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There is a nursery rhyme called ‘There once was a woman who swallowed a fly’. It describes responding to the symptoms of a problem with more and more cumulative absurdity. This rhyme feels like a metaphor that represents current understandings around poor mental health and how to respond to it: the woman in the rhyme swallows a spider to catch the fly that she has previously swallowed, then a bird to catch the spider and so on. 

Similarly, the biomedical response to symptoms of psychological and emotional distress - indeed, illness in general - focuses on managing or eradicating them, as opposed to addressing or even acknowledging the contribution of causal factors present in the broader socioecology in which people conduct their lives. It is not always possible to simply improve conditions with immediate effect, for causes are multifactorial and tend to evolve over time. However, by locating the dysfunction within the individual through diagnoses and symptom control, there is a greater possibility that the inhospitable conditions in which many people live their lives will be overlooked and ignored, as they continue to endure and manage their negative impact. 

I’m from a person-centred therapeutic background, with an undergraduate degree in Psychology from the University of Abertay. I specialise in teaching an evolutionary biological, systems-based response to anxiety. I’ve spent much of my career working in the third sector with adult survivors of childhood sexual abuse, which taught me that positioning human responses to distress as mental ‘illness, disorder or disability’ is questionable. 

Many of the individuals I worked with were prescribed multiple medications, often for Medically Unexplained Symptoms. Iatrogenic symptoms (side effects, or simply effects of medication) were rife. It was difficult to figure out precisely what the medicines were supposed to be treating. Medication side-effects were unquestioned by uninformed sufferers as organic physical illness. Concurrent syndemic clashes were seen as the norm. The resulting rampant polypharmacy issues came as a shock to my colleagues and I, who were mostly person-centred counsellors grappling with clients who had been harmed and subsequently written off by the medical system. Their complex needs were seen to be psychiatric, i.e., located in faulty brain chemistry rather than expressions of distress in response to abuse, marginalisation and epistemic injustice. We began to collect this data and ran a conference on October 25th, 2012, for GP’s across Scotland to make them aware of this issue. 

All the individuals attending our services had been stuck in the psychiatric system for a long time with long-term diagnoses of chronic psychological conditions. These individuals were brothers, sisters, sons and daughters, parents, musicians, chefs, artists, academics. Some had been athletes in their day. Once labelled and treated, often in the form of incarceration and forced medication, they were never the same again. These people had not just swallowed a spider to catch the fly - they had been told to swallow a horse in the form of diagnosis and medication, and it was destroying them. 

When I began the MSc in Global Mental Health and Society at the University of Edinburgh, I’d hoped to find evidence of new approaches at the Global Level. While there are amazing projects taking place, it’s clear that there is also a drive to establish many of the same approaches that have been developed and implemented in high-income settings. Given that the rates of diagnosis and distress appear to be increasing year on year, this feels alarming, indicating that something about this response to poor mental health is not working. 

In the module ‘Critical Perspectives on Mental Health and Wellbeing’ led by Sumeet Jain, we were introduced to a project called Iswar Sankalpa based in Kolkata. The project helped to create a bare bones supportive and creative structure around individuals with ‘psychosocial disabilities’ who live on the streets. What inspired me about the project was the ‘agenda-less’ ethos: they were neither nudged to reform, to improve or to go home - they were offered basic medical, pastoral and material care (showers, clean clothing etc), and were listened to. The project responded to their needs in the form of true Unconditional Positive Regard for their choices. Pathways to support or change, such as opportunities for community involvement and training and development, were available if it was desired by the individual.. The project also engaged support from willing members of the wider community and felt to me to be respectful, thoughtful and considerate. 

 

Research Project

This example encouraged me to look at grassroots projects through a socioecological framework. I undertook a narrative review using Citizenship, Recovery, Wellbeing and Happiness Theory and Participatory Ideology as lenses through which to analyse the projects. 

I looked at the project Burans based in India, Buena Semilla in Guatemala, and the Camerados, a UK based project. Although each of these projects were different in their approaches, what they had in common was that each was deliberately situated in the social and geographical heart of communities. Each had a co-production/participatory approach with minimal hierarchy and recovery agendas were set by individuals in co-creation with workers in the organisations. Approaches were group-based, leading to enhanced connection, relationships, and the facilitation of peer support which often resulted in strengthening relationships within the broader community. People were invited to recognise the connections between their lives, and their emotional and psychological responses. Each of these projects also placed recognition upon the assets already present in the community, and how they belonged to and could be built upon within the community, by the community. 

What I found in the projects that I researched was an emphasis on community and connection. Participation and co-production were present in the ethos of each organisation, and empowerment was encouraged at the individual and collective level through knowledge sharing. Listening and speaking was encouraged and led to people feeling heard and understood. This for me represented person-centredness in action.

 

Conclusion 

Although many organisations are doing amazing work, they often reside at the treatment end of the human experience. Help with rebuilding connection and community and fostering an improved environment tended to come after psychological deterioration rather than in prevention of it. 

I became aware that if we acknowledge the importance of conditions for ‘recovery’, then we perhaps also need to be aware that we are overlooking the original conditions in which people are expected to live in the first place. There is still an emphasis on terms such as ‘psychosocial disability’ which, although acknowledging the social aspect of distress, still locates the problem as a disability within the individual, rather than in the broader socioecology. 

If, as acknowledged by the movement for Global Mental Health, the burden of cost of poor mental health to the global economy is truly high, and funding for mental health services is hard to come by, why is prevention largely missing from the Global Mental Health narrative? 

My takeaway is that if we know that the quality of living conditions is vital to the ability of human beings to enable them to thrive, there needs to be more focus on ways to create conditions that embody human rights, person-centredness, community-focussed, fully participatory environments in the first place. If not, by continuing to fail to recognise distress as a barometer of poor conditions, we risk exporting a destructive model of symptom management that will leave people in such conditions with the added burden of a diagnosis of malfunction located within their person. As I contemplate the direction of my PhD research proposal, I’m left with far more questions than answers.

 

 

Gill Batty works one-to-one with clients across the globe who are experiencing anxiety. She is currently creating an online, fully illustrated interactive course which will be a digital version of the one-to-one work that she currently does – to enable more dedicated time to researching the impact that diagnoses and the medicalisation of anxiety has upon individual and societal understandings about anxiety and its function as a distress signal and response. 

Twitter: @GillBatty