It’s all in the mind | Dolores Gauci

Diseases of the mind have long held a sinister grip on the popular imagination. In centuries gone by, lunatic asylums often doubled up as places of entertainment, where customers would (as Bob Dylan once put it) “pay for their ticket and go watch the freaks”.

Closer to our time, many recognisable symptoms of mental illnesses were regarded as a form of demonic possession, and sometimes – along with physical disability – interpreted as a ‘punishment’ visited by God on a family for the sins of the ancestors.

But while these and other superstitions have now faded into a distant memory, misconceptions persist to this day. Among them, that mental illness – though now regarded as a health issue, and no longer as a curse or castigation – is often completely beyond the ability of medical science to address. And as has been evidenced in recent, much-publicised court cases involving possible mental illness, there may also be widespread uncertainty as to what actually constitutes a mental health problem in the first place.

Dolores Gauci is no stranger to such perceptions. This is effectively her thirtieth year of involvement in mental health issues, having started out as a social worker stationed at Mount Carmel Hospital in 1984. Since then she has been seconded to the Richmond Foundation, an NGO aiming to raise awareness about mental health issues. Today she is Chief Operations Officer, Community Mental Health Services within the National Health Service.

More people seek help today than in the past; and they tend to do so at an earlier stage of mental illness than before.

She acknowledges that enormous progress has been made in that time.

“In my professional life I have seen great developments in the sector. When I started out at Mount Carmel in the 1980s, there was still widespread fear associated with the issue. To give an example, on the occasions when I was invited to radio or TV shows about the subject, at first no one would be willing to talk in public. But we would get phone calls from people offering to talk in private, and on condition of anonymity. They were afraid. The situation back then was that mental illness was still very much a taboo. People didn’t want to associate with it in any way. And they wouldn’t willingly seek help if they or anyone in their family had a problem.”

Gradually, however, there has been a shift in perspective. “Today, people are more accustomed to the idea that mental health is, in fact, a health issue like any other. They are less afraid of the issue, more willing to discuss it openly. More people seek help today than in the past; and they tend to do so at an earlier stage of mental illness than before. It’s no longer a case that people only seek help when they are very sick…”

Broadly speaking, more is known about mental health today, and more is being discovered all the time. Part of the overall change in attitude – at least, from the medical side of things – concerns an evolution in the way mental illness is classified and treated. Medical services are now much more integrated than ever before. By pooling the resources of different disciplines in the medical and social work sectors, it is now easier for problems to be detected early and for the sufferer to find help when it is required.

It is only when that person feels he or she can no longer function normally or appropriately in everyday life that we start to talk about the problem in terms of an illness

“Seeking help for a psychological issue can also just mean going to your GP. Any doctor will be in a position to determine if a person needs specialised help, and can refer to a specialist.”

Gauci points out that this evolution is a constant work in progress. “Today, we have psychiatric nurses – nurses who specialise in psychiatric care, which is now recognised as a branch that requires specialisation. This didn’t exist until very recently…”

Another widespread former misconception concerning mental health issues is that medical science is often powerless to intervene, or at least to make any meaningful difference. This, too, is changing, largely on account of recent advances in psychopharmacology – the development of drugs to treat specific mental disorders – which have resulted in notable breakthroughs, especially in the treatment of common disorders such as depression and anxiety.

“A lot of research is being conducted even now. The more information we have about the brain, how it functions and how it manifests itself in behaviour, the more we can meet the specific needs of people who need help.”

All the same, mental illness remains a notoriously difficult thing to categorise. “When we talk about mental health, it is not just the absence of disease. The same is true of physical health. A healthy person is not just someone who isn’t sick; there are a number of other factors which are usually in place when someone is described as ‘healthy’.”

These factors, she adds, also centre on how the person feels. “A healthy person would also feel, for instance, that he or she is making a contribution, to society or to the family. There would be a sense of personal fulfilment. The person would be capable of coping with everyday stress…”

As with physical symptoms, the measure of mental ill-health also depends to a large degree on feelings. A person may suffer from a mental problem – such as anxiety, or obsession – and yet it doesn’t automatically follow that this problem will necessarily impact his or her behaviour. Gauci argues that, just as a person who suffers from a physical condition can also learn to cope with that condition and lead a normal life regardless, the same is generally true for conditions that affect the mind.

“A person with diabetes – to give just one example; it could be any other ailment – may still enjoy a good life. People learn to manage their illness, to contain the problem...”

Likewise people may suffer some form of mental condition yet still lead perfectly normal lives. “It is only when that person feels he or she can no longer function normally or appropriately in everyday life that we start to talk about the problem in terms of an illness. And unusual behaviour can take many forms. It could be a feeling of helplessness or despair; it could be a sense from detachment from reality. In all cases there are stages that indicate the onset of a possible mental health issue.”

One other widespread misconception concerns the possibility of an individual developing a mental health issue. There is tendency to think of these things as somehow inevitable, as though some people are predestined to suffer from such conditions, while others are not. In some specific cases – such as congenital disorders – this may even be true. But is it also true of the more common conditions to be classed as mental health disorders? Are some people likelier than others to develop mental health problems?

“Again, it is the same as the body. You can have a healthy body but if certain conditions are in place your health can still be jeopardised; you can still get sick. Making an effort to keep oneself healthy reduces the chance of sickness, and the same goes for mental illness too.”

There are, however, specific issues that arguably affect mental health more than other medical conditions. One of these concerns the ability to reach out to people who may need help.

