One idea that has been circling around my head a lot recently is how we commonly treat the recent “epidemic” of mental illness as something specifically pertaining to the individual sufferers concerned. We’re often inclined, however compassionately, to attributing their suffering to their personal “problematic” biology, their brain chemistry or their thinking patterns. We don’t step back and look at the potentially larger scale social and political causes of it.

In the book Life Isn’t Binary, Barker and Iantaffi provide a phrasing of this issue that has stuck with me:

Perhaps we would do well to view the depression, anxiety and other mental health struggles that most of us grapple with at some point as a sane response to an insane world.

The pain and struggles are entirely real, there’s no questioning of that. But in many cases they’re also understandable without recourse to individual “abnormalities”. They have causes; logical, rational and predictable antecedents.

Oftentimes they may in fact be the result of the body and brain working perfectly normally given the situation they find themselves in. In Lost Connections, Hari notes:

It is no measure of health to be well-adjusted to a sick society.

We’ve evolved responses to dangers that may not be “useful” for today’s challenges in many cases. But the fact that people have those responses is necessarily not a sign of bad or unusual health. They’re a perfectly normal response to situations that are perceived to pose some kind of threat.

In some instances the threats may not be real but rather the result of some misunderstanding. In these cases perhaps a valid avenue of treatment might be to try and help someone change how they think about a situation. But on other occasions times the perceived threat may in fact be very real.

As is obvious from the above, this kind of issue has been touched upon to some extent by several books and articles I’ve read in recent times. But it’s not clear to me that it’s reached the point of full acceptance, or that the conclusions that logically follow from this train of thinking have been concretely transformed into policy, perhaps outside of a few trials.

This is not necessarily through the very real historical lack of compassion and understanding that has confronted those afflicted with mental health issues. In fact, some of the resistance to this idea might be the concern that taking this view too far to the extremes could result in the ignoring of people’s very individual needs, or a failure to provide the individual-level treatments are in fact needed in some cases.

A quote I saw somewhere taken from a psychotherapist called D. W. Winnicott’s book ‘Human Nature’, which runs as follows:

The capacity to become depressed…is something that is not inborn nor is it an illness; it comes as an achievement of healthy emotional growth…the fact is that life itself is difficult. Probably the greatest suffering in the human world is the suffering of normal or healthy or mature persons.

I think that at least the first part of that must be true. No-one that I’m aware of thinks that their own life is entirely easy, uncomplicated and stress-free. But it’s often hard for us to viscerally remember that fact when it comes to understanding and interacting with other people. This is especially the case if we feel like someone mistreated us, that they’re of “bad character” (whatever that means) or that they’re somehow getting a better deal out of life than us. Even at the extremes, is there really any reason to believe that the richest man in the world, Elon Musk is presently living a happy and care-free life (actually maybe he’s only second richest now)?

If we accept that most, possibly all, people feel that their life is in some way a struggle then wouldn’t we find it strange if they didn’t ever have any kind of negative psychological response? That might feel like a disorder in itself.

Perhaps part of the controversy from the compassionate side might be a fear that, in understanding that it’s perfectly normal to have the capacity to suffer from what we now classify as mental illness one, could misguidedly come to the conclusion that, hey, we just need to live with it. Sure you’re suffering, maybe a lot more than most people - but it’s a perfect normal phenomenon. You don’t need treatment. There’s nothing we should or even could do about it. That would be entirely the wrong conclusion to draw.

But very little of import in this discussion is the result of a unmodifiable natural law. Societies have changed over time.

By many metrics they tend to improve in many ways - this famously being a core thesis of books like Pinker’s “The Better Angels of our Nature” as well as his more recent work. It does seem to me that it’s very often a fallacy to think “things must have been better in every way a few decades ago” or “if we lived a life more like someone in the past would have then we’d be guaranteed happiness”. But even if the direction has generally been positive in the past, then there’s no guarantee it always will be. Besides, there will always be hiccups, mis-steps and temporary deviations into potential despair along the way.

But the fact that there have been changes in the past show us that there can be changes in the future. I often wonder what people 200 years from now will look back on us and think “oh man, that’s wild that they used to do that. How could they possibly believe that was OK?” about in the same way that we might look back on people from past centuries, wondering how they could ever believe what they needed to believe in order behave in ways that by today’s standards we would consider illogical, foolish, and cruel.

But another bad conclusion one can draw, this time from not taking social or other macro causes of mental distress into account, comes from the idea that those who get diagnosed as depressed, anxious and so on are the unhappy victims of random bad brain chemistry or invalid patters of thought. This idea might lead people to infer that the individual medicalisation of patients is a necessary and sufficient manner of addressing their pain.

