Since Prince Harry revealed his near-breakdown, mental health has been a hot political issue. But fears about its spread may be groundless
Mental health seemed to be constantly in the headlines in 2017. The year began with the Prime Minister announcing a package of measures to “transform the way we deal with mental health problems right across society and at every stage of life”. Such problems had been one of the “burning injustices” that Theresa May had spoken about on the steps of Downing Street the previous summer, and now she was seeking to underline her credentials as a social reformer by turning rhetoric into action.
Nor was this ambitious initiative limited to the NHS. There would also be plenty of publicity for the promise made some months later by Health Secretary Jeremy Hunt that the government (now struggling after its election bruising) would soon be investing an extra £1.3 billion in mental health services annually, making possible the treatment of a million more patients. But what the Prime Minister emphasised in her speech in January last year was that it was above all attitudes towards mental health that needed changing. Striving to improve our mental wellbeing should become as much part of everyday life as striving to improve our physical wellbeing, she argued.
The speech commissioned a review into support for mental health in the workplace and in October this came back with a number of recommendations for employers. Among these was that they produce and implement a mental health at work plan. This was followed in December by a green paper on children’s and young people’s mental health that envisages all schools and colleges having a designated mental health lead.
But by far the biggest impact in terms of media attention was generated by Prince Harry, when he told the Daily Telegraph that he had come close to a “complete breakdown” after years of struggling to cope with the death of his mother, Princess Diana, when he was 12 — and how he had recently been helped by counselling. Sir Simon Wessely, then president of the Royal College of Psychiatrists, commented that the prince had done more for the communication of mental health awareness in a 25-minute interview than he had in a 25-year career. Yet this was part of a broader campaign by Prince Harry and the Duke and Duchess of Cambridge to “change the conversation” about mental health. That is the declared goal of Heads Together, a charity launched by them in 2016 with the following rationale: “Through our work with young people, emergency response, homeless charities and with veterans, we have seen time and again that unresolved mental health problems lie at the heart of some of our greatest social challenges.”
To the extent that 2017 also saw a steady stream of celebrities, politicians and sportsmen revealing the difficulties of one kind or another they have had with their mental health, it might be thought that the conversation has changed a good deal already and that openness about such matters is no longer discouraged or disapproved of. This could be the result of initiatives and campaigns that have been around for a while. Among these is Time for Change, a partnership between the charities Mind and Rethink Mental Illness that since 2007 has spent over £35 million on programmes intended to end the stigma and discrimination faced by people suffering from mental health problems. But it also points to other changes in the way such problems are regarded and responded to. Of note here, surely, is the doubling over the same period in the number of anti-depressant drug prescriptions. In 2016 some 65 million of these were issued in England alone and it is estimated that 10 per cent of the population is currently on this type of medication. Depression and other mental health problems for which treatment by medication has become the norm have themselves become normalised.
Is it possible, I want to ask, that we are actually starting to become a bit too concerned with mental health? As though, if we could only impress upon enough schoolchildren, students, employees, mothers, anyone past retirement age and so on, the importance of identifying and discussing the problems they might have in their mental health, and on top of that allocate the resources necessary for treating them, this would become a much healthier and happier country?
I raise this question as a psychotherapist working both in private practice and the prison service. Much of my day is spent thinking about the ways in which people suffer and what difference if any the “talking cure” of therapy can make to them. It isn’t often, though, that I find myself talking with someone about their mental health, nor even that I understand in such terms what they might be suffering from in the first place. This is because I feel that these two words have been tagged together, often with the third word “problems” added, and used so excessively and indiscriminately as to have become virtually meaningless.
This becomes obvious the moment you consider how many people are said to have a mental health problem. For a long time, the figure you saw on posters in GP surgeries or referred to in awareness campaigns was one in four. But recently I’ve noticed this statistic sliding around. Sometimes the proportion is even higher (one in three), while at other times it’s much lower (one in six). Obviously these are broad-brush figures intended to make a point rather than proper epidemiological estimates. But with the UK population presently around 66 million, this means that up to 11 million people may or may not have a mental health problem depending which of these ratios is being used. Isn’t that rather a lot of people to be so unclear about?
