A problem worth solving #6: We wait until we lose control before changing the way we speak and act toward mental illness.
Inspired by Victoria's Royal Commission into Victoria’s Mental Health System, and my lived experience of mental illness and of the system, these research papers provide the short and (not so) sweet low down on the remaining problems worth solving.
Often invisible, but oh so real, mental illness remains a neglected health issue. The system is overloaded, and we must find alternative, workable solutions for 'consumers' as they meet one of life's greatest challenges.
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When was the last time someone came to you and specifically ‘checked in’ on your mental health?
When was the last time your employer suggested a 'welfare check' after you were not coping at work (as differentiated from instigating a performance management plan)?
When was the last time your GP performed a mental health 'check up' on you, or asked how socially isolated you are, without you prompting so? In the event you did go to your GP seeking support for your mental health, did they, or the medical practitioner they referred you to, actively follow you up?
And, if someone did encourage you to get some help for your mental health, how did you respond?
The unfortunate reality is that for most people, the response to these questions says a lot about how far we are away from effective early intervention for emerging mental health issues, both from a public mental health care and cultural perspective.
We seem to have passively concluded that the responsibility to manage and deal with our mental health falls squarely on ourselves, and perhaps our closest friends or family. Usually, the mental health care system fails to actively intervene unless the symptoms are so severe that a person is essentially in a helpless state. On all other occasions, it is up to the individual and their loved ones to take initiative and find the help they need, in circumstances where finding appropriate help is much easier said than done.
This is so even in full knowledge of how costly mental ill-health is for our community, both economically and socially.
And, it is not as if society is any stranger to the concept of prevention in the pursuit of the greater public good; mandatory sex education for the adolescent (and conversations around contraception), state of the art medical care for newborns and young mums, mandatory seatbelts, and outlawing smoking in public spaces, just to name a few.
Yes – there comes a point at which we expect our government and lawmakers to step in and take definitive action for the greater good, even if that interferes with an individual’s right and dignity to decide what risks they chose to take in life.
Granted, however, mental health is a deeply personal facet of someone’s life, and its manifestations are unique to every individual. Indeed, in some occasions, a person may look like they are suffering, while in actual fact they are satisfied with the lifestyle they have adopted. So why ought society and the health care system actively interfere? What about privacy? These are valid questions which have no clear answer.
Nonetheless, it remains true that many who need mental health care do not seek it out. It also remains true that some of these people are suffering behind a mask, and that the people around them are grossely underestimating their mental state. This leads to needless suffering for many, and devastation for some.
The reasons for this reluctance to seek out help are complex, however primarily revolve around our tendency to wait until we become clearly unwell before taking definitive action. It is then complicated by the stigma that sometimes makes us reluctant to seek help, unless we desperately need it, and exacerbated by a system that is overwhelming to navigate.
Our mental health care system has thus evolved to deal with patients requiring urgent help, and in turn, adapted to provide a crisis level response. This approach does little to address the human story and aggravating factors behind each presentation, and so chances are the same patients will relapse into crises again.
Too often, society is left with a revolving door of chronic mental health issues which, by and large, is a seldom reminder of our collective responsibility to do better, and approach things differently.
This article explores what this collective responsibility looks like, how we might approach things differently, and ultimately, why early intervention and preventative action are at the heart of this issue.
What is Mental health? - Let's go back to basics
Mental ill-health is complex and perhaps more deeply personal than any other medical condition. And, the truth is, after decades of research, we are yet to identify any consistent patterns in our genes or a single biomedical test relevant to mental ill-health. This stands in contrast to the bulk of physical conditions which now have a clear level of genetic or biological understanding.
In the case of mental illness, genes merely indicate a slightly greater risk of mental illness, and the biomedical model (ie the chemical imbalance in the brain hypothesis) fails to sufficiently account for the various other factors in which interact. Yes - chemicals are involved in this interaction (chemicals are involved in every interaction in life science!), but it cannot simply be boiled down to certain chemicals being too high or too low.
