Conclusions
The groundwork has been laid out in previous essays. This one is where the pieces get pulled together. This article is the culmination of what this blog set out to say about mental health and mental healthcare.
Everything is social. People develop mental health issues because they can’t get on well enough (in their heads)[i] with other people. There is a problem with how they see themselves and other people. The problem is an idea (which is inside everyone) that there is something wrong with them, that they are somehow worse than other people, has become too strong, too insistent. That causes tremendous feelings of anxiety and aggression which makes them dislike themselves even more.
In response to that situation, which is hideous, they might become convinced they would feel better about themselves if they were sexy and thin (and if that goes too far it’s an eating disorder) or they might take refuge in grandiose fantasies about their own power and abilities (and if that goes too far its mania or bi-polar), they might try to escape their anxiety, or obliterate their feelings altogether, with alcohol or drugs (substance use disorder), they might use ritualistic or compulsive behaviour to ward off anxiety, often around ideas about harm to others which derive from their own feelings of aggression (OCD), they might become overwhelmed by a sense of hopelessness caused by their feelings of inadequacy and lose the ability to take pleasure in anything (depression) or their anxiety and aggression might become so intense and vivid that they have trouble telling their own thoughts from the external world (schizophrenia). And, in less extreme forms, reactions to the same set of ideas account for most of the foolish, self-destructive things we all do that don’t fit into our diagnostic categories for mental illness.
In all these cases, the root cause is the idea that you’re no good, inferior, inadequate and everyone has it. It’s been called the super ego, the inner critic, the internal bully; its where the inferiority complex comes from and imposter syndrome. And it’s always been recognised; it’s the Erinyes (Furies) of Greek mythology, a kind of self-inflicted curse pursuing and punishing you endlessly for something that’s intolerable about you.
Telling people who have got stuck in that kind of chronic self-persecution to tell themselves that, really, they’re lovely (which, in one form or another, is the mainstay of most therapy) isn’t much of a solution. If someone’s feelings of self-dislike have become that extreme, it’s for a reason: they are thinking and behaving in ways that do not feel right to them. And they wouldn’t feel right to anyone: there’s too much fear, too much grievance and resentment, too much spitefulness towards the people they depend upon. You can’t expect people to like themselves for that.
And it’s a vicious circle: people in this situation get very caught up in their own predicaments, in the intensity of their own thought processes. Their misery makes them self-centred and that makes it harder to form durable intimate relationships. Often the only people who can be with them close-up are family or people who are paid to have to do so. It’s hard to find a way out from that.
At one level, it is wonderful that we have stumbled across medications that can reduce the intensity of what these people are experiencing and allow them to bear their own minds. But that isn’t a particularly good solution either. These drugs can have serious side effects, impairing the quality of people’s lives, and they can be difficult to withdraw from. Also, these are crude instruments: this isn’t laser guided technology targeting negative emotions, drugs alter the chemistry of someone’s brain, they change the whole of someone’s experience of life. Life on medication is a mediated reality: people often complain of a sense of distance from their emotions, a ‘blunting’ - they have more difficulty feeling pleasure, or affection or a sense of closeness to people (everything is social).
If people have become ill because they dislike something about themselves so intensely, the only really durable solution is to change, to stop whatever it is that’s causing them so much trouble. That requires people looking more honestly than they’ve been able to at what they’re up to, what it is that they dislike about themselves so much they didn’t want to know about it - and it requires the idea of doing better.
Confronting what you’re so unhappy about with yourself is hard to do because it ignites that idea that there’s something uniquely wrong with us, that we’re worse than other people (the super ego, inner critic, inferiority complex etc) which everyone wants to stay away from. Things get easier if people can see that everyone else has that same idea about themselves too (everything is social). Normalising those ideas about inferiority, reducing their intensely personal quality, helps people look more honestly at what they’re up to.
And what’s inflamed the self-dislike, what’s gone wrong, is always about a misreading of reality; not ‘getting’ how things really are, which mainly means not ‘getting’ other people. It’s about unrealistic assumptions and expectations (wishful thinking, fairy stories, self-deception, full-on delusion) leading to disappointment, frustration, grievance, resentment.
