The Lingua Franca of Mental Healthcare
If you ask someone involved in mental healthcare what mental illness is and what causes it, there’s no reliable way to predict what the answer will be. That’s because psychology does not have a coherent theoretical framework for mental health: psychology does not have an answer to those questions.
There are dozens of different clinical approaches and most of those have some form of theoretical formulation attached. The British Association of Counsellors and Psychotherapists currently endorses 33 different forms of psychotherapy on its website. That’s just therapy so it doesn’t include bio-medical interventions such as medication or ECT or transcranial stimulation or surgery. Obviously enough, the reason all these different approaches and forms of treatment still exist is because there’s no convincing evidence that any of them is more effective than any of the others. If there was, we’d do that.
So, it’s peculiar how similar what all these people do tends to look and sound. They couldn’t agree about what mental illness is but there’s a striking degree of consensus on how you ‘do’ mental healthcare on the ground. That consensus covers many of the motifs encountered when people receive mental healthcare (whatever the training or qualifications of the people providing it), the social and philosophical values associated with mental healthcare and it extends to much of how professionals talk about mental healthcare.
And it’s those areas of common ground that make up most of what most people ‘know’ about mental healthcare. And as mental health as a topic has become so pervasive in society, they ‘know’ it pretty well: everyone has a pretty good feel for what mental healthcare looks like and the kinds of things it says. In that sense, everyone ‘knows’ how it’s done.
Last week it was revealed that a woman with no qualifications had managed to go undetected working as a psychiatrist in the NHS for 22 years.[1] In fact, she was never detected by her colleagues; she was only exposed because eventually she got carried away enough to forge a patient’s will. She knew well enough how to do what was expected of a psychiatrist to evade detection by other mental healthcare professionals for 22 years. That might leave you asking what else there is to the job other than looking and sounding the part: it’s hard to imagine the same thing happening with a cardiovascular surgeon.[2]
Naturally, one of the key motifs of mental healthcare is care. There is a natural human impulse to care about suffering and there’s a very natural and powerful impulse for people who are suffering to want to be cared for. But care here is a bit different to care in an oncology or hepatology ward. With cancer or liver disease you can see what’s wrong. With mental health you can’t: you can’t see it on a brain scan, you can’t see it in blood tests or even a temperature. It’s behavioural and often that behaviour is difficult to be with.
And there’s the problem that the care is not very effective. Three out of four people who receive therapy through the NHS don’t recover.[3] And there isn’t even an ambition for antidepressants or other medication to make people better: they’re just for symptom management. And a lot of people who develop mental health problems and do recover don’t seem to get ‘better’ in the sense that, when you track a population of people across their lives, the evidence shows that experiencing any mental disorder significantly increases the likelihood of developing a different mental disorder later.[4]
Mental healthcare is becoming increasingly agnostic about the idea of cure: this is from an editorial in The Lancet at the end of last year 'The aim of reducing the effect of mental illness generally is certainly laudable, but society must also accept that not all individuals with mental disorders can achieve mental health and that wellbeing should encompass living with mental illness’.[5] What that translates into is care rather than cure, that is care without end, endless care.
That’s a difficult proposition: care is a complicated idea (care in the oncology ward isn’t as straightforward as people would like to think). If you can’t give people what they really want, which is for things to get better (mental health issues are an extreme form of unhappiness; no one wants to live like that), care is a poor substitute. For the sufferer, care is never enough but, if it’s all there is, it can acquire an enormous symbolic value and there can never be enough care.
Without the idea of cure, mental healthcare (carers and sufferers) is locked into a cycle of care and with that cycle come dependency, ambivalence, grievance and resentment. It also encourages an identification of carer with sufferer. Lived experience of mental illness is a growing theme in mental healthcare: people who have suffered, or are suffering, from mental health issues recruited into the provision of treatment.[6] But, in reality, mental healthcare has always been unusually coloured by lived experience: research suggests that the incidence of mental health issues suffered by those entering mental healthcare as a profession,[7] and those working in it,[8] are higher than the general population (that’s not the case with cancer and your oncologist). That doesn’t necessarily say much for the effectiveness of the treatments they’re providing, and it may involve its own complications for how treatment is delivered, but it also fosters a sense of alliance between carer and sufferer that you don’t tend to get in the oncology ward: a sense of being ‘in it’ together, the neglected front of healthcare, together against a society which doesn’t understand and doesn’t care enough.
