All in the Mind
If we have a car and drive it every day we do not assume that we could drive it onto a beach and on into the sea. Cars are not designed to do this. Human beings have their design limits too but unlike cars the limits are rather vague and at their outermost are overwritten by ideological forces that have no mutuality with human physical limits.
While most humans may, if they have the opportunity and the inclination, elect to train their bodies so that unusual feats are possible, they will eventually reach a limit that lies well beyond everyday limitation yet represents an absolute terminus point. To push beyond that limit or to be pushed beyond it is to court trauma, probably in the form, at least, of physical damage of some sort.
Where elite athletes experience the swings and roundabouts that are seen as integral to their profession and, as a result, have a rational context for their disappointments in a structured environment, any mental health issues that arise will mostly be transitory. The focus of this essay, however, is on the far greater constituencies of those who have been pushed to their limits by adverse and chaotic circumstances beyond their control.
It is generally the case that all physical trauma will have an attendant and adverse psychological dimension, even if this does not arise contemporaneously. Proportionality is often erratic insofar as a brief, mildly injurious event may provoke either a modest reaction or an enduring and substantial disturbance.
At this point in the 21st century there may be a greater proportion of people in the global population suffering from severe distress than at any time. This supposition, in turn, conjures a vision of a future in which there are more people with untreated or unacknowledged stress disorder than there are those without it.
Clearly the most readily diagnosed stress disorders are those endured by Holocaust and genocide survivors and battlefield veterans. In the case of the latter, diagnosis of stress disorders has developed alongside the reluctant and therefore gradual acceptance by military doctors of the fact that ordinary people can be disordered by stress. The disorders were originally seen in military circles as regrettable evidence that some soldiers are more cowardly than others. The nomenclature of disorder reflects the attitudinal shifts: we have grown accustomed to the emergence of ‘shell-shocked’ soldiers from the wastes of World Wars I and II, then the ‘battle fatigue’ endured by British and American servicemen in World War II followed by the catch-all ‘combat stress reaction’ (CSR), a term that encouraged the development of a more detailed military medicine taxonomy eventually leading, in the wake of the Vietnam War but not until 1980, to the most severe and disabling condition being designated Post-Traumatic Stress Disorder (PTSD) as distinct from the transient CSR.
Veterans increasingly feature in documentaries which, probably quite accurately, characterise them as suffering from Post-Traumatic Stress Disorder (PTSD) then substantiate this by constructing one-to-one interviews that culminate in the subject succumbing to grief and incoherence. The incoherence, it should be noted, is entirely articulate in its expression of the collapse of resistance in individuals pushed beyond the design limits of any human being.
This emerging sub-genre of confessional war documentaries commonly features a highly trained and hardened professional member of the military who is asked to describe a terrifying battle experience or campaign and, more often than not, can do so haltingly but grippingly. The interviewer affects to be winding up the interview but not before asking the interviewee how they feel now about episodes that may have taken place decades earlier. Held in close shot, the veteran pauses, his eyes well up and he begins to talk about the death of close friends and platoon members who were killed in combat, often a few feet away from him. He may also refer to the children and families whose members he and his comrades executed in the course of operations. The spectacle of strong, grown men undone is invariably upsetting, not only because of empathy with their grief, bereavement and guilt but also, from the viewer’s point of view, the undermining of assumptions about the essential characteristics of maleness.
The interviewed veterans may be recalling events that took place two years or fifty years ago – the traumas cannot be shaken off. At best, it seems, they can be ‘pushed to the back of the mind’ but not expelled from it.
The veteran’s traumatising memories are almost unspeakable but the succumbing to grief, the unleashed flashbacks, the invasive and distressing thoughts can all be seen as components of an effective attack on a lifelong training designed for the maintenance of composure. Such a training is not restricted to veterans, of course, it is initiated for us all shortly after birth.
An indirect result of the TV documentary viewers’ exposure to such material derives from the submerged but logical suggestion that if these tough guys can get fucked up then so can we. Maybe, albeit in less violent and terrifying circumstances, we can all succumb to oppressive experiences by not only sustaining physical damage but being marked by related stress for disproportionately extended periods.
The ultimate objective of the foundational processes of civilisation and socialisation in relation to the individual is to eliminate the risk of such an egregious disassembly. The constituents of our minds are not naturally harmonious and might not be suited to an overall integration but the prospect of our being reduced to a discordant array i.e. a condition known as ‘madness’, is sufficiently horrifying to encourage the construction of an identity – an arrangement that is seen as stable, unique and acts as a bulwark against social contagion and personal dissolution. To lack an identity or a sense of identity is to be wretched.
