A rational response to a major threat

For several weeks now, I have been waking in the night with feelings of intense anxiety. I constantly monitor myself for symptoms of a possibly fatal illness. I can’t concentrate very well, and my usual ways of coping don’t seem to be working. I feel a bit safer inside my house but I also feel trapped. One minute I feel fine, and the next I feel terrified. Have I suddenly developed a “mental health problem,” unfortunately timed to coincide with the COVID-19 pandemic? No, of course not. I’m having an entirely rational response to a major threat to our whole way of life.

It feels appropriate to make this a more personal blog because we really are all in this together—and I don’t just mean as a community or as a nation, but as a species. Coupled with environmental damage and climate change—to which it is related—the pandemic is by far the biggest threat we have ever faced. Who can say how we ought to be feeling at such a time? Where do we draw the line between “normal” and “abnormal,” “mentally ill” and “mentally well”?

And yet that is exactly what many so-called experts are continuing to do. It is both horrifying and fascinating to see how the “mental illness” narrative is being used to individualise and pathologise our responses even as our very survival is in jeopardy. This is presenting us with a particularly stark illustration of the craziness of psychiatric thinking.

In the UK and around the world, the headlines are everywhere. We are heading for a “pandemic of severe mental health disorders.” We are facing “an epidemic of clinical depression.” Charities are lining up to express alarm—the Mental Health Foundation found that six out of ten people were anxious about the crisis and at risk of “persistent and severe mental health problems.” We are exhorted to learn the lessons from China and prepare for “a public mental health crisis.”

Distress makes sense in context

Of course, this is nonsense. A more sensible response would be to ask what is wrong with the four in ten people who are apparently not too bothered about what is happening. We should be far more worried about someone who is blithely denying the extent of the problem—especially (mentioning no names but there are several of them on the world stage) if they are national leaders charged with steering their countries through the crisis.

Only a few weeks ago, someone who was too scared to leave the house in case they contracted a fatal disease, and spent most of the day washing their hands and wiping down doorknobs, would have been regarded as having a severe case of “OCD.” Now it is the description of a responsible citizen. Never was there a clearer illustration of the fact that judgements about who is “mentally ill” are social, not medical ones. Never was it more obvious that distress makes sense in context. Abnormal situations lead to unusual or extreme responses. If we are fearful, then so we should be.

Mad in America and Mad in the UK audiences do not need convincing about the damage that results from diagnostic labelling, and unlike the general public, they will already be familiar with the large body of evidence telling us that the various forms of distress diagnosed as “psychosis,” “clinical depression,” “bipolar disorder,” “personality disorder” and so on are strongly related to experiences of trauma, abuse, neglect, loss, poverty, unemployment, discrimination and inequality. The hostile voices that some people hear often echo the words of real life abusers. Low mood and despair make sense if you are struggling with loneliness and lack of resources. Self-harm and anxiety are the predictable result of the pressures our children and young people are facing. In other words, when placed in context, these reactions are understandable responses to adversities.

Understandable human reactions

But sadly, translating these understandable human reactions into the language of “mental health” is as much of a global epidemic as the coronavirus, and just as hard to counter. We are increasingly encouraged to reframe every form of distress into a “mental health problem” under the new imperative to “talk about mental health” more or less constantly. This discourse has penetrated so deeply into the minds of professionals, the media and the general public that they simply do not see it as problematic, or even grasp what the criticisms might be. To give just one example, Public Health England has, commendably, promoted a message of “It is normal to feel anxious in a crisis” and has suggested a range of commonsense strategies and mutual supports. However, the campaign is headlined by two of our Royals, the Duke and Duchess of Cambridge, urging us to “look after our mental health.”

“Mental health” is such a seductive phrase, but as soon as it becomes just another way of saying “how we all feel,” we are sucked back into a subtly individualising and medicalising framework. Even critically-minded writers end up arguing that we should do X (where X is ordinary coping strategies and mutual support) rather than Y (where Y is diagnoses and prescriptions) in order to preserve our “mental health”—this mysterious, indefinable but apparently fragile state of mind—rather than challenging the whole concept of “mental health” in the first place.

But the idea that we are facing two simultaneous pandemics—a physical health one and, by a tragic coincidence, a mental health one as well—isn’t just nonsense. It is dangerous. In falling victim to this way of thinking, we lose connections with the wider issues just as surely—in fact more so, because we don’t even notice we are doing it—as those who are promoting the more overtly medical “pandemic of chronic disorders” narrative.

There are two main reasons for this. Firstly, the more we label our understandable human reactions as mental health problems or disorders, the greater the temptation to focus on  individual “treatments” instead—whether psychiatric or psychological/therapeutic. I have seen both groups eagerly priming themselves to receive all the new customers created by the crisis, although with nearly a quarter of the UK population already being prescribed an “antidepressant,” we would do far better to offer practical and financial support.

Similarly, we know that formal psychological interventions can actually be harmful if implemented too early. Instead of uniting us in solidarity, diagnostic labels isolate and silence us, and give us the message that we are not coping as we should be able to. On the other hand, simple human support and contact from friends, neighbours and colleagues has been shown to protect against fear and despair in times of crisis and disaster.

Secondly, diagnostic labels and the “mental health” discourse actually prevent us from dealing with the wider reasons for our distress, by disconnecting our responses from the threats. In more “normal” times, those threats typically include things like abuse, neglect, violence, discrimination and poverty. Those factors still apply, but coupled with climate change, we are now faced with an additional level of threat beyond anything we have ever known.

The immediate task is to survive the pandemic as well as we can. This in itself is demonstrating the acute failures of our public health systems and welfare networks, along with much-needed reminders that the most essential members of our society are those who are lowest paid and least valued—nurses, care workers, delivery drivers, shop assistants and so on. There is a great deal to be learned as we emerge into a post-pandemic world.