Rather, our mood, perceptions, and how we experience life are created from an incredibly complex set of chemical and structural interactions which we, to the greatest extent, do not fully understand. Indeed, you may be surprised to know that most lines psychiatric drugs (ie antidepressants, moodstablisers, and antidepressants) were originally found by accident and then modified by trial and error. Since then many theories as to how they were work have been disproved. We are left with drugs that work for some people, but not others, and lead to side effects that vary widely between the people taking them.
So, how do we untangle this mess? Let's start by avoiding our mental health from getting tangled in the first place, by means of zooming out and focusing on strategies which we do know help.
Research shows that our mental health is fundamentally shaped by two things:
- the personal experiences that tend to define us - our family, our relationships, and how we see ourselves; and
- the social, economic, and vocational circumstances we find ourselves in or having been exposed to (both past and present, and including trauma),
It is also clear the interaction between our biology and our circumstances is key to our mental health. The interaction can increase or decrease our ability to cope effectively with life stressors. In this way, the richness of the circumstances around us is not always determinative of good mental health. For example, if there is a discrepancy between our identity or personality, and the circumstances in which we find ourselves, unsustainable friction can manifest which places immense pressure on our mental health.
On the other edge of the spectrum, growing up and even living in terrible circumstances does not necessarily directly lead to mental illness. Sometimes, our relationship with ourselves in conjunction with certain personality types (such as high levels of conscientiousness and low levels of neuroticism) is enough for one to cope for longer within toxic environments.
In addition, we also know that barely any of us will live a long life without being limited by poor mental health for at least a short period of time. In this way, it seems a level of suffering is inherently part of the human form and heavily related to the unpredictability of life.
We know that mental and physical health interacts in several direct and indirect ways. For example, we know that smoking, lack of physical activity, and poor diets are much more common among people experiencing mental health problems. We also know this cohort is much more likely to feel, and indeed be, lonely and socially isolated. All these factors also increase the likelihood of physical illness and the risk of early death.
We know that negative events have a greater impact on our brains than positive ones (negative bias), and that large studies demonstrate that the vast majority of our worries are baseless and result from an unfounded pessimistic perception.
We know that mental and neurological disorders, and substance abuse problems (which often start as a self-medication attempt for mental disorders) are the dominant cause of almost half of all people living with a disability around the world. Yet, for better or worse, these disabilities do not tend to attract as much compassion as other forms of disability.
And, despite substantial advances in research demonstrating the clinical and cost-effectiveness of pharmacological and psychosocial interventions to prevent and treat common mental disorders, delivery at scale and translation into the real world has been slow.
Finally, and most likely related to the slow uptake of clinically proven interventions, it remains true that many of us avoid getting professional help due to the stigma associated with having mental health problems, and the fear of being misunderstood.
To what extent can one prevent mental ill-health by themselves?
While age-old maxims such as 'take responsibility for your life' and 'the only person you can rely on is yourself' carry some utility, they also involve significant inequities and conflicts within the context of the pursuit of good mental health. The reality is there are factors affecting our mental health that are not controlled by us as individuals but rather are dictated by our environment.
It is also often underestimated how emerging and entrenched mental illness affects our perception and ability to help ourselves. In this way, to 'take responsibility for our life' pre-supposes we have a good understanding of how our life is; a supposition that is often not true, especially for the mentally unwell. Any psychiatrist will tell you that all diagnosable mental illnesses will involve significant compromise to a person’s ability to perceive the world around them or themselves, whether by virtue of psychotic features, mood depletions, unrelenting anxiety (or compulsions), or personality idiosyncrasies.
Studies also show that factors such as living in neighbourhoods with limited opportunities, discrimination, and bullying tend to also bias the way in which we perceive our environment for the rest of our life. These perceptions sometimes evolve into paranoid ideology, even in safe situations. It is said that symptoms of psychosis, or obsessions and compulsions, are typically in response to childhood adversity.
It follows that there is a contradiction; we are experts in our own mental health, but also limited by our understanding of our own experiences and unconscious bias. This is a problem for us all, especially if we do not seek help when we need it.
