https://consciousnessofsheep.co.uk/2024/04/02/was-i-wrong/

In the early 2000s, I began working for a mental health charity – first as a development worker and later as its director. It was an interesting time insofar as there had been a series of national campaigns to raise awareness of mental illness even though stigma remained a serious problem. I was among the first generation of people to go public about having had depression, at a time when such an admission might end with losing your job (although working within a mental health charity made this far less likely).

In 2002, I was invited to join a government health promotion committee whose role was to assist the minister in balancing the immediate needs of an already over-stretched NHS with the equally important aim of improving general health. In this respect we failed. Despite being presented with data showing that the NHS would be overwhelmed in the 2020s, it proved impossible to escape the political and media clamour to spend the entire health budget on immediate needs… humans seem to be built so as not to understand or respond to future crises before they arrive.

I should explain at this point that the economics of health (at least that part which must be discussed off the record) are brutal. Consider, for example, Wales’s blanket imposition of a 20mph speed limit. Whatever else has been said about it, the outgoing First Minister’s claim that it would reduce costs for the NHS is almost certainly false. Why? Because, messy as they are, road deaths are cheaper than road injuries… for the NHS, involving no more than an ambulance ride straight to the mortuary. While the lower speed limit will cut the number of deaths, this doesn’t mean that the people hit by cars, vans and trucks will get up and walk away. Rather, it means that far more people will need treatment for cuts, bruises, broken bones, and damage to internal organs – with an expensive increase in the numbers requiring surgery and aftercare.

It was perhaps inevitable in the early 2000s, after close to two decades of Tory cuts, that under a Labour government there was pressure from media, the public and especially the pharmaceutical industry, that money should be no object. This was true in mental health, where a new generation of antidepressant drugs were still under licence, and where a lack of mental health promotion had created a potential market of more than 15 million people. But it was also true with cancer, where the potential market was smaller, but the drugs far more expensive – it was around this time that the minister backed down over a decision not to supply a cancer drug which might have provided another six months of life, but cost the equivalent of the annual running cost of a comprehensive school (only later would the QALY – quality-adjusted life-year – rationing system be implemented to provide an objective test of cost versus added years of quality living.

Health promotion, on the other hand, need not be expensive. Indeed, more often than not it was best achieved by getting government to step aside. Britain’s Park Run movement, for example, has done more to improve cardiovascular health than any number of government-run schemes. All government had to do in this case was to allow runners to use public parks. In a similar vein, the Men’s Sheds movement which began in Australia has had a bigger positive impact on male suicide and male depression than anything government has done.

Arrayed against these voluntary, bottom-up movements, however, were key vested interests. It goes without saying that Big Pharma had little time for health promotion – other than the arse covering “advice” on patient leaflets and websites which were primarily concerned with “patient compliance” (i.e., making sure we kept taking the drugs). The various public sector busybodies whose living involves lecturing the rest of us on health and safety and political correctness were always threatened by grassroots groups over which they had no control and to which they could not sell their rip-off “training.” And government itself, of course, was always fearful of that which it did not control. Most surprising – at least at first glance – though, has been hostility from the charities… particularly the large ones whose existence depends upon having the monopoly say over their chosen victim group.

For my part, I maintained then, and I maintain today, that the purpose of a charity should be to make itself redundant – that is, to overcome whatever ill it claims to exist to address. Heart charities, for example, should be helping to improve heart health, and mental health charities should be promoting mental wellbeing. In the modern world, this is likely impossible… the point is that they ought to be working in that direction. But the system works against it. Not least for charities which employ people, because employment law trumps charity law every time – which forces charities into only doing those things which do not inhibit their ability to raise money.

