Text by Andrea Ries (FU Berlin)
© Lena Bünger
Just by looking at the words laypeople and professionals alike find to describe mental suffering, we can see that causes of problems and afflictions cannot be ascribed to intrapersonal conflicts or neurochemical imbalances alone but at least as much lie outside of the individual organism or psyche. When speaking of “burn-out”, we do not simply blame the person for not allocating their time properly and taking enough breaks in an achievement-oriented society (Prengel 2011). Usually, the person needs to leave a harmful environment to have the chance to recover. A second example: Recently, psychologists have started talking about “climate depression”, a term which stresses even more clearly the interlinkages of personal well-being and the environment. Climate activist Greta Thunberg explains how she was suffering from severe depression, and how reading about climate change contributed to a deep feeling of despair (Anwar 2019). According to newspaper reports, an increasing number of students talk about “climate anxiety” or “climate depression” as they see anything but a bright future ahead of them due to exaggerated profit-orientation and ignorance.
These two examples suggest that the road towards relief and betterment does not only go via introspection, medicaments or coaching. As Psychiatrists Roberto Lewis-Fernándes and Neil Aggarwal (2015, 435) write:
“Psychopathology emerges from the interactions of all the domains, no more from the bedrock of genetics and brain circuitry than from the bedrocks of cognitive processing, emotion regulation, social structure, or culturally mediated concepts of distress.”
In the following, I want to focus on the social and cultural domains, which I understand as reaching from understandings of emotions and modes of interaction up to political and economic systems.
In his volume “Re-Visioning Psychiatry”, Psychiatrist Laurence J. Kirmayer uses a graphic (see below, p. 5) which gives an overview of the possible modes of healing on different organizational levels, along with mediating processes (Kirmayer 2015, 649). At the top level of organization, society, possible modes of healing are “[s]ocial or political activism [and] religious or spiritual engagement”, mediating processes can be “[c]hanging relationship to the environment, political system [and] spiritual order”. From there, Kirmayer moves down to “Community”, “Family System” and then to different levels within the brain (see below).
Levels of intervention in mental health problems. From: Kirmayer, Laurence J. 2015. “Re-Visioning Psychiatry.” In: Re-Visioning Psychiatry: Cultural Phenomenology, Critical Neuroscience, and Global Mental Health, edited by Laurence J. Kirmayer, Robert Lemelson, Constance A. Cummings, and Neil K. Aggarwal, 622–660. New York: Cambridge University Press.
Being a psychiatrist himself, he points out that healing fails if problems are just addressed at the level of the brain or the person. Any treatment should pay attention to and will have effects at multiple levels. Human beings need to be understood as “deeply embedded in and interdependent with their environment” (ibid., 647). This view criticizes the common perspective of the psy disciplines (i.e. psychology, psychiatry, psychoanalysis, and psychotherapy) as being built on the ideal concept of the individual which defines what we are thought to be capable of and who we are (Smith 2012, 60). As human beings, we depend on our social network and those who live with us become part of what constitutes our personhood. This dependency is neither ‘exotic’ or ‘pathological’ but rather part of what we are and part of the solution to our problems. Our health is strongly affected by “forms of political economy that delimit activity and access to resources”, such as any forms of structural discrimination, e.g. racism (Lewis-Fernándes and Aggarwal 2015, 436).
If we want to understand why somebody is suffering and what can be done to act upon the situation, we need to widen the view and look at the broader social context, up to the hegemonic political and economic system. An example: A person with depression decides to consult a therapist and during therapy, it turns out that there is too much pressure at work. The patient is a nurse working in a highly understaffed hospital. In this case, a part of the solution surely lies on the political level. Yet, it is questionable whether this patient has the capacities and energy to rally for changes in the health sector. Of course, it might have a soothing effect to go on a retreat and focus some time on personal well-being but what happens if one comes back to everyday life? And can this nurse even afford to drop out of work? Does the health-insurance pay? A long list of questions can be deduced just from this one example.
