The idea of doing better
The central theme underpinning and connecting mental health issues is crushingly low self-esteem, combined with anxiety and aggression, arising from difficulties people experience coming to terms with the reality around them.[1] That might be because they have a very difficult reality to engage with. Or it might be because they’re not very good at making a workable accommodation with the external world.[2] Or it might be anywhere between those two points.
To the extent it’s the second, it’s to do with their internal experiences being too vivid, too much difficulty coming to terms with other people’s separateness and independence, and unrealistic expectations leading to a constant diet of disappointment, frustration and experience of things going against them (even if objectively it might look as if they have a pretty comfortable existence).
Everyone has inside them, always more or less ready to be activated, the idea that they are not good enough, worse than other people. Even when people aren’t aware of that idea, it’s still exerting a pressure and affecting them. Not being able to negotiate the reality around you successfully enough is a powerful trigger: things not going the way you want or expect, getting things wrong, equals feelings of failure, guilt, shame, self-dislike (and anxiety and aggression). If someone lives too much like that, they get stuck in these ideas of inadequacy and defectiveness, which are hard-wired into everybody, and any one or more mental health issues can develop. Whenever anyone is in real trouble, not just normal human unhappiness, that’s what the root is.[3]
And there is always, for everyone, plenty of opportunities for these ideas to surface: things that inflame them and make people feel worse about themselves. Anybody’s mental life provides plenty with the potential to discomfort: just awareness of their own anxiety or inauthenticity can feel shameful. Everyone’s brain is capable of throwing up strange, irrational, disturbing ideas they don’t want to have, or own. It’s not just your thoughts: you get things wrong constantly and hurt people and cause harm through thoughtlessness and not seeing things. And then there’s cowardice, dishonesty, selfishness and spitefulness, loss of emotional control, aggression, violence.
Everybody has a kind of internal gyroscope that knows when things aren’t right, when they’ve been, or are being, a jerk. Even if they don’t consciously recognise that’s what’s going on, it still registers and they’re off-balance as these pre-set feelings of dissatisfaction with the self revive. If there’s enough around to shore up their self-esteem, it’s a bump in the road but if they haven’t got enough to balance it with, or it’s too big, it can take longer, or be harder, to recover.
Though the centrality of self-esteem (and the potential for self-punishment and self-persecution) to mental health is never spelt out in mental healthcare, you can see an implicit recognition of it in the push for de-stigmatisation of mental health issues – stigma is going to add to the suffering of people who are already feeling lousy about themselves.[4]
And you can see it in the clinical response to the feelings of worthlessness and self-hatred which are omnipresent in mental healthcare. That response broadly falls into two camps. The first (exemplified in CBT) is to examine and challenge the bases for the belief in self-worthlessness. The problem there is these ideas are too lived, too emotional, too experiential to be very susceptible to logical disputation. You can examine the evidence, you can win your argument, and they’ll be right back the next day: winning the argument is beside the point (often the case in life). The second (exemplified in person-centred therapy but really now integral to mental healthcare and well-being across the board[5]) involves telling yourself that you are, in fact, fine (or better than that) just as you are – self acceptance, self-compassion, learning to love yourself.[6] In effect, it’s trying to shout yourself down and the problem here is that one of the oldest lessons in psychology is that you can’t beat an idea just by trying to bury it. Ideas are like springs when you try to force them down. So, both approaches are pretty weak medicine.
People can get so far by evading these ideas about themselves or trying to overrule them, and everyone has to find some way of living with them, but the more urgent and pressing they get (and they get stronger the more people experience difficulties with the reality around them) the less well that works. Self-aggrandisement, frantic oscillation between self-justification (blaming others, grievance and resentment) and self-loathing, substance abuse, aggression and violence are all responses to the distress these ideas cause people when they get out of control.
