Editor’s note: Enric Garcia Torrents coordinates the Mad In America Global Network. This guest blog has also been published on Mad In America Hispanohablante.
Although experiences diagnosed as mental disorders undoubtedly have biological correlates, their nature goes beyond the body involving social, cultural, and psychological dimensions. More often than not our suffering is the result of how we organise our affairs on a collective level: the circumstances in which we are born, grow up, live, work, and age. Unfortunately, the currently dominant approach to ‘mental health,’ biologically oriented and based on the treatment of the individual, tends to lose sight of and ignore the paramount importance of the social determinants (1, 2).
Throughout this article, I briefly introduce the economic, social, and environmental factors to which we should be paying greater attention to ensure that everyone enjoys a healthier, more satisfactory, and more meaningful life (3).
To begin with, the current focus on the individual patient (trying to identify the ultimate causes of ‘mental illness’ at the genetic and neuropathological levels) should be replaced, as many researchers and critical practitioners have already stressed, by a relational and population-based approach to public health. Instead of considering only the person facing the physician, from this perspective the scope is extended to the family, the social network, the neighborhood, community, and society in general, becoming these collective entities in which we all coexist with the patient to be cared for.
This entails, of course, going beyond psychiatry and even medicine itself, embracing a completely transdisciplinary approach, and giving concerted attention to issues such as the economy, the media, and the education and justice systems, among many other aspects of life.
It also entails going beyond the mere mitigation of risk factors and the promotion of those that protect against people’s illness, attacking the root causes of the problem through socio-political engagement and interventions with distal effects on well-being and health, with a clear vision of the direction in which our societies should tend to move (4).
The first step in this sense is to recognize that, just as it has been firmly demonstrated that physical health varies along a social gradient, ‘mental health’ is strongly correlated with one’s position in society, with the most vulnerable, disadvantaged, and minority groups being disproportionately affected and exposed to chronic stressful conditions such as job insecurity, poor economic and housing conditions, relative poverty, marginalization, social isolation, lack of status and violence, all of which add to the very likely suffering of adverse conditions during childhood and the presence of barriers of access to care due to cultural, financial, and sexual orientation factors, among others (5).
There is overwhelming evidence that material inequalities have powerful psychological effects, and that less egalitarian societies have a negative effect on people, from education to life expectancy to ‘mental health’ (6-11). In Spain, for instance, the probability of being given a mental illness diagnosis, as well as the risk of committing suicide, is much higher among migrants, people with precarious jobs, and those with lower levels of education, affecting twice as much the unemployed than those in employment (12, 13). Unfortunately, the situation has only worsened due to successive economic crises and budget cuts in social policies, with a significant increase, especially among the youngest demographic, in the incidence of all kinds of so-called mental disorders, from anxiety problems to alcohol and other drug use issues, depressive states, ‘behavioral disorders,’ ‘personality disorders,’ and ‘psychosis’ (14-16).
Although the gender differences in the rates and intensity of psychological suffering is an area still very under researched, data at the international level indicates that women are approximately 75% more likely than men to report having recently suffered from experiences diagnosed as depression, and about 60% more likely to report experiences diagnosed as an anxiety disorder (17). Given the patriarchal devaluation of domestic work and unpaid care, the fact that women tend to be paid less in the workplace and that it is much more difficult for them to advance in their careers, often having to juggle multiple roles, it would be quite surprising if their daily struggles did not have an obvious emotional cost.
Recent studies suggest that, likewise, non-heterosexual people suffer disproportionately not only from psychological distress and so-called mental disorders but also from other health problems due to chronic stress caused by the prejudices still prevalent in our society (18, 19).
Multiple sources of inequality are intertwined and have a cumulative impact, disproportionately affecting the same groups and producing unique modes of oppression and discrimination. Achieving greater levels of equality, cooperation and reciprocity, promoting relational autonomy and democratic participation of all people in our collective life to reduce the weight of social hierarchy, as well as increasing cohesion and parity of opportunity should therefore be at the center of any drive to create a saner and healthier society.
It is appropriate now to list as a reminder some of the factors repeatedly identified in the scientific literature as triggering the development and emergence of ‘psychotic’ reactions, as well as other forms of psychological suffering. These are prenatal stress, child abuse, exposure to an urban environment, the person’s migration status, belonging to an ethnic minority, the repeated experience of social exclusion and defeat, and, in general, the creation of fearful attachments to others and dissociation as a way of coping with living in an adverse family and social environment (20, 21).
