The continuum is a one way street

A few years ago, the Time to Change campaign would have been exactly the kind of thing I spent my time arguing for. Now, mental health seems to be everywhere, and I feel somehow hollow and disinherited. I think blogger Purple Persuasion nailed it with her post ‘scary people need time to talk too’[1]; the gist of her argument is that, while the intent behind TtC and other anti-stigma campaigns is admirable, the claim that people with diagnoses are no different from anyone else creates a fairly narrow view of survivors which only includes those with more low-level, everyday conditions like depression and anxiety. Those with more debilitating labels like schizophrenia or personality disorder are often excluded.

The ‘we all have mental health’ type of argument is loosely based on the idea of positive mental health and a mental health continuum; this model presents mental illnesses as existing on a spectrum in which diagnoses are fluid not fixed, and mental wellbeing matters more than diagnosable symptoms. Everyone is represented on the spectrum, with the man from the Berocca advert at one end and a guy in a 136 suite at the other[2]. The ‘spectrum’ argument tries to counter mental health stigma and the ‘othering’ of patients by emphasising the fact that anyone can get ill, anyone can get depressed, and people with diagnosed depression and anxiety can sometimes do everyday stuff like go to work or go to a pub. Essentially, if there’s no threshold for diagnosable illnesses, then we’re all in the same boat. The problem is that the common ground between the diagnosed and undiagnosed is, again, inaccessible to those with more long term illnesses who maybe can’t go to work or go to the pub. The continuum  discourse is beginning to dominate the debate on mental health, and the meaning of the term ‘mental illness’ is changing as a result. Mental illness is starting to be seen as an everyday part of life for a large swathe of the population, less like cancer and more like the common cold. This isn’t the reality for chronic patients, who may spend their lives getting shuttled back and forth beyween different institutions.

The Time to Change campaign’s agenda is also fundamentally neoliberal. TtC puts a lot of stock in the everyday conversation as a means of social change, and it’s telling that so many of the types of conversation they recommend occur within the workplace[3]. Like always, the division between normal and abnormal, those who TtC say are OK and those who the campaign seems to ignore, occurs at the point where a person loses the ability to work. In this way TtC’s agenda fits in a bit too snugly with the old capitalist construction of disability[4] and especially with the DWP’s arbeit macht frei policies towards the diagnosed; those who are economically productive are incorporated, newly de-stigmatised, into the social mainstream, whilst those who cost the system more than they make for it continue to be tossed on the scrapheap. The shrinking of the term ‘mental illness’, so that it seems to increasingly mean just ‘depressed and anxious’, is part of this process. The working worried, whether diagnosed or otherwise, have become the new mentally ill. Meanwhile, the hospital population, ECT survivors, voice hearers, learning disabled and other inconvenients, aren’t welcome under TtC’s new definition. Whilst the stigma may vanish, this is only because those most stigmatised have been brushed under the carpet.

My biggest problem with the ‘we’ve all got mental health’ spectrum-type argument[5] is that it tends to be a one-way street. To give an example, an AMHP in my office today mentioned starting a mindfulness class for mental health workers. She said she thought it was sad that we spent all our time looking after other people’s mental health and it was time we started thinking about our own. This seemed at first like a nice thing to say- a breaking down of boundaries between middle class pro’s and working class patients, a show of empathy, perhaps a recognition of a common humanity. But, as I said, it only works one way. The anti-stigma campaign has freed social workers and CPNs to acknowledge their own mental health; it very much hasn’t freed patients to come up to the office and start writing their own care plans. The powerful are allowed to be powerless for a day, but the powerless are kept just as far away as ever from the corridors of power. And, again, mental health means something very different for the professionals than it does to the patient. Whilst we go to mindfulness classes and take extended holidays to treat our own mental health, our patients are treated with ECT and chlorpromazine in locked wards.  On forced treatment and psychiatric abuse, the anti-stigma campaign has been stonily silent.

Like deinstitutionalization and the recovery model before it, the continuum model seems to be just another in the long line of initially progressive ideas for psychiatric liberation that have been hijacked by the neoliberal Right as a pretext for cutting services and blaming users. Stigma is political, not just personal. It’s healthy to be skeptical of an anti-stigma campaign that’s funded by the DWP.




[2] As opposed to a traditional medical model in which mental illness means the presence of diagnosable symptoms. The continuum model is discussed here

[3] Point 2 here is work-based

[4] See Michael Oliver’s The Politics of Disablement; his basic argument is that, in a system where people are valued only for the worth of their labour,  those whose labour is worth the least are labelled as disabled.

[5] Like so


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