The underlying issue here, of course, is that for all the attention it has received over the last few years, there is very little agreement about what “mental health” means. This is true to some extent of health as a whole, which often ends up being defined negatively, i.e. as absence of illness. So it is perhaps unsurprising that the “about mental health” section on the website of Time to Change offers no definitions or descriptions of this at all. Yet the dozen or so “mental health problems” it then goes into, ranging from common, everyday experiences like anxiety to extremely rare conditions such as schizophrenia, strike me as a curiously selective list that has an alarmist ring to it while still failing to clarify what a problem of this sort actually is.
Confusion and rhetoric, I believe, permeate much of the advocacy there is around mental health and this is why less good will come of it than is hoped for. Too often there is a sense of wanting to have it both ways: persuading people that mental health is really nothing to be afraid of, that we all have our ups and downs and can find life a bit overwhelming sometimes, while also signalling that these are specialist medical matters — or are at least connected to them — that only a doctor or perhaps “mental health professional” will be able to diagnose and treat.
A BBC documentary broadcast last year offers a case-study in this sort of muddled thinking. Most of Trust Me I’m a Doctor: Mental Health turned out not be about mental health at all but about stress, because that was what nearly half of 2,000 people interviewed said they were most concerned by. Various diets, exercise routines and sleeping patterns were recommended — all of them helpful for countering stress, no doubt, but nothing a doctor is likely to have more knowledge of than a nutritionist or personal trainer. The last part of the programme entered very different terrain, however, as a psychiatrist and a clinical psychologist were shown debating the pros and cons of taking medication for depression while we also saw a surgeon in a research laboratory discussing a new treatment for schizophrenia he is working on.
What is to be gained by grouping together such diverse phenomena as stress and schizophrenia and labelling them all “mental health” — or rather “mental health problems”? And why is it that some obviously mind-related conditions are seldom if ever categorised this way?
Take dementia, for example. Undoubtedly that affects the way a person thinks, feels and behaves. Yet it is generally seen as more like a neurological disease, one arising from clearly identifiable deficits in brain tissue or functioning. The same is true to some degree of autism. But this is complicated by the fact that many people who suffer from this don’t think of themselves as ill or deficient at all, preferring to be known as “atypical” or “neurodiverse”. A third area of contention is what now goes by the name of substance misuse, referring to severe drug or alcohol addiction. Interestingly, this is missing from the list of common mental health problems highlighted by Time to Change, even though “substance-related and addictive disorders” are a prominent category in the latest edition of the supposedly authoritative Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and even though far more people will have their lives seriously damaged if not destroyed by these than by anxiety or schizophrenia. But addiction still has a level of stigma attached to it in the way that mental health problems are not meant to nowadays — despite the position taken by many experts and interest groups that it is, in fact, a disease like any other.
There isn’t room here for me to discuss any of these classification controversies — there are dozens more — in greater detail. The point is that what constitutes mental health, or indeed a mental health problem, is nothing like as self-evident as we are led to believe. How then can we be sure that there is a crisis in mental health, as is so often asserted? Another advocacy organisation active in this area, the Mental Health Foundation, states confidently on its website that “the social challenge of our time is to reverse the growing level of mental ill health”. Apparently there have been great improvements in education and housing over the last 50 years, while our mental health “has not improved and, if anything, has declined” (bold in original). No evidence is offered in support of this claim. Then again, I don’t see how there could be, given that the way mental health problems were construed in 1978 bears little resemblance to how this is done today. The edition of the DSM in use then was a modest 134 pages long, whereas the current one weighs in at 970 pages.
My own view is neither that mental illness was scandalously under-diagnosed 50 years ago nor that what prevents it being treated properly even today is that we still aren’t talking about it enough. There may well be a crisis here. But I think this lies in a medicalised, pseudo-scientific frame of reference and language being applied where they don’t belong.
Let me explain. When someone comes to see me complaining about their anxiety or depression, my heart sinks. Not because I’m an unempathic therapist who thinks only about his fee, but because I anticipate having to work long and hard before there is likely to be a prospect of getting past these vague, neutral-sounding labels to the powerful and visceral feelings this person is probably overwhelmed by but largely unaware of. Often involved are things like rage, loss, fear, love, envy, hurt, hope, disappointment, jealousy and greed. These have been the stuff of art, poetry and fiction for hundreds of years, if not longer, and that is to be expected because they are what we are made from too.
