BREAKING THE SILENCE: MENTAL HEALTH, OPPRESSION, AND CAPITALISM

Breaking the Silence:

Mental Health, Oppression, and Capitalism

by David Paul Tahrir Thurston

There is stark evidence of a growing mental health crisis in the United States.  In early October, a man who had recently lost his job, killed his entire family and then committed suicide.  A few weeks later, a 90-year-old woman shot herself as her house was under foreclosure.  Veterans of the wars in Iraq and Afghanistan suffer disproportionately.  By early Spring 2008, the number of veterans committing suicide at home in the U.S., exceeded the numbers dying of violence in Iraq.  While these are extraordinary examples, it remains true, every year, that more people in the United States die from suicide than from homicide—a fact the street crime obsessed mass media rarely discloses.

These are among the most extreme examples of a crisis that affects millions of people.  While the acutely mentally ill are a minority of the population, millions more suffer from milder forms of depression, anxiety, and other syndromes that make life in a brutally unequal and profoundly oppressive society all the more difficult. 

The mental health crisis is intimately linked to the larger crisis of health care.  The 47 million residents of the United States, who lack health insurance have little to no access to mental health services.  Millions more live with profoundly inadequate access to medication or therapy.  Insurers typically limit visits to mental health professionals at 20 per year—a level profoundly inadequate for anyone suffering severe distress.  Medications are often not covered for chronic illnesses.  Millions of people fail to seek access to treatments for anxiety or depression because of deeply rooted guilt and shame around these issues which still pervades U.S. culture.  All of this leaves aside the question of whether the predominant approaches to mental health adequately address the roots of emotional and psychological turmoil in our society.

The issues of mental health and mental illness are complicated.  It is undoubtedly true that the viscitudes of capitalist society, from economic exploitation to oppression in all its forms, are a crucial source of the emotional and psychological issues that plague so many.  Yet there is also persuasive evidence that human biology plays some role in determining each person’s likelihood of contending with particular mental health conditions.  What we know about how the mind works has expanded exponentially over the past hundred years.  Yet in many respects, our understanding of the mind and of human emotions remains in its infancy.  Many of the treatments which professionals know to be effective were discovered by scientific accident, and are barely understood at a theoretical level.

The concept of mental illness is useful as a means of describing the condition of those most acutely disabled by disorders of mood and cognition.  The notion of mental illness has been progressive in that it has established a basis upon which to compare afflictions of the mind to those of the body.  Yet the limitations of the concept are evident in widespread views of the mentally ill as an incomprehensible population whose troubles bear no relation to the daily ups and downs that effect the rest of us.  In contrast, the notion of mental health suggests that attention to moods, emotions, and psychological tendencies should be a basic part of what all of us deem important in attempting to live healthy and productive lives.

Debates on the Left

Mental health is not a subject frequently addressed by those on the left—but when it is, discord and confusion often reign supreme.  Debate has raged over the question of medication, with many voices arguing forcefully that the widespread use of psychotropic medication is the product of sinister collusion between the pharmaceutical industry and the Federal government.  Ignoring the fact that millions of people see some value in taking medication, critics argue that these treatments range from useless to harmful, and dismiss the potential of medication to provide relief for painful conditions.  Some have minimized the value of currently available mental health treatment, arguing that mental distress is simply a product of an oppressive and exploitive society, and is inevitable as long as those larger forces reign supreme. 

While there are grains of truth in these arguments, there is much to defend about the scientific advances made in the understanding of the mind in recent decades.  Capitalism exacts a severe toll on the human psyche, but has also given birth to a range of treatments that hold enormous potential for alleviating emotional suffering.  We have a multitude of tools at our disposal for treating mental health issues, and need to use all available methodologies to find what works.  One critical problem is access—those most in need of advanced treatments are least likely to be able to afford them.  While the goal of the left must be to fundamentally transform society, we should be passionate advocates for all those who need help in the present. The Marxist understanding of human society—of exploitation, alienation, oppression, and commodification—could do much to inform social work, psychology, and psychiatry.  The task of the left is to build the kind of social movements that can facilitate the fusion of the best scientific knowledge about our minds and emotions, with a materialist understanding of how change can be made in class society.