The problem is the contents of people’s heads feeling too real to them: not being able to adapt enough to external reality, not being able to do a good enough job of meeting what’s outside your head half-way. And when people develop mental health issues their internal experience becomes more vivid, and it becomes harder to make a workable accommodation with external reality: it’s the same vicious circle.
What doing better involves is finding ways to be in the world, with other people, that work: that don’t make people dislike themselves so much. And that means finding ideas about self and others that are better adapted to reality, that provide enough of what it is that people (really) need for those ideas to hold and sustain themselves.
Without that, attempts to will yourself to like yourself more are likely to crash on the same skewed ideas about yourself and the world, the same unrealistic expectations and more disappointment, frustration, grievance and resentment. It’s a common enough pattern a series of false fresh starts, oscillating between triumphant self-compassion and self-love and self-loathing and despair (like a diluted bipolar disorder).
And the hardest thing to ‘get’ about reality, the most difficult aspect of the ‘growth’ required to be able to meet things outside you half-way is that other people are separate and independent from us, with their own lives and their own agendas (and, just as inclined to be venal and self-centred as we are). They are never going to (be able to) do what we want as often as we want.
So, ultimately, mental health is about (not) getting what you want. Problems flow from anxiety, aggression and self-dislike as a reaction to the experience of not being able to – whether that’s the result of a fundamentally unrealistic set of ideas about self and the rest of the world (which means people can never get enough of what they want) or encountering something dreadful and outside their control like bereavement or serious injury or illness.
Whatever the circumstances, if they can be encountered without excessive anxiety, aggression and self-dislike - or once they can get through the shame and guilt and fear and grievance and resentment and self-dislike in their own time - people will be alright.
∞
So, if that’s what’s involved in mental health issues why is it reported to be happening so much more?
One possibility is that it isn’t (happening). The alarming statistics about increases in mental health problems relate to self-reporting (people, or parents in the case of children, describing their own mental health or presenting for treatment). Statistics involving clinical assessment of the general population (for children and adults) have shown broadly static levels of mental health issues since the surveys began. Similarly, more objective measures of behaviour such as suicide and problem drinking don’t suggest any deterioration in mental health in the general population (though self-harm statistics particularly amongst girls and young women have recently increased very significantly).
So, the argument goes, it may be that people aren’t actually iller, it’s just that the increased attention being paid to mental health has persuaded them that they are. And concerns are regularly expressed that a ‘medicalisation of normal experience’ is causing problems in trying to allocate mental health care resources where they are needed most.
Maybe - that kind of confusion could be a factor behind the statistics. But it’s likely that the impact would be worse than trying to distinguish between who’s really ill and who’s just been talked into thinking they are. This is mental health we’re talking about – convince yourself enough you’re ill and you probably are. In any event, there’s a danger that a belief in your illness will lead you to sabotage your life in ways that are calculated to bring about precisely the sense of defeat and inadequacy that create genuine mental health issues.
Another popular explanation is that modern society is making people ill. At some level that must be true: even if the rise in reported mental health issues could be tracked to, say, air pollution,[ii] mental health issues manifest in social relations: it’s about you and other people (everything is social). And excessive reliance of fossil fuels would be a feature of modern society.
But what people usually mean when they point the finger at society is social inequality. Maybe – violence, prejudice, discrimination, inequality of opportunity all hurt people. And so does inequality of outcome, actually, just as much. It seems odd to argue that society today involves more violence, prejudice, discrimination or inequality of opportunity than, say, feudalism or the second world war or the more gender-race-and class-boundaried 70s and 80s. But maybe it’s a feature of modern society that these problems cause people more trouble, more distress, than they used to? Mass advertising and consumerism; we’ve become more attuned to what’s available, what others have got and maybe more sensitive to the idea of unfairness and inequality?
And there’s social media. Social media, and the advent of the smart phone, have been widely ascribed a role in the dramatic reported deterioration of mental health in the young. Explanations differ but it’s generally held that healthy social development is being somehow impeded and children and young adults are suffering mental heath issues as a result. Maybe – maybe people do need physical interaction and a life away from screens and things are more likely to go wrong, particularly in developing children, if they don’t get enough of it. It’s also plausible that social media, with its competitive curated lifestyles, personalised feeds and uncontrollable deluge of unverifiable information is making it harder for people to gain a stable, realistic perspective of themselves and other people.
