Sarah Baba was riding her local bus when a wave of panic hit her. Her breath quickened and she felt lightheaded and dizzy. She needed to get off the bus immediately. She stepped out onto a busy street in Brixton, South London, and walked in a daze, tears streaming down her face.
That’s when she knew—it was happening again. She’d been diagnosed with depression 10 years before, when she was in her mid 20s, and this time she recognized the warning signs: trouble sleeping, the urge to avoid other people, and bursting into tears for no reason. Now the depression had brought anxiety along with it, frightening her with intense panic attacks.
Baba was put on a waiting list for specialized and intensive therapy from the NHS, the national healthcare system in the UK, since her job didn’t come with coverage for mental health. While she waited, Baba turned to self-care.
She read books on depression and anxiety, listened to podcasts, and tried to follow the advice they gave her. She’d heard exercise was an antidote for anxiety, and began to run weekly. Her sister raved to her about mindfulness meditation, so she downloaded an app. She tried journaling to empty the burdensome thoughts from her head. But in the depths of depression, she often didn’t have the energy to pick up a pen to write the date, let alone pour out her feelings. The bigger issues—“the self hatred, the guilt, pressure, self-doubt,” as she described them to me—remained.
Baba’s story is illustrative of two converging trends: the inability of institutional healthcare to address a mental health crisis among young people today, and the rise of an industry selling the promise of mental health with the kind of aspirational messaging usually reserved for luxury brands.
It’s estimated that in 2016, 275 million people worldwide experienced an anxiety disorder and around 268 million experienced depression. For the same year, the National Institute of Health in the United States reported that 16.2 million American adults—most prevalently, 18- to 25-year-olds—had had at least one major depressive episode. I myself am one tiny part of these statistics; after dealing with confusing and sometimes crippling anxiety for most of my life, I was diagnosed with OCD at 26.
The crisis is not only in the diagnoses, but in the profound lack of proper care. In 2017, the nonprofit Mental Health America found that 56.5 percent of US adults with a mental illness received no treatment, and neither did 64.1 percent of American youths with major depression.
From the ashes of these increasing mental health burdens has risen a trendy, Instagrammable solution: self-care. We young people, suffering in unprecedented numbers, have been forced to take on the responsibility of caring for ourselves, and have fallen under the spell of this hashtaggable term to do so.
Self-care is a nebulous name for a group of behaviors that should have a simple definition: taking care of yourself. But it’s no longer just meditation and journaling; everything can now be #selfcare. Eating healthfully or indulgently; spending time alone or seeing friends; working out or taking a rest day; getting a manicure or forgoing beauty routines.
At the time this issue went to press, there were 9.5 million posts on Instagram about #selfcare, which is hundreds of thousands more than when I first started thinking about the topic critically. There’s a whole marketplace of self-care items capitalizing on our distress: self-care makeup, self-care manicures, self-care face masks, self-care massages, self-care detox tea. An article about self-care in the New Yorker noted that you could now buy Self-Care Planners and “‘self-care temporary tattoos’ in the shape of Band-Aids bearing reassurances like ‘This too shall pass’ and ‘I am enough.’”
These activities and products are not sinister in and of themselves. I would hope that a life includes leisure, time with loved ones, and exercise. But self-care has been appropriated by companies and turned into #selfcare; a kind of tease about the healthcare that we are lacking and are desperate for. As Baba realized, you can’t actually treat an anxiety disorder with a bubble bath or a meditation app, and the supposition that you can is a dangerous one.
If we lived in a world in which we were being properly taken care of, would self-care have the same appeal? Is self-care a symbol of a generation that wants to take care of itself, or does it reveal how our society has failed to take care of us?
Thirteen years ago in New York City, Natalia Petrzela took a mind-body fitness class at her gym. This was before such classes could be found on every street corner—“At the time, in 2005, it was pretty woo-woo,” she told me.
It was a class in which she yelled positive affirmations while working out, and there were words being used like “self-care” and “positive thinking.” Petrzela, a historian of the contemporary United States who studies American politics, society, and culture, remembered being troubled by the language.
