Chapter 4: The impact of expectations in mental health

It is clear that the spectrum of normal human responses to various life events and stressors can be very broad, covering many emotional experiences and thinking patterns. Individuals can and do respond very differently to the same events depending on their past experiences, their current situation, their personalities, and the way in which they are used to thinking about things; and the same individual may respond very differently to the same event on different occasions. There can hardly be said to be a single “normal” human response to challenges. Returning to the “window of tolerance” concept outlined in the previous chapter (see Figure 17), mental health problems occur when people regularly move beyond their window of tolerance into dysregulation and hypo- or hyper-arousal. And among the factors that can narrow or widen that window of tolerance, or change the likelihood of moving out of it, are individual and social expectations.

Cultural attitudes to and beliefs about mental health can be powerful driving forces. Shaped by media (including social media) representations, they can influence the extent to which poor mental health is recognised, stigmatised, or supported. They can affect the perceptions people have about their own experiences, how they interpret them, how likely they are to seek support, and what sort of support they look for. For example:

• Diagnosed rates of depression and anxiety tend to be higher in more individualistic cultures than in more collectivist cultures, where community support and social cohesion may serve as protective factors.
• In cultures where poor mental health is stigmatised or seen as a sign of weakness, people may be less likely to admit to it (even to themselves). Conversely, where mental health is more openly discussed and recognised people may be more likely to see themselves as having specific mental health problems. This could have the beneficial effect of encouraging people to seek support, but could also drive medicalisation of a broader part of the spectrum of human experience.
• Cultural ideals emphasising achievement, success, and social status may contribute to feelings of inadequacy and self-doubt. Social comparison processes particularly related to pressure to achieve certain standards of success, beauty or wealth, fuelled by consumerism and the pervasive influence of social media, can exacerbate feelings of inferiority and contribute to the development of dissatisfaction and distress.
• This focus on success can also contribute to an expectation of positive experience, reducing people’s tolerance of normal negative emotions. Sadness, anxiety, anger, a sense of helplessness – all can be an entirely reasonable and healthy response to the situation in which people find themselves; they can also be deeply unhealthy and have a significant effect on people’s day to day lives for extended periods of time. The question of where to draw the line between “normal” and “pathological” responses is largely subjective and could be interpreted very differently by different individuals.

This is not to suggest that we should be returning to a culture where poor mental health is stigmatised and the expected response to difficulty is a stiff upper lip – far from it. Such a culture might have significantly lower rates of diagnosis and demand for treatment services, but it would not have lower rates of distress. Our current openness about mental health and the recognition that many people need support from time to time can only be a good thing, but it can bring challenges with it. One such challenge is when it interacts with an individualistic and materialistic culture to create an expectation that (a) we should be happy all the time; so (b) if we’re not there’s a problem; and (c) that medicine should be able to provide the solution. It is possible that the pendulum has now swung so far away from the previous culture of stigmatisation that we have lost sight of the normality of experiencing a wide range of emotions (sometimes including conflicting emotions at the same time), and of the ways in which we can live with those. Perhaps a better balance is needed.

Implications for public mental health

Challenging this culture will certainly not be easy. It is driven by a wide range of factors including an economic, cultural and media landscape that is global in its reach, and a social media world that thrives on negative social comparisons. And some of the push-back against this culture that exists already is potentially deeply unhelpful and divisive – sneering tabloid headlines about a “snowflake generation” are hardly likely to support a respectful dialogue about the right balance between personal resilience and support. However some work at local level could start to shape a different approach in Cumberland. This should include:

• Campaigning and normalisation. While campaigning in the face of such prevalent cultural and media messaging may struggle to cut through, a local focus on awareness and education initiatives that encourage people to recognise the healthiness of experiencing a wide range of emotions and mental states could be the starting point for a wider discussion with the public that challenges mainstream culture and builds a greater sense of belonging and acceptance of difference.
• Building mentally healthy communities. Fundamentally there is a need to develop a culture in Cumberland that recognises, values and supports approaches that protect and promote good mental health. There is a vital role for our universal services that provide access (and where necessary, supported access) to social and community-based activities such as physical activity, arts and culture, connecting with nature, and volunteering, where the emphasis is on kindness, belonging and wellbeing.
• Building individual resilience. Developing resilience to life’s challenges begins at a very early age, and is influenced strongly by early family experiences. Universal and early help services are therefore crucial in supporting families to raise resilient children and young people. There is also a role for teaching resilience mindsets and skills in schools, and building a co-ordinated and systematic approach to this is essential for the future.
• Providing accessible support services. Promoting greater individual resilience does not mean that people should not need support. Easily accessible support that caters to the everyday emotional needs of individuals – particularly through self-help, family and friendship groups, but also through strength-based coaching services – is crucial.
• Promotion of mindfulness and self-reflection practices. As part of building resilience, mindfulness practices and other self-reflection exercises can empower individuals to build their acceptance of who they are and to understand and manage their emotions effectively.
• Supporting realistic engagement with social media. Social media is here to stay, and it has some potential benefits as well as the downsides already mentioned. As such it is important to help people – particularly young people – to engage with it while recognising the way it can present a distorted view of reality and not falling victim to its more negative aspects.

Conclusion

Reshaping social expectations surrounding mental health support is a crucial part of delivering the change that we need to see in Cumberland. We need a shift in perspective to acknowledge the everyday emotional experiences of individuals, to recognise that most people are actually very resilient in the face of life’s challenges, and to support everyone to become more so. Changing culture takes a long time and is not easy, but we already have the foundations for many of the suggestions above and many assets we can make use of locally to shape some more realistic expectations of what has an impact on mental health and what can be done to support it.