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From Irish Marxist Review, Vol. 6 No. 19, November 2017, pp. 62–67.
Copyright © Irish Marxist Review.
The links have been checked and modified where necessary (December 2021).
A PDF of this article is available here.
Transcribed & marked up by Einde O’Callaghan for the ETOL.
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My mom calls me up every couple of weeks to tell |
Over the last 15 years or so, there has been a significant rise in awareness about issues of mental health. Campaigns such as the Green Ribbon campaign, ‘Darkness into Light’ and ‘Walk in My Shoes’ as well as celebrities like Bressie speaking about their own difficulties have made a significant impact in promoting discussion about depression, suicide, anxiety, and other ‘mental illnesses’, for want of a better term. A conversation around mental health has opened up and those who are suffering can speak about their problems now in a way that would have been impossible in the past. Although there is still some stigma around the issue, people can seek help in the knowledge that there will be people who will understand and support them when they do so. This is undoubtedly a positive thing.
However, although mental illness is becoming destigmatised, the primary aim of many of these campaigns appears to be to promote conversation and awareness, with little effort to provide or demand viable solutions. People are encouraged to ‘just talk’, told not to ‘suffer in silence’, and that people are there to listen to them. For somebody suffering from depression, talking can be comforting and may provide some relief from severe mental distress. Of course, we need to talk, but can disclosure and destigmatisation alone solve the problem? Despite the improved conversation, very little is changing in terms of tackling the root causes of mental illness or providing adequate services to those who require them.
One reason that there has been an increased drive to raise awareness of mental health is that the issue has become impossible to ignore in recent years. Recent data from the OECD found that Ireland had the second highest rate of 25–64 year-olds reporting depression in a survey of 25 European countries [1], and that the country also has the fourth highest rate of teen suicide in the EU. [2] Provisional figures indicate that the number of suicides among the general population has fallen in the last number of years, with 399 deaths in 2016, down from 451 in 2015 and 554 in 2011. [3] However, these numbers remain high, and the timespan is too short to indicate any kind of long term downward trend in the suicide rate.
Moreover, a closer look at the demographic and geographical data indicates that socio-economic factors such as unemployment, deprivation and education are significant predictors of mental illness and suicide rates. For example, in 2013, unemployed people accounted for 21.2% of all suicides, whereas the unemployment average was 12.9%. The figures in 2012 were similar, with 20% of suicides among the unemployed, while the unemployment average was 14.6%. [4] An OECD study found that 23% of 25–64 year olds with a Leaving Certificate education or lower suffered from depression, compared to 9% of those with a 3rd level education. Some of this discrepancy may well be explained by the pay gap between those with a higher-level education and those without, a gap that is higher in Ireland than most other OECD countries. [5]
In addition, a major study of suicide last year examined the association between suicide rates and deprivation, social fragmentation, and population density on a small area scale. It was found that deprivation was the highest predictor of suicide, with rates in the bottom 20% over twice as high as those in the top 20%. [6] Area level deprivation has previously been found to be the strongest predictor of self-harm. [7] Social fragmentation was also associated with risk of suicide, particularly among middle-aged people. In addition, men in rural areas were also at an increased risk of suicide, with male rates of suicide found to be 50% lower in urban areas than in rural areas. [8]
All this data prompts the question – is merely ‘having a conversation’ going to solve the root causes of mental illness? Talking might serve as a temporary pressure valve and help a person feel less isolated, but what happens when they return to a precarious housing situation, to the struggle to feed their children, or when they remain unemployed or in job instability? 2015 figures show that 25.5% of the population in the South are experiencing enforced deprivation, 8.7% live in consistent poverty, and a further 16.9% are at risk of poverty. [9] More than 8,000 people are homeless and many more are at risk of losing their homes. A survey of clients who were in mortgage arrears by the Irish Mortgage Holders Association found that 31% had had suicidal thoughts in the previous month and that 22% had active plans to take their own lives. [10] At present, the advice offered to these people is to contact services such as Samaritans, Console, or Aware. Given the reality that many people are currently facing, these services are vital and can save the lives of people who are at the verge of despair. However, it is inevitable when there are so many people contemplating suicide that some of them will follow through and take their own lives. The only acceptable solution, therefore, is to insist that the right to housing for all supersedes the right of landlords, banks and developers to their profits.
