By J. F. Conway
September 2007
While the condition of a people is prosperous, and uninterrupted by violent and sudden changes, insanity never exceeds. But when the dispensations of Providence fail of their accustomed bounteousness, or man by trouble is afflicted beyond his nature, or by his own wilfulness o’erleaps the bounds which nature and reason defines; then insanity is engendered; and an increased number of lunatics indefinitely swells the catalogues of human calamities.
- G. M. Burrows , An inquiry into certain errors relative to insanity, 1820
What good to us is a long life if it is difficult and barren of joys, and if it is so full of misery that we can only welcome death as a deliverer?
- Sigmund Freud, Civilization and Its Discontents, 1930
Back in the 19th century, the people charged with the care, treatment, and control of “lunatics,” as the mentally ill were often indelicately labeled in those days, began to notice repeating social patterns in the occurrence of the afflictions. They observed that the various mental illnesses were selectively, rather than randomly, distributed among the population, and that they tended to prey particularly on the lower classes. These were the first epidemiological studies of psychopathology, and they focused primarily on the social conditions associated with the prevalence of mental disorders.
Epidemiology is the study of factors affecting the health and illness of populations. It is built on a recognition that there is a selective and unequal distribution of many diseases within a population, and that there are important associations between these diseases and the circumstances of certain groups. For example, early epidemiological studies linked outbreaks of typhoid fever to common sources of water or food, which led to the discovery of the bacterial agent responsible for the outbreaks. By the time practitioners began applying epidemiology to the study of mental illness, it had already proven its effectiveness in identifying the causes of various infectious diseases, leading to many early medical triumphs. Its early application to the study of mental disorder focused simply on patterns of prevalence in identifiable social categories, thereby helping to identify possible risk factors that would contribute to the onset of mental illness.1
The results were dramatic and replicated repeatedly by many independent researchers. These early prevalence studies clearly proved the following: that various forms of economic distress were associated with elevated rates of admission to mental hospitals; that the strongest and most clearly replicated relationship was a direct and inverse association between social class and mental illness (the poor were at greater risk, while the more affluent appeared to enjoy a form of socio-economic inoculation from madness); and that mental illness was much more elevated among immigrants than among non-immigrants. The relationship between poverty and the risk of mental disorder was so repeatedly strong that the term “pauper lunatic” was coined, particularly after a 19th-century study in Massachusetts found that the rate of mental disorder was 64 times higher among “paupers” than among the “independent classes.”
Studies in the 20th century became considerably more sophisticated. Crude measures of poverty and economic impairment were replaced by multi-dimensional measures of social class, including the concept of socio-economic status.2 Clear associations between particular psychiatric diagnoses and dimensions of socio-economic status were uncovered. Efforts were made to detail the various risk factors that interacted with socio-economic status in the occurrence of mental disorders. Since not all poor people, nor all people of low socio-economic status, developed mental illness—-clearly the vast majority did not—-researchers began to search for protective factors, the unique characteristics of those among high-risk groups who did not develop disorders, that were absent in those who did. This search led to a series of community integration studies that demonstrated that those in disintegrating or dysfunctional communities or families, in which there was an absence of socio-psychological support systems, tended to be more at risk of mental disorder, particularly in the presence of other identified risk factors like low socio-economic status, extreme poverty, bereavement, divorce, inadequate parenting, and family violence.
“Most mental illnesses are never officially diagnosed and treated, suggesting that they are normalized and accommodated by individuals, families and communities through other coping mechanisms.”
The critics of social causation
THE FINDINGS OF THESE STUDIES WERE SO OVERWHELMINGLY strong and consistent, and so disturbing in their implications—-both as an indictment of the social system and a cry for remedial political interventions—-that two challenges were mounted against this growing body of evidence. One was the drift hypothesis, which argued that the evidence did not demonstrate a case of social causation but rather one of social selection. Those who were vulnerable to developing a mental disorder, it was argued, were inadequate, dysfunctional people who, upon the appearance of mental illness symptoms, began to suffer negative social consequences due to increasing functional inadequacy—-loss of job, loss of business, loss of friends and family—-and thereafter drifted down the social class hierarchy towards an impoverished existence on the margins of society.