But the lessons need to go a good deal further. There is a danger of “individualising” a crisis as well as a person’s reactions to it, even though all the evidence suggests that COVID-19 is not just a random disaster. It has been predicted for years, based on the known impact of destruction of animal habitats, which increases the likelihood of viruses being transmitted to humans. This environmental destruction is, in turn, a consequence of the exploitation of the natural world driven by the demands of industrialisation. Truly, the planet is fighting back. One day, unless we take drastic collective action to change the whole economic and value base of our Western industrialised way of life, there will be a virus we cannot beat.

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These are tricky arguments to make, and can quickly be interpreted as callous disregard of people’s suffering. It is very important not to deny the very real and acute distress that many people with diagnosed “mental illness” are now experiencing, especially if they suddenly find that their usual services are unavailable, and are stuck within their own four walls with no one to call upon. I’ve seen desperate pleas from people who have been dropped by their psychiatric team, just when they need contact more than ever. This is shocking and unjustifiable.

But equally, we don’t want to assume that survivors as a group will fail to cope. This is untrue and even patronising, and there are also reports of people coping better than usual as they draw on talents for survival that the officially “normal” population may lack. One service user tweeted: “For those of us who already live with trauma or the significant impact of mental health on our daily life we are perhaps more prepared/less complaining about self-isolation, surviving on low income, restrictions in movements and facing cuts in our health/social care services.“ Another said: “We have walked these extreme emotions and come out the other side.”

Similarly, people with serious physical health problems have pointed out that isolation is their usual way of life, and have pleaded not to be forgotten again when the lockdown is lifted. Psychiatric survivors have set up an impressive list of peer networks and resources in recent weeks including a set of “Lived wisdom” strategies drawn from “hard-won expertise learned through traversing challenging life experiences.”

UK journalist John Crace,¹ who has a history of mental distress, is experiencing both sides of the coin: “I wake up early and for a brief nanosecond all is well with the world. Then my mind turns to….the reality of the coronavirus pandemic. Anxiety electrifies me. It’s not just a sense of existential dread, it’s a parasitical entity that takes over my entire body. My shoulders and upper arms tingle with fear, there is a ball of dread in my guts and my legs cramp. I am immobilised for the best part of an hour. I know I should be getting out of bed but I am too afraid to do so… At present, I can’t face being in my study at home. I feel too alone and unsafe.” And then he adds: “It just feels like reality has finally caught up with my own sense of neurosis and anxiety. Which may be deeply worrying for most ordinary people, but is somehow almost reassuring for me. Almost.”

His anxiety is clearly very real and overwhelming, but who is to say that it is unreasonable? Maybe we should all have been feeling more like him for a very long time. Suddenly, the barriers between them—service users/survivors and us, the “normals”—are breaking down. All of us can both offer and receive support.

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Surviving the pandemic, as most of us will, is only the start of it. However, we must not be tempted back into a medical narrative, even though the aftermath will probably be as bad, if not worse. Healthcare staff may be deeply shaken by the suffering they saw, but we don’t have to call it an outbreak of “PTSD.” People who have lost their jobs are likely to feel desperate, but we don’t have to describe this as “clinical depression” and prescribe drugs for it. The economic recession that will follow the pandemic may lead to as many suicides as austerity measures did, but we don’t have to say that “mental illness” caused these deaths.

COVID-19 is a national and international crisis, and there is no doubt that we will all be deeply scarred by it. However, we can come out of this crisis in a better state than before by staying connected with our feelings and the urgent threats that have led to them and taking collective action to deal with the root causes. Perhaps we will, at last, be forced to make the link between rising levels of misery, fear, self-harm, suicide and despair and the social ills of austerity, insecure employment, discrimination and poverty. Perhaps we will finally drop both poles of the “mental health/illness” narrative and instead, talk a lot more about our real, valid human reactions to discrimination, insecurity, inequality and injustice in our lives and our communities.

This is a chance to challenge, not reinforce, the MH narrative, which is why I am part of a small group trying to get a different message out in the media. We have had some successes (see The Guardian and Nursing Standard). More articles, podcasts and blogs are in the pipeline, and we have collated non-medicalising, non-pathologising resources on Mad in the UK.

“Collective trauma” can be defined as an event or situation that challenges the lifestyle, values and identity of a whole society. Judith Herman,² one of the pioneers of trauma work, recognises its profound impact on whole societies as well as on individuals. She says: “The solidarity of a group provides the strongest protection against terror and despair, and the strongest antidote to traumatic experience.” She also says that truth-telling and social action can bring healing and change out of adversity. The writer Ben Okri has phrased it beautifully:

The questions raised by the pandemic should spill over into all the other issues through which future disasters might arise… climate change, universal healthcare, justice and poverty… Values of the market have taken over from values of human solidarity… We are deep in a new wasteland… All our myths point in two directions. We either go upwards, towards the true meaning of civilisation, or we head for an apocalypse.

I believe there are already signs of moving in the right direction. In the UK the wounds of Brexit are starting to heal, as “remainers” offer to shop for “leavers” and vice versa, and people join their street’s WhatsApp group to keep an eye on the vulnerable and elderly. Although physically separate, we are in some ways closer than ever. For me, there is the unexpected delight of having both my adult kids at home again, cooking and watching rubbish films together. Others are finding silver linings in new freedom from commuting and daily pressures, and in cleaner air and simpler pleasures.

We need a new narrative of shared distress to replace the failed one of individual disorders. We need human connection and mutual support. We can learn to manage our feelings in a way that helps us through the crisis and gives us the energy to make much-needed social and environmental changes afterwards. The usual dividing lines melt away in the face of global emergency. We really are all in this together.