A new article published in Social Psychiatry and Psychiatric Epidemiology offers a framework for shifting the psy-disciplines towards a fuller understanding of the role social environments play in mental illness. Author Laurence Kirmayer of McGill University argues that current models place too much emphasis on the individual and often blame people unfairly for hardships created by the environment. This undercuts the psy-disciplines’ ability to advocate for societal changes that could improve public health.
While recent research has pointed to the role of inequality, trauma, racism, poverty, and global issues in causing mental illness, the current work argues that dominant cultural institutions, such as the psy-disciplnes, often overlook and contribute to long-standing norms that cause inequity. The author writes:
“Crucially, the cultural construction of social identities and institutions goes along with particular ideologies that rationalise, normalise, naturalise and hide arrangements that cause inequities… One implication is that effort to understand the social determinants must include critical analyses that look past the taken-for-granted to call into question the structures of disadvantage.”
‘The Social’
Kirmayer defines ‘the social’ as follows:
“’The social’ here stands for all the humanly designed and generated configurations of group life that involve networks on multiple scales from the intimate sphere of [partner] and family dynamics to neighbourhoods, communities, and political entities or organisations as well as regional, national, or transnational networks.”
According to Kirmayer’s work, ‘the social’, along with the individual and inherited biology, creates ways of being. How these forces interact with each other influences the causes, symptoms, and outcomes of mental disorders. This co-creation also derives from and drives evolutionary processes in humans. Our brain has been shaped by the environment which it exists within, and for humans, part of that environment is culture. Culture and ‘the social’ then drive evolutionary patterns to “select for specific kinds of neural capacities.”
These patterns are repeated through mythology, education, language, etc., and passed down to the individual as they develop. All of these factors come together to create an individual’s identity, which could not exist without ‘the social.’ We then replicate these long-standing patterns in our daily interactions with the social world.
Critiquing Modern Individualist Psychiatry
Modern psychiatry’s roots have been firmly planted in individualistic and biomedical models which view the individual as primary and society as secondary. This view, as Foucault has pointed out, sees every individual as a separate conduit of power. This is a radical view of freedom that detaches cognition and behaviour from ‘the social,’ making the inherent assumption that each person is responsible for their conditions and outcomes. Therefore, if an individual or group is suffering or behaving ‘incorrectly,’ they just need individual treatments or adjustments.
Today’s world has doubled down on individualism through neoliberal cultural dominance, which turns competition and free-market-based ideologies into “moral good[s] and claims of functional optimisation.” As Kirmayer notes, the claim of a virtuous society arising from neoliberalism does not seem to be supported, evidenced by increasing inequality and instability that erodes well-being.
As psychiatry has not yet fully integrated ‘the social’, it focuses on the individual and continues to neglect the social world in favour of biological and psychological determinants of mental health. This has led psychiatry to neglect research and treatment that centers social contexts as causes of poor mental health. This also means that measures of the individual can be sufficient to account for pathology and recovery.
In turn, psychiatry, as many of its critics point out, can become akin to ‘victim blaming.’ As Kirmayer puts it, psychiatry has a “tendency to misidentify or misattribute causality and exaggerate individual agency” which leads psychiatry to “blame people for their own difficulties.” Because of this individualistic trap, psychiatry is not well positioned to advocate for societal changes that could lead to improved physical and mental health, especially for oppressed groups.
Social Determinants of Health
“The term social determinants of health (SDH) generally refers to features of the social environment or context that impact on health. This includes the built environment, social institution/structures, interpersonal connections, roles, and relationships.”
Social determinants of health is both a lens with which to view health outcomes, as well as a movement to change the underlying philosophical foundations of clinical practice, whether that practice be based on physical or mental health. If a culture is driven by an individualist point of view, such as today’s neoliberal dominated culture, that culture may both ignore social impact on health and drive institutions to pathologise the essential nature of individuals (i.e., genetic causality, cognitive distortions, chemical imbalance theories). The categories and diagnoses created by psychiatry and its focus on the individual also work their way into everyday conversations and larger cultural narratives, changing the way we view and understand ourselves and those around us. SDH then is not simply an additive to the current paradigm, but a model within which to question the foundations of healthcare practices.
