Friday, February 16, 2007

Finding Sanity in a Mad World

By Daphne Liddle

Britain is currently suffering an epidemic of mental illness, especially depression and anxiety. NHS mental health services are desperately under-funded but the problem is not just the shortages – it is also the remedies that are put forward that do not work.
The first remedy offered by the NHS is invariably strong drugs which do help some but carry the risk of severe side effects. Then there are the “talking therapies”, in particular Cognitive Behavioural Therapy, in which patients are told to control their thinking, block negative thoughts and to think only positive thoughts.
This approach insists that the depression comes from inside the brain of the patient – not from the objective reality of the outside world. But in a world threatened by global warming and ecological disaster, by wars involving nuclear, chemical and biological weapons and by extremes of wealth and poverty, is it madness to be depressed? At a more personal level the working classes are now more exploited, more in debt and working longer hours while traditional community and social structures are disappearing. What is the sane response to living in a mad world?

THE NEW Communist Party Congress in early December 2006 gave rise to an unexpected level of interest on the topic of mental health issues in modern Britain, including rapidly rising levels of depression and anxiety. It seemed that nearly everyone in the conference room had been involved, either as a professional health worker in the NHS or prison service, or through a close friend, family member or themselves suffering through the inadequacy of help from official services.
The whole of the NHS over the last year has suffered drastic cuts and mental health services have not escaped. One typical south-east London NHS mental health trust, which opted recently for foundation status, has restructured its services and cut £300,000 from its budget. This means that most people who now turn up at their GP with depression or anxiety will no longer be referred to specialist services but will be treated by the GP, almost invariably with anti-depressant drugs.
These drugs, Selective Serotonin Re-uptake Inhibitors (SSRIs), include Prozac, Serotonin, Cipramil, Fluoxetine and others. They do help some people but many patients find the side-effects cause more problems than they solve. These side effects include kidney problems and water retention and they can be addictive or they can make the depression worse. These drugs have been linked with suicides and violent outbursts. Last year a senior executive of Glaxo-Smith-Kline admitted that most of their drugs are effective on only about a third of patients. Even when they work, the drugs do not address the root cause of the problems of depression.
Although all these SSRIs are chemically similar (the illegal drug ecstasy is the strongest version of them), a doctor will insist the patients try all on the names on the list before concluding that these drugs do not help them. Even then, the patient has to refuse to take any more of the drugs before being referred for other treatment. One very depressed patient, fresh from hospital after an overdose of pills, was asked: “Do you want to try the pills again?”
The next line of treatment offered by the trust, for those who are not helped by the drugs or who do not recover by themselves, is referral to specialists in Cognitive Behavioural Therapy, which sometimes is offered as “anger management”.
But there has been a marked reduction in these services, with many changes of location. Drop-in centres have been closed and an annual Christmas party for patients who live alone had been withdrawn.
But the trust has presented these changes in a pamphlet as “improvements”; new services were described operating from various locations and then on the last page, under the heading “Location changes”, all the locations of the new services were listed for closure with no new locations mentioned. This led to serious confusion in some patients and confirmation in others that what they are being fed is just bullshit.
One disgruntled patient succeeded in getting an interview with the director of the trust. This elicited an admission that the changes were indeed cuts rather than improvements and that although £300,000 had already been cut, further cuts of £900,000 were needed to balance the books. But the director was an intelligent woman, trying to do the best she could in impossible circumstances. She had gone out of her way to avoid the pitfalls of Private Finance Initiative deals; she had opted to close buildings rather than cut jobs; new locations for services had not been mentioned in the pamphlet because they were not yet definite, she said. The danger is that with a further £900,000 cuts to be made, they may never be.
It also became evident that her view of the services provided was quite different to those on the receiving end. When told that a call to the trust’s emergency response team for someone in a mental health crisis had been made on a Thursday and had resulted in a call on the patient the next Monday, she thought that was a good and swift response. All patients were supposed to have a “care co-ordinator” in charge of their treatment and an emergency contact number. Many patients were totally unaware and certainly did not have one. It was one of those all too typical situations where middle and lower management fear to tell the boss that their section is underperforming for fear of their job being cut – so no bad news ever reaches the top.
But in any case bad news is something that a service based on the CBT philosophy of relentless positive thinking at all times cannot acknowledge.
