Mental health in the UK and elsewhere is in crisis. It is a crisis with many different faces. At the time of writing one of the most prominent of these is the extremely high level of emotional distress affecting children and young people. In 2018 a large-scale survey by the Children’s Society found that a quarter of girls and nearly one in ten boys in the UK self-harmed (deliberately hurt themselves) during the previous year.1 The charity estimated that 110,000 children aged 14 may be self-harming, including 76,000 girls and 33,000 boys. It is a shocking finding but one which is perhaps less surprising when set against that of a study the previous year that found that British 15 year olds are among the unhappiest in the world. Britain came 38th out of a league table of 48 countries.2
This level of emotional misery among children and young people is both tragic and appalling. However, as I argue in my book Politics of the Mind: Marxism and Mental Distress, the current crisis of mental health is not confined to a single section of society.3 The unemployed, people with disabilities, students, workers, older people—all are experiencing increased levels of mental distress. Nor is the crisis purely a UK problem. A Guardian article in 2018 extolling Copenhagen as one of the “happiest cities in the world” also noted that 23 percent of its population felt stressed “a lot of the time”!4 And a 2017 report by the World Health Organisation identified depression as the single largest contributor to global disability, with anxiety as the sixth largest contributor.5
My book was written in an attempt to show how a Marxist analysis and socialist politics can make sense of what I argue is one of the key “public issues” of the 21st century and to point a political way out. As I acknowledged in the book’s introduction, however, mental health is (in a term much-loved by academics) a “contested” topic so it was to be expected that others, including friends and comrades on the left, would disagree with at least some of the book’s arguments. In fact there has been a much higher level of agreement than I anticipated. Some readers, however, including Shirley Franklin in a review article in a previous issue of this journal, have been more critical and have challenged some of the book’s core arguments.6 In this response I will attempt to address some of the points Franklin raises.
Requirements of a fair review
Franklin’s major criticism of the book is that I “polarise” the biomedical and social models of mental distress. She seeks to redress this alleged imbalance with a defence of the biomedical model. I will discuss below the extent to which she succeeds in doing this. First, it is necessary to deal with some aspects of her review which are particularly problematic. I will begin, however, with a point of agreement.
As the title of her article makes clear, Franklin’s primary concern is with mental health treatment and in particular with the impact on services of austerity policies, cuts and underfunding. She is right to be concerned. A report published in the run up to World Mental Health Day in October 2018 found that almost a quarter of mental health patients in the UK are being forced to wait up to three months to see a specialist on the NHS.7 In some cases people are waiting much longer. In the same month an investigation by the Education Policy Institute found that referrals to children’s mental health services in England had increased by 26 percent over the past five years, but nearly 25 percent of them were rejected, meaning at least 55,000 children were not accepted for treatment in 2017-18. According to the report, most were rejected because their condition was not regarded as serious enough to meet eligibility criteria, including young people who had experienced abuse or showed evidence of self-harm.8
Given this political context, defending existing services from the effects of austerity and campaigning for increased funding is, as in fact I argue throughout the book, an essential task for socialists and for all who are concerned with supporting people experiencing mental distress. Nor should we allow progressive-sounding concepts like recovery, resilience and “promoting independence” to act as a smoke-screen for cuts.
As Marxists, however, we have to go beyond a defence of welfare state mental health services, important though that task is. For one thing, as I show in some detail in chapter 2 (in an account with which Franklin appears to agree) these services have often been experienced as oppressive and stigmatising by those on the receiving end. For another, we also need to ask the prior question of what is it about neoliberal capitalism that is making so many people unwell.
These were the central issues that I tried to explore in the book. To do so I proposed in chapter 1 a Marxist framework which aimed to be materialist, historical and dialectical and which highlighted the denial of human needs, the impact of alienation and the role of class struggle in contributing to mental distress. It is frustrating and disappointing then that nowhere in Franklin’s review is that framework or these arguments even mentioned.
Unfortunately, however, these are not the only omissions. A chapter on Sigmund Freud and psychoanalysis (chapter 3) and another on the debates between R D Laing and Peter Sedgwick (chapter 4) are similarly ignored. Even more annoyingly, following some very general comments about the ideas of the Russian Marxist psychologist Lev Vygotsky, Franklin concludes:
So when we are looking at mental health issues we need to be aware of the history of the problem, of the person, the social and cultural context, etc. We need to apply historical materialism to concrete phenomena. This also applies to our understanding of the biological brain because it is not an abstract entity. The functioning of our brains is affected by our experiences. So negative experiences, such as those caused by the impact of austerity, neglect or physical factors can cause malfunctions and poor mental health.9
In fact this statement, which is presented as a criticism of the book, could easily stand as a summary of some of the book’s main arguments, especially the “new paradigm” discussed in chapter 5 (and also not mentioned by Franklin).
