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Six short posts about mental health 2: Why I don't like the 1 in 4 statistic

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Edited by Meg-John Barker, Sunday, 16 Oct 2011, 15:39

It is important to say, before I start, that here I am absolutely not doubting the existence of severe distress, or the toll that it can take on people who are struggling and those around them. Rather I am questioning the way that we currently categorise and work with such experiences, and the role of wider culture in them (which so often gets missed).

What sparked this line of thinking, for me, was a series of adverts a few years back under the Time to Change campaign about mental health, which was put together by the Institute of Psychiatry, Mind, and several other mental health organisations, with the aim of ending mental health discrimination. The adverts featured celebrities such as Stephen Fry and Ruby Wax speaking openly about their own experiences of distress, and many quoted the '1 in 4' statistic. For example, the poster with Stephen Fry on it said: '1 in 4 people, like me, have a mental health problem. Many more people have a problem with that.' Ruby Wax's said '1 in 5 people have dandruff. 1 in 4 people have a mental health problem. I’ve had both.'

Clearly the statistic was intended to raise awareness of the commonality of mental health problems and to decrease the stigma of those experiencing them. However, I feared that it was in danger of doing quite the opposite.

The 1 in 4 figure is problematic anyway as it is not clear where the figure actually comes from. Of the few studies which have found something like this figure, some have been measuring families rather than individuals, mental health has been measured in various different ways, and it is unclear whether we are talking about, for example, 1 in 4 people at some point during their life, or 1 in 4 people in the last year, or 1 in 4 people at any given point in time.

However, for me, the bigger problem is the potential impact of the figure. 1 in 4 suggests that 75% of the population do not experience mental health problems. That is a substantial majority. The danger is that this situates people with mental health problems as 'them' (compared to 'us' who don't have any such problems). As we know very well in psychology, the creation of any kind of 'us and them' situation increases, rather than decreases, likelihood of discrimination.

Most of us will experience some form of abuse in childhood (if we include 'bullying' by peers, which I think we definitely should); all of us will experience life events such as bereavement of a loved one in adulthood which tend to result in a period of high distress; not to mention the existential givens of life which we all struggle with. Given this, is 'ill or well' a useful model at all?

The common dichotomous understanding which I see amongst counselling clients, friends, and students alike when they are talking about their own – and other's - experiences of distress and suffering is as follows:

 

Either

I'm ill – I need help – it's not my fault

Or

I'm not ill – I don't get help – it is my fault

 

People commonly feel, deeply and certainly, that these are the only two possible places to be: ill or not ill, and that the other aspects presented here follow from that. Not only is this a splitting up of the unsplittable biopsychosocial which I mentioned in the previous post. It also suggests that there are only two options: biology or choice (social doesn't even come into it). Mental health problems are seen as an individual – frequently physiological - problem which requires treatment (commonly drugs, sometimes also therapy) to fix. However, if there is no evidence of such an individual problem (if no diagnostic label fits, for example, or if there is suspicion that they are not suffering enough) then the person cannot be ill and therefore any struggles must be their own fault.

This way of understandings things is problematic on all levels. It prevents many people with distress from admitting it because, if they do admit it, they will have to give up control, take on a victim/ill identity, and open themselves up to stigma and discrimination. Those who embrace diagnosis may be disempowered (due to the sense that they can't help themselves and must require expert help). They may feel that they have to take certain treatments (often drugs) because of the common idea that mental health problems are biologically caused and must be biologically treated, despite the question marks which still exist over whether, and how, such drugs work and whether they are the most appropriate way of addressing such issues in all cases (not to mention the vested interest of 'big pharma' in perpetuating this particular understanding). There is no room here for sociocultural explanations or for more complex involvement of personal agency.

Also, many people oscillate between the two positions as neither side really captures the complexities of human distress. This means that those who don't identify as having a mental health problem are haunted by the fear that perhaps there is something terribly wrong with them which needs fixing (and hiding this fear, and any signs that they might be struggling, puts them under immense pressure). Those who do embrace a label such as 'depression' are often haunted by a huge sense of guilt that maybe they are not really ill and maybe this is all their fault and they are totally to blame (which massively exacerbates any suffering they were already experiencing).

This puts people in a horrendous double-bind when it comes to speaking about their own, inevitable, distress and struggles in life. If we openly disclose as 'depressed', for example, (as many people did on the recent 'world mental health day') we run the risk of reinforcing this ill/well split such that those who do not embrace such an identity feel their struggles going unacknowledged and the pain of that invisibility. If we keep quiet about our distress, or resist such labels, then we can equally reinforce the ill/well split as we are read as 'well' by those around us.

