Introduction
I am very familiar with the phenomenon we call mental illness, but I do not like the term at all. It is misleading and is frequently misapplied to cause harm to people who already have a psychological injury. Adding a stigma to what can be a challenging thing to live with seems cruel and pointless.
In the 1970s I worked in psychiatric hospitals, engaging with people who had severe to profound cognitive and behavioural disabilities. From December 2001 to June 2006, I worked with what are now known in NSW as Assisted Boarding Houses as a Support Manager. The resident population of these boarding houses was a combination of people with intellectual disabilities and those diagnosed with mental illness. I visited these boarding houses often and became familiar with, and comfortable in my interaction with, the residents.
In between those roles there were others that exposed me to psychiatry and the challenges of living with cognitive and behavioural disabilities in the community and at work.
I have friends and family members who live with depression and/or anxiety, and more complex conditions. And I have had my own challenges.
I have no formal learning in psychology. I have read widely for decades in psychiatry and psychology as part of my own professional development.
The mind is the brain?
The idea of mental illness arises chiefly from the idea that the brain is the source of the mind. This is a position that arises directly from empirical evidence in brain science. It is a perfectly reasonable one to hold. But it is disputed by people who hold spiritual and religious beliefs (like me).
There is absolutely no doubt that what we think, and feel, is mediated by the brain. So even if you do not believe that the brain creates the mind, you can’t escape the evidence that at the very least, brain-mediated awareness dominates our notions of mind.
The metaphysical disputes between a materialistic and religious on the nature of the mind are pointless here. Unless there is mutually admitted empirical evidence such a dispute can go nowhere.
I want to make a carefully nuanced assertion. For the behaviour we are considering here, the ‘mind as brain’ model is sufficient in most instances. Where it is not sufficient there tends to be a shared acceptance of ‘higher’ attributes of our cognition and behaviour without splitting metaphysical hairs. There is an agreeable vagueness about the language and there is a shared sense of intended meaning.
So, is mental illness a physical condition?
It seems that some are either born with, or acquire, injuries to our brain such that impaired cognition or behaviour is stubbornly persistent. That doesn’t mean the impairment causes dysfunction at a level that it can be classified as a disability. Like anything, there is a spectrum of levels of impairment – from nothing very much to serious debilitating conditions.
Beyond that, we have experiences that cause our brains to respond in ways that can impair our cognition and behaviour for short or long periods. If severe and persistent, this may result in a disability. A short-term impairment might abate in time or through an intervention. This can range from situational stress to Post Traumatic Shock.
Here I am not attempting a comprehensive discussion of the brain. I want to simply make a point that under the mind is brain model we must be talking about physical brain states. There is no thing called the mind that can explored unless the term means brain. Mind is a cultural artefact that we need to talk about our cognition and behaviour. The moment we say the mind is created by the brain we are talking about brain states – physical states.
Why does this matter? It makes mental illness a gross misnomer. And this is very important.
The problems no understanding of psychiatry create
I must declare that I am not a huge fan of psychiatry as a discipline. I don’t want to explain why here, I just need to declare a bias. This bias, I hope, will not interfere with what I want to say here.
My experience in psychiatric hospitals has exposed me to extreme manifestations of cognitive and behavioural malfunctions. I have been on wards where I have feared for my safety. There are dangerous people – in psychiatric hospitals, in prisons and in the community. But few people who are diagnosed with a ‘mental illness’ are dangerous.
The Blackdog Institute observes that. “Common mental illnesses in Australians are: anxiety disorders (14%), depressive disorders (6%) and substance use disorders (5%)”. Anxiety and/or depression is most likely what you will find in your workplace. And we all get anxious or depressed at some stage in our lives. People who are anxious or depressed are not scary.
But for most people their exposure to mental illness is via popular culture – stories and cultural traditions. Depicting mental illness in ways that do not trigger a threat response in a viewer or reader usually is a waste of a good narrative.
We all are familiar with the language of psychiatry – schizophrenic, psychotic – and the language of popular culture – mad, troppo, demented, deranged, lunatic, looney, batshit crazy and so on. Some of the language in popular culture is a residue from the language of psychiatry from the past.
We are mostly primed to respond to this language (from both sources) with some level of threat. This is because when we encounter it, it is most commonly in a highly negative context – and one usually intended to generate a threat response for dramatic effect. This includes news reports and entertainment like movies.
The result is that many people are not in a position to respond to the idea of mental illnessin the best manner. This is the foundation of the idea of a stigma connected with the term. It implies a sick mind and hence the risk of disordered thought and behaviour.
Bias and behaving badly
Implicit bias is a bias that has been developed through exposure to cultural and historic attitudes, ideas, and values. An implicit bias is an unconscious conditioning that will be activated even when there is conscious intent to respond in a positive non-biased way.