“There was this belief that all I needed to do was think happy thoughts, be positive, and do ten more push-ups, and then I could make my problems go away,” she said. “That’s dangerous ideology if you consider that there are so many problems that are structurally embedded that all those things can’t fix.”
It was a foreshadowing of our current, individual-focused wellness space, where self-care’s bedfellows are: clean eating, healthy living, #selflove, and $30 fitness classes. Together they are the well-groomed horsemen of the apocalypse for any kind of social contract, essentially a “pull yourself up by your organic patent leather bootstraps” approach to health. “There’s an insistence that, in spite of all evidence to the contrary, we can achieve a meaningful existence by maintaining a positive outlook, following our bliss, and doing a few hamstring stretches as the planet burns,” Laurie Penny wrote in an essay about self-care in the Baffler in 2016.
We all have a very basic human desire to develop ourselves into something better—through fancy workout classes or otherwise—but the ballooning #selfcare movement isn’t just about that, said Carl Cederström, an associate professor of organization studies at Stockholm University. “There are also reasons to reflect on why something like that has become so popular today,” he told me. “It’s partly a reflection of the society in which we live, which is fragmented, and where solidarity is greatly under threat. There is a very strong individualized rhetoric behind self-care, which I think is popular for a lot of people today, especially for government and states who would find it rather convenient to outsource public healthcare.”
In the United States, a study published in 2015 in the Journal of the American Medical Association (JAMA) said that more than half of people with a mental illness don’t receive any mental health services, and finances are one of the most prominent reasons. Another study in JAMA found that in 2009 and 2010, only 55 percent of psychiatrists accepted health insurance, compared with nearly 89 percent of other specialist doctors. People on Medicaid have even worse luck: Only about four out of ten psychiatrists accept Medicaid, according to research published in JAMA Psychiatry. The only lower rate for Medicaid acceptance is for dermatologists.
“We live in a society where structures are extraordinarily powerful in defining who people are and what will happen in their lives,” Cederström said. “Yet at the same time, we seem to live in a time where we refuse to see that that is the case. We really do want to believe in the American dream or in the fantasy that everything could be solved through individual measures, through self-care, through techniques of magical thinking, the power of positive thinking, or whatever it might be.”
This is like when Paul Ryan suggested that poor people see a life coach as a requirement to receive federal aid, in order to “design a customized life plan to provide a structured roadmap out of poverty.”
The sad irony is that much of the history of popularization of self-care comes from activists as a reaction to institutional shortcomings—women, people of color, and the LGBTQ communities. Self-care was a kind of protest. It was a way to look after marginalized bodies and minds when no one else bothered to. Audre Lorde famously said, “Caring for myself is not self-indulgence, it is self-preservation, and that is an act of political warfare.”
Cederström, who is also the co-author of a book called The Wellness Syndrome, and more recently, Desperately Seeking Self-Improvement, still promotes those basics: taking care of your body and mind is good. But when these practices are commodified, marketed, and suddenly become shiny and expensive—is that still self-care, or has it morphed into something else?
Even as Petrzela cringed at some of the statements her workout class was making, she felt a tension: She loved going to the class. She ended up becoming certified as an instructor. It was a great workout, and it did help her mentally. For all their issues, other self-care behaviors like eating well, going to yoga, practicing mindfulness—they did have benefits.
“We need affordable healthcare and we need the time in our day to go to yoga and meditate,” Petrzela said. “I think those are both important. It’s hard to know what to emphasize, depending who you’re speaking to. When I talk to some of the critical, intellectual, academic types, I have to be like, ‘Yoga is not silly, it’s not just an opiate of the masses. It’s stuff we need more access to, and wellness practices can be empowering.’ Then, when I talk to the more woo-woo wellness crowd I say, ‘We need to talk about policy, not about your matcha tea.’”
So let’s talk about policy. Ultimately, the #selfcare phenomenon is a canary in the coal mine of mental healthcare coverage. Why can’t we get the care we need, and instead have to hope matcha and meditation can take the reins?
