Our Mental Health – a Cause for Hope or Despair?
Dr Patrick Devitt, former MHC Inspector of Mental Health Services, author of “Suicide – A Major Obsession”
Few areas of discourse in modern life, apart from politics and religion, evoke as much controversy and entrenched diametrically opposed positions as that of mental health.
In mental health/psychiatry, we are used to talking about the concept of polarity and the term, ‘Bipolar’, has become part of the vernacular. ‘Bipolar Affective Disorder’, to give it its full title, involves an episodic mood disturbance alternating between the high of mania associated with grandiose delusions and out-of-control behaviour with the lows of severe depression, sometimes associated with crippling social withdrawal, delusional thinking of a negative nature and inability to find enjoyment in any aspect of life.
Mental health also involves other types of polarity:
In this paper, I will try to address some of these poles and argue that:
Mental Health is Difficult to Define
As is often the case in areas of great controversy, the roots lie in the absence of consensus definitions. What is mental health? What is health itself? From an etymological perspective, it comes from an old English word which means soundness or whole. The ancient Greeks regarded health as a divine gift as does the Koran. There does seem to be a randomness to health despite all the advances of modern medicine. The best known definition of health is the WHO definition (1948):
“A complete state of physical, mental and social wellbeing and not merely the absence of disease or infirmity.”
But, is this really helpful? This definition equates to what we might call happiness. Are humans meant to be happy? Those of us who were taught religion in the 50’s and 60’s were told our time of earth was “a vale of tears” and we could expect to struggle and suffer. The concept of happiness would have no meaning were it not for its opposite of unhappiness and sadness.
James Davies, anthropologist and psychotherapist, in his book, The Importance of Suffering, argues that suffering can have meaning, help us understand our lives and make us richer and more rounded people. Regarding suffering as pathology to be eliminated is counterproductive and takes away our independence of thought and dilutes our integrity. This is similar to the Buddhist perspective.
Similarly, we cannot know elation without depression, sanity without insanity, peace without agitation. The human condition is one of great emotional robustness but also fragility. If something goes wrong in any enterprise, our mood understandably goes down. We withdraw, re-trench and go into pensive mode. We go over where things went wrong and how we might do it better the next time. Depression, in this context, can be productive. When we seek new challenges, we feel naturally anxious. This is good because it helps us to acknowledge the risks. And a certain amount of anxiety improves performance.
Even psychosis or madness must have had some social or evolutionary utility as the poet John Dryden surmised:
“Great wits are to madness near allied and thin partitions do their bounds divide”
There are many examples throughout history of geniuses in various areas who have also had serious mental health difficulties leading to speculation that creativity and psychosis may be genetically associated. John Nash, the gifted mathematician and Nobel Prize winner, suffered from schizophrenia. Vincent Van Gogh, the painter, was obviously mentally infirm and died by suicide. Kay Redfield Jamison, celebrated author and psychologist, suffers from serious Bipolar Disorder. Ellen Saks, author of the Centre Cannot Hold, is a gifted writer and academic and also has schizophrenia. If we were to eliminate all depression, anxiety and psychosis, we would be a poorer species.
What is mental illness, mental disorder, disease or infirmity? The United States National Institute for Mental Health claimed in 2005 that about 26.2% of all American adults suffers from a diagnosable mental disorder in a given year. That figure is quoted on an almost daily basis on our radio and in our newspapers. The statistic is cited well-meaningly, presumably to reduce the stigma of mental illness and to increase resources for our mental health services. (The life-time prevalence of schizophrenia is thought to be no more than 1 in 100. Allowing the same prevalence for Bipolar Disorder, Melancholic Depression, Disabling Anxiety and serious Personality Disorders gives a total of approximately 5 in 100.)
When psychiatric classification started in the early 20th Century, only a handful of disorders were recognised. In the 1950’s, the first Diagnostical and Statistical Manual increased that number to 106, the second to 182 and the third to 265. The DSM-IV saw an increase to 370. The DSM-5, released in 2013, adds 15 new disorders including Caffeine Withdrawal, but does consolidate others. The manual has 947 pages. Surely we haven’t evolved into a totally different species? Has human nature really changed that much in the past 100 years? It is clear that everyday ups and downs are now being reclassified as illnesses or diseases with the implication they are amenable to treatment.