But let’s add to the implicit bias a more primed response that activates threat responses in the brain because exposure to ideas about mental illness has a current and active impact. We cannot know when an individual was last exposed to negative stereotypes. Between cultural conditioning and personal experience, the impact of bias is magnified.
If your exposure to mental illness is largely negative or sensationalistic (via movies or scary stories) you will likely have an implicit bias that is triggered when you hear the term. That could be a mild threat response, but it will move you away from, rather than toward the person to whom the term is applied. That’s the stigma at work.
There’s another level. An individual with a magnified level of bias against mental illnessmay also be experiencing any number of states triggered by stressors (work pressure, personal life stressors, psychological injury) that means an additional cognitive and emotional burden triggers an adverse response to an idea already distorted by bias.
Put simply, some people cannot respond to the idea of mental illness in a way that is respectful or compassionate, even if they want to at a deeper level.
Let’s get rid of mental illness and talk about psychological wellbeing and safety
We all have times when we struggle to keep an even keel in the midst of an existential storm. Such a storm can be short lived, or it can endure for months, or longer.
Our ability to rebound (resilience) depends on a range of factors – the nature and severity of the storm, our health (physical and emotional), and whether there are other storms around. If we are not constitutionally resilient, our ability to handle the cognitive and emotional stress triggered by responding to the idea of mental illness can be impaired.
For example, a parent whose marriage is on the rocks is advised one of their parents is dying in a problematic nursing home. This triggers issues with siblings. One of their children is being bullied at school. And a restructure at work has led to an increase in work demands. That’s a massive stress load. Normal life can do that.
I am not talking any disability here. The emotional demand on the parent may be so severe that their work performance is impacted. There’s nothing here to trigger a diagnosis of a mental illness, but the accumulated impact might be similar.
A person born with a brain state that makes a heightened sense of threat their normal state – with no functioning on/off switch – is no more ill than a person born without a left foot. Either condition will impact behaviour; and may impact cognition to some degree. True, a brain state disability may require more intentional effort to maintain effective cognition for longer than a person undergoing an existential storm, or two. But is the effort fundamentally different – or just extended in time?
A clue might be the number of people with diagnosed psychological conditions who perform perfectly well – without anybody aware of their diagnosis, or the fact that they have one – or that they are undertaking therapeutic treatment or are using medication. Now and then they may need an accommodation or an adjustment – just like anybody else.
Asking for that an accommodation or an adjustment, and having to give a detailed reason is where the problems start.
Conclusion
Being born with, or acquiring, a brain state that does not have an off switch for normal processes like feeling anxious or depressed isn’t an illness. It is a physical disability. I know I can get into a serious argument on this point with some. But it’s not going to be here.
We must move to thinking in terms of psychological wellbeing and the psychological safety at work to ask for an adjustment or accommodation when the need arises. There can be no justification based on the reason or cause, only the self-assessed and expressed need. Some may wish to say why there is a need. Others may not.
The modern workplace must be a place where a perceived need for time out can be assumed to be genuinely self-assessed. There will be some who will disagree and that there may be staff who will use this freedom to wrongly seek time out when there is no need. Leaving aside the psychological condition that motivates deception and exploitation of good intent, there are effective ways of managing the conduct of the minority whose approach is demonstrably inappropriate.
In many ways this has nothing to do with disability. A universal capacity to accommodate the psychological health needs of all will benefit people with disability who need accommodations and adjustments. It’s about treating adults at work as rational agents capable of assessing their own needs. It is not about medicalising going through a tough time to satisfy a need for ‘evidence’ beyond self-reporting.
The NSW public sector allows for a certain number of days on sick leave without a medical certificate as it is. This is legacy thinking, belonging to times when there was a presumption that staff would ‘bunk off’ whenever the opportunity arose. In fact, current research suggests that this isn’t the case – unless the workplace is toxic and unsafe. Also, its commonplace to refer to a ‘sickie’ as a ‘mental health day’.
We need to rethink how we address the need of people who have periods of emotional and cognitive overload because of a stressful situation and need time out. The culture we have created discourages open discussion. Diagnosed conditions like anxiety and depression are manageable in the normal run of things for many people. But now and then not so much. How is that different to a person balancing a bunch of stresses and needing a ‘mental health day?’
The Blackdog Institute notes that “54% of people with mental illness do not access any treatment.” But does it mean 54% of people diagnosed with mental illness? So, about half are into handling out themselves. And what about those who haven’t a diagnosis? If you take the earlier figures, that’s around 13% of the population who have a diagnosis and are doing it for themselves. That’s around 1 million people in NSW. Yeah. I had to go back to my calculator. That’s over 50,000 NSW public servants. Why aren’t we responding to their needs?
By creating and maintaining a culture which offers psychological safety and values psychological wellbeing, the stigma connected with mental illness can be eliminated because that term is no longer in use. That may create a culture of safety and trust, in which discussing one’s needs happens without fear.