Are we talking ourselves into a mental health crisis?
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The stiff upper lip is not what it used to be. In 1920, the average Briton’s emotional stoicism was so famed that, when Alexander Vasilyevich Kolchak – admiral, polar explorer and, since 1918, supreme ruler of Russia – was captured by revolutionaries, the official account of his execution approvingly noted that he died “like an Englishman”.
Britain has changed a lot since then. We now rank among Europe’s most adept at talking about our feelings and mental health. NHS officials have spent the last decade discussing the need for “parity of esteem” between mental and physical health; celebrities and politicians alike urge us to speak out rather than bottle things up.
In many ways, this effort has been a huge success. “People are realising they don’t need to suffer in silence”, says Vicki Nash, associate director of social change at the charity Mind, “and that they can seek help”.
The question is whether it’s making us healthier. All of this talking about Britain’s mental health doesn’t seem to have improved it; mental health services are overwhelmed, with a backlog of 1.2 million people waiting for treatment. The number of patients receiving antidepressants has risen by nearly 2 million since 2015, while the share of adults reporting “common mental disorders” has marched steadily upwards, from 15 per cent in 1993 to 19 per cent in 2014, followed by a record number of mental health referrals last year, up 22 per cent on 2019.
Earlier this month, it was reported that Department of Work and Pensions forecasts predict that, as a result of mental health problems, two million more people will be claiming disability benefits by the end of the decade, up from 5.5 million to 7.6 million, about one in nine of the population. Spending on disability benefits is due to rise by £17 billion a year, to £48 billion in current prices.
It’s hard to shake the impression that while Britain is a more emotionally literate country than it used to be, it may also be a sicker one.
Shattered stigma
The campaign to normalise discussing mental health was a truly worthy one, with roots deep into the last century. Originally seen as something almost taboo, with patients treated in institutions out of the public eye, mental health slowly shifted into a topic of national policy discussion. Mounting criticism of institutional care led in the 1980s to a policy of “care in the community”, and a shift in the emphasis of funding.
A new treatment model did not mean an end to the sense of stigma, however, and over the last decade campaign groups and parliamentarians have worked tirelessly to push the issue up the political agenda, securing additional funding, and launching campaigns to get Brits talking to each other about their feelings.
The “Heads Together” campaign backed by the Prince and Princess of Wales, alongside the Duke of Sussex, is an excellent example. Launched in 2016, the trio filmed the two princes discussing how they had bottled up their emotions about the death of Princess Diana, launched a 24/7 mental health texting service, urged celebrities to speak openly to “shatter the stigma” of discussing the topic, and even had the FA Cup final renamed after the initiative.
Together with the work of others, these efforts have resulted in a remarkable change. Britons are now admirably aware of the complexities of mental health conditions, topping a list of 29 countries when it comes to understanding mental illness as an illness like any other, and being the second least likely to view it as disqualifying for public office. The question is whether this has been an entirely positive thing. There are, after all, trade-offs everywhere in life.
Sir Simon Wessely is regius professor of psychiatry at King’s College London and a member of the NHS England Board. As he puts it, “the rate of defined disorders has not changed for 50-60 years. The rates of schizophrenia, bipolar, you name it – they’re the same. Autism rose because we changed the definition. The rates of everything else have remained stable, with one exception. For the first time, we’ve seen a significant rise in anxiety and depression in young women aged 16-24 across OECD countries.” But the overwhelming majority of young people of both genders are not experiencing mental health disorders.
What’s more, in surveys of workplaces and straw polls of students, “every time, two thirds put their hands up [when asked if they had a mental health issue]. Any time any occupation gets a survey, you find high rates of people with mental health problems, sometimes remarkably high rates”. So where has this rise come from?
Unintended consequences
Dr Lucy Foulkes is a research fellow in the department of experimental psychology at the University of Oxford, and the author of What Mental Illness Really Is… (and what it isn’t). Her research suggests that talking about mental health can backfire in unexpected ways.
The joint rise in conversations about mental health and mental health conditions may not purely be a matter of people better understanding their own health, and seeking the support they were always entitled to.
Britain’s policy of deinstitutionalisation was driven by concerns that institutional treatment was damaging; the cure was, if not worse than the disease, harmful in its own way. It is now increasingly clear that talking about mental health too may not be an unalloyed good. As the population becomes more aware of the symptoms of mental health conditions, we may be beginning to see people interpret their experiences and emotions through this lens.
In turn, they may begin to behave in ways that exacerbate their real, underlying symptoms. Someone with low levels of anxiety, for instance, may decide to avoid things that trigger their anxiety, and in turn become increasingly sensitive to them.