Among the most menacing barriers to the social progress we need around mental health are the profound levels of guilt and shame that suffuse these issues.  Capitalist society teaches us that we are each personally responsible for our own success.  A corollary of this is that emotional and psychological difficulties we encounter are our own fault.  This belief is such a firm part of ruling class ideology that millions of people who would never openly articulate this idea, nonetheless accept it in subtle and overt ways.  People are often ashamed that they need medication, seeing this as revealing some constitutional weakness.  People feel guilty about needing therapy, thinking that they should be able to solve their problems on their own.  Millions of people fail to seek any treatment, because mental health care is seen as something that only the most dramatically unstable person would turn to.

We need to break the silence around mental health.  These are issues that all of us should have some basic exposure to.  The proportion of the population that will experience an episode of acute emotional distress is extremely high.  Those of us who have never been depressed probably know and love several people who have.  With these issues, as with the AIDS crisis, silence is deadly.  People are left to face acute trauma not knowing that there are millions of people who share their struggle, not knowing that there are viable means of relief, and not knowing that if treatment is successful they can lead meaningful and joyful lives.

Mental health challenges are often created and compounded by the many forms of oppression that pervade capitalist society.  Sexism is a tremendous emotional and psychological burden on women, and is a likely contributor to the fact that women’s rates of depression are roughly double those of men.  Racism makes life more difficult for blacks, Latinos, and other oppressed groups, and then affects the way people from these groups are treated when they seek mental health treatment—or are forced into it through an encounter with the criminal justice system.  As mental health institutions have been dismantled, the prisons have emerged as a de-facto mental health system.  A staggering proportion of people in prison have diagnosable mental health issues; thousands probably develop mental health problems as a result of the brutal and inhumane conditions that have come to pervade the prison system.  Homophobia is also a critical factor in mental health difficulties for members of the LGBT community.  Growing up in a homophobic society produces a toxic confluence of guilt, shame, fear, and mental isolation.  Suicide rates for LGBT teens are staggering.  The immigrant community also has its own mental health crisis.  Many immigrants experience depression, anxiety, and substance abuse because of poverty, the threat of deportation, and feelings of inadequacy because of not achieving economic success in the U.S.

Depression

Depression is among the most widespread and devastating mental illnesses.  According to recent research, about 3 percent of people in the U.S.—some 19 million—suffer from chronic depression.  Yet only half of those with major depression have ever sought help of any kind—even from a clergyman or counselor. About 95 percent of those who have sought help have gone to primary care physicians, whose knowledge of psychiatric complaints is limited.  Nonetheless, about 28 million people—10 percent of the adult population—are now on selective serotonin reuptake inhibitors (SSRIs)—the class of drugs of which Prozac is the most prominent.  Rates of depression are on the rise.  Twenty years ago, 1.5 percent of the population had depression that required treatment.  Today, the figure is 5% and as many as 10 percent of people now living in the U.S. can expect a major depressive episode in their lifetime.[1]

Depression is enormously costly, both emotionally and financially. The following description by author Kay Redfield Jamison captures the range of depressive experience:

The depressive, or melancholic, states are characterized by a morbidity and flatness of mood along with a slowing down of virtually all aspects of human thought, feeling, and behavior that are most personally meaningful… When energy is profoundly dissipated, the ability to think is clearly eroded, and the capacity to actively engage in the efforts and pleasures of life is fundamentally altered, then depression becomes an illness rather than a temporary or existential state… Mood, in the more serious depressive states, is usually bleak, pessimistic, and despairing… The physical and psychological worlds are experienced as shades of grays and blacks, as having lost their color and vibrancy.[2]

