It is world mental health day and the Health Department in the North have unveiled a new strategy, but according to Gerard Stewart, it will take much more than sticking plaster to address the societal causes of of mental ill-health.
The North of Ireland has the highest prevalence of mental illness, suicide, and psychiatric drug prescription on these islands. In terms of mental health services and suicide prevention strategies, the same region is the least funded and the least resourced. NHS mental health service providers, and those in the community and voluntary sector, are starved of the means to deliver evidence-based services at a time of increasing demand, and a key government project called Protect Life 2 – intended to address repeated self-harm, support those who bereft by suicide, and improving responses to those experiencing suicidal behaviour – was kept on a shelf in the absence of a Stormont Minister until today.
While the strategy pledges £1.3 million in additional funding, charities and those on the front line have already made clear that this amounts to a sticking plaster and won’t go far enough in reversing the cuts to community services.
A combination of increased mental health awareness and destigmatisation on the one hand, and budget limitations in mental health service provision on the other has lengthened waiting times for emergency intervention, leaving many with nowhere to go. Tragically, 72% of people who have died by suicide here had not been in contact with mental health services in the 12 months prior to their death. Worse, increasing anecdotal evidence tells of those visiting A&E crying out for help but being turned away with nowhere for them to be accommodated, only to take their lives shortly after.
Understandably, then, much discourse on mental ill-health and suicide in the North focuses on the absolute necessity of emergency intervention as crises and epidemics arise. While every effort must be made to apply political pressure to this end, there is also a deeper interplay of risk factors correlating to the prevalent feelings of hopelessness and despair. There is an imperative to identify and take seriously these factors, if we are to implement the more holistic, evidence-based solutions necessary to establish effective prevention and address the root causes of many mental health problems here.
Unlike the rest of the UK where suicide rates have historically been falling, the number of people in the North of Ireland taking their own lives is on the rise at a time when mental ill health, as separate from suicide, is also expanding globally. “Not only do suicide rates look different in Northern Ireland, so too do those taking their own lives.” The average age of those most at risk are considerably younger, for one.
Unprecedented research by Ulster University social policy professor Siobhan O’Neill has documented how the long-term implications of the Troubles has resulted in intergenerational trauma for the current generation, exacerbating their exposure to risk factors leading to mental ill-health and suicide.
As Siobhan Fenton references for the Irish Times, often it is the less visible or understood, rather than the more obvious physical injuries from the conflict which leave the long-lasting psychological scars. Similarly, O’Neill’s research found that the North has the highest rate of PTSD when compared with 30 other post-conflict societies, and that those most at risk of mental distress were found in working-class communities which disproportionately bore the brunt of The Troubles, such as North and West Belfast, villages and towns in Tyrone, and Derry’s Foyle.
Therefore it is young people and young adults from communities who have suffered most from the legacy of the Troubles who are most at risk of the psychological hardship first faced by their parents’ generation. And the stat which sent ripples of shock across the North a few years ago has only worsened since: more people have taken their lives by suicide than died in the troubles.
Another group who find themselves at the sharper end of mental ill-health statistics in the North are the LGBTQ+ community. In 2017, the Youth Council for Northern Ireland published a telling research report called “Still Shouting”. Focusing on young LGBTQ+ people, aged from 13 to 25, their results were in line with the Rainbow Project’s report which focused on all ages: around 25% of the respondents reported having attempted suicide.
Similarly, an analysis of figures by Fact Check NI shows comparatively that while 4% of the general public have attempted suicide, over 25% of the LGBTQ+ community had attempted it. And studies indicate that the higher odds in suicidal attempts are also the reality for transgender people.
While appalling, the factors contributing to these stats shouldn’t surprise anyone who is privy to politics in the North. Equal marriage for same-sex couples is only due to be legalised this year because of a Westminster amendment, and the debate around marriage rights at Stormont too often allowed for heated and offensive commentary about the LGBTQ+ community within parliamentary chambers and in the mainstream media.
That the largest party, the DUP, continues to openly oppose such rights, as well as blood donations from gay men, and has a record of disgustingly discriminatory comments, which have been platformed uncritically in some of the biggest media outlets across the North, is indicative of the kind of oppression and repression that still exists here.
That is not even to speak of the dismal access to both mental healthcare and basic healthcare for trans and non-binary people in the North, for which a recent campaign was specifically launched by Transgender NI.
Again, it should come as no surprise to anyone who understands the Hostile Environment created at Westminster and enforced here in the North through detention centres, deportation and searches on buses, that the migrant and asylum seeking community of the North (and indeed the South, where high profile suicide cases have broken in the press) are among those whose mental health is disproportionately impacted by society. A report featured in Left Foot Forward details how number of recent reports have revealed that indefinite detention seriously damages people’s mental health, with suicide attempts rising dramatically.
As far right forces tried to organise in Belfast and beyond last Summer, migrants and asylum seekers spoke of being afraid to enter the city centre or communities where these forces were organising. Not only were elected representatives involved with organising the activity, and others in justifying it, too many refused to condemn it or join the counter protests organised by trade unions and anti-racist group United Against Racism.
And elements of the media had a role to play once again, as reports read of two political factions clashing in Belfast City Centre, rather than condemning the appearance of Nazi salutes and fascist campaign groups like Generation Identity or acknowledging that the majority of people were disgusted by it.
And so while reports that it is overwhelmingly young men who are taking their lives in the North are true, and should be addressed with emergency impetus, those in minority and LGBTQ+ communities also have comparatively high rates per head for all the above reasons and more. It should also be said that discrimination in the form of restrictive abortion laws in the North have had a very real impact on the mental health of women.
