It feels like there’s an epidemic of depression and anxiety at the moment. It’s being talked about a lot more and is often discussed in terms of people missing work. Why do you think issues around mental health have come to the fore recently?
I think the single most important reason is because of the huge increase in the level of mental distress right across the board that affects, perhaps most obviously, people who are out of work and are pressured by the work capability assessment, and those on benefits who are being pressured into work at any cost.
So not only in Britain but in countries such as Greece we’re seeing a huge increase in depression and anxiety but also in suicide. Other groups are also affected. There has, for example, been a big increase in the number of young people and particularly young women who are experiencing high levels of anxiety and depression — probably partly linked to competition on social media. But levels of anxiety and depression among people in work — poor, low-paid workers — are also on the increase. Some of that relates to debt, some of it to job insecurity.
So it’s fairly universal. The connecting factor, I argue in the book, is the pressure of living in a neoliberal society, whether it’s work intensification, debt, or benefit sanctions.
Why did you want to write this book now?
The central reason for writing the book was to challenge a medical model which suggests that mental distress, whether it’s got the labels depression, anxiety, schizophrenia or whatever, that these are somehow unrelated to what’s going on in people’s lives, what’s going on in society. That particular model individualises mental distress.
The starting point is to challenge that and to suggest that with the current levels of mental distress, the increase is very much related to the pressure that capitalism puts on people’s lives.
Two other factors were also important. One is that there have been debates recently — not least at the Marxism Festival in London and within the pages of Socialist Review — about different ways of making sense of mental health and mental distress. There are debates over Freud, debates over neuroscience, and so on. I have attempted to tackle some of these.
The other thing that has brought the issue of mental health to the fore in recent years has been the role of organisations like Disabled People Against Cuts (DPAC). One positive effect of the current crisis is that it has mobilised large numbers of people, often experiencing mental distress or with relatives who are, to challenge some of the factors that are producing it.
Why is it that the medical model that you describe is the dominant one and how long has that been the case?
It’s been the dominant model for over 150 years. First for ideological reasons: it locates mental distress within the individual so it’s clearly a very convenient explanation. It suggests that the fault lies in our brains or in our moral weaknesses. Not surprisingly it creates stigma. It makes people who are experiencing mental distress feel that in some way they have failed or can be labelled as a failure.
Secondly, a major factor is the idea that here’s an illness and here’s a cure, a pill or whatever that will sort it out. It’s not surprising that the pharmaceutical industry is the second most profitable global industry despite the fact that there is a lot of evidence that the cures don’t really work.
So how did people talk about mental distress, if they did, before capitalism, before this medical model?
The dominant model was religious explanations for mental distress. So mental distress was seen as a punishment from god or possession by demons. But in addition to that and running side by side with that religious model, there have always been materialist explanations which locate mental distress in the body.
For example, there were humoral explanations, which saw fluids within the body as being out of balance. That model was very influential right up until the 19th century. I mention in the book the movie The Madness of King George which portrays that quite well.
However, something I also emphasise in the book is that, particularly during periods of massive social change like the transition from feudalism to capitalism, or the period of the French Revolution, we see much more progressive explanations coming to the fore, which locate levels of stress in the events in people’s lives.
How would you summarise a Marxist approach to an issue that’s as complex as this?
There are three elements to a Marxist approach. The first is a materialist explanation. We live in a society that is based not on meeting human needs first (physical needs or emotional needs) but is driven by the need to accumulate profit.
So that means people’s needs, whether they’re emotional, sexual or whatever, are repressed, distorted or alienated. That’s really the starting point for understanding mental health.
The second aspect is a historical explanation, both in terms of making sense of why particular ideas about mental health dominate at particular times and also in terms of people’s own lives at a biographical level.
Someone commented that really the question that we should be asking is not “How are you?” but “What happened to you?” In other words it’s the events in people’s lives, particularly, though not purely, their early lives, that shape how they experience the world.
The third thing is a dialectical approach. There are two aspects to this. At an individual level people who are hearing voices, which is one of the most common symptoms of schizophrenia, will react to these voices, either being afraid or trying to manage them or whatever. Very often the ways that they react are treated as symptoms in themselves.
So the first point is that people will actively seek to make sense of their own emotions and feelings and try to deal with them but also, and this is one of the key arguments in the book, that our collective mental health is very much shaped by the level of class struggle.
Where people are not resisting collectively, they are much more likely to internalise some of the pain and some of the stress that they are feeling. There is quite a lot of evidence that where people do collectively resist and fight back against the system it has a beneficial effect on their mental health.
There’s a quote in the book, “from picket lines to worry lines”.
Yes, which I think is a lovely quote. In many ways that sums up where we are just now. The single biggest thing we can all do to improve our mental health is to collectively fight back. And that’s linked to the whole issue of alienation, which I address in the book, because a lot of mental distress is about feeling powerless. When people begin to feel some sense of their own agency, of their own power, it has a very positive effect on their mental health.
And I guess this is what’s so fundamentally different from the approaches that people will be offered if they go to their doctor. So even if they’re not given drugs, they might be sent to therapy which, on the NHS, will most likely be Cognitive Behavioural Therapy (CBT) which is about helping you to change your responses to things but very much on an individual level.