I’m absolutely not against the use of pharmaceuticals or other individual-level medical therapies of any helpful kind. Sometimes their usage may be imperative, urgent, and life saving. But in the cases where there is a plausible social or environmental cause for the condition - let’s say abject loneliness, poverty-induced fear and exhaustion, anxiety resulting from racial abuse, the legacy of past traumas, all those kind of things - giving someone individual medical “brain treatment” doesn’t do anything about removing the cause. The same cause that likely wrecks the life of many other people in addition to the one who summoned up the strength to visit a doctor and had the access to do so.

Most damningly, limiting ourselves to individually medicalising the sufferers of a structural effect lets us off the hook from even addressing the causes. Often this is convenient, in the sense that truly addressing some structural or social determinants of disease may involve solutions that are politically challenging to even discuss in the current environment, let alone carry out.

As just one example of what we know could be done, at one point in the Covid-19 pandemic the UK made a concerted and effective effort to “solve” homelessness. Being without accommodation is a life situation which is highly associated with the suffering of mental health disorders, both as cause and effect. But with this initiative, street homelessness was apparently almost eliminated and tens of thousands of people were moved from emergency to longer term accommodation.

It seems like in general the policy worked! However the Government chose to end the scheme. Last year a quarter of the beneficiaries of the scheme are back to having no accommodation It’s feared that the 2022 cost of living crisis will cause a “tidal wave” of new homelessness, and given the acknowledged connection between homelessness and mental illness, an unnecessary spike in mental suffering.

A recent New York Times opinion article provided the following metaphor:

If someone is driving through a crowd, running people over, the smart move is not to declare an epidemic of people suffering from Got Run Over by a Car Syndrome and go searching for the underlying biological mechanism that must be causing it. You have to treat the very real suffering that is happening in the bodies of the people affected, obviously, but the key point is this: You’re going to have to stop the guy running over people with the car.

If something about some people’s lives today is causing them mental anguish, then we certainly need to treat that suffering. But a solution that doesn’t also stop the metaphorical guy who is mowing down their well-being is never going to be sustainable, complete or robust.

Therapising someone who’s anxiety is exacerbated by for instance food insecurity, who knows that the only way they can afford to eat even low-quality unhealthful food is dependent on them keeping their low-paid, precarious and abusive job, may potentially help their inner state in the short term. But it doesn’t do anything to remove the actual, real, threat of them in truth not being able live without exposing themselves to abusive conditions - conditions that they don’t have any agency over; however unpleasant the job is, it might taken away from them at someone else’s whim. Someone who didn’t respond to those prospects with a substantial level of at least worry and trepidation would seem unusual to me.

If their response is damaging to their own quality of life then they surely must be individually helped. But we must also address whatever has led us to a place where their ability to lead a fulfilling life depends on your luck and ability to take employment at any personal cost. What led us to a place where more than 1 in 5 millennials feel like they have no friends? A society where financial security depends in part upon your race? That those who live in some areas die many years earlier than those that live elsewhere, even in a small and rich country? A land where the economic consequences of the Covid-19 pandemic on you were more severe if you were already poorer beforehand?

This becomes even clearer to me when we look at patterns of mental health issues. These sorts of statistics are always a little hard to interpret because to feature in such a dataset often requires you to have had access to and attended certain types of healthcare. It may even depend the specific medical practitioner you see when you do so.

In The Body Keeps The Score, the author writes that despite the best attempts of psychiatrists to define and categorise mental illnesses, for example in the famous Diagnostic and Statistical Manual of Mental Disorders (DSM), specific diagnoses often come down to tallying up a list of symptoms and may depend as much on the mindset of the doctor concerned as on the patient. The fact that new editions of the DSM categorisation come out every so often with new and altered definitions reinforces the point that we haven’t fully solved how to categorise mental illness, let alone treat it.

In her book, All Our Relations, Tanya Talaga draws a direct line between the incredibly high rate of that most extreme outcome of adverse mental health, suicide, and the social conditions that the Indigenous peoples of countries like Canada and the US find now themselves in.

She reports that in Canada, suicide and self-harm is now the leading cause of death of First Nations people up to the age of 44. Rates are more than 5 times higher than a comparison group of non-Indigenous people for males aged between 15-24.

But this wasn’t always the case. The suicide epidemic in those communities is a modern phenomenon, seen only after the introduction of forced resettlement and the “Indian Residential schools”.

The natural brain biochemistry of these folk didn’t suddenly change overnight. No genetic mutation suddenly somehow retrospectively swept their culture. Rather, their way of life, their beliefs, their freedoms, hopes and dreams had been assaulted by the political decisions and resulting social conditions at the time.

Today Indigenous children are more likely to grow up without access to the basic determinants of health, which Talaga lists as including income, status, clean water and air, decent accommodation, supportive families and communities, education, healthcare and a connection to their traditions. The absence of these basics negatively affects their physical, mental and social health.

