebrities like Stephen Fry and Ruby Wax have used the figure to speak bravely and openly about their experience of mental ill health, but the danger of that statistic is that it suggests that 75% of the population do not experience any mental health problems at all. Rather than seeing mental health as a continuum which we might all move up and down over the course of our lives, we’re forced to stake our identity on one or other side of a strict dividing line:

‘Either … I have a mental health problem – I need help – it’s not my fault
Or … I don’t have a mental health problem – I don’t get help – it is my fault’

In this way we’re placed in a double bind, because accepting one side inevitably involves denying the other, and neither side promises a great outcome. If we’re seen as having a mental health problem we may well feel utterly disempowered, as if there’s nothing that we can do to improve our situation. If we’re seen as not having a mental health problem we might feel like we can’t admit to having any problems or get any support because we’re completely responsible for our own happiness and well being. The responsibility either rests entirely with other people, or entirely with ourselves, and either way that puts us in an untenable position.

Linked to this is the fact that both sides of the binary internalise suffering, seeing it as a purely individual thing, rather than a symptom of wider social issues. We are forced to view mental health problems as inborn, either caused by illness (perhaps a genetic vulnerability and/or brain chemistry issue) or by a personal deficiency (such as bad habits, faulty thinking, or lack of moral fibre). This can be very damaging because there’s strong evidence that all our human experiences are biopsychosocial: a complex interaction between the world around us, our personal experiences of it, and our bodies and brains, with all of those aspects influencing the others. We risk doing further damage to ourselves when we attempt to change our individual experience without recognising the role of social injustice or cultural messages in our suffering.

Social suffering

For example, it’s clear that structural oppression and social inequalities have a major role in mental health struggles because we see far higher rates of such difficulties in groups who are socially marginalised. One recent UK study found that women were 40% more likely to develop anxiety and depression than men, for example, another found that LGB people are twice as likely to be suicidal as straight people, and a further one that BAME people are six times more likely than white people to be admitted as in patients in mental health services. We need to recognise the role of intersecting marginalisations in mental health struggles, and the ways in which social experiences such as poverty, discrimination, and the experience of trauma are highly related to psychological distress.

We also live in a culture, which encourages the very kind of self-critical thinking that’s a feature of all the most common mental health problems. The French philosopher Michel Foucault famously used the analogy of the panopticon prison for our culture. In this prison there’s a single guard sitting at the top of a central tower in the middle who is able to see into all of the prison cells. Prisoners end up monitoring their own behaviour all of the time, just in case they might currently be being watched.

Foucault argued that our culture works in this way through all of the pressure we’re under to self-improve, and to present a positive, successful self to the world. We’re made to feel fear that we might be lacking or failing in some way, and we’re sold products which claim to help us to allay those fears. Makeover shows, self-help books, and beauty products are some of the more obvious examples. Social media also encourages us to maintain the illusion of perfection online, leading to endless rounds of self-evaluation and comparison.

In a world where so many of us are struggling with very real social problems, it’s vitally important to acknowledge the cultural context we’re in and to resist individualising our suffering. The mad/sane binary is very effective in preventing challenges to toxic policies and practices because people are not aware of the social context of their struggles, and because there is a fear that if you do speak out you will be dismissed as ‘insane’.

We can see this at play in the recent moves to regard unemployment as a psychological problem and the insistence that those claiming benefits undergo cognitive behavioural therapy. The responsibility is placed on the individual rather than on wider societal problems, and resources are focused on psychological change rather than addressing economic inequalities. There’s a high risk that people are left in the same damaging situation, but with an even greater tendency to blame themselves for it.

A sane response to a mad world?

The psychotherapist Winnicott famously said, of depression: “The capacity to become depressed […] 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 healthy or mature persons”. Perhaps we would do well to view the depression, anxiety, and other mental health struggles that most of us grapple with at some point as a sane response to an insane world. This would shift the emphasis for change away from the individual and towards the wider societal structures and cultural messages around us.

I know that what has helped me the most in this area has been to recognise the social and cultural aspects of my struggles. It’s a huge relief to allow the weight of total responsibility to lift, and to recognise the role of internalised self-criticism and social power dynamics in my experiences. This acknowledgement also allows me to engage critically with the mad/sane binary: resisting the sense that I’m completely responsible for my difficulties and the sense that I have no capacity at all to help myself. In this way I can cultivate a kinder relationship with myself, on the one hand, and feel more of a sense of kinship with all of the others who are in the same cultural boat. Such connections enable the possibility for collective resistance and for social activism, which feel like a much better focus for my energy than continually trying to change myself.

Find out more

My zine on social mindfulness covers these ideas in more detail. My zines on Staying With Feelings, Self-Care, and Plural Selves are also relevant to mental health.