Of course, these kinds of solutions rarely feature in conversations around mental health. There is a marked discrepancy in the amount of time and energy spent on campaigns to increase awareness of the psychological distress that people are experiencing and that spent examining the root causes of mental illness and seeking concrete solutions. Even when we move beyond the first step of disclosure and destigmatisation, the framework for speaking about mental health treatments and resilience-building is extremely narrow.
Although the research generally acknowledges that social factors play a part in mental illness, this does not often reflect itself in treatments, which in the most part focus on the biological or on the psychology of the individual. With regard to biological approaches, the use of medication to treat mental illness is still one of the primary treatments prescribed to people, although this has been increasingly challenged over the years. A full review of the evidence for and against medication is beyond the scope of this article, but I will make a few brief points about this aspect of treatment. The first is that the use of medication to treat psychological problems was until recently justified by the presence of a ‘chemical imbalance’ to the brain, a theory supported by little or no evidence. In recent years, the field of psychiatry has in general disavowed this theory and even denied that it ever existed in the first place. [11] However, there is no doubt that it was promoted for years by prominent psychiatrists and the pharmaceutical industry. Many examples of this are given in a review by the psychologist,
Dr. Philip Hickey, including the following quote in 2001 from Dr. Richard Harding, who was the president of the American Psychological Association at the time:
In the last decade, neuroscience and psychiatric research has begun to unlock the brain’s secrets. We now know that mental illnesses – such as depression or schizophrenia – are not ‘moral weaknesses’ or ‘imagined’ but real diseases caused by abnormalities of brain structure and imbalances of chemicals in the brain.’ [12]
Despite the retreat from this theory in recent years, medication continues to be prescribed as a first line of treatment for problems like schizophrenia and depression. There is growing evidence that these medications are ineffective and may even be harmful. For example, there is evidence to suggest that anti-depressant use is associated with high relapse rates [13] and may also cause increased suicidality. [14] While there may be certain circumstances where medication can be effective, it must be seriously questioned as the go-to treatment for most psychological problems. It should also be noted that there has historically been a political dimension surrounding those who are prescribed medication and those who are not. In the United States, for example, Black men living in a racist police state are more likely to be diagnosed with schizophrenia and essentially medicated into submission when they ‘act out’. Similarly, women are more likely than men to be diagnosed with depression or anxiety and prescribed medication. Some researchers have identified possible biological causes for the discrepancy [15], but a far more plausible explanation may lie in socio-economic causes such as income inequality, abuse, attacks on bodily autonomy and so on. Medicating psychological distress caused by these issues may provide some surface level relief, but will not solve the underlying issues. A striking example of this comes from American psychiatrist Dr. Andy Thomson, who gives an anecdote about a patient who asked for her anti-depressant dosage to be lowered. When he asked if the medication was working for her, she replied that, ‘Yes, they’re working great. I feel so much better. But I’m still married to the same alcoholic son of bitch. It’s just now that he’s tolerable.’ [16]
Once we move beyond the biological model for treating mental illness, there is an array of psychological treatments that are prescribed to people who are experiencing psychological difficulties. Although these methods seek to give a more nuanced explanation for mental illness, the focus is still generally on the individual and on their inability to function adequately in society. For example, the most prevalent psychological treatment for common psychological illnesses such as depression and anxiety is Cognitive Behavioural Therapy (CBT). The principles behind CBT are that people in psychological distress have negative ‘core beliefs’ about themselves that lead to ‘negative automatic thinking’, ‘thought distortions’ and ‘maladaptive behaviours’, which can be tackled by challenging these beliefs and thinking, and helping the person relate differently to the world around them. The onus is therefore on the person in treatment to change how they relate to the world without challenging their environment. If they are struggling to pay their rent, being placed under increased strain by their employer, or experiencing distress due to societal racism or sexism, it is up to them to change their cognitive, behavioural and emotional responses to these issues, with the help of a therapist. Other psychological treatments use different frameworks which tend to require a deeper analysis, but generally take a similar approach in terms of focusing on the individual.
