All mental health advocacy is political

This post was originally published at Huffington Post.

Equating mental health issues with physical illness is fashionable amongst health commentators. From analogies associating mental health issues with a broken leg or cancer, to calls for parity of esteem, the inference is that mental illness and physical illness ought to be considered in the same way. But while the message may have served a purpose in recent years, it’s also a simplistic and increasingly misleading interpretation of mental health, and we owe it to our society and to the millions struggling with mental health issues to do better.

In the aftermath of the general elections last month, New Statesman journalist Laurie Penny wrote an impassioned article that linked the election result with depression. Social media backlash quickly followed, accusing the author of being insensitive and naive about the seriousness of mental illness.

A political commentator lacking insight into mental health might have been inclined to admit error, even if only to avoid confrontation. But Penny is no stranger to the subject of mental health. Quite the opposite. One of her first roles in journalism was writing for One in Four, a magazine whose raison d’etre was to provide a voice for those with mental health issues.

What Penny knows, and what we perhaps all need to remind ourselves of, is that mental health and sociopolitical factors are deeply intertwined. Not least of which is the economy, with studies showing dramatic rises in suicide during periods of recession and high unemployment.

There is also a strong relationship between inequality and mental illness. And an underlying risk factor for poor mental health is a perceived lack of control over our lives – something that almost every political decision could be said to have an influence on. Interpreting mental health with a strictly medical model precludes all of this.

None of this is to say that mental illness doesn’t also have a biological basis. Of course it does. Medical interventions can help. And a medical interpretation of mental illness can reduce blame associated with those who are suffering. But a denial of social and environmental factors can also leave us feeling helpless and insensitive to what’s going on around us.

Studies have also indicated that a narrow, brain-based interpretation of mental illness may increase pessimism about recovery, reduce confidence in psychotherapies, and actually increase aspects of stigma.

The solution, needless to say, is with an integration of biological and sociopolitical factors. That may be difficult and uncomfortable to do in our dualist, western society with its love of clear definitions and boundaries, but only when it happens will we be on the right path. Not just for the benefit of those with mental illness but also for those with mental health. (Yes, I mean everyone.)

Mental health advocates have a tendency to lose sight of this. While some campaigners delighted in political parties putting mental health service funding in their 2015 election manifestos – others were skeptical in light of the government’s rhetoric-defying NHS cuts.

Irrespective, rises in mental illness and suicide should not only prompt an increase in medical service provision – which is a given – but also an examination and reversal of social and political contributors. Like the canary dying in the coal-mine, it should be seen as a sign that something is not right.

The onus to point this out shouldn’t only fall on the mental health community. It should fall on the political ‘left’. If the left is lacking direction, as some have claimed, it would do well to reflect on its attitude towards mental health, and its neglect of the social sciences. The Conservative government has mined the area, with its‘behavioural insights’ and ‘wellbeing index’. Why has the left not done the same, and used the the abundance of social sciences literature that inherently supports its position?

Were it to do so, it wouldn’t refer to the rise in mental health issues only in terms of health services, but in terms of a need for broad social and political reform. Reform that starts by recognising that the association between recession and suicide is a symptom of a society failing to do enough to protect its people from the downsides of misfortune, whether economic or otherwise.

There is no biological reason for why economic depression should lead to clinical depression. It’s entirely social and political. We’re all affected, and we need more public figures to be talking about it.

In digital healthcare, who moderates the moderators?

The collapse of The BeatBullying Group raises serious questions about duty-of-care in digital support services, and to what extent such services need to be regulated. 

As an independent consultant to the charity’s mental health service, Mindfull, I was aware of the lengths that were taken to ensure rigorous safeguarding procedures worthy of the trust of users and third party stakeholders. My experience of working with the charity, and with the staff there, was entirely positive. It’s for this reason that the events of the last few weeks – with the sudden closure of services and secrecy – have been such a surprise, to myself and to many others.

The charity’s safeguarding protocol involved a sophisticated hierarchy of moderators, administrators and mental health professionals – all watched by NetMod, a piece of algorithmic technology that picks up on keywords and text patterns. The aim was to provide a comprehensive safety net for users so that they could depend on the service. Apparently, in spite of such measures, there was no safety net for the service itself.

