Psychiatrists call for transition to social rather than biological treatments

0
2
“Something is wrong with American psychiatry.”

With that statement, Helena Hansen, Kevin J. Gutierrez, and Saudi Garcia opened their recent article, Rethinking Psychiatry: Solutions for a Sociogenic Crisis, recently published in the journal Daedalus. Their work highlights the theories of Frantz Fanon, who believed psychiatric disorders had a social etiology (cause) and, therefore, the solutions to psychiatric suffering must be social in nature as well.

Referencing America’s current mental health crises, including the “youth mental health crisis” and the ongoing overdose epidemic, Hansen, Gutierrez, and Garcia critique the mainstream model of psychiatry, especially regarding biogenesis (biological cause) and psychogenesis (psychological cause), stating that the current models are iatrogenic (causing more harm than good).

Instead, like Fanon, they offer an alternative view of causation, called sociogenesis (social cause), which posits that the experience of society is often at the heart of psychological suffering. The team then offers three examples of interventions that are based on this sociogenic theory and how they help to heal wounds that mainstream psychiatry often cannot.

What is wrong with American Psychiatry?
“Racial inequalities… continue to worsen, with devastating effects on Native American, Black, and Latinx communities, even as white Americans also continue to suffer exponential increases in mental health–related harm and death. Yet U.S. psychiatry has little to offer for these ills,” the authors write.
“On the contrary, U.S. psychiatry is often a source of inequality and iatrogenic harm, operating within a profit-driven health care system that makes mental health care inaccessible and low-quality even for the white middle class, while clinically supporting police surveillance and mass incarceration in low-income Black and Brown neighbourhoods.”

Hansen, Gutierrez, and Garcia connect mainstream psychiatry to what they call the “medical-prison-industrial complex.” This system, they argue, is focused solely on income generation and profit, leaving most Americans without decent mental health care, let alone physical health care, and leading to the prison system becoming the largest provider of mental health services in the United States. This issue has been an ongoing source of controversy, especially with prison abolitionists and disability rights activists.

Often, the only responders available for mental health crises are police, and this starts a domino effect where the police, using their institutional processes and training, lead the person in crisis into the prison system, causing a cycle where the person becomes seen as both criminal and mentally ill; someone in need of constant institutionalization.

The research team references the work of Frantz Fanon, whose seminal work Black Skin, White Masks, where he takes on the European-dominated psychiatric system at work in colonized Algeria, stating that the view of Algerians as suffering from mental illness before they received European-style treatment was backward. That Algerians were not “mentally ill” until they started to experience the degradation and oppression of being occupied by a colonizing force. From this observation, Fanon countered the standing ideas of his contemporaries, who focused on biogenesis and psychogenesis, and stated psychiatric illness was created at the social and institutional levels.

“Fanon’s sociogeny posited that the mind, the body, and illness develop in relation to historically produced consciousness and social contexts. Among Black people, these contextually shaped bodily schemas (or habitus) derive from enslavement and colonial racial typologies.”

This would help explain why black men are more likely to be diagnosed with schizophrenia (“two to eight times more often”) than white men and more likely to be incarcerated than white men (“five times as likely”). Backing up their points, Hansen, Gutierrez, and Garcia state that “the diagnostic criteria for paranoid schizophrenia historically emerged from stereotypes of Black men as violently paranoid.”

Fanon’s sociogenesis is also at the heart of “standpoint theory.” Theorists, such as Sylvia Winter, “drew on Fanon’s sociogenesis to conclude that ‘what the brain does is itself culturally determined through the mediation of the socialized sense of self.’”

According to this theory, not only does individual experience arise within social structures, but so does scientific knowledge. When this knowledge is created through a monocultural lens (cis-male, white, middle-upper class), it reifies the position of the dominant group. This creates a cycle where the experience of the Other is pathologized, and this pathologizing leads to pathological experiences, leading to psychiatric “disorders,” which reifies the original hypotheses of the monocultural scientific community.

Using sociogenesis and standpoint theory, Hansen, Gutierrez, and Garcia call for “time and space for sociogenic healing… [and] collective projects that nourish all participants and foster mutual aid rather than competition over scarce resources.” They offer three examples of sociogenic treatments existing today.

Harm Reduction
“One of the most significant mutual aid movements of the late twentieth century was harm reduction, which emerged in the 1980s in response to HIV/AIDS among low-income, largely Black and Brown people and people who inject drugs, as well as among men who have sex with men.”

