When people become chronically distressed, their first port of call is usually their GP. A lot of the time, maybe even most of the time, people will initially come with vague physical complaints [1]. Headaches, dizziness, a digestive tract that doesn’t work as smoothly as it could. After some searching, if physical causes are eventually ruled out, words like ‘depression’ or ‘anxiety’ might enter the consultation room.
By this time, stress has been accumulating for a while. Sometimes there was hope for a period of time, for example if antacids helped calm an angry stomach and life picked up again, but then some other symptom cropped up and hope was dashed. This cycle might repeat many times, with small adjustments in various areas of life ultimately failing to bring a sense of contentment. When this goes on for too long and ‘just about managing’ becomes a way of life, it can be accompanied by a sense of failure, shame, confusion, and frustration. Feeling overwhelmed then bleeds into family life, friendships, work productivity, and interests. It’s often unclear where the problem started.
GPs do not have privileged knowledge about how to attain the social and psychological building blocks needed to live a full life, nor are they trained to search for the many subtle causes of prolonged psychological distress. They will assess symptoms and offer solutions within their remit, often either antidepressant medication or psychological therapies, or both. Antidepressants do not remove the causes either, but they can make life more bearable. Psychological therapy is supposed to be an alternative approach. It should be where people go to be heard, where they can talk to someone who is genuinely interested in their life story, who will guide them to gain or regain the self-compassion needed to openly explore what might be ailing them.
Unfortunately, this is not the kind of therapy that is integrated into primary care services in the UK, nor the kind of therapy that is predominantly offered privately these days. Instead, the typical therapies tend to focus on building resilience through changing thought patterns, again in order to make life more bearable. ‘More bearable’ is not exactly a lofty goal, and is very rarely what people want out of life. It is precisely what most distressed people have been trying to achieve without success for a long time, and why they will want to try therapy for a taste of something different. However, according to this NHS website on integrating mental health therapy into primary care, “psychological therapies, provided through the IAPT programme […] support people to get on with their lives, including getting back to work”. I wanted to take a look at the philosophy of mental health behind the notion that psychological therapy is there for finding a way to get on with your life and get back to work. Who are these goals there for? (See [2] for a detailed answer.)
First, let’s note that recovery from mental illness here is casted as a relationship between us and society, specifically us and work. What is society for us, exactly, and what sort of relationship is it? Sometimes society is conceived of as an organism, while individual institutions (such as our workplace) are its organs. Society needs us to function well in order for its organs to perfom their functions. It is assumed that there is a value consensus that we should be committed to this higher goal of being mostly all right, of ‘getting on with life’. This sort of view is termed functionalism in sociology, and it has been criticised for sometimes being used to gaslight oppressed members of society into subordination. For example, some types of family therapy used to gloss over wife beating, placing the goal of keeping the family together as a higher social value than the physical safety of its individual members, and this was directly inspired by functionalist thinkers like Talcott Parsons. [3]
These days we are less likely to hear about our obligations towards society as such, but there is a higher entity that we are repeatedly invited to relate to: The Economy. This was particularly visible when the Covid-19 pandemic broke out, and the UK government discussed lockdowns. We all needed to consider the economy. Do we do what is best for individuals, or do we save the economy? That the two were seen as opposed is already telling.
When there is an important, powerful entity we interact with to in order to survive, the kind of therapists I prefer tend to think about it as The Mother*. Although this can sometimes sound rather odd, it is a model that allows us to think more clearly about our relative positions in the relationship. It also helps us shine a light on our needs and how they are being met. Our relationship with the economy lurks in the background of our lives. In analytical terms, then, I would suggest that the economy is a narcissistic mother, a mother who only wants those children who can give her something. We must continuously prove our worthiness, and those who fail to satisfy her might be tolerated, but never respected.
This might not be true of every economy, but ours is a neoliberal one, which comes with additional individualistic hues. Success is seen as the result of personal merit – mostly perseverance and resourcefulness – instead of the consequence of safety netting, living conditions that allow for thriving, or being helped up by others. The flip side is that inability to contribute to the economy is seen as a consequence of personal weakness [4]. It might not be your fault that you have that sort of weakness (it’s just your brain chemistry or genetic makeup) but the reason you are suffering is that there is something inside you – your depression, your anxiety, your ADHD, your disordered thought patterns – that is preventing you from being functional [5]. The problem begins with you. If only you were stronger or even just more productive, it would go away.
The way to ‘support people to get on with their lives, including getting back to work’, then, is to combat this weakness. Most tellingly, the problem is thought to be resolved once people are back to contributing to the workforce. Right back to the narcissistic mother’s bosom, where we won’t feel valued unless we keep giving. This is the direction in which mental health services nudge us.
It is not wrong to simply want to get on with things, and there are many people for whom methods of distraction from primary causes of distress will be genuinely helpful to get over an isolated hurdle. But as a one-size-fits-all approach, those who wander around carrying shame and distress will simply be left with the confirmation of their deepest fear, that there is something irreparably wrong with them. I have been at the receiving end of this approach, when my (private) therapist openly told me that she thinks the problem is me – that I am depressed. I wanted to figure out why I was depressed, but she discussed this not as a consequence of a real issue, but as the issue. If I would venture towards potential causes or difficult emotions, she would shut down the conversation. She instead said that I should learn to meditate so that I can take each new day in a personally troubling situation with the same grace with which Mandela took each new day in prison. My distress was taboo.
Imagine instead a mental health service that assumes that a person is in distress because there is something in their life that they care about, that is not going well. A service that is interested to know which personal needs aren’t met, or whether we have healthy ways of handling strong emotion or interpersonal conflict [6]. One that explores what mutually enriching bonds are, and encourages strengthening them with the right people. One that allows for the suggestion that unhealthy situations can be left, or maybe even changed from the inside, instead of being endlessly coped with. One where ‘getting on with life, including getting back to work’, is a consequence of recovering, and not an obligation. Imagine if you mattered. Because that is what most of us want: to be seen, and heard, and to feel cared about here and now.
References
[1] Simon, G. E., VonKorff, M., Piccinelli, M., Fullerton, C., & Ormel, J. (1999). An international study of the relation between somatic symptoms and depression. New England journal of medicine, 341(18), 1329-1335.
[2] Davies, J. (2021). Sedated: How modern capitalism created our mental health crisis. Atlantic Books.
[3] Luepnitz, D. A. (1988). The family interpreted: Feminist theory in clinical practice. Basic Books.
[4] Fisher, M. (2014). Good for nothing. The Occupied Times, 19.
[5] Barnes, J. “The Space Between Us”. https://aeon.co/essays, published February 2023. Web.
[6] Shedler, J. (2010). Getting to know me. Scientific American Mind, 21(5), 52-57.
*Maybe analytical thinkers would forego The Economy as Mother for the pleasure of saying The Economy is a dick, but never mind that.
To cite this blog post, please use: Todorovic, Ana. "Mental Health Disservices". Web blog post. NeuroAnaTody.com, published February 2023. Web.
Well said Ana
I would change therapist/psychologist who is not in line with your value.
It is hard as our society is also on verge of a change. Society does not know how to handle one who changes faster than society. There is no algorithm for that.