My other blog posts on mental health include:

• Mental health: Beyond the 1 in 4
• Mental health: Beyond a health focus
• Mental health interview 1
• Mental health interview 2
• Supporting each other through mental health crises
• Mental health and relationships

For more on LGBT and GSRD mental health,  check out:

• New Resource on Gender, Sexual & Relationship Diversity (GSRD) and Mental Health
• LGBT+ mental health video
• Bisexual mental health

The post Mental health beyond binaries appeared first on Rewriting The Rules.

Certainly it is extremely important to make support available when people are struggling. However, these news reports seem to miss something by regarding this purely as a health issue, and by focusing only upon treatment once mental health difficulties are present rather than also considering measures which may prevent such problems or increase resilience.

The fact that so many people suffer with issues such as depression and anxiety has implications far beyond the health service, and the focus on targeting funds only at treatment for existing mental health problems seems somewhat blinkered.

As a starting point, here is a list of other arenas which could usefully attend to statistics on mental health and shift policy and practice accordingly. In all of these areas a broader biopsychosocial understanding of the experience of mental health problems would be of value:

Education

Many of the negative patterns of thinking about, and treating, ourselves when we are struggling are laid down in childhood and adolescence, and experiences such as bullying, alienation, abuse or neglect in youth certainly increase our vulnerability. For this reason we could put more resources into addressing problematic school cultures and into cultivating the kinds of emotional and social skills that we know to be helpful during the early years of life. It seems strange that we wait until people are really suffering before teaching them how to understand, and work with, painful emotions and difficult relationships.

The workplace and employment

Viewing mental health as a purely internal personal matter neglects the role that the world around us has on whether or not we find ourselves struggling. Situations of workplace bullying or harassment, and toxic cultures where everyone is expected to work long hours or where employees are not valued, are certainly implicated in suffering and could be usefully addressed by awareness raising and increased resources.

Additionally, the perception of mental health difficulties could be usefully addressed on an organisational level. Destigmatising mental health problems such that employees are able to say when they are struggling could help a great deal, as could allowing everyone a few ‘stitch’ days a year when they take time out to look after themselves (after the phrase ‘a stitch in time saves nine’).

Finally, many find that some kind of employment – whether of a more or less conventional type – acts as a buffer against mental health problems in various ways. It can provide an income, give a structure and routine to the day, enable some form of contact with others, and ideally provide a sense of meaning and purpose. As a culture we seem to have swung from a situation of encouraging those who are struggling not to work (in ways which often increases their isolation and sense of being unable to do so), to one of forcing people who have become used to not working back into work. Resources could be usefully put into finding a more balanced and supportive approach.

Media

There could be greater recognition of the role of media in encouraging a certain way of viewing and treating ourselves, which many authors have linked to problems like anxiety and depression. Research consistently links limited beauty ideals to body image anxiety, but it goes further than that. Advertising, and much other media such as magazines and self-help books, often rely on encouraging people to think that there is something wrong with them that needs fixing (in order that they will buy a product). Makeover shows, reality TV, and popular contests like X-factor promote a limited idea of what it is to be a successful person, and arguably exacerbate a sense of failure among those who don’t meet the standard. The sense that we need to monitor ourselves and compare ourselves against others is opposite to the kind of compassionate and kind treatment that many regard as the key way of avoiding/combating problems like depression.

Wider culture

News articles often neglect to report the differences in rates of diagnosis of mental health problems. All of these suggest that those in more marginalised groups are more prone to such difficulties. Again, this suggests that access to individual counselling and therapy should not be the only approach to dealing with this problem. Attending to societal inequalities and injustices is vital, not just from a human rights perspective, but also from a mental health perspective.

The post Mental health: beyond a health focus appeared first on Rewriting The Rules.

I’m about to start writing a chapter for my mindfulness book on depression so I’ve been mulling over what the experience of being depressed Is like, and what things help and hinder when we’re in that place. At the same time I’m becoming fascinated and concerned by the processes of conflict between people which seem to inevitably happen in all the academic and activist groups I’m part of. I’m wondering what might be done to maintain some kind of useful dialogue, rather than people convincing themselves that the other side is wrong and bad while they are right and good, and thus ceasing all engagement. Even as I see the problems in this approach I recognise the same tendency in myself.

As these two lines of thoughts unfurled themselves yesterday I found that they began to weave together into a similar set of ideas, so I decided to write a little about the patterns that I see in how we experience depression and conflict, and in how the experience can shift. Perhaps I shouldn’t be so surprised that these ideas have come together: I deliberately started my book on relationships with a chapter on the self because of the connections that there are between how we relate to ourselves and how we relate to others.

