Hazel Croft argues that, while reducing stigma is a good start, we also need a more radical approach to mental health.
Mental health has become a huge issue in the media in recent months, with Theresa May unable to escape questions about it during the election, and with Prince Harry and a host of celebrities launching campaigns to address the stigma still attached to those experiencing mental health problems. Open discussion of these issues can only be a positive step, but reducing stigma is not enough on its own.
“They almost always ask what is wrong with you and hardly ever ask what happened to you.”
These words of mental health activist Eleanor Longden sum up current approaches to mental health. The mainstream narrative – from the government, psychiatrists, health care professionals and the media – is dominated by explanations that locate mental ill-health as being a “problem” within the individual. Mental health is nearly always couched in individualised terms about what is damaged, lacking or inadequate about a person’s behaviour and feelings. There is far less discussion of what has happened to those experiencing mental health problems – what is their housing like, how is their work organised, what abuse have they suffered, how have poverty, racism and sexism affected their mental wellbeing?
To take just one example, think of the stress and anxiety that living in the private rental sector causes to someone’s mental health – anxiety about paying rent, short-term tenancies forcing you into frequent moves, cramped and inadequate conditions, and the constant insecurity caused by fear of eviction. We are living in what some have characterised as a mental health crisis – where stress and anxiety from insecure living conditions, badly paid and often precarious jobs, a vicious benefits regime and the wider effects of austerity are causing more people to struggle with suicidal thoughts, and with depression, anxiety, personality disorders and other mental health problems. At the same time, mental health services have been slashed and all too often fail to provide the support that people need. An estimated three quarters of those with an ongoing mental health problem, for example, receive no psychiatric help or support, and one quarter of those with serious mental health diagnoses are said to be at serious risk of self-neglect due to inadequate care and support being available. In this article, I want to explore some ideas about psychiatry and mental health today, and to look at what has happened to the understanding, diagnosis and treatment of mental health.
Psychiatry under neoliberal capitalism
The biomedical model of psychiatric diagnosis and practice has become ever more dominant over the past 40 years. Mental illness, although still not funded and treated on a par with physical ill-health, is overwhelmingly conceptualised by psychiatrists, in the media, and by many service-users, as being a problem, fault or disease located in the body, most usually in a person’s genetic make-up or brain chemistry.
Of course, biological explanations for mental illness are not new, although the scientific justifications for the argument have changed. Ever since the mid-19th century, doctors and psychiatrists have been obsessed with finding a physical cause for mental illness – from the 19th-century obsession with finding a lesion in the brain, including by dissecting the dead bodies of those deemed insane, to theories in the early-20th century about toxins and bodily infections being the prime cause of mental illness, to recent theorisations about chemical imbalances in the brain, such as too much dopamine causing schizophrenia. Through the 20th century a plethora of often barbaric physical treatments were deployed to ‘treat’ mental illness, including leucotomies, which involved carving out chunks of the brain, to inducing comas through insulin injections and the development of Electroconvulsive Therapy (ECT). Since the development of the mass production of anti-psychotics and anti-depressants in the 1950s, drug treatments have replaced most of these cruder experimentations on the bodies of those diagnosed with mental illness – although ECT continues today, and its use has reportedly increased significantly over the past ten years. Despite all the brain research, physical experimentation and the widespread use of drugs, no definitive biological explanations have been found for mental illness.
Nevertheless, over the last four decades the biomedical model has undergone a resurgence, dominating all research into mental illness, to the detriment of research exploring psychological, social and structural factors in the development of mental distress. How can we explain this continued dominance of biological theories and treatment? Here the influence of the pharmaceutical industry on governments and the psychiatric profession cannot be underestimated. Big Pharma has a huge investment in psychiatry, using its billions to exert influence on how various behaviours and emotions are defined and classified as distinct conditions for which the same companies can then sell medication. As David Healy has written of the marketing tactics of the big pharmaceuticals, “they now sell diseases rather than just drugs.”
