Escaping the Black Dog's Shadow

Several weeks ago, Johann Hari told us that everything we knew about depression was wrong.

Several weeks ago, Johann Hari told us that everything we knew about depression was wrong. As an opening gambit for any new book it was a brave one, never mind it coming from a disgraced investigative journalist. Hari’s claims, excerpted in The Guardian were doubly dubious, partially based on dubious statistics and where more reliable rather less new than the book’s title claimed with depression having causes external to the brain known by and taught to healthcare professionals for decades. Even to those outside the healthcare profession, the suggestion that we were unaware that mental health problems were socially determined is at best disingenuous and at worst actively harmful. Speak to anyone who is depressed or mentally distressed in de-industrialized towns, or forgotten seaside resorts, and they’ll tell you it’s not because they’re a biologically distinct tribe to the residents of Kensington (or at least Kensington’s richer residents). Perhaps because the vast majority of what they, or anyone facing oppression or systemic injustice, know about depression, is right.

The ‘You’ that Hari was addressing in his article and book isn’t really any of these people though. Looking at the sleeve of Lost Connections, adorned with gushing quotes by everyone from Matt Haig to Elton John, the desired audience for his piece and book becomes clearer. The ‘You’ conjures up the commentariat and mainstream media narrative that currently exists around mental health - a narrative that for years has ceaselessly circled around the need to ‘speak out’ and ‘break the stigma’, and has become so hollowed out and devoid of real insight that the Royal Family is able to enter into the fray, clearly signifying the debate as wholly apolitical. If this is the space into which Hari intended to launch his book then the suggestion that social factors can influence our mental health would undoubtedly be seen as a novel take. Reading his book makes clear that his years of jetsetting to uncover the truth about mental health only produces a series of ahistorical and unlinked anecdotes, giving rise to individualised self-help hacks. Rather than collectively piling in on the flaws in this, there’s a need to present a counter narrative that listens to the voice of survivors to understand how we got to this apolitical space, and consider what is our way out.

The black dog’s shadow

In March 2006, a statue appeared in Norwich of depicting Winston Churchill constrained by a straight jacket. It later turned out the 9ft figure was commissioned by mental health charity Rethink as part of a campaign to tackle mental health stigma. This served as something of a harbinger for the years to come, both for mental health policy and discourse. This was a period in which the space to discuss the politics of mental health was chipped away - and then colonised by the third sector- a process that could loosely be termed the ‘black dog-ification’ of mental health. Looking at the figure, Churchill was undoubtedly chosen by Rethink (and later Time to Change) as a mental health icon due to his writings on the ‘black dog’ that visited him during periods of poor mental health. It mattered little that Churchill was also in favour of compulsory labour camps for those he saw as ‘mentally defective’, the function he and his black dog served was perfect for the myopic vision of the next decade’s mental health campaigning.

Perhaps most immediately harmful in the conjuring of a ‘black dog’ associated with mental health problems is that it encouraged people to see their distress as something external and, even more importantly, inexplicable. Though metaphor at times has its merits, this process can serve to prevent us from establishing the triggers and underlying causes of our symptoms, and ultimately hinder debate by refusing to name structural causes of mental illness. The ‘black-dog’ anti-stigma approach to mental health can then claim progress by encouraging discussion of a sanitised image of mental health, with a dark unnamed cause lurking at the edges, invoking sympathy for those who did not choose to be visited by this creature. The anti-stigma initiative has been described as a process of ‘benevolent othering,’ which speaks of others in ways that are ostensibly positive but which function to maintain their subordination to capitalist market forces. Mark Fisher famously wrote on the privatisation of stress, encouraged by capitalist systems to further exploit a workforce conditioned to dissociate work stresses from their mental health. The encouragement of this dissociation was perhaps exemplified by 2017’s World Mental Health Day with its theme of workplace wellbeing. Amid the current crisis of work, it’s an incredible sleight of hand that such a theme aims to reconcile us with distressing work, while also championing the employers responsible for their ‘mental health awareness’. As David Frayne pithily remarked at the time: “dare we imagine a Mental Health Day on the theme of ‘inequality’, or ‘capitalism’?