So the first problem with Franklin’s article is its failure to meet what is perhaps the most basic requirement of a review, namely that it addresses the book’s contents. No less problematic, however, is the misrepresentation of some important arguments. So, for example, Franklin suggests that my “strong opposition” to the medical model:
is exemplified by his suggestion that the mental distress of a person with depression would be alleviated by knowing that it was austerity that was causing such problems in their life. Of course, the poverty, unemployment or other stress caused by austerity can be a significant factor in depression; but, unfortunately, resolution of the problem is not this simple.10
In fact I suggest nothing of the sort. I can only assume that this is a reference to the discussion in chapter 1 of the importance of meaning in mental distress.11 A central theme of the book is precisely the complexity of mental distress and the danger of any kind of crude reductionism. However, one does not have to be an advocate of cognitive-behavioural approaches to recognise that ideas and beliefs do matter in the genesis of mental distress. The woman who has carried all her life the belief that she was responsible for the abuse she suffered as a small child and whose mental health has suffered as a result, or the person who sees every setback, be it divorce, unemployment or loss of whatever kind as evidence of his own worthlessness are familiar figures in mental health research and practice. And yes, one role of therapy (and also of political agitation) is to challenge such beliefs and pin the blame where it should lie. This is very different, however, from simply telling someone capitalism is to blame and expecting them to recover!
Polarising the medical and the social models?
Moving on to Franklin’s substantive criticism of the book, she argues that while its approach is “predominantly Marxist”, it is over-critical of the medical model of mental distress (which, ignoring the debates around this issue, she states categorically should be called “mental illness”). She writes:
A model of mental health needs to relate the biological brain to consciousness, which stems from biological brain function, and to the body, as well as social experience… Clearly Ferguson is concerned to show the impact of social factors on mental health, which he achieves in fascinating detail, but the polarisation between the medical and social models is problematic. We should not dismiss a biological account in order to show the predominance of social factors as causes of mental distress. A Marxist account should really address both a biological and a social model.12
The first point to note is that this is rather a misleading account of what my aim was in writing the book. It was not primarily “to show the impact of social factors on mental health”—lots of non-Marxist writers from Émile Durkheim in the 19th century to Richard Wilkinson and Kate Pickett in our own time have done that very effectively. Rather it was to offer a Marxist analysis of mental distress, employing the framework referred to above.
Secondly, in speaking of a “polarisation” between the medical and the social models, Franklin gives the impression that there is parity, both ideological and treatment-related, between the two models and that the truth lies somewhere in the middle. The reality is very different. In the book, for example, I refer to the fact that prescriptions for 64.7 million items of antidepressants were dispensed in England in 2016—a staggering 108.5 percent increase on the 31 million dispensed ten years earlier and an all time high. As I argue, these figures reflect not only the enormously high levels of unhappiness in capitalist society but also the overwhelming dominance of a model—the biomedical model—that sees drugs as the first line of response to human misery (conceptualised as brain malfunction). As the authors of the Power Threat Meaning Framework, a comprehensive review of mental health research published by the British Psychological Association in 2018 (hereafter referred to as the PTM Framework) have noted, while there is indeed now greater recognition of the role of social factors than was previously the case:
On balance, however, we are still a very long way from a full recognition of the implications of this evidence as applied to the role of biology in emotional and behavioural problems. Although new research strategies are emerging, most research still presumes the primacy of biology, and most work conceptualises its influence in terms of disease, illness and pathology.13
Thirdly, it is Franklin, not me, who is at risk of counterposing the biological and the social. For as noted above (and as discussed in chapter 5 of the book), if there is one key finding that has emerged from the neuroscience research of recent decades it is the extent to which the human brain (and our biology more generally) is shaped by the environment. As neuroscientist Bruce Wexler has argued in his book Brain and Culture, data from a range of different brain sciences “demonstrate that our biology is social in such a fundamental and thorough manner that to speak of a relationship between the two suggests an unwarranted distinction. It is our nature to nurture and be nurtured”.14
This is not to substitute an environmental determinism for a biological determinism. As Wexler also argues (in what is essentially a development of the dialectical arguments put forward a century and a half earlier by Karl Marx and Friedrich Engels):
In addition to having the longest period during which brain growth is shaped by the environment, human beings alter the environment that shapes their brains to a degree without precedent among animals. These human alterations in the shared social environment include physical structures, laws and other codes of behaviour, food and clothes, spoken and written language, and music and other arts. It is this ability to shape the environment that in turn shapes our brains that has allowed human adaptability and capability to develop at a much faster rate than is possible through alteration of the genetic code itself.15
And as I argue in the book, a range of other factors linked to the exploitation, oppression and alienation that shape our lives in class society also play a role in the onset of mental distress.
