Figure 1 - What it's not, quite, really
When I was a young man, even after initially studying psychology, I suppose that I saw mental health and mental illness in terms of Figure 1. Broadly speaking, I thought, most people - normal people - cruise along happily untroubled by mental health issues, beyond perhaps a bit of neurotic emotional navel-gazing if they're the over-thinky type that watches too many angsty TV dramedies. Mostly, normal people (I didn't necessarily think I was one) get through life being relatively functional, happy and successful without ever having to deal with their "brains going wrong", I thought - but a minority of poor souls have periods where bad times happen or their chemicals go wonky and they fall off that normality wagon and things get all messed up. With treatment and time these poor souls can get better; though for some even poorer souls they get stuck in that messed up place of "mental illness" for life.
Very, very generally, of course, that outline is not completely
wrong... it's not that it's without a shred of truth, but it comes nowhere near
doing justice to how things actually are, or how life actually feels for the majority of people - it's far too simplistic. For a start, where are these normal, functional,
happy and successful people, untroubled by mental health issues? I seem to be discovering that they are a much rarer beast than I imagined, the more I get to know people in general.
In fact, to me, normal people just don't appear that normal anymore - by which I
mean both that everyday "normal" folks are choc full of strangeness and dysfunction (and in that I include myself); and that these fabled paragons of unwavering good mental health that you hear of in myth are just not normal. The older you get the more aware you
become that your family, friends and colleagues are all a bit peculiar in their
habitual ways of being, and so are you;
people's relationships are even more peculiar, riddled with questionable
quirks, unhealthy habits and habitual irrationality; and people's mental health
is not consistent and smooth, it rises and falls with circumstance, sometimes dramatically
and alarmingly.
Biology and context
I don't mean to downplay the experience of those with more
severe mental health challenges here - a "we're all mad really and that's
just fine" attitude is lovely in sentiment, but it really is a bit insulting to
compare feeling-sad-for-a-bit-too-long-after-your-pet-died to the full-blown
staring-into-the-abyss-with-the-weight-of-a-mountain-on-your-back-24-hours-a-day-for-months of major depression; or being-a-bit-of-a-clean-freak to the hundred-life-crippling-little-rituals-you-HAVE-to-carry-out-before-doing-anything
of severe OCD. We have to be able to distinguish, certainly.
That said, I
don't think the general public realises how uncertain - and how thinly
supported by hard science - many of the current categories of mental illness
that you hear about really are. Currently not a single mental illness is diagnosed solely by
looking at the brain or biology. That means the assertion that we know for sure that many diagnostic labels are definitely, basically, mainly, simply just down to brain wiring and chemicals and all that, is not a safe assumption to make - because actually we don't know the mechanisms by which the biology is linked with what are by definition behavioral and psychological expressions. Certainly some conditions must have a heavy influence from things like genetics and brain changes, as the biology and the behaviour appear together - but as for how exactly the nuts and bolts of it works, a huge damn lot of that is still "black box": we know there is a relationship but we don't know exactly how it works.
For many other disorders (depression, anxiety, PTSD, OCD) the role of biology is often overstated well beyond what the current evidence can tell us, and there is just as much empirical evidence that environmental and experiential factors - as well as purely psychological therapies - affect the associated biology. Many mental health issues arise in a particular social, environmental or personal history context - e.g. trauma, poverty, work stress, bereavement, bullying, childhood abuse and neglect to name but a few more obvious examples. By analogy,
suggesting we could adequately explain language by looking only at what happens
in the brain when we use it would be absurd - to understand language, how it
arises, functions and is transmitted we need to understand social interactions,
developmental context and even human cultural history - which is not to say the mechanisms of the brain involved in it are not also massively important.