Since the service was taken offline, communication from The BeatBullying Group’s Trustees has been slim-to-none. Staff and consultants were aware of delays in paying salaries some months ago, but were unaware that the service was under threat. Emails since the closure have been deliberately vague, speaking of “intense negotiations with a number of third parties”, but revealing no details. For those professionals with concern for the service, all that’s really known is that the Trustees decided that it would be better to pull the plug on services rather than openly discusses the challenges of keeping it online.

I have no reason to doubt that the charity’s trustees did what they thought right for users, or that they consulted legal professionals and mental health experts before switching off services. But had they sought the views of those of us working for the services, I have no doubt that the idea of switching services off without notice would have received no serious consideration.

At the heart of any digital support service is trust. Those turning to an anonymous service like BeatBullying are often doing so because they find it difficult to find places of trust elsewhere; it may have been ripped away from them by troubled family lives or abusive parents. BeatBullying promised to be a place of trust and dependability, and the thousands of young people using the service saw it as such. That trust and dependability has disappeared. Not just because of the loss of the service, but because of the manner in which it was switched off. To do so without prior notice or consultation has the whiff of a foster parent that has tucked their children into bed and then vanished during the night.

Were it a face-to-face support service or rehabilitation centre with regular day users, it would surely be immediately investigated if it closed its doors to users without notice – particularly as a registered charity with public funding. There would be an explicit duty-of-care to service users. At present, online support services appear to be held to a different standard, or none at all. For the public and mental health professionals to have faith in such services, this must be addressed.

As for the future of The BeatBullying Group, and its services, staff and volunteers continue to wait patiently for news whilst worrying about those young people who were depending on the service. For those feeling let down by the charity, the only consolation a conclusion may bring rests with the hope that important lessons may be learned.

Anyone needing support can access a 24 hour listening confidential listening service through Samaritans.org

Mental Illness: Not A Personal Failing, A Social Failing

As campaigners encourage the world to recognize mental illness as a biological, rather than moral, failing, we must be vigilant in not diminishing the significance of social and political factors.

The UK’s mental health campaigning is the envy of the world.  In Time to Change we have the world’s largest campaign to tackle mental health stigma. With the likes of Mind and Rethink, we have some of the most influential mental health charities. The UK paves the way in teaching that mental illness does not infer moral baggage, and opposing views are rightly condemned as remnants of archaic bigotry.

Being at the front of the curve of public opinion isn’t easy. It means managing the tensions between narrative and truth; between popular ideas and the more subtle nuances of reality. Of late, the mental health narrative has tended towards the view that mental illness is biological and unavoidable, and whilst there is some truth in that, it’s not the whole truth.

Campaigners often liken mental illness to physical diseases such as cancer. The point they make is that, like cancer, mental illness isn’t a choice and isn’t a reflection on the character of the person who’s suffering. These statements are true, and awareness of them lifts the burden of responsibility off the individual. But, crucially, they also lift responsibility off communities and societies – something we need to be increasingly aware of. Because communities do have a responsibility, and I don’t just mean with the provision of mental health services.

The basis of mental health may be hard-wired, but it’s at the mercy of our social, political, and economic environment. Having our freedoms taken from us cannot cause cancer. Nor is there a direct link between debt and cancer, or social isolation and cancer. But these things can aggravate mental health problems and push us into depression, and they are conditions that communities, institutions and governments determine. We must not forget this.

Every time we compare mental illness to cancer, we do a good and a bad. We do good by dispelling the ‘moral myth’ of mental illness, but we are also implying that we are prisoners of neurochemistry. By implying that our environments are irrelevant, a message that starts as an attempt to give people more of a sense of control, paradoxically, accomplishes the reverse.

Control is at the heart of the relationship between mental health and politics. To the degree that politics is about exercising control over our situation, as Hunter S. Thompson once suggested, mental health is as much a matter of politics as it is biology. When we feel like we lack control over our situations, we are more susceptible to depression. If the situation persists, depression is an inevitability. Just as poison to the body, tear down the conditions that enable me to retain a sense of control and my mental health will suffer. But give me cause to hope for a better future and I can persist.

Those of us with concern for increasing rates of mental illness have a choice to make. We can continue to diminish social and political factors by attributing the rapidly increasing global burden of depression to the influence of chemicals in the water, or air pollution.  Or we can make a point of acknowledging that our communities and institutions are not structured in a way that is conducive to psychological wellbeing and that we need to be prepared to push for radical political measures that address this.

