Ben Hoban is a GP in Exeter.
There is something odd about the way in which we have come to talk about emotional or psychological problems. It has become normal to refer to having mental health as if this were somehow a bad thing. Naturally, we mean a mental health problem, and I don’t mean to be pedantic, but have you ever heard anyone refer in the same way to their physical health? We are used to talking in detail about our bodies and the various ways in which they let us down, but it’s as if we only have a vague sense of how our minds work and don’t quite know what to say when something goes wrong. I have been consulted by some patients who seemed genuinely to lack the words to say more than “I feel s£!t, doctor,” and by others who talk about being depressed, manic, paranoid or psychotic, using these terms loosely in a way that obscures what they are trying to describe.
Similarly, we talk about feeling suicidal as if the word had a fixed and specific meaning. It is certainly meaningful but must be unpacked carefully, like an abandoned suitcase at a train station, or in layers, like a set of matryoshka dolls. Do you ever feel as if it’s getting harder to keep going? Do you sometimes fall asleep thinking you wouldn’t mind if you didn’t wake up again? Are there times when you wonder what it would take to put an end to it all? Have you looked into it seriously? Do you have the stuff you would need? What’s holding you back right now? As with the word literally, usage varies.1 By asking proactively about suicidality, we’ve made it easier to use a word, but harder to know what someone means by it, and perhaps easier to overlook the more subtle indicators of risk. When a measure becomes a target, it often ceases to be a good measure,2 and this applies to words as much as statistics.
By asking proactively about suicidality, we’ve made it easier to use a word, but harder to know what someone means by it, and perhaps easier to overlook the more subtle indicators of risk.
The way we talk about mental ill health can end up creating a linguistic black box which we see but cannot see inside. How then can we know what to expect from our distressed patients, and how best to help them? Are they well served by medical treatment and the sick role,3 or should we try to normalise experiences that to one degree or another are near-universal? There is a danger that well-intentioned interventions may be counter-productive. The use of trigger warnings, for example, has been shown to increase feelings of anxiety and reinforce the idea that past trauma is central to someone’s identity.4
Just as pain is an unpleasant sensation that by and large helps us to navigate life safely, negative emotions have their place too. Sadness is a healthy reaction to loss, fear to threat or uncertainty, anger to injustice, and disgust to the breaking of social norms. These feelings are all physiological in the sense that despite being uncomfortable, they may be appropriate to our circumstances, in which case they are adaptive, allowing us to attract sympathy and help, or motivating and guiding our actions. Mental illness by contrast is pathological in that what we think and feel are incongruent with our situation and have a negative impact on normal function.
Sadness is a healthy reaction to loss, fear to threat or uncertainty, anger to injustice, and disgust to the breaking of social norms.
Chronic situational stress is commoner than mental illness, although it sometimes leads to it. Our emotional responses are entirely appropriate but are nevertheless maladaptive simply because help is unavailable or circumstances are too complex or entrenched for us to be able to change them. Rather than enabling us, our thoughts and feelings wear us down. Stress can be buffered or offset through various coping strategies or forms of support but the source of the problem is located outside our minds, and simply treating our minds cannot fix it.
These are broad brush-strokes which fail to take into account the nuances of both mental illness and normality, but they are an attempt to move beyond simply “having mental health.” Now that we have arrived at a point where it’s considered acceptable to talk about our feelings, it is crucial that we also help our patients find the words with which to express themselves constructively.5 The great danger otherwise is that we blur too much the boundaries between the physiological and the pathological, between mental illness and situational distress, making it harder to know how we can help. We have already made it the norm for people who wouldn’t previously have been considered ill to see themselves in this way, and for this to lead sometimes not to sympathy, understanding or practical support, but rather to medication, personal validation and avoidant behaviour, while those who need our help most have trouble accessing it.6 Mental health is about more than just feeling happy or avoiding psychological discomfort. It is about being able to see oneself and the world clearly, and thinking, feeling and acting in a way that flows from this.
- Have we literally broken the English language?, Martha Gill, The Guardian, Tue 13 Aug 2013 (accessed 10/10/23)
- Wikipedia entry for Goodhart’s Law, accessed 4.10.23
- The Social System, Talcott Parsons, Glencoe, 1951
- Jones, P. J., Bellet, B. W., & McNally, R. J. (2020). Helping or Harming? The Effect of Trigger Warnings on Individuals With Trauma Histories. Clinical Psychological Science, 8(5), 905–917. https://doi.org/10.1177/2167702620921341
- Skills Training Manual for Treating Borderline Personality Disorder, Marsha Linehan, Guilford Publications, 1993
- Arie S. Simon Wessely: “Every time we have a mental health awareness week my spirits sink” BMJ 2017; 358 :j4305 doi:10.1136/bmj.j4305