Journalist and author, Sathnam Sanghera wrote The Boy with the Top-Knot: A Memoir of Love, Secrets and Lies in Wolverhampton, which won the Mind Book of the Year in 2009. He returned to his Punjabi Sikh home in Wolverhampton for 2 years from his work as a journalist in London to immerse himself and study his own family, in particular, his father and sister who suffered from schizophrenia.
Sanghera wrote a trenchant article in the Times on the notion that 1 in 4 of us suffer from a mental disorder in any given year. Most of these conditions bear no resemblance to the severity of thought disorder and behaviour which he witnessed in his own father and sister. He was of the view that this type of statistic attempts to sanitize mental illness and does not address the reality of the most severe sub-types and may even have the effect of depriving these serious illnesses of resources and banishing their sufferers out of sight.
In the United States, the Community Mental Health Act 1963, which set up a network of community mental health centres associated with the closure of the large psychiatric hospitals, in itself was only partially effective to the extent of attracting the “worried well” who clogged up clinics causing those with serious mental illness, now deinstitutionalised, to become homeless living under bridges and moving to San Francisco and San Diego.
The definition of mental health is quite elusive. It is clear that mental health has many different causative influences including genetic, social, developmental, moral, cultural, behavioural and medical, each encompassing its own set of definitions and polarities. Dr. Anthony Clare, in 1976 wrote the landmark book Psychiatry in Dissent in which he outlined the various viewpoints within psychiatry including those of the anti-psychiatry movement, psychotherapy, social psychiatry and biological psychiatry.
In addressing the optimal way of defining mental health, he quoted Sir Aubrey Lewis, the first Professor of Psychiatry at the Institute of Psychiatry in London between 1946 and 1966:
“Anyone who has reflected on the many definitions of health, and mental health in particular, will, I think, conclude that there is no consensus and he will see that when moral or social values are involved, there are scarcely any limits to the behaviour which might be called morbid. Medical criteria are safer: that is criteria essentially concerned with the integrity of physiological and psychological functions” (1963)
The Trajectory of History
This summer school has the theme, “2016, Ireland at the Crossroads”, one hundred years on from the events in 1916. Just a short walk from the GPO on O’Connell Street, was the Richmond Lunatic Asylum based at Grangegorman, where, at the time, there were 2000 residents. At that time, the institution was 100 years old having been developed in order to free up the Richmond House of Industry or workhouse where there were an increasing number of lunatic wards.
Around the 17th Century, a great increase in the power of the State took place. Accompanied by the increasing importance of economics and secondarily the importance of work, it was estimated that in the 17th Century half of the residents of Paris were homeless, many of whom were poor, criminally inclined, unable to find employment or mentally deranged. According to Michel Foucault, the State needed to separate the abnormal so it could define for itself what was normal. It was in that context that an intolerance of madness flourished. From then on, there was an inexorable rise in the numbers of social misfits, rejects or mad incarcerated.
This reached its high water mark in Ireland at the end of 1958 when there were incarcerated under the label of mental illness, 20,046 in public psychiatric hospitals and 1,029 in private hospitals. From 1916 to 1958, there was, therefore, only a straight road without any turnings, crossroads or apparent choices except to incarcerate more and more. Currently, there are about 3,000 or 4,000 individuals resident in mental institutions.
When I started work in psychiatry in the 1980’s, in St. Ita’s there were 800 patients, 400 with mental handicap and 400 with psychiatric illness. There was no community treatment other than rudimentary outpatient clinics. Medications, anti-depressants and anti-psychotics, had become available from the 1950’s,. It was the advent of these medications, with the political changes from the liberal 60’s, which primed the reduction of numbers in psychiatric institutions. The Policy Document, “Planning for the Future” in 1985 recommended that mental health treatment should take place in general hospitals and community services should be developed.
A Vision for Change in 2006 detailed a consensus that modern mental health services should be mainly conducted in the community, be multi-disciplinary in nature, less medically focused and that the patient should be at the centre of the whole process in partnership with the treatment team. These principles have been accepted by all with an interest in mental health services including patients, families, advocates, service providers and professional bodies. Everybody is on board, at least in theory.
