Psychoeducation…Run, Run, Run Away

The evidence is that Psychology (which for these purposes includes psychiatry and psychotherapy) is not very effective at treating mental health. The most reliable data sources tell us only 1 in 4 get better with therapy (and that might not be the therapy making any difference anyway), antidepressants are only marginally more effective than a placebo and 85% of people who encounter mental illness and ‘recover’, get ill again.

That’s not an impressive case and it’s something that really ought to be more widely appreciated. There’s a general supposition that mental health is something we understand and there are solutions readily available when people get into trouble and that’s not helpful. When people or their loved ones encounter real problems, they’re generally shocked to find out how little is really there.

But healthcare isn’t just about treating illness; isn’t prevention is better than cure? So, maybe what we should be judging Psychology on is its ability to help people to avoid mental health illness, because that’s where it could make the most difference?

Short of adding Citalopram to the water supply, the most direct route would appear to be education: trying to influence the ways people think about mental health and manage theirs. And we certainly do hear a lot more about the subject these days: school programmes, mental health ambassadors at work and a hugely increased degree of attention to mental health and wellbeing in every branch of the media. We are a great deal more aware of mental health than we used to be.

But, at the same time this has been happening, mental health issues are reported to have been rising at the fastest rates we’ve ever seen. There is constant talk (including amongst the Psychology industry) about an epidemic of mental illness, especially amongst the young. That is not convincing evidence that Psychology’s efforts at helping people to manage their mental health are succeeding.

If Psychology has failed on this score, it must mean it hasn’t been able to communicate the things that people need in order to be OK; what really matters to people. And since it’s not having a problem in getting listened to, that surely means it’s saying the wrong stuff.

And that’s not surprising because it doesn’t know itself; there is no coherent account in Psychology about what mental illness is, why people get ill and what they need to get better.

∞

One of the defining features of therapy is its focus on the self: when people come for help, they get taken away into a dimly lit room and subjected to an intense process of self-scrutiny. Therapy is about you, it's your therapy (like it was some kind of treat). What we’re talking about is how you feel and what you think and how you're affected. That can be quite a blinkered take on the world.

It’s really just an accident that things got off on that foot. There’s any number of different approaches you could take to mental health issues: pharmacology and medication, ECT (still occasionally used) and its modern descendant transcranial magnetic stimulation, even surgery are all examples and the whole lie on a couch in a quiet room thing was only because Freud started by exploring hypnosis as a clinical technique. And therapy hasn’t evolved in the ways it has since because of compelling evidence that’s what worked (see above), those are just the directions the people providing it, and using it, wanted it to go down.

And from the outset, alongside that intense focus on the self was the idea of the individual – the self - paying a psychological price as a result of pressure to conform with social norms and diktats.[1] That was true of an era of repressed sexuality, rigid gender roles and overt and explicit racial discrimination and it still is – LGBT+ people, for example, report significantly higher levels of mental health problems than the rest of society.[2] Psychology can probably take a fair amount of credit for some of the progress made in equality and diversity during the last hundred years.

But over the years, things being done to us has increasingly taken the central focus of mental healthcare: “Don’t ask what’s wrong with you, ask what happened to you” – Tedded,[3] Oprahfied[4] and on the landing page of a thousand therapist’s websites. Even in psychiatry, the most traditional and conservative branch of mental healthcare, the prevailing model is shifting from a bio-medical model to one based around social injustice and inequality.

Last week the Centre for Mental Health published its 10-year strategy to overhaul the nation’s mental health.[5] Supported by the Royal College of Psychiatrists, the British Association of Counsellors and Psychotherapists, Mind, The Mental Health Foundation and more than 30 other organisations involved in health care in the UK, the principal recommendation are the eradication of child poverty, improved housing and environmental conditions and ending discrimination and disadvantage (and a whole lot more money, for unspecified purposes, to the members of the organisations who supported the report).

It’s all about society, how people live, what’s being done to us; there’s virtually nothing there about treatment (other than just generally wanting more, even though the evidence shows that what’s being done at the moment isn’t very effective).

Just about every medical condition has an association with social deprivation.[6] Healthcare professionals regularly warn governments about health inequalities and the cost of social deprivation. Governments formulate policies which they hope will get them re-elected, so we get a society whose closest organising principle is what the most voters think they want. You need healthcare professionals to point out some of the consequences of the way society has organised itself, but you do need more than that from them, you want them to be able to provide effective treatment too.

No other branch of healthcare is as invested in the idea of inequality and social injustice as mental healthcare. Those ideas just do not feature in the same way in the medical response to, say, diabetes or cancer but those are equally significant health issues. And that’s the case even though evidence suggests that physical health is more susceptible to impact from socio-economic factors than mental health.[7] Psychology is in danger of looking like it’s thrown in the towel and just wants to blame an unfair society.