Of course, this criticism does not mean that psychological treatments are useless and ought to be discarded. Many people do benefit from treatment and their learning to manage their lives without experiencing great psychological distress is undoubtedly a positive outcome. However, the lack of any meaningful analysis within therapy of the social conditions people face creates two major problems. Firstly, if the person in therapy cannot overcome their difficulties, the nature of the therapy is such that they may well blame themselves as an individual for ‘failing’ to cure themselves. Secondly, if the person does manage to do well in therapy, it is quite probable that they do so by accepting that they cannot change the world around them, and that they merely continue to ‘cope’ in an oppressive society. Moreover, when this is the dominant view in psychological care, it affects the wider attitude of society towards mental health. People suffering from depression may be more understood and less stigmatised, but they are still considered to be ‘ill’ rather than disillusioned, struggling to make ends meet, isolated, or distressed at the injustices in the world around them. There has also been a particularly pernicious trend in recent years where employers have incorporated psychological treatments such as Mindfulness into the work place. Rather than improve the conditions of workers to better their lives, these techniques are encouraged so that employees can cope with an increasingly stressful work environment and maintain their productivity. You might be at the end of your tether because of long hours, unstable working conditions and low pay, but the bosses need their profits. So, go and meditate and sort yourself out!
What can we do, then, to combat the mental health crisis? The first thing must be to recognise the role of capitalism in creating mental health problems. As Iain Ferguson puts it:
We live in a society that is based not on meeting human needs first (physical needs or emotional needs) but is driven by the need to accumulate profit. So that means people’s needs, whether they’re emotional, sexual or whatever, are repressed, distorted or alienated. That’s really the starting point for understanding mental health. [17]
The most obvious and egregious example of people’s needs being subordinated to profit in Ireland is probably the housing crisis. As previously discussed, this has had a devastating impact on people’s mental health, but it is by no means the only example. The Irish state’s treatment of asylum seekers in maintaining the Direct Provision system has caused tremendous psychological damage to people who have fled war, famine and torture. Depression and mental health problems are five times higher among those in Direct Provision than among the general population. [18] This had the most horrific consequences last year, when a Korean woman hung herself in a Direct Provision centre, leaving behind her 6-year-old son. This is the result of the need of the capitalist state to create racial, ethnic, and religious divisions between people to maintain control.
Outside of these extreme examples of oppression, the atomisation created by the profit-driven system can affect everybody. Karl Marx’s theory that workers’ lack of control over the process and products of their labour leads to alienation and ‘estrangement’ from their labour is ever more relevant today. Peadar O’Grady points out that this concept is not widely spoken about:
While our lack of control over work is arguably the most important social factor in the cause of human misery it is also the most potentially politically explosive and therefore suppressed. It is remarkable how, when financial worries are ranked the most common; and workplace stress is also very common and distressing; and that stressed parents are such an important factor in mediating fear and mental health problems in children; we hear so little of work as the cause of mental illness and distress but often hear of the concern of the effect of mental health problems on someone’s ability to work (it is possible even to view the choice of use of stimulating or sedating drugs as reflecting whether or not there is pressure on a person to go to work or not). [19]
