This is an excellent commentary on current society's overzealousness of focusing on "mental health" and the false equivalency with mental illness. To build on Foulke's prevalence inflation hypothesis, I might add that the overdiagnosis of certain disorders (e.g., anxiety disorders, depressive disorders, and ADHD) is actually exacerbating stigma for individuals who have the most severe phenotypes of these disorders. Those who have the most severe phenotypes of these disorders will be the most deprived of limited psychiatric resources and also have their diagnosis potentially trivialized. If everyone and their grandmother has ADHD ("if everyone has ADHD, then no one has ADHD"), then the value and meaning of the diagnosis effectively becomes watered down. It may be easy for said diagnoses to be met with a shrug if it seems everyone can get a diagnosis. I have seen this phenomenon in clinical practice, but have yet to come across a term that succinctly describes this. I am curious if you have come across any terms? My best attempt is to call it a "paradoxical stigma due to prevalence inflation."
Maybe! I hadn’t come across this before. I guess labels like bipolar disorder have lost strength over time (compared with, say historical descriptions of manic depression) whereas labels like schizophrenia seem to have relative stability
As a patient I like this shift. Let me explain. The words health/illness, are too binary. We need something between health and illness, neither healthy or ill.
In physical health, we would call it lack of fitness. Someone very obese, or emaciated from starvation, walking with small shuffling steps, is not healthy, not fit, but also not necessarily ill.
That is where I am mentally. Unfit, not ill. Getting an anxiety attack from taking the bus, spending whole weekends in bed. But it is not at the illness level. I am basically functional, I drag my carcass to the office, work, do every second week parenting, and not thinking of any kind of self-harm. It sucks, but it is not serious suffering.
My mind needs to get fitter. Tried a couple of things that did not work, Quiteapin, magnesium, l-theanine, l-tryptophan, GABA. I will have a two month job gap and will try to get back into exercise, surely it will help but somehow I don't feel it will be a 100% fix. I don't even have any anxious or negative thoughts, not consciously.
At any rate, what my mind needs is not the mental equivalent of a hospital, as is the case of true illness, but the mental equivalent of the fitness coach.
BTW merging Asperger Syndrome with autism was a terrible idea. The Sperg is mostly just like being Mr. Spock from Star Trek, quite functional for an engineering job.
Similarly, my kind of not-ill-but-not-healthy depression and anxiety needs to be separated from the clinical one. If that was your point, I agree. But in that case we need both, not either-or, a concept of clinical illness and a concept of lack of health.
Very thoughtful essay. I agree that the emphasis on “hacks” to promote mental health or “strength” or “wellbeing” often leads us back to well worn paths of stigmatization and blame towards those who are sick and suffering. The inability to distinguish categorical differences leads to an attitude of “you must not be trying hard enough”. I think this is true of a lot of chronic illnesses in medicine. The fact remains that as a society we are afraid of mentally ill people and that patients themselves often fear their brains. In my experience this is a very common experience- patients in remission from mood disorders who remain anxious/vigilant about relapse and fundamentally see themselves as damaged or weak because they might get sick again. The narrative of wellness cannot account for these phenomena.
You can see how this narrative of wellness gets hijacked by corporations (delivering wellness programs while not increasing actual insurance benefits for access to clinicians) and school districts (spending money on mindfulness programs instead of funding increased access to afterschool programs or food security).
Mental health and wellness are real things, but they may not be determined by mental events (thinking, talking, reflecting) as much as by material factors like physical health, safety at home and in the community, continuity within social networks, and sleep.
Thanks for this comment. Destigmatisation will always struggle with the fact that for many people (patients, families, carers) severe mental illness IS frightening. For people with mood disorders fearful of destructive relapses and of course in people going through acute psychotic episodes. It is difficult to present such disorders in a sanitised package to the public while being honest about their nature.
Fascinating piece! Particularly the research on the potential negatives of CBT due to attention being drawn to negative emotions. I think this shows how we need to be careful in pushing ahead with interventions with just good intentions (and limited evidence). These interventions put a greater responsibility on the individual to look after their mental health, and we just assume that children how the capacity to engage in this challenging introspection!