So why is it that these tend to be absent from the debate around mental health? Why does so much of that come over either as safely bureaucratic (“services”, “interventions”) or strangely anodyne (“wellbeing”)? Does the language used have to be so mind-numbing — and if so why? I think there is a range of possible answers to this question and will limit myself to considering four of them.
The first of these follows from the fact that the way the mind is understood nowadays is essentially materialist (in the philosophical sense of the term). We may not be machines, exactly, but the consensus view among scientists on the one hand and practitioners of so-called Evidence-Based Medicine on the other, is that the mind doesn’t exist independently of the brain — countless neuroimaging studies are said to confirm this — and therefore in speaking about mental health we are really speaking about the health of the body or its organs. If this is your starting-point, then mental health problems are no different to the illnesses that doctors treat patients for all the time.
It’s true that there are many health professionals (and indeed scientists) who don’t take this view. But there is no arguing with the success modern medicine has had in tackling and sometimes eliminating diseases that filled earlier generations with fear. So of course there are hopes that the same methods can be brought to bear on the equally frightening afflictions of the mind. Though politically on the centre-right, The Times has recently become a champion of such hopes, loudly calling for more investment in mental health services. And in one of several editorials it ran last year pressing for this, mental and physical illness were naively equated with each other in a way that I suspect owes a good deal to wishful thinking: “Mental illnesses such as depression or obsessive-compulsive disorder are as real as cancer and kidney failure but they are as yet only dimly understood.” As we have seen, the reality of most mental health conditions is anything but clear-cut — it depends what you think these are to begin with — and assuming they are in the body or brain does not get round what is fundamentally a philosophical problem so much as relocate it.
A second obstacle to being able to have a more meaningful discussion about mental health stems from our reluctance to allow people who might be suffering from anxiety, say, or — to take a more extreme example — from paranoid delusions, any degree of responsibility for their state of mind. This is meant to indicate how modern and enlightened we are. We don’t lock people up any more for being mad (actually we do, even if we no longer use that particular word), and we don’t think anyone should be ashamed for having faulty brain chemistry. You wouldn’t make them feel bad about having a broken leg, would you?
The trouble with this supposedly compassionate approach is that it robs people of their agency and autonomy, when in my experience it is the exercise — and in many cases the discovery — of these that are essential to their feeling better. Yes, “better” and “bad” imply the making of value-judgments — and nowadays these are said to have no place in the treatment of mental illness, which like the setting of a broken bone ought to be a largely technical procedure. I notice that nearly all the people I work with as a psychotherapist, however, have no trouble making value-judgments: about their families, friends and colleagues, about themselves, and also about me. I take this to be human and encourage them to explore the possible contribution of their values, along with other aspects of their character and personality, together with their overall life situation, to the unpleasant symptoms that are usually the reason for their seeking therapy in the first place. This doesn’t always make for the easiest of encounters. But that is human too — and often the very thing people find healing is being able to express the dark and sometimes cruel thoughts that preoccupy them, without these being either condemned as irrational (there’s a pill you can take for that) or condoned as normal and nothing to worry about (we’re all on a spectrum, you know).
Most modern mental healthcare, by contrast, seems to me to be conducted in a moral vacuum which it then spreads further across society. Right and wrong, good and bad, are thought to have little part to play in it, and “service-users” while held in high esteem as consumers and potential litigants are at the same time looked down on as the more-or-less mindless recipients of treatments that fail to acknowledge their capacity as human beings for making choices or forming habits. It is these choices and habits, I would argue, that are generally the source of suffering. Having said that, I would be the first to agree that the freedom someone has, say, for thinking well of themselves or of other people in the present will be greatly affected by their experiences from the past (in this example by how they might once have been thought about). But to see them only as a victim of circumstance, like someone whose leg is broken in an unfortunate accident, is to underestimate the extent to which they may be able to free themselves from the effects of the past — and conversely to remain trapped in them.
Much of the lobbying for an increase in mental health spending strikes me as caught up in a victim mentality of its own, however. The case for this is often made less on its own terms and more with regards to what the NHS already spends on all its other services, as though this was yet more evidence of the stigma there is around mental health. Frequently cited here is the 2012 legislation that actually makes it unlawful to discriminate between physical and mental health, in spite of which funding for the latter is only about half what it should be given the proportion of NHS activity (nearly 23 per cent) it takes up.
