I spent most of Wednesday at a meeting (rather a positive meeting) about the relationship between public health and mental health strategies. As is quite common at these kinds of meetings, we discussed the origins of distress and the nature of threats to our well-being. We don’t like to talk too much about blame in mental health. And when we do consider issues of cause, responsibility and blame, we tend to assume that we (whoever the ‘we’ are) have the morally correct view – the one that leaves anyone in emotional distress reassured, positive and confident. But it’s more complicated than that.
We know that many of our medical colleagues believe that the ‘illness like any other’ message should alleviate a sense of personal responsibility. The logic is that, in the same way that a person infected by chicken pox is not felt to be blameworthy for the rash, so a person with a mental ‘illness’ should not be blamed. But, of course, this rather ignores the known sociology of public attitudes towards mental health across millennia and the rather transparent observation that fascists tend to attack, not exonerate, people with disabilities and illnesses.
Equally, however, psychologists tend to assume that their models reduce a sense of blame. We like to see ourselves as moral and caring. But it’s obviously more complicated than that. A focus on ‘errors in thinking’ or ‘dysfunctional attitudes’ (or any other form of words) can all too easily lead to concluding that the person is at fault – it’s their thoughts that are ‘distorted’, and that’s a hair’s breadth from finding them culpable.
Many colleagues focus, instead, on social determinants. This, of course, is particularly common in the public health field. The message, here, goes something along the lines of: “being depressed isn’t an illness, and it’s certainly not your fault, there’s nothing wrong with your thinking, it’s perfectly understandable that you’re depressed since you’ve lost your job”.
That doesn’t strike me as a fully satisfactory account. First, it doesn’t fully explain why I and my colleagues should offer individual help. If the root causes of a person’s problems are social and political, does that mean any form of therapy is a disingenuous placebo? And, while I fully accept that social factors offer the greatest possible explanatory power, an account such as this doesn’t fully explain why psychological factors (yes, sorry, the altered cognitions so beloved of CBT therapists) are part of the picture.
I resolve this dilemma by (as I said in a paper in 2005) seeing psychological factors as mediators in a kind of two-stage process. My logic is that our beliefs, emotions and behaviours – including our mental health – are the product of the way we think about the world; our thoughts about ourselves, other people, the world and the future. But I also believe that these thoughts are, in turn, the product of a process of learning. They are the consequence of our experiences, the life events we’ve encountered, our social circumstances and, importantly, how we have understood and responded to these.
I guess I’m trying to have my cake and eat it – I want to say that social and circumstantial factors, not personal failures or weaknesses, have led us to where we are, have shaped our mental health and well-being. But I want to say that these circumstantial factors have achieved their effect by shaping how we look at the world, ourselves, other people and the future. Our psychology is, indeed, important, but it, too, is the product of our experiences. Our psychology is, itself, a consequence.
And this, if I’ve got it right, means that I’d like to focus less on blame and responsibility, but also less on what we might call a victimhood (where a person is the passive victim of circumstances, bobbed like a cork on the tides of life). I’d like to focus on ‘agency’. We may well look at the world through the lenses of experience (which changes the sense of blame, at least in my mind), but we can be helped to regain a sense of agency – we can be helped to retrain our perceptual faculties. I want to say; “it’s not your fault, and in fact it’s perfectly understandable that you see the world as you do, but it does have unfortunate consequences, it isn’t inevitable or unchangeable, and it is possible for you to do something about it”
So I would like to think I don’t blame people for looking at the world the way they do – I assume they see the world through the prism of their experiences in life. But neither do I see people as passive victims. Because we make active sense of the world, we have agency – we are agents in our own life trajectory. Not mere victims, not simply blameworthy, but capable of learning how to reflect on our own thinking, and, thereby, change.