As someone who's dealt with anxiety, depression, negative thinking, been in and out of therapy, and read books, I think it's probably better to have more mental health awareness than not.
I also believe, which a lot of pro-"awareness" people refuse to acknowledge out loud, that for a lot of people, talking about their mental health is a really good way to procrastinate on actually working on their mental health.
(For the record, I feel comfortable saying this- because I've recognized this pattern in myself. I would read a lot of things about mental health awareness and openness and destigmatization and feel a warm general glow over myself. But actually addressing negative self-beliefs, examining my own behavior, acknowledging that in the past, I'd behaved negatively in ways I couldn't just wave away at me being depressed...that was scary. It required reflection, and time, and acknowledging that while I'd been anxious and depressed, there were also underlying patterns in the way I lived my life and reacted to it that couldn't just be solved by society being more "aware" of my mental health.
It's true that a journey of a thousand miles begins with a single step. It's also true that just because you take the first step doesn't mean the other thousand miles aren't important.)
Thank you for sharing this experience - I think you've summed up how this is not a straightforward issue. Even within a single person, more awareness can have benefits and downsides.
Do you think we’re over diagnosing these conditions in primary care too? More and more I’m seeing patients in my general practice presenting with bothersome mood symptoms. How would you suggest approaching it on a community health level? It’s not an easy one.
This article hits close to home. My generalised anxiety condition was on the extreme end of the scale, but when talking to clinicians (including some psychiatrists), I never felt like I was able to communicate how severe the condition was. I had no language to describe it - the word "anxiety" had been taken away from me. For many people it has replaced the word "worry". I had a similar experience with my panic attacks (which has come to mean in the popular lexicon "anxiety attack")
The result was it contributed to the persistent downplaying of my symptoms, a lack of urgency in my care, and a fight to get the medications that I needed.
Is the real problem viewing these issues as occuring more on a spectrum -- which can be true even if there is a highly multi-humped distribution -- or the idea that things like mindfulness are a good way to deal with the problem? Seems to me most of the issues here are coming from this polyannish attitude/pseudoscientific psychology that asks us to believe all we need to do is a bit of self-help book style self-care and things get better.
Psychiatrists may need to divide up the space into illnesses to choose the appropriate intervention but from the POV of the individual all that really matters to them is the tradeoffs they face with various treatments not how it's classified.
When it comes to accomodations, the idea that there are some people who have disability and others who don't seems potentially counterproductive. If some people benefit from longer time for a class exam or taking that exam in an environment that's less stressful it shouldn't matter if we call it a disability or not? Ultimately, shouldn't the test be about the costs of accomodations relative to their benefits? Even if the division into normal and mentally ill is a natural kind in medicine that doesn't make it a moral natural kind and trying to do so inevitably leads to all sorts of cheating. Maybe sharp boundaries are sometimes needed but we shouldn't necessarily assume those boundaries have anything to do with the medical boundaries as they ultimately rest on practical tradeoffs.
I'm reminded of Corey Keyes' dual continuum model of mental health and mental illness, which frames the distinction in terms of flourishing and the promotion of well-being.
According to Keyes, several key factors contribute to mental flourishing. These factors encompass various aspects of emotional, psychological, and social well-being:
1. Positive Emotions: Experiencing frequent positive emotions such as joy, gratitude, interest, and love. Positive emotions help build resilience and buffer against stress.
2. Engagement: Being deeply involved in activities that are engaging and absorbing. This can include work, hobbies, or other interests that provide a sense of flow and fulfillment.
3. Relationships: Having strong, supportive relationships with family, friends, and community. Positive social interactions and connections are crucial for emotional support and a sense of belonging.
4. Meaning: Having a sense of purpose and meaning in life. This involves feeling that one's life has direction, significance, and that one’s activities are worthwhile.