Those are the three most popular explanations for the mental health epidemic: the medicalisation of normal experience, social inequality and tech and social media. They are fixed features of the conversation around mental health. Other candidates exist like the breakdown of the wider family. It’s rarer now for people to grow up in close proximity to several related adults and other kids invested in their wellbeing. More children grow up in very small family units, often living with only one biological (equal) parent. You’d expect the result to be narrower, more enmeshed, relationships and a lack of engagement and perspective from alternative sources of trust and affection. That could have a significant effect on people’s sense of themselves and other people.
But this is Psychology:[iii] none of these theories is proven, none of them is even supported by particularly compelling evidence. And none of these ideas are ever reconciled with each other. Any of them could be true; it’s more likely that they all have a contribution to play. The conversation about mental health getting worse just goes round and round and settles on a kind of vague consensus that suits the people most invested in the outcome: mental healthcare professionals, administrators and policymakers and sufferers.
What these essays have been about is the possibility that Psychology itself, the way its taught us to think about and approach mental health and mental healthcare, is making a very significant contribution to the problem - not just in terms of making people think they might be ill, but actually making them ill. That never gets discussed.
∞
The big problem with Psychology is it can’t show that it can treat mental health issues effectively. NHS figures tell us that only around 1 in 4 people who receive therapy recover. The most recent large-scale review of the effectiveness of antidepressants concluded that, despite the concerns about side effects and withdrawal, the best drugs are only ‘modestly’ more effective than a placebo.
If you can’t show that what you’ve got works, it’s difficult to be relevant. That’s a major problem for the hundreds of thousands of people employed in mental healthcare in the UK[iv] and their millions of colleagues round the world. And that evidence about the effectiveness of therapy and medication isn’t something that the 20% of the adult population receiving mental health treatment want to hear either.
So, to stay relevant, Psychology has had to concentrate on what people do want to hear. And what they want to hear most is that it’s not their fault. We all do but for these people it’s more urgent because it’s precisely the idea that they are inferior, inadequate, defective that’s causing their misery and making them ill.
Psychiatrists, psychologists and the dozens of different schools of therapists have quite different ideas from each other about the causes and mechanisms of mental illness and how to treat it but there are certain aspects of mental health and mental healthcare where their views coalesce, and they present a united front. And this consensus isn’t based on evidence, it’s pragmatic, it’s based around trying to stay relevant to the largest, and most economically significant, constituent of the community involved in mental healthcare – which is the users (and those are people who are struggling to maintain a workable accommodation with reality).
In the early days of modern mental healthcare, dominated by psychoanalysis, there were plenty of warnings about the risk of inadvertently colluding with illness and keeping patients stuck where they were. You don’t hear much about that anymore.
The unifying themes most firmly embedded in the public face of mental healthcare, the ideas everyone involved in mental healthcare is prepared to sign up to (and the ones that most directly affect everyone else’s ideas about mental health), include:
destigmatisation (it’s not your fault), it’s biological – chemical imbalance in the brain or neurodivergence (it’s not your fault) or it’s being done to you (it’s not your fault), self-determination, difference, divergence (its being done to you), self-care, self-acceptance, self-love (it’s being done to you), the need for greater public awareness of mental health issues (it’s being done to you) and the need for more resources (it’s being done to you). What comes across, what these themes are reflecting, is an intensely anxious, highly defended (latently aggressive) focus on the self, as is the case with mental illness.
What’s very low in that mix is universality, shared experience, other people’s predicaments or much sense of personal responsibility, recognition of your own capacity to cause harm, remorse or the idea of doing better. But those are essential components of mental health.
You would naturally expect that the ideas which mental healthcare chose to use or endorde, or not to use, could have serious consequences for mental health.
That’s most obvious in relation to treatment. Very little deliberate use is made of the experience of discovering that other people are struggling, in similar ways, with the same issues as you. That experience is regularly cited as the most helpful aspect of group therapy but it’s an accidental by-product of something driven primarily by economics. The gold standard of therapy remains ushering someone, who is already suffering from acute self-consciousness, into a dimly lit room in the company of someone who is pretending to be extremely well and talking exclusively about them and their problems, as if they were unique.