Depression: Tuning out, turning in

When I reflect on being depressed the experience is one of being simultaneously tuned out, but turned in. What I mean by tuned out is that when we’re depressed many of us become terribly concerned with other people and the outside world. We monitor ourselves closely through the imagined gaze of others and judge what we think they are seeing very harshly. We become anxious about what others will see in us, and frightened that we will get it wrong somehow and be exposed in all our uselessness. Decisions become very difficult because we are so tuned out – trying to be okay for everyone else – that it is almost impossible to tune in to what we want and need ourselves. We might find ourselves busily rushing around trying to please everyone and not letting on how much we are struggling, or we might withdraw from contact as much as possible for fear of what others might see if we let them in close.

At the same time as being tuned out, we are also turned in. While we are hugely concerned with what other people think of us or how we are being seen out in the world, we don’t really see or hear the people around us because we are so turned in and focused on our own struggles. We often spend a great deal of time in internal conversations with ourselves about whether something is wrong with us, what it is, and how we might fix it. We view other people in terms of their danger to us (‘they might see me as I really am!’), or the possibility that they might be able to help (‘maybe they have the answer’), but it is hard for us to make the shift that is necessary to understand how they are feeling and what is going on for them. Often we assume that we are the only person who is this bad and full of problems, and we are so fixated on not showing other people that this is the case, or apologising to them for our perceived wrong-doing, that there is no space available to turn towards their experience and let go of all of our own stuff for a moment.

Depression: Turning out, tuning in

When I think about the moments of relief when that heavy tangled weight of depression has lifted, they are often moments when I have managed to ‘turn out’ in spite of all this. Perhaps somebody else’s pain has pierced my bubble, or in professional mode (as a tutor or counsellor) I’ve had to put my stuff down and turn towards another person to hear about their struggles, or I have remembered how this worked and deliberately reached out to somebody else and asked how they are doing. Sometimes the relief just takes the form of sitting on a train or walking down the street and suddenly opening up to the fact that all the people that I see have their own fears and desires, tragedies and triumphs, which are just as precious and concerning to them as mine are to me.

This turning out works on several levels. On a very basic level listening to somebody else, or imagining their world, means that our mind is occupied with something else for a moment and we have a brief relief from the clatter of noisy and critical thoughts that has been exhausting us. Then there is the way that helping somebody else (anything from flashing a kindly smile through to giving them a supportive shoulder to lean on) can leave us feeling better about ourselves: we do have something to offer after all. Perhaps most fundamentally though is the sense of connection to others which is an antidote to the sense of isolation and alienation that is a major element of depression for so many of us. If people let us in through opening up to us, or just reveal their pain on their faces, we might realise that they struggle too, often in similar ways to ourselves. We realise that they are also scrutinising themselves constantly with a stream of critical comments running through their heads. We are no longer alone. In fact that pain is the very thing that links us to everybody else.

Related to this it is often the case that in finding compassion for another person we become able to find a little of the compassion that we need for ourselves. This is an important part of what I’m calling tuning in. Instead of only being attuned to what other people think of us (whether we are normal or abnormal in society’s view, whether or not this person approves of us, etc.) we can tune into our own feelings and experiences. By turning out and really seeing and hearing the other people around us we might realise that they aren’t really that concerned with us because they are so busy worrying about themselves. Or, if they are judging us and disapproving of us, we might realise that they are doing this out of their own pain and anxieties rather than because they are seeing any true flaw in us. For example, it might be that putting us down gives them a brief reassurance that they are okay, when they secretly fear that they are not. Even if there is an element of truth in any criticisms they are making of us, we can manage to hear it and bear it because we are no longer trying to present an unreal perfect image to the world. We are turned out enough to be able to appreciate our impact on other people, and tuned in enough to own up to such things without thinking that it means that we are a terrible person in total.

When we are depressed, or otherwise suffering, it doesn’t really matter whether we start by turning out or tuning in. Either one begins to make the other easier. So it might be that we deliberately try to empathise with other people or imagine what they are going through, and that gives us the space to find a bit more compassion for ourselves. Or we might start by tuning in to ourselves – sitting with however we are feeling without judging it or criticising it – and that might enable us to open up and see the other people around us.

Conflict: Tuning out, turning in

How are similar processes involved in conflict situations? It seems to me that often when a conflict bubbles up our reflex response is to tune out but turn in. We focus entirely upon the badness and wrongness of whatever has been done to us (tuning out), while our concern with the pain and suffering that the other person has caused in us means that we turn in on ourselves and find it almost impossible to hear where the other person is actually coming from (turning in).