And the same themes dominate when it comes to individual treatment in mental healthcare. The emphasis is very much on passivity, on victimhood in childhood (that was very much the focus of earlier models), in current relationships and (increasingly the focus now) from social injustice. And the key elements of support people are generally offered are about assertion of the self over a hostile environment: imposing boundaries, learning to say No, speaking your truth, re-claiming your own agency, self-compassion, self-forgiveness, self-love.

It's a terribly limited and limiting perspective. Two things missing are, first, anything much about other people, their predicaments and experiences and, second, anything much about the contribution you’ve made to your own unhappiness (other than just giving too much of yourself).

It’s also a very isolating position to take. What it does make clear though is what’s going on for people when they’re in trouble, what’s causing them distress. People who come for help are suffering from feelings of weakness, disadvantage, vulnerability, and it causes them anxiety and (even if it only stays in their heads) aggression and crushingly low self-esteem/self-hate. It tells you that’s how mental illness is experienced, that’s what mental it is – and it just finds ways to express itself in any of the diagnoses we normally adopt.

Telling someone who regularly falls into that hole, or has got stuck there, to tell themselves that in fact they are strong, powerful, and also lovely, is weak medicine. If it goes in at all, generally, it just sets up an argument with the voice inside them telling them that they’re really not. The argument never gets resolved and keeps things destabilised, restless, fretful, oscillating endlessly between self-justification, self-bolstering and self-hate.

What can provide some form of resolution is being able to see other people’s experience more clearly, being able to see how much of the things that bother you most about yourself are affecting them too. Because at the heart of problems with self-esteem is the idea that you are somehow secretly, shamefully worse than other people. Once people can see that everyone else has that idea about themselves too, it loses a great deal of its power. 

And if people have come to dislike themselves so much it’s made them ill, it’s for a reason. They are behaving or thinking in ways that they don’t want to, which feel fundamentally wrong and there’s limited amount that can happen until that stops. The best way to do that is to be able to take seriously their own capacity for shittyness, to be able to look hard and see what’s wrong (and what isn’t) and find ways to do better. That’s harder to do if people are so traumatised by the idea of their own unique awfulness that they can’t look at the idea of getting things wrong.

The sense of getting things wrong, and the idea of doing better all have a lot to do with other people (because that’s where things go wrong or right). And so does being overwhelmed by feelings of being uniquely awful (because it’s tied up with the idea of other people not being troubled by the same things). So, there isn’t really much reason to expect that therapy which concentrates almost exclusively on the self and neglects the subject of other people too much would be particularly effective.

∞

With this focus on the self in mental health has come an emphasis on difference, on divergence and the validity of subjective experience. The validity of subjective experience can get overdone: if the only way you can get by is taking powerful psychoactive medication or with constant support from mental healthcare professionals who are having to be paid to prop you up, you’re doing it wrong. It is ‘lived’ experience and, in an ontological sense, that makes it valid but it is not OK: it is a problem. It shouldn’t be like that. Likewise, an over-emphasis on difference and divergence: too often the ideas of personal authenticity encountered in the context of mental healthcare and wellbeing don’t amount to much more than a licence for people to take out their anxiety and aggression on other people. That isn’t valid - neither is it particularly authentic – it’s just making things worse for other people.

There has been quite a lot of concern expressed over the last couple of decades about the effects of a drift towards individualism and isolation in society. Robert Putnam’s 1995 essay Bowling Alone: America’s Declining Social Capital was an early example. In the UK we’ve had Oliver James’ The Selfish Capitalist: Origins of Affluenza and Will Storr’s Selfie: How the West became self-obsessed. People speculate that increased focus on diversity, intersectionality and identity politics has been a factor behind a perceived global trend towards greater polarisation and more extreme, less stable political systems.[8]

And people have drawn a connection between these developments and mental health – in May this year the US Surgeon General published a report tracking a decline in social connections, particularly amongst the young, and referring to ‘an epidemic of loneliness and isolation’ which, he said, ‘has been an unappreciated public health crisis that has harmed individual and societal health’.[9]

So, it’s really curious that so much of mental healthcare is so obdurately individualistic in its approach, so centred on the self.

A popular explanation for dramatic increases in reported mental health problems, especially amongst the young, is the smart phone and social media. In fact, that’s probably the most popular theory; it’s one generally accepted by mental healthcare professionals, and you’ll often find it treated as established fact. Probably the two best known proponents of this idea are Jonathan Haidt of NYU and Jean Twenge at San Diego State University. But they have other ideas too – both have written extensively about problems caused by what Twenge refers to as an ‘inflated sense of self’.[10] Those ideas have proved much less popular and (see above) they definitely haven’t been taken up by mental healthcare professionals.

