Thomas Dixon is Professor of History at Queen Mary University of London, where he researches and teaches the history of emotions. Since 2019 he has been leading the ‘Developing Emotions’ project, helping to teach and support emotional literacy in UK primary schools. In this post he reviews Dr Lucy Foulkes’s new book, Losing Our Minds: What Mental Illness Really Is And What It Isn’t (London: The Bodley Head, 2021).
Emotions are not illnesses, but you’d be forgiven for thinking they were. “Anxiety” and “depression” have both named emotional states for longer than they have named illnesses, but both words now convey inescapably double meanings, referring both to feelings and to disorders. There are subtle semantic differences between “being” anxious or depressed, “feeling” anxious or depressed, and “having” anxiety or depression – but such subtleties are rarely brought out in public discussions, in which everyday feelings keep morphing into other things. When does an emotional experience become a “mental health issue”, a “disorder”, or a “mental illness”?
These are among the questions that Dr Lucy Foulkes takes on in Losing Our Minds. She remarks that the main reason she wrote the book was her concern – both as someone with a history of mental illness and as a psychology lecturer supporting young people – that the language being used around mental illness is exacerbating the very problems it is designed to help (p. 162). The book opens with a ‘Note on terminology’ and a quote from Nathan Filer: “There is no uncontroversial language when talking about mental illness – and that includes the phrase ‘mental illness’.” (Filer is, incidentally, the author of one of my favourite books about mental illness – originally published in 2019 as The Heartland, and since reissued as This Book Will Change Your Mind About Mental Health.) Although Foulkes, “cautiously” uses the phrase “mental illness” throughout her book, she nonetheless offers powerful reasons why others might think twice before doing so in future.
This emphasis on language is really important. We must all have noticed that, whatever the rates of particular mental illnesses, we are undoubtedly living through an epidemic of discussions of “mental health”. “We all have mental health.” “Are you struggling with your mental health?” “Take a walk in the sunshine for your mental health!” “How has Covid-19 impacted mental health?” The phrase “mental health” now includes within its ever-expanding semantic remit both its own opposite (mental illness) and also pretty much every other kind of emotional experience. There has also been a medical process of disorder inflation, a bit like the grade inflation people complain of in academic settings. Each successive edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) is fatter than the last – containing, overall, more disorders, with lower thresholds for diagnosis. In other words, it has been getting easier and easier, over time, to qualify for a disorder.
The first step Lucy Foulkes recommends towards puncturing some of this linguistic inflation is to make clear, in how we speak, that there is a difference between difficult feelings and clinical disorders, in other words “to allow space for normal human emotion in response to difficult events without labelling it as a disorder, even when that emotion is devastation. We should be comfortable talking about and responding to distress in its many forms – worry, loneliness, grief – without immediately resorting to a dictionary of disorders” (p. 175).
Losing Our Minds provides tools with which to map the muddy and misty borderlands between emotions and mental illnesses. Foulkes brings her own experience of a mental breakdown as well as her academic expertise to bear on the topic identified in the subtitle: ‘What mental illness really is and what it isn’t’. The thread of her personal story is woven unobtrusively into what is primarily a guide to the state of the art in the science of mental illness, as applied to pressing issues such as whether there really is an “epidemic” of mental illness among young people, whether using social media is bad for your mental health, the shifting meaning of “trauma”, and why young people seem to be increasingly drawn towards self-harm. The book is lucidly written and builds its case with a winning combination of care and concision.
Along the way, we learn about the best recent scientific studies on, for instance, the impact of genes, brains, and parenting on mental health. The discussion of parenting will make uncomfortable reading for those who, like me, are already all too aware of the way they “model” unhelpful feelings and behaviours to their children. In fact, this is pertinent to the longer history of human emotions too. The way that parents pass on to their children deep-seated emotional attitudes and responses which they, in turn, learned from their own parents, is one of the main mechanisms through which emotional regimes are transmitted through the centuries. There is also an interesting historical resonance in the idea – discussed in a section entitled ‘Might there only be one mental illness?’ – that delusions and irrationality could be shared features of many mental illnesses today (pp. 62-65). Such an idea would have been recognised by philosophers and physicians from the time of John Locke onwards as they worked within their much simpler taxonomies of mental derangement three centuries ago.