Harm reduction is a movement to bring needed services to people who use drugs (PWUD) whether or not they are willing to abstain permanently, and includes syringe exchanges, STI and other disease testing, drug testing kits (to ensure a person’s drugs aren’t adulterated with Fentanyl or Xylazine), medication-assisted treatment (Methadone, Suboxone, etc.), and even moderation management. This movement is designed to fill in the gaps left by a legal system that has criminalized certain drugs and drug paraphernalia based on socio-cultural and socio-economic factors, such as ethnic ties to certain drugs (Opium, Marijuana) or class-based differences in drug use (Crack vs Powder Cocaine). People who lack access to clean syringes or medication-assisted treatment are often left out of the current addiction treatment and policy system, leading to higher incidences of diseases and other issues, such as accidental overdoses. The ethos of harm reduction “is one of community and mutual support, in which those subject to dehumanizing treatment can find refuge and comfort.”

The research team connects the harm reduction movement to other non-drug related movements that share the idea that instead of “eradicating… psychiatric symptoms,” the underlying social conditions are causing the isolation, difficulty, and suffering of people with diagnoses. One example is the “Hearing Voices Network,” which advocates for people who have auditory hallucinations. The group believes that these voices can be as protective as they can be destructive, and they work to help people better understand themselves rather than pathologize the experience. Another example is the “Mad Pride” movement, which, like disability and neurodiversity advocacy groups, rallies for social changes to accommodate people’s differences rather than seeing differences as needing medical and biological reformation and treatment.

Some groups that the team researched include “Boom! Health” in New York City, one of New York’s oldest harm reduction centres, the Atira Women’s Resource Society in Vancouver, and the nationwide to the U.S. Urban Survivors Union (USU). Boom! offers respite and drop-in services, including naloxone kits, laundry, lounge chairs, a pharmacy for medication-assisted treatment, and support groups, which included topics such as “survival sex, intergenerational trauma, an LGBT group, [and] a women’s only group.”

Atira is “internationally known for its safer drug consumption facility reserved for women,” called SisterSpace. This space offers drug testing kits, clean “works” (paraphernalia such as syringes and “spoons”), and well-lit spaces to ensure that drug use is safer and won’t lead to accidental overdose or death. Being women only also allows for safety from any abusers, of which many women WUD are often victims. The USU became well known during COVID by creating the first virtual safe use spaces, where people isolated because of the pandemic could have video resources to ensure notification of authorities in the case of overdose when they used alone.

All these groups attempt to bridge the gap created by social structures and inequalities without pathologizing their users’ and members’ existence and experience. Instead of focusing on diagnoses, medication, and (sometimes forced) psychotherapy, they are offering sociogenic resources to alleviate sociogenic pain.

Harriet’s Apothecary and Systemic Racism
“Central to the movement over the past decade to counteract the detrimental impact of systemic racism on mental health is the work of the Brooklyn-based collective Harriet’s Apothecary. As several other scholars have noted, Harriet’s Apothecary is an example of healing circles dedicated specifically to the trauma of racial oppression.”

Named after the Underground Railroad’s Conductor, Harriet Tubman, this organization tries to carry on Tubman’s goals of liberation from racism, helping people of colour find “power, healing, and safety” while also reflecting on Tubman’s background as a nurse and herbalist, who used “botany, geography, astronomy, herbal medicine, and wildlife biology to help lead enslaved people to freedom.” The Apothecary travels between multiple sites, including “the Black Women’s Blueprint in Crown Heights, a community arts centre in East New York, the Brooklyn Museum of Art, and Soul Fire Farm in upstate New York.” Each event is timed with seasonal changes, connecting to forgotten and oppressed religious and cultural practices, which help ground members and users to their own experiences of systemic racism and oppression.

The group speaks about health, including mental health, through ancient and current holistic models and energy-based therapies and helps connect local healers to the apothecary’s attendees on a sliding scale. These healers include art therapists, massage therapists, Reiki, nutritionists, acupuncturists, yogists, peer-support groups, and healing justice workshops. From a sociogenic perspective, this is a vital resource as it “provides a space for Black people to reconnect with the shreds of the land-based identities and practices that their ancestors, many of whom had lived off the land for generations, had left them.” These connections help create multiple and varying narratives, outside of contemporary and mainstream theories, around colonialism, oppression, slavery, generational trauma, and economic injustices.

The Apothecary connects powerfully with existing Blac feminist movements and organizations, especially land-based healing groups, including “the Audre Lorde Project; Soul Fire Farm, the most prominent Black farming hub in the Northeastern United States and a founding member of the Northeastern Farmers of Color Network; Southerners on New Ground; and the Detroit-based Allied Media Conference and Emergent Strategies Immersion Institute.”

By grounding psychiatric disorders and diagnoses literally in the ground and with the land, discussions, and understanding of the social and institutional violence that was perpetrated for centuries, including contemporary events such as George Floyd, affect their user’s individual experience of the world and themselves. This changes the narrative from internal to external brokenness and offers opportunities to heal at the social level.