This was most obvious for those charities which took money from Big Pharma. The allegation was that the Pharma sales reps leant on charities to put out messages supporting drug use. But that isn’t really how the system worked. Rather, Big Pharma took their lead from government – which also funded, and funds, a vast number of “charities.” As an example of how the system worked, at a conference in the mid-2000s, I found myself sat next to a senior Department of Health manager who I had earlier argued against. I confronted him, saying “I suppose you would cut the funding of a charity which opposed you like that.” His response was instructive: “Oh no, I’d give them more money than they knew what to do with.” That is, government and Big Pharma sought to create a situation where their respective “charities” were too dependent to oppose them… they didn’t need to tell the charities what to say because the charities already knew.

In mental health, most of the charities jumped out of the Big Pharma frying pan into the Cognitive Behavioural Therapy (CBT) fire – a response which was inevitable following the backlash against SSRI drugs. Since most of the work of the mental health charities up to that point had been in “awareness raising” and lobbying government for more money for mental health services, they had nothing to offer mentally ill people who didn’t want the drugs. And since the only alternative was an already over-subscribed (and expensive) clinical psychology, some kind of halfway house between counselling and psychology was needed. CBT fitted the bill. It falsely promised – and often overstated its results – to cure people in a matter of weeks. And it could be delivered by cheaper, non-graduate therapists for a fraction of the cost of traditional psychology (which is why Tony Blair was keen to promote it).

Oliver James was wrong to call CBT a scam, Many people did, and do, benefit from it (the behavioural elements worked but not the over-emphasised cognitive elements). The problem – rather like with the first SSRIs – is that CBT was sold across mass media as a kind of miracle cure… which it could never be. Mental illness is simply too complex for any one intervention to work for everyone. Indeed, for every intervention it was easy enough to find recipients who claimed to be made worse by it. So that, in the end treatments became a kind of “suck it and see” process, where the best one could say was if it helps keep doing it, and if it doesn’t, then stop.

One of my first acts on becoming a mental health charity development worker had been to conduct research among people affected by depression to find out what helped. Frustratingly – at least to begin with – nothing and no one seemed to help. That is, what worked for one person would make matters worse for someone else. The same went for medical professionals. There was no single profession which stood out, although individual members of those professions did. One person, for example, would speak highly of their GP. Another of their Occupational Therapist. Someone else of their Psychiatric Nurse. But across the surveys, each profession balanced out.

Digging deeper though, a phenomenon observed by Erving Goffman offered an answer. Goffman observed an experiment in which actors were sent into a mental hospital where they played the part of mental patients. The surprising result was that, while the medical staff failed to spot the difference between the actors and the patients, the patients did. The reason concerns personal boundaries – which are usually shot to pieces in mental patients. All of us erect barriers to avoid dealing with things we find unpleasant or difficult. This is especially true of health professionals who have to deal with walking examples of what can go wrong in life. And so, as it were, they play the part of psychiatrists and nurses and OTs in just the same way as the actors in the experiment were playing the part of a patient. And since the real patients were used to being blocked by people playing the part of medical professionals, they could spot the same blocking in the actors.

Why am I telling you this? Because when depressed people pointed to one or other medical professional as having helped, they were not talking about that person’s professional skills. Rather, in every case it was because that person had, as it were, dropped the act and had related to the depressed person as one human to another. And yet, for their own sanity, no professional can do this for everyone – so simply asking professionals to be more human was not a solution.

Nevertheless, a lack of human contact pervades the lives of people with depression. Most often, this is simply because people say and do nothing for fear of saying or doing the wrong thing – that is, making the depression worse – and yet saying and doing nothing is the wrong thing. For the depressed person on the receiving end, it is as if everyone, including closest friends and loved ones, have abandoned them in their proverbial hour of need.

This was a big problem in the workplace too. Early research had shown that losing a job can be the first stage of a journey of despair. Not long after the job – or at least the income derived from it – is gone, then relationships break up, financial problems stack up, and homelessness beckons. But this is the life story which takes place before people arrive on the mental health service waiting list. As one of the GPs I worked with back then put it, “its like were busy pulling drowning people out of the river, but nobody is looking upstream to see why they are falling in.”

