The Surprising Downside to Mental Health Awareness

It’s common knowledge our society isn’t great with mental health. We don’t talk about it enough and invalidate those who are struggling. We often simplify mental health issues as personal weakness while ignoring complex factors which comprise mental well being. By focusing mental health awareness on illness or “weakness,” we are not adhering to scientific research which shows a complicated web of factors comprises mental health.

It’s interesting how many of our mental health “awareness raising” narratives relate to illnesses and chemical imbalances. Awareness raising campaigns often portray mental health as an individual medical problem. However, when we consider this on a societal level, it is hard to justify the idea that nearly everyone develops abnormal brain chemistry. We don’t have a collective wonky wiring making us all depressed or vulnerable to mental health issues.

Our personal challenges might be emotional bruises from our childhood circumstances, for example, poverty, trauma, bullying, instability, or learning difficulties. We may also face more recent challenges such as a lack of fulfilling friendships, stress, alcohol or drug dependency, debt, trauma, or tumultuous relationships. Indeed, some of our challenges might have followed us across the spectrum of life such as factors to include gender, race, sexuality, (dis)ability, emotional sensitivity levels, etc.

We know those of us who face greater life challenges are more likely to be at the sharp end of distress. To me, it’s not as simple as an individual medical problem or failing. The common “illness like any other” narrative simplifies a complex issue, suggesting some people are ill and others are simply not.

This narrative would be necessary, perhaps, if psychiatric diagnoses were reliable and clearly differentiated people with and without mental “illness.” This narrative might also be necessary if conditions of distress were proven biological illnesses, but they’re not. Mental health diagnostic criteria are subjective and culture-bound, there is no clear line between mentally “ill” and mentally “well.”

Depending on which mental health professional one sees, the kinds of questions which are asked, even factors such as one’s age or gender, one could get a very different diagnosis. For example, Borderline Personality Disorder is characteristically feminine. Many people cycle through a range of professional labels before finding one which fits their personal experience – often, a person adopts several diagnoses before finding their best fit.

Also, note how the presence of a “chemical imbalance” or any other biological test for that matter, is not a criterion for a mental health diagnosis. We cannot detect depression, developmental disorders, eating disorders, or “personality disorders” in a blood test, brain scan, or any other biological test. Indeed, science has not proven there is a chemical imbalance for many mental health diagnoses.

According to the British Psychological society, “Our experiences and distress are likely to arise out of a range of factors. The things that have happened to us, including influences on our development before, during and after birth, childhood and educational experiences, our current circumstances and responses, our brains and bodies, and how we make sense of our lives are all important… there is no firm evidence that mental distress is primarily caused by biochemical imbalances, genes, or something going wrong in the brain (with a few exceptions, such as dementia).”

Of course, we know taking medication can help some people feel better. But by promoting an “illness like any other” way of understanding mental health, we are suggesting distress should largely be treated as a physical illness, i.e. with biological treatments. However, medications have the best results when given to people with severe distress and for the shortest time needed, considering long-term medication often has serious side effects.

Many people find the illness narrative useful and validating. For some, it offers answers or proof their distress is valid and should be taken seriously. But, this is up to the individual who should have a choice as to whether or not to accept the medical “illness” metaphor of understanding or to seek alternative understandings about their distress.

This article is an evidence-based suggestion we, as a society, need to be more open to dialogues and alternatives when addressing mental health. We need to consider the full spectrum of understanding mental health and raise awareness of the multiplicity of factors supporting and hindering our well being. Only then can we be truly empowered to take control of our mental health – both as individuals and as a society.

Framing Mental Health from the Biopsychosocial Model

As someone who now works with people experiencing depression, anxiety, addiction and a range of other issues, and being a person who has experienced my own battle with depression, I have my own unique perspective.

Reflecting on his experience at a preview session from the Health Promotion Agency’s National Depression Initiative, Phillip shared his own common and unique experience of depression and anxiety.

Philip talked about his objections to the idea that depression is “an illness, not a weakness” because, in his view, the causes of depression and anxiety are often social factors – and that these problems (and other mental health concerns) need a “social model” rather than a medical one.