Paul Gionfriddo, the CEO of Mental Health America, a nonprofit that advocates for the needs and health of people with mental illness, told me that we’ve done a poor job in supporting people with behavioral health issues for decades. He’s seen mental health be given lower priority since his first job in the policy-making world.
In 1978, at 25 years old, Gionfriddo was elected to the Connecticut state legislature, and held a seat on the state appropriations committee. As the person with the least seniority, he was given the last subcommittee assignment: healthcare. “I told them I didn’t want to work on health, and they said, ‘Neither does anybody else, so you’re going to do it,’” he told me.
Today, Gionfriddo is still tackling that assignment. Mental Health America offers an anonymous online screening program for a range of common conditions, like depression, anxiety, PTSD, bipolar disorder, psychosis, eating disorders, and more. It has been doing this for about four years, and Gionfriddo says around 3,000 people a day take the quiz. The vast majority of people who fill out these questionnaires test positive for a moderate to severe diagnosis for the condition for which they’ve chosen to self-test—about three quarters, Gionfriddo said. And two thirds of those people say they have never been diagnosed before.
“What we have is a large, help-seeking, undiagnosed population,” Gionfriddo told me. But there’s more. He told me that most of these people who are screened, about two thirds, say they are under 25. And one third of those screened say they are 11 to 17 years old. “So, we have a help-seeking, undiagnosed, largely young population.”
When asked what services they want, Gionfriddo said people are generally looking for four things: referrals to care and treatment, information about their condition, engagement with other people with their condition, and self-help tools.
“The interest in self-care is in that fourth domain. It’s logical,” Gionfriddo told me. “It makes sense to me that that’s one of the things people are looking for, especially when you can’t find the other three domains very easily. We know there are things we can do to keep ourselves healthy, no matter what our condition is. But it’s not enough to ask people to diagnose and treat themselves.”
Gionfriddo’s own son, Tim, has schizophrenia and has been frequently homeless in his adult life, living on the streets of San Francisco. Gionfriddo and his wife have repeatedly tried to get their son proper treatment, housing, and support, but to no avail. There wasn’t one specific instance in Tim’s early life that led to his current situation, but many institutional failures along the way, with insurance, education, law enforcement, and medical care.
“This is the mental health delivery system that I helped build,” Gionfriddo wrote in an essay about his son for the journal Health Affairs. “It begins when we shun our children’s needs and ends when we isolate them after they become adults.”
Our problems are rooted in a medical system that has treated mental and physical health differently for too long. When Medicaid was established, in the 1960s, Gionfriddo explained to me, it specifically excluded payments for care of nonelderly adults in state institutions for mental disease, or any facility with more than 16 beds that specializes in psychiatric care. This was done to avoid paying for potentially lifelong costs in care.
During that era, arguments against funding mental healthcare cited “difficulty in defining mental illness, the lack of evidence on effective treatments, the high cost of covering mental health care, and the uncertainty in making actuarial estimates of costs,” Richard Frank, a professor of health economics at Harvard University, wrote in a 2000 review on Medicaid and Medicare.
Mental health services were said to be harder to quantify than other medical procedures, and had open-ended treatment times. “All of these points were invoked as reasons to limit ambulatory mental health coverage,” Frank noted. “Even today, the echoes of these arguments are frequently heard before Congress and state legislatures.” The notion of a “cure” to a mental health problem is harder to grasp; for psychiatric conditions, there wasn’t a broken bone to fix, or a cancerous cell to target.
Still, in 1996, Congress passed the Mental Health Parity Act, which was supposed to ensure that mental health coverage was treated the same as physical ailments, according to Paul Appelbaum, a professor of psychiatry at Columbia University and the past president of the American Psychiatric Association. In 2008, Congress passed the Mental Health Parity and Addiction Equity Act (MHPAEA) which attempted to further expand the original health parity act. In 2014, it was projected that more than 30 million Americans gained coverage under the Affordable Care Act, and mental health parity was supposed to be in place for all those insurance policies.