A key aspect of best practice recovery and living well with mental illness is closing the perception vs reality gap; developing the ability to identify and separate the symptoms of mental illness, from the actual reality which surrounds them. In other words, developing a level of self-awareness that allows a person to acquire a 'birds-eye view' of how their’s mental illness and emotions are affecting them.
The aim here is for a person who is experiencing mental health challenges to acquire the ability to let destructive emotions & thoughts pass them by, while focusing more energy on their strengths and what they can control.
However, developing this level of self-awareness without therapy and other psychological services (i.e. medical intervention) is difficult, especially once a person’s mental health has deteriorated significantly. And, as previously discussed, people do not tend to reach out for these services until their mental illness is profoundly affecting them.
As humans, we are hard-wired to act on our emotions, but as we mature and become more socially astute, we learn to control our emotions, rather than letting them control us. We even learn to suppress them in certain situations that are not conducive to a positive outcome.
But learning to manage our emotions is a long process and requires a process of familiarizing ourselves with our emotions within the context of our environment.
However, falling mentally ill usually produces emotions of which we are fundamentally unfamiliar. In any case, they are emotions significantly more powerful than what we have experienced before. We haven't had the time nor the capacity to establish coping mechanisms.
Such emotions, thoughts and feelings are generally extreme and destructive, and because our basic instinct to act on our emotions has not changed, being mentally ill produces a well-manicured garden path towards poor decisions.
In addition to a compromised decision-making ability, mental illness usually has significant effects on one’s ability to function due to disruptions to concentration, irritability, and the ability to undertake complex tasks. If you are affected by one or more of these effects for a prolonged period, keeping a job, forming new friendships, or keeping your daily affairs in order can become a struggle.
Even if these periods are only episodic (as is the case for mental illnesses), society is yet to have created space and awareness for such kinds of disabilities; the baseline expectation is consistency unless your disability is obvious for all to see. Welcome to the ‘missing middle'.
Ultimately, the sicker or more disadvantaged we are or become, the more deprived we tend to become of the things that support good mental health. When you boil it all down, this is the most compelling explanation for how and why chronic mental illness persists in society.
The way in which society is structured and incentivised, and has changed over the centuries is not a coincidental. It is the result of a series of decisions and attitudes we have collectively taken, which have become self reinforcing.
Many of these decisions and attitudes have led to marvellous convenience and prosperity. However, some have led to the pursuit of mental wellbeing being fraught with inequities. If we are to reduce mental illness in our community we need to face these inequities and fix the levers which prevent the efficient distribution of support structures.
We all have a responsibility to do everything in our power and control to protect ourselves from mental ill-health, such as getting better sleep, practising mindfulness, drinking less, exercising more, and taking time to connect and care for others. Developing our awareness, letting go of old grudges, and building lasting friendships are also within everyone’s reach, should we be willing to do the work. We also need to find the strength to get help when we need it.
However, there is only so much we can do, especially when we are already unwell, or in a society plagued by stigma toward mental illness. There is also only so much we can be expected to know about ourselves, which is also related to and complicated by stigma. And, if you come from a disadvantaged background, the level of responsibility society can attribute to the individual only reduces.
If we are serious about addressing the number and severity of mental health problems in our community, we need to tackle the risk factors for mental illness and maximise the protective factors - for example, equipping parents with more support to nurture their children, entrenching emotional awareness and vulnerability training into our schooling system, and providing early professional and peer support by people with lived experience of mental illness.
We must also continue our move away from substance abuse being a criminal justice issue towards being a public health issue - and doing everything we can to support people facing the perils of addiction. We ought to consider and be open to the fact that not all illicit substances are created equal. We should continue to explore how some substances, under the right supervision and in the right dose, can in some ways 'reset the brain' or offer other therapeutic advantages.
What are main forms of prevention when considering mental illness?
In public health, 'prevention' is a multi-layer pursuit, and should not be understood in a narrow sense. Prevention encompasses:
- Primary prevention - preventing problems to the wider community;
- Secondary prevention - prevention specifically targeting people exposed to inequality and higher risk; and
- Tertiary Prevention - prevention targeted at people with ongoing complex needs and aimed at best practice management of their condition.