5. Achievement: Setting and accomplishing goals, which provides a sense of competence and mastery. Personal growth and the pursuit of excellence in various areas of life contribute to a sense of accomplishment.
6. Vitality: Maintaining physical health and energy through regular exercise, healthy eating, and adequate sleep. Physical well-being is closely linked to mental health.
7. Environmental Mastery: The ability to manage and control one's environment to meet personal needs and preferences. This includes having the resources and skills to handle life's demands effectively.
8. Autonomy: Having a sense of self-determination and independence. Feeling in control of one's actions and decisions is important for psychological well-being.
9. Personal Growth: Continually developing and growing as a person. This includes being open to new experiences, learning, and self-improvement.
10. Positive Self-Perception: Maintaining a positive view of oneself, including self-acceptance and self-esteem. Feeling good about oneself is fundamental to mental well-being.
11. Social Contribution: Feeling that one is contributing to society and that one's actions are valued by others. This can involve volunteer work, helping others, or participating in community activities.
12. Social Integration: Feeling part of a community and experiencing a sense of social belonging and coherence. Strong social networks and community ties support mental health.
These factors interact and reinforce each other, creating a comprehensive framework for understanding and promoting mental flourishing. Keyes' research suggests that fostering these elements in individuals and communities can lead to higher levels of well-being and a flourishing society.
The demands of inpatient work can make it difficult to address these issues deeply with our patients, but they are discussion points in try to incorporate in my work as a nurse.
Thank you for the insightful and thought provoking post!
Dr. David Rettew, a child and adolescent psychiatrist: “Just about everything in mental health is dimensional. It exists on a spectrum. And that doesn’t make our conditions less real, but it does make them more complicated."
This is an excellent commentary on current society's overzealousness of focusing on "mental health" and the false equivalency with mental illness. To build on Foulke's prevalence inflation hypothesis, I might add that the overdiagnosis of certain disorders (e.g., anxiety disorders, depressive disorders, and ADHD) is actually exacerbating stigma for individuals who have the most severe phenotypes of these disorders. Those who have the most severe phenotypes of these disorders will be the most deprived of limited psychiatric resources and also have their diagnosis potentially trivialized. If everyone and their grandmother has ADHD ("if everyone has ADHD, then no one has ADHD"), then the value and meaning of the diagnosis effectively becomes watered down. It may be easy for said diagnoses to be met with a shrug if it seems everyone can get a diagnosis. I have seen this phenomenon in clinical practice, but have yet to come across a term that succinctly describes this. I am curious if you have come across any terms? My best attempt is to call it a "paradoxical stigma due to prevalence inflation."
Thanks for taking the time to share this - I completely agree. It is a real problem and annother unintended consequence of anti stigma campaigns.
I haven’t seen a term that encapsulates it, so maybe you have just invented one!
https://rationalpsychiatry.substack.com/p/the-case-against-mental-health/comment/70143148
Maybe! I hadn’t come across this before. I guess labels like bipolar disorder have lost strength over time (compared with, say historical descriptions of manic depression) whereas labels like schizophrenia seem to have relative stability
As a patient I like this shift. Let me explain. The words health/illness, are too binary. We need something between health and illness, neither healthy or ill.
In physical health, we would call it lack of fitness. Someone very obese, or emaciated from starvation, walking with small shuffling steps, is not healthy, not fit, but also not necessarily ill.
That is where I am mentally. Unfit, not ill. Getting an anxiety attack from taking the bus, spending whole weekends in bed. But it is not at the illness level. I am basically functional, I drag my carcass to the office, work, do every second week parenting, and not thinking of any kind of self-harm. It sucks, but it is not serious suffering.
My mind needs to get fitter. Tried a couple of things that did not work, Quiteapin, magnesium, l-theanine, l-tryptophan, GABA. I will have a two month job gap and will try to get back into exercise, surely it will help but somehow I don't feel it will be a 100% fix. I don't even have any anxious or negative thoughts, not consciously.
At any rate, what my mind needs is not the mental equivalent of a hospital, as is the case of true illness, but the mental equivalent of the fitness coach.