The major cause of workplace stress is the nature of work relations themselves. In a society where democracy and freedom are deemed to be the most important values, it is overlooked that the workplace itself is basically a kind of a mini-dictatorship. Pay, working hours and tasks are all decided by the boss, and any significant challenge to how they wish to run things will usually result in dismissal. Bosses and managers attempt to hide this dynamic by trying to create ‘team spirit’ and a ‘healthy work environment’, but this is often undermined by the nature of the system itself. To compete with other capitalists and maintain their profits, they are often forced to cut wages, make people work longer hours and remove other benefits. All of this creates feelings of alienation in the worker, whose activity, as Marx puts it, ceases to be, ‘his spontaneous activity. It belongs to another. It is a loss of his self’. [20]
How can workers and oppressed people overcome the alienation created by the profit-driven system? A by-product of the system is that capitalism drives workers together in ever larger numbers. As bosses seek to increase their profits, they require increasing numbers of workers to produce commodities, whether through physical or intellectual labour. This in turn means that workers increasingly organise, co-operate and develop solidarity with one another in and around the workplace. Class consciousness and struggle can develop in situations where wages and working conditions come under attack from the capitalist class. Struggles can also develop in areas that are not strictly related to work relations, such as women’s rights, anti-racism, and housing. This kind of solidarity and unity in campaigns must be fostered in order to fight for a better society. In the intermediate term, the focus should be on winning reforms in areas that will better the lives of the many: mental health services and health care for those who require them, housing for all, employment, better wages, public transport and services, particularly in rural areas, an end to Direct Provision, and equality for women. The eventual goal must be the abolition of the class system and the creation of a society that requires ‘from each according to his ability’, and gives ‘to each according to his need’.
1. Natasha Salmon, Britain is one of the most depressed nations in the Western world, Independent, 14 September 2017.
2. Elaine Edwards, Ireland has fourth highest rate of teen suicide in Europe, Irish Times, 6 September 2016.
3. Denise Calnan, Ireland’s suicide rate has stabilised since recession – report, Independent.ie, 27 September 2017.
4. Ken Foxe, Suicide – The Figures, RTÉ, 9 March 2015.
5. Niall Murray, Irish ‘most likely to be depressed if uneducated’, Irish Examiner, 13 September 2017.
6. O’Farrell, I.B., Corcoran, P. and Perry, I.J., 2016. The area level association between suicide, deprivation, social fragmentation and population density in the Republic of Ireland: a national study. Social psychiatry and psychiatric epidemiology, 51(6), pp. 839–847.
7. O’Farrell, I.B., Corcoran, P. and Perry, I.J., 2014. Characteristics of small areas with high rates of hospital-treated self-harm: deprived, fragmented and urban or just close to hospital? A national registry study, J. Epidemiol Community Health, pp. jech-2014.
8. O’Farrell, Corcoran, & Perry (2016), op. cit.
9. Survey on Income and Living Conditions (SILC) – 2015 results, Central Statistics Office, 1 Febrary 2017.
10. Many people in mortgage arrears are contemplating suicide, theJournal.ie, 20 March 2016.
11. http://psychologytoday.com/blog/mental-illness-metaphor/201709/the-myth-the-chemical-imbalance. [No longer available online]
12. Philip Hickey, Psychiatry DID Promote the Chemical Imbalance Theory, Mad in America, 6 June 2014.
13. Andrews, P.W., Kornstein, S.G., Halberstadt, L.J., Gardner, C.O. and Neale, M.C., 2011, Blue again: perturbational effects of antidepressants suggest monoaminergic homeostasis in major depression, Frontiers in psychology.
[14] Nischal, A., Tripathi, A., Nischal, A. and Trivedi, J.K., 2012, Suicide and antidepressants: what current evidence indicates, Mens sana monographs, 10(1), p. 33.
15. Albert, P.R., 2015. Why is depression more prevalent in women?, Journal of psychiatry & neuroscience: JPN, 40(4), p. 219.
16. Depression’s Upside, New York Times Magazine, 28 February 2010.
17. Iain Ferguson, Interview: Marxism and Mental Distress, Socialist Review, November 2017.
18. Lives in Limbo, Irish Times, August 2014.
19. O’Grady, P., 2014. Stop making sense: Alienation and mental health, Irish Marxist Review, 3(11), pp. 36–47.
20. Ibid.
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