Briefing Note: Charting a New Course for Mental Health and Well-Being in the UK

Andrew Garman and Della Austin^[1]

 

The statistics are truly shocking:

• • The financial burden of poor mental health in the UK has been conservatively estimated at £300 billion per year: much of it due to losses in productivity.^[2]

• • In a global survey of 64 countries, the UK is ranked equal bottom for mental well-being, with 35% of the population found to be “distressed” or “struggling”.^[3]

• • 20% of the UK population have taken a psychiatric drug in any one year^[4]

• • about one in five children and young people have a probable mental health problem, according to the NHS.^[5]

• • UK ranks last in a survey of life satisfaction in 15 year-olds; girls and those experiencing disadvantage are particularly affected.^[6]

Do not these data demand a fundamental rethink about mental health?  Why does the UK perform so poorly?  What are the underlying drivers? Why are these issues not more front and centre in political debate and public discourse?

We argue in this paper that this current toll of human misery and its huge financial burden could be greatly reduced if policy making were taken out of the medical framework and re-oriented around the social pathways that lead to psychological suffering.  We see that the medicalisation of psychological well-being has constrained past thinking: a radical re-set is indicated.  A more holistic approach, centred around causation and solid science, needs to bring in the currently-marginalised expertise and knowledge among academics and a wider range of helping practitioners. 

Analysis

 

We believe that the lack of progress on mental ill-health is due in part to a lack of a consensus view or theory of the underlying causal mechanisms at work.  Academia is sharply divided between a medical (psychiatric) view, to the advantage of the pharmaceutical industry, and a psycho-social view, supported by research in a range of disciplines.  Furthermore, within these two groups there are multiple views about causation.  This situation has led to a free-for-all, where policy-making and investment is not based on any widely-accepted theory.  

Although the role of environmental factors is accepted by most psychiatrists, their dominant position in mental health nevertheless perpetuates a medical model which pathologises psychological suffering.^[7]  An alternative view considers that such suffering is a normal response to adversity in the sufferer’s world.  According to one theory, the point about psychological pain, like physical pain, is to prompt the sufferer to change something in their lives.^[8]  This might occur in the practical realm, such as changing jobs or dropping a toxic relationship; or in the psychological realm, such as re-evaluating their self-concept or their view about how the world works. 

Injustices

 

We highlight here three injustices that underpin much suffering:

1)  The medical model constrains the thinking of those that suffer, leading them to look in the wrong place for a solution: inside their heads, rather than in their environment.^[9]  This misdirection leads them to unreasonably blame themselves for their plight, causing a negative spiral of despair.  It also hands power to others who might benefit from their weakened position.  The faulty-brain belief is not supported by research evidence and is very harmful to the individual, and perpetuates (even aggravates) the problem, rather than resolving it.  

2) The belief, dominant in neoliberal countries, that we live in a meritocracy, and that those who are seen to fail in society have only themselves to blame.  In reality, the UK is not a meritocracy, for research shows that life outcomes are determined more by luck (birth family, genes, connections, etc) rather than anything the individual can responsible for.^[10]  

For those who experience disadvantage, their sense of failure typically contributes to mental health problems, for example, it diminishes their self-worth.

3) Psychiatry’s use of diagnoses – about 300 in the latest DSM manual^[11]  – can lead the sufferer to believe that they have a condition which is innate and irreversible.  This belief is fuelled by the pharmaceutical industry encouraging an expectation of long-duration therapies – this is a big topic not to be explored here.^[12]  The vast majority of common forms of psychological suffering are not innate and can be alleviated by a mixture of life changes and appropriate talking therapies.^[13]  

The above injustices are examples of what Fricker calls hermeneutic, in that is they relate to frameworks for interpreting the social world.^[14]  It tends to be the powerful in society who determine or perpetuate these frameworks, to the advantage of themselves and to the detriment of less powerful or vulnerable groups.

Preventative action

 

It is perhaps obvious that greater knowledge of the causal pathways would naturally lead to less psychological suffering, but to what extent does our culture already grasp what is going on?   While some factors such as poverty and precarity^[15], social media, bullying, workplace stress etc. are well-known, few observers have access to the breadth and complexity of other causal pathways.  An almost ubiquitous presence in causal pathways are the adverse childhood experiences (ACEs), such as abuse, trauma and neglect:  these cause immediate problems for the child, but also set up vulnerabilities which cause issues in adult life.  While awareness of these factors is now growing, their impact on policy-making so far seems to be small.^[16]

Government could also do much more to recognise and challenge the societal myths that cause the hermeneutic injustices mentioned above.  This low-cost step could be a very important policy area to explore. But more generally, we suggest that further opportunities for other preventative approaches become more obvious when the complex pathways that cause suffering are grasped. 