If things are getting out of hand, the only real solution is to engage with these ideas, to take them seriously because they’re telling you something important and true – they’re telling you that you don’t like the way you are. And an essential element of the ability to engage with these ideas successfully is the idea that you can do better. It’s when people can’t stand themselves, and are convinced there’s nothing they can do to change, that you get the hopelessness that runs through depression setting in.
∞
The prevailing approach in mental healthcare is to dismiss people’s ideas of worthlessness, to do anything but take them seriously and that evades what’s really hurting them. Strategies include blaming people’s difficulties on family dynamics, trauma, bio-medical causes or social inequality and injustice and, increasingly, re-characterising them as valid responses, or legitimate alternative experiences, to be accepted and respected rather than addressed as problems. But they don’t feel valid or like legitimate to the people suffering them who’ve come for help: they’re immensely unhappy, that’s why they’ve come for help. That kind of response offers them a palliative life, involving endless special measures and adaptation by others; the idea of getting ‘better’ has gone out the window.
Or (and you can have your cake and eat it and get both at the same time) therapy is invoked as a kind of superpower, a sort of ‘with a single bound he was free’ escape into an enlightened happy ever after.[7] Here’s Harry, complaining in his current litigation in the English courts about having been ‘conditioned’ by his family not to take action against the British press.[8] That’s extreme language to use in public against the people you’ve been closest to all your life and it’s significant that it’s been couched in psychological terms (‘conditioning’, with its connotations of brainwashing, Stockholm Syndrome, lab rats). It’s a plotline that follows a firmly established trope in mental health and well-being: emergence of victim into a state of strength and grace, buoyed by the insights of therapy.
What’s entirely missing with any of this is any kind of reconciliation of people suffering from mental health issues with their own acute sense of error, of culpability or with their own real capacity to cause trouble. It’s been swerved but it’s still there and it’s still causing trouble.
It really isn’t OK not to be OK; it’s very shitty. And if people want to celebrate it, indulge it, weaponise it or exploit it, it’s not clear why other people should go along with that: they wouldn’t if it was cancer. Mental illness isn’t flu, you don’t catch it on the train. It may have a bio-medical cause or be contributed to by bio-medical factors (at some level it’s physiological because it’s happening in the brain), it may have been caused or contributed to by developmental experience, or by trauma, but it’s also ideas about the world, ideas people have about themselves and other people and they’re ideas which aren’t working well. In that sense people are doing it to themselves.
So, yes, it seems like a good idea to get rid of stigma around people’s emotional lives, around vulnerability but it’s not so clear why there should be such an impetus to eliminate every trace of stigma around mental health. Or, rather, it is clear why the impetus might be there - it’s because it’s anxiety, aggression and self-hatred caused by feelings of worthlessness that lie at the heart of the mental health issues and there’s a knee-jerk reaction to try to soothe that distress - it’s just not clear why it’s a good idea to try to avoid the reality of what’s going on in this way. You can't get entirely round stigma to do with mental health: shame and self-disgust is what the illness is. Try to evade that and you’re running away from the issue.
Nothing here should be ‘OK’. People are undermining their own lives and making things worse for others (and other people have generally already got enough on their own plates), they’re damaging or destroying relationships, they're exacerbating their own loneliness. And, often, they’re unable to fend for themselves and someone else has to pick up the pieces. It’s very far from ‘OK’ and that’s obvious to them. You can feel it when you're being shitty and it's real: imagine living like that all the time. The only people this could be ‘OK’ for are the ones who are supposed to be treating them (and failing).