“If you tell people that disorders are really prevalent, they’re more likely to interpret their own symptoms in that way”, says Foulkes. “When people self-identify as having depression, that predicts worse coping with their mental health, over and above what you’d predict from their level of symptoms. It could ultimately be self-fulfilling.”
Phrased in this way, talking about mental health sounds like the opposite of effective therapy. As Foulkes puts it, when it comes to cognitive behavioural therapy, a key element is “doing things that you don’t want to do”, because “once you’ve done it, it makes you feel better. For anxiety, it’s about testing yourself, doing things that make you anxious. Because that’s how you learn things aren’t as bad as you thought they’d be.” In other words, precisely the reverse of what those catastrophising their own symptoms appear to be doing.
The result is that this can lead to a worsening of mental health, increasing the rates of illness – and intensifying efforts on the part of well-meaning people to spread awareness in a vicious circle of what’s known as “prevalence inflation”.
A different, but potentially related process plays out online. A paper published earlier this year in the journal Comprehensive Psychiatry examined social media as a potential “spread vector” for tic-like behaviours and identity disorders in young people that differed significantly from classical psychiatric symptoms. The conclusions drawn by the authors were startling: it appeared that some young people were seeking attention or acceptance within an online community by assuming an identity associated with a mental disorder, rather than genuinely experiencing symptoms.
For anyone who’s been a teenager on the internet – or at least spent time with younger relatives – this will all sound dreadfully familiar. The desire to stand out, garner attention or find a group of like-minded people is extremely powerful in teenagers and children, and it’s difficult to avoid the conclusion that giving young people the language of mental health to talk about their feelings and emotions may have contributed.
Sir Iain Duncan Smith, a former secretary of state for work and pensions, believes that this is a warning sign. In his words: “We’re building up a massive problem with the young.” Social media, and smartphones, are proving “incredibly damaging”, and at least one policy priority should be “finding ways to tell parents to get their kids off social media”.
Both this trend and the different phenomenon of prevalence inflation take as their root people adopting new language to talk about emotions and feelings. In Sir Simon’s view, “the phrase ‘mental health’ is the new thing on the block. It’s not that in other times people never talked about their emotions; you only need to read classical poetry to know that they did. They just didn’t use the language we use now... Until the end of the 20th century, ‘trauma’ meant physical trauma. Most people now use it for emotional trauma. And that is new.”
This medicalisation of normal emotions and feelings is not harmless. As Dr Foulkes puts it, too often we find that mental health advice is ”making teenagers think they have a problem without giving them the necessary tools to manage them… You leave them with this framework and language for understanding distress that’s very psychiatric and medical, but isn’t helpful in understanding their problems.” By encouraging people to see things “through the lens of a medical illness”, we may encourage “a sense that they can’t do anything about it; it’s fixed and can’t be changed”.
Sir Simon has similar concerns. He believes we risk “over professionalising or medicalising disorders that are not really the business of doctors and GPs, and taking them away from those whose business it is – your employer, your university and so on.” In his view, many people identifying as having mental health conditions are actually experiencing natural responses to their circumstances; stress at work, stress over exams, loneliness, debt, climate change, homesickness and so on.
This is not without costs. “We have to be very careful that we don’t waste our money in areas where it frankly won’t do much good. If universities genuinely had these rates of disorders, they’d have to employ the world’s population of counsellors. But doing so would take them away from the serious conditions where we do have interventions that are modestly effective.” Worse still, “if you give the wrong intervention to the wrong person at the wrong time, it can do harm. And that’s not just psychiatric drugs, but even talking therapy.”
Our drive to spread awareness of mental health may be backfiring in unexpected ways; not only is it increasing the numbers presenting with mental health conditions, it may genuinely be making us sicker. And it is also not cheap.
Benefits system
As any economist will tell you, people respond to incentives. Britain’s mental health revolution hasn’t just been a medical one; it’s also played out across the benefits system. In 1992, some 2 per cent of working age adults claimed disability benefits. Last year, that number reached 6 per cent. The rise is mostly down to an increase in claims for mental health conditions, which are now the main disability cited by 44 per cent of claimants.
Some of this increase may be the result of genuine stress and anxiety experienced following a worldwide pandemic, and soaring inflation. But there have also been strong financial incentives for people to shift their claims.
Tom Waters is head of income, work and welfare at the Institute for Fiscal Studies. As he tells it, this rise has taken place over decades, leaving us in a state where “the Government is spending more and more on these benefits without any particularly clear sign of any reduction, really. And it hasn’t really made any efforts to try to reduce spend.”