At the same time as the big multinational drug firms have built their markets in psychiatric drugs, psychiatric services have been decimated in an era of spending cuts and austerity. The 1970s and 1980s saw the closure of the big mental hospitals, which were shut down and the property, usually on lucrative sites, was sold off to the highest bidder. At Napsbury Hospital, where I worked in the early 1980s, swanky flats worth millions now occupy the spaces that were once home to long-term patients. Many of us welcomed the closure of these vast institutions, and hated their association with the oppressive asylum system of the Victorian era which locked people away, out of public view. But the much lauded ‘community care’ that was supposed to replace them remained woefully underfunded, and in many cases, non-existent. Day centres have also since been closed, and those needing care and support are often left alone in substandard accommodation, often grotty bedsits, forced to rely on medication and only able to access any help at times of acute crisis. Although psychiatric drugs can be a life saver, providing people with relief from their symptoms, those who take psychotropic and other psychiatric drugs on a long-term basis often suffer from debilitating side effects, such as nausea, lack of libido, weight gain, insomnia, fatigue, and hallucinations.
As the effects of mental health cutbacks have hit harder, the government has increasingly deployed coercive measures to be been seen to be reducing risk of harm, such as the introduction of Compulsory Treatment Orders and the widespread introduction of the ‘recovery model’, which many mental health campaigners and service user groups have viewed as an insidious neoliberal tool of coercion. The group Recovery in the Bin, for example, write: “Many of us will never be able to ‘recover’ living under these intolerable social and economic circumstances, such as poor housing, poverty, stigma, racism, sexism, unreasonable work expectations, and countless other barriers.”
The pathologisation of everyday life
Since the early 1990s psychiatric drugs have also been prescribed far more widely outside of psychiatric institutions. Today some 90% of those who come into contact with psychiatric services outside of hospital are prescribed some form of psychiatric drug. Take the example of Prozac, which was first introduced in 1987 and quickly became the fastest-selling psychiatric drug in history. Prozac has been prescribed more often than any other drug, and has become a household name and the topic of bestselling books. It was marketed on the idea that it could not only control people’s depressive symptoms, but would make people feel ‘better than well’. The drug companies prey on the real stresses and insecurities that people feel in order to sell them back a ‘solution’ in the form of a pill.
The dominance of Big Pharma also helps to explain the proliferation of new psychiatric disorders over the past four decades. Problems in more and more areas of life, often previously viewed as having social roots rather than medical ones, have been pathologised and treated as an illness that requires medication. To highlight the ways that new psychiatric disorders have been created is not to suggest that all diagnosis is a myth or should be rejected. Many people experiencing mental health problems welcome a diagnosis because it helps give meaning to the way they are feeling or to what can be experienced as frightening symptoms, such as hearing voices. In this society, diagnosis also gives people access to help, treatment, and support, however inadequate. Often a psychiatric diagnosis has been the only way that people can access the services they need. It was the struggles of Vietnam Veterans for recognition, compensation and support for their traumatic symptoms following the Vietnam War, for example, that led to Post Traumatic Stress Disorder (PTSD) being recognised as an official diagnosis in 1981. Continued cuts to health funding, however, mean that the way a diagnosis like PTSD is understood and applied can also be used to limit and/or deny the types of treatment available, despite the diagnosis’s origins in the struggle of Vietnam veterans.
Under the current neoliberal order, our mental health is subordinated to the needs of the market. On the one hand, the government and big business sell us the idea of happiness and wellbeing, a kind of consumerist dream where we seek our personal fulfilment through a well-paid job and a happy relationship, furnished with consumer goods as markers of our success. On the other hand, when the capitalist system fails to deliver on our dreams and goals, we are encouraged to blame ourselves for our failure to succeed. But if we begin to crack psychologically, then we find there are few psychological services available to help.
Psychotherapeutic services, counselling, and other ‘talking therapies’ are harder thanever to access, particularly if you are poor or marginalised. Moreover, what is on offer are services that increasingly provide a version of the insidious message of the ‘happiness industry’ that we are ultimately responsible for our own mental wellbeing. Those seeking help through the NHS are mainly offered Cognitive Behavioural Therapy (CBT), which is offered on a time-limited basis, sometimes through online programmes, or Mindfulness programmes, again often provided through online programmes. These services can be very helpful for some people, and should be more widely and extensively available. But CBT and Mindfulness are not necessarily suited for everyone or applicable to coping with every mental health issue. Such therapies focus on helping people to change their behaviour or patterns of thinking to cope better with everyday life and do not address the underlying causes of mental distress, which might be better helped through longer-term in-depth psychotherapy or open-ended counselling, for example. Nor do they deal with the economic, social and political restraints, such as job insecurity or inadequate housing, which have caused or exacerbated the person’s mental health difficulties in the first place.