So, care here looks more intense, more impassioned, more activist and (even) more beleaguered than other forms of medicine and that’s something that tends to be visible right across the different constituencies of mental healthcare.
If you can’t show people that what you’re selling works (i.e. cure), you have to be able to give them something else they want. And, in the case of people suffering from mental health issues, they want to not feel inadequate and worthless (because that is what underlies their problems in the first place[9]). So, the single most important element of the professional consensus around mental healthcare is that it isn’t the sufferer’s fault. That can take several forms but they’re all capable of being accommodated within that broad consensus.
In the bio-medical model, in which the pharmaceutical industry has an enormous vested interest, mental illness is a physiological event; it’s no more your fault than, say, cystic fibrosis (just a great deal more common). The bio-medical model (in the form of the chemical imbalance in the brain theory) has lost a lot of ground in the academic literature around depression recently.[10] But that’s only in the context of academic discussion around the nature and causes of mental illness: it’s of no practical relevance and it’s had no effect on treatment - there’s been no decrease in antidepressant usage or prescription. And any ground lost in academia by proponents of the bio-medical model has been more than made up with the exponential increases in diagnoses of ASD, ADD and ADHD (clustered together under the label ‘neurodevelopmental’ disorders); territory around which the discussion is monopolised by the bio-medical model (and for which the predominant treatment is medication).
In the social injustice model,[11] which is a trending theme in mental healthcare, mental health issues are predictable, natural consequences of the trauma people suffer in an inherently unequal and unfair society. This is a development of the old family model where peoples’ problems weren’t their fault because they were the product of dysfunctional family dynamics or neglect or abuse. This way, family members get a free pass too (though it was always emphasised in the family model that parents were doing their best because, even if it doesn’t recognise that the idea of fault is at the heart of mental illness,[12] the ways mental healthcare behaves have always reflected that). Now, it’s society’s fault and the bogeymen are big business and the rich and powerful.
Of course, these models can combine, so someone’s physiology (particularly their genetic inheritance) might pre-dispose them to particular mental health issues in particular circumstances. And different socio-economic backgrounds might be more likely to involve exposure to Adverse Childhood Experiences including trauma, abuse or non-adaptive parenting.
That’s completely plausible but what all this evades is the idea in people’s heads that there is something, somehow wrong with them, that it is all their fault. That idea is still there, it hasn’t been addressed and it’s what’s making them ill. Trying to keep people away from it is a fundamental part of the consensus around mental healthcare.
Here are some other shared ideas, elements of common ground to which everyone (psychiatrists, psychoanalysts, cognitive behaviourists, research psychologists, art therapists, trauma specialists, addiction specialists, forensic psychologists) seems prepared to sign up, at least in the public domain. Together, all these themes make up a generally accepted version of mental healthcare: something mental health professionals can fall back on to feel unified, with a common vision and (crucially) can put forward collectively for public consumption. They form the lingua franca of mental healthcare and that’s all that people outside mental healthcare generally get to hear.
Mental health issues are the result of things done to people. This is very much an idea of the moment: a search for ‘don’t ask what’s wrong with you, ask what happened to you’ will reveal dozens of You Tube videos, TED talks, podcasts, blogs and book titles.
The primacy of emotion. Intense feelings are a good thing. Therapy has always been about talking about feelings, uncovering what you really feel, getting at the real impact of things, and expressing yourself.
It’s about you. It’s about self-care (self-compassion, self-forgiveness, self-love), re-negotiating your boundaries with the external world, saying No, learning to assert yourself.
