All In the Mind?
WHAT SHOULD SOCIALISTS think about mental illness? At one level the answer seems obvious and urgent: we should protest against the grotesque underfunding of NHS mental health services. Yet for many left wing activists this political support for mainstream psychiatry sits uncomfortably with a suspicion of medical approaches to mental illness. Is this suspicion justified?
One recent suggestion that it is well justified can be found in Johann Hari's book on depression, Lost Connections, excerpts of which have recently featured in the Guardian. Echoing many left leaning critiques of standard approaches, Hari thinks that regarding depression as an 'illness' like physical diseases, treated primarily with drugs, ignores the human and social factors underlying depression. If we think that the best remedy for depression is chemical, aren't we in danger of forgetting that among its causes might be alienation or patriarchy or abuse or grief?
The left's discomfort on these questions reflect the extremes of a more general theoretical debate over the nature of mental illness. For the so-called biomedical model, mental illness is to be understood as of apiece with physical illness, which in turn is regarded as the malfunctioning of a biological organism. Meanwhile proponents of the social model regard mental illness as the manifestation in individuals' minds of social problems.
Neither model is adequate on its own. Human beings are part of the material world - Marx realised the political importance of this point. We cannot ignore the possibility that biological factors might affect our moods or perceptions of reality, or that chemicals might set them right again. On the other hand, as Marx again insisted against the people he called “vulgar materialists”, we are not just biological organisms. We are social beings, existing in a communal context, constrained or empowered by political structures. A proper understanding of mental illness requires that we take seriously both that we are animals and that we are social creatures.
This kind of holistic approach gets called biopyschosocial and commands broad support on paper. Yet in practice it has become a 'bio-bio-bio' model, with personal and especially social factors being ignored. This feeds into the agenda of those like Hari who seem reluctant to allow biomedicine any place in our understanding or treatment of mental illness.
Hari is wrong, and his position dangerous. Psychiatric medication, for example, has saved numerous lives. Yet the truth in his attack on psychiatry is that too many ignore the role society and politics might have in explaining, and in relieving mental illness. Why is this?
Under-resourcing is a key part of the answer. In a context where serious talk therapies, addressing a patient's life and relationships in any depth, are expensive and scarce, medication or more superficial therapies (CBT, increasingly available online, rather than involving interpersonal interaction) are the only realistic options for clinicians who want the best for their patients but who are constrained financially and in terms of time. This reinforces a view of mental illness as a discrete, individual problem, to be treated with a prescription.
And there's a further, related reason for the retreat to a bio-bio-bio understanding. Mental health professionals cannot, in their clinical capacity, do anything about capitalism or patriarchy, or even, for the most part, about workplace stress or abusive relationships. There is therefore a temptation to bracket them out of consideration when thinking about 'what's going on' with mental illness.
Yet this doesn't show that mental illness is special, or political in a way that so-called physical illness is not. The previous paragraph could have been written about cancers or asthma caused by pollution, about workplace injuries, or about the physical effects of domestic violence. Our health is always a matter of our being animals who exist in a social context, and the division between the physical and the mental here is entirely artificial.
What does this mean in practice? It means that the ongoing attack on health services as part of the austerity agenda can only make things worse, both for those who suffer from mental and physical illness, and for our understanding of these illnesses. Ultimately, though, it means that the conditions which make our lives less fulfilled, more painful, or shorter can only be adequately addressed through a wholesale transformation of the society in which those lives are lived.
The challenge for the left with respect to the politics of mental health is to relate the immediate struggle against cuts to this more all-embracing future vision.