I realise that this title won’t mean much to Americans or people outside the UK, so let me share a small anecdote by way of explanation before I get into the topic I want to discuss. I was on an American airlines flight back from New York in 2003, having done a lot of walking around the city over the preceding week. When I removed my shoes and straightened my socks it transpired that a burst blister had adhered to my sock, and it started to bleed surprisingly profusely. I asked a member of cabin crew for a sticking plaster, and got entirely blank looks in response. When I explained the situation, a steward showed a sudden look of recognition and sighed “oh, a Band Aid! I keep one of those in my wallet for my kids” and provided what I needed. So yes, a sticking plaster is a Band Aid – an adherent protective dressing for a small wound.
I found it quite an insight into American marketing, as I had also tried to buy antihistamine cream in a drug store to utterly blank looks, until someone realised I wanted “Benadryl”. I had also seen the TV advertising persuading people they had adult ADHD (with a symptom list that seemed to encourage false positives, and a link to a small quiz online that seemed to classify almost anyone as having ADHD), or that they needed Viagra (with the almost comical warnings that “erections lasting more than two hours can be dangerous and require medical attention”). Disease mongering is a pretty interesting phenomenon, and well worth reading about – Did you know that the vast majority of viagra prescriptions are “off label” and written for groups in which there is no evidence of efficacy (including women, when there is not a single study showing evidence of efficacy in this population)? And that the pharmaceutical companies are trying to medicalise “Female Sexual Dysfunction” to create mass markets to address lack of desire or lack of pleasure, with minimal consideration of the context or wider issues, because of the success of such marketing with men? Or that “restless legs” has been marketed to the public as a common condition requiring medication? It made me quite glad for our generics, and lack of medication marketing targeting the public.
But the reason I wanted to talk about sticking plasters is that they are a response after the event. A means of short-term management, and covering up of an injury, rather than preventing it. Like my blisters adhering to my sock, there were many stages at which that bleeding could have been prevented – by covering the blister earlier, or better still by taking the subway more and/or wearing more sensible shoes to explore New York. The problem is that if we become overwhelmed by demand for the reactive response, we lose the capacity to look at what underlies the demand. And if we spend too much time reacting to distress in health services, it can mean that we fail to do the preventative work that would reduce the need for such services. With austerity politics ensuring that the health and social care sector are too underfunded to be proactive, I think that is where the NHS is heading, along with most of the public sector.
Every single day I seem to read about travesties of social justice, and the lack of thought about the people that bear the brunt of them. Time and time again the most vulnerable members of society are being abused and neglected at a national and global scale. Whether it is the man who has paid UK taxes for 40 years who is being denied essential cancer treatment because he doesn’t have a British passport (due to a paperwork oversight when he arrived as a child with his parents from the Caribbean 44 years ago), or the deportation of a humanitarian/academic couple who are being told to leave because they went abroad for too many days – to complete a government study. Or how about the person that tweeted about having waited for over a year for support after a sexual assault, with rape crisis waiting lists closed for most of London for more than a year due to the scale at which demand exceeds supply?
Perhaps we should look at the rapid rise in mortality in the UK so far this year, falling life expectancy (especially in lower socioeconomic groups) or the rise in deaths amongst mental health patients – despite the falls in smoking and improved outcomes in many health treatments. A man/woman in an impoverished estate in the north of England can now expect to enjoy 32/35 fewer years of life in good health, compared with a counterpart in a wealthy suburb in London or the Home Counties. Or perhaps we can look at the impact of cuts to NHS funding (albeit masked by fake claims of record wage rises) record waits for A&E, the cancellations of operations, and the burnout of NHS staff.
Or look at the increase in homelessness over the last few years (it went up 16% in 2016 alone, with almost 50 000 families living in bed and breakfast accommodation and many more “hidden homeless” living on floors and sofas of friends and acquaintances) with the knowledge that being homeless can worse than halve your remaining life expectancy (homeless women die on average at 43 and homeless men at 47, compared with 77 for the rest of us). As the author of the BMJ article puts it “Homelessness is not an episodic event, but something systemic. It is a neon sign that something is fundamentally wrong with policy across health and housing”. This lack of provision doesn’t even save money as the cost to the NHS of society’s failure to deal with homelessness and other examples of inequality has been estimated at £4.8bn (€5.4bn; $6.7bn) annually.
These same austerity policies have a wider impact on mental health. Psychologists for Social Change have identified five ways austerity policies impact on mental health: 1. Humiliation and shame 2. Fear and distrust 3. Instability and insecurity 4. Isolation and loneliness 5. Being trapped and powerless. They remind us that “These experiences have been shown to increase mental health problems. Prolonged humiliation following a severe loss trebles the chance of being diagnosed with clinical depression. Job insecurity is as damaging for mental health as unemployment. Feeling trapped over the long term nearly trebles the chances of being diagnosed with anxiety and depression. Low levels of trust increase the chance of being diagnosed with depression by nearly 50 per cent”.
So we can’t see mental health in isolation. Whether it is the individual context (for example in the power threat meaning framework I discussed in a prior blog) or in the wider sociopolitical context, we are not brains in a jar, but socially connected beings with experiences that impact on our wellbeing. When we talk about the shortfall in mental health services, too often we are saying that in the context of demand for services exceeding supply, and feeling strongly pulled as psychologists to provide more of the same. That makes sense in at the coal face, where it is hard to have the energy, time or resilience to look at the wider picture beyond the demands hammering on our own door. However, it means that we are discussing the lack of sufficient reactive responses to a problem that could have been dealt with more effectively further up the timeline with proper proactive and early intervention work, and in a lot of cases could have even been prevented with better social policy and provision for vulnerable population groups.
Of course, doing preventative or early intervention work also takes resources, and we can’t take them away from the people currently in need/distress now. But instead of us constantly asking for a little bit more of the same to deaf ears who reply with excuses about finite pots and efficiency savings (and sarcasm about magic money trees), maybe we need to think more creatively about intervening at different levels and in different ways to the set up of existing services. I’d rather be providing sign-posts to avoid hazards than doling out sticking plasters when people trip over them – and best of all I’d rather be fixing the hazards, and helping vulnerable people identify routes that are less risky.
I’ll give Psychologists for Social Change the last word: “Mental health isn’t just an individual issue. To create resilience and promote wellbeing, we need to look at the entirety of the social and economic conditions in which people live”.