Where are we with mental health stigma?

On March 24^th 2015, the world was hit by the news that a German aircraft had crashed into the French Alps, killing 150 people. Information quickly started to circulate about an apparently ‘suicidal pilot’ who had deliberately caused the crash. He would later be named as 27-year-old Andreas Lubitz: he had co-piloted the flight and locked himself into the cockpit while the principle pilot was in the bathroom. Prior to any formal investigation, news outlets reported that Lubitz had been treated for depression. In a casual conversation the following day, a man in Belfast with no connection to or special knowledge of the circumstances told me “he should never have been flying with depression”.

For a few minutes let’s leave aside how correct or otherwise that assessment was. What struck me was how definitive it was, how black and white. He was depressed. And look what happened. End of.

When starting to unpack and assess the stigma around mental health and the residual extent of that stigma, we have to start with the word ‘mental’. In the school playground, that was something you could call someone to slag them off: mentaller, mental case or plain mental. I grew up near a hospital called St John of Gods, described today on its website as an acute psychiatric hospital, known to us as kids as ‘the mental’. If you lost your cool in a game in the yard, boys would swoop about you calling ‘Nee-naw, nee-naw, off to John of Gods’. Our teachers’ references to mental maths were greeted with daily sniggers. Okay we were kids and what did we know. But more to the point, how long was it before anyone challenged all that stereotyped vocabulary about being crazy, mad or mental.

What a journey that word has come on. Derived from the Latin mens, meaning ‘mind’^[1], the first usage of ‘mental’ is traced to the 16^th century when it was used to refer to cerebral tasks performed internally. Emotions weren’t a major feature of how the logical computational mind was understood to work. I suspect that when ‘mental hospitals’ began to be so-called in the mid-19^th century, this was the beginning of society’s insistence on using euphemism to avert our eyes from the reality that among us were people suffering in ways our doctors could not observe or treat and in many cases which prevented them going along with the flow of modern social life. The events and conditions which often lay at the root were an equally inconvenient truth for people avoid. At the same time, the mental hospital concept was a more humane-sounding iteration on the asylums built for people with intellectual disabilities and mental health disorders (denoted legally as ‘idiots’ and ‘lunatics’ respectively – Basil Clarke and Peter Rushton have written about the legal significance of this distinction namely that either status impacted the right to inherit property, the latter temporarily and the former permanently). These newer terms also had the credo of the emerging fields of psychology and psychiatry, where the first ‘mental tests’ were beginning to be developed by the likes of Francis Galton to bring observation of the mind more into line with the ‘objectivity’ of medical diagnosis.

But whatever these buildings were called and however refined their practices, their existence reinforced the dominant presumption in polite society that mental problems were for some other poor unfortunates. Ordinary people ‘suffering with their nerves’, the ‘worried well’ filling the couches and cheque books of these new-fangled psychotherapists continued to be viewed with suspicion. Anna Burns’ celebrated novel Milkman has a memorable passage where the narrator’s mother refers to her late husband and ‘his psychologicals’.

“ ‘What these people with the moods and heavy matter should realise’, said ma…’is that life’s hard for everybody. It’s not just for them it’s hard so why should they get preferential treatment? You’ve got to take the rough with the smooth, get on with life, pull yourself together, be respected.’ ”

I think an easy trap to fall into is to assume everything is much more enlightened now and any lingering stigma will melt away with the passing of time. Burns’ dialogue may sound like caricature, but once in every four or five times I disclose that my research touches on mental health, I hear a version of these sentiments.

This cartoon by Robot Hugs does a good job of summing up how differently people respond to physical complaints compared to mental health issues.

What if people treated physical illness like they do mental illness? Oldie but a goodie from @RobotHugsComic #WorldMentalHealthDay pic.twitter.com/69WNlEu48F

— John Moriarty (@JohnJMor) October 10, 2017

My sense is that precisely because the nuanced terms we use, such as depression, anxiety and stress have both (a) emerged as descriptors which can be widely understood and (b) diffused into everyday speech. For example ‘feeling depressed’ and ‘depression’ are commonly conflated. One is a mood and the other is a mood disorder, which is to say that depressive moods can be chronic and don’t change in the way one might expect with changes in circumstance or environment. Maybe if the condition had a jargony medical-sounding name with a scientist’s name, or a number or some unpronounceable syllables, fewer people would say ‘sure everyone gets that’.