The evidence on which Twenge and Haidt place most reliance when attributing problems to the smart phone and social media is that statistics show a dramatic increase in in mental health problems amongst children and young adults from about 2011, coinciding with the emergence of the smart phone and corresponding surge in the use of social media. But something else that has coincided with these children growing up has been the massively increased prominence of mental health as a topic in everybody’s lives.

That link between increased awareness of mental health issues and the dramatic increases in reported mental health problems has not gone unnoticed. Concerns are regularly aired that we might be medicalising aspects of normal human experience; that people might be being talked into the idea that there’s something wrong with them (and we all are very susceptible to the idea that there’s something wrong with us).

That idea isn’t even, of itself, a particularly controversial thing to suggest. The first Psychiatrist President of the Royal Society of Medicine got himself in a lot of trouble with it but that was because he tried to get in the way of something the Psychology industry wanted to do by calling for an end to public awareness campaigning for mental health: “Every time we have a mental health awareness week my spirits sink…we don’t need people to be more aware. We can’t deal with the ones who already are aware.”[11] Medicalisation of normal experience was a (gently unobtrusive) theme of a recent book called Losing Our Minds: What Mental Illness Really Is and What It Isn’t and that was received perfectly well.

It's a thing; an occasional talking point in the literature, at conferences and in the media. The possibility is acknowledged but it’s not being taken seriously because if it were true (and it almost certainly is), it would be appalling. It would mean that the people who were purporting to help us were actually making things worse and that millions of people might be being made much more unhappy than they needed to be.

And if that possibility were being taken seriously, we’d get a more thoughtful response to the mental health epidemic than demands that social, economic, fiscal and environmental policy be reconfigured around the requirements of Psychologists and infinite resources be applied to something that can already be seen not to be working very well (see the Centre for Mental Health 10-year strategy report above for an example).

But, in fact, it’s likely that the situation is worse than that. It’s not just a matter of talking people into thinking they’re ill, it is highly probable that the ideas coming out of mental healthcare are actually making people ill.

∞

Mental health problems are about difficulties in making a workable accommodation with external reality (which is mainly other people). They are about the contents of peoples’ heads becoming too vivid, too real to them. They are about not being able to meet what’s outside your head (which is mainly other people) halfway.

The overarching themes coming out of mental healthcare are about a highly defended relationship with the external world - the premise is it’s being done to you. Other people are characterised as threat: they are about demands, intrusion; they have to be told ‘No’, to be boundaried. You have to find your strength and power; you have to speak your truth and you get there with ‘self-care’. It sounds like a gigantic fantasy of self-reliance (fuelled by anxiety and aggression), it sounds neurotic, it sounds ill.[12]  

It’s beside the point to argue that these are cartoon like misrepresentations of what therapy really involves. These themes have become inextricably associated with mental health; mental healthcare is used as the reference point, the authority, for them. And mental health care professionals don’t speak out, they go along with it. And anyway, the truth is, they’re not an inaccurate reflection of a lot of what does happen in a lot of therapy.

And, the irony is, within mental healthcare, these ideas are just orthodoxies: there’s no authority for them at all. It’s intuitive that regimentation and imposing social order on the individual might be bad for mental health but there isn’t any evidence that greater respect for difference, divergence and subjectivity is effective at promoting mental health. Not just the evidence is crap; there isn’t even any evidence being relied on. These ideas grew out of a mulch of what interested parties wanted mental healthcare to look like. And the biggest constituency in that community of interested parties is the users of mental healthcare (people who are having difficulties reaching a workable accommodation with external reality).

At one level ‘self-care’ simply means taking practical steps to manage your health: good diet, health sleep patterns, exercise etc. That’s where it started but, in the context of mental health, it has acquired another connotation which is ‘putting yourself first’.[13] Therapists are always urging each other to practice ‘self-care’ - the analogy is often drawn with the instructions on aeroplanes to put your oxygen mask on first before trying to help others.

There’s a number of different ideas hidden away here. One, that we aren’t aways doing things (including providing therapy) for our own benefit anyway. Secondly, that there is a separate category of important psychological needs that can only be met this way, by you, for yourself. And lastly that this is all rather enlightened and self-reliant and you’re taking responsibility for things in a very grown-up way.

Everyone can get fed up with the demands made on them and need a break. That’s fine, take a walk, go fishing, get a massage; you’ll probably feel better. But elevating this into the idea that there is an inherent need for self-care; that this is, of itself, a separate, significant component of mental health, is overcooked – and it misses the real point. There is no separate world available, with us at its centre that we can dip in and out of and get what we need without other people: your family is sitting beside you and your real happiness and wellbeing depends on theirs (and getting their oxygen masks on).