Hallucinations and delusions, more than symptoms of a supposed genetic predisposition or biological alteration, are understandable reactions to life events and circumstances (22). This is the most parsimonious explanation for the pattern of findings observed since it is very unlikely that the genes that contribute to a certain type of aberrant neurological development also code for migration, the condition of a disadvantaged ethnic minority, upbringing in environments with a high density and population size, homosexuality, socio-economic problems and so forth (21).
In short, there are a host of circumstances that adversely affect people’s well-being, prevent the formation or gradually undermine their resilience and self-esteem, and can lead to collapse at times of particular vulnerability or in the face of events perceived as overwhelming. Moreover, we must recognize that no one is immune to suffering and, at one point or another, we could all reach the point of breaking down. More than a false and very insidious dichotomy between mentally ill and healthy people, what is observed — beyond the chronification due to stigmatization, social exclusion, the medicalization of misery, and the damage caused by the treatments themselves — is a dynamic continuum in which each person occupies different positions throughout his or her life (23-25).
As for vulnerabilities and predispositions to suffer the so-called mental disorders, it should be noted that the more nuanced formulations of the diathesis-stress model point to a differential susceptibility in which certain people are especially sensitive to both negative and positive experiences (27). It’s also interesting to point out that the intensity of environmental stress necessary to reach the point where the person irremediably breaks down varies not only from one individual to another, but also depends on variables such as the level of optimism and positive expectations for the future, the fact of practicing exercise and the level of physical fitness and conditioning, the application of techniques that allow better management of stress, such as meditation and relaxation, the conscious rethinking of negative perceptions, the choice of a healthy lifestyle avoiding sleep deprivation and the consumption of toxic substances, adequate nutrition and, perhaps above all, the fact of enjoying a sufficiently solid social support network (28-32).
It is neither fair nor sufficient, in any case, to place the burden entirely on the victim of abuse and/or unfavorable circumstances, asking the very same people who have suffered or are suffering situations of anguish, conflict, and loneliness, and are embedded in oppressive, alienating and oftentimes violent social hierarchies, to adapt their behavior and mentality to alleviate the impact of the negative social conditions in which they live, reducing the allostatic overload they suffer (33-35).
Nor is it to focus practically all attention and resources on the study of the supposed genetic factors, of gene-environment relationship mediated by epigenetic changes of the genome, and neurological factors that can confer greater vulnerability — exacerbating feelings of inadequacy and anxiety in the affected persons — while neglecting research and interventions at the psychosocial and collective level that would much more effectively contribute to the prevention and alleviation of suffering (36).
First, do no harm. It is inconceivable that coercive, violent, dehumanizing, and (re)traumatizing interventions are still routinely carried on in mental health settings, contributing to reinforcing learned helplessness and depriving affected people of practically all hope of recovery by attributing their ills to genetic causes and neurodegenerative processes yet to be determined, all while isolating them from their environment and community and making their condition worse and chronic with neurotoxic pharmacological interventions which, applied beyond their possible short-term palliative function, contribute — in collusion with veiled economic interests and the preservation of a status quo that has little to do with people’s health — to the deterioration and disability of those affected.
Access to safe, respectful, and effective care is a human right; unfortunately, the care available to persons diagnosed with a mental disorder often does not meet any of these three characteristics (37).
This is not because of negligence or carelessness, of course, but simply because considering and treating ‘mental illness’ as an individual chemical-biological problem brings enormous benefits to all parties with a vested interest in the current socio-economic system.
First, this prevailing model of “care” strengthens the drive towards individualization and the destruction of social bonds, weakening the population’s capacity to resist and fight. The biomedical psychiatric and psychological discourse emphasizes that individuals take responsibility for the results of the injustices they experience; this intentional situation serves to obfuscate reality and lead people to question their mental capacities instead of confronting the institutions and factual powers that oppress them, accepting suffering as a personal deficiency.
This system needs the connivance of mental health professionals in this farce as a kind of prop: psychiatric and psychological services — without denying the good intentions of many, if not most, of the practitioners involved — mask the inadequacy of other social and governmental resources by making it difficult to have more complex and responsible approaches to socio-economic issues; the use of mental care allows states to pretend to care and help people to overcome their problems while in fact promoting their conformity to the conditions that generate them (38).
Second, this state of affairs provides an enormously lucrative market in which multinational pharmaceutical companies can sell their products to an increasing proportion of the population (39-41).