BTW merging Asperger Syndrome with autism was a terrible idea. The Sperg is mostly just like being Mr. Spock from Star Trek, quite functional for an engineering job.
Similarly, my kind of not-ill-but-not-healthy depression and anxiety needs to be separated from the clinical one. If that was your point, I agree. But in that case we need both, not either-or, a concept of clinical illness and a concept of lack of health.
Thanks for sharing your experience and view - this is a well-made point!
Very thoughtful essay. I agree that the emphasis on “hacks” to promote mental health or “strength” or “wellbeing” often leads us back to well worn paths of stigmatization and blame towards those who are sick and suffering. The inability to distinguish categorical differences leads to an attitude of “you must not be trying hard enough”. I think this is true of a lot of chronic illnesses in medicine. The fact remains that as a society we are afraid of mentally ill people and that patients themselves often fear their brains. In my experience this is a very common experience- patients in remission from mood disorders who remain anxious/vigilant about relapse and fundamentally see themselves as damaged or weak because they might get sick again. The narrative of wellness cannot account for these phenomena.
You can see how this narrative of wellness gets hijacked by corporations (delivering wellness programs while not increasing actual insurance benefits for access to clinicians) and school districts (spending money on mindfulness programs instead of funding increased access to afterschool programs or food security).
Mental health and wellness are real things, but they may not be determined by mental events (thinking, talking, reflecting) as much as by material factors like physical health, safety at home and in the community, continuity within social networks, and sleep.
Thanks for this comment. Destigmatisation will always struggle with the fact that for many people (patients, families, carers) severe mental illness IS frightening. For people with mood disorders fearful of destructive relapses and of course in people going through acute psychotic episodes. It is difficult to present such disorders in a sanitised package to the public while being honest about their nature.
Fascinating piece! Particularly the research on the potential negatives of CBT due to attention being drawn to negative emotions. I think this shows how we need to be careful in pushing ahead with interventions with just good intentions (and limited evidence). These interventions put a greater responsibility on the individual to look after their mental health, and we just assume that children how the capacity to engage in this challenging introspection!
Totally agree Jack!
Where can I go to a psychiatry conference to hear thoughts like this? Refreshing!
One of your best
Thanks Pete!
As someone who's dealt with anxiety, depression, negative thinking, been in and out of therapy, and read books, I think it's probably better to have more mental health awareness than not.
I also believe, which a lot of pro-"awareness" people refuse to acknowledge out loud, that for a lot of people, talking about their mental health is a really good way to procrastinate on actually working on their mental health.
Very interesting point!
(For the record, I feel comfortable saying this- because I've recognized this pattern in myself. I would read a lot of things about mental health awareness and openness and destigmatization and feel a warm general glow over myself. But actually addressing negative self-beliefs, examining my own behavior, acknowledging that in the past, I'd behaved negatively in ways I couldn't just wave away at me being depressed...that was scary. It required reflection, and time, and acknowledging that while I'd been anxious and depressed, there were also underlying patterns in the way I lived my life and reacted to it that couldn't just be solved by society being more "aware" of my mental health.
It's true that a journey of a thousand miles begins with a single step. It's also true that just because you take the first step doesn't mean the other thousand miles aren't important.)
Thank you for sharing this experience - I think you've summed up how this is not a straightforward issue. Even within a single person, more awareness can have benefits and downsides.
Do you think we’re over diagnosing these conditions in primary care too? More and more I’m seeing patients in my general practice presenting with bothersome mood symptoms. How would you suggest approaching it on a community health level? It’s not an easy one.
This article hits close to home. My generalised anxiety condition was on the extreme end of the scale, but when talking to clinicians (including some psychiatrists), I never felt like I was able to communicate how severe the condition was. I had no language to describe it - the word "anxiety" had been taken away from me. For many people it has replaced the word "worry". I had a similar experience with my panic attacks (which has come to mean in the popular lexicon "anxiety attack")
The result was it contributed to the persistent downplaying of my symptoms, a lack of urgency in my care, and a fight to get the medications that I needed.