Those manifesting disorders that cannot be readily linked to distressing and, ideally, recent experiences are often offered reinforcement to the cause of identity maintenance in the form of derisive advice to ‘Suck it up’ or ‘Get over it.’ This school of luxurious thought may stem from the possibility that while symptoms describing PTSD are found in extreme cases, such as those arising from combat, bereavement, assault or accidents, the bar for the diagnosis of ‘lesser’ stress disorders is set too high. It may be that levels of stress associated with everyday life significantly and routinely overlap with those related to terrifying and shattering experiences. In other words we are generous with labels for conditions generated in the most dramatic circumstances but far less so with those that proceed from what appear to be mundane situations.
It is perhaps easier to admire those whose disorders have some heroic dimension, as in the cases of those returning from the battlefield: their distinction has been earned and the disorders are not neurotic or self-indulgent. The wives, mothers, daughters and relatives who were not called to battle but generally consigned to spectatorship at home did not qualify for psychiatric categorisation because it is not possible, in this view, to experience significant stress in the home. This is one of those covert compacts that entail a conspiratorial disavowal of shared anxieties in the name of maintaining esprit de corps. It is not disputed that those at home have endured protracted disquiet but it is assumed that once they are reunited with their returning family members their distress will be alleviated. Their anxiety is normal. Their stress is manageable.
As noted above, diagnostic terms exist for a range of stress disorders, including those featuring the above mentioned ‘significant stress’, but within military and military medical circles their relatively low profile stems from an initial suspicion that those presenting with classic ‘shell-shock’ symptoms were malingerers swinging the lead. This irritable reaction to soldiers who dared to be unmanly persisted throughout World War I and their summary execution by firing squad was gradually and reluctantly administered with the provision of psychiatric units and dramatic interventions such as anaesthesia and cold baths. Notoriously, in 1943, General Patton, confronted by two battle fatigued soldiers, accused them of cowardice and slapped them round the face. By this time, however, it had become difficult to ignore the increasing numbers of post- battlefield soldiers who were not merely moody but chronically damaged.
It appears that rather than risk an epidemic of medicalisation wherein disabilities are endorsed and multiplied at the expense of social coherence and self-sufficiency, the milder classes of disorder have their diagnosis withheld, not by the medical establishment but those who feel that anything that is ‘all in your mind’ marks the entrance to a slippery slope.
Framed in this way, ‘all in your mind’ describes the purely imaginary, a condition with no physical substance, evidence of nothing more than chicanery. It indicates the lowly status of mental phenomena in a globally diffused anti-psychological culture. More inconveniently the term also denotes a destabilised condition that may in many cases endure well beyond the period of the healing or stabilisation of physical damage.
In 1940 the possibility of the invasion of the UK seemed increasingly likely after the fall of France to the Nazis. This situation induced widespread chronic anxiety in those remaining at home and the condition could be said to be covered by the term ‘generalised anxiety disorder’. It manifested in excessive worrying (a term used in symptom lists) and similar terms can also be applied today to the experiences of burgeoning numbers of individuals not employed in traditionally harrowing occupations. When the relatively mild term ‘worrying’ is introduced as having diagnostic significance then the possibility arises that worrying is so widespread that to diagnose it is unnecessary and threatens to trivialise the criteria. Those who worry about worriers are worried that the worriers may infect them and give the game away. The game being the maintenance of the idea that most people are not worried. At the moment most people are worried. It might even be useful to develop diagnostic criteria for those who are not worried.
A less prominent but statistically extensive diagnosis is the condition known as ‘acute stress reaction’, sharing an almost identical range of symptoms with PTSD but generally seen to recede within 48 hours to a few days of a traumatic event. When the symptoms persist for up to a month an ‘acute stress disorder’ is diagnosed and when they persist for longer still then PTSD is diagnosed.
The transfer of individuals from the social to the medical field is often an invalidating operation insofar as it produces invalids. The process leads citizens to believe that their infirmities are an individual problem rather than a shaping effect of the state or ‘the state of the world’. They may receive treatment but this tends to be suppressive given that a thorough remediation would necessitate factoring in the collapse adjacent nature of the contemporary global experience.
What may be more to the point is that public awareness has been diverted to the most dramatic disorders in part as a hedge against the emergence of the notion that stress is pandemic and attendant disorders are the new normal.
This distracting operation has reached its limits, however. A tendency to withhold diagnosis has been gradually diluted and the proposition that ‘It’s all in the mind’ has been replaced by an awareness that ‘It looks as though physical trauma is invariably accompanied by mental trauma of some sort’, to coin a phrase.