We need to move to more biopsychosocial model of distress. We need to recognise that distress – in its various forms - happens for complex multiplicity of reasons, and that we can have a personal role in exacerbating and ameliorating it, but that acknowledging such a role does not mean that we are totally 'to blame' or 'at fault'. We need to understand that we can all access support rather than it being something only for a certain few, and that different things work for different people at different times. We need to challenge either/or illness/wellness dichotomies and to consider other possible models and metaphors for distress.

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Six short posts about mental health 3: Diagnosis

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Edited by Meg-John Barker, Sunday, 16 Oct 2011, 15:41

The common practice within the current mental health system when people are distressed is to diagnose them (to find the category in the DSM or ICD which best fits them) and to treat them accordingly.

In the previous post I said a lot about why people who are suffering might want to embrace a diagnosis of a mental health problem. In the next post I will say more about why practitioners may be wedded to this way of working with distress. Here I will outline some problems with diagnosis in general.

As I mentioned, for people who are struggling, diagnosis is often seen as the only option other than seeing themselves as totally 'to blame' for their own distress. Also, it may be the only way to access support and community, and to be taken seriously by employers and others whose understanding they may need as they are struggling. Given that this is the world we currently live in, it is important for those who are critical of diagnosis not to impose that on others. Rather we might explore, with them, the potential losses and gains of taking on a diagnostic label (something explored in the Open University counselling module). Common losses which people express are that no label fits them perfectly, that – if they do embrace a label - they feel trapped by it (that this is all that they are are all that they'll ever be), and that they are treated differently by other people.

Irving Yalom points out this problem with diagnosis, that it easily fixes people (the way that a kiln fixes a pot) and can prevent us from treating people as whole, complex human beings. Rather, it is easy for professionals to see people as a 'bipolar' for example, or as a 'borderline personality disorder' (assuming that that category is all that they are, and that this person will be the same as other people in that category). Actually there can be multiple diverse meanings for people who fall into the same category which it is vital to explore. Take agoraphobia, for example, which involves fear of being outside the home. This could be about a fear of social contact, a sense of shame about oneself, an oversensitivity to noise, a genuine concern around violent attack (racist or homophobic, for example), an inflated concern over the risk of crime, superstitious fear of an accident happening, worry over one's own capacity for anger and violence with others, or many other things (and combinations of things).

The point about fixing people is supported by the famous Rosenhan study 'on being sane in insane places' which was conducted in the 1970s. He got a group of people to present to psychiatrists. They didn't wash for three days and said that they heard the word 'thud'. All were admitted to hospital and all were diagnosed with schizophrenia (except one who presented to a private clinic who was diagnosed as manic depressive, which is telling about class and diagnosis). Once admitted, the people said that they were fine and didn't report any further symptoms. Nonetheless they were kept in for weeks at least and their behaviours were still read as ill or disordered. For example, queuing up for lunch early because they were bored was labelled 'oral acquisitive syndrome' and making notes was labelled 'compulsive writing behaviour'. Science writer, Lauren Slater, repeated the study in the early 2000s herself. She didn't get admitted, but was diagnosed and medicated by everyone she presented to, reflecting shifts in understanding and treating mental health problems.

Clinical psychologist, Richard Bentall, has pointed out the incoherence of many diagnostic categories: It is possible for two people, categorised in the same way, to have completely different clusters of symptoms. Some symptoms which are generally seen as signs of mental illness, such as hearing voices, are experienced by many people and are not always viewed as problematic.

Also, there are issues with the cultural and historical specificity of diagnosis. The classic example of this is the fact that homosexuality was included as a disorder in the DSM until 1973 and in the ICD until 1992. Other consensual sexual behaviours which are considered 'outside the norm' (such as fetishes, sadomasochism and transvestism) are still listed despite lack of evidence linking them to distress and calls for them to be removed.

This raises the question of to what extent diagnosis of disorder represents individuals being in conflict with the norms of society rather than a genuine pathology. There are many other examples of this. For example, the 'sexual dysfunctions' are categories for people who don't have the amount, or type, of sex that they are expected to have by wider society. Categories of 'premature ejaculation' and 'vaginismus' suggest that 'proper sex' involves penile-vaginal penetration.