Firstly, like Philip, I can see why someone would classify anxiety or depression as “an illness, not a weakness”.  I agree that no mental health problem comes about as the result of a weakness of character and that anyone, anywhere, at any time, can experience these kinds of problems (and indeed, one in five New Zealand’s do in their lifetime).

I think that experiences like depression and anxiety get called “illnesses” as a way of signaling the vast difference between someone when they feel mentally “well”, compared to when they don’t.  Indeed, most of the diagnostic criteria for mental “illnesses” include the fact that the symptoms either cause significant distress to a person, or significant impairment in their day-to-day functioning.

So my take is that “illness” is perhaps used as an inadequate shorthand for “not functioning in the way that I do when I’m feeling whole, connected, supported, complete and satisfied with my life – I’m struggling, help!”

But I agree too, that “illness” also does not feel like quite the right term.  Philip suggests that depression, anxiety, and other mental health concerns can be valid emotional responses when a person is struggling with the state of their life.  As both a therapist and a person who has experienced significant depression, I completely agree.

Philip goes on to suggest that rather than a medical model, we need a “social model” of mental illness.  The thing is, that is exactly what we have and use in mainstream mental health.  We base most modern, evidence-based mental health intervention on what is called the “bio-psycho-social” model of mental illness.  I’ll break this down briefly, with examples.

The Biopsychosocial Perspective

The “bio” part of the model refers to the fact that we are pretty sure that some mental health problems have a genetic component.  Now, this doesn’t mean that if you have a particular gene you are guaranteed to get a particular disorder, rather than your brain chemistry might just be a little bit more vulnerable to developing one, given the right life circumstances.  It’s a bit like heart disease.  Two people can have the same healthy (or not so healthy) diet.  One, who has a particular genetic marker in their family, may have a heart attack; while the other goes on to live a long life with no heart problems.

It’s a bit like heart disease.  Two people can have the same healthy (or not so healthy) diet.  One, who has a particular genetic marker in their family, may have a heart attack; while the other goes on to live a long life with no heart problems.

“Bio” also refers to the fact that experiences like anxiety and depression do affect your physical body just as much as your mental health.  In terms of treatment, many people will find that particular medications help (others don’t, and that’s okay too).  We also know things, like getting enough sleep and exercising a little, can help people manage these problems too.

The “psycho” part refers to your internal functioning – your mind, mental and emotional experience.  When I was growing up, I learned particular ways to think about and manage my emotional experiences, that didn’t really serve me so well as an adult. For example, thinking “negative” emotions like sadness or anger are a bad thing and should not be experienced or expressed…that’s a pretty common right across Kiwi culture, I think.

Part of my recovery involved learning a different way of understanding and managing my emotions. This is generally where therapy can be the most helpful and can heap other benefits as well.

The last is the “social” part of the model.  This is the acknowledgment of the idea that crappy life experiences or a not-so-great situation can significantly contribute to mental health concerns.

Again, treatment often involves helping someone to get themselves into a better or more stable environment, and connecting to good support.  I’ve had many clients realize they needed to do things like end relationships, quit a job or move house, as I did myself, to help improve their mental health.

Now, our mental health system is far from perfect.  There is a massive shortage of resource and funding, as well as an ongoing battle with stigma and discrimination, amongst other issues.  But, for better or worse, that’s a super short summary of the model that the majority of mainstream mental health support services are based on.

So given that we are supposed to be acknowledging, integrating and working with all the parts of a person and their situation – why is it that the message is still out there in the media that mental health problems are a medical, not a social issue?  Is it short-hand, a simplified way of raising awareness that mental health problems are common, and not a character flaw?

Or is it is lack of understanding as to how mental health problems develop, and how we treat them? I’m really not sure on this one – but I’d love to find out.

Therapy 101 Series: Lesson One is Knowing Your ABCs

If you’re a therapist, ideally, you have access to intervention training and a good clinical supervisor. What if you don’t? Many new therapists, social workers, and other psychosocial professionals enter the field without concrete psychotherapy intervention training, and most without sufficient experience to know  how to immediately implement it in every unique presenting situation. One may be an intern and are hopefully closely supervised and guided. Another may have earned an entire, relevant graduate degree without specifics on evidence-based psychotherapy practice included. There is hope, however, since this is where most of us started either way. Being a therapist may wrack your nerves at baseline.