This pattern is what leads to the escalation of conflict. Often both people or groups regard themselves as the wronged parties (tuned out) and both are so concerned with the suffering that this has caused to them that they can’t find any empathy for the others involved (turned in). Under those circumstances each thing that one person or group does is interpreted as a slight by the other, who then try to express their pain and anger at what has been done to them which is read as an overreaction and unreasonable response by the original person or group who then responds defensively. We are all prickly and hyper-aware of everything that the other person says and does (tuned out), at the same time as being defensive and protective of the sore spots in ourselves that the other person is (often inadvertently) bashing up against (turned in). This means that we tend to interpret what ‘they’ do in narrow and simple ways, often assuming that they are acting out of malice or personal defects while we are very aware of all of the complexities of the situation that have led us to act in the ways in which we have.

In some ways conflict is the opposite of depression because we are hard on the other person and see them in limited ways, while being much more understanding of ourselves (whereas in depression we are much more forgiving of others than we are of ourselves). However, these kinds of conflicts and depressions often have the same thing at their root: Our secret vulnerabilities and shames which we are afraid might be exposed. In both cases we are hyper aware of others who might be seeing these things (tuning out) and defending against the possibility that they will reveal something we fear is there (turned in). But in depression we defend by withdrawing and separating ourselves off, whereas in conflict we defend by lashing out and trying to make our pain all somebody else’s fault.

Conflict: Turning out, tuning in

It follows that we can also shift conflict situations in the same ways that we shift depression. We can attempt to turn out and/or to tune in. Again it doesn’t really matter which one we shift first, it will probably make shifting the other one easier as well.

For example, we might start by tuning in. Instead of allowing ourselves to react in a knee-jerk defensive way to the other person or group, we might sit down on our own for a while with the aim of listening compassionately to ourselves: Why it is that whatever is happening has hurt us so much? Each time we start trying to list whatever the other person did wrong and why they are so bad we can gently bring ourselves back to tuning into ourselves instead: What are we feeling? What does it remind us of from other times in our lives? Which of the vulnerabilities that we know that we have have been triggered by this situation?

Alternatively we might start by turning out. We might recognise how we are limiting the other person or group by imagining them as just stupid, bad, crazy or malicious, and start trying to open up to the fullness of what they are and really trying to listen to where they are coming from. We may remind ourselves of the complex and multiple reasons that have led to us responding in the way that we have, and try to assume that the same will be true of the other ‘side’ of the conflict. In Rewriting the Rules I suggest we might turn our common accusation ‘how could you do that!’ into a genuine and curious question ‘how could you do that?’ This might involve us on our own imagining all of the different reasons why the other person or group might have done what they did (given what we know about them if they are somebody we know, or just what we know about people). Alternatively, or after this, it might involve us sitting down with them with the intention of really listening to where they are coming from and trying to create a situation where they feel safer to tell us this.

The combination of turning out and tuning in will hopefully mean that during such conversations we can be more aware of what is triggered for us, so that we can respond to the situation itself rather than bringing in all our previous baggage. Tuning in also means treating ourselves kindly so we are less likely to take everything else somebody throws at us. If they are still in conflict mode then we can hear the pain behind their words, while not remaining in situations that are hurting us or taking on board criticisms that are unfair. This may involve, for example, insisting on more time apart before trying to communicate, or asking somebody else to mediate.

Conclusions

Of course every depression and conflict are unique to the people involved in various ways, and I will not have captured here all the different things that they can mean to different people at different times.

With depression there are aspects of the social situations which are involved that mean that another important element is turning out towards wider society and the ways in which it encourages that self-monitoring, critical, way of being with ourselves. I’ve written more about that here and here.

With conflict there are some important things to tease out about how we deal with very real power imbalances, oppressions, and privileges which are often in play. In my view the compassionate approach makes it more, rather than less, likely that people will be able to own up to these things and speak openly about their impact, but I also understand the fear that compassion and empathy for others could smooth over such things and lead to an acceptance of abusive and problematic situations. I write more about those tensions here and here.

I hope that the idea of shifting from tuning out and turning in to turning out and tuning in is a helpful one for thinking through your own experiences of depression and conflict, and I’d be very interested to hear other people’s reflections.

Find out more…

There’s more about how to tune in in my Staying with Feelings zine, and this post about noticing.

There’s more about depression and conflict in relationships here, here, and here.

You can find out more suggestions for practical ways of turning out and tuning in in the Rewriting the Rules chapters on self (in relation to depression) and conflict (in relation to conflict), and in my Social Mindfulness and Self-Care zines.

The post Tuning out, turning in – Turning out, tuning in: Depression and Conflict appeared first on Rewriting The Rules.

Biopsychosocial Perspectives

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:

Either

I’m ill – I need help – it’s not my fault

Or

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.

Diagnosis

The common practice within the current mental health system when people are distressed is to diagnose them (to find the category in the DSM or ICD which best fits them) and to treat them accordingly.

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.

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