Last year Labour economist and peer Robert Layard suggested that millions of people suffering from depression could be helped much more effectively through talking therapies rather than taking pills. He proposed that the Government train a small army of counsellors capable of delivering Cognitive Behaviour Therapy (CBT). He claimed that 16-session course usually gets the patient well enough to resume work and would save the economy a fortune in rehabilitating most of the long-term mentally sick
It sounded good at first – better than the pills at any rate. The National Association of Cognitive Behavioural Therapists (based in the United States) described CBT: “It is a form of psychotherapy that emphasises the important role of thinking in how we feel and what we do. CBT therapists teach that when our brains are healthy, it is our thinking that causes us to feel and act the way we do. Therefore if we are experiencing unwanted feelings and behaviours, it is important to identify the thinking that is causing the feelings/behaviours and to learn how to replace this thinking with thoughts that lead to more desirable reactions.”
The NACBT claims links to stoicism and the Socratic method – continually questioning one’s own thoughts and assumptions.
In practice it comes across with patients being given work sheets with instructions on “How to challenge thoughts: You need to know what you are thinking to be able to challenge your thoughts. Thoughts occur automatically. They flash so quickly we are therefore not always aware of them, or their content. There may be an error in the way you are thinking about something.
“To challenge negative thoughts you must: 1) identify what you are thinking 2) challenge the thought 3) replace the negative thought with a positive one.”
Patients (no longer called patients, that is too negative, but renamed “service-users”) who report that global warming, ecological disasters, wars, injustice, poverty and exploitation make them feel depressed are told that they are thinking too much. “Thinking is the cause of your illness. You must stop thinking your way and start thinking our way. You must think positively about the world.”
This soon becomes close to the philosophy satirised by Voltaire in his book Candide, where the eponymous hero is told by his mentor, Dr Pangloss, who taught “metaphysico-theologo-cosmolo-nigology”, that there is no effect without a cause and that this is the best of all possible worlds.
“It is proved that things cannot be other than they are, for instance since everything was made for a purpose, it follows that everything is made for the best purpose. Observe: our noses were made to carry spectacles, so we have spectacles. Legs were clearly intended for breeches, and we wear them. Stones were meant for carving and for building houses, and that is why my lord has a most beautiful house; for the greatest baron in Westphalia ought to have the noblest residence. And since pigs were made to be eaten, we eat pork all year round. It follows that those who maintain that all is right talk nonsense; they ought to say that all is for the best.” Throughout wars and disasters Pangloss, at every turn, insists that everything they are suffering is “for the best”.
This perpetual optimism, totally at odds with objective reality, is likely to make depressed patients feel worse, not better. They are told that the world is as it is and cannot be changed but that thinking it might be changed makes you ill and depressed.
This of course consigns every social reformer and revolutionary, every member of a left-wing political party or progressive campaign to be labelled as mentally ill. History makes nonsense of this. If the CBT view of the world was correct we would still be living in slavery under the Roman Empire. We could list thousands of people, from Cromwell, Robespierre, Marx and Lenin, to Kim Il Sung, Mao Zedong, Fidel Castro and Hugo Chavez who have brought major change to the world – and millions of others who have played an active role in the process.
There is another school of psychologists who reject CBT. They include Dr John Read from New Zealand and Oliver James. They claim that mental illness is a natural reaction to a mad world.
James writes: “All too often, CBT tutors the patient to tell a relentlessly positive story, to ignore many of their true feelings, just as drugs do. Not surprisingly, the studies show that once the teacher is no longer there, the depressed or anxious truth of our crazy world reasserts itself within a few months.
“CBT comes from a stable of psychology that deems accurate negative thoughts about oneself as ‘depressive realism’, and health as living in a rose-tinted bubble of positive illusions. For, truly, emotional distress is a form of dissent – an important signal that early family experiences and adult society have been or are distressing.”
He has recently written a book, Affluenza, in which he depicts the values and pressures of modern consumer society as the root of the growing epidemic of mental ill health. “The Affluenza virus is a set of values which increase our vulnerability to psychological distress: placing a high value on acquiring money and possessions, looking good in the eyes of others and wanting to be famous. Many studies have shown that infection with the virus increases your susceptibility to the commonest mental illnesses: depression, anxiety, substance abuse and personality disorder.
“The virus values prevent you from fulfilling fundamental human needs which seem to exist in every society.” He lists the four most commonly identified fundamental needs as “security (emotional and material), connectedness to others, authenticity and autonomy, and feeling competent”. He says that urban societies are more affected by the virus than rural ones; that the epidemic is worst in America and Britain and that younger generations are more afflicted than older ones, “the young being especially influenced by America’s Affluenza-promoting cultural imperialism”.