This was paramount to patients too. Of all the things they reported would have made life easier, being able to keep their jobs was by far the most important. And again, while a minority claimed that they had been dismissed out of malice, the majority reported that line managers and colleagues simply did not know how to respond… often trying to ignore the problem in the hope it would go away. But again, leaving the individual with mental health problems feeling ignored and ostracised.

Clearly some kind of workplace intervention was required. Unfortunately, the Blair government, in partnership with several American insurance-busting corporations, chose to go down the road of less eligibility for sickness benefits and a focus on forcing people back to work (rather than the likely easier task of keeping them in their old jobs to begin with). And while, at the time, a few of the trade unions showed an interest in preventing job losses to mental illness, there was neither the hours nor the money to change government thinking.

My concern – even before the proverbial hit the fan in 2008 – was that modern living was producing more “common mental health problems” like anxiety and depression, despite their being little will to do anything to prevent it. This meant that the already grim health promotion data which forecast the NHS starting to collapse in the 2020s, was likely too optimistic. Mental illness alone would overwhelm the NHS if everyone who could benefit from treatment were to receive it. Although, even then, it was clear this was a pipe dream – the reality was that millions of people would be defined as “too ill” or “not ill enough” to receive any formal help beyond a sick note and a packet of pills.

Today, across the developed states, we have precisely the mental illness epidemic that I feared back then… and with all of the attendant cost implications. And yet, I still maintain it could have been different if only our institutions had been capable of processing time. In the mid-2000s, I parted company with the other mental health charities in their lobbying for more funds and different treatments because it seemed to me a blind alley. Like every other area of health, the more money thrown at it, the more money it would demand, as there would always be some new and expensive drug or therapy which promised to be the miracle cure.

Instead, I proposed – and set about developing – a two-pronged approach, one prong aimed at public awareness the other about self-management. Central to awareness raising was the Australian Mental Health First Aid training, which has since expanded around the world. My organisation was the first in Wales to run a MHFA course – more than a year before the Welsh Government agreed to fund it – as part of an EU-funded project to improve workplace mental health. If the funding had continued (it didn’t) we had intended to develop a mental health at work award scheme both to raise awareness and to celebrate (and encourage emulation) employers who worked to promote mental wellbeing.

The second – and for me more important – prong was in the development of self-management training and coaching to be delivered by people who had recovered from depression. This was key to the whole approach – not out of some misplaced political correctness, but because trainers and coaches who had lived with depression got around the issue observed by Goffman – they could relate to people with depression because they had been there. And, crucially, the people who they were training or coaching could not dismiss them as not understanding what it is like.
They gave us an award for our efforts, then turned the other way…

The programme itself drew on one of the strengths of the CBT which was being touted as a miracle cure at the time – the idea that people can be “taught to become their own therapist.” The problem with CBT was not so much that it didn’t work, but that it only operated on one part of what it is to be human… cognition. Indeed, in this it was likely symptomatic of a western culture which had placed cognition over and above all other dimensions of humanity. Cognition certainly plays a role in depression, but you have no hope of recovery if that is all you focus on.

Since western approaches to depression were limited, I followed John Kabat-Zinn east. Although I went far beyond mere mindfulness (important though that is). Where Zinn started with the mind, I began with the (much neglected in western culture) body. Consider that there are depression postures which are so ubiquitous that we find them in other apes. You would recognise straight away the posture with the knees pulled up to the chest and the head facing down. And it has its neighbour in the standing position with shoulders hunched forward, head bowed down and, at worse, with hands folded protectively across the chest. In addition to causing physical pain and discomfort, these postures severely restrict breathing – forcing the breath into the upper chest where it encourages the fast, shallow breathing associated with anxiety and panic attacks. Simply encouraging better posture and improving awareness – and control – of breathing turned out to be helpful. You might try this experiment for yourself. Begin by hunching your shoulders and looking down. Now, without changing the posture, raise your eyes and notice how little of your surroundings you can see. Then stretch your shoulders back, raise your head so you are facing straight forward, and notice the difference. Then repeat the process but notice how your breathing changes.