And that’s a very real point. Virtually all the talk about mental healthcare is just signposting, the buck being passed. People are constantly encouraged to be more aware of mental health and to seek help. But what help, where? Behind all the educational drives, awareness campaigns and activism, behind all the compassionate messaging everyone’s engaged in, what’s really there? Waiting times on the NHS are so long that last year more than three quarters of mental health patients had to seek help from emergency services.[9] That’s why Simon Wesley, the first psychiatrist president of the Royal Society of Medicine, made his controversial statement back in 2017 calling for an end to public awareness campaigning about mental health.[10]
Perversely, the effect of this mismatch between expectation and demand and the resources available to meet it is to inflate peoples’ belief in the effectiveness of treatment. When they find out how hard it is to get, they feel deprived; they imagine there’s something tremendously precious there which would solve their problems, and they’re being kept away by a cynical, cruel refusal to commit sufficient resources and funds. If only: NHS figures show that only around one in four who go through the door marked ‘therapy’ are deemed to have recovered at the end of their treatment. And a good proportion of those are likely to be down to regression to the mean or the placebo (or flight to health) effect.[11] Medication doesn’t even attempt to cure mental illness, just assuage symptoms. So, the number of people for whom you could say treatment actually works (in the sense of being the active ingredient in recovery from mental illness) looks vanishingly small.
It’s a major problem (and fundamentally dishonest[12]) that mental healthcare professionals have allowed the impression to persist that they have effective solutions to mental health issues. If people understood how inadequate the safety net really is, they might have a different attitude to the importance of not slipping, keeping things together.[13] And, so far, we’ve only talked about the people who actually get into the mental healthcare system. This is from an interview last month with an ex-inmate of Pentonville Prison: ‘The noise of shouting and wailing is the first thing that hits you when they open the door on to the wings, and it never stops through the night… You hear people screaming out and smashing up their cells, just desperate for some kind of attention. I could see their mental state deteriorating so quickly from being locked up 23 hours a day’.[14] A lot of people suffering from readily diagnoseable mental health conditions end up in the criminal justice system instead and never get anywhere near a qualified clinician.
And there’s another reason why it’s important not to succumb to mental illness: there is (by the standards of psychology) compelling evidence that crossing that line once makes it more likely that you will cross it again. Research suggests that a very high proportion of people who have recovered from depression will relapse (85% within 15 years[15]) and diagnosis of any mental health condition dramatically increases the prospects of being diagnosed with another (half of all psychiatric patients will develop another diagnoseable condition within 10 years of their first diagnosis[16]).
So, a lot of how we talk about mental health and treat it looks like a kind of compassion trap. People want to avoid hurting those suffering from mental health issues and (even if psychology can’t express it coherently) everyone intuits that self-worth is at the heart of the whole thing. So, every attempt is made to destigmatise and normalise mental illness and to steer away from any suggestion of fault or shortcoming in people who are in such distress.
Everyone is anxious to show their concern about mental health, their sensitivity towards it and their support for sufferers and for mental healthcare services. And they’re convinced that by doing that, they’re doing something good (and that’s an idea about themselves they can use to help manage their self-worth). But nothing very good is actually going on. The stats make it absolutely clear that nothing that’s much help is happening and it’s hard to see how much can, whilst things go on like this.
∞
If people are depressed, it’s because they dislike themselves, they dislike the way they think and the way they behave. And disliking themselves that much has got in the way of being able to enjoy anything. If you’re depressed because you know you’re being a jerk, it’s time to stop being a jerk.
That’s a very complicated proposition because it means working out what not being a jerk is, for you. It means re-thinking things to bring yourself more into line with ways of thinking and behaving that can allow you to like yourself more. And if things have got that bad that’s likely to require a fairly wholesale revision of your approach to yourself and the world. Which is likely to be a difficult, bruising process, destabilising, frightening. And to take time, in fact, the process of people adjusting their perspective to find better ways of engaging with reality and being at ease with themselves, never really ends. And it’s likely to involve slips and errors and backward steps. Luckily none of that need matter too much because the idea of doing better can itself be enough.
Competence is a vital idea for mental health. Here,[17] someone who experienced severe mental illness talks about the real psychological benefits of doing a small, mundane task like brushing your teeth, really well. And that same sense of doing something for yourself, of making progress - of competence - is a significant part of the well-established mental health benefits of exercise, diet and exposure to nature.