Negative emotions are valid. They tell you that things around you have to change.
Anger is a tool. Anger empowers people to make the changes they need to realise their potential.
Individuality and difference have to be respected. Experience is subjective, everyone is different, your feelings are your feelings and everyone is entitled to theirs.[13]
The interesting thing is that none of these instantly recognisable ideas belong to any of the grand theories of psychology. Aspects of them could be reconciled with elements of, say, psychoanalysis or behaviourism but they wouldn’t be recognised by Freud or Klein or Skinner or Beck. There’s a good reason they don’t belong to any of the key theories, which is that they are the meeting point which a group of people with very different theoretical backgrounds have found, and necessarily that meeting point had to be found outside any of those theories. But because they don’t derive from any of the theoretical frameworks, they haven’t had, and they don’t get, the same intellectual scrutiny as ideas within those traditions. In fact, they get none: they depend on consensus, that’s their whole point, they are part of the common language mental healthcare has evolved in order to be able to speak with one voice.
At the same time, there isn’t any evidence to support them. As a practical matter, they’re high-level themes and they’d be very difficult to validate experimentally – how would you test that anger empowers people to make the changes they need to realise their potential? But no one is testing them anyway. They just evolved, they were adopted, they are the badges of belonging to the mental healthcare community. No-one is responsible for them and it isn’t anyone’s job to examine them.
So, these themes don’t represent a psychological theory and they haven’t been derived from research. Other than the fact that you hear mental health professionals talking about them, these ideas don’t seem to have any connection to psychology at all.
And that’s potentially a big problem because it’s saying that fundamental elements of how we approach mental health, the treatment individuals who are suffering a great deal receive, the ideas given to them in the consulting room, and the ways we talk and think about mental health in parenting, in education, in society as a whole and the ways in which mental health as an idea affects how we think about ourselves and other people, are made up. They’re just what a bunch of mental healthcare professionals came up with to agree upon because they needed something to agree upon and they liked the sound of these ideas enough for them to fit the purpose. And this process happened intuitively, accidentally, without anyone paying much attention or saying what was going on - unconsciously, you might say.
Worse, when you look at this stuff, a great deal of it, in fact, seems to fly directly in the face of a lot of what psychology does suggest is good for mental health and is bad for mental health. Here’s some examples.
Poor ‘affect regulation’ (the ability to contain and manage emotions) has been demonstrated again and again to have a very strong association with a range of mental health issues.[14] The most common mental health problems are mood (i.e. emotion) disorders. There’s long standing consistent evidence that one of the effects of antidepressants (and therefore presumably one of the ways in which they help people) is emotional blunting, they dial down the intensity of people’s thoughts and feelings.[15]
One of the most common, and distressing, aspects of mental health problems is people’s internal experience becoming too vivid – rumination, intrusive or obsessive thoughts and, ultimately, delusions or hallucinations. If 20% of the adult population (the proportion prescribed antidepressants or other psychoactive medication)[16] have to be chemically protected from their own feelings, how well-informed is that idea that intensity of experience, of feeling, is somehow, of itself a psychological virtue?
Psychology has for a long time attempted to identify and analyse personality traits. You can make what you like of whether these traits really exist, or whether the dozens of different formulations have really captured the whole of personality, but one of the characteristics most commonly used in these studies is neuroticism, which covers emotional instability and tendency towards dissatisfaction and negative feeling (including irritability and anger). And one of the most consistent findings in psychology is that this tendency is strongly associated with mental health issues.[17]
So why that emphasis on the legitimacy of negative emotion, the validity of complaint, the idea of things being done to you and anger as a superpower? How sensible is the idea that all emotion is a guide to action in the outside world and the subjectivity of people’s individual experience must be respected? Negative emotions will be telling you something important, they will be telling you that there is a mis-match between your expectations and the world around you. That doesn’t necessarily mean the solution is to set about trying to change the outside world.
