Mental Health and Social Injustice
Mental healthcare has always been suspiciously susceptible to paradigm shift and transformation. One of the tell-tales that it doesn’t really know what it’s doing is the ease with which it gets blown about by different ideas (another is its readiness to split into different configurations). During the last century, rates of diagnoses shifted dramatically from hysteria and psychosomatic conditions to schizophrenia and then depression[1] (and the dominant theoretical framework slid from psychoanalysis to cognitive behaviourism to the bio-medical model). It’s really not feasible that the conditions actually affecting people changed so dramatically during that period, just the ideas holding sway.
An idea now exerting more influence than ever before is that the symptoms of what we have traditionally regarded as mental illness should be understood as natural, ‘normal’ responses to loss, to trauma and to coercive social structures: to inequality, discrimination and other forms of social injustice (though, at the other end of the spectrum, the bio-medical model, which lost ground with the decline of the chemical imbalance theory, is still making good with ASD, ADD, ADHD and other forms of neurodivergence).
According to this approach, the explosion in reported mental health issues can be explained as the medicalisation of human distress through a malign confluence of interests between neoliberal capitalism, the bio-medical model of mental health and the pharmaceutical industry. People demonstrate these symptoms of distress as a result of what happens to them and they are labelled as ill because that’s convenient and profitable. What’s needed for many people to get ‘better’ is change to the social conditions we live in: less inequality and justice, greater tolerance of difference, diversity and the rights of the individual.
There’s almost certainly a strong element of truth in this (though many different things can be true at the same time and sometimes they can be hard to square together). There is a strong reported association between social disadvantage and mental illness[2] and reported links with discrimination and experience of violence and abuse.[3] And that all makes very good sense: the heart of mental health issues is problems with self-esteem (and the anxiety and aggression that generates) and poverty, poor living conditions, exposure to injustice, unfairness or violence would all be good ways to feel worse about yourself. But this viewpoint also has serious limitations, and it has the potential to cause its own serious problems.
One reason for its popularity is that it exonerates people and that’s always critically important in the context of mental health (see below). Seen under this light, there’s nothing ‘wrong’ with the sufferers, or with the way they’re behaving: these are natural expressions of human distress caused by the way we’ve constructed our society and the conditions we live in. It relieves the families too – it’s not their fault that their child or brother or sister is so unhappy, its society’s. And it exonerates the mental health care profession – there’s a reason you can’t ‘cure’ these people: they’re not ill; you’re dealing with the consequences of a brutal economic system and a structurally unfair society. Something for everybody here.
An immediate and obvious problem with this position is that it seems a little naïve to expect society to change, in the ways you want, just because a bunch of mental health professionals have ‘diagnosed’ it.
That can also make it seem a little callous: if people who are excruciatingly, even lethally, unhappy come to see you for help, because you are held out as the expert, how helpful is it to say they’ll just have to wait for the Revolution?
A little self-serving too: if these are normal human responses to prevailing social conditions, the pitch goes, there’s a limit to what the mental health profession can be expected to achieve until society changes. And in the meantime, you’re relieved from the tedious and difficult business of trying to make very unhappy people better, whilst getting a bit of a ride on the sense of victimisation that goes hand in hand with mental health issues and presenting yourself as a bit of a social warrior, bathing in your own virtue and radicalism, whilst enjoying the (social) trappings of a middle-class life. That’s quite nice! We’d all like a bit of that.
What’s more, it’s hard not to see a thread of cold, economic logic here: if you can’t show that what you’ve got works,[4] the best way left to sell it is by telling everybody what they want to hear (and being very emphatic about the urgent need for what you’ve got). The mental health profession will claim but we’re the good guys; we’re trying to help. To which the obvious response is, well you aren’t (helping)[5] - so what else is going on?
And there is the potential for this way of thinking to make things worse. In the same way that the bio-medical model can inhibit the idea of recovery (you’re unlucky enough to have this condition – probably down to a chemical imbalance in the brain – and now you’ll just have to manage it as best you can) the idea that these are natural responses to the conditions of their lives, can keep people in their suffering. It can exacerbate peoples’ sense of something having been done to them and all the anxiety, aggression and isolation that entails.
Because, surely, there is an important point being missed here – most people aren’t ‘ill’. And when people do get better, it’s not because the social conditions have changed. At some level, the problem was in them. What’s being evaded in this way of thinking is the idea that you’re getting it wrong, you’re at fault. That idea can’t be evaded because it’s that idea that’s causing the problem; it’s too strong to just go round because it’s true and it has to be addressed in order for people to have any long-term peace. The distress is people’s feelings of incompetence and inadequacy, shame, guilt and worthlessness (and all the ways they react against those feelings to harm themselves and other people).