He quotes the works of the German social democrat psychologist Erich Fromm who taught that being is more important than having and that anxiety about possessions leads to a transfer of our sense of identity into the things we own – a form of madness.
Bourgeois psychologists have wrestled long and hard with the problem of optimism. Statistical analysis shows that pessimists are usually better at predicting the future than optimists. Yet they insist that optimists have better mental health. They also say that those most in touch with objective reality are the sanest. Both statements cannot be true. They advocate the adoption of rosy illusions in the hope that these will become self-fulfilling prophesies.
CBT is taking the place of religion in persuading the exploited masses to resign themselves to their lot in life but it is grounded in an idealistic philosophy which ultimately claims that the material world exists as the creation of an idea (God’s) and is experienced through our ideas of it. This is the opposite of the Marxist-Leninist historical materialist view of the world which says that objective reality exists outside our own heads. And not only can it be changed but it is in a constant state of change in any case. For us, the sane method is to analyse that objective reality and the way it changes in order to be able to influence those changes – to think for ourselves and not be fooled by rosy illusions.
Dr Read, in his book Models of Madness, disputes the definition of schizophrenia, claiming that it a name for a collection of different conditions that result from bad experiences, especially in early childhood. He claims the idea of this as a genetic illness that should be treated by drugs is sustained by the drugs industry. He is part of what is known as the anti-psychiatry movement which began in the 1950s and 60s with psychologists like RD Laing. He advocates instead psycho-analysis and talking therapy of the type that looks into the patient’s past to find the events that have triggered the problem. Getting this high quality and effective therapy on the NHS can take years of waiting; properly qualified psycho-analysts are very thin on the ground – though there are plenty in private practice serving the rich.
James does not go quite so far. He agrees that some people are possibly more susceptible to mental ill health than others but that it is the circumstances of their life, and particularly their childhood, which determine whether the susceptibility is triggered. In other words mental health, or the lack of it, is produced by a dialectical process between nurture and nature.
But both Read and James look only at the immediate personal circumstances of the patient. They do not look at the wider class and political context. As soon as we do this we can pinpoint the things that make us depressed and anxious at a global and at a more personal level: social injustice, extremes of poverty coexisting with obscene levels of wealth, threats to the ecological future of the planet, the threat of nuclear war, other weapons of mass destruction, exploitation, being deep in debt, working excessively long hours, lack of time to spend with our families, lack of control over our own lives and general helplessness.
The root of almost all of these problems is the capitalist system.
If we take the view of the CBT advocates, we cannot do anything to change any of this but must adjust our minds to see it all through rose tinted spectacles. This leads some people to hedonism – escapism through refusing to listen to the news, being obsessed with the celebrity culture, drinking and partying as much as possible: “if there is no hope we might as well enjoy ourselves while we can”. This is one trend that has taken a large proportion of the working class away from active participation in anything political.
The other trend is despair, which has captured many of those who cannot turn off their minds, who cannot help but see what is happening around them. But feeling isolated and helpless they become paralysed by depression and or by suppressed anger. They become unable to function as part of a society which they can see is going mad.
The only sane and rational alternative is to ignore the CBT people and the pills, take stock of objective reality and set about trying to change it. And to do that we have to believe that it can be done – and we have the whole history of human society to provide the evidence that it can.
We recognise that the individual alone cannot change the world political situation. The great leaders of historical change: Cromwell, Robespierre, Marx, Engels, Lenin, Kim Il Sung, Mao, Castro and so on did not accomplish anything alone. They were leading millions of others who shared their views and worked together in an organised way.
There were many other movements for social and political change that did not succeed in their own time but made an impact on history long after they were gone, like the Chartists and the Irish volunteers of the 1916 Easter Rising. Even those who have made mistakes and gone off on the wrong path, who may seem to have ended their efforts in defeat and despair, have helped future generations to learn from their mistakes. It is never a mistake to try.
But we don’t have to keep repeating the mistakes of the past. One lesson that workers have learned over the last 200 years of struggle against capitalism is that unity and solidarity are key – that means we must be organised. If everyone is rowing in a different direction our boat can only go round in circles. This is why all working class organisations operate democratic centralism. Every member has a right and duty to take part in discussing policy and voting on it. But once the decision is taken all fall in line behind the agreed policy and work together.
This is why the bourgeois psychologists are no use. The root of all our depression is capitalism and the only solution is to join a fighting working class party to combat it. They would have to tell their patients to join the New Communist Party.