Obviously, I am not suggesting that something as simple as posture and breathing is sufficient to overcoming depression. All I am pointing out is that it is one of those many overlooked elements of being human which is often unhelpful, but which we can all learn to adjust for ourselves. Some things though, proved to be far less amenable to change. These are what I labelled “the quick fixes.” In biochemistry, they would likely be regarded as the product of the dopamine reward system. Although I preferred the way in which several religions explain them as a form of finding meaning – or as I preferred, “filling the god-shaped hole.”

The idea is that somewhere in the descent into depression is a lack of meaning or a sense of anomie (normlessness) – often the result of some sudden, unpleasant and unwanted change of circumstances, such as the death of a loved one, the loss of a job, or the break-up of a relationship. To cope with the feelings this gives rise to, we each reach to things which had helped us to deal with normal anxiety, worry, and stress in the past… things which are often helpful in moderation, but which can be deadly in excess. Note that it is rare for people to develop new “quick fixes.” Rather, they turn to substances and activities they used to use into a form of self-abuse. Someone who drank alcohol, for example, might take to getting seriously drunk day after day after day. Someone who comfort-ate might take to binging. A smoker might go from 10 to 40 cigarettes a day. A coffee drinker might increase their caffeine intake to the point where the heart palpitations which precede panic attacks became inevitable.

Nor were quick fixes limited to substance use. Almost anything you could think of could become a quick fix if it filled that individual’s sense of emptiness. In the course of teaching self-management, we encountered people who would listen to music at volumes seemingly designed to cause permanent harm to their hearing. Others drove cars or motorcycles at speeds far above the legal limit. Casual sex worked for some, masturbating to pornography for others. Even something as apparently healthy as running could be taken to an excess in pursuit of an endorphin hit.

At the very least, overcoming depression requires that we become aware of our personal quick fix behaviours, since these prolong and worsen the depression. The point is not so much to get people to “give up” – as if that is something that would happen quickly – so much as to recognise the harm and to begin thinking of alternative ways of responding to anxiety, worry, and stress. In any case, with the exception of cigarettes – which are harmful in any quantity – most of the quick fixes people use are pleasant and relatively harmless in moderation.

In all of the areas of being human that have to be addressed in overcoming depression, a similar process of identifying those things which cause harm and those things which offer a healthier alternative is followed. We see this, for example, in CBT, where people are taught to become aware of various types of “thought distortion,” such as:

Emotional reasoning – I feel bad, therefore that person or thing must have intended me to feel bad.
Catastrophising – imagining that things will turn out badly and then acting as if this is true.
Mind reading – applying your interpretation of what someone else is thinking.
Negativity – persistently looking on the dark side of life, and
Discounting the positive – mentally blocking out anything good which may happen.

Indeed, modern culture seems to encourage at least some of these distortions… something which may be contributing to the big increase in people developing conditions like anxiety and depression. Although the purpose of CBT was to learn to identify and then moderate these forms of thinking.

CBT itself though, was founded on a wrong observation. Its originators came to believe that “the thought gives rise to the feeling,” and that if a negative thought were swapped for a positive one, a negative emotion or physical feeling would turn into a positive one. While there is some truth to this, human feelings, emotions, and thoughts – having evolved over millions of years – are a little more complicated than that. This led the Dutch partners in the mental wellbeing at work project I was involved in to talk about “the elevator.”

You may have noticed that I have referred to three things which most people assume to be synonymous – anxiety, worry, and stress – as different things… because they are. Colloquially, stress refers to the unconscious adrenaline, fight v flight system. And in this context refers to how you feel physically. How is your breathing? Is it fast or slow? Where is your breath? In your belly, your ribs, or your upper chest? Is your jaw tense? Are you hungry or thirsty? Are your shoulders hunched? Is your neck tight? Notice that these are things that we are generally unaware of unless we stop and check (or if they are so severe that they result in indigestion, a headache, or, in the case of restricted breathing and the rapid heart rate that accompanies it, in panic).