Thus we hear a lot about mental health services being “poor relations” or “second-class citizens” within health provision as a whole, and of the need to achieve “parity of esteem” by campaigning against the prejudice and discrimination that always hold this sector back. To my mind this politicises the language of mental health and is the third reason it can often seem so full of sound and fury while not signifying very much.
The fourth reason relates to the question of resources and what we as a society decide to spend our money on. Mind-altering substances like alcohol have always been popular, and it is well-known that in the 19th century there was widespread use of preparations containing opium until a reaction against that led to be it being regulated — at which point the medicinal and recreational qualities of cocaine were promoted instead. That too was banned, to be replaced by the new phenomenon of synthetically-manufactured “pscyhopharmaceuticals”. Over the course of the 20th century, amphetamines (uppers) and benzodiazepines (downers) passed in and out of official favour. Sometimes these were widely prescribed for a variety of physical and psychological complaints. At other times production and prescription both plummeted as concerns were raised about their addictive properties or the threat posed by a “turn on, tune in, drop out” type of drug culture.
More recently, pharmaceutical companies and psychiatrists — often working closely together — have tried to isolate a swathe of psychoactive substances from these concerns, by advancing a disease-centred model of mental illness in which for every specified cluster of symptoms there is a drug that is said to target precisely those symptoms. Attention Deficit Hyperactivity Disorder? No problem, we’ve got just the product. Hearing voices or seeing things? Try this new brand of anti-psychotic medication.
This is meant to to be a far cry from the era of “mother’s little helper”, when Valium was dished out liberally as an all-purpose calmative. It also allows for a principled stand against drugs like cannabis or heroin that are not medically prescribed and which continue to be illegal. The problem is, though, not only that in spite of the claims they make to be reversing a chemical imbalance in the brain, many psycho-pharmacological drugs operate as uppers/stimulants or downers/sedatives by another name, but that thanks to these having become normalised and almost as much part of the conversation you might expect to have with your GP as statins, the population is now on levels of mind-altering substances such as Timothy Leary — the counter-cultural guru who coined the slogan “turn on, tune in, drop out” back in the Sixties — might have dreamt of on one of his wilder acid trips.
In recent years there has also been a dramatic increase in the number of opioid painkillers prescribed for the treatment of chronic pain. This group of drugs is associated with serious side-effects and withdrawal difficulties too, the latter adding to the risk of long-term dependency. According to the All-Party Parliamentary Group for Prescribed Drug Dependence, over one million patients in England are unnecessarily taking addictive, psychoactive drugs (primarily benzodiazepines, anti-depressants, opioids and sleeping tablets), and in 2017 it began campaigning to set up a national helpline to support them.
Although this campaign has the backing of the BMA and several of the medical royal colleges, you will nonetheless often hear representatives of these bodies justifying current prescription levels on the grounds that they merely reflect the rate of disease. In a letter to The Times last year defending anti-depressants, for example, the newly-elected president of the Royal College of Psychiatrists explained, “As more people seek medical help, the number of prescriptions rises. More people receiving cancer treatment would not lead to criticism. Similarly, more anti-depressant prescriptions simply mean more people getting treatment”. Once again this begs the question. The fact that there is medical treatment available for depression involving the use of drugs, just as there is for cancer, does not itself prove that the former is a disease — let alone one that is comparable to cancer.
Perhaps the disease that really needs treating — or, rather, careful exploration and understanding — is the belief that drugs of any kind, legal or illegal, can bring us happiness. I do not want to say that this too is mere wishful thinking, as though throughout history societies have not turned to intoxicants of all sorts and for an equally wide range of reasons: for everyday relief, in ceremonies and celebrations, and also for spiritual insight. But this seems to me very different from a view which may be starting to take hold in the Western world today that suffering of any kind is an affront or abuse and should be eliminated psycho-pharmacologically.
The ready availability of anti-depressants and prescription painkillers certainly reinforces this view, and I go along with those critics of “Big Pharma” who are scandalised by the huge profits some of these products make — especially where these owe something to ties between pharmaceutical companies and the medical profession that are clearly a conflict of interest. But my main point is far from being an anti-capitalist one. If Marx were alive today I think he would need to rephrase his famous statement about religion being the opium of the people. With the demand for analgesic medication as high as it is, and with the supply of same approved both legally and socially as never before, it looks rather as though opiates are becoming the religion of the people.