Andrew Solomon describes depression as a “noonday demon,” a metaphor that evokes depression’s power to rob one of the vitality for living in any circumstances:

There is something brazen about depression.  Most demons—most forms of anguish—rely on the cover of night; to see them clearly is to defeat them.  Depression stands in the full glare of the sun, unchallenged by recognition.  You know all the why and the wherefore and suffer just as much as if you were shrouded by ignorance. There is almost no other mental state of which the same can be said.[3]

Depression is related to grief, but is distinct from it.  While emotions of sadness and loss can trigger depression, the demon itself is distinct in character.  Depression also begets depression.  It leads us to isolate ourselves from people around us, and to withdraw from outside commitments and human engagement.  Fighting these tendencies is central to the struggle to conquer ones own depression.

Fortunately, depression does respond to treatment. Medications do work for many people, though patience is required as they are is no clearly established methodology for establishing which anti-depressants will work for which subsets of the population.  Medications often take weeks to be effective, and for no apparent reason, a medication which works well for one person, will have no effect on another.  Particularly treatment-resistant depressions often respond well to a combination of medications each influencing different neurotransmitter systems.  Therapy can be enormously helpful, as can regular exercise, good diet, and a range of alternative therapies.[4]

There are also treatments for depression that strain the imagination.  Electroconvulsive therapy is a remarkably reliable means of treating severe depression.  Electric shocks delivered to an anasthetized patient induce seizure-like activity which has the effect of rebooting the brains neurochemistry and delivering relief.  Unfortunately, one dramatic side-effect of this treatment is the disorienting loss of short-term memory.  Transcranial magnetic stimulation has also shown positive results with some patients.  These treatments indicate how complex our minds are and how little we understand about the science which makes certain treatments effective.

Anxiety

Anxiety is depression’s cousin.  If depression is brings on despair about the conditions of one’s own life, anxiety brings anticipation of problems because of actions and situations yet to be encountered.  Anxiety can be paralyzing and can lead to acute panic attacks in which a person can lose consciousness:

The psychological core of acute anxiety attacks can center around fears of internal physical disaster… or of mental disorder…or of social catastrophe.  Sometimes a person cannot pinpoint the precise nature of an anticipated catastrophe but expects that some very noxious event is occurring or is about to occur.[5]

  As Aaron Beck and Gary Emery write, “anxious individuals innacurately appraise neutral situations as dangerous.”  The fear involved may be of physical harm, social discomfort, or a recurrence of trauma.  Studies have indicated very little genetic basis for anxiety disorders.  Rather, anxiety disorders seem to be a response to trauma, whether mild or severe, and to the pervasive insecurities engendered by a social system racked by alienation and shaped intrinsically by competition.  As Beck and Emery write:

Anxiety may be distinguished from fear in that the former is an emotional process while fear is a cognitive one. Fear involves the intellectual appraisal of a threatening stimulus; anxiety involves the emotional response to that appraisal… One can label a fear as being realistic or unrealistic, rational or irrational.  A fear is realistic is based on a sensible assumption, logic and reasoning, and objective observation… Anxiety on the other hand cannot be labled realistic or unrealistic because is refers to an affective response not to a process of evaluating reality.[6]

Cognitive behavior therapy works by teaching clients to intervene in their own cognitive processes, thus dimming the intense emotional reactions to apparently threatening situations:

The role of cognitive therapy… is to test whether a particular situation labeled dangerous is actually dangerous.  Thus, through questioning the degree of danger, evaluating danger-laden automatic thoughts, and experimental exposure, the patient is enabled to detach and “extinguish” the fears that have been erroneously attached to a given situation or object.[7]

Other treatment methods are also effective with some patients.  Medications can be enormously helpful, and anxiety often coexists with depression, which must be treated in its own right.  Post-traumatic stress disorder, a key subset of the anxiety disorders, is obviously a growing problem because of the wars in Iraq and and Afghanistan, and requires its own specific treatments.