And this may not be how people like to think about it, but if whatever’s providing a sense of competence has attached to it a veneer of exclusivity (pilates or yoga in an expensive spa or studio versus the school gym or community centre), that can help too. Because money isn’t, of itself, a bad proxy for competence (though what people have to do to get it can cause problems and, irrespective of the price paid to obtain it, too much is always a problem). Money can be a brutally effective token of competence for people who haven’t got it (and that’s the cause of a great deal of psychological damage) but for billions of people, for much of the time, it functions pretty well. And that’s a big part of its success. Well, whatever it takes.
Competence – you understanding what’s around you well enough to reach an accommodation with it that works for you - is more important than being understood.[18] In fact, part of what people get from feeling understood derives precisely from feelings of validation, a sense of competence, from the fact that other people appear to understand what’s going on for them. And that’s nice occasionally but, at the same time ‘understanding’ can feel a little intrusive and it’s only ever incomplete – who really wants the whole contents of their head understood? Too much of having to be the object of other people’s efforts at understanding is exhausting and debilitating and it reinforces a sense of incompetence.
Connie Convers was (possibly is) an American folk singer in the 50’s, now regarded as a pioneer of the genre and compared to Dylan.[19] In middle age, nearly 50 years ago, after a long history of mental health issues, she deliberately disappeared and no-one who knew her has seen her since. In a note left for her family she wrote this: ‘Let me go, let me be if I can, let me not be if I can’t. For a number of years now I’ve been the object of affectionate concern to my relatives and many friends…have received not just financial but spiritual support from them; have made a number of efforts, in this benign situation, to get a new toe-hold on the lively world. Have failed’. There’s no sense here of a shortage of being ‘understood’ or lack of concern or care, but there is a sense that in the end it’s become a burden and none of it has helped the sense of incompetence and failure, which, it looks most likely, in the end became lethal.
If the idea of failure, not being good enough, is the problem, the idea of doing better is an obvious candidate for at least part of the solution. But to do better, people first have to be able to recognise, to admit to themselves, what it is that’s wrong. The vague, shifting, generalised ideas of worthlessness that pervade mental health issues aren’t going to cut it.
For Connie Convers it looks as if there wasn’t enough of an idea of being able to do better. And it’s hard to get without a clear enough, specific enough, picture of where you’re going wrong. But the ideas of defectiveness hard-wired into everybody feel so intensely personal, so disturbing, that the process of getting that picture can be merciless. There’s not much more frightening than having to look at what you don’t want to see. That’s why (tragically) it so often needs a crisis for things to change - no choice left, it’s right in front of you and it’s got more difficult not to see. But you do have to be able to stand seeing it enough.
When people can’t come to terms enough with their own responsibility for what happens in their lives, the result is a constant restless attribution and re-attribution of fault and blame, and excuse and justification and grievance and resentment, between themselves and external factors. It’s a draining, endless process of trying to manage the anxiety, aggression and self-dislike generated by ideas of failure and inadequacy. If enough goes wrong in a life, these issues can become all consuming.
If people can come to terms enough with their own capacity to cause harm, these issues can become more settled, some kind of resolution becomes possible, some peace of mind. In fact, that is the sign that they have been able to do it (for now): the situation holds, they are enough at ease with themselves. They are not doing too many of the things people do that makes them despise themselves: they’re not neurotic or manic or depressed. They’re not trying too hard, they have found a system of living that keeps the idea of their own worthlessness in check.
Finding an adequate sense of responsibility for what goes on in their lives, recognising their own contribution to things that have disappointed or hurt them, or caused damage to others, gets easier with the idea of being able to do better. Because, really, that’s the only consolation there is for the way things often turn out, for the way we are, for our endless capacity to make mistakes, to get things wrong, to be weak, cowardly, dishonest or vicious – that we can do better.