Longitudinal studies which have followed subjects through a lifetime, have concluded that the greatest contributor to happiness and mental health is the quality of personal relationships – being able to get on with people.[18] Alongside the epidemic of reported mental health issues, particularly amongst the young, there’s been a dramatic increase in reported loneliness (a nearly 30% increase in people saying they ‘often’ or ‘always’ feel lonely in two years), particularly amongst the young.[19]
So, what’s all the emphasis on self-determination, the sanctity of individuality and difference, the individual reaching their personal potential, their own way, as the ultimate good?
When you step back and look, the messages that come out of the lingua franca of mental healthcare are about high states of defensiveness, emotional intensity (and instability) and preoccupation with getting what you want and not getting compromised or intruded upon by other people. Does that sound like a good way to live? Fraught, dissatisfied, isolated, anxious but in pursuit of self-realisation? That’s the message mental healthcare collectively is putting out there.
And it’s through these ideas (rather than the more theoretically and empirically backed material used in the consulting room), and their absorption into the media and mainstream society that mental healthcare has its greatest influence on people’s attitudes and behaviour - and on their mental health. That’s what gets beamed in at people from all those ‘how to’ articles and books, well-being experts, life coaches, in schools, in parenting guides, in films, novels, music and in celebrity interviews.
How odd then to find that mental health care professionals are just winging it when they say these things. They don’t come from psychology at all, they’re not connected to the theories these people are supposed to believe and they’re not supported by evidence. In fact, most of what psychology does have to tell us about happiness and mental health points in the direction of these ideas having very significant potential to be positively harmful to mental health. That’s quite a remarkable situation when you think about it.
[1] https://www.bbc.com/news/uk-england-lancashire-64797676.amp
[2] Fake doctors are as old as medicine and people do bluff their way into operating theatres (for example, in 2009 a fake was convicted in Germany after participating in surgical procedures for 14 months - https://www.telegraph.co.uk/news/worldnews/europe/germany/6270792/German-banker-used-fake-documents-to-work-as-a-surgeon.html) but in a branch of medicine which does know what it’s doing, it’s easier to see when an individual doesn’t and you don’t tend to last 22 years
[4] https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2764602 and https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2720421
[5] https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(22)00344-3/fulltext
[6] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9346508/
[7] https://blogs.ucl.ac.uk/stigma-research/2018/04/11/mental-health-disclosure-amongst-clinical-psychologists-in-training-perfectionism-and-pragmatism-by-tom-grice/
[8] https://onlinelibrary.wiley.com/doi/abs/10.1002/jclp.22614
[14] https://pubmed.ncbi.nlm.nih.gov/22262030/
[15] https://www.theguardian.com/society/2023/jan/23/antidepressants-emotional-blunting-study?
[17] https://psycnet.apa.org/doiLanding?doi=10.1037%2Fa0020327, https://link.springer.com/article/10.1007/s10862-005-5384-y and https://psycnet.apa.org/doiLanding?doi=10.1037%2Fa0015127
[18] https://www.simonandschuster.com/books/The-Good-Life/Robert-Waldinger/9781982166694
[19] https://www.statista.com/chart/28505/loneliness-rates-in-the-uk-by-local-authority-supergroup/
Excellent. Self-esteem and feelings of worthlessness enjoy a bipolarity promoting the idea that, instead of lifting the bonnet and trying to fix the faulty wiring in your own head, it is healthier to invert your feelings into a sovereign right to be your authentic self without any need to reorient your approach to other people or to any other aspect of 'reality'. The pathologisation of unhappiness into mental health 'conditions' requiring a 'cure' or 'treatment' offers many people a way of aggrandising their negative experiences of being alive into an asset that can be spent in the attention economy. I wonder, however, if mental health is any worse than the other pseudo-sciences such as economics or neuroscience or cybernetics. In an age of 'fake it 'till you make it', we are all colluding in the marketisation of proxy solutions that monetise our desire for cures or cares that aren't yet possible. That's all therapy is - a way for people to make money from other people's unhappiness.