An SDH approach to health would account for individual symptoms and experiences, while also considering access to food and housing, environmental concerns (i.e., air and water pollution), childhood development, trauma, access to education, social environments, and historical disadvantages when assessing the health of both individuals and communities.
Take for example a child with childhood mental health diagnoses, such as Reactive Attachment Disorder or Conduct Disorder. An individualised view would take the diagnoses at face value and understand the cause of the disorders to be some internal, inherent, and essential problem within the child. However, an SDH view would take into account things like the household of the child (for example, trauma, abuse, neglect), the social environment (for example, growing up in a community with higher than average crime rates), and access to education (for example, growing up in a community with underfunded/understaffed schools) before coming to a conclusion on the nature of the child.
Kirmayer believes that, for psychiatry to adapt to an SDH understanding of mental disorders, it must understand the brain in a new way: as an organ of culture. He writes:
“Psychiatry aims to identify brain circuits that contribute to psychopathology, but the circuits of the mind go beyond the brain to traverse the social world and do not reside only in our cognitive representations of the world or of each other but in the social environment, engaged through cultural affordances.” He calls this innovative approach a “cultural eco-social framework.”
The Cultural-Ecosocial Framework
A cultural eco-social framework for understanding mental suffering would exist not in a hierarchical structure, but in a complex net of interactions. The biopsychosocial model believes that the biological, the psychological, and the social interact to create individuals and individual suffering. Yet, it keeps the three arenas separate from each other, with three separate levels of experience.
The cultural eco-social framework has a multilevel view similar to the biopsychosocial model, but also includes explanations for how behaviours and the way they are understood can span different levels. This framework is founded on pre-existing models, including Bateson’s Ecology of the Mind, Bronfenbrenner’s Ecological Systems Theory, and Krieger’s Ecosocial Epidemiology. All these models take into account how the biological is affected by the social, and vice versa.
Kirmayer believes that the psychological in the biopsychosocial, is often neglected. He argues that human behaviours and thought patterns shape adaptive (and maladaptive) responses to the world around us. Human cognition and culture then play a role in mediating the biological and ‘the social’.
4E Cognitive Science
“4E cognitive science builds on work in phenomenology and systems biology to elaborate a view of human cognition as embodied, embedded in a social context, enacted through active engagement with the world, and extended through the artifacts and institutions that constitute the social world.”
In addition to the social world “getting under the skin” through such means as epigenetics, pollution, trauma, and food, it is created by meaning-making, language, and culture which are dependent on the human body. The social world created by culture reflects that body. For example, it’s the sounds our mouths make (or the waves of our hands) that creates language. Our need to walk creates paths which have become sidewalks. Our body’s ability to experience certain chemicals in pleasurable ways creates drugs (and the rituals associated with drugs, such as the eucharist). In these ways, our culture is always embodied.
Our experience is arising as we are embedded in that which came from others, and from those who came before us. We are shaped by our native language, the paths that have been laid, and the rituals into which we are born. Thus, culture is embodied and embedded at the same time. As the world influences our bodies and minds, our minds and bodies can influence the world. We enact the culture we embody and within which we are embedded.
The impressions we leave do not stay within a localized bubble. For example, this article is extended out into the world, spreading language, meaning, and thought not just of my own, but of that which has influenced me. Through our enactment of culture, we extend ourselves into the world through artefacts (such as this article) and institutions (such as Mad in America).
Conclusion
Kirmayer believes that this cultural-ecosocial model can change the psy-disciplines’ approach to mental health and illness. He points to four key features of this new model and how they can change psychiatry’s outlook on psychopathology:
- Health problems and solutions must be understood in and through local and wider social contexts which vary for populations, groups, and individuals; these contexts have histories and politics that assign individuals to particular niches and positions, and both enable and constrain their agency.
- Mental health problems are embodied, embedded, enacted, and extended through bodily, narrative, and social practices that depend on cultural affordances and resources. Embodiment and enactment are central to individual sense-making and socially constructed meaning.
- Mental health problems may reside in loops that extend beyond the individual to the family, community, and environment and not be reducible to lower-level explanations. Understanding community, environmental, and global network dynamics is necessary to explore the range of problems and solutions.
- The treatment or prevention of mental health problems can involve changes in social dynamics in the family, community, or larger society. This may require re-examining, critiquing, and developing alternatives to dominant, taken-for-granted values and ways of life.
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This article was first posted on Mad in America here.