What’s normal in the world of mental health labels?
How do we distinguish between the normal emotional upheavals of life and something that can be defined as a “mental health” problem? I recently heard the jockey Sir Tony McCoy speaking on the radio of his difficulty in adjusting to retirement after horse racing. The headline of the report was that large numbers of people facing retirement are suffering from mental health issues. I know that many of my friends and clients have found it difficult to adjust, as McCoy has, to retirement. They miss the structure, purpose, social life and status of work. However, this is generally a fairly natural period of bereavement when there will be an inevitable cycle of loss. And what I am questioning is the ease with which people seem to be given labels of mental illness these days. Could it not be that they might be experiencing the fairly typical emotions of just being human and going through a difficult patch?
Don’t get me wrong, I am delighted that mental health issues are being spoken of in a more transparent way. I remember a close family member who had recovered from a nervous breakdown saying that she wished people had been able to see her illness in the way they can see a broken arm. Luckily we are now gaining more understanding, although a cure for psychological problems is still quite hard to find.
But at the same time, I worry about the burgeoning number of mental health labels that are given as diagnoses of emotional problems. The number of disorders listed in the Diagnostic and Statistical Manual of Mental Disorders, the diagnostic tool published by the American Psychiatric Association (APA), increases year by year. In the United States, the DSM serves as a universal authority for psychiatric diagnoses but according to recent surveys some 46.5% of Americans will have a diagnosable mental illness in their lifetimes, based on this manual. Really?
Let’s look at these labels – grief can be packaged as ‘Adjustment Disorder’, a child’s temper tantrum as ‘Disruptive Mood Dysregulation Disorder’, shyness can be defined as a mental health illness, where it was a totally natural, if uncomfortable, experience when I was a child. Three to five people in every 100 are estimated to be diagnosed with ‘personality disorders’ in the UK, with one to three in every 100 living with ‘schizophrenia’. Are these diagnoses accurately differentiating real mental illness, which can be life-threatening, from a transitional period of emotional disturbance? Is it that people are now expecting to feel ok all the time? Is there some new intolerance to feeling miserable, uncertain, sad, uncomfortable that leads people to seek a fix that in previous times they might just have to have accepted as a phase of life? A pill for every ill rather than accepting emotional distress? Have we always been mentally sick or are the labels increasingly embracing what would previously have been perceived as normal?
In her new book “It’s OK That you’re not OK: Meeting Grief and Loss in a Culture that Doesn’t Understand” Megan Devine emphasizes that grief is not a problem to be solved or resolved. Rather it’s a process to be accepted, tended and lived through. The suggestion is that those going through bereavement, redundancy, retirement or teenage anxiety could benefit from accepting that they will feel bad some of the time and that this is perfectly normal. Having experienced bereavements myself I endorse the view that the pain is very real and difficult to bear but I don’t believe it would have helped me if someone had tried to medicalise it. Being upset when someone you love dies is absolutely natural. Time is, as the saying goes, a great healer but if grief becomes long-term and overwhelming it is at that stage that someone may need help, not necessarily by handing out anti-depressants before.
I personally believe that we need to communicate more realistic expectations of life. Young people are bombarded on the one hand by celebrity ‘perfection’ on social media and on the other by angry ranting politicians and news media complaining of everything that’s going wrong. So it is hardly surprising that people end up feeling aggrieved that they sometimes find life difficult. But when has life ever been easy? With all the money in the world you can still get ill, lose a child, be struck down by war, natural disaster or terrorism. Life is and always has been challenging and it is surely more helpful to enable people to accept this and learn the tools of resilience to support them in managing these ups and downs. One of the insights I gained recently about the statistics that suggest Scandinavian countries are happier than we are is that they have different expectations of life and so are not so disappointed by it.
The other problem with labels, if given too readily, is that they can ramp up anxiety about a condition, both in the individual and also in their family, and so become a self-fulfilling prophecy. There can be a negative pay-off in the fact that the person can be treated in a special way and allowed to retreat from the responsibilities and challenges of life. This is certainly a very difficult balance for families to manage.