To get to that idea of doing better, people have to be able to experience remorse. They have to be able to tolerate recognition of their own culpability and the consequences it’s had for them and others, without retreating into excuse or self-justification or some kind of blanket exonerating, self-acceptance (‘I am enough’). The more that’s gone wrong, the more pain that’s been caused (death, divorce), or the more blameworthy the behaviour (betrayal, violence) the harder that becomes.
Remorse is key because, if the feelings of guilt and shame can be borne, it leads to the desire to try to make up for what you’ve done, to try to put things right. This is an entirely natural process; no decision is required. If people can take on a share of responsibility which is honest and accurate enough to hold, things settle; they get to a point where they know what’s happened. And, immediately, they know what they have to do: they have to try to make good, they have to do what they can to make up for the harm they’ve caused, they have to do better.
That’s an entirely different state of mind: realistic, generous, concerned about others and genuinely self-accepting. The ideas of inadequacy and worthlessness have been appeased because (a realistic measure of) guilt has been admitted and balanced with a desire to atone. It’s a release, a fresh start, a new opportunity: the anxiety, aggression and self-dislike dissolve.
What actually happens next isn’t what’s important. It’s the impulse to make good, to do better, that’s transformative. And its mutable: once it’s arisen, it will find a way through. If it’s impossible, or impracticable or just a step too far, to try to make things up to the people who have suffered harm, it will translate to some gesture in another direction, some softness, some kindness, some form of restitution as a re-balancing between you and what’s outside you.
And what doing better – people finding a more workable accommodation with reality that lets them like themselves more - always involves in some form is greater tolerance of other people’s separateness and independence, more realistic expectations and the contents of their own head becoming less intense: doing a better job of meeting what’s outside their heads halfway.
∞
So, sorry seems to be the hardest word? Not really, it’s pretty easy to say: people do it insincerely all the time or in resentful irritation at being called out for something. Saying sorry doesn’t always mean a great deal but that genuine sense of remorse at recognition of your own fault and the harm it’s caused, that is hard. It can be excruciating, because it’s staring right into the eyes of the ideas of personal inadequacy and worthlessness that are what everybody hates and fears most about themselves. And people need to be able to hold that gaze for long enough, to be able to accept their own fault enough, before the idea of making good, of doing better, can rescue the situation. It may be hard but it’s the most powerful protector of mental health there is. It’s the best way for people to keep safe from a much worse unhappiness that can last a lifetime.
The idea of having got it wrong and the idea of doing better - the idea of being able to do better making it easier to come to terms with having got it wrong and the ability to accept your own capacity to cause harm as a necessary step towards wanting to do better. The two are inextricably linked and it’s a vital link, especially for people who are tormented by their sense of worthless (which is everyone who comes for help with mental health issues). That link doesn’t really feature in modern mental healthcare, and it doesn’t feature at all in the ideas it’s given society about mental health.
[1] https://jonathancoppin.substack.com/p/the-great-secret-shame-game and https://jonathancoppin.substack.com/p/self-esteem-and-mental-health
[4] There is a potential less selfless, unconscious, motivation for de-stigmatisation campaigns: if your livelihood depends on selling mental healthcare services, it’s going to be in your economic interests to oppose any stigma attached to them.
[6] See 2 above
[8] https://www.theguardian.com/uk-news/2023/mar/28/prince-harry-royals-agreed-not-to-sue-newspapers-over-phone-hacking?
[9] https://www.rcpsych.ac.uk/news-and-features/latest-news/detail/2022/10/10/hidden-waits-force-more-than-three-quarters-of-mental-health-patients-to-seek-help-from-emergency-services#:~:text=Waits%20can%20be%20longer%20than,including%20divorce%20and%20family%20breakdown.
[10] https://www.bmj.com/content/358/bmj.j4305
[13] See 11 above
[14] https://www.bbc.co.uk/news/uk-england-london-64869698
[15] https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30036-5/fulltext
[16] https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2720421
[17] https://www.theguardian.com/lifeandstyle/2019/jun/21/hannah-jane-parkinson-15-minutes-on-teeth-feel-good?
[18] See 2 above