Categories vs continuum
So if mental illness is not diagnosed by looking inside the brain, how is it diagnosed? Currently by tick lists of symptoms. Which, clearly, is not an exact science. If you display a certain number of apparent symptoms on this list or that, that's what you get diagnosed as, even if you don't have every symptom on the list. This means, in some cases, two people can have more differing symptoms than the same symptoms, yet be diagnosed with the same condition. The same symptoms can also appear on the lists of different distinct mental illnesses, something called co-morbidity. This is not necessarily a problem - for example in physical illness, the symptom of "fatigue" may have many different ultimate causes, and appear as a symptom in many different illnesses. In mental health, though, due to our poor understanding of the mechanisms behind mental illness, it also means people can be given a different diagnosis at different times by different professionals for expressing very similar behaviour, sometimes with worrying potential consequences - they may be given an incorrect life-affecting label that they can't shake off and may never get corrected, or they could be given inappropriate treatment that may do more harm than good. In some cases the distinction between diagnostic categories may be artificial, more a result of us clinging onto past theories than what current evidence is telling us.
I admit I'm not too keen on the "categorical"
approach to mental illness, that treats labelled disorders as strictly distinct from, and of a different quality to, the common mental health ups and downs in
the general population. There are serious questions over how well supported such hard-and-fast category distinctions are by the current evidence. Schizophrenia in
particular has been called a “failed category” with too wide a spread of symptoms
and pretty poor support for it being a single, distinct and cohesive condition. For example, evidence
is mounting that similar biological, social and
environmental factors may underlie the symptom of psychosis - a key symptom in
schizophrenia but also a symptom of mood disorders - regardless of which diagnosis category it appears under. And importantly the same factors underlying psychosis may be involved in less severe "sub-clinical" symptoms in the general
population, such as social withdrawal, unusual visual and aural perceptions and
magical thinking, that may reveal a proneness to psychosis under the right (or
wrong) circumstances. Basically, there is co-morbidity too between
defined categories of mental illness and also the more common mental health
issues of the general population - the distinction may be a matter of degree,
of severity, of extremity rather than a strict fire-walled difference of type, in at least some cases. The ramifications
of this are huge, as it means the relation between good mental health and
mental illness is more of a constant continuum or spectrum than we previously
thought, rather than a bunch of different boxes and labels that do not overlap
and should be treated separately.
Figure 2 - More like how I see it at present
Anyway, enough of that guff and back to my original point. I
no longer see mental health as a straight-and-true track that most people are on
and a poor minority fall off of. Rather we are all involved in the same kind of
processes, bombarded with pressures and having to adopt often only
half-successful strategies to deal with them. But some people, for some periods
of their lives at least, have a lot more to deal with than others, whether
that's a barrage of seismic life events; the awful way other people treat, or have treated, them;
work, money and social pressures; ingrained and damaging bad habits that they
struggle to break out of; the continued effects of trauma in the past; their
own bodies malfunctioning; or, most likely, a toxic combination of more than one of those factors.
Life is complex and chaotic and living it is difficult. The
purpose of most mental health treatment is not to "cure" us of our
"illness" and set us back on the problem-free healthy highway with
all of the other mentally healthy normal people. That highway doesn't exist. The purpose of mental health treatment
is, as suggested in Figure 2, to arm us with whatever tools we can get our hands on to carry on the fight
and get through life - which for many involves very tough circumstances - and perhaps even be able enjoy (some of) it. That is, tools to calm the symptoms that cause us distress and stop us from living well; tools to bolster our resilience,
store up our support, preempt predictable problems; tools to help us learn about ourselves and
others and learn how to manage ourselves and others; and tools to get strategies to cope that work and are not dysfunctional. In short, I didn’t decide to pursue a career* in mental health to "cure" people. I decided to do it simply with the aim of hopefully, somehow, some day, helping
people to live. That is all. But in the broader, long-term view, we also need to take more seriously the task of addressing the societal and environmental factors that can apparently play such a key role in damaging our mental health - and not simply ignore them because it's easier to blame each individual's condition simply on the attributes of that individual themselves, in isolation from context.
*Speaking of categories, the rather "unique" combination of roles I have thus far undertaken may be too broad to call a "single, distinct and cohesive" career. Ho Hum.