Anxiety is where we have been taught to mistake or conflate feelings (how I am physically) with emotions (how am I with this?). Clearly if someone is in physical discomfort, then they are likely to have accompanying negative emotions. Indeed, this can become fixed in Pavlov’s dog style. Someone who experiences panic attacks in a supermarket or a busy railway station, for example, may come to hate those situations and may go out of their way to avoid them. But of course – and hence the elevator – the emotion may also give rise to a physical response. If, for example, someone says something unpleasant to you, you may well instinctively tense your muscles and clench your jaw. And if you remain in that physical state for long enough, your emotions will likely turn negative too.

The same goes for the relationship between emotion and worry. The latter being the cognitive process which the originators of CBT took to be the cause of the emotional and physical state which follows. Worry, in this sense, is a form of mental rumination in which the same thoughts are churned over – crucially – without resolution. This is very different to the kind of forward planning which we all engage in – where we mull what we want to do and how we are going to do it. Worry often involves catastrophising and seeing things negatively, but without the forward planner’s ability to think of contingencies. Instead, the thought goes around and around and – again, the elevator, changes the emotional and physical state.

From this foundation, it was easy enough to address the various problems common to people experiencing depression, such as disrupted sleep, lethargy, and poor diet. However, it proved essential to understand just how difficult behaviour change is. Consider just how many times you have resolved to make a positive change, only to relapse in a matter of weeks. The last thing someone already in the grip of depression needs is to be set up for failure. What works is to allow people to become aware – which is why mindfulness had such a positive impact – of their thoughts, emotions, physical feelings, and behaviours. As this opens up the possibility of change.

During the time that I taught self-management courses, I found that as participants became more self-aware, they would find their own way to the changes which best suited them. One person, for example, would choose to improve their diet, while another would become more physically active. All that was required was some basic knowledge about how to do this (for example, signposting to a local cookery class or – as existed at the time – an exercise on prescription scheme).

The final element of the self-management programme was what we termed “the slope.” This came from the ancient Greek story of Sisyphus, who was condemned to push a boulder up a slope every day, only to wake up the following morning to discover the boulder had rolled back down during the night. In our analogy, all of the elements of depression talked about above can be rolled up into the boulder – the personal burden that we each must carry through life. The slope, in contrast, refers to the outside world, and it has two key properties – the angle (steep or shallow) and the surface (firm or slippery).

The angle refers to those things which as individuals and even as collectives, we have no agency over. This would include the state of the economy, the political system, and the natural environment. Sure, we might protest, join campaign groups, form political parties, etc., but even these seldom make a difference other than in the most extreme circumstances. Some people are fortunate enough to live in times when the angle is shallow – the period of good harvests in twelfth century Europe, or the brief but far more prosperous post-war (1953 to 1973) years spring to mind.

The surface refers to the institutions within which we live our lives. An institution is not (as is often thought) a large building like a hospital or a bank. Rather, the term “institution” refers to the social relationships between groups of people. Often, institutions have unequal distribution of power and resources. Thus, a hospital is an institution because it is run by a powerful health board, managed by officers and doctors of various rank, and containing relatively powerless patients. Less obvious “institutions” include neighbourhoods, families, and social groups such as ramblers’ clubs—each has its (albeit informal) hierarchy and power dynamic. A healthy institution is one that is nurturing and helps its members realise their full potential as human beings.

The broad point is that in periods of high prosperity and benign social cohesion (shallow and firm slope) even someone with a big and heavy burden can get by. However – as I believe is occurring today – when prosperity retreats, cohesion breaks down, and institutions become dysfunctional (steep and slippery) those with large burdens are left to suffer, while even those with relatively small and light burdens more easily descend into the downward spiral of depression.