The central issue of debate, then, is not about whether a relationship exists between the biological and the social—it clearly does—but rather the nature of that relationship. Franklin believes that the biomedical model has an important contribution to make to our understanding of that relationship. It is necessary therefore to look more closely at that model.
The medical model
In her article, Franklin identifies the defining features of the medical model as its focus on “malfunctions of the brain and the importance of medication”. This is a useful working definition. In his book Lost Connections the journalist Johann Hari similarly identifies these two features as the central components of the medical model, the “story” that he was told by doctors—and told himself—from his mid-teens until his early 30s.16 By the end of his first meeting with a GP to discuss his depression, he says: “I had my story. In fact, I realise now, it came in two parts. The first was about what causes depression: it’s a malfunction in your brain, caused by serotonin deficiency or some other glitch in your mental hardware. The second was about what solves depression: drugs, which repair your brain chemistry”.17
For the purpose of this response therefore, I will focus on these two elements.
Malfunctions in the brain?
Let’s begin with the areas of agreement. There are clearly very many ways in which brains can malfunction. Some of these malfunctions may be inherited, some the result of illness, others typically develop later in life. Examples might include epilepsy, brain tumour, the effects of stroke and dementia. Malfunctions of the brain can also be caused by external factors. Alcohol and other drugs can affect both brain functioning and structure, as can hormonal imbalances. There is also of course brain injury; over half of all reported traumatic brain injuries are the result of an automobile accident.
All of these conditions have psychological effects as people struggle to deal with their impact on their lives and day-to-day functioning. The writings of the late British neurologist Oliver Sacks and his mentor, the Russian psychoneurologist (and colleague of Vygotsky) Alexander Luria, show the very creative strategies that people can develop to compensate for the losses resulting from profound brain damage.
Nevertheless it is important to distinguish between conditions such as epilepsy, Korsakoff’s Syndrome and dementia, historically referred to by psychiatrists as organic disorders, and diagnoses such as schizophrenia or bipolar disorder for which there is no evidence of an organic basis (for which reason they have historically been known as functional disorders). As the authors of the PTM Framework argue:
There are important differences between forms of distress and troubling behaviour that are enabled and influenced by our biology—as all human experience is—as opposed to bodily and other problems where there is evidence for a primary causal role for biological disease processes or impairments in the major aspects of the difficulties. We would argue that this distinction is sufficiently valid to require different theoretical frameworks for each as well as to inform research programmes and practice.18
The first and most obvious of these differences is that there are no physical markers for most forms of mental distress. If my doctor thinks I may have angina or diabetes there are blood tests or internal investigations she can carry out to confirm that diagnosis. By contrast there are no such tests for conditions such as depression or schizophrenia. The current state of knowledge was summarised in 2013 by Dr David Kupfer, chair of the DSM-5 task force (the body responsible for preparing the psychiatric “bible”, the Diagnostic and Statistical Manual of Mental Disorders):
In the future, we hope to be able to identify disorders using biological and genetic markers that provide precise diagnoses that can be delivered with complete reliability and validity. Yet this promise, which we have anticipated since the 1970s, remains disappointingly distant. We’ve been telling patients for several decades that we are waiting for biomarkers. We’re still waiting.19
So, for example, the most common theory of depression (and the “story” that Johann Hari’s doctors told him over many years) has been that it stems from a lack of a chemical (or neurotransmitter) in the brain called serotonin which acts as a chemical “messenger” between neurons. The theory is partly based on the fact that when people are given medication to boost serotonin, their mood improves, for a short while at least. It’s a flawed argument, however. As the writer and psychiatrist Joanna Moncrieff has argued, it’s a bit like saying that if I am feeling anxious and take a drink that relaxes me, my anxiety is due to a lack of alcohol in the brain. Or if I take an aspirin and my headache disappears, the headache was due to a lack of aspirin. No one has proved the serotonin theory of depression. To quote again the authors of the PTM Framework:
