A Wider Paradigm for Meeting the Global Challenges of Mental Ill-health
5th April, 2020
In September 2020, Zinc will launch a new mental health academy bringing together passionate individuals from diverse backgrounds who are frustrated by the unacceptable levels of mental ill-health they see around them locally, nationally and globally.
As society becomes more advanced and complex, and as quality of life, by some measures, increases for some, we are more aware that these developments appear to be paralleled by: an increase in stress, distress, inequality and dislocation; distressed children and adolescents; mid-life despair; isolated and neglected older people; overwhelmed staff; populations ground down by poverty; increasing deaths of despair; and many more suffering the effects of trauma, discrimination, erosion of human rights, and exclusion.
For a few years now there has been an increasing awareness that mental ill-health is ubiquitous and has many downstream health and social consequences - and that we should be more prepared to deal with it. It is too soon to know whether the tide has turned but my suspicion is that it has not.
Things are changing but progress is inhibited by the language of disorder.
I believe this is because progress is systematically inhibited as we are still rooted in the language of disorder. We are thus failing to appreciate the complexity of underlying determinants of ill-health and health at both an individual and population level.
This biomedical framing in turn sends the implicit message - at the level of the individual - that suffering is disordered and that the responsibility of recovery is that of medical systems.
At the population level it has perpetuated stigma by dividing us into those who are sick or ‘disordered’ and those who are not. I believe that this has been a grave mistake and has impeded any real progress.
How did this happen?
Early discoveries in medicine and psychiatry led to a century of fruitless monocausal (or single cause) theories.
When I started medical school in 1996 the serotonin theory of depression was just cresting. The idea had a certain attraction and some utility. Among other things it absolved people of blame for their condition - a positive move. But this and other movements to medicalise stress and distress had a secondary effect of absolving governments, corporations, educational institutions, and employers of the responsibility for safeguarding the health of those under their influence.
If these were diseases, then the culprits must be genes and haywire brain chemicals. Tom Insel oversaw the resulting research movement at The National Institute of Mental Health in the US and subsequently reflected: “I spent 13 years at NIMH really pushing on the neuroscience and genetics of mental disorders, and when I look back on that I realize that while I think I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs—I think $20 billion—I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness”.
How should we view Mental Ill-health?
The labels we use provide virtually no explanatory information. They provide only the false sense that one has captured something discrete and understandable. At worst they are a scapegoat for toxic contexts and serve only to absolve responsible individuals, systems, and organisations of their responsibility for safeguarding the welfare of those under their influence.
One of the core principles of the Stevenson/Farmer "Thriving at Work" review of mental health and employers is: “Provide employees with good working conditions and ensure they have a healthy work life balance and opportunities for development.”. Without the recognition that unhealthy systems produce unhealthy people, any discussion of ‘mental health’ is window dressing.
Whose responsibility is this and what is the way forward? Understanding systems, complexity, and underlying processes.
Society needs a new approach to the rising tide of mental ill-health. We should emphasise underlying contexts and processes rather than emphasising disorders. Processes and mechanisms both of the development of illness and of recovery and change. Around the world now there is a small but growing community of clinicians, researchers and others who are doing just this.
Understanding and alleviating mental ill-health requires great skill and empathy. Not only at any given moment is it necessary to understand scores of interacting frameworks for understanding mental ill-health - but it is also necessary to be able to zoom out and zoom in to capture the necessarily scale-dependant nature of these problems.
One must be able to speak to an individual and understand their problems at a given moment in terms of predominantly beliefs and personal schemas, or cognitive styles - while also being able to zoom out and see a population's problems as predominantly a consequence of inequality, economic adversity, wider social and cultural determinants and discrimination.
Psychotherapy research has historically been separated by school of psychotherapy rather than focusing on common mechanisms. Each school views distress only through its own lens. Examining mental health by looking through only one of these lenses will frustrate any attempt to effect change.
I believe that if we embed in people, in our communities and in our institutions an understanding of temperament - or personality, of individuals’ strengths, as well as: their vulnerabilities; the effects of trauma, abuse, and neglect, habits and behaviour change, thinking styles and rumination, good nutrition, sleep, and physical activity, chronic stress and inflammation. Plus, the importance of: meaning, purpose, connection and belonging; the power of personal narrative to thwart and to elevate; the difference between the experience of individuals and the experience of populations; the systems and other contexts in which people reside - such as families, communities, the workplace, and society at large; the experience of abuses of power, inequality and poverty; and yes - disease processes, we will go a long way towards helping people to recover and thrive.
We must acknowledge that modern society is unhealthy in many ways. And that it is therefore society’s - that is, our - responsibility to countervail this unhealthy effect, through widespread education and support.
Passionate and motivated individuals need to be trained, supported, and empowered to understand mental health and ill-health and know how and when to take action.
The moon-shot goal of The Zinc Mental Health Academy is to use the extensive body of knowledge of things that do work to prevent and alleviate mental ill-health, to empower people to implement and scale these solutions in their institutions, their workplaces, communities and wider society, and to identify and scale novel solutions. We need people from every walk of life to help us achieve this. After all, there is no conceivable realm of human experience or endeavour that is not by definition both affected by, and a component of, mental health.
Get in touch at email@example.com if you want to join us on this mission. The Zinc Academy will accelerate the impact of those individuals who want to contribute other system-level solutions. It’s a place for changemakers who are passionate about making progress on complex problems. The first Academy programme starts in September 2020.
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Dr Iain Jordan is a Consultant in Psychological Medicine in Oxford University Hospitals NHSFT, Chief Medical Officer of Betterspace, and Chief Scientist at Wakey! He specialises in treating people with complex physical and psychological ill-health. His main area of interest is using lifestyle change to improve wellbeing and prevent mental health problems. He is also interested in making psychological strategies and therapy more available to everyone. He spends his spare time building bicycles to improve his own wellbeing