And for many of the young men, those in the LGBTQ+ community, minorities, and in particular, the generation whose parents lived through the troubles, the likelihood of developing mental ill-health is increased again by the likelihood of those groups to exist on the fringes of society due to socioeconomic factors.
The generation suffering mental ill-health in the greatest numbers today also grew up during the years of austerity. Research has consistently pointed to deprivation and poverty as key risk factors for mental ill-health. The persistence, therefore, of deeply embedded inequality in the North, and the failure to deliver the promised peace dividend into the hands of working class people, has intensified psychological suffering in the region hardest hit by cuts to public sector jobs and services.
And when the North‘s higher levels of deprivation and social need are taken into account, its health and social care system proportionately spends 7-16% less than England on health and social care. Here in the North, we are ignored in UK mental health funding.
Alarming, albeit predictable, statistics confirm that almost half of young people and young adults in the North of Ireland have experienced a mental health problem as they lose faith in their ability to achieve their life goals, with an average of 65% disclosing they always or often feel anxious and stressed, and over a third admitting they always or often feel hopeless.
“[This is a generation that has]… come of age in the years of… increasing precarity”. We have long known that our social conditions exert overwhelming influence over our psychological well-being. For young adults attempting to meet their needs and meet social expectations in an austere and anxious age, many “have come to view their failures to get on in the world as a result of their own inadequacies, resulting in feelings of inferiority, resentment, and shame.”
These feelings become more manifest with the addition of social media creating an “overwhelming pressure” for young people and young adults who privately compare their sense of success with others. Where comfortable salaries are rare, where employment protection is weak, where homes are hard to come by, and where steady jobs are few and far between, hopelessness and despair burgeons and contentment is out of reach for many.
As concluded by sociologist Émile Durkheim in his groundbreaking monograph ‘Suicide’ (1897), which first identified the correlative relationship between suicide and social factors, those who rigorously “pursue which is unattainable are condemned to a state of perpetual unhappiness.” It is no wonder, then, that charity Parenting NI found that almost 70% of parents say they are more worried than hopeful about parenting in the future, identifying more challenges than opportunities for their children and citing mental health as a major concern.
In analysing the characteristics of those who died by suicide and the circumstances surrounding their deaths undertaken by the Institute of Mental Health Sciences at Ulster University, more than double the proportion of those who died by suicide lived in the most deprived areas and endured economic adversity, compared with people who lived in the least deprived areas and faced little to no economic adversity. Furthermore, around two thirds of those who died were unemployed. The Policy and Practice Briefing on suicide prevention in Northern Ireland recommends that suicide prevention strategies need to address economic deprivation, targeting people experiencing employment and financial crises, and that the association between economic adversity and psychopathology should be taken into account when deliberating social and economic policies in Northern Ireland.
The de-contextualisation of mental health crises hollows out holistic solutions, giving way to an overemphasis on public ‘awareness’ and ‘de-stigmatisation’ approaches which direct people into the therapy and medicinal pipeline.
While mental health service provision is of course an indisputable essential for those at crisis point, significant consideration must be paid to the numerous reviews of clinical trials and pharmaceutical remedies that consistently show that although popular treatments such as counselling and prescribed psychiatric drugs provides short-term improvements in reducing anxiety and depression, mounting evidence finds that they alone provide no long-term cures when absent of psychosocial solutions where the root causes are not based in trauma. So, while we should always protest the slashing of local, community mental health provision such as counselling, we must also continue to fight for the kind of society whereby poverty, deprivation, and the socio-economic factors which lead exacerbate mental ill-health are eliminated.
As Johann Hari illustrates in his eye-opening and controversial book, ‘Lost Connections: why you’re depressed and how to find hope’, the notion that mental ill-health chiefly occurs because of some intrinsic flaw divorced from your social context does not, in many cases, hold true.
Moreover, the idea that anxiety, stress, or depression and the behaviours that arise from them are personality imperfections is dangerous, as it is this very stigma that shames people into silence and isolates them, thereby increasing their likelihood of self-harm. It is this privatisation of distress, which individualises and internalises personal troubles, that creates the conditions whereby people feel a deep alienating social pressure to hide their feelings and mask their mindset.
In the words of radical cultural theorist Mark Fisher, “The pandemic of mental anguish that afflicts our time cannot be properly understood, or healed, if viewed as a private problem suffered by damaged individuals.” Rather than misunderstanding anxious, depressed, and stressed individuals as machines with malfunctioning parts, “at the heart of many mental health problems is a perceived lack of control over one’s circumstances… and how we perceive our place in the world.”
In recent years, the United Nations has likewise recognised that how we regard and respond to mental ill health is based on deeply flawed research, recommending that member states abandon the dominant biomedical narrative of depression in favour of focusing on equality imbalances rather than chemical imbalances.
If we are to address the epidemic of mental and ill health in the North of Ireland, we need a dualistic approach that on one hand fights tooth and nail for interventionist services, while on the other hand fights like hell for equality and the quality of life of the living as a preventive. As argued by Richard Wilkinson and Kate Pickett in their sweeping study The Spirit Level: Why equality is better for everyone, “the solution to problems caused by inequality is not mass psychotherapy aimed at making everyone less vulnerable. The best way of responding to the harm done by high levels of inequality would be to reduce inequality itself… psychology and inequality relate to each other like lock and key.”
Until we solve underfunding, inequality and address the legacy of the past, minority communities, the young and the impoverished will continue to be particularly harmed by the crisis of mental ill-health exacerbated by each of those factors. That is why fighting for a society with better mental health has to be part of fighting for a different kind of society altogether.