Articles in the Therapy 101 series will focus on tips, tricks, and tools that can help get you started if you can’t get intervention training immediately and/or you can’t use clinical supervision to get you over the anxiety. What follows is only the beginning, and does not necessarily make you more qualified, magically clinically licensed, and does not offer specific intervention training.

Please note: This series is not intended to endorse practicing therapy without intervention training, licensure, or good clinical supervision, but rather empower social workers without the tools and resources to get needed training keep their therapy job, and get to the next, best practice step.

So where to start?

If you’re not new to providing therapy, imagine the last time a client said something that really threw you for a loop. You didn’t know what to say. You didn’t know what to do. Maybe you sputtered a bit. Maybe you were just silent. Maybe you communicated volumes with shocked nonverbal cues. Either way, you felt like there was a void or crisis you couldn’t adequately fill or resolve. If you are new to providing therapy, this may very well describe your day job! Congrats! It’s pretty exciting even with that semi-regular feeling of helplessness.

What is therapy anyway?

Therapy generally defined in the dictionary is “medical treatment of disease”, but since you are probably a social worker or social work student, we will assume you are more likely to be curious about psychotherapy, which we will refer to simply as “therapy” for the rest of this article, and which the National Alliance on Mental Illness defines:

Psychotherapy, also known as “talk therapy,” is when a person speaks with a trained therapist in a safe and confidential environment to explore and understand feelings and behaviors and gain coping skills.

That could very easily be you with or without specific intervention training. If you have a Master of Social Work degree, you are trained in Human Behavior in the Social Environment and Social Work Practice, at the very least. That me be little consolation to you as a new or inexperienced practitioner of therapy, so what do you do first when you don’t know what to do next?

Know Your ABCs

  • A for Affect – How do you feel? What emotions are you experiencing?
  • B for Behavior – What do you do? What actions do you take or have you taken?
  • C for Cognition – What are your thoughts? What are you thinking?

These are the most core questions you will ask any client/consumer and once you connect them to a trigger/context, you’re one hop, skip and jump away from many forms of therapy. They can come in any order. In fact, many psychotherapy styles specifically focus on thoughts, feelings, actions, and behavior so being comfortable asking these questions, or falling back to them when you’re not sure what else to say and the “strategic silence” you improvised or rationalized is going on a little too long.

Imagine a client describes something you have never heard about before, have never heard described to you by someone who experienced it, or is quite clearly traumatic. You may picture yourself as the perfect therapist knowing just the right question to ask to pop the clearly present keg of catharsis. Chances are, you will not have the perfect question in a situation like this. But you can always ask the following:

“What are your thoughts on that?”

“How do you feel about that?”

“What did you do beforehand? Afterwards? As it was happening?”

These three questions can (almost) literally be repeated into infinity:

What did you think and feel after you did that thing?

What thoughts and feelings led up to doing that thing?

What did you do/think/feel next?

How often do you think/feel/do that? When was the first time?

If you’re not careful, you can actually end up asking questions into infinity, because clients and everyone else tends to really enjoy when someone sincerely asks them questions about themselves. Stay tuned for a post on setting boundaries on your allotted time and everything else in a future post.

Also, don’t forget the other “A”

The above does not include the trigger or as Albert Ellis stated it “activating event.” The questions above will become less random and purely reactive to the client’s responses as you organize them around triggering events, people, situations, activities, and places.

Albert Ellis, who established Rational Emotive Behavior Therapy, had his own ABC’s which can be similarly helpful if you’re first trying to wrap your head around how to provide therapy: A for Adversity or Activating event, B for Belief about the Adversity, and C for Consequences.

I know and am comfortable with my ABCs: What next?

A previous mentor once suggested picking a “home” theory and/or technique to fall back on when you’re not sure where to start. Different theories and techniques are certainly more effective with different client populations, so there’s nothing wrong with being a bit eclectic, but as a therapist you will be working with people who are their most overwhelmed, anxious confused, angry or sad. It’s likely you won’t always know where to start or what to say. This makes sense, because it’s likely for many new to therapy that they don’t know what the “right” thing to say is either, and they’re the premier expert on themselves.

