Mental illness: it’s not about ‘choice’

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E very day of our lives we apparently make thousands of choices, from the banal to the relatively momentous.

I’ve thought about the concept of ‘choice’ a lot lately, prompted by mental ill-health and the inference that, perhaps, people like me ‘choose’ to be unwell.

It rattles me. So now let’s get a few things straight. Here is what ‘choice’ is. Choice is, ‘Do you want white or brown toast?’ Choice is, ‘Shall we paint the bedroom blue or green?’ or even ‘Shall we start a family?’

Choice is not, ‘Shall I have constant PTSD (post-traumatic stress disorder) flashbacks?’, nor is it, ‘Shall I be bipolar and be so hard to live with that my partner leaves me?’ It is also not, ‘Shall I feel so depressed that I’ll think about ending it all?’ (90 per cent of those who commit suicide have a mental disorder).

Any sensible person would understand that these last ‘choice’ scenarios are nonsense. And this is because mental illness – whether depression, bipolar, postnatal depression or any other type – simply doesn’t happen that way.

I can tell you, when you’re mentally ill, you’re not making a decision to be there, whether it’s in a place of psychosis, spinning mania or knuckle-gnawing despair. Really, who <em>would</em>?

Would Star Wars actress and bestselling author Carrie Fisher have ‘chosen’ to have a severe manic episode whilst working on a cruise ship recently, leading to her being briefly hospitalised?

Would Shobna Gulati, ex-Coronation Street actress, have ‘chosen’ to have depression that led to her quitting the programme?

Would Sir Winston Churchill, arguably Britain’s greatest statesman, have ‘chosen’ to be beleaguered by his ‘black dog’, depression?

Dr Jim Bolton, of the Royal College of Psychiatrists, tells me: “I recently asked several patients of mine, ‘How would you feel if people said, ‘You’ve chosen to be ill’? One of them told me, ‘I’ve said to people, ‘Do you honestly think I would choose to be like this? Do you think I would choose to lose my family, my friends and my job?’ Of course I wouldn’t”.

Perhaps it’s because mental illness is to do with the brain, the seat of our choices, that people think it’s a state of health we ‘choose’, even though the evidence suggests otherwise.

Psychiatrist Dr Ian Drever of The Priory Hospital Woking, says: “It seems that for conditions such as schizophrenia and bipolar disorder there’s a very strong biological component, and in a multitude of other conditions there’s at least a sizeable element which could be inherited. So there’s certainly no choice around that – it’s essentially in the genes.”

Some of us, it seems, have a genetic propensity which renders us less capable of weathering the storm – such as a stressful childhood or difficult times as an adult – than others who don’t have these genes. And so we end up ill and possibly on medication to help make us well.

Yet, for a range of reasons, the choice issue endures. Perhaps it’s because the symptoms aren’t visible. Or possibly the average person equates their ‘bad day’ with their friend’s severe depression and thinks the ‘Pull yourself together’ philosophy will work equally for them both.

”The key thing is that people no more choose to be mentally ill than they choose to have a heart attack or cancer,” says Dr Bolton. Exactly. As someone who suffers from mixed affective state, a type of bipolar, I’m irritated by the implication that my illness was something that I chose.

The hopes and dreams I had as a youngster and the choices I made to realise them included university, a job I enjoyed, marriage and children. At no point did I say, ‘Hmm, let me see – something is missing from my wish list. Ah, I know. I’ve forgotten to choose mental illness!’

Over the years, I’ve heard ‘Cheer up’ and ‘Chin up’. It’s been suggested, ‘Go and paint your nails’ or ‘Put some colour in your hair’, to change my mood, albeit by terribly well-meaning people who perhaps thought that a rudimentary beauty treatment would ameliorate my marrow-deep bleakness. Of course, such prompts don’t work when you’re really ill. It’s like offering a tiny sticking plaster to someone with a severed artery.

By and large, I can cope with these misconceptions about ‘choice’ – I’m fired up enough to challenge them when they come my way. But what I find worrying is that these micro-misconceptions, these personal brushes with misunderstanding, are the start of something bigger. Much bigger.

They start off as ‘Cheer up!’ comments in people’s private lives before rising with a strong and worrying trajectory to become prevalent and perdurable ‘People choose to be mentally ill’ viewpoints (and worse) in society.

It’s these viewpoints that prevent ill people seeking appropriate help, drive decisions about health expenditure and all too often lead to knee-jerk media reports on mental health (as discussed at a Time to Change event held last night and chaired by Alastair Campbell who said, “People still talk in cliches.”)

And it’s these viewpoints that sow the seeds for social problems that might otherwise have been nipped in the bud.

Paul Burstow, LibDem MP and former UK Care Minister who is to lead a new Commission on mental health, recently wrote an article in which he said the NHS is ‘biased’ against treating mental health.

He told me about a constituent with known mental health issues who was advised by a housing department employee, ‘Don’t go pretending you’ve got a mental health problem’ as it may have hindered their ability to get help. “What I draw from this is that part of the prejudice that drives stigma is a belief that there’s a choice being made by people with mental health problems,” he says.

“It’s why parity of esteem between mental and physical health is not just a service issue for the NHS – it’s a cultural one for the NHS, other public services and wider society.”

I understand why people may balk at the view that you don’t ‘choose’ mental ill-health – if you haven’t made a choice, are you therefore a ‘victim’ with little scope for improvement?

Dr Drever suggests that whilst we may not have a ‘choice’ over mental illness, we may be able to exercise some ‘control’ over it by choices we subsequently make, such as learning skills to help manage it.

Now that I know what’s wrong, I’m able to exercise some ‘control’ over it in the form of medication, therapy and lifestyle changes (sleep is my best friend). I can see this.

What I don’t accept is that I ‘chose’ mental illness in the first place. That was down to factors beyond my control. The ‘choice’ notion in relation to mental illness is one that needs to be challenged. Now.

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Freelance journalist and mental health blogger, based in London UK

One Response to “Mental illness: it’s not about ‘choice’” Subscribe

  1. Lisa March 20, 2013 at 11:08 am #

    Brilliant as ever Martha. Incisive and totally on the money. Keep writing these posts. You voice will help so many.

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