In relation to the diagnosis of “major depression”, for example, high-profile claims for a causal “imbalance” of neurotransmitters such as serotonin remain unproven. Studies that show serotonin depletion amongst people given this diagnosis (as compared to controls) sit alongside others that show equivalent or even raised levels of serotonin. The overall picture is that there is no consistent pattern relating serotonin (or any of the other monoamines) to the experiences associated with a diagnosis of “depression”.20
In fairness, Franklin’s arguments in support of the medical model remain at a very general level and she does not specifically refer either to the chemical imbalance theory of depression or to the dominant dopamine theory of schizophrenia (which Moncrieff and the authors of the PTM Framework also challenge). It is to genes, rather than to biochemistry, that she turns to support her argument: “In addition, not all people experiencing similar social or emotional circumstances react in the same way. Some have a greater vulnerability to mental trauma than others. This difference in response has been shown to have its roots in genetic variation”.21
In fact, the evidence for the role of genes in the onset of mental ill-health is weak and contested. The conclusion of one of the leading researchers of a (much-hyped) global report into the genetic basis of depression that appeared in April 2018, for example, was that: “We know that thousands of genes are involved in depression with each having a very modest effect on a person’s risk. There is certainly no single gene for depression”.22
This does not mean that genes have no relevance for mental ill-health. But the nature of that relevance remains far from clear and there is no basis at present for the kind of hype that invariably accompanies the publication of new research into genetics and mental health. As the authors of the PTM report note:
None of this is to deny the general relevance of genetics: every human experience and behaviour will have some more-or-less distant genetic contribution. For example, it is quite possible that footballers are more likely to carry genes for faster, more agile or more powerful legs. But we would not take this to mean that playing football is best understood as a disease with a genetic predisposition; nor would we conclude that these genes somehow “caused” the person to sign with a team and then run up and down a field chasing a ball. In relation to distress, however, the prior presumption that these experiences simply must be expressions of disease or illness makes this kind of flawed reasoning appear superficially plausible.23
More and better drugs?
The second plank of the biomedical model is its promotion of medication as a way of relieving mental distress. In her article, Franklin favourably cites an international study of the effectiveness of antidepressants published in 2018.24 While acknowledging (as did the researchers) that cuts to both NHS and community-based services over the past decade are one reason why GPs are now more likely to prescribe antidepressants for people suffering from depression, she nevertheless argues:
But their findings also show that antidepressants are more effective than placebos for participants with major depressive disorders. So we should not write them off.
At least 0.1 percent of the UK population suffer from psychosis. They also need treatment with medication to alleviate some of the symptoms, although in such cases medication is still problematic in terms of side-effects and efficacy. Surely what people suffering from mental health trauma require is appropriate medication and psychological support.25
There is no room for moralism here. Clearly some people find prescription drugs helpful in managing depression and anxiety and getting on with life. There should be no stigma attached to taking them. Similarly, despite their sometimes appalling side-effects (often mistaken by the general public as symptoms of the illness) people diagnosed as schizophrenic and also their families may find anti-psychotic medication useful as a way of managing their symptoms, such as voice-hearing, especially in the absence of non-medicalised alternatives.
But in no sense are these drugs an answer to the current epidemic of mental distress. Firstly, and despite the hype, their effectiveness is very limited and much of the efficacy that they do have is derived from the placebo effect—in other words, if you believe that they work, they’re more likely to make you feel better. Given the hype that often surrounds these drugs, that’s hardly surprising. As an example, the development of Prozac and similar antidepressants (known as the SSRIs) in the 1990s was hailed as a massive breakthrough in the treatment of depression. Books were written about what a life-changer it was. Financially it was probably the most successful drug ever, with annual sales of $2.6 billion for its manufacturer, the pharmaceutical giant Eli Lilly. So what does the research report cited by Franklin now tell us about the effectiveness of Prozac?
