'How would you expect to feel?' - mental illness, or staying sane in an insane world?

Medicalisation of emotional and psychological distress is something I regard with disquiet.

I have no doubt that mental illnesses exist, but my feeling after working with many hundreds of clients is that they are rarer than we sometimes think. The phrase I find myself using most often, to a client who first presents with “anxiety”, “depression” or panic attacks and then tells me the story of their life, recent, historic or both, is “how would you expect to feel?”. Didn’t RD Laing call going crazy (his word) “a sane response to an insane situation”?

When you meet someone who is terrified by panic attacks, the first thing you do is explain what a panic attack is, why we have them, and why they are a perfectly natural and healthy response to threat; it just so happens that in most cases in the modern world, in peacetime, that response is not helpful. You then explain what can be done, purely physically, to mitigate that response. They go away understanding that the panic attacks are not a mysterious illness, but a response to something that has happened to them which may or may not be in awareness.

That’s a very basic example. Response to bereavement is another. “How would you expect to feel” after losing someone who made up an essential part of the very fabric of your life, your world, your identity? Correct – it is something so big that you have no idea how you would react. It’s too big, too all-encompassing, for any of your previous reaction-patterns to come anywhere near it.

“How would you expect to feel” after a lifetime of poverty, abuse, bereavement, bullying or friends disappearing because they can’t cope with the level of distress?

If I find someone lying in the road with a broken leg, my first thought won’t be “this person has a disease that makes their bones break”, but “this person has had an accident – the location suggests to me that they may have been hit by a car”. We will take them to hospital, we will do what’s required to set the leg, put it in plaster and give them painkillers. We will not medicate them for brittle bone disease.

I trust the parallel is obvious. If I meet a client presenting with anxiety I won’t assume they have brittle nerves disease. I won’t say “away to a doctor to get diagnosed and medicated”. I will ask what has happened to them, what car, bike or lorry has hit them... and how many times. Maybe they will find medication helpful in addressing what has happened, just as the person with the broken leg will find a plaster cast and painkillers helpful.

I think it likely (though I’m not a doctor) that there are mental illnesses and disorders called depression, anxiety, bipolar disorder, obsessive compulsive disorder, schizophrenia, and so on. I am also a fan of Occam’s Razor, the principle that states "a plurality is not to be posited without necessity", or just “the simplest solution tends to be the correct one”. If I hear a history of abuse, bullying and neglect that is a sufficient explanation for the distress, mood-swings or dissociative episodes of the client in my room, I do not need to posit an organic disorder, just as I do not need to posit an organic disorder for the person lying in the road with the broken leg.

If you are feeling, responding, or behaving in a way that is distressing you, maybe the first question isn’t “what’s wrong with me?” but “what’s right with me, and what’s it telling me?”. What it is telling you is wrong with your environment, your circumstances, or your history? What was the trauma (it takes very little to traumatise a child) or the unhelpful message or narrative that you are still carrying in your body or primitive brain and to which your body or primitive brain is trying to draw your attention?

When I hear someone saying “it’s stupid” or “it’s irrational”, it is a pointer to me that it’s nothing of the kind. It is wise and it makes total sense. It is our primitive, survival brain and our body doing their utmost to keep us safe. It is irrational to the thinking, processing brain because it happens not to be in its awareness... yet.

A client once said to me (quoted with permission): “The better I know myself, the better I feel about myself”. Listening to, observing and noticing those apparently irrational or exaggerated thoughts, feelings, or reactions without judgement, as information, as evidence, saying “how interesting” rather than “that’s terrible” or “I shouldn’t do that”, is the first step towards knowing yourself better.

Perhaps the most important of the “core conditions” which Carl Rogers (the founder of person-centred therapy) said were necessary and sufficient for therapeutic change to take place is what he called unconditional positive regard. It means completely supporting and accepting a person no matter what they say or do. There are no conditions of acceptance; the therapist cares for the client as a separate person, with permission to have his own feelings, his own experiences. While you are waiting to see a therapist, try applying unconditional positive regard to yourself. Look at your responses, reactions and feelings with interest, with acceptance and with compassion. Another client said to me (again quoted with permission): “I want to be the person I needed back then”.

Remember that the traditional Buddhist loving-kindness meditation begins with directing the loving-kindness towards oneself. That’s where love and compassion must begin, before we can be fully able to direct it outwards. It is not selfishness. It is becoming the best version of ourselves, the person we needed “back then” and still need now. For ourselves, then for the people we love, and then for the world.