Similarly with anxiety. Who doesn’t get anxious? One viewpoint I’ve encountered is that we’ve gone “Too Far the Other Way”: that by raising awareness of mental health as an important domain of overall health and wellbeing, all we have done is pathologise the normal ups and downs of human experience. We’ve created an oxymoron in mood disorder, when the whole essence of mood is that it fluctuates. This argument continues, people are anxious about the fact that they are anxious so run all too quickly to their GP to ask for a cure for something that is nothing more than a natural and adaptive response to circumstance. (Further along that continuum is the view I once heard a doctor express that people would be better off not excavating trauma, because what’s the benefit being sad about something you previously weren’t aware of?)

Again, the distinction which programmes such as Mental Health First Aid^[2] try to clarify for people is that feeling anxious isn’t the same as experiencing prolonged anxiety which is out of proportion with the importance of the events and demands which trigger it. The latter is something which needs to be understood and accommodated for, and which is treatable in a variety of ways. Some people respond over time to talking therapy, where the act of naming aloud those anxiety-inducing stimuli enables them to acknowledge, understand and control their responses. Others benefit from medication or a combination of these treatments.

Awareness of these nuances is on the increase. Honest personal accounts from Prince Harry, Stephen Fry, Aisling Bea, Danny Rose and others in the public eye, as well as campaigning movements like Mad Pride have helped stimulate a more open public discourse. Where confusion persists is with some less common conditions, such as Chronic Fatigue Syndrome. Another term used in the International Classification of Diseases to describe chronic fatigue is Myalgic Encephalomyelitis, or ME. The increasingly widespread use of Chronic Fatigue Syndrome reflects a jargon-busting trend in the evolving lexicon of mental health, where making terms more descriptive of the key symptoms has been prioritised over medical precision. But a perverse effect of foregrounding symptoms is that it feeds a sentiment I’ve personally heard expressed that these conditions sounds made up and are open to abuse by people who want their doctors to sign them off work. They’re fatigued? Who can’t claim that they get tired? If knowledge can help erode stigma, then our knowledge needs to be broadened as well as deepened, and experiences such as those of people who wake up after sleeping for 16 hours and feel not remotely refreshed, often still in significant pain, need to be understood.

But all too often, mental health is defined exclusively by its absence. People think ‘health’ in the sense of ‘health system’ or ‘health scare’ rather than in the sense of ‘health kick’ or ‘health food’. Beyond expanding knowledge of mental illness, an important step away from stigma is acknowledging the spectrum that is mental health and the fact that we all occupy different spaces on that spectrum at different times.

We can think of this on micro and macro levels. The very concept of Mental Health First Aid reframes mental health as a collective responsibility: knowing what to look out for in family members, work colleagues, neighbours and students puts me in a position to prevent someone coming to harm and to make some kind of positive difference. This pulls mental wellbeing out of the private domain and implores us to look for signs around us. The person who is suffering could be the person least in position to instigate and initiate change. So it’s up to someone who cares. And here I believe is where stigma lives on: are we prepared to act on what we see?

If you suspected someone close to you was experiencing depression, would you broach the topic with them?

Would you feel confident suggesting someone speak to their GP, their family or their friends? What about their line manager, or an appropriate person within their workplace? What reaction would you fear for suggesting this?

What about counselling- would you suggest a friend or family member seek support of a trained therapist?

I suspect these are not unconditional yes questions. And if you think I’m judging, I find myself defaulting to ‘it depends’ as I think through my own responses. I mean what if we’re wrong? Most of us aren’t professionals. What if the person reacts badly? If it’s a work situation, might they complain?

I think this brings us back to the comparison between mental and physical health. Would I hesitate recommending a physiotherapist to a neighbour or colleague whom we encountered limping on a sprained ankle? Would I fear their opprobrium, worry that they might be defensive and ask aggressively where I got my medical degree?

