It’s not all about you, you know

As early as May 2020, the BBC was warning us psychiatrists feared a “tsunami” of mental illness because of the pandemic. Eleven months later the Guardian confirmed those fears, reporting: “Extent of mental health crisis in England at ‘terrifying’ levels”.

Alarmist or accurate? Probably somewhere in the middle, but did the headlines make those suffering from mental health issues feel they were less alone? Or, perversely, can “news” like this bring on or intensify distress, or lead those feeling down in the dumps to wonder if they have something more serious?

Someone says they ‘have OCD’ because they are ìobsessiveî about cleaning, which is not OCD at all

It’s not easy to come up with a nuanced attitude to mental illness. The language we use to describe our emotional states is made up of imprecise words and idioms – depressed, lonely, under the weather, out of sorts – that encompass conditions ranging from the ephemeral and mild to the chronic and severe. Recent discussion of mental health by the likes of Stephen Fry, Miranda Hart and Alastair Campbell, but also from less expected sources such as celebrity footballers and the Tory party manifesto,    has ostensibly encouraged us to talk openly about emotional crises. But we do this using scientific-sounding acronyms. I’ve heard employers, TV presenters and children casually referring to PTSD, ADHD and OCD, and employing terms like bipolar and autistic. Some of the jargon travelled here from the US, where specialists rely on wordy summaries of recognised mental health conditions in the Diagnostic and Statistical Manual of Mental Disorders (DSM), now in its fifth iteration. But the DSM defined homosexuality as a mental illness until 1973. Even the so-called mental health bible needs updates.

No one would want a return to the old way of dealing with mental illness – brushing it under the carpet, storing it under the stiff upper lip – but is the current revision of attitudes to emotions and wellbeing actually doing us any good?

Psychologist Lucy Foulkes, in her recent book Losing Our Minds, draws a direct line between the way we talk about how we feel and the medicalisation of mental health by the medical establishment and mass media. It leads, she argues, to myriad distortions about ordinary life and the way we see ourselves and other people. Clinical depression, for instance, encompasses a huge range of symptoms and combinations of symptoms, and yet public health services tend to triage all “depressed” people with the same multiple-choice interviews and, subsequently, treat them with a few well-known drugs. False equivalence is common in wider society (someone says they “have OCD” because they are “obsessive” about cleaning, which is not OCD at all) and in professional circles (where those with one or two symptoms of a disorder are treated as if they suffer from the disorder, which they do not suffer from at all).

Adolescents and young adults are at the thin end of the wedge. The media and political parties love to tell them they belong to a “blighted generation”, because there are no affordable houses, no jobs, no truly safe social media, only lots and lots of debt. Young people respond by getting down, upset, sick and angry. They’re then told they are “snowflakes”.

Foulkes reminds us that there is a huge gulf between completely normal developmental problems and serious mental health issues, and that adolescents are susceptible to both ends of the spectrum.

“The tendency to take risks, and the desire for extreme physical and psychological experiences… both peak in adolescence.” Anxiety and regular, sometimes quite extreme lows are, therefore, part of growing up. Young people are more likely to be involved in car crashes, crime and social dramas. In those contexts, an experience of PTSD could be completely normal – and complete recovery in the short term highly likely.

Scientists and the medical establishment, who should know better, are a major part of the problem. Academics create new labels for disorders. Professional psychiatrists and therapists adopt them because it can seem useful or practical to pigeonhole people. These individuals tell friends and go on to social media. The newly coined label becomes widespread. Soon, people are turning up at their GPs having already self-diagnosed that they have, for instance, “binge eating disorder” – it’s already on its way to being included in the next edition of the DSM. Psychologist Nicholas Haslam has called these “looping effects”: as professional understanding of mental disorders change, people shape their behaviour, experience and self-understanding in response. If Stephen Fry has manic depression, we might think it is not such a “bad” or unusual thing after all. Off we go to the doctor to tell her we have manic depression. The tragic upshot of this is that, contrary to received wisdom, the more we talk about mental health, the more we end up helping the wrong people.