Gauci explains that in her own experience, the vast majority of people seeking help will have themselves recognised that they had a problem, and taken steps to address it. But she concedes that there are certain instances where this is not possible, or at least extremely unlikely. People suffering from severe delusions are less likely to recognise that they have a problem, as part of the symptoms will include a detachment from reality.

“At the risk of simplifying: it is quite normal for people to ‘talk to God’ in their daily lives. But if you actually hear a reply – and I don’t mean in any figurative way in which God can ‘talk’ to people; I mean if you hear a physical voice in your head replying to your prayers – that would be an indication of a problem.”

The problem, in such a case, would probably be classed as some form of psychosis, and it is the nature of such conditions that the sufferer may not be aware that it is in fact a health issue at all. “But if they don’t notice themselves, people around them will. This is why education is so important. You never know when someone in your family can develop a mental health condition.”

Research indicates that this form of condition affects around 1% of the population.

By far, the more common situations involve conditions such as depression and anxiety, which are not necessarily related to any direct pathology, and as such can happen to anyone.

Depression alone is understood to affect as many as one in four females, and one in six males.

But Gauci also cautions against jumping to conclusions when questioning one’s own state of mental health. “The fact that person may exhibit one or more symptoms associated with a condition doesn’t mean that they have that condition. I remember when I started out at Mount Carmel Hospital, I often found myself thinking: but sometimes I myself exhibit the same behaviour as this or that patient. Does this mean I have the same problem?”

The key to answering that question, she adds, is to determine what impact these symptoms will have on one’s daily life. It is not abnormal, for instance, for a healthy person to occasionally lapse into a depressive state; to feel helpless, anxious or frustrated. It is only when the depressive state starts to affect one’s ability to function – to be responsible for actions, to carry on working, to attend to daily obligations – that it is considered a health issue that requires medical attention.

Yet for all these advances in our understanding of mental health, the same topic continues to occasionally get misrepresented. Recently, two separate news stories – both involving mental health issues to a degree – attracted a lot of publicity and occasioned a good deal of alarmist conjecture. The Mosta cat crucifixions, for instance, led to a nationwide debate that often bandied medical terms about indiscriminately… words like ‘psychopath’ were often used to describe the behaviour in question, and there was open speculation about how the perpetrator might turn his attention to human victims next.

More recently, the alleged suicide of a 15-year-old teenager fuelled much discussion on the nature of depression and anxiety, particularly among teenagers. This particular case also dragged to the surface echoes of distant taboos – the media convention of not reporting suicide cases, for instance.

And in different ways, both cases seemed to expose a remnant of the same fear – some would say hysteria – formerly associated with pathologies of the mind.

Gauci is reluctant to talk about specific cases, but admits that she is less than impressed by the way the media – both traditional and non-traditional, such as the social networks – tend to portray mental health issues in their reports.

“It’s not just the media. Films, television programmes, even children’s cartoons, tend to only focus on the dramatic or sensational aspects. This in turn reinforces the stigma of mental illness being something sinister or dangerous… and the harm this does is very extensive. It may discourage other people from seeking help."

"Don’t get me wrong, I have a lot of respect for the media. They have a responsibility to inform, and I’m not saying they shouldn’t tackle the issue at all. But what is needed is accurate, non-sensational information. And that is what has so far been lacking.”

As an example, she argues that news stories tend to focus on certain types of pathologies – namely, those associated with violent behaviour – while ignoring the fact that violent or hostile behaviour is in fact a rarity in the broader picture of mental health. “Serious delusions already constitute a small minority of the cases seeking help. Of these again, only a very small number will exhibit violent or anti-social behaviour. Usually, it is the other way round. It is mentally ill people who are the victims of violence. They are very rarely the perpetrators.”

But by selectively reporting only such cases, and in the way they present data, the media may unwittingly impart the message that mental illness can very easily lead to violent repercussions… when in fact the opposite is true.

This tendency becomes arguably more pronounced in the setting of social media, where blogs and sites like Facebook create fertile ground for misinformation to be spread like wildfire.

“The social group dynamic is such that minor issues tend to very quickly get inflated into major problems. Social media open up the possibility of things flaring up very quickly, especially on issues which tap into emotions. And with the speed of information, it becomes very difficult to control the situation, or set the record straight.”

On this score, it would seem the advances in medical attitudes have not been mirrored by corresponding advances in other sectors. “Abroad, in places like the UK, there was acknowledgement that the media needed the right tools to address the issue. The result was ‘Lexecon’, a set of media guidelines on the portrayal of mental illness in the press…”

Does she see the need for similar guidelines in Malta? She nods. “I do, for sure. The media can be a very effective tool in educating people on the issue – and to be fair it often does fulfil this role. It is good to see the media taking an interest in the subject; and it can help too, in the sense that people become more aware of health matters and of what services exist."

"But there is a responsibility to inform. I sometimes think that people, even those writing comments on blogs, should seriously reflect on what they actually putting down in writing. A lot of what is said is very harmful… not just for the people involved in the reported cases, but also for other people reading it, who may also suffer from mental health issues.”

With so much hostility often directed at the persons involved, the net result is invariably to heap more fear and ignorance on an already much-misunderstood issue. This naturally hinders attempts to intervene in other cases, too.

“People reading all this may say: that is precisely why I don’t seek help for my own problem. If I do, people will perceive me in exactly the same way. And yet there are many appropriate and helpful biopsychosocial treatments to address mental illness. People who need help should seek it as it is the only way to ensure a healthy and good quality life. The information and education which the media can provide can help to encourage people to access services.”