It makes very good sense that people in group work routinely find it hugely liberating and reassuring to discover that others share the same experiences as them. The main source of sufferers’ distress and illness is the excruciating conviction that they are somehow secretly, shamefully worse than other people. So, if people were able to see that, in fact, everyone else has that specific idea about themselves too – not just the ill and not just in some incidental, hypothetical way but actively driving every aspect of their lives –you would expect that might have very significant therapeutic potential. It doesn’t seem surprising that mental healthcare which so thoroughly neglects such an essential link to what underlies the illness might struggle to achieve results.
Then there’s the concern about the medicalisation of normal experience and the potential for mental health campaigning, activism and well-being boosterism to make people think they’re ill (or compromise their sense of competence so they sabotage themselves and become ill). That’s widely acknowledged as a real possibility in mental healthcare, an essential element of any balanced discussion on the statistics but, if true, it would be incredibly serious: it would mean the people meant to be looking after us (and our kids) were making things worse.
But it’s not the worst potential consequence of the way Psychology has taught us to think about mental health. There’s an even more serious risk from ideas emanating in a clinical framework crossing over and becoming entrenched into our ideas about ourselves and other people and influencing how we behave with each other.
Here's one trivial illustration. It’s the wrap-up on a (5-star) review of an album by a young female musician in a national newspaper last week - “Ultimately this is a record about healing and figuring out life, with all its heartbreak, on your own terms”.[v]
That short sentence reflects several of the themes picked out above: there’s (your) suffering (an implication of things being done to you), a (slightly pious and smug self-improving) claim to healing (yourself) and life as a highly individual quest, a quest to find ways to live on your own terms.
That’s just a random review in a paper but that’s the point: it’s completely unremarkable, you could encounter the same ideas being expressed anywhere. And the reference point most consistently offered for these views is mental health: that’s how you protect your mental health. It’s just one of countless illustrations of the potential for ideas to travel (via journalism, music, movies, literature, social media, well-being programmes, coaching, the workplace, education, political soundbites) between the clinical framework and everyday life.
‘Figuring out life… on your own terms’ - 20 years ago, let alone 50, that would have sounded like quite an extreme mandate for anyone; the kind of thing you might reserve for a maverick, an outlier, a Nina Simone, say. Now it's regarded as a given, a universally approved value, that’s how everyone should aspire to live – on their own terms.
But that’s not how people can live successfully and it’s not how people really do aspire to live: they want to (they need to) get on with other people more than that allows. People have to be able to meet the world outside them half-way; if they can’t, they become very unhappy. Nina Simone suffered from severe mental health issues her whole adult life: intensely anxious, frequently abusive and violent (including serious assaults against children) with years of dependency on antipsychotic medication.
Setting up false standards of self-determination and independence isn’t helpful to anyone. At best it leaves people confused (and with the idea that they’re doing something wrong) by the discrepancy between how they really do feel and this idea of how they ought to be living. Worse, the more that is how people really come to feel and see the world, the more likely they are to become ill.
And it’s a fantastic irony that Psychology and mental health are invoked as the validation for these ideas. It’s ironic because there isn’t any evidence at all for them from Psychology. Their adoption in Psychology was really just an (unconscious) strategy by mental healthcare professionals to reflect back to people who were ill what they wanted to hear, in an effort to stay relevant when Psychology couldn’t provide a cure.
Something strange has happened with mental healthcare over the years. It’s involved a welcome shift away from the arrogance and dogma of early psychoanalysis (although Psychology is definitely still not above allowing an impression to be created that it knows a great deal more than it does). But rather than adopting a more modest, tentative approach to helping people recover from illness, mental healthcare has largely abandoned the idea of cure and, with it, the idea of well.
That’s created confusion. In reality, Psychology does not have a great deal to offer sufferers beyond solidarity with people it can’t make better. But it’s not honest enough about that: it wants the impression that it knows what it’s doing. So, when Psychology promotes so forcefully themes like the subjectivity of lived experience, difference, divergence, self-determination and self-care, they are taken as the ingredients of good mental health: how to be well. They really aren’t (and there’s no basis for treating them like that), they are more a reflection of the experience of people with poor mental health, and how they manage their situation. They are more about how to be ill.