Something as natural and innocuous as getting enough sleep, eating well, pursuing hobbies has been made part of a grand narrative about a threatening, intrusive world and a vulnerable, beleaguered self whose only real resource is itself.

∞

We are always surrounded by ideas; they affect how we experience the world without us having any way of being aware of it (the water we swim in) and they shift. The goods in shops now are quite different to what was in the shops 20 years ago and the ideas we’re living with now are different too. The idea of mental health has a prominence and penetration it’s never had before – in parenting, education, the workplace, print media, literature, film, music, social media and social and intimate relationships.

So, it is inevitable that the values, attitudes and perspectives attached to mental health as a topic will be shaping things, affecting how we feel about ourselves and other people and how we think we should behave with other people. If you’re a child or a young adult, you’ve only ever known what’s in the shops now and these ideas are all you’ve ever known.

The ideas coming out of mental healthcare are about a highly defended self, an emphasis on difference, divergence and subjectivity. There is a dearth of material around shared experience, connection, other people’s predicaments or about your own capacity to cause harm. Meeting things ‘halfway’ means finding a balance that can hold comfortably enough between what people want and the reality around them, because it works well enough to be stable and sustainable. There’s an accommodation to be made with partners, children, friends and with work and with the bank and the energy company and the garage and the supermarket and the weather and their health and everything else people encounter. But the themes coming out of mental healthcare, and infusing society, are about doubling down on the sense of self: that’s the overwhelming take-away people have been left with. The emancipation of the self was there from the outset in Psychology, but it was balanced, held in check; now it’s emerged as the dominant note and Psychology is everywhere. And there aren’t really any competing ideas around to challenge it.

To be OK, people need to feel enough acceptance and connection to be able to trust situations, they need to feel gratitude, concern, empathy and, best of all, they need themselves to feel affection. And they very much need to spend enough time not feeling grievance, resentment, anxiety, aggression and isolation. Because otherwise, their ideas about inferiority and worthlessness (which inhabit everyone) will push them towards difficult or destructive behaviour or overwhelm them completely. The things people need to be OK, the things that really matter for mental health, they can only get from other people.

To be OK, people need to be able to get on with each other. The ideas coming out of Psychology, and which Psychology is being used to validate, have made it harder for them to do that. That’s very likely to be making more people ill.

This piece started by asking whether, if Psychology can’t cure mental health issues very well, it can justify itself by helping people to manage their mental health, so they avoid problems. This is Psychology; not much can be proven, including the idea that the plotlines Psychology is running are harming us. But there is evidence to support it, by the standards of Psychology, compelling evidence. And the picture this idea paints of mental health and mental illness is a coherent one, which isn’t something Psychology can offer at the moment. It’s an idea that deserves to be taken as seriously as any other ideas in Psychology.

Jonathan Haidt and Jean Twenge have two main theses: the harmful effects of the smart phone and social media and the rise of entitlement and the inflated self. One thesis has been enthusiastically taken into the mental healthcare consensus and one hasn’t. Smartphones and social media make a great bugbear – blame it on technology run by rich, faceless people in large companies. Ideas around an inflated self are much harder to reconcile with the approach that the mental health consensus itself wants to take. If anything was going to change, the idea that it is doing harm would have to be taken seriously by the mental health care community. That makes it a dangerous situation.  

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[1] It’s there in the idea of repression (the price of doing what you’re supposed to), it was explicitly addressed in Freud’s Civilization and its Discontents and mental healthcare has always enjoyed an element of outsider, ant-establishment status

[2] https://www.rethink.org/advice-and-information/living-with-mental-illness/information-on-wellbeing-physical-health-bame-lgbtplus-and-studying-and-mental-health/lgbtplus-mental-health/

[3]

[4] https://www.amazon.com/What-Happened-You-Understanding-Resilience/dp/1250223180

[5] https://www.centreformentalhealth.org.uk/publications/mentally-healthier-nation

[6] https://www.kingsfund.org.uk/publications/what-are-health-inequalities

[7] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6352250/

[8] https://www.the-american-interest.com/2018/05/16/the-top-14-causes-of-political-polarization/

[9] https://www.hhs.gov/about/news/2023/05/03/new-surgeon-general-advisory-raises-alarm-about-devastating-impact-epidemic-loneliness-isolation-united-states.html

[10] https://journals.sagepub.com/doi/full/10.1177/2167696812466548 - see also Jonathan Haidt and Greg Lukianoff The Coddling of the American Mind: How Good Intentions and Bad Ideas are Setting Up a Generation for Failure and Jean Twenge and Keith Campbell The Narcissism Epidemic: Living in the Age of Entitlement

[11] https://www.bmj.com/content/358/bmj.j4305

[12] Statistically, neuroticism has been powerfully associated with mental health issues https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5428182/

[13] https://www.self.com/story/putting-yourself-first