An influential UK psychologist argues we are increasingly medicalising anxiety and grief and that experiencing negative emotions is a normal part of the human condition. By Eleanor de Jong.
When psychologist Lucy Foulkes reflects on her mental breakdown in her early twenties, she’s amazed that the clear signs of distress were missed by herself and so many around her. It’s unlikely they would have been today, in a society so keenly aware – even preoccupied – with looking for and diagnosing mental-health issues.
Foulkes’ spiral into a severe episode of depression and anxiety saw her temporarily drop out of university, start taking psychiatric medication and begin intensive psychotherapy. The experience was terrifying, she writes in Losing Our Minds, her overview of our knowledge about the causes and nature of the most prevalent mental illnesses. But for her work, it has provided a useful insight into the minds of the mentally ill and the often thin barrier between being sad and clinically unwell.
“I have been interested in mental health for a long time, and I was interested that about 10-12 years ago, there was this explosion in efforts to talk more about it publicly, with campaigns and celebrities admitting to serious illnesses,” says Foulkes, 33, speaking to the Listener from her home in the UK.
“But I felt the more I read in the media and the more things I heard people say in private conversations, the messages they were getting weren’t even necessarily true, especially in terms of facts and statistics. It had gone from famine to feast.”
In the past decade, headlines about the mental-health “epidemic” have become commonplace and successive governments have scrambled with toothless review after intervention after toothless review.
Rates of antidepressant prescriptions have skyrocketed in the Western world, and more people than at any other time in history are self-identifying as mentally ill. Most affiliate with a depression or anxiety diagnosis – what Foulkes describes as the “palatable” mental-health concerns of the modern age.
“I think we have now slightly overshot. In the book, I refer to it as ‘collateral damage’,” she says.
“I think there has been a positive net gain from talking about it, but I think there have been some problematic consequences, too.”
But as the stigma-busting public conversation has grown – buoyed by mental-illness memoirs, the introduction of mental-health pets, mental-health days and the description of mental illness as a “superpower” – so, too, has a creeping scepticism.
“The message now is if you feel something negative, that’s a problem and you need to do something about it straight away,” says Foulkes. “But in terms of normal human pain, many of us will not ever need clinical psychiatric help.”
Foulkes says the co-opting of psychiatric language to describe common emotional pain and experiences – depression to describe sadness, grief or a bad day; anxiety to describe performance nerves; bipolar to describe moodiness; and OCD to describe cleanliness or attention to detail – poses a real risk to those suffering clinical psychiatric disorders, whose anguish may go unheard and untreated amidst the sea of the supposedly “sick”. Take these lyrics from Katy Perry’s Hot N Cold:
“Someone call the doctor
Got a case of a love bipolar
Stuck on a roller coaster
Can’t get off this ride.”
Recently, a New York Times article describing a new – although not officially recognised – form of mental distress went viral: languishing.
Dubbing it the emotional state of 2021, writer Adam Grant, a Wharton psychologist, described it as a low-key depression, an ennui and a lack of spark, interest or zest for life. “Languishing is the neglected middle child of mental health,” he wrote. “It wasn’t burnout – we still had energy. It wasn’t depression – we didn’t feel hopeless. We just felt somewhat joyless and aimless. It turns out there’s a name for that: languishing.
“Languishing is a sense of stagnation and emptiness. It feels as if you’re muddling through your days, looking at your life through a foggy windshield.”
It is this medicalisation of a very normal response to very abnormal circumstances that Foulkes is getting at. It is even more telling that “languishing” has hit a chord around the globe.
Foulkes stresses that raising public awareness of mental-health issues is still needed, but she also sees an urgency for society to “hit pause” on the frenzy and reassess what is true and what is not, what is normal and what may be pathological.
“How do you get yourself heard if everyone is saying they have these problems?” she says. “I am not remotely interested in dismissing anyone’s problems. I think it is right to talk about unhappiness and stress, but my concern is, if you don’t talk about it in the right way, then serious distress is going to be missed.”