In a hyper-stressed, extremely competitive, and materialistic society like ours, the so-called mental disorders are not mere aberrations but the natural result of obscene social conditions and a way of life that is not in line with the most basic and genuine human needs. Normality in this context is nothing more than a “pathology of normalcy”, an aberration imposed upon us to pacify the population and sustain a rapacious system that requires social and economic oppression, alienation, the mystification of individuals, and unrestrained exploitation of the natural environment (42).
To be fully adapted to a profoundly ill context, being forced to fit into an alienating socio-economic reality as if it were a true Procrustean bed, without fighting back, struggling, suffering, and deviating from the norm, cannot be considered something non-problematic in itself (26, 43-46).
These kind of criticisms of what is usually considered normal are very close to the diagnosis made by many counter-cultural movements when considering the problems that afflict us — from wars, genocides, the threat of atomic annihilation, the ongoing ecological disaster, poverty and inequality, racism, sexism, unbridled consumerism, extreme individualism, and very long etcetera. Put simply, the World is becoming more of a madhouse by each passing day; a place where to make it worse, the use of psychopharmaceuticals is normalized and even trivialized, bringing us rapidly and dangerously close to the dystopian vision of a submissive and pharmacologically controlled but supposedly happy society that Aldous Huxley warned us about (47, 48).
Overcoming this unhealthy and pathologizing state of affairs necessarily involves simultaneously promoting transformations in the economic, socio-political, and cultural spheres, rethinking and tackling head-on the causes of suffering and the impediments to human development (49).
This must be, inescapably, a collective effort that requires not only the coordination of interdisciplinary groups of committed professionals, academics, politicians, and all kind of other actors, but also a deep understanding, respect, and embracement of the knowledge, experience, and desires of those most affected and disadvantaged among us — the long forgotten, the voiceless, the incarcerated, the sedated and medicalized — working all together to find and reach meaningful and constructive solutions.
This, as far as I can see, is the essential precondition for achieving any kind of positive, long-lasting, and meaningful change.
- Bracken, P. et al. Psychiatry beyond the current paradigm. In The British journal of psychiatry 201.6 (2012): 430-434.
- Compton, M. T., and Shim, R. S. The social determinants of mental health. In Focus 13.4 (2015): 419-425.
- Morgan, C., McKenzie, K & Fearon, P. Society and psychosis. Cambridge University Press, 2008.
- Wilkinson, R & Pickett, K. The inner level: how more equal societies reduce stress, restore sanity and improve everyone’s well-being. Penguin Books, 2020.
- Fisher, M & Baum, F. The social determinants of mental health: implications for research and health promotion. In Australian & New Zealand Journal of Psychiatry 44.12 (2010): 1057-1063.
- Babones, S. J. Income inequality and population health: correlation and causality. In Social science & medicine 66.7 (2008): 1614-1626.
- Burns, J. K., Tomita, A. & Kapadia, A. S. Income inequality and schizophrenia: increased schizophrenia incidence in countries with high levels of income inequality. In International Journal of Social Psychiatry 60.2 (2014): 185-196.
- Marmot, M. G. Status syndrome: a challenge to medicine. In Jama 295.11 (2006): 1304-1307.
- Pickett, K E. & Wilkinson, R.G. Inequality: an underacknowledged source of mental illness and distress. In The British Journal of Psychiatry 197.6 (2010): 426-428.
- Ribeiro, W. S. et al. Income inequality and mental illness-related morbidity and resilience: a systematic review and meta-analysis. In The Lancet Psychiatry 4.7 (2017): 554-562.
- Singer, B. H., Ryff, C. D. & National Research Council. The influence of inequality on health outcomes. In New horizons in health: An integrative approach. National Academies Press (US), 2001.
- Espino Granado, A. Crisiseconómica,políticas, desempleo y salud (mental). In Revista de la asociación española de neuropsiquiatría 34.122 (2014): 385-404.
- Moreno-Küstner, B. & Gutierrez, A.M. Economic crisis and mental health–findings from Spain. In Die Psychiatrie 14.02 (2017): 95-102.
- Frasquilho, D. et al. Mental health outcomes in times of economic recession: a systematic literature review. In BMC public health 16.1 (2015): 1-40.
- Gili, M., Campayo, J. M. & Roca, M. Crisis económica y salud mental. Informe SESPAS 2014. In Gaceta Sanitaria 28 (2014): 104-108.
- Read, J. “Can poverty drive you mad? ‘Schizophrenia’, socio-economic status and the case for primary prevention. In New Zealand Journal of Psychology 39.2 (2010): 7-19.