The passing of the MHPAEA was not for nothing. Before it, many insurance plans imposed larger deductibles for mental health services. Now they’re not supposed to do that. The law was also supposed to block insurers from putting a limit on the number of mental health sessions you can go to.
But there are loopholes that make this less than effective in the real world. Since more mental health providers are out-of-network than medical, deductibles still tend to be more of a barrier to mental health services. Insurers can mandate that after a set number of sessions, say 20, they must evaluate whether you need additional treatment, creating paperwork for patients and therapists alike. In one case, researchers found that 25 percent of plans in the marketplace didn’t meet MHPAEA requirements, and National Alliance on Mental Illness surveys published in 2015 found that people were twice as likely to be denied for mental healthcare by their insurance companies as for general medical care. And despite the laws that have been passed, reimbursements for behavioralhealth professionals from insurance companies are still too low, Appelbaum told me, leading providers to opt out of insurance altogether.
In 2015, insurance companies reimbursed mental health providers 83 cents for every dollar they gave primary care doctors. In nearly half of the states, reimbursements were 30 to 70 percent higher for non–mental healthcare doctors. A 2017 study found that psychiatrists get lower in-network reimbursements than non-psychiatrist medical doctors—about 13 to 20 percent less—sometimes for the exact same services. As a result, many therapists choose not to work with insurance in order to make a living. A national study found that in 2015, behavioral care was four to six times more likely to be out-of-network compared with medical care, including surgery. More than one in five people said they had trouble finding an in-network mental health provider.
Throughout all this, there’s been little enforcement from state or federal regulators. The Department of Labor has jurisdiction over private sector health plans, and the Department of Health and Human Services has jurisdiction over public sector health plans, and the split responsibility makes follow-up difficult. In many instances, it can be up to employers or employees themselves to accuse their insurance companies of not living up to the parity law—a daunting task to take on.
What all this policy failure and financial disparity leads to is an, arguably, even bigger issue: We’re now facing a shortage in psychiatrists and psychologists. Three quarters of counties in the US have a shortage of psychiatrists, and this is largely due to insurance issues. Because fewer people are choosing to be psychiatrists and psychologists, there’s even less reason for those practicing to opt in to insurance policies that aren’t paying them well. They’re in demand, so why choose to make less money? And so the cost of care continues to rise.
These problems look like they’re only getting worse: Nearly half the psychiatry workforce is 65 years and older, and the number of people graduating from psychiatry residency programs is declining. The median pay for psychiatrists is the third lowest among 30 medical specialties; students are graduating with debt and aren’t choosing a field that will pay them less than other fields.
Appelbaum said that groups are currently fighting for enforcement of our parity laws, and there are class-action lawsuits ongoing in multiple states. One complaint in New York against Excellus BlueCross BlueShield led to an investigation by New York’s attorney general. That investigation found 64 percent more claim denials for behavioral health treatment than for any other type of treatment, and required Excellus BlueCross BlueShield to inform 3,300 members who were denied coverage of their right to appeal, possibly up to $9 million.
There was hope, Appelbaum told me, that as the biological underpinnings of mental health issues became better known, our society could finally shed this separation between mental and physical health. But that hasn’t proved to be the case. What’s at the root of this segregation? Leftover stigma? Red tape? Shying away from regulation enforcement? Probably some sticky combination of them all. Either way, it leaves patients and therapists with piles of paperwork and large bills, seeking other, less bureaucratic solutions. Like #selfcare.
“Self-care is fine for people who are experiencing some degree of mild stress, or simply are looking to it as a way of improving their satisfaction with life,” Appelbaum said. “But for people who are actually experiencing symptoms of a mental disorder for which effective treatments are available, to ask, expect, or encourage them to take care of themselves in that circumstance is to shift the burden of the condition from the system that should be addressing it to the individual. Frankly, if they could take care of themselves in the first place at that level, they wouldn’t have the problems that they do. For many people, getting help from someone else is essential to recovery.”
Despite everything I did to try and self-care myself out of OCD, it consumed my life until I got outside help.