A ubiquitous statistic in the Western world, including in mental-health promotions in the UK, US and New Zealand, is that in any given year, one out of every four people will experience a mental illness.
Foulkes questions the validity of this statistic, saying that the majority of mental-health surveys and studies are conducted by non-clinically trained professionals over the telephone or internet and measure rates of self-identified distress rather than a certified diagnosis.
This is important because, if the language someone is reaching for is “anxiety” when what they really mean is “nerves over a final exam”, the rates of clinical anxiety recorded within the community can quickly become inflated.
“Since we’ve started talking publicly about mental health, the language people are using to describe common, transient negative feelings has become caught up in the language we should be reserving for mental illness,” she writes in Losing Our Minds.
The vast majority of people will never develop a mental illness in their lifetime. Those who do will usually have it by their early twenties and have been presenting with pathological issues as young as puberty, especially for the more severe disorders such as schizophrenia and bipolar disorder. Family trees are important for these diagnoses, with both showing strong genetic presentation in families through the generations.
As well as the usual risk factors of poverty, child abuse and neglect, there is also evidence that parents with depression and anxiety disorders can unwittingly “model” these behaviours to their children, by avoiding parties, for example, or frequently expressing a gloomy outlook on life.
Universally, the risk factors for serious mental illness remain the same: a mixture of your genes, your environment and your adverse experiences in life, such as emotional neglect during childhood, abuse, bullying in school, physical ill-health and disability, trauma from a car accident or a relationship breakdown.
Crucially, however, although trauma is a known risk factor, it is in no way definitive in terms of developing a mental illness. Many people who have undergone significant multiple traumas in their life never go on to develop a clinical disorder. This field of research remains intriguing to the psychiatric community, though resourcefulness, grit, adaptability and resilience are known – and to some extent learned – qualities that help people recover from adverse life events.
Adolescence is a particularly vulnerable time for anyone predisposed to a mental illness, and it is when many sufferers begin showing the first signs of clinical, rather than typical, mental-health issues.
Is there an epidemic?
Between 2008 and 2018, prescriptions for antidepressants increased from 36 million to 70.9 million in the UK. A study of 29 countries, including Australia, Canada and many in Europe, found that all of them had seen a rise in antidepressant medication between 2000 and 2015, doubling on average.
This would appear to be damning evidence that mental illness rates are rising, but maybe not. A safer way to analyse mental-illness rates is to study its occurrence among the general population, rather than among people already seeking help (and being prescribed antidepressant medication by their GP – rightly or wrongly).
A 2019 meta-analysis led by sociologist Dirk Richter crunched data from 42 studies from around the world, combining more than one million participants.
From 1978 to 2015, the researchers found that there was a “statistically significant increase in these types [depression/anxiety] of mental illness and mental distress across time, but it was ‘small’”.
The authors were at pains to note their findings were at odds with the “evidence of a tremendous increase” and “the impression of a mental health epidemic during the same period”.
Along similar lines, a UK study conducted by the National Health Service (NHS) interviewed 9000 5 to 15-year-olds in 1999, 2004 and 2017. Foulkes writes that a “slight increase” was recorded in overall rates of depression and anxiety between 1999 and 2017, while the prevalence of other disorders remained consistent. In 1999, 9.7% of five- to 15 year olds had a diagnosable disorder; in 2004, this figure increased to 10.1%, and in 2017 to 11.2%.
Tamsin Ford, a child psychiatrist who worked on the NHS survey, said of the rise: “It was smaller than we thought … it’s not huge, not the epidemic you see reported.”
Experts think diagnosable rates of mental illness have largely remained stable in the community, with any increase “relatively small”, and most pronounced in the mild to moderate categories of depression and anxiety.
Foulkes argues that every generation experiences its share of unique and stressful crises and challenges, and the conditions of the past few decades alone do not explain an “epidemic” of mental disorder.