Some physical traumas may heal satisfactorily but can leave persistent mental scars in addition to the traces left on the body. Furthermore, the bar is being set, in a good way, lower and lower as those suffering from ‘everyday life in the 21st Century’ feel empowered to affirm their disempowerment.
The current concern about ‘over-diagnosis’ is simultaneously progressive and restrictive. How can it be wrong to enable those who are stressed and disordered to receive medical treatment? How can it be right to muffle and deflect inevitable reactions to the maddening dysfunctions of the world?
It wouldn’t be wrong to facilitate medical treatment if the administering of medicines was not so thoroughly medicinal – that is to say lacking a significant psychotherapeutic dimension. The solution is obvious: every town and city in the country should have a team of fully trained therapists who give free, regular counselling to citizens initially on a drop-in basis then, on the basis of a referral, weekly or bi-weekly 50 minute sessions. It will never happen.
Overdiagnosis is said to prevail when the symptoms subject to diagnosis are unlikely to cause future harm to the patient who is, nevertheless, labelled and in some cases, given treatment. The further argument for minimising diagnosis in order to avoid stigmatising swathes of the population is persuasive, especially if it were the case that stress disorders could be readily remedied. This latter, however, is not the case. While many stress disorders are susceptible to therapeutic intervention, the accessibility and availability of appropriate remedial responses is severely limited. The alternative is psychotropic medication in which contact with physicians is largely restricted to the monitoring of dosage and assessing the desirability of changing or combining medications. Given the difficulty of accessing any form of treatment, the aspiring patient may derive modest comfort from being awarded a label.
The third season of ‘Educating Yorkshire’ (Channel 4, UK) is fascinating, inspiring and moving. Since the initial two series in 2013, covid has ravaged school attendances and levels of anxiety in school children have risen considerably. Some of the Year 8 kids in Thornhill Community Academy, Dewsbury are presenting quite florid symptoms of distress, such as Tourette’s and chronic ADHD. Their teachers are patient, firm and unfailingly supportive. It becomes apparent, however, that while it could not be described as a skill, the kids are not only enduring chronic stress but osmotically absorbing the sense of generalised anxiety that pervades the home, the school, the leisure time, the streets that lead to these sites and the social media that hystericise them. This enveloping mode of unease would consist of an array of destabilising inputs that equal, if not outweigh the manageable or mostly manageable so-called everyday stresses that we are encouraged to take in our stride.
The key question is ‘Does it really matter if lots and lots of people are suffering from conditions that are all in the mind?’ Let’s say that some people are hypochondriacs. The luxurious school of thought would entail ignoring these people. Another approach might conclude that hypochondria is a mental health issue. There could be a middle way wherein you say ‘The ailments of which this hypochondriac complains are imaginary but the hypochondriasis (illness anxiety disorder) is susceptible to some form of treatment’. We don’t, of course, have the human or financial resources to cater to this 1-2% of the population or, indeed, the 5-10% of individuals who worry excessively about their health but don’t meet the full criteria for a diagnosis (Criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)).
The gradual multiplication of ‘new’ classes of stress disorder could be taken as an indication that such disorders are proliferating rather than their being inconsequential or even nonexistent. The notion that this needlessly creates populations of invalids must be carefully qualified: since the characterisation of PTSD as an extreme response to extreme experience has achieved wide circulation it has become possible to consider less dramatic models of the condition. While PTSD features unthinkable or unspeakable or uncontrollable contents and behaviour, it is clear that many individuals are and have been reporting levels of chronic anxiety, uneasiness or worry which, in turn, are reported to doctors and eventually arranged in terms of their severity as subsets of stress disorder.
There were, of course, widespread disorders in existence before the terms were formalised but their status as being ‘all in the mind’ in the most negative sense precluded their being taken seriously with the implication that all the subject had to do was ‘change your mind’. Cognitive Behavioral Therapy (CBT), in fact, rose to this challenge splendidly, plundering then jettisoning Freudian ideas in order to construct a behavioral management technology based on the idea that is possible to ignore, suppress or sideline invasive thoughts in order to make room for more agreeable mental events.
What is needed is considerably more diagnosis, but this suggests that there is something profoundly dysfunctional at the heart of society. The runaway figures for stress diagnosis do not indicate that doctors are credulous or that patients are snowflakes. Both factions know something is up but articulation of this insight is a threat to national security. There is something profoundly dysfunctional at the heart of society.