Multi-disciplinary policy-making

 

What leads people to psychological pain and suffering becomes very evident from psychotherapy^[17] and yet these data are not typically made available to opinion leaders and policy-makers.  We feel these experiences should have a more central role in policy making.  But there are other disciplines that could contribute, and we finish with outlining their potential roles:

1. 1. Neuroscience could contribute more by anchoring policies in a scientific consensus and thereby avoiding the non-scientific ideas about mental health which prevail in our society.  
   2. Psychology and anthropology offer a broad (pan-cultural) perspective on human needs, relationships and co-operative behaviours, including the need to belong and to thrive in communities.  
   3. Epidemiology also offers a broader perspective, both within and beyond UK society, highlighting the factors and trends behind mental ill-health and social ills.^[18]  
   4. Economics and sociology offer knowledge and perspectives regarding the impact of poverty, precarity and the inequalities of income and wealth.  
   5. Political philosophy features here, for example concerning the issues of justice and power in an age of neoliberalism and emergent extremism (arguably a mental health problem in itself).  
   6. More generally, philosophy offers perspectives on the age-old question of what is it to live well.^[19] Furthermore, it offers some unaligned, cross-discipline oversight and expertise in the better use of language (which is much needed to bridge the discipline gaps), both of which could aid policy-making.

Summary

 

We argue for a drastic change in policy.  A focus on the complex pathways that lead to suffering should be an essential component of policy-making; this could unite the contributing disciplines in a common goal and provide a common understanding.  There is nothing inevitable about the current situation: we do not have to tolerate it.  There are plenty of European countries that do things better, and we suggest that useful learning can be gained from looking at Denmark, the Netherlands and Spain, among others.

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^[1] Co-founders of Flourish Network CIC^[1], a new non-profit organisation whose aim it is to develop and evaluate new approaches to the burgeoning mental health problem in the UK.  Flourish founders have together some 70 years’ experience of counselling and psychotherapy, covering adults, children and couples, especially in disadvantaged communities.  From individual client stories, we clearly see the development of psychological suffering not in terms of a brain disorder, but rather as a result of various forms of historic (mainly childhood) and current adversity in the social environment.

^[2] https://www.centreformentalhealth.org.uk/publications/the-economic-and-social-costs-of-mental-ill-health/#:~:text=This%20analysis%20finds%20that%20the,due%20to%20mental%20ill%20health.

^[3] In contrast the figure for Italy is 17%.  See: https://sapienlabs.org/wp-content/uploads/2024/03/4th-Annual-Mental-State-of-the-World-Report.pdf  Other surveys paint a similar picture.

^[4] For England data, see: https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2023-wave-4-follow-up#:~:text=Key%20Facts,20%20to%2025%20year%20olds.

^[5] https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2023-wave-4-follow-up#:~:text=Key%20Facts,20%20to%2025%20year%20olds.

^[6] https://www.childrenssociety.org.uk/sites/default/files/2024-08/Good%20Childhood%20Report-Summary-Report.pdf?_gl=1*1yjip4b*_up*MQ..&gclid=CjwKCAjwuMC2BhA7EiwAmJKRrHXE11aArugn1JnTExev-Xl2YtddVZ2RVQrH-32tqbUZWCpc4yxebxoCZxwQAvD_BwE

^[7]Underpinning the medical approach is an assumption that there is a biological fault in the brain which causes a “disorder”, due either to genetics or to a chemical imbalance in chemicals (neurotransmitters) in the brain.  The problem is that evidence for genetic contributions suggests, at best, only a minor contribution, and the chemical imbalance theory has no credible scientific support.  See for example: Davies, J. (2022).  Sedated: how modern capitalism created our mental health crisis. London: Atlantic.

^[8] See for example: Garson, J. (2022).  Madness: A Philosophical Exploration.  Oxford University Press.

^[9] Everyone’s experience of adversity and trauma is encoded in the brain’s neural network, but it is both inaccurate and unhelpful to suggest that this amounts to a defect in brain function.

^[10] Sandel has provided a useful summary of these data, see: Sandel, M.J. (2021).  The Tyranny of Merit: what’s become of the common good?  London: Penguin.

^[11] Peterson, T. (2019, October 23). The DSM-5: The Encyclopedia of Mental Disorders, HealthyPlace. Retrieved on 2024, August 23 from https://www.healthyplace.com/other-info/mental-illness-overview/the-dsm-5-the-encyclopedia-of-mental-disorders

^[12] See: Davies, J. (2022).  Sedated: how modern capitalism created our mental health crisis. London: Atlantic.

^[13] Here we caution against reliance upon Cognitive Behavioural Therapy (CBT) because it asserts that the brain is thinking incorrectly, thus directing attention inwards rather than outwards.  CBT’s efficacy has also been widely disputed, see for example: Dalal, F. (2018).  CBT: The Cognitive Behavioural Tsunami: managerialism, politics and the corruption of science.  London: Routledge.

^[14] Fricker, M. (2007).  Epistemic Injustice: power and the ethics of knowing.  Oxford University Press.

^[15] Precarious living and the fear of one’s income (e.g. zero hours contracts), housing, relationships etc

^[16] This immediately indicates one opportunity for preventative action, namely a stronger focus on helping disengaged parents create stable and nurturing families, such as by provision of appropriate talking therapies combined with practical support. Flourish’s pilot study of this approach is showing promising results, see: https://flourish.org.uk/the-nurturing-families-project-how-therapeutic-advocacy-engages-the-hard-to-engage/

^[17] Here positive therapeutic outcomes do not involve addressing genetics or chemical imbalances in the brain.

^[18] See for example: Wilkinson, R. and Pickett, K. (2018).  The Inner Level: how more equal societies reduce stress, restore sanity and improve everyone’s well-being. UK: Penguin Random House. 

^[19] We are grateful to faculty at the New College for the Humanities (Northeastern University London) for their support and philosophical expertise.