New Haven Farms and Community Gardening
“Over the past decade, public health discourse in the United States has focused on food deserts and the aggressive marketing of cheap, nutrient-poor, and calorie-dense processed and fast foods in low-income communities of color as an explanation for their disproportionate diabetes and cardiovascular disease…. Many U.S. cities and towns have launched local urban farming and community garden initiatives that produce food and increase social connectedness.”

In New Haven, CT, you will find New Haven Farms. This urban farming program works with Medicaid programs in Connecticut to serve low-income, often Latinx neighbourhoods with healthy food options not often found in those communities. These programs were so good for the participants’ health that “health centre providers began writing prescriptions for farm participation to patients at risk for diabetes and other chronic conditions.” Research showed that participants’ A1c level, a blood measurement used to detect and diagnose diabetes, lowered and became healthier due to the better food.

As for psychiatry, it would assist and offer support as wanted while running available support groups. Still, in terms of medicine, a local farmer went through all the plants being farmed at the location and identified all the medicinal and nutrient properties being grown. This allowed participants to use food medicine before pharmaceutical interventions or even as an alternative to pharmaceutical interventions.

“Horticulture therapy” has been practised by Helena Hansen at other sites, including the Sobriety Garden at Bellevue Hospital in New York State. It has “operated for twenty-five years on a half-acre plot bordering the hospital and Franklin Delano Roosevelt Highway… [as] both a site for horticultural therapy and community-building for a socially disconnected patient population, often referred from the city’s homeless shelter system or mandated to the clinic by drug courts.” This form of therapy was often helpful for patients with significant trauma histories who were uncomfortable in traditional settings. People would also return to the garden to stave off emotional crises and addiction relapses.

Food and gardening itself can serve as an alternative psychiatric practice. “Annatina Miescher explained that she practised psychiatry as ‘art with found objects: our job is to help people take the shards of their difficult lives and put them back together in new and beautiful ways.’” In addition to the physical alleviation, practising gardening can help “remediate root causes of sociogenic mental health problems.”

This all begs the question, “Where does the psychiatrist who practices biomedicine fit into this sociogenic model?”

Hansen, Gutierrez, and Garcia identify multiple ways where psychiatrists can become involved and have been involved in these alternative, sociogenic treatment models. First, psychiatrists can work alongside (instead of over) these groups, offering support for acute needs and medical assistance for those who want it. But they can also create shifts in understanding medicine by prescribing food and gardening as medicine and therapy.

Second, psychiatric researchers can show how these tools and approaches actually work at the biological level, shifting the discourse from an in-out (a person’s internal psyche/brain is broken, causing maladaptive emotions and behaviours) to an out-in model (the social and institutional constructs are affecting the person even at the biological level). This research can “foreground the biosocial turn in the life sciences… to explain how social environments influence brain development and function.” These changes include epigenetics, gut-brain connections at the microbiome level, and the contemporary understanding of neuroplasticity, as opposed to the past view of a static brain.

Third, these changes can help save the profession itself.

“The leading reasons offered for burnout involved providers’ inability to address the social and systemic drivers of their patients’ health outcomes. For psychiatry to survive as a profession, to attract and retain practitioners, psychiatrists must be enabled to intervene on social and systemic drivers of their patients’ health.”

For this change to take place, practitioners must advocate and act for change to the current model, elevating the status of these approaches to mainstream techniques. In addition, Hansen, Gutierrez, and Garcia point out that an uncomfortable conversation around power must occur. This means that biomedical practitioners can no longer be the top authority on these issues, and that would mean that therapists, alternative practitioners, and even the patients themselves exist at the same level as the psychiatrist. This also means that psychiatric providers need to be recruited and even trained within the communities they are from and will serve.

“Psychiatrists must organize this change, in recognition of Rudolph Virchow’s famous observation in 1848 that ‘Medicine is a social science, and politics nothing but medicine at a larger scale,’ with the addition that medicine is also politics, on a community-partner and clinician-training scale.”

 

 

****

Hansen, H., Gutierrez, K. J., & Garcia, S. (2023). Rethinking Psychiatry: Solutions for a Sociogenic Crisis. Dædalus152(4), 75-91. (Link)

 

 

Editor’s Note: Part of MITUK’s core mission is to present a scientific critique of the existing paradigm of care. Each week we will be republishing Mad in America’s latest blog on the evidence supporting the need for radical change.

SHARE
Previous articleUndoing Colonialism in Psychology
Kevin J. Gallagher is a Critical Psychology Ph.D. Student and Adjunct Professor at Point Park University. His work focuses on rethinking mental health, substance use, and addiction through critical lenses, focusing on the effects of macro-level issues on individual experience.