I observed at the beginning of this article that mental health seemed to be constantly in the news last year. Although I can understand why someone might welcome this, the argument I am making is that the concept of “mental health” — as it is generally understood in the media, public awareness campaigns and also the medical profession — is a flawed one. The flaws I have concentrated on fall into four main categories: philosophical, moral, political and socio-cultural.
Is there an alternative to this concept? Surely anything is better than a return to the days when, either out of ignorance or shame, people were unable to talk about what they found disturbing or distressing? Even if there is a bit too much hype around mental health at the moment, in subjecting this to criticism isn’t there a danger of our throwing out the baby with the bathwater?
I disagree. In my view, the trouble with the mental health paradigm is precisely that it is infantilising: we should take our medicine from the experts who know what’s best for us and be grateful for it. They may not mean to hold back our development into adults with a capacity for taking difficult decisions about our lives and for tolerating the feelings of sadness or guilt to which we are naturally vulnerable when things go wrong. But I think that this is what has happened, as a result of a model of illness drawn from the body being applied to the mind.
In 1961 the Hungarian-American psychiatrist Thomas Szasz warned against this danger in The Myth of Mental Illness. “Psychiatrists are not concerned with mental illnesses and their treatments,” he wrote. “In actual practice they deal with personal, social and ethical problems in living.” For this book and others like it, Szasz found himself at odds with most members of his profession as well as conventional opinion more broadly.To me there is an element of truth in Szasz’s position. At the same time, I find it simplistic and of limited help when working as a psychotherapist with people struggling to be freed from what Blake called “mind-Forg’d manacles”. The mind is a delicate but also complex instrument quite capable of creating misery for itself. This is something we have always known. The plays of Sophocles and Shakespeare are full of self-inflicted suffering. But I would argue that we now have a much fuller appreciation of the mechanisms and motives involved in what seems to be so irrational. This is thanks mainly to the findings of “depth psychology” and those well-known figures from the last 150 years who have led the way in this field: on the continent, Freud and Jung, and closer to home our own John Bowlby and Donald Winnicott.
Szasz himself was in favour of the kind of psychotherapy associated with these names — so long as it was between consenting adults. In his day this was still quite widely available within the NHS, whereas now there is not much meaningful psychotherapy of any description. The “talking therapies” that are offered either as an alternative to or in conjunction with medication tend to be short-term and superficial, and there is now a push to eliminate human contact altogether by turning some of these digital.
For all that the present government is promising us the biggest expansion of mental health services in Europe, as though this could not be anything other than the best possible news, one of the striking trends of the last few years has been the emergence of patient-led groups and initiatives that have chosen to opt out of these services on the grounds that they pathologise everyday experience. Best-known among these is the Hearing Voices Network, which offers an alternative way of thinking about and living with what they call “unusual perception” to the standard psychiatric one. But dissent is starting to become quite mainstream among practitioners, too. As president of the British Psychological Society from 2016-17, Professor Peter Kinderman frequently questioned the “disease model” approach to mental health, while the existence of the Critical Psychiatry Network is proof that not all psychiatrists are wedded to this model either.
So before we rush ahead with introducing the language of mental health and the methods associated with it into the workplace and even schools, it might be worth asking whether we are clear what we hope to achieve by this. To claim that there are hidden epidemics of anxiety or depression in these settings that need treating is precisely that — a claim.
I am not denying that there are many employees who struggle in their jobs or children who can’t face going to school. There are people at all stages of life for whom feelings of confusion, rage or despair, to name just three, are more than they can bear. The question is whether we want to medicalise these states of mind and, as part of doing so, to seek to “cure” them.
It seems to me that until quite recently we had in the West religious and philosophical frameworks that gave us ways of understanding ourselves which were profound, rich and above all true. Having largely discarded these frameworks, it may be that the shallow and specious vocabulary of “mental health” is all we have left to us for reflecting on the life of our minds and even our souls. But as these lines from the poem Ars Poetica? by Czeslaw Milosz suggest, this is a poor substitute:
There was a time when only wise books were read,
helping us to bear our pain and misery.
This, after all, is not quite the same
as leafing through a thousand works fresh from psychiatric clinics.