The issue is one of social progress and evolution, and it starts with the way we talk about mental health. Attitudes towards mental health are constantly evolving, and a necessary part of this evolution is to go through a stage of seeing mental illness through a biological lens. Of course emotion and cognitive functioning is seated in the brain. And of course genetics and trauma can predispose or tip us into mental illness. But it doesn’t end there, and if the narrative fails to encompass a due recognition of social and political factors, then, individually and communally, we risk navigating into precisely the conditions most harmful to us.

On the selfishness of suicide

“I cannot make you understand. I cannot make anyone understand what is happening inside me. I cannot even explain it to myself.”

Let’s say sweeping leaves is ‘leavish’. And chopping wood is ‘woodish’. In the same way, we might say suicide is selfish. The action necessarily involves the self.

But the word ‘selfish’ has moral connotations. It doesn’t just imply paying attention to the self, it suggests a kind of self-interest and disregard for others that exceeds moral norms, even by the narcissistic standards of the West.

From a logical point of view, it makes no sense to describe suicide as selfish. Suicide extinguishes the self. What could be more at odds with the interests of the self than its annihilation? To the degree that the action achieves nothingness from self, it’s better described as non-selfish.

But those making moral judgments about suicide are not speaking from a logical point of view, just as those suffering from suicidal depression can find themselves caught up in beliefs that defy reason. And those that hear such claims, and feel hurt and angered by them, would do better to consider that such judgments may be coming from a place of deep anxiety and trauma rather than careless ignorance.

Many of those who make moral claims have witnessed the pain that suicide can cause to those left behind, and find it hard to understand why anyone would inflict this upon others. To live is seen as the easiest of things, and to die by one’s own hand, the most destructive to others. In this respect, the biases of those making such a judgment are a mirror image of the biases of the suicidal.

Those making moral judgments may look at the suicidal or clinically depressed and deplore their preoccupation with self, but such self-occupation comes not from volition but compulsion, as if, like the protagonist in Kafka’s Metamorphosis, we have woken up to find ourselves suddenly set apart from others by some hideous and shameful peculiarity. No cause is more desperate than to diminish this uncompromising sense of differentiation. Suicide follows when all other attempts to return things to a sense of natural order fall short.

Speak to someone bereaved by suicide and, in spite of their grief and confusion, more often than not they will describe the deceased as having been someone who was exceptionally concerned for the feelings of others. Clinical depression feeds on the compassionate. It latches onto a concern for others and uses it as a weapon with which to bludgeon the self into submission.

Suicide necessarily concerns the self, but it is the least self-interested of acts. As in other areas, the person left most exposed to criticism by ill-founded moral judgments is the judge.

The rise of 'hapitalism', and what can be done

Hapitalism (hap-i-tal-ism)
noun (portmanteau of ‘happy’ and ‘capitalism’)
An economic system based on a state measuring collective happiness in a way that encourages a level of individual competition and inequality typical of unregulated, free-market capitalism.

Yesterday, I wrote something for the Huffington Post exploring the correlation between happiness and suicide rates in US states (and nations). In it, I raise concerns over a developing ‘hapitalism’ in which average happiness levels are raised by sacrificing the happiness, and, in some cases, lives, of a minority.

A central principle behind capitalism is that free markets allow for economic growth and that this benefits all of us on condition that interventions such as taxation and public services exist. In the same way, happiness advocates argue that an increase in gross national happiness will benefit us all. The problem is that, as the happiness-suicide correlate indicates, conditionals are also needed to ensure that a rise in GNH benefits all. I’ll look more at these conditionals shortly.

The importance of conditionals in a happiness economy risks being overlooked due to happiness being seen as an intrinsic moral good. On the surface, an increase in the happiness of a group seems like a good thing, but the problem is that an increase in average happiness can be attained even if one member of the group has come to find themselves in extreme suffering. The tendency to assume that we can draw conclusions about individuals from the condition of a group is known as an ecological fallacy.

