Beyond R U Okay

Dan Reede calls for an end to the depoliticisation of mental health advocacy.

Artwork by Lena Wang

Anyone with Facebook, especially those who have experienced challenges to their mental health, no doubt recalls the wave of awareness that swept people’s newsfeeds in 2016. Blokes of all varieties, even those renowned for their toughness, let down their guard, if only temporarily, to offer insight into their own experience and to encourage their followers to do the same: ‘R U Okay?’, they asked earnestly. But amid the blur of tags and encouraging hand signals, something was lost in the conversation. The awareness that was raised, it seems, was unaware that people other than cis-males experience mental health issues; unthinking of the limitations of mere acceptance; unconscious to the role external circumstances play in generating neuro non-typical patterns of thought. For a movement no doubt spurred on by people with the best of intentions, such inattention seems regrettable.

Increasingly, mental illness is recognised as one of the most significant causes of suffering in our societies. In some respects, we have responded to this crisis admirably: we organise fun runs, we grow our facial hair, we trot therapy dogs through campus, all in support of the mentally ill. And what has come of our efforts? Awareness is at all time highs. Gone are the days, or so we think, when the depressed were typed as lazy, the anxious as cowards, and the schizophrenic as dangerous. Where so many of the world’s problems seem intractable surely, one thinks, we are at least here on promising ground.

As the beneficiary of these efforts I have serious doubts—and not just the kind I take Zoloft for. The awareness-based mental health advocacy which has become so prominent lately is important. In all likelihood it has saved lives. In my view it is also facile, platitudinous, and reductive, insisting on a depoliticised and medically-segregated understanding of mental health which risks missing the point: that despite over 100 years of psychotherapy and countless billions spent on research, the world’s collective mental-health seems to be getting worse. So, though it’s on the tip of our tongues, I think we have cause to wonder: is the current form of advocacy all we think an issue as complex as mental health amounts to, and do we really intend to try and ‘R U Okay’ our way to a solution?

It’s time we re-orient our understanding of the mental-health crisis.

One does not need to scratch far below the surface to uncover the sentimentality of awareness advocacy—embodied as it is in the Facebook hashtag, the Movember moustache and the stump speech. In the face of an enormous diversity of experience it really only offers two broad brush messages: that mental illness is a real phenomenon and that it is something we ought to be sympathetic towards. Whilst these are important points it is unclear what precisely they purport to accomplish. The raising of such a highly abstracted awareness coupled with a one-size-fits-all interpersonal approach (captured so succinctly in that single phrase—‘R U Okay?’) offers little solace to sufferers beyond the vague relief that perhaps they won’t be stigmatised as brutally as they once would have been; that a confessional moment might now be met with a confused but affirming nod instead of overt disgust. In the more cynical analysis, it simply allows the unburdened to discharge their moral obligations through passivity alone.

The point is this. Just as the abstract knowledge of racism does not motivate one to address its various manifestations, sympathy for the mentally ill does not necessarily engender meaningful changes in individual behaviour. This becomes clear once we reflect on the relative absence of campaigns emphasising the practical exigencies of mental health services. Indeed, when all one is armed with are vague sympathies and an open mind, old prejudices are given plenty of room to re-emerge. In my experience, well-meaning people still tend to conceive of all mental-health issues as if they were crude caricatures of a depressive disorder, with suicide being a perpetual risk. This is understandable: our popular discourse is almost exclusively focused on suicide prevention and everyone has, in their own grief, an experiential analogue which allows them to more easily imagine what severe depression must be like. But it’s also harmful.