In general the tendency to ignore or at best under-diagnose those who present with signs of anguish is not a sign of compassion so much as a reflexive attempt to dismiss any possibility of the spread of contagious weakness. The most catastrophic outcome of such an outbreak would feature a despicable idea bubbling to the surface: that we are all, without exception, much weaker than we think we are. In turn, it is not that we really believe we are stronger than we are but it is imperative that this idea should prevail in order to preserve public order. Less stringent turns of thought will be suppressed.
The anger of those who deride the ‘over-diagnosed’ is largely fuelled by envy. In a culture of vigilant individualism the only solidarity resides in the sharing of the experience of not being able to share experience. Such is the value attributed to self-sufficiency that to dilute the supportive criteria for the condition is regarded as tantamount to “Human sacrifice, dogs and cats living together… mass hysteria” (Ghostbusters, dir. Reitman, I. 1984). Yet here are the diagnosed weaklings in their droves, surrendering to the sickness that threatens to return bodies to slime and getting all the attention for giving up!
Not only is chronic self-sufficiency a fortification against the admission of weakness, its relinquishment would, it is feared, not just expose the inner weakling but actually liquefy the subject beyond the reach of any reconstitution.
The generously termed ‘over-diagnosis debate’ is a Victorian notion that, at a point when the world seems about to ignite, serves to smother a body of feeling that demonstrates a widespread ability to appraise a network of threats with considerable accuracy. The act of diagnosis, while conferring, as noted above, the questionable benefits of categorisation on the patient, is an endorsement of the existence of disorder on a grand scale, such that the individual is drawn into a pool rather than being an anomaly at its periphery.
Nevertheless, the extent and persistence of disorder, expressed in a variety of ways, continues to be under-diagnosed.
Human beings are not designed to withstand as much stress as we are encouraged to believe. We are not nearly as strong or as resilient we feel we should be. The ones that actually are strong and resilient have exceeded their natural capacity. It is, of course, possible to be strong and resilient both within and beyond one’s natural capacity but resilience does not necessarily stretch to an ability to move beyond the limits of one’s resilience. That would be resilient to a fault.
To live beyond one’s capacity is damaging. It is, of course, very well regarded, widely admired and seen as the fount of our best endeavours. In many circles it is considered to be the seal on a pedigree that indicates the fullest realisation of human potential.
The admiration of such an achievement goes some way to assuage damage that will never be erased. If no admiration or endorsement is forthcoming then the damage will persist uncomfortably beneath the level of consciousness.
The current population of Gaza is approximately 2.1 million. It is evident that the entire population is experiencing extreme stress. If the situation is ever resolved then the managers of that population will be responsible for applying therapeutic support. This will not happen. There are too many people.
At least 17,000 children in Gaza are unaccompanied or separated from their families. Many of these will have also sustained life-changing injuries. It is likely that, in terms of mental health issues, initially acute and then chronic disorders will affect the majority of this group, possibly for the duration of their lives.
Studies of the lives of post-Holocaust survivors have shown that symptoms of PTSD will be prominent for at least 50 years after the Holocaust. During this period typical symptoms include recurrent distressing memories; repetitive dreams (night terrors in children); flashbacks, or intense psychological or physiological distress when reminded of the event; inability to experience positive emotions like happiness, success, or love; feeling detached from oneself and emotions, or experiencing dissociative amnesia not related to intoxication or traumatic brain injury; avoiding thoughts, memories, or feelings related to the traumatic event, as well as external reminders (like people or places); sleep problems (difficulty initiating/maintaining sleep); irritability and rage attacks; abnormal alertness, distractibility, or an unusually strong reflexive reaction to sudden environmental events; reliving the traumatic event as if it is happening again, which can include physical symptoms like a racing heart or sweating. (DSM-5)
There are indeed therapies that can alleviate or diminish these symptoms. Among the more successful approaches are those that involve the revisiting and reprocessing of traumatic memories in order to reduce their power to overwhelm. As noted above, the point is it’s very difficult to get the appropriate treatment.
If the statistics from Gaza are extrapolated to a consideration of the global distribution of comparable fields of conflict and catastrophe, including not just wars and genocides but famines, climate change events, bereavements, accidents and assaults but also the less dramatic so-called ‘ordinary’ stress-inducing events and situations that blight the experiences of those in work, out of work, out of love, out of home, out of country, in debt, wanting to get on, wanting to get off, wanting to get out, listening to the news, not listening to the news, sleeping poorly, eating badly, barely eating, enduring invasive thoughts, worrying, not getting over things, being sad, being flat, being not quite there then there will come a time, if it has not already come, when stress-induced premature cognitive decline will reach globally pandemic levels and change will be arrested.
