This is an exciting time: a new Labour – NZ First Government, with support from the Green Party, with new leadership focused on how “capitalism must regain its human face”. This people and environment-centred Government will also rightly be focused on addressing the mental health problems and misery experienced by many in New Zealand, and setting policy to address this.
We know that the underfunded health system has not been coping with increased demand for mental health services for far too long. Since 2007/08, there’s been a 60 per cent increase in people accessing mental health services, but funding increases have been less than half of that over the same period. The rate of youth suicide in New Zealand is the highest in the developed world, as reported by the OECD. A recent report looks at how well countries perform in relation to the UN Sustainable Development Goals. New Zealand comes last in the “Good Health and Well-Being” category – 38th overall. But it’s the high adolescent suicide rate that is really highlighted in the report. The rate of 15.6 youth suicides per 100,000 people puts NZ at the bottom of the table.
We already know is that too many people get lost in the mental health care system, between primary care, acute care, and all the layers in-between. It can be confusing for patients, and service providers are hard-pressed and often aren’t funded for the number of referrals they are receiving. When people come forward for help, all too often, they see GPs who are struggling to help people presenting with mental health difficulties. Often, short time slots and patient expectations mean that they leave with a prescription for medication, which may not be the most effective way of helping them. A recent meta-analysis showed that people are less likely to start pharmacotherapy than psychotherapy, and less likely to finish the treatment too. It’s also clear that it appears to be that current brief models of psychotherapeutic intervention are not long enough. Recent studies show that perhaps around 16 contacts are needed in order to make a difference in the course of mental health difficulties that patients present with. And this is just at the primary care level. In services that were originally designed to meet the needs of people with more complex and / or enduring mental health needs, service development and provision has been lacking for some time, producing incredible strain for families and those working in these services alike, resulting in needs being unmet for those who wish to use the service, and burnout and high staff turnover for the services trying to function in very demanding circumstances.
On the one hand, the increased rate of presentations is encouraging as it means that that we have a health system where people are actually going to their GPs and mental health services to get help – many don’t even make it that far, and those barriers need addressing. But it is not good that people need this help, in increasing numbers, and that our system is clearly not coping.
What is driving these terrible statistics, this real human suffering and need for help?
Determinants of mental health
At a broad level, we know from much research and many reports by the WHO, the OECD and other institutions that mental health and many common disorders are actually shaped to a great extent by the social, economic, and physical environments in which people live. A whole-of- life approach seems to be important, understanding that different influences exist in the prenatal period, through pregnancy, early childhood, adolescence, working and family building years and through to our older years, and that all this is highly related to gender and ethnicity too. Parenting is incredibly influential: how we are parented, and how we in turn learn to parent others too.
But it is the broader social determinants of mental health and well-being that “Capitalism with a Human Face” might influence. Things like material conditions; that is, income, access to resources, food and nutrition, water, sanitation, housing, safety, and employment, as well the conditions of that employment. Other aspects of ‘place’ also play their part in determining health and wellbeing – neighbourhood deprivation and resources, the opportunity to participate in the life of one’s community, as well as the standard and capacity of local services such as schools, healthcare, and social services. The influence of family fragmentation, dislocation from cultural practices, language, shared values and the impact of colonisation and the intergenerational impact of these experiences – all these are important determinants too. All these are are social determinants of not only common mental health disorders, but also sub-threshold disorders that people delay seeking help for, for many different reasons.
Yet, the approach that is often taken is not to locate the source of these problems in social, economic and physical environments in which they are generated. Rather, the dominant discourse is where the location of dis-ease, difficulty or dysfunction is located within the individual – meaning that the sufferer carries the blame for their suffering, and the onus is put upon them to make changes to fit in with the world they find themselves in, as if this is the only choice left. Indeed, if we think of the world as an atomised universe of individuals, I can see why we might think this. And the pressure is all around us, – through the medicalisation of distress and therapies that focus upon changing how we think – to fit into a reality that is precarious and pernicious in its influence. The modern traits of society – individualism, materialism, consumerism – have all risen at the same time as declines in levels of individual and social well being. Or course, there are many economic and social advantages in living our modern lives, but at what cost to ourselves and our communities? Do we have that balance right?
