Hammer and Dance: A New Model for Mental Health?
Why society treats mental health problems as if they were infectious diseases.
Is Mental illness an infection? Certainly not, but the so-called “hammer and dance” theory of managing COVID-19, is much like how we as society choose to deal with mental health.
As coronavirus infection rates soared, governments worldwide struck heavy hammer-blows of social measures — including lockdowns — in an attempt flatten the curve. The theory goes once the virus has been suppressed, measures are relaxed, and the dance of containment begins.
A similar scenario plays out every time an individual succumbs to a mental health crisis: A surge in symptoms, provoke a hammer blow of suppression. Once symptoms remit, so begins a dance to keep them under control. However can such a theory be applied to ideas of crisis and recovery?
Warning signs of a Mental Health Crisis
Let’s go with the analogy to begin with: The warning signs of an impending mental health crisis emerge like a pandemic. Like the reports of ‘mysterious new penumonia’ of an unknown origin coming out of Wuhan in early-January, the “prodrome” of any illness often goes unheeded.
Individuals experiencing mental health problems, behave much like protectionist countries: Already isolated and cut-off, they’re often unable to get feedback from friends or family. However, as the table below shows, even when help is sought; treatment is often inaccessible, inappropriate or wholly ineffective.
In reality, while 25% of the population will experience a mental health problem, only one third will get treatment; two thirds won’t. Furthermore, those that do, may be subject to the wrong kind of treatment. For instance, from 2008–2018 the use of psychotropic medication increased by 97%; on the other hand levels of therapy remained staggeringly low. While the UK’s Improving Access to Psychological Therapies (IAPT) policy, has helped, those with severe mental illness, conditions like Schizophrenia, Bipolar or Personality Disorder continue to be excluded. As a result, early warning signs are missed and symptoms begin to accelerate. A crisis point is reached.
When it came to COVID-19 many countries swung the hammer too late: as infections began spiking, governments dragged their feet. As a result, many health systems were overwhelmed. Lockdowns have now been introduced in over 100 countries, many of whom lack an exit-strategy; quarantine has instead become the standardised response.
Is a hammer-blow an appropriate remedy for a mental health crisis? Absolutely not. In the United Kingdom, mental health services are near breaking-point. This was true even before the pandemic; historic under-investment, has taken it’s toll, and most NHS Trusts have been left under-resourced and poorly equipped, creating a wide discrepancies in treatment quality and access.
An individual tipping into crisis, provokes (to borrow a term from virology) a kind of spillover event: symptoms become so extreme they begin to affect (infect) others including family, friends and eventually health professionals. The 1983 Mental Health Act, gives the clinicians the power to ‘section’ individuals they deem high risk, meaning patients get locked-up in inpatient units until the crisis resolves itself. Detainment, can be seen as a way to suppress a crisis much like a virus; but it doesn’t work, appearing instead as a punishment designed to reinforce the idea of something being wrong.
As we go into summer, and countries begin lifting their lockdown, the potential for new waves of the virus means we’re likely to be in for a prolonged dance of containment; involving extended social distancing, testing, and contact-tracing.
On the contrary society’s response to mental illness is to dance on tip toes or not dance at all. An individual emerging from a mental health crisis is especially vulnerable to a relapse. In fact, UK emergency mental health readmission rates range from 11 to 18%; furthermore 17% of all UK suicides are psychiatric inpatients who’ve recently been discharged. As the graph below demonstrates the risk is highest in the first week, but remains present even after 3 months. According to a recent report, clinicians believe improved outcomes depend ‘better supervision,’ and ‘access to psychological treatment.’ This is often unavailable and what sparks the unrelenting crisis.
Prevention is the Best Medicine
Much of this can be avoided. Mental illness is not an infection, and yet in the UK it’s endemic; a cruel irony, given that the “hammer and dance” theory doesn’t exactly work. State sanctioned suppression, such as detaining individuals under the Mental Health Act strike a hammer blow to the individual, temporarily flattening symptoms but pulverising the personality in the process. Perhaps, the only place worse than a secure unit is a police custody cell increasingly used as a ‘place of safety’ for thousands of vulnerable adults every year, when beds run out. As Simon Wessley’s timely 2018 review of the Act made clear, “Just as truth is often described as the first casualty of war, the same is true of dignity when compulsive powers are being invoked.”
Lockdowns may work for infections, contrarily recovery mental illness requires opening-up: Opening-up services and purse-strings for that matter. Too many times, individuals are denied access to treatment which could in fact contain a crisis before it occurs. The ‘revolving door’ patient is not a myth; it’s the result of the successive government failure, and a Health Service which unimaginatively sticks to the script, forcing patients into vicious cycle of shame, stigma and helplessness. It shouldn’t be this way; just as with the response to COVID 19 the state must mobilise quickly. We can start with simple things — streamlined referrals from a single point of access, prompt allocation of care coordinators, better treatment options and of course more patient involvement.
Fighting for your Life?
The irony in all this, is that the “hammer and dance” theory is not only used in society’s fight against mental illness, but by the individual as well. Those experiencing mental illness will most likely mimic society’s response, seeking to crush symptoms under heavy hammer-blows of suppression — ignoring, denying, minimising pain and suffering, or else punishing it in acts of gratuitous self-harm. This internalisation of shame and stigma, is not usually the results of friends or family, nor even ordinary members of the public — after all, we’re all talking more openly and honestly about this — rather institutions, which proliferate the same old messages of relapse and recovery. The incessant push to ‘change’ behaviour; as most readily seen in therapies like CBT, posit a cure which perhaps like with COVID 19 doesn’t exist. We cannot avoid pain and suffering; it’s part of life, but by placing the onus on the individual to “think better” and “do better” there’s ample room for failure. The blunt message of pull yourself together just doesn’t work.
What then should the message be? Acceptance and Commitment. Like society, the individual must open-up; this means not only talking about pain and suffering, but experiencing it. The advent of social media, has fundamentally changed the conversation around mental health; much of this is to be celebrated. However, at the extreme end it risks fetishises mental illness. Symptoms become attributes; people become personas. True healing is more likely to occur in real life relationships. Perhaps even better than talking is tolerating; allowing distress to surface in consciousness without pushing it away — though it may bring, fear, shame, sadness or anger — just allowing distress to be what it is works wonder. Avoid the hammer and uproot the nail; and instead of a post-discharge dance walk forward with your head high. In the end this acceptance strategy will prevent another pandemic, that of mental health.
Jason Gale, China Pneumonia Outbreak Spurs WHO Action as Mystery Lingers, Bloomberg (4 Jan 2020) https://www.bloomberg.com/news/articles/2020-01-04/china-pneumonia-outbreak-spurs-who-action-as-mystery-lingers
Sally McManus et al (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/556596/apms-2014-full-rpt.pdf
Mental Health: 10 charts on the scale of the problem, BBC, (4 Dec 2018) https://www.bbc.co.uk/news/health-41125009
The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Making Mental Health Care Safer: Annual Report and 20-year Review. University of Manchester. (October 2016).(http://documents.manchester.ac.uk/display.aspx?DocID=37580
Sir Simon Wessely, Modernising the Mental Health Act Increasing choice, reducing compulsion, Final report of the Independent Review of the Mental Health Act 1983. Crown Copyright, (Dec 2018) https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/778897/Modernising_the_Mental_Health_Act_-_increasing_choice__reducing_compulsion.pdf
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