Dr Karen Galway is a Lecturer in Mental Health at Queen’s University Belfast. You can catch Karen on her soapbox at the Belfast event on 24th June 2017 giving a talk called: “Can science fix broken emotions?”
By Karen Galway
But for the Grace of God go I…
I’m not religious, but this phrase has driven me to devote my research efforts to the ‘Cinderella services’. My job is to answer questions about mental health (MH) – what works, what doesn’t, who needs what and how to avoid becoming mentally unwell and reduce the number of suicides. MH problems represent a third of all GP visits and 28% of the total cost (burden) of disease and premature death but MH services receive only 13% of the NHS budget. Equally disappointing is that staggeringly only 6% of the money spent on health research in the UK focuses on questions related to mental health. After many years working as a researcher I have gathered lots of facts and figures about MH, but I know that unless you have walked in a person’s shoes you are no expert on how they think, feel and act. Even when people have similar experiences, they can react very differently. MH is a complicated, messy, human and very personal ‘system’ to get a scientific handle on.
In a relatively short period of time the global scientific effort towards understanding MH allows us to confirm some key facts. For example, psychologists have discovered that behaviour is reinforced by rewards and discouraged by punishment. This provides scientific legitimacy to the well-known idioms about carrots and sticks, catching bees with honey and once bitten, twice shy. We also know that certain physical and emotional systems are connected through common biological processes. For example, the production of stress hormones (cortisone) interferes with digestion, reproduction and the immune system. So constant or chronic stress is scientifically established to be bad for your physical health. The same applies in reverse because we know that chronic physical health problems require practical and emotional adjustments and these can compromise MH.
From studies that look at patterns of MH problems in the population over time we know that a person can be born lucky into an affluent, safe and loving environment. Or born unlucky into poverty, into homes with a threat of physical or emotional violence or into a minority group, or all of the above and more. So our emotional development in the early years of life shapes our future risk of emotional problems. The statistics also show that MH problems are associated with poor educational attainment, addictions in later life and involvement in the criminal justice system. In short MH problems are very costly.
When I’m chatting to people about what I do I sometimes get the slightly awkward ‘taboo’ face. Increasingly these days I might be met with a personal account of a relative or friend (rarely first hand) who experiences mental health problems, suggesting that people are starting to feel more comfortable discussing mental health, with a ‘safe’ audience. Scientific studies have found that an effective way to address these fears and prejudices (known as stigma) is to involve people with experience of MH problems in the delivery of training and awareness about MH. Personal testimonials break down taboos. The current “I’m me” dementia awareness TV campaign is a good example of this.
I often wonder why mental health still sits in such a sacred space for so many people? It’s comparable to how we used to talk about The Big ‘C’ but a diagnosis of cancer was a death sentence not so long ago and death has always been a difficult taboo. In contrast poor mental health only rarely kills people. If you have a chronic long term mental health problem you are at least ten times more likely to be hurt through violent crime, than to hurt others or yourself. However, being mentally unwell can have a huge impact on quality of life, relationships, financial stability, physical health and independence. So can cancer and we’ve addressed that taboo, so we can address this taboo around mental health.
I work on suicide research, the ultimate MH taboo. Suicide is a huge issue in Northern Ireland (NI), where I live and work. A recent media report pointed out that more people have died by suicide since the Good Friday Agreement brought relative ‘peace’ to NI (in 1998), than the total number of people who died in ‘The Troubles’ over more than 30 years of terrorism and civil unrest. That’s a shocking headline. In NI where we have around 2 million residents, and traditionally close knit communities, as a result almost everyone knows someone who has died by suicide. Yet our UK and Ireland rates of suicide are not even in the top 10 across Europe. That is also quite shocking.
The relationship between MH and suicide is well accepted, with a mental health diagnosis almost always reported as the most important risk factor. However, in NI over 40% of those who die by suicide do not have a diagnosed MH problem. That figure may partly reflect the taboo around disclosure to a medical professional. Equally the figure might partly reflect a lack of faith in services to address social and personal anguish, seen as outside the traditionally medical remit of the GP. Or it could be that GPs chose not to categorise or do not recognise MH risks when they are presented. Very few do not seek any help at all prior to their death. Whatever the reason, we might all agree that something about a person’s emotional regulation is not quite right when they chose to end their life this way. An exception could perhaps be the choice to end suffering in terminal illness. Can we accept that every person who ends their life is choosing to end unbearable suffering?
Herein lies the problem. I have heard people vehemently deny that there was any mental health problem present when their relative died of suicide. What do they think of as mental ill health? Would they agree that their relative had lost their sense of perspective? This leads us to a deeply philosophical debate about the meaning of mental health. We need to have that debate and to keep on having it to raise mental health literacy and reduce the very real fear of the stigma associated with mental vulnerability. We all have a state of MH and we all have vulnerabilities. We’re human.
Knowledge is power, so we do need more and better information about how to support people. Although there are many successful, evidence-based coping strategies to help us manage difficult emotions and chronic mood problems, there is no “one size fits all” solution. Help seeking may therefore fail, time and again, until a connection is made, until a strategy matches the individual needs that are presented, until a person finds a solution that works for them.
For me, good mental health means laughing, crying, experiencing all kinds of acute and chronic, positive and negative emotions, and understanding that fluctuations in how we feel are what make us human. I am very grateful to have had a good grounding on some rules of engagement for life that certainly help me protect my mental health. For example, that we reap what we sow, that good effort usually leads to a good return, that balance is important, that time for your loved ones is key, and time for yourself probably more so. Social isolation is a challenge to mental health and people can feel isolated even when they are surrounded by family and friends or in a crowd.
People generally recognise that some days are better than others and that the vast majority of mistakes or failings can be rectified or improved, with a little confidence, will and determination. When your mental health is fragile, these important characteristics of strength can be difficult to maintain. For example, to get through a crisis of confidence, “sometimes you’ve got to fake it until you make it.” I’m very grateful for this mantra from an academic colleague and mentor.
It’s adversity that helps us learn how to cope. The difficult times make us appreciate the fun and the laughter, and that elusive idealistic work-life balance is what we are all striving for, to maintain good mental health. If you feel you have achieved it, for even for one minute of one day, give yourself a massive pat on the back and just keep doing what you are doing. We are all wonderfully, eccentrically, complexly, human. Embracing your vulnerabilities can help you learn about yourself and others. If I can use the Soapbox Science event to share this message and raise the MH debate with even one person I might indulge in one of those back-patting moments myself.