We might also think about what things are classified as addictions and what are not (in relation to what is socially acceptable), or what forms of self-harming are pathologised (cutting and burning oneself, but generally not smoking, drinking to excess, risky sports or driving, or cosmetic surgery).

Many have argued that the high levels of diagnosis of depression in women (and the greater likelihood that distressed men will be criminalised as 'bad' whilst women will be pathologised as 'mad') are related to cultural expectations around femininity and masculinity. Also, black and minority ethnic people are more likely than white people to be diagnosed with 'severe' mental health problems and to be hospitalised and treated with drugs, arguably due to the western norms inherent in the diagnostic categories, as well as experiences of racism and social injustice.

Going back to Rosenhan's study we may regard the world that we currently live in as rather an 'insane place' (particularly given the current economic and ecological situation) and question what it means to respond 'sanely' to this. Winnicott famously said, of depression: 'The capacity to become depressed, to have reactive depression, to mourn loss, 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 health or mature persons...this is not generally recognised.' In recent goals for everybody to be 'happy' there is a danger that we pathologise, even more, quite reasonable forms of distress.

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Six short posts about mental health 6: Alternatives - self-care and compassion for all

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Edited by Meg-John Barker, Sunday, 16 Oct 2011, 15:40

In the preceding posts I have argued for a complex understanding of suffering and distress which is very cautious of applying diagnostic criteria and of dividing people into 'ill and well' 'us and them' boxes. Perhaps a better model of distress is of a continuum which we all go up and down during our lives, and where we are not fixed at any given point. I've also emphasised the importance of not splitting up the bio, psycho, and social in our understandings of distress, and suggested that we must not neglect the social aspect of the biopsychosocial because societal ways of understanding people (which we internalise and which, no doubt, are represented on a neurological level) are involved in our difficulties. This is particularly the case in the way in which we are encouraged into self-monitoring, and in the way in which individuals who are in conflict with societal norms tend to be pathologised as disordered individuals.

If we resist the temptation to 'us and them' thinking then perhaps we can make more of a connection with people when they are distressed (rather than attempting to distance ourselves from them in ways that maintain them as 'them' and protect us from any sense that we might experience similar things ourselves). Then we might be able to ask questions such as 'what works for me when I am distressed?' which may lead to more helpful responses when others are struggling (although, of course, we must be cautious of assuming that everybody works in the same way that we do – perhaps the question is more like 'given everything that I know about this person, what might they be needing right now?') We might reflect, for example, on times when we've been under chronic stress or when a crisis has occurred in our lives.

Broadly speaking, when we reflect on what is unhelpful when we are distressed we might come up with things like: taking away the aspects which makes the person what they are (things that they regard as central to their identity such as work or relationships), removing people's sense of personal freedom and choice, and regarding them as inexplicable or baffling, for example questioning why they can't just stop feeling, or responding, in the way that they are doing. On the other side, we might find that what helps when we're distressed is not being overloaded with anything else, being treated kindly and patiently and being around those we feel safest with, being reassured that we are still free (but perhaps we don't have to make lots of decisions right now), and feeling that we are understood and that our response is a perfectly explicable way of responding to this situation (which involves somebody taking the time to understand what it means to us).

The vital role of compassion (from others and towards oneself) has been emphasised by many recently, and is part of the reason, perhaps, why various forms of mindfulness-based therapies are suddenly so popular (as they often encourage practices of self-care and compassion). Compassionate treatment of self and others is, perhaps, an opposite to the judging-comparing-monitoring mode which is so culturally encouraged at present. Rather than fearing that we are lacking, pretending that we aren't, and trying to prove that we are better than others, we accept that everyone is imperfect, are open about our struggles, and move away from a competitive way of relating with others.

Vitally, an alternative compassionate, or self-caring, form of working with distress does not present this as something that is necessary just for people who are struggling (reinforcing that 'us and them'). Rather it is seen as something everybody needs to engage in to counter those omnipresent self-monitoring messages (which affect us all) and to address the struggles and distress which we all experience.


Find Out More

  • Many of the ideas in these posts are explored, in more detail, in the textbook and module for D240.

  • A very accessible book that covers may of these areas is Richard Bentall's Doctoring the Mind.

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Suggestions for Fear and Sadness

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Edited by Meg-John Barker, Wednesday, 17 Aug 2011, 16:52

 

Suggestions for Fear and Sadness

Understanding Counselling & Psychotherapy

My main job at the Open University since I started working here in late 2008 was to produce and present a module called Counselling: Exploring Fear and Sadness. As part of that process my colleagues Darren Langdridge, Andreas Vossler and I edited a textbook which brought together experts on all different types of counselling to say how their approaches would work with fear and sadness.