In terms of mental health, primary prevention is relevant to all of us, such as a public campaign addressing the stigma associated with mental ill-health, or a 24-hour hotline anyone can call if they are experiencing psychological distress.
Secondary preventative actions target those at a higher risk of developing mental health problems and include looking into the social, economic, and other factors which render people more vulnerable. They are also aimed at people who are already experiencing some symptoms of distress and about intervening on an individual level when it matters most.
Tertiary prevention is more about reducing the severity of pre-existing mental health problems or reducing the risk of further relapses. In doing so, such interventions typically include strategies which reduce the level of disability associated with symptoms. The goal of tertiary prevention is to empower people to manage their own symptoms as much as possible.
Tertiary prevention sits alongside and is complementary to a person’s treatment, but it is not the same. Treatment is administered and recommended by the clinician, while tertiary prevention is focused on a person who is in the process of learning what works best for them, in their circumstances, and is typically focused on lifestyle, circumstantial factors, and managing extreme emotions.
Sometimes we refer to primary and secondary prevention as ‘upstream care’ and tertiary prevention as ‘downstream care’.
But does early preventative care really work?
Make no mistake, early preventative care is highly effective and there are opportunities to intervene early in the onset of mental illness, regardless of age.
Even for those with hereditary predispositions, early interventions inclusive of the right support, education, and pharmaceutical intervention can lead to remarkably better outcomes.
For example, there is an abundance of evidence that if we intervene early in psychotic illnesses, we delay and reduce the impact of mental illness. The Singh & Fisher model of effective early intervention for psychosis is an example of a clinically-proven intervention model.
There is also research that shows that for every episode of depression or mania a consumer with bipolar experiences, the structural underpinnings of the brain, including grey matter, is damaged. This leaves the brain vulnerable to further, prolonged episodes and may lead to cognitive impairment. Hence, it is paramount that those experiencing their first episodes get effective early treatment (mainly in the form of mood-stabilizing medication), which avoids the brain effectively becoming damaged and difficult to repair.
In this way, bipolar can be one of the most devastating mental disorders if not treated, yet one of the most responsive to psychotropic medications. Unfortunately, bipolar disorder is one of the most misdiagnosed mental illnesses, with its signs, symptoms, and episodes typically emerging years before the diagnosis is made.
For anxiety and depressive disorders, there is high quality, consistent evidence that relatively cheap internet and mobile delivered interventions are effective, particularly when they use cognitive behavioural therapy strategies. For Depression specifically, positive psychology, problem-solving therapy, mindfulness-based stress reduction, interpersonal therapy and psychodynamic therapy have also been proven to be effective early interventions.
Finally, it has been demonstrated that when adolescents with anorexia nervosa are given family-based treatment within the first three years of the illness onset they have a much greater likelihood of recovery.
What preventative actions are society currently taking?
It is a rare breed of a person (usually with high levels of compassion and loyalty) that stick by those making bad decisions, who occupy negative mindsets, and who are otherwise struggling in life. Yes, we can all be fickle characters, and the silent champions who buck the trend ought to be hailed as society's guardian angels.
However, distancing oneself from negative people is not necessarily without reason; studies show that negative energy, rumination, and destructive decision making and thinking styles are somewhat contagious within groups. Even families have a limit as to how much they can tolerate, as they need to consider their own welfare (and safety).
While you can occupy a negative mind space and make poor decisions, and not necessarily be mentally unwell, you will at least be more vulnerable to becoming mentally unwell by reason of the fact that people will distance themselves from you. This means that the more mentally unwell one becomes (or the more attributes of being mentally unwell you are perceived to possess) the more likely you will be ostracized by society. This is a real issue.
The most obvious way in which society attempts to counter this problem is through social work. Social work is an embedded profession now that essentially provides social support to the most vulnerable in our society on behalf of the State and private donors.
A distinct part (or at least cousin) of social work in Australia is the National Disability Insurance Scheme which provides those with a serious psychosocial disability the autonomy to choose the services they (and their carers) feel will most benefit them, many of which gravitate around social support and inclusion. In other words, we use money to purchase social support for those that need it, as supplied by those that have high levels of compassion and are skilled in having maximum impact.