At some point in the course of this panpsychogenic development the various modes of decline will inevitably affect behaviour to such an extent that when children currently blighted grow up and have their own children the latter will be fortunate not to inherit intergenerational trauma, in which the trauma of one generation is passed on to the next generation. As many as two or even three generations may succumb to this mode of transport. Studies of Holocaust survivors’ offspring show increased symptoms of PTSD, greater anxiety risk, and altered stress hormone levels. Similar patterns are found in the offspring of parents who have had experiences including famine, war, terrorism or sexual abuse. Epigenetic studies show, furthermore, that the genes of traumatised individuals may undergo modifications that are passed down to descendants in the form of conditions that reflect in some way the post-traumatic experiences of the parent generation.
It is not medical diagnosis that is problematic but the concomitant assumption that what is revealed by the procedure, in the cases of those presenting with anxiety, is primarily biological in nature rather than sociopsychological. If treatment follows such a diagnosis it will leave much to be desired insofar as symptoms will not be traced to personal experience and/or social conditions but will be chemically suppressed or rebalanced, leaving root causes unexamined. A further concern relates to the great difficulty of securing timely appointments within the health system. In relation to this complication there is a view that simple diagnosis is better than nothing at all: it situates the patient who may feel that to be shaped by a situation is preferable to navigation without a compass, even if you never get anywhere. This fairly romantic view is given the lie by the subsequent experience of the ‘diagnosed invalid’ wherein anxiety continues to prevail but is compounded by uneasiness about the likelihood of receiving timely treatment.
The process of reporting symptoms to a doctor is not in itself problematic, the pseudonymised data generated will be submitted to national databases in order to identify tendencies and patterns in public health. At this point in the mid 2020s the statistical value of such data is that they suggest epidemic and possibly pandemic levels of mental health disorder. The scale of such a situation makes it unmanageable yet it must somehow be managed. Despite the limitations of the medical model it is more likely than not, as emphasised above, that patients will receive medication rather than psychotherapeutic intervention. Referrals to mental health services are, of course, routinely made but can take four months or more to materialise due to the uneven distribution of psychiatrists across the country and the current national backlog of 6.25 million post-referral pre-treatment cases, a figure that includes referrals to mental health services.
If the psychiatric path will, in most cases, lead to the administering of psychotropic medications and these, in turn, will defer rather than facilitate recovery then instead of applying ‘diagnosis’, which carries inescapable medical associations, it might be more fruitful to simply to ’describe’ an individual’s experience in a framework that encompasses a social dimension.
Much of the above has been ruefully acknowledged throughout the current century. The paradoxes of over-diagnosis seem far from resolution and will remain so until a progressive biopsychosocial model is implemented. The problem is, of course, that such a model will raise a volume of mental health disorder reports on a global scale that cannot possibly be processed.
It can be argued that socialisation itself has become pathogenic inasmuch as the norm has been elasticated in order to admit contents that can, in theory, be neutralised by admitting them. The logic would seem to be ‘We cannot possibly cater to pandemic mental health disorder so we must adjust the boundaries of the norm in order to include and thereby disarm contents that had previously caused those boundaries to be constructed.’
An assertion in a Guardian article from 2020 that ‘we are all facing entirely normal fear, anxiety, despair and confusion’ (Johnstone, L.) will give the norm a bad name unless, as she goes on to make clear in her qualifying statement, it is conceded that ‘[we are all facing]… a truly terrifying situation that challenges our whole way of life.’ This significant elastication of the norm recasts the norm as a non-safe or only marginally safe place rather than a dependable territory which routinely features manageable difficulty. The elastication preempts a crisis by discouraging those who would press for a greatly expanded social analysis that, if practically implemented, would gravely challenge resources.
Anxiety casts its shadow across populations that feel increasingly rootless and unshielded and many will feel that this is not normal. Some will seek diagnosis, some will not subsequently receive treatment, of these some will feel that at least with diagnosis that does not lead to treatment because of the logjammed system there is a small amount of relief because you have a name for what you feel, some will receive treatment in the form of medication, some will feel less upset because of the medication, some will feel less upset because of the medication but also sense that the original problem was not a product of what they are like but because of the environment in which they have spent their lives in the process of becoming what they are like. The treatment leaves much to be desired. The idea that the complaints, or ‘symptoms’ are all in the mind is both naïve and absolutely spot on.
In addition to stigmatising those who are diagnosed and medicalising those for whom psychotherapeutic treatment is more appropriate, over-diagnosis will continue nevertheless to provide an indicator of the extent to which even ‘normal’ anxiety is steadily increasing in volume and may lead to a fundamental modification of the capacity of the norm to normalise. In such a case the centre may not hold, it may become fissile.




