Mental illness and modern life
I’m not advocating a return to the dark ages, but I do argue that contemporary capitalist consumer culture appears to corrode and undermine social solidarity, such that the individual is expected to stand alone, and lip-service is paid to the notion of community. Modern economic conditions mean that those who are dependent on their own labour for a living have had their conditions eroded to the point of insecurity, sometimes on a day-to-day basis. This has resulted in the proportion of the working population that can also be classified as being in poverty rising at an alarming rate. One of the problems with a rising of materialism in consumer cultures like ours is the undermining of any deeper sense of purpose or meaning about what a good life is and should be about. I saw this in my professional role in Canterbury after the quakes, where the very literal jolts delivered into many people’s lives made them pay attention to what is valuable to them, and many took, and are still taking, radical steps to orient their lives towards people and places and their connections to them, rather than things and objects they can purchase. There was a realisation that what defined them was not their consumption choices, rather it was how they spent their time, and who they spent that time with.
But are such levels of mental illness as we experience in New Zealand an inevitable consequence of modern life in high-income societies? Is modern life inevitably rubbish?
That doesn’t seem to be the case at all. Rates of mental illness vary substantially between rich societies. There is a strong relationship broadly showing a much higher percentage of the population have a mental illness in more unequal countries. Inequality is associated with threefold differences in prevalence: in Germany, Italy, Japan and Spain, fewer than 1 in 10 people have been mentally ill within the past year; in Australia, Canada, New Zealand and the UK it is more than 1 in 5 people, and in the USA more than 1 in 4.
So, why do more people tend to have mental health problems in more unequal places?
Psychologist Oliver James uses an analogy with infectious disease to explain the link. What James terms the ‘affluenza’ virus is a ‘set of values which increase our vulnerability to emotional distress’, and he claims that these values are more common in affluent societies. They lead to a high value being placed on acquiring money and possessions, looking good in the eyes of others and wanting to be famous. He goes on to make the case that these values increase the risk of depression, anxiety, substance misuse and personality disorder. You can just imagine what the impact of social media has had, and the premium it has attached to looking good in the eyes of others, as we catalogue shares, likes, comments, and delete those posts that are not liked enough for fear of being perceived as not popular enough.
Philosopher Alain de Botton argues that our anxiety about our social status is ‘a worry so pernicious as to be capable of ruining extended stretches of our lives’. When we fail to maintain our position in the social hierarchy we are ‘condemned to consider the successful with bitterness and ourselves with shame’. Indeed, Professor Michael Marmot has a long and distinguished research track in his Whitehall studies of civil servants in the UK showing how important social status is to our wellbeing, without us even consciously being aware that it is. Economist Richard Layard portrays us as having an ‘addiction to income’ – the more we have, the more we feel we need and the more time we spend on striving for material wealth and possessions, at the expense of our family life, relationships and quality of life.
And so the treadmill continues, until something happens and we fall off. And we are told that it is in our power to get back on again, if we take the right medications or get the right therapy to change ourselves, because the status quo is the status quo, and it is us that have to adapt. This minimises the significance of culture and values, and locates a deficit in the individual which needs to be rectified, rather than actually addressing the atomisation and isolation of that individual from purpose, and their lack of connection to others with whom they share beliefs and values, never mind the wider social determinants of mental health.
Changing the story
My argument is that unless we address precarious work, poor housing, and limited opportunity to secure good housing, good diet, educational opportunities addressing increasing inequalities, ultimately, we will continue with this production line for poor mental wellbeing and increasing mental health problems that we have created. When we are frozen out of good housing, good healthcare, good education, good work, we are caught up in processes that lead us to what is at best, a boring and monotonous existence, and at worst, the risk of real misery and all its attendant future focused anxieties, hopelessness, and intergenerational transmission and negative cycles of impoverishment.
Unless we change the content and sequence of processes that lead to these poor outcomes, it is frankly delusional to think that we can change the risk of poor outcomes. And as increasing number of people fall into the orbit of these dysfunctional and limited opportunities for good work, housing, education and health care, more and more people are at risk of real misery in their lives and for their loved ones, and with all the consequences this may bring.
This is where ‘Capitalism with a Human Face’ can take its place in altering the settings of the economy in favour of the experience of those who live and work in it, in balance with the goods and services that are produced, rather than being subservient to those. Our contemporary cultural discourse of materialism and individualism is a trap us in drives us into locating the problem and the solution in the individual, through medicalisation or individual therapy, when it is clear that the reality is that we are social beings and that we derive purpose and well being largely through being connected positively with others. A huge opportunity lies before us. The attitude of the incoming Government looks promising, announcing the re-establishment of the Mental Health Commission alongside a host of other expected policy confirmations.
Next week, I will write about some of the possible solutions that are being proposed, and some of the principles I think we should be using to organise any planned interventions and policy changes in the mental health system.
Declaration of Interests: Dr Sarb Johal is a registered clinical psychologist with over 25 years of professional experience. He was also a NZ Labour Party List Candidate in the 2017 General Election.