The appropriateness of equating a capitalist economy with a happiness (‘hapitalist’?) economy depends on the way in which individual ‘growth’ occurs in the two types of economy.  In my blog post, I explore the idea that the happiness of some may be directly enhanced by the suffering of others, and that those who are suffering may feel worse by comparing themselves to happy people (hence a correlation between happiness and suicide)*. If this is an accurate description, then, just as capitalist societies tend to favour the wealthy and may widen inequalities of wealth and income, a happiness economy may widen the wellbeing gap between the happy and unhappy unless interventions are in place to help encourage the reverse.

Interventions

1. Improving happiness indicators
For happiness indicators to be a measure of the wellbeing of all, they need to focus on more than just aggregating individual happiness. The economist Sagar Shah suggests that this might be done by also looking at the ‘features of a society’, or by giving higher weight to those with ‘lower well-being’. Discrediting simplistic aggregated measures of happiness may also be an important step.

2. Improving communication
Those writing, speaking and teaching about happiness ought to appreciate the degree to which suffering is unavoidable, and to be mindful of the impact of their words on those who are suffering. Proponents of positive psychology tend to use Martin Seligman’s theories of learned helplessness and learned optimism to argue that we all have influence over our wellbeing. This can be a message of hope and encouragement to some, but it may also dishearten those with poor wellbeing. Whilst our perception of suffering may influence our ability to move on from the situation, the presence of suffering is often a normal and healthy reaction to adverse stimuli. (Try being happy when you’re repeatedly being subjected to electric shocks.) If we deny this, we risk stigmatising something that we will all experience at some point in our lives.

3. Improving policymaking
All official happiness policy should factor in public health principles, and any messages or interventions designed to boost collective happiness should consider implications for mental health and suicide-prevention. Economists and policymakers should be liaising with public health professionals — and also vice versa; as the World Health Organisation reminds us, “Health is created and lived by people within the settings of their everyday life; where they learn, work, play, and love.”

 

*This may only be the case for people, communities and societies that are driven by competition and comparison. In fact, research from Japan suggests that happier people are kinder.

Even China admits that its schools have been damaging students. So why is the UK trying to emulate them?

‘The grass is greener on the other side’, or so Minister of Education, Elizabeth Truss seems to think. Next week she will be travelling East to see what can be learned from Shanghai’s schools.

In the latest PISA report into maths and science education, Shanghai once again topped the global charts, with children performing approximately 3 years above the international average for maths. By all statistical measures, Shanghai students seem to be “streets ahead” of their Western peers (as Truss puts it). But it’s far from being that straightforward.

The success of Chinese schools has come at a heavy cost. Student suicides, linked to long hours and intense pressure, are rife, and measures to try and curb the issues have been being gradually introduced for the past few years – such as with the rolling out of student counselling services and mental health education.

After broad reviews under the new Chinese government, involving examining education systems in 10 countries, last year the Ministry of Education announced plans for root-and-branch education reform. Long hours would be cut back, free time extended, focus would move away from standardized testing and a more holistic, softer flexible evaluation framework would be introduced; one that placed greater emphasis on the emotional and social skills of young people.

Concern over the mental health of young people wasn’t the only reason for the reforms. For a nation that boasts some of the world’s most important inventions, the last century or two has been a barren period for innovation; something that the current regime is keen to address. As the country gradually opens itself up to the rest of the world, China wants to have more to offer than just manufacturing – a function that will become increasingly redundant as incomes rise and sources of cheap labour diminish.

China’s review of education systems worldwide concluded that in order to boost innovation, it needed to pull back on productivity, and reorientate towards an appreciation of free time and spontaneity. That these should underpin creativity might seem obvious. But as China recognizes the role of soft power in the global economy, it seems strange that the UK seems so intent on moving things in the opposite direction, apparently oblivious to the impact that a pressure cooker education system has on the wellbeing and creativity of young people. So why are they doing it?

The paranoid might claim that the British government’s intentions are to decrease youthful dissent and create a more compliant generation, more willing to submit to authority – attributes that many associate with Chinese citizens. But the apparent intent on mimicking Shanghai’s education approach seems more like a lack of imagination on the part of the British Department of Education, and a confusion over what role they expect British graduates to play in global society. The relationship between China and the West, that, for decades, could be described as China copying a ‘visionary’ West, seems to have come full circle.

If we follow Shanghai into pushing rote learning of maths and science before all else then it seems that the only hope for Britain’s artistic, creative and entrepreneurial legacy is with those who manage to escape the education system early. As for the health and wellbeing of young people, well, we’d better start training more therapists now.