When we wrote the book I thought that it would be great to do another book covering the same areas, for people who are not interested in studying counselling themselves but who just want to know about what different kinds of counselling suggest. As Mick Cooper and John McLeod have recently pointed out: different things work for different people at different times, whereas most books on the market cover just one approach in detail. Maybe I'll write that book one day, but meanwhile here are what I personally think are the top suggestions from each chapter of the book we did write. If you find them useful of course you can always do the whole module (D240) through the OU.

1 - Introduction

Remember that everyone gets frightened or sad, and everyone also has times in their life when this becomes overwhelming. There is not really an 'us' (the professionals) and a 'them' (the clients or patients) because all people will find themselves both in the position of struggling and of helping others who are struggling.

2 – Diagnosis

We used the words 'fear and sadness' rather than 'anxiety and depression' for the module because there are pluses and minuses to the more diagnostic categories. It can be useful to think about what is gained, and what might be lost, from taking on such labels. For example, they can make it easier to find others who are in a similar situation, to access support, and to feel legitimate in what you're experiencing. But they can also mean being stigmatised by others or feeling as if you are stuck this way for good. Diagnosis can also be more or less useful for different people at different times, and doesn't have to be the way you see yourself forever.

3 – Drug treatments and the biopsychosocial approach

People often link diagnosis and medication. It can feel like either you have an illness, you take drugs and therefore it is not your fault that you are struggling, or you don't have an illness, you don't take drugs and therefore it is your fault and you should 'pull your socks up'. That's a really unhelpful (but sadly common) way of looking at it. We become overwhelmed by fear and sadness for all kinds of complex reasons involving our bodies, our background, things going on in our lives, and the world we live in. Drugs can certainly help some people at some times, but taking them doesn't mean you can't do anything for yourself as well. And deciding that you don't want to take drugs doesn't mean you are struggling any less or don't need support.

Interestingly the one thing that everybody we interviewed for this module agreed on (including celebrities like Trisha Godard and Stephen Fry) was that some form of physical activity had helped them immensely. It can be really hard to do when you're feeling bad, but well worth keeping in mind just how beneficial it can be.

4 – Psychoanalysis

I'm not a great fan of psychoanalysis myself, but the chapter that Ian Parker wrote on this topic for the book was a real eye-opener about the starting points of the 'talking cure' of counselling. I loved Freud's metaphor that we are like those 'magic slate' toys which kids have.

Magic Slate

When things happen to us it is like writing on the front layer of plastic. Then that gets wiped clean, but there are still traces of the writing on the wax behind that will have an impact on whatever we try to draw next (the lines will get a bit broken and distorted). Freud believed in the value of exploring what there is back there on the wax layer which is affecting us now. And I think that is valuable as we often find ourselves responding to current events in ways that are hugely influenced by what has happened in the past. Making sense of that can help it to feel more manageable and understandable.

5 – Humanistic counselling

A key concept here is empathy. Can we cultivate empathy for ourselves and for other people? Carl Rogers proposed a challenge where each time you speak – in an argument or discussion – you first have to restate the ideas and feelings of the previous speaker accurately and to their satisfaction, before you get to have your say. This might seem a long way from fear and sadness, but many authors are now seeing compassion as centrally important in these areas. If we can learn to be more understanding and kind in our interactions with others we end up feeling less alienated from them, and it also helps us to recognise that it makes sense when we struggle as well, and that we also deserve kindness. When people are feeling really distressed one of the best things they can do is just to make sure that they do one kind thing for themselves every day. It helps to remind them that they are as worthy of kindness as everyone else.

6 – Existential counselling

Existential counselling challenges our common idea that there are good emotions (joy, pride, happiness, etc.) and bad emotions (fear, sadness, anger, etc.) Rather it sees all emotions as important parts of human existence. When we have to make choices we often experience deep anxiety but that is part of embracing our freedom and really living. Similarly there are inevitably points when it all feels too much and we give up and retreat from the world. Existential therapist Emmy Van Deurzen suggests that emotions are on a kind of compass, from happiness (North) through anger (East), down to sadness (South), and back up through hope (West) to happiness again. We move endlessly around that circle – like it or not – so it is worth understanding all those states, and what we get from them as well as what is difficult about them, rather than trying hard to avoid some of them which means we might well get stuck in one place.