Clearly context matters. If an organisation has foregrounded wellbeing, team cohesion, introduced policies supporting their people to support one another, then those conversations are more likely to happen. The economic logic of system-level preventative approaches has become inarguable. As someone who periodically has to ask the government for money to support research, I can usually summon at will a current most shocking official estimate of the annual cost to the economy of poor mental health. These are arrived at through adding items like lost productivity, sick pay, the cost to the public purse of treatment, many of which any employer can calculate on a local level and see the potential windfall from early investment.

And here we arrive at legitimately contentious territory. The stigma I’ve discussed, the stifling of open conversations about mental health, is distinct from critiques of how mental health, wellbeing, resilience, happiness and human emotion generally are routinely politicised and individualised as a way to side-step other duties of care which the state and institutions have towards individuals. So, taking those critiques as read for the moment (or as in the works for a subsequent article), let’s focus our critical attention on the question: in what should we invest?

The answer is lots of things, but what isn’t the answer is lots of nice-sounding initiatives which locate the problem at the level of the individual. To borrow a line from Professor Simon Gregory, “you can’t yoga your way out of a toxic environment”^[3]. Similarly, I would say mindfulness isn’t a strategy. A series of ‘take or leave’ offers of support to individuals won’t work in the absence of a drive to improve environments, systems and conditions. If anything, an unbalanced approach that foregrounds our individual responsibility to mind our health and ignores the importance of context could be just as counterproductive as admonishing someone surrounded by 60mph roads for not getting out and exercising.

The most difficult thing for any of us ever to acknowledge is when we bear part responsibility for a problem, but don’t have the wherewithal to fix it on or our own. It’s an inconvenient proposition for people to tell them the way they speak, or accept others speaking about the world, could contribute to the conditions in which people suffer. Consequently, the heaviest lift conceptually in the next phase of tackling mental health stigma is seeing that we all contribute to the psychological environment, but that there are structural and cultural forces shaping our experiences and overwhelming some amongst us and that these forces can only be addressed through collective action and brave, honest leadership.

On the day in 2015 when the man was telling me the pilot should never have been allowed to fly because he was depressed, I didn’t feel like pursuing it, or even challenging him to say why he thought that. It’s hard to be the voice sticking up for tolerance of any group of people when 150 lives have just been lost because one of that group chose to end those lives so as to end his own. But playing back the conversation later I found myself asking, what made him so sure of his position? What a difficult week that must already have been for anyone coping with depression. Imagine overhearing this guy effectively say he wouldn’t trust them to fly a plane.

At the time there weren’t any details confirmed: this was prior to the investigation which would later reveal Lubitz as having expressed suicidal thoughts in treatment and as having been declared unfit to work by his doctor. Undoubtedly he should not have been allowed enter the cockpit, but not because he was depressed but because his depression had reached a point where he was actively planning his own death. Might lives have been saved if depression weren’t something to be hidden and weren’t compounded by fear of losing the ability to do cherished and rewarding work? What job would you have let him do? Drive a bus? Chef? Tree surgeon? Carer? If it is the case that a job which is ‘high risk’ and puts others’ lives in the hands of the employee, then the list of jobs from which you would exclude people with mental ill-health would be very long indeed. And moreover how many pilots the world over (and indeed tree surgeons) live with depression and myriad other complications, without ever causing any fatality in their work? If it sounds like I’m still frustrated at someone for an offhand remark in 2015, that may be partially true, but my deeper frustration is that a difficult and tragic case like this could afford us a moment for reflection and learning, and all too often, those moments pass unheeded.

1. https://www.etymonline.com/word/mental ↑
2. https://aware-ni.org/mental-health-first-aid ↑
3. Professor Simon Gregory is Primary Care Lead for Health Education England. You can read his report into NHS Staff Wellbeing at https://www.hee.nhs.uk/our-work/mental-wellbeing-report; the quote I use is from this overview of a national roundtable on preventing suicide and self-harm – https://www.youtube.com/watch?v=ErcAN3CR1AQ ↑

“Two embracing lonely teddy bears look out the window.” by shixart1985 is licensed under CC BY