Mental health shouldn’t just be about individuals, we need strong communities too. Dinyar Godrej makes the case.
This special report was published in the May edition of the New Internationalist ‘Mental health: Looking beyond the pills’. Buy this issue or subscribe from just £7
Depression is so common that at times it has felt as if I had more friends who were battling it than weren’t. Various compulsive behaviours are constantly pored over by the media, often in an attempt to demystify them. With the advent of the internet there has been an explosion of mental health issues advocacy. Sound, down-to-earth information is now easily available, perhaps excessively so. Surely we are better equipped than ever to view mental distress and illness as part of a continuum of our life experience, rather than as a site of stigma and taboo?
The lived experience is, however, quite different. People with mental health problems still run up against a wall of unhelpful attitudes, ranging from ‘normalization’, which basically denies the problem, to an overly diagnostic attitude which sets the sufferer as a creature apart. Disbelief is in there, too, aided no doubt by a US-led tendency to classify an increasing range of common human behaviours and emotions – such as shyness or grief – as pathological disorders. The last things you want when confronting mental illness in yourself is to either let others define you by it or for them to deny it outright. Little wonder that people often feel that they find true understanding only among a community of peers.
Were the vistas of the mind easier to map, our imaginations a little less creative, would we be better at fixing things that go wrong? All the evidence of mental health ‘treatment’ suggests, however, that this is perhaps the most misguided question one could ask.
For it is often when we take fixed hypotheses as the point of departure that mental healthcare goes seriously wrong. Take the increasing belief that mental problems are due to chemical imbalances in the brain. A friend undergoing a major depressive episode was told by his general practitioner, after some cursory questions, that the cause was probably said chemical imbalance. An antidepressant drug was duly prescribed and day-to-day life became somewhat more bearable, but possible psychosocial triggers were left unexamined. A trajectory that will be familiar to many was set in motion.
Ten years along the line, the drug dependency is complete, while the effectiveness has diminished. As a result, a psychologist’s help has become an important support to this so-called ‘chemical’ problem. The drug has not prevented further depressive episodes (many people experience problems of increased gravity some years into medication), and no-one has any idea what the lifetime effects of the drug will be, because it is still too recent a discovery. Yet the doctor is convinced that it must be taken life long – as is my friend. Current estimates are that 1 in 10 US and Belgian adults are on antidepressants
There is no doubt that medication does help many people who don’t have recourse to the other kinds of support needed to tackle depression. But drugs are as much a symptom of mental healthcare today as they are a proposed cure. And the question of whether there are better options (which, incidentally, may also include some degree of medication) tends to get silenced when the convenient pill is to hand.
EXPANDING THE MARKET
There is a growing stream of medications aimed at mental health ‘conditions’, and they are being marketed aggressively by Big Pharma. And why not, when the mental health system, even in wealthy countries, is in such a shambles that pills are seen as quick fixes and getting the right kind of help either involves running from pillar to post or a miracle. Insurers increasingly refuse to pay for talk therapies. In the US, psychiatrists (who are seeing an influx of victims of the Wall Street meltdown) are dispensing with dealing with patients’ inner lives and going for short consultations geared towards ‘management’ with medication.
Yet for decades, this increasing medicalization has been resisted by a vocal psychiatric survivors’ movement, who decry unfeeling ‘care’ by professionals, the chemical cosh of ill-considered medication, and the assumption that their lives must be reduced to and arranged around a series of problems or ‘symptoms’. They are in search of more caring therapies, appropriate medication (when it is needed) and more meaningful ways of interpreting their experiences.
The long-term use of antipsychotics (studied among people with schizophrenia for whom the drugs were originally designed) was recently shown to shrink brain volume. Previously, this shrinkage was assumed to be associated with the disorder itself and was correlated with worsening symptoms and impaired functioning. Now that it looks like the medication causes such shrinkage, it is no longer being paired with the negative effects.2 At the very least, a vigorous risk-benefit debate of such medication is needed.
A UNIVERSE OF DISORDERS
The online publication of the draft of the fifth edition of the US psychiatrist’s bible Diagnostic and Statistical Manual of Mental Disorders (DSM-5, due to appear in print in May 2013) has caused uproar with its proposed huge expansion of what is considered mental illness – to include teenage rebelliousness. With a widened range of human behaviours pathologized, the door is open to further overprescription of psychiatric drugs. Opposition, even from within the mental health services community, is fierce, with groups as far afield as the Society of Indian Psychologists calling for radical changes. DSM-5 will further the tendency of reducing the mind, as one writer put it, ‘to a batter of chemicals we carry around in the mixing bowl of our skulls’.3 Its global influence will be enormous.
US research tends to dominate the mental health field through its sheer volume and published output. An unfortunate result has been a universalizing view of mental distress and illness which is actually an American view. Common sense suggests this must be nonsense; different cultures can have different ways of expressing and enacting emotion and mental illness. More dangerously, Western treatment models become accepted as ‘standard’ even when they may not be as effective, or are underresourced.
Different cultures have different ways of expressing and enacting emotion and mental illness, yet Western treatment models have become accepted as ‘standard’
Over 30 years, beginning in the early 1970s, the World Health Organization (WHO) carried out three large international studies which delivered a startling finding: people with schizophrenia in the Majority World had better long-term prospects than in the US and Europe, with much lower relapse rates. So did all the specialist care available in the rich world make no helpful difference? One possible explanation offered was that even unscientific beliefs about the cause of illness, such as spirit possession, had the benefit of keeping the affected individual within their social group and allowed a contained view of their problem that was distinct from their identity.3
We are back at stigma. One cannot suggest that mentally ill people are always better treated in the Majority World; instances of cruelty abound. But research suggests that biological explanations of mental illness that have gained currency in the West actually strengthen stigma rather than reducing it – the popular perception is of the person with the problem belonging to ‘a breed apart’.3
ANOTHER BIG SOCIETY
It has long been recognized that the roots of mental illness lie in three areas: biological factors (including genetic predispositions), life events of the individual concerned, and the social sphere. The first two have hogged the attention, whereas the third is possibly the most important. Even mental health problems at the more extreme end of the scale, such as schizophrenia, can be triggered by experiences of social deprivation and exclusion. The social matrix becomes crucial when one considers that anxiety is the underlying thread of most mental illness. A British lecturer in mental health nursing went as far as to say, ‘Good mental health is rooted in social cohesion, not the individual.’4
Both the promotion of mental health and the recovery from mental illness need to happen at a social level. Many mental health workers will tell you that being able to work and reconnect with society can be of greater benefit for an individual than other, more specialized, interventions.
In the West we are caught in the bind of fragmented, unequal societies that often lack any resemblance to community, and where individualism and the desire for privacy has led to alienation and loneliness. The material security we count on is getting increasingly wobbly for many as the financial crisis keeps racheting up. When in trouble, there is often no social safety net. In addition, there is the onslaught of consumer culture, the constant corrosive influence of advertising, and a hitherto unforeseen state of perpetual distractedness brought about by the multiplicity of digital media channels. Having forgotten how to live in the moment, it would appear we are being forced to live in the instant.
There is no doubt that people with mental health problems benefit from being in the community. The question is: does the community exist? Here is one view from the US: ‘[In the 1970s] large numbers of patients were discharged from psychiatric hospitals only to find themselves adrift in uncaring communities: isolated, lonely, and lacking meaningful relationships. Limited financial resources restricted their social activity. The media’s frequent portrayals of persons with mental illnesses as dangerous validated community rejection… Community and mental health professional stereotyping altered the quality and spontaneity of interpersonal relationships as negative attitudes were internalized.