There is a risk, here, of swapping the medicalisation of what Freud called ‘normal human unhappiness’ for its politicisation. Yes, the conditions of life include social factors like inequality, injustice, discrimination but there are so many things that can make you unhappy: falling in love with the wrong person, physical illness or injury, or just your own unrealistic assumptions, and expectations of other people or of your life. Diogenes, Montaigne, Shakespeare, Tolstoy, Karl Ove Knausgard: it’s not a bed of roses. Happiness is hard to come by and it’s easy to knock off track. There’s a good reason why the consolation of a better life after death has been such a strong sell for religions.
And, if what we have regarded as mental illness is, in fact, just the by-product of social conditions, then are we saying that the dramatic increases in reported mental health issues are because, in neoliberal capitalism, we have managed to design a social system which, despite its apparently benign aspects, is actually more exquisitely calibrated to make us unhappy than anything that’s gone before? More than the gender and racial segregation of the last century, the rise of mass consumerism, the Dickensian poverty of the Industrial Revolution, indentured servitude to the landed gentry or medieval feudalism? Or maybe we’re saying that we have just entered a more enlightened, progressive phase of history, in which the enlightenment consists of a more acute awareness or experience of unhappiness, and this will lead us to a fairer, more healthy society – the people we have traditionally regarded as mad are our canaries in the coal mine?
And if it’s not illness, but a response to social conditions, then how are we to approach it? Is it a question of greater tolerance and diversity: society should find better ways to accommodate these people and their symptoms of distress? But they are very unhappy – and the way things are seems to suit most people reasonably well: we can’t shape society round these people and change it all for them, that would be undemocratic. And surely that idea that, actually, that kind of re-arrangement of things might be better for everyone, that we’re all really suffering, we’re all ‘ill’, and only these guys know it, is a little dangerous? Who gets to police what’s really good for us if we can’t feel it ourselves?
Also, the symptoms of distress we’re talking about can cause a lot of trouble and unhappiness to other people – lack of economic productivity (someone else is going to have to pay for the food and the rent), the financial cost of care (around £34 billion a year of increasingly precious public funds in England alone[6]), the emotional burden on family and carers (you try it!) and the potential for adverse impact on colleagues or other people who interact with them. Tolerance and diversity need balancing principles such as ‘don't cause harm’ – terrorism and criminal violence can also be seen as responses to social conditions. People traditionally regarded as suffering from mental health issues frequently do cause harm. If they're not ill, why tolerate it?
And, anyway, - it's obvious - some survive these conditions, and the things that happen to them, better than others. Some are more vulnerable. Surely what we need is to understand better what makes people more vulnerable, which would probably involve understanding better what is actually happening to people when they get into trouble. At the moment, we just accept that it happens, more or less like catching flu. And that takes you back towards the bio-medical model everyone’s reacting against or the old developmental models of therapy.
And it isn't like flu, it's mental: it manifests in ideas and emotions (as well as physiology). You can look at that at different levels, you can look at the ideas affecting people, their assumptions about the world, their expectations and the ideas and emotions affecting them when things go wrong for them. And (in theory) you could look at the physiology because ideas don't take place in ether, they are physiological events (in practice, at the moment, neuroscience can’t do anything to match mood or states of mind, let alone ideas or thoughts, with events in the brain).
So, round and round we go. In the end, the social injustice approach doesn’t really take you anywhere; it breaks down, it just peters out. There’s lots of noise and nothing changes. Same place, same arguments, same ignorance, same problems.
Mental illness is hideous. Whatever the social or economic conditions people are living with, mental illness is a tragic spoiling of life. You would think there ought to be more pertinent angles we could take than the people meant to be treating it denying there’s anything ‘wrong’.
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[1] Making Minds and Madness: From Hysteria to Depression – M. Borch-Jacobsen, Cambridge University Press, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3480686/#__ffn_sectitle
[2] https://digital.nhs.uk/data-and-information/publications/statistical/adult-psychiatric-morbidity-survey/adult-psychiatric-morbidity-survey-survey-of-mental-health-and-wellbeing-england-2014
[3] https://www.mind.org.uk/information-support/types-of-mental-health-problems/mental-health-problems-introduction/causes/
[4] See
or …
[5] See https://jonathancoppin.substack.com/p/newsflash-new-research-proves-mental
[6] That’s dedicated mental health support and services across government departments (excluding dementia and substance use): Mental-Health-Taskforce-FYFV-final.pdf www.england.nhs.uk