Laurence Kirmayer describes three different ways of looking at personhood: Psychiatry “sees the person as a biological organism, shaped by constitution and experience”, psychoanalysis looks at the “psychological self, with its inner theater of conflict, fantasies” and lastly the view of social sciences “emphasizes the ways in which individual agency and capabilities are shaped and constrained by social contexts and the environment” (Kirmayer 2015, 622). I do not argue, that social sciences should overrule all other views on the person, but this perspective is too often neglected when solutions are sought in the context of therapies. The cause of suffering often is not simply inside a person’s brain or psyche and a person’s options of finding help might be restricted, depending on e.g. financial situation or family support. As Kirmayer further writes: “In [the social sciences’] view, individuals’ plans and aspirations are structured by society, which affords some people advantages and confronts others with endless obstacles and structural violence” (2015, 622). A too individualistic view creates large blind spots on all organizational levels. Simply pathologizing and medicalizing suffering might silence any discussion about social and political circumstances. Kirmayer cautions that mental health strategies center mostly around diagnosis and medication, which frequently leads to “ruling out as impractical any consideration of changes in social structure and values that could promote healthier and more sustainable environments and communities” (Kirmayer 2015, 644). Treating mental suffering needs to move towards prevention by creating a healthier society. Anthropology can contribute to this endeavor by continuing to examine individuals’ experiences and distinct realities while placing them in a broader politico-economic framework. Mental health issues cannot be addressed and treated on the level of the individual alone, i.e. by sending everyone to a psychotherapist or by distributing psychotropic drugs. Rather, individuals need to be seen as social beings, shaped by their environment, experiences, and relationship, and at the same time having an agency and as being capable of inducing change.
Treating medicalization as the universal cure is one part of this problem. Criticizing the over-usage and immediate prescription of psychotropic drugs is a common critique in social anthropology. As the anthropologist Claudia Lang writes “Problems that are deeply social or socio-economic are redefined as individual and relocated in a neurochemical imbalance of the brain” (2018, 16). In her ethnography “Depression in Kerala”, Lang describes how despite knowing the social factors and socioeconomic transformations that are causative to depression, mental health professionals in the Indian state Kerala still identify providing antidepressants as the most expedient solution (Lang 2018, 95). She further refers to the issue of farmer suicides in India. If the depression of farmers is medicalized, the phenomenon is looked at “through a framework of the individual self and overlooks the multiple complexities of the lived distress and poverty” (Lang 2018, 96). The anthropologist Daniel Münster has pointed out that suicides relate to “intimate biographies of migration, personal aspirations, choking debts, bad family relations and, possibly, diseases and alcoholism” (2012, 204), yet this is just one part of the bigger picture. The individual biographies and experiences are shaped by structural inequalities. If these are played down, political protest and dissidence are silenced.
Byron Good describes how he began reflecting upon political action causing disorder and thus being classified as pathology, during the Indonesian election campaigns of 1997 (Good et al. 2007, 260). Good et al. find that by reporting about incidents of mass violence as amuk, a state and expression of violent behaviors, formerly described as a ‘culture-bound psychiatric disorder’, these outbreaks were naturalized as pathology in the media. Yet, there is the broad perception among Indonesian intellectuals that mass violence is the result of frustration over current issues like corruption or the gap between the rich and the poor and that democratization processes consequently reduce violence outbreaks. Amuk was not only seen as pathology but as a reaction to inequality, by some even as an instrument of social protest, yet being ascribed to “emotional illiteracy” (ibid., 264).
The cases from India and Indonesia show how pathologizing discontinuities and any kind of behavior that disrupts order functions in playing down dissent and silencing attempts to look for the causes and complex structures of suffering.