The pandemic has been devastating, she writes, but other generations suffered through successive world wars, the Great Depression and the threat of nuclear annihilation.
Crucially, today’s younger people are far quicker to self-report and self-refer themselves for psychiatric help than previous generations, and although it is great that more people feel comfortable asking for help, this phenomenon also has its downsides.
“Negative psychological experiences are universal and so is our desire to label them,” says Foulkes, adding that every culture in the world has special words, beliefs and diagnoses for mental illness.
“We desperately want to understand our experiences and have language for them, but there’s a very messy overlap at the moment between the psychiatric and the normal. We all experience negative emotions, we all have aspects of our personality that we don’t like, we all behave in ways that we don’t like or that we find difficult and upsetting. But that makes us human, not sick.”
Why are we crying wolf?
Foulkes, who lectured in psychology at the University of York from 2018 until 2020, says battles with students self-identifying as mentally ill are becoming a persistent and complex dilemma for academics.
Most live in fear of missing a serious case, but likewise struggle to justify excusing dozens of students from presentations and exams who ask to be exempted on the grounds of “anxiety”.
In a startling anecdote, Foulkes recalls how she asked one of her students in a first-year class how many in the class of more than 100 would describe themselves as depressed or anxious.
All of them, the student reported. Every single one.
“All these problems are on a spectrum, between someone who is having a bad day because they argued with their girlfriend and they’re feeling low, to someone who is clinically depressed,” says Foulkes, adding that, statistically, she would expect no more than 10 or so students out of 100 to potentially meet the threshold for a clinical diagnosis.
“Mental-health days are important if you have a mental disorder or you’re in crisis, but the issue is when these ideas get co-opted way further down the spectrum to the point where these things become a bit of a joke. This is what I am worried about in terms of people becoming sceptical [about the mentally ill].”
In 2020, Michelle Obama hit the headlines when she revealed in a podcast that she was suffering “low-grade depression”.
“Not just because of the quarantine, but because of the racial strife and just seeing this administration; watching the hypocrisy of it day in and day out is dispiriting.”
Some mental-health groups welcomed the former first lady’s comments, but others questioned exactly what “low-grade depression” meant. Did it really just mean blue?
“Thank you for talking openly about how you are managing your depression @MichelleObama,” the American Association of People with Disabilities tweeted. “Talking about how we manage our mental health, especially at times like these, reduces stigma and creates a more inclusive society.”
Although sympathetic to Obama’s experience, Foulkes argues it’s language and sentiments such as this – now widespread – that are dangerously muddying the waters.
Clinical depression is a debilitating condition in which sufferers are unable to function in their daily lives and may suffer psychosis or delusions. Clinical depressives account for half of all people who attempt suicide in the US. The disease can persist for decades and is often extremely resistant to treatment.
Over time, it can also result in memory loss, cognitive decline and decreased neuroplasticity, as well as fractured family, professional and romantic relationships. Using the word “depression” to describe feeling down – especially when ordinary life challenges are present – helps no one, Foulkes says.
Foulkes argues there is a growing risk and evidence that people may not be building up the necessary resilience and “grit” to cope with negative life experiences – the often-maligned “snowflake”generation – while those who are labouring under clinical issues may not be getting the help they need. There is ample evidence that helicopter parenting harms, rather than helps, children and young people in the long run.
“No matter how cautiously we try to live, we are all going to come up against unavoidable darkness in our lives. We all need to know that sometimes distress is normal and cannot be fixed,” writes Foulkes.
Bad well-being advice
Foulkes thinks people with ordinary life experiences are now deploying psychiatric terms in a bid to have their pain heard in a noisy world, and because the terms have become so commonplace that ordinary emotional language no longer suffices.
She also argues that psychiatric terminology can be used to indicate “there is something unique about you”.
“The terminology that should be reserved for the more extreme end has been bleeding down into the end where people have milder problems,” says Foulkes.