The ‘black dog’ has further aided market forces through the commodification of mental health, creating a new social issue that brands can tack onto products, or, in some cases, help to target individuals whose online search behaviour might indicate they are distressed with consumption proffered as the solution. The sole intervention into markets for the cause of our mental health has been to prevent the sale of stigmatising halloween costumes - an incredibly minor disruption in a two week period of the consumer capitalist calendar, but one that has been heralded as a key win of the now decade old Time to Change campaign, into which the government has poured at least £20 million to date. If the anti-stigma campaign, and the work of mental health charities, have only ever sought to evoke sympathy and place a slight veneer over the ongoing atrocities of neoliberalism, what then is to be made of mental health charities’ complicity with a system that repeatedly punishes those they claim to represent?

The co-option of recovery

“The message we want to portray is that it is possible to recover from mental illness and overcome it and be successful - because Churchill is an example of someone who was able to do that” was the statement put out by Rethink following the stunt. The role recovery plays in this statement is significant, as it’s closely followed by an expectation that this involves overcoming mental illness and being ‘successful’. This emphasis on recovery as ‘success’ within the narrowly defined purposes of existing society stands in stark contrast to the conception of the Recovery Model that held its roots in the civil rights movements of the 60/70s. Emerging during this time the movement sought to question power, and emphasised the importance of autonomy and self-determination. Ultimately, however, such radical potential was defanged allowing aspects to be reorganised in ways useful to the purposes of the state and capital.

Much of the third sector in the 00s heralded the notion of recovery as a sea change for mental health services. Rather than focusing on deficits, people would be encouraged to become experts in their own self-care and pursue their aspirations and goals. Within this new recovery framework, service users were recast as ‘experts by experience’ and framed as equals alongside professionals, working together to “co-produce” mental health services. These were all nice rhetorical flourishes, but processes which were fundamentally incompatible with the third sector. Uneven power dynamics that limited the input of service users and the expectations of funders meant that these efforts were bound by the neoliberal impact-driven nature of the sector, and “pursue your aspirations and goals” became “be successful” on our metric driven terms. The drying up of funding post-financial crash meant that many of the smaller, more radical user led groups lost funding or were outbid by these growing impact-driven charities presenting a homogenous definition of recovery.

The idea of work as a cure was central to the new conception of recovery, with employment being seen as a key outcome of mental health treatment and job-seekers expected to be work-ready, with a positive mindset and disposition. The work cure as a capital based intervention also serves as an ideology through which to manage its own reproduction even as it produces and amplifies distress and melancholic apathy. Writing on the “political economy of unhappiness” William Davies noted that these states currently represent the “critical negative externalit[ies] of contemporary capitalism.” As work becomes progressively more atomised and service based, and constant cognitive attention online is required to drive profits, this mental malaise strips the ideal neoliberal subject of their enterprise and desire to better themselves as well as limiting their consumptive capacities. Marx notes how,

Capitalist production, therefore, develops technology, and the combining together of various processes into a social whole, only by sapping the original sources of all wealth — the soil and the labourer.

This provides a framework for thinking about unhappiness as a major contemporary way in which the worker as source of wealth is sapped and then of interventions on this terrain as a means of securing capital’s reproduction as cheaply and in a way as compatible with capitalism’s interests and purposes as possible. Davies again highlights how the work cure serves to aid capitalism’s reproduction across all these levels:
The depressed employee is stricken by a chronic deflation… which can lead him or her to feel economically useless, and consequently more depressed. The workplace therefore acquires a therapeutic function, for if people can somehow be persuaded to remain in work despite mental or physical illness, then their self-esteem will be prevented from falling too low, and their bio-psycho-economic potential might be rescued.

Against the backdrop of austerity, the links between mental health charities and ‘work cure’ have flourished. Mind have bid for contracts with - and seconded a senior member of their team to - the Department of Work and Pensions (DWP), while maintaining a doublespeak that also enabled them to condemn conditionality and sanctions. Until last month, Conservative MP Esther McVey sat on the advisory board of the Samaritans. Even prior to her appointment as Secretary of State for Work and Pensions, this was an MP who is consistently voted to decrease disability benefits, leaving those facing the brunt of cuts to benefits and services wondering - is there anywhere truly left to turn?