Manic Depressive Illness

Manic depressive illness is the most strikingly dialectical of the major mental illnesses.  People with manic depressive illness have episodes of depression, but also episodes of mania or hypomania which are in many ways the polar opposite of depression.  This is why this condition is often called bipolar disorder.  The term bipolar is misleading however in that episodes are not neatly packaged, and one can have agitated depressions or dark and melancholy manias.  There are an enormous range of transitional states that can mark the movement from one pole to the other, or that can come and go as part of a distinctly manic or depressive episode.

Manic depressive illness is a very serious disease.  Prior to the widespread availability of lithium as a treatment, close to one in five with manic-depressive illness committed suicide.  Rates of suicide for this population are still startlingly high, and substance abuse is frequently the hand-maiden of the illness.  Severe episodes of mania or depression can lead to intensely delusional thinking and dangerous behavior.  There are lucky people who find deep wells of social support in times of severe mania or depression, but many more lose friendships, relationships, ties to families, and careers during the wild cycles of mood the illness brings on.[8]

Since we have already described depression, it seems that some description of the nature of mania and hypomania is in order.  Kay Redfield Jamison is a pioneer in this field as a clinician who also lives with manic depressive illness herself.  In her autobiography, An Unquiet Mind, Jamison writes:

I was a senior in high school when I had my first attack of manic-depressive illness; once the siege began, I lost my mind rather rapidly.  At first everything seemed so easy.  I raced about like a crazed weasel, bubbling with plans and enthusiasms, immersed in sports, and staying up all night, night after night with friends, reading everything that wasn’t nailed down… and making expansive, completely unrealistic plans for my future… I felt I could do anything, that no task was too difficult.  My mind seemed clear, fabulously focused, and able to make intuitive mathematicfal leaps that had up that point entirely eluded me… it al began to fit into a marvelous kind of cosmic relatedness.[9]

But manias tend to move from the blissful to the frighteningly chaotic.  Wild uncontrolled spending, risky and often violent behavioral, and outrageous levels of substance abuse frequently accompany strong manias.  Delusional thinking, including the potential for all manner of hallucinations is also common.  Withoun medications, these manic spells could last for years, and manic patients were generally hospitalized for life.  Today, it is possible to catch mild manias in their hypomanic phase and tame them before anything too disastrous takes place.

Interestingly, manic depressive illness is closely associated with artistic talent and many forms of creativity.  This is not to say that all manic-depressives are budding geniuses, but there is a strong correlation between the presence of the disorder in families, and the presence of artistic and creative genius in afflicted individuals and among their immediate relatives.  Kay Redfield Jamison has written a wonderful book called Touched By Fire: Manic Depressive Illness and the Artistic Temperament, which details this relationship over centuries.[10]  When controlled, the hypomanias, or mild manias, which emerge for those with manic-depressive illness can be times of immense productivity and inspired thinking.  This is a disorder which brings great danger, but also confers certain strengths.  The danger of untreated manic depressive illness must be underscored.  Suicide rates are shockingly high, and can occur both in the depths of depression, and in manic states that follow from depressive ones.  The prevalence of disastrous self-medication for those with the illness, complicates the medical problems and brings its own severe dangers.  Correctly diagnosing manic depressive illness and seeking safe and effective treatment are critical to preventing deeply avoidable human tragedy.

Schizophrenia

Schizophrenia is perhaps the most treatment-resistant mental illness.  Those affected by schizophrenia experience delusional and paranoid thinking, and can often appear to have multiple distinct personalities.  Treatment for schizophrenia has advanced tremendously since the 1950s when overconfident Freudians believed that through talk-therapy alone they could cure schizophrenics.  This perspective also involved blaming mothers and families for the condition, which is now understood to be largely genetic in origin.[11]  The first generation of medical treatment for Schizophrenia, the neuroleptics, a class of powerful tranquilizers, was also quite controversial.  To day the battery of medications used to treat the condition has expanded, and some patients have seen dramatic results with these new therapies.