For a long time, I thought I wouldn’t be able to have an office job because the stress of it was too much for me. I have obsessions and rituals around cleanliness, eating, health, and lastly, perfectionism—which leads to worries that others are watching and judging me for doing these behaviors. Keeping my act together in a room with 50 other people feels like a job all on its own; I leave exhausted and drained, getting half the amount of work done than I would have at home.
I once found myself at a kundalini yoga class surrounded by women in white turbans because I was looking for some kind of meditative practice to soothe my intrusive thoughts. After 45 minutes of chanting and breathing in and out of alternating nostrils, I left the class in a rage when the teacher said that the breathing we had just done could cure eating disorders. I was devastated at the thought of someone with a serious eating disorder—which has one of the highest mortality rates of any psychiatric disorder—trying to get better only by wearing a white turban and chanting Sat Nam.
I needed years of therapy to make any meaningful dent in my mental health woes. And to do so, I faced the same barriers so many young people have faced trying to find a therapist. I didn’t seriously start looking for one until I had only a few years left on my parents’ insurance plan. After that, no one I wanted to see was in-network. Therapists I did make a connection with cost $200–$400 per session. When I wanted to see someone who specialized in OCD, the list of available practitioners dwindled even further. One therapist, who was an expert in an obsession I have, informed me her intake evaluation would cost $2,500.
Taking better care of yourself—sleeping more, exercising more, eating better, all of it—is a crucial piece of the mental health puzzle. But ironically, I have often had to make sacrifices in self-care in order to afford my mental healthcare. I have to choose therapy over things like eating out, fitness classes, or buying organic produce. I fully recognize the place of privilege I come from. Unlike Gionfriddo’s son, Tim, I am not a black man, I don’t have severe mental illness, and I could afford to make that choice for myself, rather than live on the streets.
Still, my income is effectively $5,000 less per year than that of a colleague, all because I need to reach my deductible, sign up for out-of-network coverage, and pay a larger copay to see a specialized OCD therapist every week.
It’s easy to lash out at the compensatory #selfcare trends I see, as a way to release frustration at a system that’s not working. But the truth is that I also do an array of #selfcare to keep myself afloat, and it does help. I work from home when needed, go to yoga, eat a vegan diet, and watch bad television. I’ve bought my share of gratitude journals. These are activities that bring me from the brink of panic to slightly lesser panic, which is the state that some people with anxiety disorders live in all the time.
Yet I cringe at these practices being labeled as self-care, as if that’s all there is. For me, it could be partly a problem of language. I still feel that putting mental health coping strategies in the same bucket as lightweight self-care activities undermines the true meaning of self-care, and suggests that there’s no difference between taking care of your mental health and getting a spray tan. Shouldn’t there still be a differentiation between recreational self-care, necessary self-care, and the type of care you shouldn’t have to do on your own?
At an event held this summer by Bon Appétit’s wellness site Healthyish, I sat through a panel aptly titled “Self-Care: Indulgence or Activism?” Meredith Talusan, the executive editor of Them, Condé Nast’s LGBTQ publication, led the discussion along with the wellness advocate Sara Elise, the writer Fariha Róisín, and Alisha Ramos, the founder of a self-care newsletter and community called Girls Night In.
They debated whether it was problematic to partake in the increasingly product-driven #selfcare world while it feels like the country is crumbling around us. The talk landed pretty firmly on self-care’s side. But the commodification of self-care, i.e., the million things to buy that are branded as such to sell themselves, should be carefully watched, and not taken too seriously, the panelists said.
“Self-care shouldn’t be policed,” Róisín told me later over email. She’s currently writing a column on self-care for Healthyish about wellness and who has access to it. “For sure capitalism has become enmeshed in the idea of self-care, and sure a lot of that bypasses its true purpose (which is about deeper love with yourself) but I guess there’s no way to monitor that. I’m less interested in judging folks and more invested in how I can help heal other people in my community and beyond.”
Róisín told me that when she was growing up, as a woman of color, actual self-care and wellness weren’t obvious priorities, and we should push for these people to embrace self-care, no matter what it entails. She says she gets my frustration at the #selfcare world, but not because of what it’s called, but because of who it excludes.