There are many options with which to start:

  • Cognitive behavioral therapy forms (rational emotive behavioral therapy, trauma focused CBT, etc.)
  • Motivational interviewing
  • Psychodynamic/psychoanalytic (many models including brief psychodynamic therapy)
  • Solution-Focused Therapy

Once you have decided what theory and intervention you want or need to start with, seek certified training. Some of the links above will take you official training for each style, which will ensure you are actually getting the training that has been studied to be effective for that style.

It is great and best practice to do the full training and receive certification in whatever theory’s intervention you select, and if that’s an option you should certainly do it. Many therapy programs do not reimburse your extensive training in a therapy discipline. If that’s the case, and you can afford a three day, single day, or couple hour training in an intervention style, you may be able to use techniques, if not the entire intervention. You could use open-ended questions, affirmations, reflective listening and summaries, but not be implementing the actual Motivational Interviewing intervention.

Therapy 101

Posts in the Therapy 101 series focus on tips, tricks, and tools that can help get you started as a social worker practicing as a therapist. They do not necessarily make one more qualified, a licensed, clinical therapist, and does not provide specific intervention training or information.

This series is not intended as an endorsement of practicing therapy without intervention training, licensure, or good clinical supervision, but rather empower social workers without the tools and resources to get needed training keep their therapy job, and get to the next, best practice step.

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The Biopsychosocial Perspective to Mental Health and Illness

As we go through life and the environment changes, our brain and it functions also changes. Likewise, a person’s genetic makeup and the environment they interact with will have a profound effect on their mental health, biological health and their brain functions. In order to truly understand someone’s mental health, we must take into account all of the factors affecting them both positively and negatively in order to get a better picture of their overall health and well-being.

According to Drs. George Engel and John Romano, the biopsychosocial perspective is more appropriate when analyzing the causes of mental illness. This model introduces the idea that there are biological, psychological, and social determinants to mental health. This idea links the outside world to someone’s biology and psyche.  It also involves our consciousness, sentiments, and behaviors.

One reason why the biopsychosocial perspective is so useful is because it explains how some people who are seemingly “healthy” can get mental illnesses and why some are more prone to mental illness than others. Those who are mentally healthy most likely exercise, have positive energy and strong social bonds does not exempt them from mental illness. The biopsychosocial perspective gives evidence that although someone can be mentally healthy at some point in their life, they can still experience mental illness if their biopsychosocial balance is disturbed.

  • According to the biopsychosocial model, interactions between people’s genetic makeup (biology), mental health and personality (psychology), and sociocultural environment (social world) contribute to their experience of health or illness.
  • The biological influences on mental health and mental illness are varied, and include genetics, infections, physical trauma, nutrition, hormones, and toxins.
  • The psychological component looks for potential psychological explanations for a health problem, such as lack of self-control, emotional turmoil, or negative thinking.
  • Social and cultural factors are conceptualized as a particular set of stressful events (being laid off, for example) that can differentially impact mental health depending on the individual and his or her social context.
  • The biopsychosocial theory posits that each one of these factors is not sufficient to create health or mental illness, but the interaction between them determines the course of one’s development.
  • Despite its usefulness, there are issues with the biopsychosocial model, including the degree of influence that each factor has, the degree of interaction between factors, and variation across individuals and life spans (Boundless)

This perspective can give clinical workers many benefits when treating a mentally ill patient. They are now able to apply every aspect of the patient’s life to their illness.  Those with mental illness can now gain a sense of self-awareness. Mental illness sufferers can understand their health as a whole entity with several parts that function together. It also broadens the way we view a mental illness by no longer looking at it as a black or white issue. The biopsychosocial perspective also challenges the stigma on mental illness by enabling people to realize that anyone can suffer from a mental illness because we all have biological, psychological, and social influencers in our lives.

Listen to Episode 3 of my podcast Anxious Ramblings!

This episode will cover my thoughts on avoidance and a little introduction to agoraphobia and exposure therapy. We will hear from Phillip about his struggles with Generalized Anxiety Disorder and Agoraphobia. This episode will conclude with me sharing how people’s perceptions can change after being exposed to mental illness.

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