Written by Natalia Lomaia

Edited by Andrew Neff

November 2019

Social Psychiatry

The folly of the dominant biological paradigm,

and importance of being aware of a possible social causation of mental Illness

The most crucial factor in the development of an effective health system is to understand the causes of the disease while simultaneously improving the system in compliance with existing knowledge, the needs of patients, and budgetary constraints. This should happen in an ideal scenario; unfortunately, the reality is not so positive. 

Today, psychiatric practice is being influenced by findings in the fields of genetic studies, neuroimaging, psychopharmacology, molecular biology, etc. This is undoubtedly of the utmost importance, but the problem is that the approach has become predominantly biological. For some reason, the mental health system is validating one type of research and neglecting the others (for example, social theories). The latest edition of the Diagnostic and Statistical Manual of Mental Disorders, DSM-5, was criticized by British Psychological Society: “we recommend a revision of the way mental distress is thought about, starting with recognition of the overwhelming evidence that it is on a spectrum with 'normal' experience, and that psychosocial factors such as poverty, unemployment and trauma are the most strongly-evidenced causal factors”. 

It may indeed make more sense for the approach to be holistic, biopsychosocial, since the causes of most mental disorders are not fully understood. At the end of the day, there are at least some facts scientists, researchers and medical professionals know for sure: mental disorders are a result of a combination of several different factors (biological, psychological, environmental) rather than just a single factor. Why would this notion not be fully integrated into clinical settings? Why would just one biological approach dominate the whole mental health system?

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In the book "Capitalist Realism" Mark Fisher mentions that viewing mental illness an individual chemico-biological problem has huge benefits for capitalism: “It reinforces Capital’s drive towards atomistic individualization (you are sick because of your brain chemistry). It provides an enormously lucrative market in which multinational pharmaceutical companies can peddle their pharmaceuticals (we can cure you with our SSRIs).” Fisher claims that of course all mental illnesses are neurologically instantiated “but this says nothing about their causation. If it is true, for instance, that depression is constituted by low serotonin levels, what still needs to be explained is why particular individuals have low levels of serotonin. This requires a social and political explanation”. 

As Mark Fisher calls it, “chemico-biologization of mental illness” is very prevalent in clinical settings. When you go to a psychiatrist, he/she will ask you concrete questions about your medical history, mood, libido, etc. Then, if these psychiatrists find “symptoms” in your answers, they will try to diagnose you. If, for instance, they get the overall impression that you may have clinical depression, they will try to “collect” all the symptoms suggested in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or ICD and try to match diagnostic criteria according to the manual. In order to assign a diagnosis of depression, symptoms named in the manual (such as a depressed mood most of the day, nearly every day, diminished interest or pleasure in almost all activities, significant weight gain or loss, etc.) “must cause the individual clinically significant distress or impairment in social, occupational, or other important areas of functioning.” They will also make sure that the symptoms are not a direct result of another medical condition or substance abuse but there is often little consideration of an individual's socioeconomic situation or how the person’s direct environment is or has been affecting him/her. This is especially strange because there are more than enough studies which find social causation of mental illness is not just one of the reasons, but one of the main reasons - nevertheless, it's rarely mentioned to patients. The problem is not the lack of research or evidence, but that it’s simply not being implanted into psychiatry. 

Why this is happening, we can only attempt to analyze. 

A recent study carried out by Erik Lindqvist, Robert Ostling and David Cesarini mentioned the “widespread misperception that science has proved that winning the lottery often makes people miserable.” Thousands of Swedish lottery winners used fewer sleeping pills and anti-anxiety medications after collecting their money. In short, the study suggests that having more money does lead to a more satisfying life. 

Of course, if, for example you say to a psychiatrist that you're a refugee, feel alienated, have a housing problem, have a poor-quality job, are broke, in debt and/or poor (which is of course not only a problem on its own but can spread into other aspects of a person’s life) they will "keep it in mind", but still within the context of diagnosis - not as the main or direct cause. In short, if it comes to diagnosis, most often the message to the patient is: the main reason for your diagnosis is a chemical imbalance in your brain and everything else like poverty, unhealthy environment, abuse in childhood, etc. was just a trigger or contributing factor. 

The chemical imbalance story is known to help diminish stigma and ease the patient’s shame, but imagine: If someone's suffering and mental deterioration is the direct result of their unhealthy environment and their socioeconomic situation, yet they are still told the problem is basically in their head—not in the sense that it's made up or is their fault, but in the sense that the problem is still in them—this obviously does not ease the shame, but instead creates even more confusion. 

It seems like the psychiatry is adjusted not only to the realities of conducting research and the needs of patients, but to some extent to ideology and big pharma. By ideology, I mean the dominance of individualistic culture in almost every aspect of our life. Writer Ronald Purser, in his new book “McMindfulness”, explains “how mindfulness became the new capitalist spirituality" and the product of "narcissistic individualism of the wellness industry”. In an interview with Huck Magazine, Purser mentioned that “mindfulness is so market-friendly because it appeals to this highly individualistic, entrepreneurial ethos. It’s all about ‘me’ and self-improvement. It’s thriving in a culture of narcissism. The focus is firmly on delivering a more happy self. This is a real kind of social myopia: it squarely places the responsibility of being ‘happy’ within the individual themselves, rather than taking into account all the systemic, structural aspects of society that are causing the cultural malaise that has so many people flocking to the wellness industry for answers.” The exact same pattern we could trace in the mental health system - we are pushed to focus on ourselves, not the environment or the system that might be broken.

Recently, the non-profit organization “Mad in America” whose “mission is to serve as a catalyst for rethinking psychiatric care in the United States (and abroad)” re-published a personal essay of suicide survivor and her struggle to recover in existing mental health system. In it, the author writes: "It’s World Suicide Awareness Day. Or week, or month – I forget how long this empty virtue-signaling exercise goes on. And I thought to myself, as a survivor of more than one serious suicide attempt, what do I really want people to be aware of? I want people to be aware of how scared I am of getting ill again . . . but not in the way you think. The symptoms of the illness, as bleak as they were, are not the thing I’m most worried about if things go south . . . Please stop telling us to ask for help, and start thinking about how society and the psychiatric system needs to change in order for people to receive the care and help they need. I ‘recovered’ despite the system, not because of it." Even if there is no doubt that asking for help is extremely important, and even if hearing these kind of massages in the mainstream media pushes people to seek help, we must also be aware that we almost never hear what is wrong with the mental health system. Unfortunately, we are always pushed to stay focused on ourselves, our own actions. 

Stigma and shame can not be fully challenged in this scenario, because the predominant message of psychiatry remains the same: The problem is always in the patient, not the environment. Even if it’s communicated that the illness is not the patient's fault, even if it’s communicated that there is no shame in getting help, the patients are still told that the cause lies within them, in their past, in their biological imbalance—which is to say, it’s almost always inward.

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