When 'I' Is Replaced By 'We' Illness Becomes Wellness
CAMBRIDGE: In early November, on a cold, foggy evening, a group of us gathered in a small room in Cambridge. We, all graduates, were brought together to find an answer to a single question – What will be the next quantum change in mental health?
It was an intriguing question. For much of its existence, science has ebbed and flowed. Overnight, serendipitous discoveries have changed the way people thought about ideas. Mental health is no exception. Some quantum leaps are obvious. Sigmund Freud’s psychoanalysis influenced the way we think about mental health for decades. Cognitive behaviour therapy, developed in the 60s, is still one of the most popular form of psychotherapy.
Closer to the turn of the century, several advances in mental health were ushered in by newer, cheaper, and less invasive scientific technologies. Improvement in genetic technologies, data sharing, and the development of sets of reference genomes have enabled tremendous progress in our understanding of mental health. Today, some of the largest consortia in science are working on the genetics of mental health. Similarly, non-invasive neuroimaging technologies have given us greater temporal and spatial resolution of structures and events in the brain than we thought possible.
Yet, despite this, quite a lot remains inadequate. Many of the tools we use for the diagnosis of mental health conditions remain the same. Unlike cancer or cardiovascular diseases, we have not identified any biological or molecular clues that can easily diagnose someone with a mental health condition. The methods remain the same – interviews, observations, questionnaires and tests. Access to mental health facilities remains woefully inadequate, funding for mental health research is still poor, and the stigma surrounding mental health seems intractable.
It would be a lie to suggest that these quantum shifts haven’t contributed to our understanding of mental health. They most certainly have. We are where we are because of these pioneering ideas, methods, and experiments. But more often than not, one can’t help wonder if these quantum leaps promised more than what they actually delivered. With every one of these quantum leaps, we realize that the original problem is just way more complicated than we had originally envisaged.
It certainly is tempting to think that the next quantum leap in mental health might come from science. Perhaps we will finally identify biomarkers for several psychiatric conditions. Perhaps large-scale personalized medicine in psychiatry will become a reality. But I wonder if the next quantum leap will – and should - come from somewhere entirely different. I wonder if it is outside the realm of science altogether.
Last winter, I met a friend for dinner. We were in a cheerful place, filled with flickering red and yellow lights and lively music. Over the course of the dinner, he told me that he had been struggling with clinical depression. We talked a bit more about it, and I asked him if he had spoken about it to anyone else. He shrugged, and told me that only a handful of his friends know about it.
He isn’t the first person I have met with clinical depression or any other mental health condition, nor is he the only person who is reluctant to talk about mental health issues. The WHO estimates that 1 in 4 of us have a diagnosable mental health condition. That is more than cancer and cardiovascular disease. Yet while these and several other conditions have entered into our conversations, we still do not talk about mental health problems. Studies suggest that the stigma around mental health is so deep that people find it easier to come out about their sexuality than talk about mental health issues. We are frightened to seek help, frightened to ask for support, and surrounded by numerous misconceptions about mental health issues.
Unfortunately, the way we see mental health issues is still very much in black and white. When we talk about depression or addiction, schizophrenia or autism, we talk about the stereotypical, romanticized ideas of these conditions. It does not help that the majority of mental health representation in popular culture is caricatured. I remember, as a young boy, watching Russell Crowe in A Beautiful Mind. For years afterwards, I believed that I knew what schizophrenia was. I believed that schizophrenia meant seeing things and hearing voices. And when I had the opportunity to hear of other stories of schizophrenia – stories were hallucinations and delusions were not the central features – I almost refused to believe them, despite that I was hearing from experts who had worked in the field for decades. My idea of schizophrenia was informed by a single, powerful story that blindsided me.
Not all stories of mental health conditions are negative. It isn’t too difficult to think of the creative genius of Vincent Van Gogh or Virginia Woolf when we think of schizophrenia or depression. Or perhaps, an autistic savant like Raymond Babbitt, when we think of autism. But these are stereotypes nonetheless. As the psychiatrist Christine Montross eloquently writes “It is audacious and self-serving of us to celebrate mental illness as rebellious and brave, as productive and ingenious, as the mythical, maniacal muse of our artists and writers. At the end of so many of these stories, we are left with their masterpieces. But the lives behind the stories are riddled with suffering and hospitalization and suicide.”
Autism, addiction, and schizophrenia are the few mental health conditions that have entered popular narratives, but there are a whole host of others that have not. On a recent train journey, I met a young American who was interested in knowing more about what I did. We spoke about autism and bipolar disorder without difficulty. When we started speaking about eating disorders, however, it became a lot more difficult. I was struggling to convey how debilitating and reasonably common the condition is. I could not adequately tell her that it was not a simple case of people refusing to eat, that it has the highest mortality of any mental illness, that it is accompanied by a gamut of psychological, behavioural, and systemic difficulties. Part of it is because I don’t work on eating disorders (I work on autism) and, so, my story is incomplete, but part of it is also because, I suspect, there aren’t enough stories about eating disorders out there that my travel companion could use as a reference point.
Ultimately, these stories, in their incompleteness, do more harm than good. We caricature mental illness, and the vast diversity in these conditions is reduced to a few stories. When we believe in these stereotypes, we fail to identify, appreciate, and empathize with the many different shades of mental illness. Instead of supporting and understanding, we alienate and stigmatize individuals with mental health conditions. We lead ourselves to believe that we are weak if we admit to a mental health condition.
Things are changing in some countries. There are online platforms where people can talk about mental health. Celebrities are talking about their mental health difficulties. People are demanding greater access to rights and facilities. In some countries, mental health difficulties are no longer completely invisible. They are no longer forcefully hidden. But much of these still exist in secure spaces – in liberal newspapers, on online forums, on websites dedicated to mental health support. Even in Cambridge, where the access to services is far superior to most other places, people hesitate to talk about mental health problems openly. The conversation I had with my friend over dinner is rare, and it shouldn’t be that way.
Conversations drive change. But to bring about this change, our conversations shouldn’t be limited. In Ishiguro’s Remains of the Day, Stevens muses that the great decisions of the world are made in the privacy of great houses. I disagree, great decisions are made not in great houses, but rather, in every house, great and small. They are made in the supermarket aisles, in the queues to buy movie tickets. We need to teach ourselves to talk openly about mental health. We need to educate ourselves to talk more openly about mental health. We need to educate our kids, in homes and in schools, to talk about mental health. Only when this happens will we lose the stigma that surrounds mental health.
After several rounds of discussion, on that cold November night, we decided that the next quantum change in mental health will come from biomarker discovery. That certainly will be revolutionary, but I don’t think that will be the next leap. The next leap in mental health shouldn’t come just from science. It should come from all of us.
(Varun Warrier is a graduate student at the University of Cambridge).