A related critique of the “DSM-5” type categorisation approach to mental illness was made by the British Psychological society in their response to the development of the that system.

…systems such as this are based on identifying problems as located within individuals. This misses the relational context of problems and the undeniable social causation of many such problems

In all this I want to remember that it’s very likely that some mental illness does have a biochemical, brain or genetic basis that might be directly treatable in more conventional ways. Few people seem to argue against the idea that pharmaceuticals in this sphere do have their uses. They may be necessary even when the underlying cause of an issue isn’t due to unusual brain chemistry. But cannot be the be-all and end-all of interventions when the cause of the condition being treated lies outside of the person.

Furthermore, it may bring comfort to those with particular suffering to have a medicalised label. If nothing else it provides a valuable recognition that those around them can acknowledge, understand and treat. Perhaps a sense that your pain is real, and can be addressed. It may be reassuring in some sense to feel biologically unlucky as opposed to blameworthy. But of course issue there is more about the invalid and illogical misuse of blame concepts.

A categorisation also provides a potential identity that allows them to seek out a peer group of those who face similar battles. This might be beneficial either in terms of learning strategies to tackle the issue directly, or by providing a social group of people with a common interest who you know understand rather than stigmatise you.

Despite my general skepticism about the benefits of social networks, this does seem like one possible use of these technologies, perhaps especially for rarer conditions. In 2016, Naslund et al. wrote

People with serious mental illness report benefits from interacting with peers online from greater social connectedness, feelings of group belonging and by sharing personal stories and strategies for coping with day-to-day challenges of living with a mental illness.

A potential downside I can imagine may be risk of the person ending up feeling like “they are their illness” and that it’s a fixed and permanent trait as opposed to something that can often be addressed. It may also be damaging if the idea that those outside the peer group can’t help, and perhaps are even not to be trusted is cultivated. But overall, these types of peer groups are likely invaluable - “given the evidence to date, the benefits of online peer-to-peer support appear to outweigh the potential risks”, to quote the Naslund paper.

Whilst I’m don’t get the sense that this way of thinking is particularly routine in healthcare today, there have been a few interventions that do seem to acknowledge the social, political and environmental causes and exacerbations of mental health issues.

Recently the results of a National Health Service intervention that involved the prescribing of heating reported success. “Prescribing heating” simply means paying the home heating bills for patients who cannot afford to do so themselves. This is an increasing number given the dramatic increase in energy costs in recent times.

Many illnesses and other reductions in quality of life are caused or exacerbated by living in cold environs. It’s estimated that 10,000 people a year die of cold home related issues. Dealing with the other health consequences of cold homes costs the NHS £860 million a year. Most of the reporting on this trial addresses physical illnesses, such as respiratory or circulatory conditions, rather than mental illnesses, but the report that calculated the £860 million figure does note that living in cold or otherwise inadequate homes can also have a severe impact on mental health.

In 2018 we saw a “social prescribing” initiative that would enable doctors to prescribe therapeutic art or hobby based treatments for instance. Related trials so far have shown improvements in patients physical and mental health. This approach is one potential plank of the Government’s anti-loneliness strategy.

The NHS notes that social prescribing is effective for a wide range of people, including those who need support with their mental health. The Royal College of Psychiatrists agrees, reporting) that social prescribing helps people connect to their community in a way that can improve their health, both physical and mental.

Of course, as with almost anything, there’s a risk of taking this idea too far. We must avoid people being “socially-prescribed” to on the basis that it’s a simpler or cheaper option than the alternatives (if it is - I don’t know).

It will not be a suitable solution for everyone. The Royal College of Psychiatrists notes that it, in isolation, social prescribing will only likely be sufficient treatment for patients with mild mental illnesses. For moderate or severe conditions, more traditional forms of therapy and medication are still usually to be recommended, with social prescribing being considered as an accompaniment if suitable. Social prescribing might potentially also play a role in the prevention of these conditions originating in the first place.

Social prescribing is of course only one intervention that addresses the idea that the way we live is causing many mental health issues.

Many, perhaps most, future interventions may take place outside of the healthcare system. This is particularly the case if we continue to imagine healthcare as being something that you access when you’re already ill rather than a service that helps lessens the likelihood of the illness in the first pace.

One example currently outside of the domain of the UK healthcare system - although the line often seems somewhat arbitrary to me - are food banks. Food banks exist to directly address the problem of people going hungry by giving free food parcels to people who are in such a state of destitution that they cannot otherwise obtain food. In the UK these are typically run by charities or NGOs, such the Trussell Trust, who have stepped up where the state has dramatically and unnecessarily failed its citizenry.

According to a report by mental health social worker Tom Pollard, the increasing demand for food banks is driven simply by an increasing number people not having enough income to buy food. This phenomena is growing dramatically, driven by conscious, visible, political choices such as cuts to social security support, insecure employment practices and rising house costs. 43% of households on Universal Credit benefits experienced food insecurity in 2019-2020.