Suicide

Suicide is the ultimate mental health failure.  Suicide kills approximately 30,000 people each year in the United States.  The figures are still more staggering for the young—rates have more than tripled since 1955.  Suicide is the second major killer of women between 15 and 44, and the fourth major killer of men in this age group.  Rates of suicide have been increasing throughout the world.  Between 1980 and 1992, the rate of suicide for children from ten to fourteen increased by 120 percent.  In 1995, more young adults and teenagers died from suicide than from cancer, heart disease, AIDS, pneumonia, influenza, birth defects, and stroke combined.[12]

 Suicide and mental illness are closely linked.  International studies indicate that 90 to 95 percent of people who commit suicide had a diagnosable psychiatric illness.  According to Kay Redfield Jamison, “At least one person in five with major depression will attempts suicide, and nearly one-half of those with bipolar disorder will try to kill themselves at least once.[13]  Suicide is also prevalent in a controversial diagnostic population, those with borderline personality disorder.  This so-called personality disorder is criticized  by many professionals today as simply being a compounded version of other mood disorders.  Nonetheless, three quarters of patients with this diagnosis attempt suicide at least once, and 5 to 10 percent are successful.[14]  Anxiety, when combined with depression, is also a potent trigger of suicide.[15]  Suicide is also closely related to substance abuse, and unfortunately substance abuse and mental illness frequently coexist:

Two of every three people with manic depression, and one of every four with depression, have substantial alcohol or drug abuse problems; the rates for those with schizophrenia are nearly as high… Drugs and mood disorders tend to bring out the worst in one another: alone they are dreadful, together they kill.[16]

Efforts at suicide prevention must involve a comprehensive assessment of a person’s various risk factors, and aggressive treatment for each is essential.

Effective suicide prevention must involve intense engagement with clinicians and psychopharmacologists and the support and engagement of family and friends.  Antidepressants, especially lithium, have proven ability to help prevent suicides.  Electroconcvulsive therapy also has an excellent track record in pulling people out of the most intractable depressions. According to Jamison, every study of individuals who have committed suicide has found that depression has been underdiagnosed and that antidepressants have been underprescribed.[17] This runs counter to the growing conventional wisdom that implicates antidepressants themselves in increased suicide rates.  The incidence of suicide while on antidepressants however has not adequately explored whether medications were being taken at sufficient doses and whether side effects were monitored adequately by patients, family, and clinicians.  It is a tragic irony that one of the moments when suicide becomes most likely is when someone is just beginning to recover from a deep depression.  Suddenly new energy and ability to plan are turned toward morbid ends out of fear that the worst of depression will soon return.  As Jamison writes, “A resurgence of will and vitality—ordinarily a sign of returning health—makes possible the acting out of previously frozen suicidal thoughts and desires.[18]  This may partly explain why even progress because of antidepressants needs to be closely monitored by family, friends, and trained professionals.

Effective suicide prevention involves a multi-pronged approach:

Individuals who are at risk of killing themselves… can do several things to make suicide less likely.  Being well-informed about mental illness, actively involved in their own clinical care, and very assertive about the quality of medical and psychological treatment they receive is a good start.  Patients and their family members can benefit by actively seeking out books, lectures, and support groups that provide information about suicide and drug abuse.  They should question their clinicians about their diagnosis, treatment, and prognosis and, if concerned about a lack of collaborative effort or progress in their clinical condition, seek a second opinion.[19]

Suicide prevention efforts, while crucial, need to be rethought in light of the available evidence about the nature of suicide.  A careful study of 115 school-based programs found that most were two hours or less in length and focused on a stress model, which suggests that anyone under sufficient strain might be at risk for suicide. Only 4% of programs argued that suicide is likely to be the result of mental illness.[20]  The fear of talking openly about mental health and mental illness with young people, may be taking lives.

