Surely Everyone Already Knows that Distress Is Social?
For all of the efforts in neuroscience, genetic research and neuroimaging (and the efforts have been quite considerable over the years), we still don’t understand the pathophysiology of what are commonly referred to as ‘mental illnesses’. This is despite the ratio of biological to psychosocial aetiology (cause) studies being 16:1.9 Indeed, the mass of research into genetic predispositions for schizophrenia has been described as one of the ‘costliest blind alleys in scientific history’.9 There has been a failure of decades of science to find any biological or psychological marker identifying a psychiatric diagnosis, a failure to link psychiatric processes to diagnoses, and molecular research is failing to uncover any specific genetic profile of any disorder.10 This failure has now been understood by the pharmaceutical industry where, after more than 60 years, the focus is beginning to shift from mental disorders to neurodegenerative diseases like Alzheimer’s.11 However, despite evidence to the contrary, many in academic psychiatry and mainstream psychology continue to behave as though the big breakthrough is just around the corner.10 It is not and can never be.
The principal reason for this is that misery and suffering result from complex and embodied arrays of social experiences that are embedded within specific historical, cultural, political and economic settings. These complex and embodied arrays of social experiences that are embedded within political and economic settings do things to people, sometimes that can be experienced positively, sometimes negatively and other times with indifference. Trying to create artificial boundaries between the intrapsychic and the socio-economic works really well if you’re in the business of treating individual people for individual problems. But if your business is trying to understand the complex nature of distressing experiences, it makes little sense, not least because much routinised misery is invisible12 both to the sufferer and to the professional who has placed the sufferer within their, vacuum-sealed analytic chamber with a view to devising a cure.
All manner of large-scale social forces and discreet local social experiences can come to be translated into personal distress and misery.13 Life choices and ways of knowing the world are structured through experiences of social class, abuse, gender, race, sexuality, disability, exclusion and grinding poverty. To explain suffering, you need to embed individual biographies in the larger matrix of culture, history and political economy which, when understood through the intrapsychic biomedical lens of the psy institutions, are often rendered invisible. The psy institutions, the socially approved authorities in personal misery, have understood and actively reproduced these as organic illness and disorders of thinking and feeling. However, these are actually how most of us would respond to periods of intense pressure, loneliness, despair, deprivation and/or mistreatment. And what have been discussed as ‘symptoms’ that need treatment can be better understood as the attempts of everyday people to control, deflect or ignore the pain that accompanies these.1 That these attempts can destroy lives, make carers and distressed people themselves endure untold misery, and that they may often make no rational sense, does not make them any likelier to be disorders.
What has been made knowable as symptomatic behaviour can often be better or just as convincingly explained by forms of social deprivation.14 Sixty to seventy per cent of people experiencing visual or auditory hallucinations have been subject to physical or sexual abuse as a child, and distress is consistently associated with markers of social inequality such as unemployment, low income and impoverished education.2,15 People abused as children are 9.3 times more likely to hear voices, and people who have endured three types of abuse, sexual, physical and bullying, have an 18-fold higher risk of hearing voices and the link is causal. Social exclusion and relationship breakdowns can cause neurological changes that are experienced as real pain.16 The long-term impact of racism, bullying, poverty, inequality and the corrosive effects of dysfunctional families, social worlds and political regimes are reasons why people become distressed.17
There is consistent evidence that the daily occurrences and fabric of people’s lives play a major role in creating different forms of emotional distress and behavioural problems, including psychosis; and the many different forms of evidence, taken together, are compelling.18 Distress is an acquired and embodied way of being in the world. Distress is not an idea that someone holds but a legacy of encounters with a social world that can manifest in misery and confusion that leave ‘crazy’ or disordered people isolated, vulnerable, disliked and unreachable.19 Our current responses to this are health care systems that in one sense provide forms of support for some people, some of the time, but that also fundamentally disguise the realities of social distress. In so doing, such systems can protect and make invisible many of the institutions and factors in society that are central to creating distressed lives.
If we dispense with the popular western fallacy that we are rational, unitary people whose normal response to challenging social encounters and social worlds is to keep being rational unitary people, then it’s easier to accept change, low mood, misery, suicidal thoughts and hearing voices as a fundamental part of the human experience rather than illnesses or symptoms that require treatment. The misery of mental health is a misery of, for and between individuals, families, carers, friends, communities and societies.20
One problem is that when we understand distress as having a social dimension, it makes an awful lot of things difficult. If you understand distress as a discrete biological and/or cognitive experience situated in an individual unit that you can standardise into an illness, then it can be meaningfully talked about, researched and treated. It can be understood by employers, teachers and government departments, and it can be understood by distressed people and their families. This is workable—well, to a point it is. But the idea of embodied, socially and culturally mediated experiences that are made manifest and knowable through recent and distant social experiences and that can be facilitated and contextualised by social, political and economic institutions, and where those who are distressed may have as little idea about the precursors of their distress, is much more difficult. How we know distress, what we call it, how we experience it and what causes it are socially mediated. However, in the techniques of naming distress and treating it, the psy institutions have not sufficiently paid attention to this. And as a result, their techniques of naming and treating it are profoundly problematic.