Intuitively this seems a solvable problem. As the report says:

It is not right that people need to rely on charity handouts to get by. Our social security system, at both a local and national level, and our economy, should ensure that everyone is able to afford food and other basics.

In the mean time, the struggle to not starve, the lack of personal agency, the feeling of failure and the cognitive effort required to jump through the necessary bureaucratic hoops to access these services can come at a great cost to mental health. And all this to typically receive a one-off package containing up to 3 days worth of food - enough to not starve to death right now, but it surely can’t do a lot for the person’s ongoing peace of mind and ability to live a fulfilling life.

In the words of the Big Issue’s writeup of the report,

Soaring UK poverty forcing people to use food banks is creating a ‘toxic environment’ for their mental health.

A third of households relying on these services include someone with mental health problems.

Furthermore, the use of foodbanks is stigmatised by some, with potential users reporting feelings of shame, anxiety and embarrassment at the thought of even visiting such an establishment. The film “I, Daniel Blake” portrays this kind of situation, and many of the other life-crushing effects of poverty in an effective and harrowing way.

There are certainly people who don’t seek even this most meagre assistance due to the shame they feel. The same goes for welfare benefits in general, as the recipients of those too are routinely shamed and abused by our elected officials, the media and the public at large.

A few years ago, polling showed that most claimants feel shame sometimes, most or all of the time, with one in four potential claimants deferring or declining to apply for the assistance they are absolutely entitled to for this reason. Analysis suggested that a ball-park figure of £10-15 billion per year in benefits went unclaimed in 2016. For what it’s worth, this is roughly 5-8x the estimate for the value of benefit fraud during the same period, if I read the Government report correctly.

As it stands, one study found an association between how many people are claiming benefits in an area and the amount of prescriptions for anti-depressants. For every 1% increase in people in a Local Authority area claiming Universal Credit there was a 5.6% increase in anti-depressants.

With all these type of associative studies, the direction of causality is usually not clear. Does having mental health problems make you more likely to need to claim benefits? Or does the experience of claiming benefits and the limits of the life you can live on them lead to mental health problems? My assumption is that both are true to some extent, although I haven’t looked much into work in this area.

The Covid Realities project did however find instances of people describing the latter:

…parents and carers living on a low-income reported experiences of stress, anxiety and low mood associated with claiming Universal Credit, connected to financial insecurity and the overall inadequacy of payments.

In any case, there is clearly a set of people that both have distressing mental health conditions and live in poverty. Solving the latter is a moral imperative in its own right, and the direction of evidence would suggest that doing so would likely “automatically” improve the former.

For those that are able to claim Universal Credit, the Government increased the amount of some entitlements by £20 in 2020 in response to the Covid-19 pandemic and associated lockdowns. This was presumably intended to assist with the increased financial pressure on those that already received benefits, and also those that the pandemic would end up forcing into the position of requiring them. After a year of Covid-19 raging the number of Universal Credit claimants had nearly doubled, up to 6 million recipients.

This £20 boost was well-received by anti-poverty campaigners. However in October 2021, despite the pandemic very much still being with us and inflation making the cost of living ever more unbearable for the non-wealthy, the Government chose to abolish even that £20 increase.

Many experts and campaign groups pleaded with them to not go ahead with that cut, including Mental Health UK, who highlighted the dangerous loop effect between mental health and poverty.

This is not just a financial issue; we’re very concerned these pressures will result in more people seeing their mental health problems spiral, in turn making it difficult to manage their money worries and sending them deeper into the red.

The British Psychological Society had similar concerns:

This decision will see health inequalities widen, placing more pressure on our already stretched and underfunded public services, as well as intensifying the mental health difficulties of people already struggling with rising debts, reduced income and soaring living costs.

Nonetheless, the Government went ahead with the cut, forcing people’s lives into trajectories likely to cause or exacerbate mental illness. This was a political choice to knowingly create an environment that endangered mental health. Sure, some of the fallout symptomology might be treatable with medication (which comes with its own costs, financial and otherwise). But the suffering may never have occurred in the first place had we not consciously changed our societal environment in such a way.

There are clearly numerous other ways we might think about enabling poorer people access to money, unhoused people to accommodation, lonely people to socialisation, hungry people to food, exploited workers to quality jobs, people who suffer prejudice to equity, people with disabilities to a full and happy life and so on. Many of these might be much more creative and affirming than simply providing food and income enough to live a tolerable life to those who need it - although doing that might well be a good, necessary and urgent first step given the dire situation we currently find ourselves in.

But however we choose to address the subject, whilst taking care not to remove or reduce access to conventional medical therapies to those that need them, putting the foundations in place to solve the structural issues that in part cause the need in the first place is surely the sane response to an insane state of affairs.