I am extremely wary of the emerging establishment media narrative that the current epidemic of mental illness is not real, and that lazy workers are merely using it to dupe unsuspecting medics into signing them on the sick. Not least because this is a mirror image of the stigma that persisted through the 1990s – if you can’t see it, then you’re not really ill… you just need to pull yourself together, etc., ad nauseum. Certainly after two years of the most extreme disruption that was lockdown, followed by the unhinging of the economy for the majority of the workforce, and given that social cohesion had begun to break down long before SARS-CoV-2 popped onto the world stage, we should hardly be surprised that more people are becoming clinically anxious and/or depressed – particularly the young, who have seen their future plans trashed over the past decade or so.

Nevertheless, as many of those who have recovered from depression learn, we only have so much nervous energy to act in the world. And there is little point wasting it trying to change the immutable. Since we cannot alter the angle of the slope, and have only minimal influence on the surface texture, our energy is best spent addressing our personal burdens so that they become as small and as light as possible – and even this is becoming harder as the economy around us disintegrates.

In the years prior to the 2008 crash, I made the case as strongly as I could, that insofar as the end of a universal National Health Service was in sight, the only viable means of dealing with common mental illnesses in future would be through self-management supported by a more general understanding – hopefully leading to a more benign environment – of these conditions. It was an argument I lost. Big Pharma wanted – and got – patents on the final tranche of antidepressant drugs. (Not-quite-as-) Big Psychology persuaded government to expand funding for “talking therapies” in general and CBT in particular. And the big charities grew fat by casting themselves as the champions of yet another supposedly oppressed victim group – with the unwritten belief that people affected by mental illness cannot act or speak for themselves. Nobody at that time was interested in the view that, most people affected by mental illness can speak for themselves and are able to act in their own best interest.

Perhaps the same case can be made for people affected by the host of common medical conditions which are also converging to render a comprehensive NHS, free at the point of delivery, impossible. For the moment, this is being hidden behind a process of quasi-objective rationing. There is more than a suspicion that beyond a certain age, over a certain weight, or suffering from various pre-existing conditions, and you no longer qualify for treatment. In the case of NHS dentistry, even this attempt at legitimacy has disappeared. It is surely only a matter of time before whole swathes of the NHS follow the path of unavailability that dentistry has taken.

In the 1990s, when I carried out research into disaster management – which developed out of war planning at the end of the cold war – I learned something interesting about health plans for a nuclear war. This was that very few consultants and doctors had places in the various fallout shelters. The two medical professions given high priority were vets and nurses. Vets, because the health of the remaining livestock would be critical, and nurses because any injury which couldn’t be patched up or which wouldn’t heal on its own would be a death sentence, so there would be no point wasting resources treating it.

We might hope that as developed industrial economies like the UK unravel due to growing shortages of energy and resources along with an increasing dependence on imports, what remains of the NHS might be scaled back rationally. But hope is always a triumph of optimism over experience. And just as we witnessed corporations – particularly those that donate to the Tories – lining up like pigs at a trough to feed on the Covid currency being ostensibly created to fund essential medical equipment during the pandemic, so we should expect to see the same corporations and vested interests lined up like vultures to feed on the still warm corpse of the dream of universal healthcare.

Some months ago, I talked about some of the issues raised here with a friend who currently works for one of the mental health charities. Was I wrong to pursue self-management in the face of a mental health industry that was going in the opposite direction? Her response was, “you were either 10 years too late or 20 years too early.” That is, had we developed a self-management approach before the first SSRI drugs were patented (older drugs, because of their toxicity were only available under the care of a psychiatrist, and so far less prescribed) instead of GPs handing out prescriptions for mostly ineffective – and sometimes dangerous – pills, they might instead have been referring people to a local self-management programme. On the other hand, if our approach had lasted the ensuing twenty years, and given the obvious failures of the approach taken during that time (we have more mental illness today than ever) then GPs might also have had local self-management programmes at their fingertips.

For better or worse, with the economic base on which the NHS depends visibly breaking down, various versions of self-management are likely to emerge from the grassroots anyway as the only means of addressing those conditions which – like depression – can be mitigated and even overcome without recourse to formal medical treatment… It is only a matter of time.