Many of us have also grown familiar with the love and loyalty that pets can offer us, irrespective of the mental struggles we may face. In its most distinct form, some dogs are specifically trained to support owners who live with significant psychosocial disabilities.
The problem is, however, social and psychosocial disability work in today's society is largely focused on tertiary prevention or ‘downstream care’; measures that are designed to alleviate the symptoms of chronic mental health problems. In other words, we are putting most of our effort into problems that have become so entrenched that primary or secondary prevention is of little benefit anymore.
Some would even go so far as to say there is no such thing as ‘upstream care’ embedded into the Australian health care system; i.e. we do little by way of primary and secondary prevention. Many more would say that those that have struggled with mental illness have mostly received a crisis style response; reactive rather than pre-emptive.
It is comforting to know that 88% of us agree that we need to treat mental illness like other illnesses, ‘nipping them in the bud when they first emerge, rather than waiting until people get really sick’. Yet, it is a hard political sell because prevention is only achieved through long-term commitments and cross-government policies, which are rarely achieved over the course of short political cycles.
If we are to truly make headway on mental illness in our community, early intervention or ‘upstream care’ needs to be the primary goal underpinning our approach.
In practice, what challenges are associated with early intervention?
Before a medical practitioner can even consider what interventions to make, several complex issues arise.
First, they need to identify that there is in fact a potential mental health issue, which needs to be explored carefully in the context of what is happening in the consumer's life. It is not enough to simply accept a patient’s account that they are ‘fine’, ‘ok’, or have people they can talk to. Stigma, embarrassment, ignorance, or misunderstanding can lead to the patient underreporting or the patient being in a state of denial.
Second, the practitioner needs to have some idea of what exactly that issue is (and the time to make the relevant enquiries). This will require some level of specialist mental health training or considerable experience, and longer appointment times.
Third, a practitioner needs to convince a patient they have something worth intervening in before that patient has experienced the wrath of how debilitating their emerging mental illness can become. This can also be difficult as consumers often resist diagnosis, at least in the initial onset stage, as the powerful threat the diagnosis poses to their sense of self (often exaggerated by self-stigma) outweighs the temperamental effects of their emerging illness. Too many would prefer to 'tough it out' or 'play it by ear'.
Then, early intervention needs to be coordinated and closely monitored. Interventions need to be tailored and embedded into the patient's life. Medical practitioners and psychologists need to be held to account, but also need more support and technology to manage multiple patients. Services need to be better integrated. Roles between practitioners need to be more clearly defined.
And, given we now know that social circumstances play a huge role in the development and severity of mental health problems, we need targeted opportunities to measure and then respond to people within our communities who face isolation and greater mental health risk.
The system also needs to be consistent, dependable, and not difficult to navigate. When patients start falling through the cracks the entire recovery process is compromised, and we will creep back towards crises orientated mental healthcare system.
Thankfully, we already have a blueprint for what early intervention looks like.
While coordinated early intervention or ‘upstream care’ may seem like an impossible feat, the fortunate reality is that we are not seeking to reinvent the wheel here.
‘Preventative’ medicine for physical disease has matured vastly over the last 100 years, to the point where physical check-ups and various tests are considered part and parcel of our lives. This is especially the case as we age. Many tests have become extremely advanced and accurate, and there is a defined path forward for a patient if clinical tests come back positive.
However, the same cannot be said of psychiatric disorders where a patient’s first interaction with mental health services is often when they are in crisis or at least unwell enough to not be able to go to work.
This needs to change, and the health care system needs to introduce doctor or psychologist initiated mental health check-ups to not only identify early signs of mental illness but to normalise conversations around mental health with their patients. Having had these conversations in the past, patients will be much more likely to seek help if their mental health deteriorates.