For those of us who have experienced a suicide in our family or among friends the loss can be unspeakably devastating.  Feelings of guilt hang upon suicide as around few other phenomena.  It is critical that those left behind by suicide seek the emotional support they need, and that immediate action is taken in relation to close friends or family who may suffer from precipitating factors themselves.  Suicide has a documented contagious effect.  Suicide is a reminder of the importance of taking mental health seriously, and should lead us all to take care of our own emotional and psychological needs and to urge that those we care about do the same.[21]

What is to be Done?

Developing solutions to the mental health crisis requires developing both short and long-term goals.  In the debate about national health care and in debates over employment based health care, socialists should argue for the full coverage of mental health issues.  We should challenge the preference of insurers for funding medication, in lieu of therapy, arguing that each patient should have the right to craft appropriate treatment in consultation with professionals.  Medication can be extremely effective, but for it to work properly, one needs a strong balanced relationship with a professional in which the client can honestly report symptoms, side-effects and seek changes if necessary.  Psychiatry is unique in medicine in that the best instrument for judging the efficacy of a treatment is the client herself.

Being educated about mental health issues is also of tremendous importance.  Whether we encounter issues in our own lives or those of others, an informed perspective on mental health allows us to be active participants in treatment.  To do their jobs well, professional social workers, counselors, and psychiatrists need clients who are engaged and participatory.  We also need to consciously challenge the stigma around mental health.  Of course, we should defend each person’s right to choose whether or not to disclose the existence of a particular ailment.  But it should be no more shameful to say that one has manic depressive illness, than to announce that one is asthmatic or has breast cancer.  Talking about these issues is part of the solution.  Breaking the silence can be liberating.

Ultimately, however, the struggle for mental health must be a struggle to transform the social conditions that produce unnecessary psychological and emotional damage for millions of people.  In a world without poverty, war, racism, sexism, or homophobia, we would surely still have mental health issues, but the nature of those issues would be unimaginable in relation to the profound destruction of the human personality that is carried out daily by capitalism.  Mental health needs to part of what a socialist left talks about when it expands upon a vision for a changed society.  Mental health care should be part of what we demand when we think about solutions to the economic crisis, or the needs of Iraqis and U.S. soldiers in the wake of a senseless war of occupation.  We are fighting for a world where the best mental health care will no longer be a luxury possessed by a tiny few, but the natural right of all.  That is a world worth fighting for, and consciousness about the importance of a mental health can be a piece in the armament that helps us get there.

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[1] Solomon, 25.

[2] Jamison, Touchedby Fire, 18.

[3] Solomon, 293.

[4] Solomon, 101-172

[5] Aaron T. Beck and Gary Emery, Anxiety Disorders and Phobias: A Cognitive Perspective, Cambridge, MA: Basic Books, 1985, 2005, 29.

[6] Beck and Emery, 9-10.

[7] Beck and Emery, 98.

[8] Jamison, Touched by Fire, 16.

[9] Jamison, AnUnquiet Mind, 36-37

[10] Jamison, Touched by Fire, 50-99.

[11] Edward Dolnick, Madness on the Couch: Blaming the Victim in the Heyday of Psychoanalysis. New York: Simon and Schuster, 1998, 83-166.

[12] Jamison, Night Falls Fast, 21, 46-48.

[13] Jamison, Night Falls Fast, 100, 110.

[14] Jamison, Night Falls Fast, 123

[15] Jamison, Night Falls Fast, 121

[16] Jamison, Night Falls Fast, 128

[17] Jamison, Night Falls Fast, 245, 251.

[18] Jamison, Night Falls Fast, 114

[19] Jamison, Night Falls Fast, 258

[20] Jamison, Night Falls Fast, 275

[21] Contagious factor?