“If everyone else is depressed and you just say, ‘Oh, I’ve been feeling a bit down,’ your distress will be taken less seriously. So there’s a bit of a fight to say, ‘I’m suffering, I am struggling.’ And if I use these words you might take me seriously and help me.”
Another risk with failing to distinguish between mild and severe mental distress is that well-intentioned self-care and well-being advice often become grossly misdeployed.
Although exercise and a hot bubble bath is good advice for someone having a bad day or week, it’s “a joke” for someone mired in clinical depression. Likewise, many of the cheery, tokenistic mental-health campaigns designed to target the mentally ill end up alienating the people most in need of help.
“I am a big fan of exercise for managing mental health, but it’s far too simple that all people need to do is exercise. If you’re sufficiently depressed, you can’t,” says Foulkes.
“If you allow that part of the conversation to swell too much, you’re leaving out the people for whom self-care is almost irrelevant considering how seriously unwell they are.”
Guardian columnist Hannah Jane Parkinson has battled bipolar disorder for more than a decade. In a 2018 piece that went viral, she described her anger at what she perceived as the shallow mental-health conversation engulfing society.
“In the last few years, I have observed a transformation in the way we talk about mental health, watched as depression and anxiety went from unspoken things to ubiquitous hashtags,” she writes.
“In recent years the discussion around mental health has hit the mainstream. I call it the Conversation. The Conversation is dominated by positivity and the memeification of a battle won.
“There is a poster in my local pharmacy that exclaims, ‘Mental health can be complex – getting help doesn’t have to be!’ Each time I see it, I want to scream.
“I have lost count of the times mental illness has been compared to a broken leg. Mental illness is nothing like a broken leg.”
Stories of recovery often mask the reality. Foulkes eventually recovered from her breakdown, but says staying mentally well is something she has to remain vigilant about. “It’s all a little bit too neat if we only hear recovery stories.
“It took a long, long time for me to get better. But the reality for many people with severe mental illnesses is they never do.”
In the final chapter of Losing Our Minds Foulkes argues for the inclusion of messier, more complicated mental-health stories to be included in the national conversation, not just the “more palatable” stories of breakdown, reflection and recovery.
She’s talking about the people in society who are often left out of the mental-health conversation: the bipolar and schizophrenic, the chronically ill and those with symptoms such as delusions, aggression, violence or hallucinations who remain “scary” to society.
“I am very lucky to not be chronically unwell, because those people are not able to write books to advocate for themselves, so we don’t hear from them. But that’s absolutely the life course that some mental illness takes – you don’t get better in a straightforward way,” says Foulkes.
In the Independent, psychiatrist Stanley Kutcher wrote that “mental health is not a static concept wearing a big smile”, and the increased public perception that being well means only having positive feelings is wrong.
For Foulkes, there are still good days and bad days and the threat of another breakdown lurks like a shadow in the corner of her mind. But learning to live with the knowledge that a good week can easily become a bad week, or a bad month, is the key to surviving – and thriving – in an imperfect world.
“All forms of psychological distress are the price we pay for being human. This is a truth many of us, including myself, struggle to accept. Like everyone else, when I’m in pain, I want it to go away. And yet some pain simply cannot be controlled, and we must find ways to live alongside it or through it.” l
‘How bipolar are you?’
When the Diagnostic and Statistical Manual of Mental Disorders (DSM) was first published in 1952, it contained diagnoses for 106 different disorders, including homosexuality, which was eventually removed in 1987.
By 2013, when the controversial DSM-5 was published, the number of disorders and diagnoses had swollen to between 298 and more than 400 and ballooned to nearly 1000 pages.
Has the human race grown more mentally ill, or are the goalposts changing?
“One possible explanation for this is that over time we have discovered the existence of more disorders,” writes Lucy Foulkes in Losing Our Minds.
“[Or] maybe we’re now labelling too many psychological experiences as disorders, applying the term ‘mental illness’ to things that shouldn’t be called mental illness at all. Because in almost all cases, the boundaries around what is officially considered to be a mental illness are expanding.”