Labeling someone as “mad” means cutting this person’s civil rights, pushing them to the margin of society and not listening to their story anymore. The anthropologist João Biehl has described how classifying a person as “mentally ill” gives societies the possibility to “dispose” of who is “unwanted and unproductive” (Biehl 2004, 476). He describes the case of Catarina, a woman who lives in Porto Alegre, Brazil, whose “voice was annulled by psychiatric diagnosis” (ibid., 478). She was kept in abandonment without any possibility to communicate what she actually needed and without anyone listening to her. Indeed, she had a story to tell and she was misdiagnosed, she was not talking ‘nonsense’. Diagnoses may result in silencing individuals who might be capable of telling stories that reveal more about how society decides over the value of a person.
Anyone dealing with patients who suffer mentally needs to consider that an individual’s experience is in some way the reflection of processes happening in a broader context. The patient is just one part of a bigger puzzle. As the symptoms felt by a single person add up to mental illness, sick people add up to a sick society – and vice versa. I believe that another way of looking at mental suffering is to understand it as a means of expressing dissent. The individual does not accept and disagrees with, for example, a neoliberalist system that demands people to constantly work hard for their personal fulfillment and creates a society in which someone’s value is measured by their professional performance. Standing against such an environment and not just succumbing might result in symptoms like fatigue (because resistance consumes energy), lowered self-esteem (because you are told you don’t function) and loss of interest (because you question the purpose of life).
This leads me to the conclusion that a patient does not only need advice on how to cope with the given situation and how to function or to understand their inner conflicts but, whenever possible, to be encouraged to act upon the situation. We need more than psychotropic drugs and therapy, we need empowerment. In a broader sense: We all need to act to build a healthier environment for everyone.
References
Anwar, André. 2019. “Aus dem Mädchen mit Depressionen wurde die Anführerin einer Bewegung: Eine 16-Jährige verändert die Welt.“ Hamburger Abendblatt, April 30, 2019. https://www.abendblatt.de/nachrichten/article217059279/ Klimaaktivistin-Greta-Thunberg-wie-alles-begann.html.
Biehl, João G. 2004. “Life of the mind: The interface of psychopharmaceuticals, domestic economies, and social abandonment.” American Ethnologist 31 no. 4: 475–96.
Good, Byron J. 1997. “Studying Mental Illness in Context.: Local, Global, or Universal?” Ethos 25, no. 2: 230–248.
Good, Byron J., Subandi and Mary-Jo DelVecchio Good. 2007. “The Subject of Mental Illness Psychosis, Mad Violence, and Subjectivity in Indonesia.” In Subjectivity: ethnographic investigations, edited by João G. Biehl, Byron J. Good and Arthur Kleinman, 243–272. Berkeley: University of California Press.
Kirmayer, Laurence J. 2015. “Re-Visioning Psychiatry.” In: Re-Visioning Psychiatry: Cultural Phenomenology, Critical Neuroscience, and Global Mental Health, edited by Laurence J. Kirmayer, Robert Lemelson and Constance A. Cummings and Neil K. Aggarwal, 622–660. New York: Cambridge University Press.
Lang, Claudia. 2018. Depression in Kerala: Ayurveda and Mental Health Care in 21st century India. New York: Routledge.
Lewis-Fernandez, Roberto and Neil K. Aggarwal. 2015. “Psychiatric Classification Beyond the DSM: An Interdisciplinary Approach.” In Re-Visioning Psychiatry: Cultural Phenomenology, Critical Neuroscience, and Global Mental Health, edited by Laurence J. Kirmayer, Robert Lemelson, Constance A. Cummings and Neil K. Aggarwal, 434–468. New York: Cambridge University Press.
Münster, Daniel. 2012. “Farmers’ Suicides and the State in India: Conceptual and ethnographic notes from Wayanad, Kerala.” Contributions to Indian Sociology 46 no. 1+2: 181–208.
Prengel, Haiko. 2011. “Gut verdienen mit Burn-out.“ Die Zeit, December 1, 2011. https://www.zeit.de/karriere/beruf/2011-11/besuch-burnout-luxusklinik/seite-2.
Smith, Karl 2012. “From dividual and individual to porous selves.” The Australian Journal of Anthropology 23 no. 1: 50–64.