A social framework
Although written before the full effects of neoliberal policies on psychiatric practice and diagnosis, the work of Marxist writer Peter Sedgwick provides a useful social framework to explore mental health under neoliberal capitalism. In his 1982 book Psychopolitics, and in several articles written in the 1970s, Sedgwick conceptualised mental illness as being both real and constructed. His book was a critique of anti-psychiatrists, such as RD Laing and Thomas Szasz, who had argued that psychiatry was a tool of oppression. Sedgwick agreed that psychiatric diagnosis and treatment were not value-neutral but were laden with judgements about what was considered ‘normal’ behaviour. But physical illnesses were also socially constructed, Sedgwick argued. Most anti-psychiatrist thinkers had an individualist critique of psychiatry, which construed the problem as one of the behaviour of psychiatrists. But for Sedgwick, psychiatry could not be viewed as a battle between the oppressive psychiatrist and the patient labelled as mentally ill. It was necessary, he argued, to look at the wider social context in which mental illness developed and psychiatric diagnosis took place. Mental health was part of a social process, and linked to wider social and political interests and struggles.
Such a social framework provides a way in which we can connect an individual’s psychological feelings to the relationships and structures of society. In this way, we can begin to focus on the question of what has happened to us in our lives, rather than to focusing on what is wrong with us. Mental health is not disconnected from wider social relationships of exploitation and oppression, but is enmeshed in them. We can see this in the way that mental health, and its treatment, is gendered and racialized. Women, people from ethnic minorities and those who are LGBTQ are all more likely to suffer symptoms of mental distress and to face mental health problems. A recent study, for example, found that people from ethnic minorities in Britain were five times more likely to suffer from psychotic disorders, with first-generation migrants who arrived in Britain as children most at risk. The researchers identified factors such as racist discrimination, a sense of belonging, perceived threats and the conflicting demands of living in a new country as factors in the development of psychotic episodes.
At the same time, racism, sexism, homophobia and transphobia within the psychiatric system mean that people from oppressed groups are more likely to be diagnosed with mental illness and to be categorised according to wider assumptions about gender, race or sexuality. Whereas men are more likely to be diagnosed with anti-social personality disorders, over 70% of those diagnosed with Borderline Personality Disorder (BPD) are women, many of whom have suffered childhood physical or sexual abuse. Those diagnosed with BPD (sometimes called Emotionally Unstable Personality Disorder) are often characterised as being ‘difficult’ and manipulative patients, always trying to catch out the psychiatrist or clinician. Such a patient’s words and actions are then interpreted in ways that fit in with gendered assumptions about women with BPD, and she is viewed as being too argumentative, too needy, too clever and too sexual. As feminist critics of the BPD diagnosis have pointed out, the diagnosis detracts from a recognition of the important role of childhood abuse in the development of trauma and mental illness. In this way, the diagnosis works to individualise and pathologise women’s responses to sexual violence and gendered oppression – even if that is not the intention of psychiatrists and psychologists.
In his brilliant book, The Protest Psychosis, Jonathan Metzl analyses how the diagnosis of schizophrenia came to be associated with the figure of the angry, black male protester during the time of the Civil Rights Movement and other black struggles in the US in the 1960s and early 1970s. Metzl shows how psychiatric diagnosis is infused with racialized and gendered assumptions, which shapes all aspects of the encounter between psychiatrist and patient, even if unconsciously. Psychiatric diagnosis, he argues, works to “define, circumscribe and contain abject populations”, such as “unruly housewives”, “addicted war veterans”, “inattentive children” or “angry black men”. At the level of what Metzl calls the “structural unconscious”, assumptions and fears about such groups shape psychiatric perceptions and the way people are defined and diagnosed, even when psychiatrists and mental health workers are aiming to help.
Viewing mental health through a social framework is not to deny the agency and demands of those experiencing mental health difficulties. On the contrary, as psychologist and psychiatric survivor Jay Watts wrote recently in an insightful article in The Guardian:
“We must shift our focus to one that validates the lived experience of people who are suffering, however they choose to understand their pain. Some will choose to conceptualise their distress as an illness, others as a result of trauma, others yet as an embodied response to the mixed messages that are rife in our society about who and how we are supposed to be.”
A social framework allows us to see how mental health is central to every aspect of our lives, and connected to all the battles we face – against racism and sexism, for sexual liberation, for decent housing, or in our struggles in the workplace against precarious work and attempts to make us work longer and harder. Our struggle is alongside mental health workers, service users and others. Yes, to defend services when we must, but also to envisage how we could conceptualise mental health in a liberatory way that doesn’t reduce us to our biological bodies or view us as units to be measured against happiness scales.