Research has also shown that clinicians can tend to box those whom they have labelled with a mental illness. They can wrongly assume tendencies and behaviours associated with the label that may not actually be present in the specific individual. Patients have reported being told that they will never recover – a real ‘nocebo’ effect. Experiments have also shown that a label can immediately change the perception of those interacting with them – in experiments someone introduced as a ‘patient’ was seen as having serious psychological problems whereas someone introduced as a ‘job-seeker’ was seen as ‘well-adjusted’. The mere use of the word ‘patient’ can encourage a more pathological view of someone’s behaviour, and so can trap the person within the label. Consider the weight of negative associations connected to a diagnosis of depression.
I remember watching the BBC Horizon programme How Mad are You? where a team of psychologists observed a group of people, some of whom had been diagnosed with mental health conditions such as schizophrenia, anxiety, depression and Obsessive Compulsive Disorder. The team of psychiatrists were tasked with identifying which individuals had which condition. They frequently got it wrong, diagnosing normal people with conditions they didn’t have and missing the signals of bi-polar in another participant. In the end, participants were delighted that their condition could not always be detected, even by experts. It helped them feel more normal.
The programme demonstrated that mental health is something we all experience on a spectrum – after all we all have some quirks and neuroses, don’t we? As Freud said, “Every normal person is, in fact, only normal in part”. His suggestion is that most people are relatively unhappy most of the time and – contrary to the aims of the celebrity social media age – “The more perfect a person is on the outside, the more demons they have on the inside”.
The Horizon programme also demonstrated that the stigma that the individual associates with their condition, and which is transferred so readily to those around them, can negatively impact their ability to recover. As an article by Chris Langer, an integrative counsellor, argued, the label of a mental health illness not only stigmatises but also isolates people, creating an artificial divide between ‘normal’ and ‘abnormal’. Langer suggests that once these perceptions become embedded, the patient can become institutionalised in a framework of healthcare to the point that the label reinforces, rather than alleviates, the presenting symptoms. It also pigeonholes people in the same box when the reality of one person’s ‘bi-polar disorder’ symptoms may be very different to another’s. Interestingly, Carl Jung believed that a correct diagnosis could only be made at the end of treatment.
Of course a specific diagnosis or label can be helpful, in the understanding of an individual’s predicament, the potential support of network groups with similar conditions and information about medications and actions to alleviate symptoms. What one doesn’t want to do is infer that what might be the normal but uncomfortable experience of, for example, being a teenager means that the person is mentally ill. Last week there was a report of numbers of girls ordering, from the internet, Xanax as a self-prescribed medication for anxiety. The teenage years are always difficult ones, full of angst and anxiety about the future. It is inevitable that teenagers get worried about how it might pan out – will they pass exams, will they get into university, will they find a job, will they find love, will they get married and have kids, etc. Nothing is certain and at the same time the neurons in their brain are doing a major rewire and their hormones are rampaging around their bodies so it is not surprising that they feel unsettled. And the endless headlines about increasing numbers of them suffering from anxiety, loneliness and depression hardly help, in my view. Being sad and lonely sometimes can be part of life. Being alone is not necessarily being lonely but it can become so if someone tells you it is and if you don’t take action to get out and create new connections.
Surely it is more helpful to provide resilience tools to those going through such transitions, to help them manage the uncertainties and changes of life? Don’t we need to learn to accept that emotions, however uncomfortable, are part of the rich and deep experience of being a human being in a complex world?
Of course there are those who have serious conditions who absolutely need clinical support and medication. I just worry about the tendency of medics and journalists to dish out quite so many labels to quite so many people when maybe those people are just going through a normal, if difficult, stage of life.
Bath University: Mental Health Labels can do More Harm than Good http://www.bath.ac.uk/research/news/2015/08/18/negative-impact-mental-health-labels
The Guardian: “How TV show turned the spotlight on stigma
250 Labels used to stigmatise people with mental illness by Diana Rose, Graham Thornicroft, Vanessa Pinfold and Aliya Kassam
Understanding Grief by Jane E Brody, New York Times, 15.1.2018
National Health Executive: Be Wary of Mental Health Labels, 7.4.16
Emotional Healing for Dummies: Dr David Beales and Helen Whitten, Wiley, 2010
It’s OK that You’re Not OK by Megan Devine, available on Amazon
The Almost Nearly Perfect People, Behind the Myth of the Scandinavian Utopia by Michael Booth.
www.thelostconnections.com Johann Hari