Then, from 2008, we were no longer able to pay for all of the fuel to transport us to the promised land. The principles of A Vision for Change have taken hold in a sporadic way across the country. There are still many strongholds of a purely medicalised approach, with almost exclusive use of medication and sometimes large doses of many different medications seen as the only approach. In the 1980’s, almost all of the 19th Century asylums were still in operation. The infrastructure and the physical plant had deteriorated and conditions were scandalous. It is only in recent years that nearly all of the work of civil psychiatry is now practiced outside of these types of institutions. The Central Mental Hospital in Dundrum is one of the last strongholds, but there are now plans to move this service to a new building on the campus of St. Ita’s in Portrane. Some of our mental health services, at least, have improved. If this trajectory continues, we can expect to see further improvement.
Improving Our Mental Health
It is sometimes thought that improvements in physical health were due to the influence of modern medicine, but the main causes of improvements in our mortality and our lifespan have actually been socio-cultural. Clean water, safe shelter, good nutrition and humane working conditions accounted for far more improvement in our physical health than any of the modern medical interventions.
Similarly, with respect to improving our mental health. Rather than relying solely on medical or pseudo-medical interventions, we should also focus as a society on providing our children with stable, loving environments where they are not exposed to abuse, violence or the ravaging effects of alcoholism or drug abuse. At school, our children should be taught resilience and the importance of healthy activities including physical activity and “the virtues” as espoused by Aristotle. Children should learn of the human condition and that struggle and suffering are part of it. Coping skills should be taught. It would be unrealistic to expect that this would be universally effective. Those who do take to drugs or to crime, should have adequate access to rehabilitation.
We should recognise that it is human to have everyday ups and downs and there is quite a wide range of normality. Some of us are more robust than others. Most of us can cope with our emotional ups and downs by simple reflection, temporary withdrawal or self-soothing. Sometimes we will need to involve our friends or families. We need to accept that these everyday ups and downs are normal and not a cause for identifying ourselves as the 1 in 4 who suffer from a mental disorder in a given year. When everyday measures are ineffective, a network of counsellors should be available, operating on a statutory and, perhaps, voluntary basis, to be the first port of call for emotional problems. We must not medicalise human distress.
Has the medical profession anything to offer? Psychiatrists, as medical doctors, are trained to identify patterns of symptoms and signs, diagnose conditions with respect to predicting the likely course of a condition and which interventions are likely to be helpful (the “Medical Model”). Psychiatrists and other mental health professionals including nursing, social workers and occupational therapists are trained to treat the most serious conditions, those of schizophrenia, bipolar disorder, melancholic depression, disabling anxiety disorders and the more serious personality disorders. Treatment of this category should be the sole remit of the professional mental health services.
These services should, of course, as much as possible, respect the autonomy and the liberty rights of patients. The current culture of blame should change such that professionals are prepared to take meaningful risks for the benefit of their patients and their quality of life. Budgets for these serious mental illnesses and for “human distress services” should be ring-fenced from each other.
Mental health professionals should be less obsessed with the idea of suicide, which, to a large extent, is socio-cultural in origin. Suicide is rare in our community. For such a phenomenon with a low base rate, year to year and even decade to decade variations are not particularly informative. Psychiatrists and mental health professionals are not good at predicting suicide. They should regard suicide as an indication of distress. Our efforts should be towards alleviating the distress, but not with the primary aim of preventing the suicide (a cause for many unnecessary admissions to hospital).
Psychiatrists and all mental health professionals should respect patients’ own views of their illnesses. Patients should be asked how quality of life can be improved and how their distress can be interpreted in the context of how their hopes, dreams and aspirations relate to their current lives. It is often the case that patients with even far-fetched meanings for their particular symptoms can cope far better than accepting the doctor’s view that this is merely a disorder of chemicals.
We have discussed how Ireland and its mental health are at a crosswords. A more apt metaphor might be that we are on the old Red Cow Roundabout with a signpost on a pole at each exit, each stating “Good Mental Health”. So, naturally, we are going round in circles. The following means of bypassing this circle of hell is suggested:
Within the psychiatric profession and without, there are already individuals and groups practising in this manner and advocating for these measures to be adopted universally.
That is a cause for hope.