Foulkes also points out that history should make us sceptical of the idea that people today have unprecedentedly stressful lives. As she rightly says, war, sickness, financial crisis, and injustice have been the rule rather than the exception in human history, noting also that late nineteenth-century ideas about the ‘neurasthenia’ caused by modern life is just one precursor of modern discussions of a unique crisis in mental health. Despite this warning, Foulkes’s own account hints at a somewhat exaggerated sense of the extent of change in the very recent past. She states a couple of times that as recently as 2008 “no one talked about mental illness” (p.3). This doesn’t chime with my own personal recollection. When I was a student in the early 1990s I attended the university counselling service for treatment, and also volunteered on a student nightline designed to help those suffering mental crises. A report published in 1989 by the Office of Health Economics began by stating: “Some commentators regard the term mental illness as being so wide ranging that it is at best virtually meaningless and at worst misleading”. Even the most recent phases of our discussions of what is and isn’t mental illness has a history going back some decades. Dr Sarah Crook has published research on debates about a crisis in the mental health of undergraduates in the period 1944-1968, offering another useful counterpoint to the idea that students in the twenty-first century are uniquely prone to mental illness.
I don’t want to give away too many of the findings that Foulkes explains and discusses in her book, but the general picture is one in which any real rises in levels of mental illness are much lower than media reporting tends to suggest. For instance, an NHS-led study of young people aged five to fifteen, from 1999 to 2017, found an increase in the rates of depression and anxiety disorders from 9.7% of the cohort in 1999 to 11.2% in 2017 (p. 18). The book is also really good at explaining how and why that mismatch arises between careful scientific studies and the headlines based on them – a perennial frustration for those of us wanting a careful and evidence-based discussion on this topic. Foulkes approvingly quotes Mark Rice-Oxley’s comments on how a survey finding that a quarter of participants reported having a number of depressive symptoms (which might, or might not, in consultation with a medical professional result in diagnosis and treatment) will get reported as “A quarter of the nation has depression” (p. 177).
While rises in overall levels of mental illness in the last twenty years have been relatively modest, there are some other areas where the changes are more alarming. This includes massive rises in the use of anti-depressants. Prescriptions of these drugs practically doubled – from 36 million to 71 million between 2008 and 2018 in the UK (p.13) – an increase totally out of proportion to any change in actual levels of mental illness, and all the more worrying given the debates about effectiveness and side-effects. Foulkes also looks at rising rates of self-harm in girls and young women, and explores how such behaviours arise, and why they spread. On this and other topics, she is always guided by available scientific studies and, refreshingly, will often conclude that we just don’t know – for instance on the question of whether rising reported rates of mental illness reveal that mental illness is itself rising (p.161). It could be that we are all talking about mental health more, and differently, and that emotional experiences that were not previously considered evidence of illness now are.
So, where does Foulkes stand on the question of what really is a mental illness and what isn’t? Are we misusing the language of “illness” and “disorder”? The picture Foulkes paints is one in which normal emotional experiences and mental disorders exist on a spectrum, and in which there is no clear, non-arbitrary way to mark the dividing line. Mental illnesses do not have “biomarkers”. You cannot scan my brain or body, or do a blood test, to see if I have depression the way you might test if I had a physical illness, like cancer, a cold, or Covid. Nevertheless – and perfectly consistently – Foulkes urges us to take the admittedly blurry line between mentally healthy states and mental illnesses seriously in the way we think, talk about, and treat them – for the sake of those on both sides of the line. It does not help those experiencing stressful but ultimately manageable emotions if we label and treat them too hastily as sufferers of an illness. And it does not help those most in need of treatment, Foulkes argues, if those of us with emotional problems that fall short of “real” mental illnesses are channelled towards over-stretched mental health services.
Towards the end of the book, Foulkes explains the distinction she wants to draw by contrasting two episodes in her own life – one at the age of seventeen following the painful end of a relationship, and a second more severe disruption to her life when she was twenty. The first she calls a “period of prolonged sadness” and the latter a “fully-fledged breakdown”. In the first episode, she concludes, she didn’t have a mental illness, in the second she did (pp. 172-3).
I think we definitely need to distinguish between manageable emotional states and more severe incapacity, but I am not as optimistic as Foulkes about the possibility of doing so in a consistent and helpful way using current concepts of mental illness and mental health. During the discussion of her “period of prolonged sadness”, which she does not consider to have been an episode of mental illness, Foulkes notes that she probably fulfilled the criteria for a diagnosis of clinical depression. This is crucial, and suggests a bigger question, which Foulkes does not answer. How are we to distinguish between prolonged sadness and clinical depression if not by the diagnostic criteria used by health professionals? The implication of Foulkes’s comment is that it is the diagnostic criteria used by mental health professionals themselves, rather than loose talk by patients and commentators, that are the real problem. But she doesn’t quite come out and say so.
Although I remain unsure how we can best address the harms done by the concept creep exhibited by “mental illness” and “mental health”, this impressive book is a great starting point for well-informed conversations on the issue. It speaks with calm, rational humanity about why we should hesitate before medicalising our emotions.
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Read a blogpost and listen to a podcast about the ‘Developing Emotions’ programme of lessons for primary schools