Take depression. Originally, bereavement was a reason for psychiatrists not to diagnose depression in patients, with the general understanding being that a profound experience of death could seriously, and at length, alter the state of one’s happiness and quality of life.
Now, in the DSM-5, the “bereavement exclusion” has been dropped and patients can be diagnosed as clinically depressed as long as their symptoms have been present for most of a two-week period – even if they lost their partner, father or child 13 days before.
Critics have argued that the new parameters risk “medicalising” ordinary grief and encourage over-prescription of antidepressants. Proponents say you can suffer bereavement and clinical depression at the same time – and the medical part of the sadness should not be left untreated.
Similar expansions have been made to bipolar disorders – of which there are now half a dozen subcategories – as well as social-anxiety disorder, post-traumatic stress disorder and obsessive-compulsive disorder, among many others. Conversely, other disorders have been reclassified, such as Asperger syndrome, which now falls under the catch-all of autism spectrum disorder.
British psychoanalyst Darian Leader says the question in modern times is not, “are you bipolar?” but “how bipolar are you?”
Māori approach to mental health
Psychotherapy in its current form, as practised in Aotearoa, is in thrall to an American world view, say Tauranga psychologist Wol Hansen and social worker Merrill Simmons-Hansen.
That is in terms of what constitutes mental distress and the origins of the therapeutic methods used to resolve this, such as cognitive behavioural therapy (CBT), acceptance and commitment therapy (ACT) and dialectical behavioural therapy (DBT).
Mental-health practitioners describe the conditions of the people they work alongside through the lens of the DSM-5: the Diagnostic and Statistical Manual of Mental Disorders fifth edition, which is a product of the American Psychiatric Association. This hefty tome prescribes the shape of our perceptions of the aetiology and causes of mental distress, which can then in theory be “cured” through the use of the therapeutic methods and medication.
Te whare tapa whā is a model of the four dimensions of well-being developed by Sir Mason Durie in 1984 to provide a Māori perspective on health. The dimensions are: taha tinana (physical well-being), taha hinengaro (mental well-being), taha wairua (spiritual well-being) and taha whānau (family well-being). The foundation of this model is whenua/land or roots.
Durie developed a Māori-centred counselling model in response to the limited focus of Western psychological practice, known as paiheretia.
“These concepts have yet to find a significant place in the provision of care for those in mental distress in Aotearoa, in particular for Māori,” say Hansen and Simmons-Hansen. “We are in the main still trained and educated in and from an American perspective about and around mental health.
“Although gains are being made to free practitioners from this influence, we still have some distance to travel before we can truly say that we have developed our own unique style and method of psychotherapy and a global view of healing the hinengaro that is particular to this land.”
Mental health in New Zealand
- The estimated number of adults with anxiety disorder more than doubled between 2011 and 2019.
- The estimated number of adults with depression grew by 32 per cent over the same period.
- The estimated number of children with anxiety disorder doubled between 2011 and 2019. In 2019, the estimated number of children with depression was 75 per cent higher than in 2011.
- In the year to June 30, 2020, provisionally, 654 people died by suicide, compared with 685 the year before – a decrease of 31 deaths. There was an increase in suspected suicides in the 80-84 age range, with 12 more people dying by suicide. The Māori and Pacific Island suspected suicide rates both decreased over the period, but the Asian rate increased.
- In 2018, New Zealand had the lowest number of practising psychiatrists per capita compared with 10 other countries, including Australia, the UK and Canada.
- DHBs frequently exceed 100 per cent occupancy levels for mental health and addiction inpatient beds – well above the 85 per cent occupancy considered clinically safe.
- In the 2019 Budget, the Government announced $1.9 billion for mental health, with $235 million set aside for building mental-health and addiction facilities. It was reported last month that only five extra acute mental health beds have been added.