The figures are truly jaw-dropping. Personal Independence Payments (PIP), formerly known as the Disability Living Allowance, currently costs the Government around £22 billion each year, with around 38 per cent of this spend going on cases related to mental health issues. In addition to the up-front bill, there is the lost tax revenue, and the lost productive capacity in the economy; of the 2.6 million people economically inactive due to long-term sickness, over half report depression, bad nerves or anxiety.
The golden rule of economics is that people respond to the incentives you give them. And at the same time that Britain was busily encouraging its population to talk about its mental health, the government was making a series of changes to the welfare system that made using that knowledge to claim disability benefits significantly more attractive.
While a series of cuts were made to the welfare system after 2010, “that hasn’t really been true for the disability system, and certainly for PIP,” Waters says. This means that “the relative value of getting on PIP has increased; it’s more of an economically rational thing to do when proportionately it will make up more of your income.”
This incentive may well have been strengthened by attempts to get people into employment; “if you’re on standard out-of-work benefits, you’re usually required to look for work,” Waters points out. “We have good evidence that that sort of tightening encourages people to apply for health-related benefits that don’t have work requirements associated with them.”
Where do we go from here?
Although well-meaning, Britain appears to have got itself into a muddle. Our efforts to talk more about mental health have had significant positive results, with our population more literate, more tolerant and better able to seek help. At the same time, we appear to be misdiagnosing everyday stresses as mental health issues, overcrowding services, directing people towards treatments that aren’t appropriate for them, and running up a huge benefits bill in the process.
How do we go about fixing this mess? Vicki Nash disagrees that “talking about mental health is damaging to people”. Instead, we’ve reached “an uncomfortable realisation that our mental health system can only support a fraction of those who need help… in no other health condition would we accept the fact that three quarters of people will never get treatment”. This will require “better investment in services”. Changes to the benefits system, meanwhile, are “brazenly motivated by a desire to save money, driven by baseless assumptions about disabled people”.
As Foulkes puts it, the idea that talking about mental health can leave people worse off “is a possibility that we need to take more seriously”, but also one we need to be “very careful about”; there’s a risk that we undo the good work of the last two decades, and end up with “no one being believed”.
So how do we strike a balance between recalibrating our view of mental health, and making sure people who need support receive it? Sir Simon believes that part of the solution lies in the people around us. When in a bad place, “you activate your own social networks, and if you do want to see someone, you see your GP or your padre, and you see someone who already knows you. You talk to your friends, colleagues and your family, and that works for most people most of the time. We mess that up at our peril. Only when that doesn’t work, or perhaps when we don’t have social networks, should folks like me get involved.”
Alongside this, people in positions of responsibility – managers at work, tutors in universities, school teachers, and so on – should receive some simple training in how to help those they are responsible for to manage their situations. That does not mean spreading awareness; “there’s little evidence that increasing knowledge of mental health issues by itself does any good for the people you look after”, he says. “But giving people skills – then you get a change.”
It may be that this should come alongside efforts to help people with lower level issues into employment. For Tom Waters, disability benefits “do create incentives to leave work and try to get on them, at the same time as providing insurance for those who have health conditions”. There is good evidence that when restrictions are tightened, a “significant fraction” of those who go off benefits do end up in work, but that some do not; those people end up taking a significant hit to their incomes. How we navigate that trade-off is a question for the politicians, rather than the economists.
Attempting to tighten the regime for mental health in particular presents unique challenges; the definition of mental health conditions is reliant on self-reporting. Then again, Foulkes notes, “a lot of physical disorders are reliant on self-report. This is why I dislike the argument that mental health disorders don’t have objective biomarkers but physical ones do – it’s much murkier than that.”
Sir Iain echoes this sentiment. Mental health problems have “replaced the old business of the bad back… a significant number of people are coming out of work for mental health conditions that are anxiety and depression”. What we should be doing is aiming to get them into employment; in his view, and increasingly that of the NHS, “work is a health treatment.” The route to achieving this runs through the benefits system and bringing people into Universal Credit, where there are advisers trained to assist with this.
The Government is making small steps in this direction. Whether it will prove sufficient is a different question; as with the initial drive to discuss our mental health more freely, dealing with the consequences is going to be something we have to work on together. There are fixes to be made to the benefits system, changes for places of work and education to make, funds to be spent on diagnosis and support. Perhaps the most consequential change, however, would be another shift in attitudes – from emphasising greater awareness to distinguishing between normal stresses and mental health conditions, seeking to alleviate the former but recognising that it is the latter alone that need medical treatment.