“I get that feeling of frustration when a white woman is getting manicures as #selfcare but not identifying how they interact with their nail technicians,” she said. “I think it’s important we have self awareness when it comes to self-care and really consider, ‘How does your own self-care impede on another’s?’”
I also find it depressing that we need to use the term #selfcare to justify regular behaviors at all. I’ve seen people on social media call taking a walk outside during their lunch break #selfcare. Or drinking your morning coffee without checking your email, calling a friend you haven’t talked to in a while: All of it is #selfcare.
When we expect self-care to substitute for our larger systemic flaws in our healthcare, we also over-endow activities that should be basic privileges. Instead of finding faults with the more frivolous forms of self-care, and their pollution of the more “serious” self-care, maybe we should instead feel indignant about how every little moment in our lives needs to be productive and meaningful and presented to the world as such.
“It’s a sad commentary that we’ve come to this place where the basics of ambulating—walking from here to there—or talking to a member of our family, are now on lists of things that we have to remind ourselves to do,” Gionfriddo told me.
We should be allowed to go on a walk during our work days and not qualify it as #selfcare. “I think most of us just feel so deeply anxious about what we do all day,” Cederström said. “Are we really spending hours in the best possible way? Are we really successful in being that best version of ourselves that we are constantly told to be? You can’t just take a walk. You need to do it in the right possible way.”
(When I asked Cederström if he had practiced any self-care that day, he wryly responded: “I have a one-year-old and I changed his diaper today. Could that be self-care?”)
Sometimes, I do spend extra time cooking a meal, cleaning, going to a yoga class, or resting because I’m feeling anxious, or because my OCD symptoms are especially bad. But sometimes it’s just enjoyable. If we had access to the systemic care we need, we wouldn’t need to lose #selfcare. But perhaps a yoga class could go back to just being a yoga class, rather than needing to be defined as something more.
Last December, when Baba’s suicidal thoughts were overwhelming, she began to feel seriously afraid for her safety. She googled “safe places to go when suicidal,” and found a place called Maytree Suicide Respite Center in London. It was a free place to stay, with around-the-clock supervision and support.
“This kindness helped me to understand what self-care really is about,” she said. “When you are suffering from mental illness, you often have such low self-worth, caught in a cycle of guilt at how your illness is affecting others, shame that you can’t do simple things or ‘sort yourself out,’ and ultimately a loss of self-belief. When you feel this way, it can be virtually impossible to be kind to yourself. Which is really what self-care is about. How can you practice self-care if you don’t believe you are worth caring for?”
Baba thinks that before her stay at Maytree, she was going through the motions of self-care as if they were items to be crossed off on a to-do list. “It was robotic, and there was no real ‘care’ involved,” she said. “If you are completely lost, swimming through the murky waters of depression, self-care can be a very futile activity.”
She feels Maytree was the turning point for her, because she was finally receiving the care from others that she needed. It’s like something that Róisín told me: “The granular process and purpose of self-care is to start by liking yourself. Which I think is a way to help ensure that the work you do get from the outside—whether it’s with a therapist or healer, or what have you—can be solidified into an actualized reality, and not just be a theory of liking yourself on a broader level.”
Baba stayed at the center for just five days, but it helped bring her out of the dangerous place she was in. Now her relationship with self-care has changed because she gained access to that kindness to herself, through the care of others.
“Now when I go for a run, I see it as me looking after my body, getting out in the sunshine, looking around and enjoying being able to move,” she said. “When I write, I see it as me nurturing the creative part of my mind, not just mind-dumping.”
But this isn’t an entirely happy ending. Baba says she’s still only on the waiting list for mental healthcare. In the meantime, she’s been paying out of pocket for a private practitioner, something she won’t be able to do forever. “I am still to be notified of an assessment date, let alone starting the therapy,” she said. “It is costing me £140 [$181] a session. I clearly can’t sustain this treatment for the length of time I will need it.”
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