Stigma around mental health problems has significantly improved in the last couple of years. In a recent study, the National Centre of Social Research found that mental health had become a “much more commonly discussed area of life”, something that they said had lead to a cultural shift in the way we think about mental illness. Campaigns like Time To Change have helped, with charities like Mind, Rethink Mental Illness, and the Mental Health Foundation consistently pushing for changes both in policy and in practice.
Celebrities, too, have got in on it; Stephen Fry, Ruby Wax, Professor Green. Added to this the thriving discourse found online and it’s safe to say that mental health is now a firm part of the Cultural Conversation.
"'Mental health' as a concept is quite distinct from mental health as lived experience"
To an extent, my own experiences reflect this. Having just written a book about mental health, I’ve had to talk about it a lot over the past year; when colleagues or people at parties ask me what my book is about I tell them, matter of factly, that it’s about mental illness. Responses have been at worst disinterested. During the making of a doomed TV pilot, I canvassed people in the street about mental illness; rather disappointingly, everybody I asked was eloquent and understanding about the issues, which didn’t make for particularly gripping viewing. To the casual observer, it would seem like stigma is on its way out.
But “mental health” as a concept is quite distinct from mental health as lived experience. The nature of my job means I talk a lot about mental health, but most of the time it’s in a theoretical sense. I deal with concepts and ideas – and necessarily so, because lived experience alone just doesn’t cut it when you’re thinking or writing about the topic. That’s not to say that lived experience isn’t important – of course it is. But the ideas I deal with everyday are bigger than the individual, even if that individual is me.
Even therapy, one of the most intimate and personal experiences someone can have, is in part an intellectual exercise. My therapist asks me questions about my motivations and my behaviours and it’s vital that I step back and intellectualise them, at least to a degree. I can’t simply feel the answers to these questions because feeling is so often obfuscating. And as much as I would like to, pathological narcissist that I am, I just can’t inhabit my own mind constantly for fear of going mad or, worse, being incredibly boring.
To a different degree, this is also how the non-mentally ill think about mental health. They understand it conceptually – they’ve watched documentaries or read articles about it, they’re discarded outdated stereotypes about what it means for someone to be “mad” – even if they’ve never actually engaged with it critically. Depression particularly falls under this category; as the primary focus for many mental health campaigns, more and more people seem to be getting to grips with the reality of depression. What hasn’t had such a big PR boost is mania and psychosis. And subsequently, there’s a huge gulf between the way people think about – and the way people treat – these conditions.
If I tell a colleague or friend that I’m feeling depressed, the support is almost unconditional. I get offers to talk, cups of tea made for me even when I don’t ask. Plans are made; trips organised to the cinema or the theatre or a museum. People will come round to my flat to check on me or make me dinner; they text me more. It’s a rather nice side effect of the Time To Talk narrative, even when at my worst the idea of talking seems impossible.
“At the smallest hint that I may be be nearing a manic episode, people seem to disappear”
Not so with mania. At the smallest hint that I may be be nearing a manic episode, people seem to disappear. If I actively voice my concerns it’s even worse. If the subject isn’t swiftly changed – which it often is – conversations often become strained and awkward.
Reaction to psychosis is even worse, even when I’m not currently experiencing it. “I was so depressed I didn’t get out of bed for two weeks” elicits sympathetic nods; “I had a psychotic episode so bad I thought I was dead” or “I have auditory hallucinations when I’m manic” are met with a palpable thud of discomfort. There’s obviously an element of exposure here – around 3 in every 100 people have experienced depression, while figures for psychosis are closer to 4 in every 1,000 people. It’s a big difference. But it’s also about the way we think about mental illness, the way we’ve neatly categorised and filed each manifestation of madness in the cultural imagination.
Depression, as a condition, is rather understated. It’s insidious; it’s subtle. Depression doesn’t take up space; in fact, it does the opposite. It makes things smaller and dimmer; “Depression doesn’t stop you leading your normal life,” says Mind’s guide to depression. “But it makes everything harder to do and seem less worthwhile”. Depression neatly sucks the joy from everything; “markedly diminished interest or pleasure in all, or almost all, activities most of the day nearly every day” is how the DSM-IV(the manual of recognised mental health conditions) puts it. I physically shrink when I’m depressed; like a child who closes their eyes and subsequently thinks that nobody can see them either, it makes me want to disappear completely.
But while depression may be difficult, it also has some basis in reality. The irrational thoughts you may have when you’re depressed (“I would be better off dead” or “I’m worthless”) may not adequately represent anything true or meaningful, but they do at least possess some modicum of rationality. It’s self-loathing taken to the logical extreme.
Psychosis, on the other hand, does not look like anything most people have ever experienced. My last psychotic episode consisted of a dizzying array of absolutely ludicrous delusions; someone had broken into my flat, planted a pair of keys on my coffee table and left, purely to fuck with me. Conveniently forgetting the concept of CCTV, I became convinced that traffic lights secretly held cameras that were monitoring me; in the end, I believed anything round was some kind of nefarious eye. I heard things; a dog told me that he had kidney problems. These are not experiences that most of the population has experienced.
“Psychosis is terrifying: it’s an unknown quantity”
It’s therefore terrifying; it’s an unknown quantity. It can be difficult to empathise with something you haven’t experienced, even harder when it’s something you could barely even imagine. When I recount them people become uncomfortable because they’re scared of them. Psychosis represents the most terrifying extremes of the human mind; it’s the closest thing to cliched literary “madness” you can get. There’s no empathetic affinity here – how could there be? – so sympathy is out of the question. Unlike depression, there’s no attempt to understand; instead, I’m merely placated. We pathologise psychosis in a different way to depression not just because it’s more severe but because it’s inherently unknowable.
It may be a rather uncharitable view, but people just aren’t going to understand psychosis without extended education on the topic. If we’re really going to commit to destigmatising mental illness, then we need to do more than just talk about things we already understand. Valid as that diagnosis is, endlessly talking about depression just serves to exclude and alienate people with less-media friendly conditions.
It may be difficult, awkward and upsetting to go into how and why we need help, or even to explain what we’re feeling, but it’s vital that the conversation on mental health includes a spectrum of experiences. For those who aren’t mentally ill, critical analysis about what we assume about mental illness – and why that is – is vital. If we want our understanding and treatment of mental health to be consistent, we need to be more inclusive and more intellectually curious – and we need our empathy to be a little less shallow.