Absolutely, and if the therapy is helpful that’s fine, but essentially CBT is about changing the way you see the world as opposed to changing the world. The other side of that is that a feature of neoliberal ideology is the way it can co-opt essentially progressive ideas and turn them to its own ends. So, for example, the notion of recovery in mental health is very influential at the moment. The positive aspect is that it suggests that people don’t have to be unwell all their lives. The negative aspect is that it puts the onus on the individual to “get well”.
In your book you run through the main challenges to the dominant models but also look at how they’ve moved things on. Obviously the big name in the world of psychoanalysis is Freud and you talk about the innovations of his approach and the strengths of it but also the critiques.
Freud was not himself a revolutionary but there is a very radical element to his thought, which is to suggest that society represses and distorts not only people’s sexuality but also other basic needs in a way that produces what he called neurosis.
The psychoanalytic tradition has been for the most part a very conservative tradition that has similarly individualised mental distress but one of the things that I argue in the book is that there has always been a current within Marxism which has seen a radical kernel to Freud’s thought.
And some prominent Marxists at the time did engage with Freud, didn’t they?
Yes, particularly during revolutionary periods, like Russia in the early 1920s. One of the things I found most fascinating in researching the book was the extent to which psychoanalysis almost had official approval in Russia in the early 1920s. It was the Soviet government publishing house that published Freud’s book. He was supported critically by people like Trotsky, Radek, Vygotsky and others.
In Germany in the same period many of the people involved in psychoanalysis, including a large number of women psychoanalysts, were also very attracted by Freud’s ideas and saw them as having a radical potential. That changed as psychoanalysis was imported to the US in the 1930s and 1940s and it became almost an official ideology, which was very far from radical.
The other great period that you talk about is the 1960s. Again a period of massive turmoil and political struggle. One of the figures associated with that period is R D Laing. He’s become a bit more popular recently — there was a film about him this year starring David Tennant. What was Laing’s contribution?
I think Laing is a very interesting, contradictory character. His initial contribution was to challenge some of the more barbaric psychiatric practices that were going on at the time, such as lobotomy (cutting up people’s brains), the very widespread use of electrical convulsive therapy, and so on.
I see Laing as a tribune of the oppressed in the sense that he was arguing we need to listen to people who had been labelled with conditions such as schizophrenia. Their behaviour and their feelings were not simply chemical reactions but actually had something to do with their life experiences.
Laing was then criticised for appearing to blame families and parents for causing schizophrenia. I think that’s a little bit unfair, but he was ambiguous around that.
He became very involved in the new left of the period and organised a major conference in London in the late 1960s. Sadly thereafter in the 1970s, his intellectual contribution was much weaker, and also personally he became increasingly addicted to alcohol.
But in the 1960s Laing’s central idea that mental distress has a meaning, and the way that we would find out that meaning is to listen to people, is important. A sense in which Laing has been vindicated is that there is now a very substantial body of evidence from empirical research which shows that there is a very strong connection between people’s life experience, including their experience of abuse, and mental distress.
Towards the end of your book you talk about the new movements that have begun to appear in the last few years, particularly involving mental health service users and, like yourself, people involved in radical social work, both practitioners and academics. How much are these shaped by the movements of the past? And how much of their approach is new?
We’re in a very interesting period and the basis for these new movements is the fact that more people with mental health problems will no longer find themselves in hospital — they are likely to be “in the community” receiving varying degrees of support.
The fact that people are now in the community is one reason that it’s much easier to organise than it would have been in a psychiatric hospital. I think the fact that mental health problems are so widespread and the fact that there has been a challenge to the stigma mean that it’s easier to organise today.
Undoubtedly one impact of austerity has been to radicalise and expand the mental health movement and so mental health service users have been very active inside organisation like DPAC and others.
There are features of these movements that are completely new but I think it’s also interesting that they are reaching back into their own history. One positive aspect of what’s now called “mad studies” is that people are looking back to examples of earlier struggles, in the 1960s but also before that, and they’re looking to the ideas of people like Laing to see what they can use today.
I think where there might be more debate is about whether forms of identity politics are the best way to take the movement forward. It does seem to me that the widespread experience of mental distress today means that there has been a reduction in the stigma, and so the possibilities for building a broad based movement are very strong.
There have been a whole number of campaigns up and down the country in opposition to the closure of community-based mental health services over the past year where service users, trade unionists, and different activists have worked very closely together.
And in organisations like the Social Work Action Network and Psychologists Against Austerity, we see service users, social workers, psychologists and others working very closely together to challenge austerity policies.
Finally, why does Marx’s concept of alienation point to a more thorough way of dealing with mental distress?
I suppose the central point that I’m making in the book is that the roots of mental distress are not in this particular policy or that particular ideology but are rooted in a society — capitalism — that deprives us of any control over our lives, and it denies our most basic needs to be creative, to shape things.
So whatever aspect, whether it’s the intensification of work, the increased competition that school children face, whether it’s the loneliness of older people in an increasingly atomised society; all of these different aspects come back to the same problem — that we live in a society whose driver is accumulation, not people’s social and emotional needs.
The only way we can really address the crisis of mental health, then, is by creating a society that is built around meeting human needs rather than around accumulating profit.
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