“Therein lies the strange paradox we face right now, with all disorders,” writes Foulkes. “We are over-diagnosing mental illness, coating too many types of distress in psychiatric language, but the confusing thing is that we are also under-diagnosing some cases. So much devastating mental illness is going unmanaged and untreated. In the UK in 2018, 6,507 people took their own lives. Even one single suicide is damning evidence that extreme distress is being overlooked.”

This really matters. Any society has a limited number of resources to deal with mental, and other, health issues. If these resources are being used to inform, treat and medicate the wrong people, we are doomed to miss those who suffer from conditions that cause them immense pain and distress and whose symptoms are so overwhelming that they cannot function in life.

In 2017-18, well before the pandemic, 7.3 million people (17 per cent of England’s adult population) were prescribed anti-depressants. Most league tables place the UK in the top ten antidepressant-using countries globally, and over the past decade the trend has been consistently upwards.

Neurologist Suzanne O’Sullivan travelled the world for her latest book, The Sleeping Beauties, to look at how other, usually poorer, countries cope with illness – and, specifically, how they define and treat psychosomatic disorders. She notes that from Sweden to Kazakhstan to Cuba societies struggle to make sense of mystery illnesses because doctors are too specialised, culture and social context are not taken into account, patients are wont to demand to be “diagnosed” with a specific illness, and, frankly, because neurological orders are very complex indeed. In some societies, what the west calls a “witch doctor” is more useful to people’s wellbeing than drug therapies.

Mental health issues – from depression to catatonic states to mass outbreaks of psychogenic disorders – are susceptible to oversimplification. Expressions like “mass hysteria” were once used for conditions we can now understand to be “biopsychosocial” – that is, affected by factors such as culture and environment, personal history and family ties.

“Western medicine often sees itself as superior, coming up as it does with technical names, technology and research studies to support it,” says O Sullivan. “However, when it comes to psychological illness, it is worth remembering that most mental health research is done on white, educated people in industrialised countries and therefore does not represent the majority of the world’s population. More holistic, spiritual and collectivist cultures may have a lot to teach us about supporting those in psychological crisis, if we care to listen.

“The indigenous Miskito people of Nicaragua suffer with a culture-bound condition called Grisi Siknis [crazy sickness]. It manifests as seizures thought to be caused by a demon. When I first read about Grisi Siknis I referred to the beliefs surrounding it as superstition. I underestimated it. Grisi Siknis is actually a highly sophisticated method through which the Miskito community deal with social conflict. It is an illness that allows young people to express distress. It attracts strong social support.

“Observing it made me realise that some social and psychological problems are hard to articulate and that asking for help through physical symptoms can be an elegant solution. Formulations for illness that do not rely on blaming the psychology of the individual also keep people within their community, rather than excluding them – as often happens in developed western societies.”

Western societies consider themselves “enlightened” if they can find the right words and find a way for an individual to talk about their trauma. But if some of what we call “mental health” problems – from anxiety to depression to panic disorder – are in fact biopsychosocial ones, then arguably it’s the social factors we need to consider first. We tend to focus on changing our brains and bodies when the problem might be, for example, housing, income, work or friends.

A recent press release I received from a PR firm came with the following “exclusive” claim: “Want to be happier? Get a bigger garden, study reveals.” Without specifying a source, credible or otherwise, the email declared: “Cities such as Chichester, Winchester and St Albans with bigger than average gardens report higher levels of happiness when compared to cities such as Portsmouth and Hull, with smaller gardens.”

Happiness is used to sell us gym passes, £5,000 bikes, smartphones and other devices, second-hand cars and spa breaks, but also retail, insurance and financial services. Advertisers exploit illusions and insecurities about youthfulness, the natural world and peace of mind to sell us stuff. A landing page for the RBS banking app, showing a woman of retirement age seated in woods, eyes closed, meditating, is typical.