In framing the discourse around suicide, we have moved towards establishing a binary between being suicidal and being ‘Okay’ which needlessly circumscribes our sympathies. In doing so, we have failed to recognise the chronic nature of most mental health burdens and the should-be obvious danger of treating OCD or PTSD or bulimia as if they were simply strange iterations of suicidal depression. This encourages unwell individuals to play up or misrepresent their symptoms in an embarrassing plea for the basic decency of having their suffering deemed legitimate. On the other hand, it also makes the responsibilities of friends and family seem far more daunting. In this respect, I doubt I am the only one who knows the cruel sting of being sent the Lifeline number by a friend misinterpreting my attempts at sincere dialogue for suicidal ideation.

When popular campaigns do settle on a more coherent image it tends to be a homogenous one: the straight white man with clinical depression who, struggling against a socially conditioned masculinity, is ashamed of perceived emotional weakness. The dynamics of men’s mental health are an important aspect of the broader crisis (as well as an essential part of my own story). Nevertheless it is problematic that they have been deemed the most significant demographic outcome.

Whilst it is true that suicide takes more male lives than female, it goes unspoken that eating disorders have by far the highest morbidity rate (disproportionately affecting women); or that working class men are more likely to commit suicide than upper-middle class ones; or that refugees in Australian detention centres are ten times more likely to commit suicide; or that young Indigenous men have the highest suicide rate in the world. Against this backdrop the heavy emphasis on the broad umbrella of men’s mental health and the concomitant implication that male stoicism is its root evil starts to look quite sinister indeed. What’s more, the oft trumpeted slogan that ‘mental illness does not discriminate’ reveals itself as mere rhetoric. Some groups do suffer more from mental illness—not because they are inherently predisposed, but because the problem is, in many ways, political.

None of this is to say that the awareness we’ve raised isn’t valuable. But when it sets the parameters of our discourse, however, we run the risk of mistaking our rusted cog for the oiled machine. And with estimates that 45 per cent of Australians will suffer from a mental illness at some point in their lives, this would surely be a grievous mistake. We need to start asking why we’ve been so reticent to embrace the complexity, both personal and political, of the mental health crisis, and what we can de to meaningfully improve the lives of those suffering. The answers to these questions begin with overcoming the assumption that mental-illness is a strictly medical phenomenon.

Psychiatry in general, as well as increasing swaths of the public, insists on viewing mental illnesses in the same light as physical ones. Just as you can come down with the flu, so too can you develop a generalised anxiety disorder. This approach, often referred to as the ‘medical model’, conceptualises mental illnesses as discrete disease entities which can be isolated and studied under the microscope. Mental illness, the medical model explains, is caused by and consists in biochemical imbalances in the brain. In this context our discourse seems reasonable. If depression is medical in the sense of cancer, then the public’s capacity to bring about change, in a political sense, is limited. There’s no point in politicising a biochemical issue just as there’s no point in demanding justice from nature itself. But, as the unequal distribution of mental illnesses suggests, there is something political going on.

Even if we accept that disorders like anxiety and depression do represent discrete biochemical pathologies (which some researchers vehemently deny), we are still left with the burning question of why more and more people are suffering from them. Indeed, it’s the sheer ubiquity of disorders like anorexia, anxiety and depression—as well as the inability of psychiatry to stay this trend—which should raise the most cause for concern. So too should the fact that these diseases are disproportionately prevalent among the groups worst off under the status quo: queer people, people of colour, Indigenous people, and refugees. Clearly, socio-political reality plays a role in causing and maintaining mental-illness. Of course, it would be wrong to claim that mental illness is never exclusively the product of random bio-chemical processes. But the insistence on treating human minds in perfect clinical isolation is equally unreasonable. Full-blooded mental health advocacy must focus squarely upon the fundamental role our socio-political reality plays in causing and maintaining mental illness.