The most famous antidepressant of them all, Prozac…was [found to be] one of the least effective but best tolerated, measured by a low drop-out rate in the trials or fewer side-effects reported. The most effective of the drugs was amitriptyline, which was the sixth best tolerated.26
In other words, Prozac made little difference to depression but people took it for longer because it had fewer side effects. Amitriptyline, by contrast was more effective but people stopped taking it quickly because the side effects were so unpleasant (Amitryptiline, by the way, is a drug developed in the 1950s). The issue of side-effects is the second reason we should be concerned about the mass prescription of these drugs. Unlike placebos, they are not harmless. According to a recent review of the evidence commissioned by MPs, half of all those taking antidepressants experience withdrawal problems when they try to give them up and, for millions of people in England, these are severe—one reason perhaps why many people often stay on them for very long periods of time.27
Thirdly, there is the issue of choice. Many people take antidepressants because there are no alternatives on offer. Yet studies consistently show that people experiencing mental distress would like more access to talking treatments and other forms of social support. Many mental health professionals agree. As retired psychiatrist Edward Hallowell observed in a Guardian interview promoting his memoirs published in 2018: “We have become far too much a profession of ‘diagnose and medicate’. In many practices you have 20 minutes with a doctor and come out with a diagnosis and a prescription… There is so much more to it [such as]: ‘How are you? What is your story?’”.28
In addition, we should argue for greater availability of the kind of non-medical initiatives developed by service users and their allies such as the Hearing Voices Network which helps people to develop more effective strategies to cope with voices in their heads or the Open Dialogue approach pioneered by mental health professionals in Finland. (A disappointing aspect of Franklin’s review is her failure to address any of the concerns or proposals of the service user movement, whether over the meaning of mental distress or over the medical model more generally.) The problem is that many of these non-medicalised responses have been located in the voluntary sector which has been one of the main victims of the austerity politics of the past decade.
There is, however, a more fundamental reason why as socialists we should be critical of the current reliance on drugs to treat depression and anxiety. According to recent figures, almost one in five adults in Scotland is now on antidepressants.29 In the North West of England the figure is one in six. One would have thought that if the drugs were effective, the numbers of people experiencing depression in these areas would be going down, not up, as is in fact the case. Yet the only response of the authors of the report cited above is to argue that a million more people in the UK should be taking them!
So, in conclusion, we can see the current epidemic of mental distress as evidence of the malfunctioning of genes or brains on a mass scale, a phenomenon that has inexplicably got much worse in the past few decades. Alternatively, as I argue in the book, we can see it as the predictable outcome of a society—neoliberal capitalism—which denies our most basic social and emotional needs. Or in the words of Moncrieff:
Many people will be wondering why on earth we are reacting to the increasing burden of human misery in this way. Why are we not asking why it is that so many people in the modern world feel miserable and stressed? What are the pressures that people are under that make coping with life difficult? I could name many—insecure or inadequate employment, finances and housing, loneliness, increasing pressure to perform and reach ever higher targets at work and school, loss of meaning in life and the disappearing nature of community in many areas. These are the things we need to focus on to stem the “epidemic of depression”—not doling out ever more placebos with side-effects!30
Iain Ferguson is a long-standing member of the SWP in Scotland and author of Politics of the Mind: Marxism and Mental Distress (Bookmarks, 2017).
1 Children’s Society, 2018.
2 Ward, 2017.
3 Ferguson, 2017.
4 Boseley, 2018a.
5 WHO, 2017.
6 Franklin, 2018.
7 Royal College of Psychiatrists, 2018.
8 Crenna-Jennings and Hutchinson, 2018.
9 Franklin, 2018, pp124-125.
10 Franklin, 2018, p122.
11 Ferguson, 2017, p21.
12 Franklin, 2018, pp123-124.
13 Johnstone and Boyle, 2018, p157.
14 Wexler, 2006, p13.
15 Wexler, 2006, p3.
16 Hari, 2018.
17 Hari, 2018, p9.
18 Johnstone and Boyle, 2018, p14.
19 Cited in Johnstone and Boyle, 2018, p164.
20 Johnstone and Boyle, 2018, pp153-154.
21 Franklin, 2018, p123.
22 Sample, 2018.
23 Johnstone and Boyle, 2018, p160.
24 Cipriani and others, 2018.
25 Franklin, 2018, p122.
26 Boseley, 2018b.
27 Boseley, 2018b.
28 Rhodes, 2018.
29 Clews, 2018.
30 Moncrieff, 2018, p14.