All changed, changed utterly. Such is the state of public debate regarding health, welfare and the economy after a few weeks of lockdown. The global pandemic may also alter for good the debate on mental health, and it’s vital we get it right. Writing for the World Economic Forum, Dr Elke Van Hoof, a Belgian clinical psychologist, notes that around the world some 2.6 billion people are in some kind of lockdown, which is “arguably the largest psychological experiment ever”.
The critics of the lockdown in Britain typically stress not only the immense costs to the economy of current policies but also the psychological toll of keeping people isolated. That objection is wrong. There is no inherent reason why the greatest public health crisis in a generation, and perhaps in more than a century, should create an epidemic of mental illness in its wake. But the crisis ought to raise the profile of mental health provision. And public health information on it during the crisis has been of good quality.
The objection made by critics, including President Trump, is that by creating a precipitous recession, the lockdown will cost more lives than it saves. Yet the Nobel laureate Angus Deaton, an expert on the relationship between economic conditions and life expectancy, concludes that the short-term impact of recessions is to reduce the overall mortality rate. (I owe this reference to the economist Jonathan Portes.) We can expect, for example, fewer fatal accidents with less traffic on the roads. It’s true that suicides increase as a result of recession but these are a very small fraction of total deaths.
Suicide is an urgent humanitarian issue regardless of the current crisis. The World Health Organisation (WHO) estimates that each year almost 800,000 people globally take their own lives and that depression is the major contributor to these deaths. The coronavirus crisis has undoubtedly wreaked emotional havoc among those worried for the future, isolated from loved ones or suffering the grief of bereavement. They need support. Whether their emotional states mutate into depression, in a clinical sense, may depend on it, for these are different things.
Everyone feels low and sad at times. It’s part of the human condition. And low mood is what you’d expect when we can’t visit our friends or loved ones, engage in normal recreation, or even just change the scenery by getting on a train. It will particularly affect those who live in cramped or substandard accommodation, without access to green spaces, and in dysfunctional or abusive domestic relationships.
Depression is an illness not only of sadness, however, but of distorted thinking. It’s what clinical psychologists and psychiatrists call an affective or mood disorder. Sadness is a normal part of the human condition but an affective disorder is characterised by abnormal emotional states. It comprises a host of symptoms that will differ from person to person. Some sufferers will be worn down by ennui – a sense of listlessness and hopelessness – rather than more specifically sadness. What formerly gave life a purpose no longer matters. What once provided pleasure palls. The appetite for food, recreation, conversation and human intimacy has, the sufferer finds, abruptly departed.
When we’re left isolated, these distortions of thinking can be magnified by the constant process of rumination. Public Health England (PHE) issued a set of guidelines in March on the mental and wellbeing aspects of the coronavirus, which identify the threat accurately. The document stresses: “It is okay to acknowledge some things that are outside of your control right now but constant repetitive thoughts about the situation which lead you to feel anxious or overwhelmed are not helpful.”
That’s right. We will all feel low but the depressive state is more than this: it’s a clinical illness that can be utterly incapacitating. The emotional difficulties experienced by those in lockdown are not inevitably the same as illness. There is no reason why the crisis need spark an epidemic of depressive disorder; the means of preventing it lie with ourselves. Following the advice of PHE to stay in touch with people, to support others, to look after your physical wellbeing and to take time to focus on the present will make our society as well as ourselves more resilient in dark times.
To do that effectively will require challenging two myths that are incompatible but that perversely give sustenance to each other. One is the charge that the citizens of affluent western societies are infantilised by a “therapy culture”. In this modern narrative, critics argue, life’s normal hardships of sadness and setback are exaggerated and their sufferers are flattered by being depicted as bravely battling against illness. Not only is this fable false, the critics say, it’s also debilitating.
That may seem a caricature of callousness but it is the argument of Frank Furedi, an academic sociologist who wrote a book some years ago identifying “a new narrative of illness [which] does not simply frame the way people are expected to feel and experience problems – it is also an invitation to infirmity”. In the current crisis, Furedi’s disciples believe their time has come. Their message is that we need to collectively develop a bit of backbone and tell children that setbacks are part of the stuff of life which we must get used to. Joanna Williams, a columnist for Spiked magazine, worried last month that the lockdown might obscure this bracing message: “Ironically, one unintended consequence of shutting schools might be that children have the opportunity to forget directives that everything in life is to be considered stressful.”
This is pernicious nonsense. So far from there being a “new narrative of illness” in the media and public life, depression and other mental disorders are still commonly regarded as somehow not real: they are instead manufactured ailments of affluent societies and privileged people that would be unrecognisable to people suffering real hardship amid famine, oppression and war. The critique of the “the therapy culture” isn’t really about medicine or the mind at all. It’s part of what’s come to be known as the culture wars, though the metaphor is wrong as only one side is engaged in fighting them. This “war” is in reality a protest by people who regret the social changes that have occurred throughout the advanced industrial economies over the last half century or so.
It is an advance in civilised society if we take more seriously the incidence of mental illness and erode the stigma that attaches to it. And while the habits recommended by PHE can make you more resilient against mental illness, resilience itself is not a remedy for those who have depressive disorders. You can no more make yourself better by an act of will than you can mend a broken limb by the power of prayer.
The second myth is that our society is so dysfunctional that treating mental illness is futile without radical social change to abolish the conditions that give rise to it. You may find this an odd belief but it has a lineage. A recent book by the medical historian Lucas Richert, Break on Through: Radical Psychiatry and the American Counterculture, documents the rise of an “anti-psychiatry” movement in the 1970s that accused mental health professionals of being complicit in the military-industrial complex.
You can find an echo of this in claims that the individualistic ethos of market economies spreads mental disorder and makes people ill. I’ve even come across the charge that depression is a tool wielded by the forces of political reaction in order to suppress dissent and enforce control of a compliant population. This has been argued, for example, by Laurie Penny in the New Statesman: “There’s a reason depression and its precarious cousin, anxiety, are the dominant political modes of late capitalism. This is how you’re supposed to feel.” Unfortunately she conspicuously refrains from identifying anyone who has ever made such a case, and I conclude that no such source exists.
The truth is more prosaic. Depressive disorder is real and widespread but it’s treatable even under the political modes of late capitalism. What this requires is good science. There are effective, clinically validated treatments that are far removed from the open-ended groping for meaning operated by psychotherapists (an occupation that, unlike the rigorous disciplines of psychiatry and clinical psychology, requires absolutely no specialist knowledge or training).
An approach devised in the 1960s by Aaron Beck, an American psychiatrist, known as cognitive-behavioural therapy (CBT) stresses that clinical depression can be caused by distorted thinking. A stressful event, such as bereavement or the breakup of an important relationship, can stimulate a self-reinforcing chain of negative thoughts and stress.
CBT works to correct these disorders of thought. It is cheap for the health service to provide and has a record of success. Deploying it, and allied approaches such as what’s known as compassion-focused therapy, will help people cope with this pandemic and its aftermath. Just as the tools of economic policy are available to navigate this crisis, so are the methods of mental health professionals. With luck, they will become better known and more widely applied.
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