7 – Cognitive-behavioural therapy (CBT)

When we find something frightening or depressing we tend to avoid it, but often that leads to it becoming more scary or saddening rather than less so, and we can then become quite paralysed. Our world narrows as more and more things seem difficult. A very basic CBT idea would be to gradually approach the things that scare us rather than avoiding them (starting small and working our way up). Another useful CBT technique is to pay attention to the little negative thoughts we have throughout the day – like an ongoing commentary – maybe noting them down as we are aware of them and challenging each of them. Is it really realistic? What alternative explanations are there? Is it useful? How might I think about this differently?

8 – Mindfulness

Make a little time every day just to sit somewhere peaceful and breathe. The idea is to be comfortable without distractions and just focus on the sensation of the breath going in and out of your body. You will find that you keep getting carried off on thought processes and distracted by sensations and that is absolutely fine. Just notice that it has happened and bring your attention gently back to the breath. Notice how the thoughts and feelings bubble up and then pass away again eventually if you don't get too stuck to them. The idea in mindfulness is that if we practice doing this regularly we will start to be able to bring the same accepting awareness to whatever is going on in the rest of our lives.

9 – Systemic counselling

The fear and sadness we experience feels like it is inside us and that there is something that we need to do individually to change it. Systemic counselling proposes that actually much fear and sadness is really in between people, in families, relationships, and groups of work colleagues. Think about your own dynamics with people you are close to: do you tend to bounce off each other sometimes in ways that leave one or more of you feeling bad? A nice exercise from systemic counselling is to take some different shaped stones or modelling clay and make a model of your family or group, representing each person as an object, and where they are in relation to each other, by the way you position them. Then you can move it around to show how you would rather it was. This can help you to be aware of how the dynamics in relationships can get stuck and also how they might shift.

10 – Sociocultural issues

Similar to systemic counselling, sociocultural approaches remind us that a great deal of our fear and sadness are about the culture surrounding us and how we are viewed within it. Being marginalised is strongly linked to experiences of distress, and we all occupy multiple sociocultural positions (in relation to race, gender, sexuality, age, class, (dis)ability and so on). It can be useful to reflect on which position you are in on all of these dimensions and what the assumptions are 'out there' about people like you. Do your experiences of fear and sadness relate to those assumptions at all? Are there ways of sharing these with other people who are in a similar position?

11- Context and setting

This chapter was all about counselling over the phone and online. One idea from it was to write about a time when you were feeling particularly sad or frightened – noting down what was going on and how you felt about it – without thinking about it too much. This was really an exercise to think about how people express their emotions online or over email, but actually researchers like Pennebaker have found strong evidence that writing regularly about our feelings is hugely beneficial. Private blogs and personal journals can be a helpful way of doing this.

12 – The therapeutic relationship

This chapter explored how different types of counselling involve different relationships between the client and the counsellor. Many people who decide to go for counselling don't realise how many different types of counselling there are, and how they will all involve very different kinds of relationship and quite different focuses. I wrote a bit about the different counselling approaches here. It is definitely worth thinking about what would work for you and asking counsellors about their qualifications and approaches before committing to it. You should always make sure that they are accredited with one of the major bodies (e.g. BACP, UKCP, BPS). If in doubt, ask.

13 – Outcome research

As well as finding out about what approach might suit you, it is also worth checking out the research that has been done into the kind of counselling you're thinking of going to. Mick Cooper's book on this topic is very accessible if you are interested, and even online searches can give you some idea of whether the kind of counselling you're considering has been found to be helpful for the kinds of issues you have. However...

14 – Process research

...perhaps the main research finding about counselling is that all of the main approaches (covered in this book) are generally about equally effective (with some exceptions like CBT being particularly good for simple phobias). According to the research, a good relationship between client and counsellor is one of the main things which predicts how useful counselling will be. So it is worth shopping around for someone you have a good rapport with. If you are accessing free counselling it is still okay to ask for a different counsellor if you don't feel a good relationship with the one you have.

15 - Conclusions

There is always a risk with going to a counsellor that this will reinforce the idea that many of us already have that there is something wrong with us that needs fixing. Our commercial culture is very good at giving us a sense of anxiety about the things that we lack, and selling us products to relieve this anxiety. In this culture it is all too easy to think that we are not good enough. Therefore it is important to remember that going to get some support or talk through what's happening doesn't mean there is anything inherently wrong with you, and also remembering that counselling is just one of many ways of thinking things through, looking after ourselves, and getting support.

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