Mental Health and Community

I recently received this request from a reader:

Have you written a blog post on mental health/depression in community? In particular, I’m curious on your thoughts on how a community might make reasonable accommodations while a member is suffering and at what point, if any, might that burden be too much for the community to manage. How does the community balance the delicacy of mental health while also ensuring the health of the collective?

While I've touched on mental health issues here and there (in particular, see my June 25, 2011 posting: How Strong to Make the Safety Net), I don't think I've ever tackled this topic head on and now seems as good a time as any.

There are a number of things that come into play on this topic. In no particular order, I'd like to spotlight five:

A. Stigma
First of all, mental health is a hidden issue and people are reluctant to disclose it for fear of being labeled and isolated. Yet lack of information (especially accurate or current information) is part of what makes this complicated. Like many issues in community—others include how to work constructively with feelings, how power is distributed, how aware is the membership about the distribution of privilege and how it impacts dynamics, what are the limits of diversity, and how you'd define healthy leadership in your group—developing a robust model for how you're going to work with mental health issues hinges on being able to talk openly, authentically, and compassionately about it.

In most cases this means going to a deeper level of vulnerability than the group is used to. Do you have the skills and the will to go there? It is very hard to get community support for mental health challenges if the affected individuals and households are not willing to disclose what's they're wrestling with, yet there is no guarantee that support will be extended before you disclose. Do you have the kind of culture where taking that kind of risk is possible (by which I mean that people will be treated gently and respectfully even if their request is not fully met)?

Is discussing this (both what the community's position on it is, and asking the candidate if they have any mental health issues) part of your membership intake process?

B. Depression
This is a widespread phenomenon in the wider culture (I've seen estimates that perhaps a third of the population suffers from some form of depression—which might usefully be thought of as lowering one's energy in the presence of a challenge) and comes in a wide range of degrees of severity, some of which can be ignored by the group and some of which require serious attention. 

I mention depression explicitly because it's the most common mental health issue extant, and as one almost certain to exist in a group with more than a handful of members. Thus, if you're a group of 15+ people it is almost a statistical certainty that you already have members with mental health issues—even if you didn't think you did. To be sure, that doesn't mean you're in trouble, but it's already part of the make up of your group and it behooves you to think about what it means and how you intend to work with it in case it becomes problematic.

One of the insidious aspects of mental health challenges is that once you're suffering from it in one version or another, it tends to be more difficult to think clearly about how to cope with it. Also, if you delay the conversation until you have someone in need, it is much more delicate to establish an even-handed policy because you can't ignore that it will be immediately applied to dear old Sylvia or good old Charley, which tends to dampen frank conversation and skews the consideration. Yuck.

For both of these reasons, it's a big advantage to try to discuss this pre-need—yet this virtually never happens because it's not a pleasant or easy conversation and it's hard to be motivated until you have need. Catch 22.

C. Amateur Diagnosis
It makes a big difference whether the person owns the diagnosis, or has it thrust upon them. People can be problematic for a number of reasons, only some small fraction of which are caused by mental health issues. It is one thing to be diagnosed with a problem by a licensed mental health practitioner; it's another to have the group develop a story that labels a challenging person as suffering from a personality disorder (an inability to accept responsibility for having any culpability when when things go south).

As a professional troubleshooter, it's relatively common for me to encounter difficult members being labeled as mentally unwell by frustrated group members who are indulging in amateur diagnosis. While this doesn't guarantee that they're wrong or make it any less likely that the person so labeled has patterns of behavior that are truly challenging, the problem is that once someone is labeled as having mental health issues the group tends to give up on trying to make it work with that member—effectively writing them off. It can be chilling observing the herd culling out the "weak."

D. Limits of Support
The group needs to discuss what it can and cannot be counted on to do. No group can be all things to all people. One of the beauties of community life is how the collective can hold and nurture those who are sick and debilitated because the fabric of relationship tends to be stronger and because it is possible for many hands to contribute substantial aid in the aggregate without overloading the capacity of any one individual. However, there are limits even then. 

Not only is there a question of how many members with mental health issues can be cared for or accommodated in the community (apples to apples), but you also have to factor in other member needs when discussing the limits of what can be extended, such as physical disabilities, old age, even Syrian immigrants (apples to oranges, lemons, and pineapples). And how close to capacity are you willing to extend yourself now, while still protecting enough flexibility to be there for unknown future needs of members who are otherwise not needing support today?

When discussing limits, be sure to take it far enough to identify the markers that indicate you may be at your limit. Having those in place ahead of time will be very useful when it comes time to apply them.

Finally, note that there may be limits of what group resources are make available to help people in need, but that doesn't have to limit what individuals members do on their own.

To be sure, these can be can very tender conversations, but not talking about them at all is worse.

E. Timing
It matters whether the person joins with a mental health issue or develops one after already being a member. In fact, it matters how long they've been a member before the need is apparent, and the extent to which they are viewed as a contributing member. In short, social capital comes into play here. 

Communities have been known to stretch heroically to support beloved members in time of need, yet it is not likely that the door will be open if you approach community as a prospective member with a debilitating mental health issue that requires long-term community support. Understandably, groups are chary about embarking on a path that looks like long-term deficit spending (by which I mean the incoming member appears to need more support than they can ever give back).