The observation that mental health is necessarily bound up with the world is increasingly supported by the research. As clinical psychologist Peter Kinderman notes, “it’s not just that there exist social determinants” but that “they are overwhelmingly important” to our mental health. Indeed, neuroscience is making it clear that the very structures of the brain are, in Allan Schore’s words, “experienced-dependent and influenced by social forces”. Poverty, social isolation, racism, sexism, a lack of housing, and displacement all seem to drastically increase one’s chances of mental anguish, especially when experienced during childhood. What’s more, there appears to be a substantial connection between rising rates of mental-illness and neo-liberal economic policy. Beyond the psychological collateral wrought by cuts to social welfare, researchers such as Sue Gerhardt and Oliver James have argued convincingly that neoliberal capitalism actually rewires the brain, leaving it vulnerable to disordered thinking.

Our minds have never been so bound up with the logic of the free-market and its ideology of self-interest. Caught between enormous global suffering and impending environmental catastrophe, we are encouraged to focus on getting our cut of an ever-diminishing loot, which has become the gauge for individual self-worth. In this endeavour we are promised meritocracy but confront limited economic opportunity, meaningless work, and unaffordable housing, which are then attributed to the lack of personal ambition. In the absence of community and culture, we have only materialism and perverse self-comparison to turn to for consolation. Mental-health has not been made very easy for us to achieve under the status quo, and yet achieve is exactly what we are expected to do. Indeed, as therapist David Smail has noted, neoliberal individualism has found a home in today’s preferred-therapies: if your mental-health doesn’t improve, it’s not because of some external reality, but because you aren’t practicing enough mindfulness, or taking CBT seriously, or reading the right self-help books, or doing the right exercise. While CBT and mindfulness can be hugely helpful (they have been for me), if the problem is understood as socio-political then the insistence of such therapies on learning to better tolerate one’s condition must be seen as a band-aid solution at best.

The upshot of all this is put best by Andrew Samuels: “From a psychological point of view, the world is making people unwell; it follows that, for people to feel better, the world’s situation needs to change.” As one can imagine, neither governments or big pharmaceutical companies have been particularly interested in embracing the perspective of socio-political complicity and the call to action which results from it. For the former, it would be to expose the enormous hypocrisy of emphasising mental health in one breath while supporting offshore detention and neoliberal expansion in the next. For the latter,  it would entail enormous financial losses. Those who thinks this sounds a tad conspiratorial would do well not to forget psychiatry’s history: It is one of asylums and electroshock therapy; of pathologising homosexuality, runaway slaves and ‘hysterical’ women in service of political ends.

For those of us who care deeply about the mental health crisis, however, the socio-political perspective should come as a profound one.  Instead of passively supporting individuals who bear the primary responsibility for their mental-health burdens, the mental-health crisis becomes something that we are all collectively responsible for—social problems, after all, have social solutions. This means recognising the very real opportunity one has to make the lives of people suffering from mental-illness easier: not just by dismantling harmful taboos, but by endeavouring to understand and accommodate the specific dynamics which make living with a mental illness so difficult. More broadly, it means taking a stand against those structures which work to maintain mental suffering: racism, sexism, economic inequality and exploitation. From this perspective ‘men’s mental health’ advocacy requires not just encouraging men to be more open about their experiences, but recognising that the toxic masculinity which makes it hard for them to do so also directly contributes to the psychological burdens women suffer. It means acknowledging the reality of intergenerational trauma experienced by Indigenous peoples and the ongoing role non-Indigenous people play in this. In the last analysis, it means holding politicians and big business accountable when individuals are treated as a means to financial ends.

For people with diagnosed mental illness, a socio-political view of mental health can be initially hard to stomach. There is enormous relief in being correctly diagnosed and, for many, being able to point to their condition as a strictly medical issue is a helpful thing.  In my experience, however, the perspective of social-causation is an ultimately liberating one. It has allowed me to escape the isolation of my own suffering and approach a universalist solidarity. To recognise that one is not to blame for being unable to get better, that blame lies elsewhere, that one’s pain is not the thing which sequesters them from the world, but the very thing that connect them to others—these are truly profound realisations. And with more and more people affected by mental illness, directly or indirectly,  perhaps a fuller understanding of mental-health could be the thing that unites us.