In his 2015 book The Happiness Industry, political economist and sociologist William Davies argues that happiness is sold to us by businesses chiefly to make us work harder and increase productivity – that is, their profits. Some corporations employ a “chief happiness officer” while Silicon Valley-type firms dupe their employees with the ruse that work is fun and hip offices joyous temples of self-realisation. He also nails the irony that capitalists realise – that it’s consumerism and working all the time to pay for it that have made us miserable. Having sold us the problem, they now want to sell us the solution.

“One thing that changed in the 1990s, and has accelerated since, is that there developed various new scientific projects to discover the ‘truth’ about happiness,” says Davies.

“Positive psychology took off during this period, but so did the neurosciences and happiness economics. All of these, in different ways, presumed that it would be possible to place the study of emotion – and happiness in particular – on a fully objective footing, to remove the guesswork and the ethical dimensions of happiness.

“Pushed to an extreme, that creates the conditions for a whole science of behaviour and society, in which people don’t need to think for themselves any longer. That prospect then became more plausible and daunting with the rise of giant platforms from around 2007 onwards, leading to the point where companies like Amazon and Facebook are building up vast data banks, including data on psychology, behaviour and emotion. Amazon Alexa, for instance, constructs psychological user profiles of different members of a household, including calculations of their mental health, on the basis of tone of voice. This is a big step away from where things were only a few years earlier.”

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There are so many factors at play here, from shifting trends in social sciences – with economics on the up, sociology in decline – to the core Thatcherist emphasis on the individual over society (which was also stressed in 1960s counter-culture) – that it’s hard to peel back the layers. But the main trick being pulled is that one of the fundamental ways late capitalism works is by telling us we’re depressed and then offering to fix it with “happiness” – as defined by our employers, the retail sector, tech giants or big pharma.

In Shakespeare’s Hamlet, the prince is told he is mad, sad and bad in order to deflect attention from his murderous uncle Claudius’s guilt and Denmark’s rotten state. ’Twas ever thus: it’s easier to fix – or ignore – an individual than it is to heal a society.

But the mental health crisis and happiness industry are two sides of the same coin. We’re being told all the time – by media, politicians, corporations and public health agencies – that we’re lonely, anxious, depressed, sick and ill. We’re also being told, the rest of the time, that this job or that holiday or a specific drug or therapy can help to make us better. We’re led by habit, culture and society to believe that the problem lies within and not out there in wider society.

Though they come at the question of our wellbeing from different backgrounds and angles, Davies, Foulkes and O’Sullivan are part of an emerging consensus that social and mental health are profoundly inter-related, and that something is amiss in our approach to both. It’s no accident Davies followed up his study of the happiness industry with a book titled This is Not Normal: The Collapse of Liberal Britain. If anything, he suggests, it’s the government that’s in need of psychiatric help. The swing to right-wing populism and authoritarianism, like past swings in that direction, comes after decades of subtle shifts in a disturbing direction – Davies calls it “ideological drift” – that has culminated in the election of a joker-entertainer we’re increasingly struggling to laugh with. The country is more unfair, more divided, less tolerant and less free than ever before.

But what is it that holds us back from demanding societal change? Is it deference, past disappointments, self-loathing? O’Sullivan suggests it is born of a misplaced reticence. “I think our reluctance to frame mental health problems through a social lens is in part a result of our fear of being seen to blame a person, their family or their life choices for how a person is feeling.” But by avoiding individual responsibility, we fail to point the finger at our leaders. Doctors, meanwhile, behave like members of the royal family and avoid airing their views on socio-economic reality.

“The medical community doesn’t have much control over the external factors in a person’s life – especially the really big factors like poverty or prevailing politics – so it can be more practical for a doctor to look inside their patient’s head rather than out into the world for answers..

“I fear something is lost by neglecting the social and cultural driving factors of mental health issues. Perhaps if we had more supportive social institutions people would not need to rely so heavily on medical institutions when they are suffering.”

Image: Steph Coathupe