Best ways to self-care
Adolescence is a time of heightened risk for the development of a mental illness, writes Lucy Foulkes, not least because of surging hormones and a peer-oriented – even obsessed – world view.
“If you are ever going to develop a mental illness, more likely than not it will start in your adolescent years,” writes Foulkes, with about 50% of diagnoses appearing by the age of 15, and 74% by the age of 18 for a host of disorders, including anxiety, depression, bipolar, schizophrenia, eating disorders, personality disorders and substance-addiction disorders.
“The majority of mental illness starts by the age of 24. If you make it to 25 without experiencing a mental illness, the chances that you’ll get one beyond this age – although it certainly does happen – are reduced considerably.”
Foulkes has some suggestions for adolescents to take care of their mental health.
Exercise
Foulkes writes that for many people, mental illness is experienced in the body, such as a hollowed-out feeling in the chest during depression or electricity in the blood during a panic attack.
For this reason, getting the body moving can be an important way to boost sensation and activity in the mind. “There is now a wealth of evidence showing that exercise is helpful for preventing, treating and reducing the relapse of mental illness,” Foulkes writes.
Any kind of physical activity is good, but social team sports are particularly beneficial for the added social bonds they create. If all exercise is off the cards, either through disability or physical or mental sickness, Foulkes recommends people train their muscles to relax and reduce physiological stress by deploying mindful relaxation techniques – look up a simple technique developed in 1929 called “progressive muscle relaxation”. A number of apps are also well regarded, including Headspace, which may appeal to teens.
Sleep
“Disrupted sleep can cause a mental disorder in itself,” writes Foulkes, saying that improving our sleep habits is one of “the best ways” to improve our mental health.
Poor sleep, particularly when chronic, impacts emotional and cognitive skills, the ability to concentrate, and mood regulation. Sleep problems can not only exacerbate illnesses such as depression, schizophrenia or bipolar, but can contribute to their onset, prolong or deepen an episode and significantly impact recovery.
There is no way to overstate how important quality sleep is to good mental health. So what to do?
People who exercise more often tend to sleep better. Not working and avoiding social media before bed is beneficial, as is steering clear of caffeine or alcohol near bedtime and keeping the bedroom cool and dark.
Some specialised therapies, such as variations of cognitive behaviour therapy, target insomnia, including an app, Sleepio, developed by University of Oxford researchers. A visit to a sleep clinic should be in order if issues are chronic and persistent.
If you want any “superpower” to help deal with your mental health problems, sleep is it.
Some stress is good
“Within reason, some degree of distress might actually be a good thing,” Foulkes writes. “We shouldn’t design our lives – or our children’s – to avoid stress altogether. In fact, the evidence suggests a certain level of stress is better than none at all.”
Stress that is time-limited and allows opportunity for recovery might be “protective” in terms of coping with future hardships, as is stress that further develops skills and talents, often leading to a boost in self-esteem and confidence.
“The idea of stress inoculation is that mildly stressful challenges teach us ways to cope,” writes Foulkes. “When future stressors arrive, we are more likely to believe they are manageable.”
This story was first published July 10, 2021.
Where to get help:
If it’s an emergency and you feel that you or someone else is at risk, call 111.
· Need to talk? Free call or text 1737 any time for support from a trained counsellor
· Suicide Crisis Helpline – 0508 828 865 (0508 TAUTOKO)
· Lifeline – 0800 543 354 (0800 LIFELINE) or free text 4357 (HELP)
· Youthline – 0800 376 633, free text 234 or email talk@youthline.co.nz or online chat
· 0800 What’s Up - 0800 942 8787
· Samaritans – 0800 726 666
· Depression Helpline: 0800 111 757 or free text 4202 to talk to a trained counsellor, or visit depression.org.nz
· Anxiety New Zealand - 0800 269 4389 (0800 ANXIETY)
· Healthline – 0800 611 116
· Additional specialist helpline links: https://www.mentalhealth.org.nz/get-help/in-crisis/helplines/