As usual, an excellent article Thomas!
Thanks for sharing this experience. I suspect others with severe OCD or ADHD will have had similar problems, unfortunately.
Is the real problem viewing these issues as occuring more on a spectrum -- which can be true even if there is a highly multi-humped distribution -- or the idea that things like mindfulness are a good way to deal with the problem? Seems to me most of the issues here are coming from this polyannish attitude/pseudoscientific psychology that asks us to believe all we need to do is a bit of self-help book style self-care and things get better.
Psychiatrists may need to divide up the space into illnesses to choose the appropriate intervention but from the POV of the individual all that really matters to them is the tradeoffs they face with various treatments not how it's classified.
When it comes to accomodations, the idea that there are some people who have disability and others who don't seems potentially counterproductive. If some people benefit from longer time for a class exam or taking that exam in an environment that's less stressful it shouldn't matter if we call it a disability or not? Ultimately, shouldn't the test be about the costs of accomodations relative to their benefits? Even if the division into normal and mentally ill is a natural kind in medicine that doesn't make it a moral natural kind and trying to do so inevitably leads to all sorts of cheating. Maybe sharp boundaries are sometimes needed but we shouldn't necessarily assume those boundaries have anything to do with the medical boundaries as they ultimately rest on practical tradeoffs.
I'm reminded of Corey Keyes' dual continuum model of mental health and mental illness, which frames the distinction in terms of flourishing and the promotion of well-being.
According to Keyes, several key factors contribute to mental flourishing. These factors encompass various aspects of emotional, psychological, and social well-being:
1. Positive Emotions: Experiencing frequent positive emotions such as joy, gratitude, interest, and love. Positive emotions help build resilience and buffer against stress.
2. Engagement: Being deeply involved in activities that are engaging and absorbing. This can include work, hobbies, or other interests that provide a sense of flow and fulfillment.
3. Relationships: Having strong, supportive relationships with family, friends, and community. Positive social interactions and connections are crucial for emotional support and a sense of belonging.
4. Meaning: Having a sense of purpose and meaning in life. This involves feeling that one's life has direction, significance, and that one’s activities are worthwhile.
5. Achievement: Setting and accomplishing goals, which provides a sense of competence and mastery. Personal growth and the pursuit of excellence in various areas of life contribute to a sense of accomplishment.
6. Vitality: Maintaining physical health and energy through regular exercise, healthy eating, and adequate sleep. Physical well-being is closely linked to mental health.
7. Environmental Mastery: The ability to manage and control one's environment to meet personal needs and preferences. This includes having the resources and skills to handle life's demands effectively.
8. Autonomy: Having a sense of self-determination and independence. Feeling in control of one's actions and decisions is important for psychological well-being.
9. Personal Growth: Continually developing and growing as a person. This includes being open to new experiences, learning, and self-improvement.
10. Positive Self-Perception: Maintaining a positive view of oneself, including self-acceptance and self-esteem. Feeling good about oneself is fundamental to mental well-being.
11. Social Contribution: Feeling that one is contributing to society and that one's actions are valued by others. This can involve volunteer work, helping others, or participating in community activities.
12. Social Integration: Feeling part of a community and experiencing a sense of social belonging and coherence. Strong social networks and community ties support mental health.
These factors interact and reinforce each other, creating a comprehensive framework for understanding and promoting mental flourishing. Keyes' research suggests that fostering these elements in individuals and communities can lead to higher levels of well-being and a flourishing society.
The demands of inpatient work can make it difficult to address these issues deeply with our patients, but they are discussion points in try to incorporate in my work as a nurse.
Thank you for the insightful and thought provoking post!
And Misery begets Misery. Do what you do do well boy.
Dr. David Rettew, a child and adolescent psychiatrist: “Just about everything in mental health is dimensional. It exists on a spectrum. And that doesn’t make our conditions less real, but it does make them more complicated."
The category versus dimensional debate will continue!