Every day, it seems, is mental health awareness day. In the U.S., there’s Eating Disorders Awareness Week in February. May is National Mental Health Awareness Month, which includes National Children’s Mental Health Awareness Day. September is Suicide Prevention Awareness Month and in October we go global, with World Mental Health Day.
Mental health awareness campaigns work on a key principle, applied to everything from exam stress to suicidal thoughts: If we can get people to identify and understand their mental health problems, then they can access effective help and treatment. Awareness is good, in other words, because it should ultimately alleviate people’s distress.
The trouble is, no one really knows if awareness initiatives actually work in this way. There is some evidence that England’s 2009-2011 Time to Change campaign improved attitudes toward individuals with mental health problems and led more people to say they intended to seek help, which is important.
But from the data we have so far, these campaigns don’t seem to be resulting in more people actually getting help. At a population level, rates of mental health problems certainly aren’t decreasing; quite the opposite.
It’s one thing if mental health awareness efforts are simply ineffective. But as an academic psychologist who researches mental health in teenagers in particular, I’ve started to ask a tricky question: What if these well-intentioned campaigns are actually contributing to the problem? What if the more we encourage people — especially young people — to talk about their mental health, the worse they end up feeling?
If you think about it, this wouldn’t be all that surprising. It’s only useful to be made aware you have a problem if it leads to meaningful change. Right now, this isn’t happening: Many people who have mental health problems cannot access the treatment they need. In the U.S., this might be because they don’t have insurance, or don’t have the right insurance. In the U.K., people can’t access help because waiting lists are too long. This pushes up the threshold at which treatment will be offered, meaning that in some cases even people who are actively suicidal are being turned away from services.
Yet these campaigns are encouraging more and more people to turn up. In 2017, the psychiatrist Simon Wessely said: “Every time we have a mental health awareness week my spirits sink. We don’t need people to be more aware. We can’t deal with the ones who already are aware.”
Some of these people are seriously unwell and badly need help. But there’s another, rather more subtle problem happening at the moment: I think the current conversation about mental health might be encouraging people to interpret their difficulties as mental health problems when they’re not, in a way that’s actively unhelpful for the individual.
Take the example of anxiety – both the physical symptoms (also known as panic) and the cognitive symptoms (worry). The tendency to experience anxiety lies on a continuum throughout the population. Some people experience it very occasionally or not at all. As you move up the spectrum, you find people who experience it more frequently and more severely. Gradually, anxiety causes more distress and becomes more difficult to control. Up at the extreme end, anxiety becomes so destructive that it affects someone’s ability to function in their life at all. At that point, we would say the person has an anxiety disorder.
But here’s the thing: There’s no line in the sand between the people who experience “normal” anxiety and those who experience “clinical” anxiety. It’s a gradually changing spectrum with a thousand shades of gray. But this point gets lost in the public conversation. Campaigns and social media posts just churn out the message that there’s this problematic thing called anxiety, and so people start interpreting all the lower-level stuff as symptomatic of a disorder. That’s unhelpful in itself — some people find it scary and stigmatizing to believe they might have a mental disorder. But I think it might be worse than that: interpreting common difficult emotions (like anxiety) might actually bring on these symptoms, in a self-fulfilling manner.
If a person believes their anxiety is the sign of a disorder, this can lead to changes in their self-concept — they will say to themselves and others “I am an anxious person” or “I have anxiety.” They might also start to change their behavior. In particular, they might start avoiding the things that make them anxious, and the people around them support this. But in the long run, avoidance prolongs and exacerbates anxiety symptoms. In other words, the changes in self-concept and behavior could actually generate anxiety in a way that becomes self-fulfilling.
Then bear in mind that much of the public conversation is focused on teenagers. Adolescence is a period of critical identity formation, and adolescents are easily influenced by their peers. When I give talks about this subject, to academics and the general public, I am often asked the same question: Is it possible that it’s now cool for teenagers to have a mental health problem? One parent told me that their teenage daughter says she feels left out because she’s the only one among her friends who doesn’t have anxiety or depression. It might be that we have so encouraged destigmatizing of mental health problems that we have swung too far the other way, and these labels have become desirable for some teens. This isn’t helpful for anyone, not least those with debilitating mental illness, such as schizophrenia, who continue to be left out in the cold.
Right now, this is all just a hypothesis. But there’s a lot of theory and related evidence that suggests I might be on to something. For example, when you (falsely) tell participants that they have elevated blood pressure, they end up reporting more symptoms. There are a number of studies showing that public health campaigns and school initiatives designed to reduce problems actually end up increasing them, from drug use to teenage pregnancy, but also, critically, mental health problems. Philosophers, psychologists and sociologists have long theorized that the way in which we label our symptoms might, ironically, exaggerate and exacerbate the problem.
Over the next few years, along with my colleagues, I’m going to test this hypothesis in more detail. One aspect of this will involve qualitative work: interviewing people, particularly teenagers, to gain an in-depth understanding of how they interpret and respond to mental health awareness efforts. A second aspect will involve conducting experiments — examining whether exposing people to different information about mental health problems will affect the type and level of symptoms that they subsequently report. If we can demonstrate this in the lab, it’s a clue that this may be happening on a larger scale across society as a result of awareness-raising campaigns.
Let me be very clear: None of this means mental health problems aren’t real. There are an awful lot of people who need mental health treatment right now, and who are being badly failed by the people and systems who are supposed to help them. And everyone deserves compassion and support, wherever they fall on the mental health spectrum: you don’t need to meet criteria for a mental disorder for your distress to count. But what we call that distress, and how we respond to it in ourselves and others, really matters.
The way we are dealing with mental health problems at the moment is very clearly not working. Maybe awareness efforts sometimes help to reduce stigma and enable people to understand themselves. But things can be good and bad at the same time, and helpful things can have unintended consequences. Maybe awareness efforts are both useful and problematic, depending on the context, depending on the individual. Right now, we really have no idea.
But as rates of mental health problems continue to swell, particularly in young people, it’s time to at least start asking these difficult questions. Because one thing is true: As awareness efforts proliferate, they’re certainly not solving the problem.
Lucy Foulkes, Ph.D., is an academic psychologist at the University of Oxford, U.K. Her first book, “Losing Our Minds: The Challenge of Defining Mental Illness,” was published in the U.S in 2021.
If you or someone you know may be considering suicide, contact the 988 Suicide & Crisis Lifeline: call or text 988 or chat 988lifeline.org. For TTY users: Use your preferred relay service or dial 711 then 988.