Is Britain really in the throes of a mental health crisis? Turn on the television or open up a newspaper and it can be hard sometimes not to have this impression – and I’m not referring to the fretful state of mind of a country at the end of a long, hot summer during which divisions around Brexit kept threatening to boil over and that also saw our hopes first raised then dashed by England’s performance in the World Cup.
I’m thinking, rather, about those ubiquitous posters warning us that one in four people will have a ‘mental health problem’ at some point in their lives. I’m thinking also about the spate of Government initiatives intended to tackle these problems, which are now said to be widespread, both in schools and the workplace. I’m thinking about the endless arguing over whether we’re investing enough in mental health services within the NHS. And about the disclosures we have become used to hearing from politicians, celebrities and even members of the Royal Family, as they tell us about the mental health difficulties of one kind or another they have battled with.
As a psychotherapist, I find myself reacting to all this talk about mental health with mixed feelings. On the one hand, I welcome the openness there is around discussing issues that until recently were shrouded in ignorance and shame. On the other, I worry that as a society – and as practitioners – we are being steered towards a very particular model for conceptualising suffering (and, indeed, flourishing): one rooted in medicine rather than the mind.
I don’t know about you, but when someone comes to see me complaining about ‘anxiety’ or ‘depression’, my heart sinks. This is 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 these tend to be absent from the debate around mental health? Why is it that so much of that comes 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 in this article will limit myself to considering four of them.
Materialist perspective
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.’1
In fact, the reality of most mental health conditions is anything but clear-cut. Readers of this journal will be familiar with the controversy triggered by each new edition of the supposedly scientific Diagnostic and Statistical Manual of Mental Disorders (DSM). Assuming that said disorders are in the body or brain does not get round what is fundamentally a philosophical problem, so much as relocate it.
Victim mentality
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.
Disease-centred model
The fourth reason relates to the question of resources and what we as a society decide to spend our money on. Mindaltering 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 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 antipsychotic medication.’
This is meant 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 psychopharmacological 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 1960s – might have dreamed 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, antidepressants, opioids and sleeping tablets), and in 2017 it began campaigning to set up a national helpline to support them.2
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 antidepressants, for example, the 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 antidepressant prescriptions simply mean more people getting treatment’.3 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 don’t 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 that 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 psychopharmacologically.
The ready availability of antidepressants 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 their supply approved both legally and socially as never before, it looks rather as though opiates are becoming the religion of the people.
Alternative view
If, as I have been arguing, the concept of mental health is a flawed one, the question remains whether there is an alternative to it – one that acknowledges the distress and disturbance people often endure without medicalising their experiences. This is what the Hungarian-American psychiatrist Thomas Szasz put forward 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.’4 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 with people struggling to be freed from what Blake called ‘mind-forg’d manacles’.5 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’ 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.
Despite the Government 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 perceptions’ to the standard psychiatric one. But dissent is starting to become mainstream among practitioners, too. As the 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.
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.’6
A longer version of this article appeared in the July/August issue of Standpoint magazine. standpointmag.co.uk
Johnathan Sunley is a London-based psychotherapist who works in private practice and the prison service. He has a particular interest in cultural and philosophical questions pertaining to psychotherapy and is co-editor of the collection of essays Merely a Madness?: defining, treating and celebrating the unreasonable (Inter-Disciplinary Press, 2012).
References
1. The Times. Editorial. 31 July 2017.
2. All Party Parliamentary Group for Prescribed Drug Dependence. [Online.] http://www.prescribeddrug.org (accessed 20 July 2018).
3. The Times. Letters. 27 July 2017.
4. Szasz T. The myth of mental illness. New York: Harper and Row; 1961.
5. Blake W. London. [Online.] https://www.poetryfoundation.org/ poems/43673/london-56d222777e969 (accessed 27 July 2018).
6. Milosz C. The collected poems 1931–1987. New York: WW Norton and Co; 1991.