- Freeman, D. & Freeman, J. The stressed sex: Uncovering the truth about men, women, and mental health. Oxford University Press, 2013.
- Flentje, A. et al. The relationship between minority stress and biological outcomes: A systematic review. In Journal of Behavioral Medicine(2019): 1-22.
- King, M. et al. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. In BMC psychiatry 8.1 (2008): 70.
- Lim, C, Chong, S A & Keefe, R. S. E. Psychosocial factors in the neurobiology of schizophrenia: a selective review. In Ann Acad Med Singapore 38.5 (2009): 402-406.
- Selten, J.P. VanOs, J. & Cantor‐Graae, E. The social defeat hypothesis of schizophrenia: issues of measurement and reverse causality. In World Psychiatry 15.3 (2016): 294.
- Read, J. & Haslam, N. Bad things happen and can drive you crazy. In Models of madness: Psychological, social and biological approaches to schizophrenia (2004): 133.
- DeRosse, P., & H.Karlsgodt, K. Examining the psychosis continuum. In Current behavioral neuroscience reports 2.2 (2015): 80-89.
- VanOs, J. et al. A systematic review and meta-analysis of the psychosis continuum: evidence for a psychosis proneness-persistence-impairment model of psychotic disorder. In Psychological medicine 39.2 (2009): 179.
- Verdoux, H., VanOs, J. Psychotic symptoms in non-clinical populations and the continuum of psychosis. In Schizophrenia research 54.1-2 (2002): 59-65.
- Huxley, A. Brave new world revisited. 1958.
- Belsky, J & Pluess, M. Beyond diathesis stress: differential susceptibility to environmental influences. In Psychological bulletin 135.6 (2009): 885.
- Carver, C. S., Scheier, M.F. & Segerstrom, S.C. Optimism. In Clinical psychology review 30.7 (2010): 879-889.
- Maté, G. When the body says no: The cost of hidden stress. Vintage Canada, 2011.
- Peterson, C. The future of optimism. In American psychologist 55.1 (2000): 44.
- Ratey, J. J. Spark: The revolutionary new science of exercise and the brain. Little, Brown Spark, 2008.
- Southwick, S. M., et al. Adaptation to stress and psychobiological mechanisms of resilience. In Biobehavioral resilience to stress (2008): 91-116.
- McEwen, B. S., & Wingfield, J.C. “he concept of allostasis in biology and biomedicine. In Hormones and behavior 43.1 (2003): 2-15.
- Rapley, M., Moncrieff, J. & Dillon, J eds. De-medicalizing misery: Psychiatry, psychology and the human condition. Springer, 2011.
- Speed, E., Moncrieff, J. & Rapley, M eds. De-medicalizing misery II: society, politics and the mental health industry. Springer, 2014.
- Moncrieff, J. Psychiatric drug promotion and the politics of neoliberalism. In The British Journal of Psychiatry 188.4 (2006): 301-302.
- Higgs, R. N. Reconceptualizing Psychosis: The Hearing Voices Movement and Social Approaches to Health. In Health and Human Rights Journal, Volume 22 Number 1 (2020): 133-144.
- Ratner, C. Psychology’s Contribution to Socio-Cultural, Political, and Individual Emancipation. Springer Nature, 2019.
- Moncrieff, J. Neoliberalism and biopsychiatry: A marriage of convenience. In Liberatory psychiatry: Philosophy, politics and mental health 9 (2008): 235-256.
- Moncrieff, J. Psychiatric diagnosis as a political device. In Social Theory & Health 8.4 (2010): 370-382.
- Fisher, M. Capitalist realism: Is there no alternative?. John Hunt Publishing, 2009.
- Maté, G. The Myth of Normal: Illness and Health in an Insane Culture. Penguin Random House, 2021.
- Fromm, E. The pathology of normalcy. Lantern Books, 2011.
- Fromm, E. & Anderson, L.A. The sane society. Routledge, 2017.
- Morrall, P. Madness: Ideas about Insanity. Taylor & Francis, 2017.
- Ratner, C. Pathological normalcy: The psychological dimension of alienation and a guiding construct for overcoming alienation. In The Humanistic Psychologist 42.2 (2014).
- Frances, A. Saving normal: An insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma and the medicalization of ordinary life. In Psychotherapy in Australia 19.3 (2013): 14.
- Staub, M. E. Madness is civilization: When the diagnosis was social, 1948-1980. University of Chicago Press, 2011.
- Rose, N. Our psychiatric future. John Wiley & Sons, 2018.