The danger is that now it’s more about representing the experience of people suffering from mental health issues than curing anyone, Psychology’s most effective role is acting as a conduit to bring ideas which derive from illness, and which are likely to make more people ill, into everybody’s lives.
To be OK people need things from other people: they need enough inclusion, acceptance, connection, and to feel enough goodwill and affection in themselves for other people, to mitigate the idea that they are no good, that there’s something wrong with them. Everything is social: to be OK, people have to be able to get on well enough with other people. One of the key reasons for the dramatic increases in reported mental health issues, especially amongst the young, may be that Psychology has been acting as a kind of Trojan Horse for ideas that are making it harder for them to do that.
The problem isn’t so much what goes on in treatment (however ineffective it may be). There’s not much wrong with the idea of intervention through medication when people are in crisis or in danger of becoming locked into misery. There’s scope for valuable things to happen in individual consulting rooms: more awareness, more openness, more tolerance of vulnerability. If you’re clueless about yourself, it’s going to be harder to understand other people and that will make you more difficult to be around. If you can’t understand yourself, you’re more likely to do stupid things.
Therapy can generate insight and self-awareness; it can use people’s capacity for responsibility and accountability, it can be a process through which people gain a determination to make a better job of things based on a more realistic assessment of themselves and the world around them. It can…but the evidence suggests that the great majority of the time not much very effective is going on in the consulting room and, in any event, it’s slow, painstaking (expensive) work saving the world, one soul at a time: low impact, low volume.
The ideas for which Psychology allows itself to be used as the authority, on the other hand, they work and they’ve got everywhere. We are all surrounded by them in our everyday lives (not just a 50-minute session once a week). Look at the tone, look at the overarching themes of how people are being taught to think about mental health: individualistic, exceptionalist, an intense focus on subjectivity, the primacy of emotion and ‘lived’ experience, a sense of threat and intrusion from others, the need to assert, difference and divergence, feelings of inadequacy and inferiority, self-reliance, self-determination, self-care, self-love and seizing your own power. Look what’s not there: a sense of shared experience, connection, generosity, affection, competence, responsibility or accountability. Anxious, aggressive, pervaded by low self-esteem and all about you: these ideas are (literally) mad.
It is entirely plausible that, looked at in the round, taken as a whole, mental healthcare does a great deal harm than good: that the real reason so many more people are reporting they are ill is that the ideas coming out of Psychology have made people more likely to become ill.
It’s not that talking more about mental health has made people think they’re ill; it’s that the ways we’re talking about it have made people ill. By explaining what mental illness actually is, these essays have described how that would happen.
[i] Externally they may be very socially adept. Stephen Fry, for example, has a well-publicised diagnosis of bi-polar disorder but it’s hard to imagine a more charming dinner companion.
[ii] A link has been claimed: https://www.psychiatry.org/news-room/apa-blogs/air-pollution%E2%80%99s-impact-on-mental-health#:~:text=Links%20Between%20Air%20Pollution%20and%20Mental%20Health%20Symptoms,bipolar%20disorder%20and%20personality%20disorder.
[iii] As ever in these essays references to Psychology include psychiatry, psychoanalysis, clinical psychology, every form of psychotherapy and any other mental health interventions.
[iv] 13,000 psychiatrists 2022: https://www.statista.com/statistics/462704/psychiatrists-employment-in-the-united-kingdom-uk/, 96,000 mental health nurses on the register 2022: https://www.hee.nhs.uk/sites/default/files/documents/Stepping%20forward%20to%20202021%20-%20The%20mental%20health%20workforce%20plan%20for%20england.pdf, 66,000 members British Association of Counsellors and Psychotherapists 2023: https://www.ft.com/content/c0a4958c-3e8b-4274-9ad9-228d7772ab1c, 133,000 full time equivalent mental health staff in the NHS 2022: https://www.nuffieldtrust.org.uk/resource/the-nhs-workforce-in-numbers
[v] http://digitaleditions.telegraph.co.uk/data/1521/reader/reader.html?social#!preferred/0/package/1521/pub/1521/page/144/article/NaN