Are we programmed to certain individually-located mental illness?
There are a few assumptions that underly the concept of mental illness in western medicine. One of these is that there is a specific process of illness that is contained within an individual person. This can seem obvious for many medical issues. If I have high blood pressure, is this not my genetic characteristics alongside my choices about what I eat and how I exercise? Sure, all three of these individual factors are influenced by access to nutrition, socioeconomic factors, cultural and systemic biases regarding my specific multiculturally-influenced needs, community organization, etc. But it still feels right to locate the problem and many of the solutions in the individual. After all, the high blood pressure itself is in the individual, right?
Are mental illnesses individual?
It is not so clear that mental illnesses are individual. Take a look across the diagnoses in the DSM, American psychiatry’s manual of purported mental illnesses, or the ICD, Europe’s version. You’ll see depressive disorders, anxiety disorders, psychotic disorders, disruptive behavior disorders, personality disorders, and so forth. At first glance, these names seem to confirm their individuality: it is the individual who is sad, or anxious, or hearing voices, or acting impulsively, or acting with disregard for others. However, this first impression doesn’t hold up to peeling back the surface.
For depression and anxiety – how do those emotions arise? Inevitably, they come out of social situations. Either being in them, or the potential for them. Moreover, they involve specific skills. Many are fortunate to learn these skills in their families or communities in childhood, while others are not. For example, it’s scary to stand up and give a presentation in front of peers and people judging me: if I feel supported and have the opportunity to try and try again, I can fail, learn from the experience, try again, and eventually figure it out. I’m unquestionably an important part of this process, but to put it all on me is absurd.
For psychosis, disruptive behavior, and personality disorders, who decides what is acceptable? Who decides what is reality, what is present, and what is not? If I see an angel, am I hallucinating and psychotic, am I gifted with a deep spiritual experience, or does it mean something else? If I’m awkward to be around and say rude things from time to time, that may be unpleasant for others or even me, but what makes that illness? This expectation may not come from me at all, but from society. Perhaps society is ill and should learn to deal with me!
Psychological misinformation in the current model of illness
Major models of mental illness have these assumptions built in. One prominent framework is the diathesis-stress model. The concept here is that the individual has predisposing factors to specific illness, and then the illness becomes an actual, happening thing when certain environmental stressors prompt it. That the illness is individual is so central an assumption, that it isn’t even mentioned. It’s the water the model swims in. You start with an individual – not even an individual; a collection of genes – and test this individual’s fitness for social acceptability. Take person, add stressor, and see if they are ill. After all, even after experiences of trauma, only ~15% meet criteria for diagnosis of posttraumatic stress disorder (e.g., Alisic et al., 2014). Surely this means that it is the individual factors that make those unfortunate 15% suffer, when the environmental factors are equivalent?
This reasoning is again swimming in the water without noticing the water. The same endpoint stressor does not mean the prior environments are equivalent. In reality, at every moment, there is a reciprocal relationship between the individual and their environment. This happens at the level of behaviors, where what the person does has effects on how others respond, which then trains the person. It also happens at the level of genetics, where the environment turns genes on and off and alters expression.
Thought experiment
Let’s say a tragedy strikes. A 4 year-old, who has had the resources and caring you’d expect for a child in a middle-class, urban, loving family, is cut off from all interaction. They are isolated in a room, with no social contact whatsoever, for the next 21 years. In other words, until all theorized youth brain development is complete. Somehow, all basic necessities are provided for (food, bathroom, sleep, temperature control, etc.). How will they be at 25 years old? Will they learn: how to regulate their emotions? how to get along with others? Will they be able to regulate their sexuality? Or handle stressful, provocative, intimidating situations?
How do we learn these skills? Already at four, their environment will have taught them foundations for some of these skills, but certainly not all. Yet if illness is truly individual, we would expect a 50% chance that the 25 year-old would come out well adjusted on all of these factors (Horder, 2010). You and I both know that likelihood is laughably optimistic.
Which raises the crucial question. If a person is struggling with something, where do you locate the dysfunction?
Identifying dysfunction: Why choose?
There are many potential candidates. There’s the person themselves, who may lack certain skills to handle their situation. There’s their parents, who weren’t able to provide them with that training. How about the people in their current environment? Who are enabling them to keep avoiding learning those skills, or not helping them step up to do so. What about the economic systems? Which make the person have to spend all their waking hours (along with some of the time they should be asleep) taking care of work and chores and bills, leaving no time or energy to add new skills into the mix. Or the laws and policies, which don’t provide, or even bar, access to ways to learn or work around those skills? Or cultural factors, that say you’re expected to act a certain way based on your gender or ethnicity?
So is the individual ill? Or their family? Or their town? Their country? Their culture, or the dominant culture they find themselves in?
What if we don’t have to choose?
Conclusion: Diagnosis as an ecological system of factors
Ecological systems theory identifies a set of nested, interacting levels surrounding each individual person. Just like the ones discussed above. Right now, you may go to a psychiatrist and they tell you, “You have generalized anxiety disorder.” What if, instead, the psychiatrist says, “For the specific challenges you identify facing in your life, here are the individual, family, home, economic, physical environment, community, cultural, national, and global factors that are presently influencing your ability to navigate those situations.” Perhaps with weightings on each, so you can have a sense of how much impact a particular change will have.
Instead of coming away with a message that you are broken in some way, you’d have a roadmap. You’d know how different tools – medicine, psychotherapy, exposure work, exercise, sleep, relationships, moving, changing your job, spiritual resources; the list is endless! – will influence the system, and how they may work together or undercut each other.
This type of diagnosis would also show that your current situation is dynamic and ongoing, and not a final destination.
Postscript on medical diagnosis
One quick extra note. Even with the high blood pressure example above, diagnosing just the individual, rather than all layers together, may be quite limiting. As just one example, the role of education may go unnoticed. When I say education, I’m going beyond the limited time and resources that a physician has in their 15-minute meeting. There’s only so much a doctor can do in a 15 minute, annual visit to educate their patient on the what, how, when, and why of the complex factors that go into addressing blood pressure.
Actually learning and using skills involves much more than a dump of information. Real education comes from integrating knowledge into practice, with feedback to broaden and deepen the skills. What if 3rd graders got homework to identify with their parents how much salt is going into their meals? Or an assignment of 30 minutes of physical play every day outside of school?
In the absence of this education, people develop whatever skills are already in their families and communities. For those with lots of resources, this may be adequate. For families stretched to the breaking point to make ends meet, and communities that lack basic resources, this may leave a huge gap, potentially dooming more of them to issues like high blood pressure.