Such an active policy is particularly important for those in their adolescence and 20’s, when a vast majority of mental illnesses first emerge. During this time people tend to be the most vulnerable, and the risk of mental illness derailing the rest of their future is the greatest. Given the economic considerations alone (ie long term loss of productivity and economic contribution), it is plainly irresponsible that preventative psychiatric care is not an established part of healthcare for youth.
Early intervention should also be focused on education, resilience and policies needed to protect everyone’s mental health. Active and innovative interventions should benefit everyone, but be more intensive for those experiencing higher risk or more severe problems. The preventative mental health care structure could operate in a manner similar to the prevention of certain physical health issues in the ageing population.
In doing so, we need to inject much more funding into the mental health care system to allow treating practitioners the time and space to identify and address the early signs of mental illness, and social isolation. We then need to make sure the mental health care system is user friendly, and not one in which the user will reject or fall through due to it being overwhelming. Of note is that according to the Lancet, for every $1 invested in scaled-up treatment for depression and anxiety, there is a $4 return in better health and productivity.
We need a preventative structure that acknowledges that mental health is a mediator of our overall good health, and that our mental health and physical health are closely connected. Our initiatives need to empower all people to develop themselves as social beings with a sense of value, purpose, and belonging, and ensure social support is provided when it is needed the most. Our initiatives should also encourage and perhaps incentivize all people to give support to those that have become isolated; we should not just outsource providing social support to the mental and allied health system.
Granted, however, it’s not an easy feat. The whole community, the entire medical profession, and each individual need to make headway together and figure out workable, harmonious, and economical solutions if it is to have a sustainable positive impact.
Early intervention for children and early adolescents; unchartered territory.
Intervening when mental health problems emerge during childhood and early adolescence can be particularly powerful in preventing or reducing the severity of mental illness in adulthood.
Yet, the system can be slow to meet the mental health and well-being needs of infants and children under the age of 12, as well as the needs of new parents. Parents typically experience long wait times and face stigma when looking for help. This is a missed opportunity.
Targeted early intervention services for youth include:
- supporting early childhood trauma
- supporting children in families where a parent has a mental illness;
- providing early treatment for anorexia nervosa ;
- programs addressing adolescent substance use.
About the Author: Heath Mitchell works as a personal injury lawyer (including psychiatric injury) and as a volunteer peer worker in the mental health industry. With lived experience of mental illness, he is devoted to progressing mental health care and advocating for consumers.
'I once lived in a dark house with bipolar disorder. I have since fixed the lights, and they have moved out. I now carry a torch at all times. If we cohabitate again, I will not be alone, and they will know the house rules. I am in control.'
Are you experiencing psychological distress? ??????????
Support is available! I am not a doctor or clinician. I write from my own experiences and research only. If you are experiencing psychological distress please reach out to your treating practitioner or one of the resources below. You have more options than you think.
Lifeline Australia — Call 13 11 14 — Lifeline is staffed by volunteer telephone crisis supporters who are ready to take calls 24/7.
Carers Australia — Call 1800 242 63 — Counselling, emotional and psychological support services for carers and their families.
Relationships Australia — Call 1300 364 277 — Relationship support services for individuals, families and communities.
NACCHO — Call 02 6246 9300 — National Aboriginal Community Controlled Health Organisation.
Suicide Callback Service — Call 1300 659 467 — Free, professional 24/7 telephone and online counselling to people who are affected by suicide.
Mensline Australia — Call 1300 789 978 — Supports Australian men and boys dealing with family and relationship difficulties. 24/7 telephone and online support.
Beyond Blue —Call 1300 22 4636 — Telephone and online support for those experiencing depression or anxiety.
Butterfly Foundation — Call 1800 33 4673 — Information, counselling and treatment referral for people with eating disorders.
Kids Helpline — Call 1800 551 800 — Free, private and confidential 24/7 phone and online counselling service for young people aged 5 to 25.
1800 RESPECT — Call 1800 737 732 — Counselling and support service for people impacted by sexual assault, domestic or family violence and abuse.
Open Arms — Call 1800 011 046 — Veterans & Families 24/7 Counselling and support services.
QLife — Call 1800 184 527 — Australia-wide anonymous, LGBTI peer support and referral services.