Missed connections

In the immediate aftermath of Hari’s piece and the launch of his book, many rallied against him claiming it was dangerous to allow him such a prominent place in the mental health debate. The issue is that the way in which we talk about mental health is already dangerous, serving to privatise our distress, to placate us with toxic work practices and further entrench the creeping neo-liberalisation of the third sector. These processes feed off each other and leave us without any clear solutions of how to overcome them. If we truly want to escape the shadow cast over the last decade by this black dog, a key aim must be to break the link between work and treatment that have now become so tightly fused. From this we can consider how the principles of autonomy and self-determination could once again be reclaimed in both these spaces.

Working isn’t working

Hari’s suggestion to readers to simply ‘democratize your workplace’ wilfully avoids the fact that a fight for mental health at work cannot be won through individual action but must involve collective agitation and organisation against employers and the forces of capital. However, resistance to work no longer manifests itself in an organised voice, but through a wide range of mental distresses. 322,000 working days were lost due to industrial disputes in 2016, while 12.5 million were lost due to work related stress, anxiety or depression in the same year. The overall trend in sick days is declining, but those taken due to mental ill health seem to be rising: we are bearing the brunt of the current crisis of work individually - and often silently - and need to take collective action. Trade unions must re-emphasise the vital role they can play to support workers’ mental health that has always been at the movement’s core. Every bargain negotiated by trade unions provides a benefit to workers’ collective mental health, as the Trade Union Congress (TUC)’s 1880 annual report states: “In a normal state of things wages at any given time and place should not fall below…whatever the contemporary local civilisation recognises as indispensable for physical and mental health.” The new normal should not be a situation where two in every five employed people in the UK are in work that doesn’t provide a secure, living wage. Nor should a commitment to mental health be merely a tick box exercise on top of toxic work practices and structures, where it is easier and cheaper for employers to prescribe a wellness course for individuals than to change how a workplace is organised.

Going further, trade unions can integrate with growing demands on the left for a ‘politics of time’ that questions the embedded nature of the work ethic and calls for greater freedom and autonomy. These calls are situated between the neo-classical perspective of work in itself being the opposite of utility, and the more modern economic view of employment as a wholly positive force for mental health, alleviating the suffering caused by unemployment. Rather than encouraging workers to instill meaning to their roles, or to simply follow what they love, such a project has broader aims in rejecting the assertion that work is inherently good, and instead emphasizing how a better sharing out of good work can benefit society. This rebalancing could provide mental health benefits at both ends of the scale. Last year, workers were estimated to have put in 2.1 billion hours of unpaid overtime, a working pattern associated with a host of mental and cardiovascular strains. Moreover, with the contemporary world of work defined by high insecurity, low control and high demands, most notably in the numbers of workers employed on zero hours contracts, much vaunted flexibility has severe impacts on workers’ mental health. Beyond paid work, unwaged work, often entailing tremendous amounts of physical and emotional labour, continues to be overwhelmingly carried out by women, a vast inequality that not only erodes women’s free time, but also their own mental health and happiness, with middle aged women being two thirds more likely to suffer work stress than men.

Listening to survivors

A lot of the focus of Hari’s book will be on the fact he has recycled his evidence while describing his conclusions as novel and this reinforces his reputation as a plagiarist. What also should not be ignored, however, is that many of the solutions Hari proposes are watered down presentations of the more necessary and radical demands already being called for by numerous survivor groups. When discussing the scarring effects of childhood trauma on our mental health, Hari speaks with Dr. Robert Anda, the director of the ’90s ACE study on trauma, who he quotes as saying that the study’s findings made him realise it’s time to stop asking “what’s wrong” and instead ask “what’s happened”. This would be novel if it hadn’t already been called for by survivors for at least a decade earlier than the ACE study, or, at the time of Hari’s writing, was not being asked in the NHS.

A recent review found that, at most, only a quarter of psychiatric patients are asked about their experience of abuse or violence, despite the Department of Health requiring staff to ask this question since 2003. Even if patients are asked about these experiences, the current mental healthcare system is ill equipped to give people the space and time to work through this trauma. Those from more marginalised backgrounds, already more likely to have experienced abuse and violence and often unable to access private treatment, are faced with up to year long waiting lists for trauma informed care or an NHS that can reinforce abuse and trauma along axes of oppression. In the most extreme cases people of colour are three times more likely to be restrained in mental health units. However, re-traumatisation visited on patients receiving mental health treatment through the NHS extends beyond, and can be more insidious than, the use of restraints.

Radical therapist David Smail has suggested Thatcher’s belief that there is no such thing as society finds “an unacknowledged echo in almost all approaches to therapy”. It is certainly the case in Cognitive Behavioural Therapy (CBT), the most common therapy accessed through Improving Access to Psychological Therapies (IAPT), a program introduced by New Labour in 2008 following the advice of economist and workfare proponent Richard Layard. In this original advice, CBT is heralded as a means by which to overcome mental health problems using a “here and now” approach to therapy that focuses on negative thought patterns and problematic behaviours. This de-contextualised approach to therapy could be seen as problem-solving, but implicitly it encourages individuals to carry out continual self-work to become more attractive to the labour market. The onus is on the individual to respond almost stoically and rationally to their negative thought processes. The issue is, however, that we exist outside of our thoughts, in a material and systematically unjust world. People of colour who are already more likely to disengage with health services, may be being routinely abused by a method of therapy that encourages the erasure of the structural violence they encounter. Being in financial difficulty drastically reduces the likelihood of recovery from common mental health problems, and CBT is unlikely to help that; there are only so many ways you can mentally reframe the gnawing uncertainty as to whether your landlord may kick you out, or when the bailiffs may next come round. IAPT was sold not only as a means by which to “cure” half of people experiencing common mental health problems, but also to produce the largest dataset on wellbeing in history. However, committing to such reductive rationalism leaves you nowhere when your numbers don’t even add up: relapse rates following IAPT treatment are over 50%, and (ironically given what was a key selling point of IAPT in the initial cost-benefit analysis) as few as 5% that complete treatment return to work.

Any forthcoming Labour government, alongside restoring NHS funding and ending privatisation, needs to seriously grapple with the actual nature of mental health treatment. A first step will involve listening to the demands and needs of the public, as the Labour Party has in so many other areas of policy recently. However recent evidence suggests Labour is still wedded to an overly data driven approach to treatment. ‘For the many not the few’ contained a pledge to ask NICE to evaluate the potential for increasing the range of evidence-based psychological therapies on offer. This would sound promising if evaluating the potential to increase the range of therapies on offer wasn’t so far removed from actually calling for them to be increased. It appears even less promising given this is something NICE already systematically does, having published a draft on its updated guidelines for depression last July. One option put forward is the grim possibility of group CBT through IAPT, but this suggestion isn’t surprising, as the paradigm through which NICE evaluates its evidence is overly-reliant on medicalised models of mental health that serve to minimise patient preference and need, as well as their external context and circumstances. We may conceptualise our distress as an illness, the result of trauma, or social factors, but a guiding principle for treatment should one that best validates our lived experience, and however we choose to to understand it.

Nothing about us without us

In his 2010 book Thrive, Richard Layard remarked: “It is not reasonable to expect much activism from those who are mentally ill or their relatives: they are naturally reticent. It is all of us who should be demanding change.” Though we are still left with the deep roots that Layard was allowed to plant into mental health service provision, thankfully time has shown the folly of his and New Labour’s condescension and supposed benevolent managerialism. Groups like Recovery in the Bin, Disabled People Against Cuts and individuals like RF - whose recent High Court Case produced the ruling that changes to Personal Independence Payments (PIP) were discriminatory to people with mental health problems - are just a few examples of the vital radicalism that can only come from survivors. Though largely overshadowed, the much heralded ‘For the many not the few’ manifesto was also accompanied by ‘Nothing about you without you’, laying out Labour’s disability policies. A strong statement on Labour’s commitment to these issues, but also with the title, itself a rephrasing of the call by disability activists from at least the 1980s, containing the possible future pitfalls of this effort. Any future Labour government would do well to ensure they don’t follow the same mistakes as Johann Hari and others: finally hearing the calls from survivors and appropriating them as your own is no substitute for a movement that repeatedly listens to and places survivors at its core.

This piece takes influence from and draws on themes in a chapter by Ivor Southwood in the forthcoming book The Work Cure (edited by David Frayne)