The drift hypothesis was seized upon by conservatives to dismiss the evidence that demonstrated the social causation of mental disorder. After the proposal of the hypothesis in 1940, however, researchers went back to the data from earlier studies to test for drift. Further, all research after 1940 tested systematically for drift, and was designed to control for the phenomenon. The evidence of these tests did not support the drift hypothesis, pointing strongly toward social causation rather than social selection. Certainly, drift occurred in individual cases as people fell mentally ill and suffered disastrous socio-economic consequences, but this phenomenon is easily controlled for in research designs. The facts were clear: the drift hypothesis failed to explain the repeatedly strong links in very large populations between lower social class and higher rates of mental disorder.
To this day ideologically conservative policy makers and planners in governments, and many scientists, have consistently embraced the drift hypothesis despite clear evidence to the contrary. The reasons for this are pretty easy to understand. Acceptance of the “social causation” explanation implies a need for costly programs of social intervention for both prevention and treatment. The costs of alleviating the extremes of poverty, of providing decent housing, of ensuring basic economic security, and of community-based, socially oriented treatment programs would be astronomical, and certainly contrary to the spirit of capitalism. The “social selection” explanation, on the other hand, suggests there are no clear causal social patterns behind the occurrence of mental disorder, and therefore causal factors are found in the individual psychology, genes, or idiosyncratic predispositions of those afflicted—-making it much easier to blame the victims for their own conditions and to develop cheaper, individually focused treatment programs.
The second challenge to the notion of social causation noted that the studies linking class and mental illness were based on rates of admission to mental hospitals and/or actual diagnoses of mental disorder by psychiatrists in clinics. Since those of higher socio-economic status have the means to avoid being committed to mental hospitals and to pursue private and confidential remedies to psychological problems, the data may have missed large numbers of higher-status individuals afflicted with mental disorders. Hence, it was argued, the elevated frequency noted among the lower social classes may only signify that the less affluent cannot afford private and confidential care.
This was a valid criticism. In response, some of the larger and more compelling among the studies—-the Stirling County study in Nova Scotia (1949-63), the Midtown Manhattan study and re-study (1954-74), and the Camberwell study of depression in women (1978)—-avoided the problem by sampling the entire population and carrying out psychiatric assessments of the sample. These studies confirmed the earlier epidemiological evidence, while adding considerably to our more precise knowledge of other risk factors which interact with low social class.
Interestingly, these studies also found that of those people suffering from mental afflictions serious enough to warrant clinical intervention, most do not enter the psychiatric care system. The ratio of treated to untreated is estimated at 1 to 14. Hence most mental illnesses are never officially diagnosed and treated, suggesting that they are normalized and accommodated by individuals, families and communities through other coping mechanisms. Clearly, we need to know more about such informal coping strategies, and the extent to which they could be supported and extended by public investment in family support and community resources.
“Governments across Canada closed mental hospitals and discharged patients, but the necessary accompanying investment in community psychiatry never occurred.”
Who killed community psychiatry?
THE EARLY 1970s IN NORTH AMERICA WAS A TIME of considerable optimism about the potential to prevent and treat mental disorder. The epidemiological studies provided a solid foundation for evidence-based prevention and treatment programs. Forty-four independent prevalence studies confirmed the strong, direct and inverse association between social class and psychological disorders. Consistently, those in the lower classes facing the extreme hardships of poverty and insecurity were found to be exposed to much greater stress, often compounded by a lack of resources for coping.
Beyond class, other stressful life events have been identified as risk factors for psychological disorder: advancing age; divorce or separation; death of a spouse; being an immigrant; participation in war; chronic illness; unemployment or loss of business; low levels of community integration; and non-white ethnicity (a correlation that disappears when rates are standardized for parental socio-economic status, suggesting, again, that class is the true culprit). Among women, the risk of depression is correlated to clearly documented vulnerability factors: low social class; lack of an intimate relationship; three or more children under 14; lack of job outside the home; and loss of a mother before the age of 11.
Studies of the risk of psychopathologies related to family relationships also provided a wealth of evidence of association between risk factors or traumatic life events and psychological disorders: divorce or separation; bereavement; family violence; emotional, physical or sexual abuse; drug or alcohol abuse; and inconsistent, unpredictable or bizarre parenting. Clear gender differences were also documented: married women are more at risk of psychological disorder than single women; single men are more at risk of psychological disorder than married men; girls suffer triple the rate of clinical depression compared to boys as well as elevated rates of the eating disorders anorexia nervosa and bulimia nervosa.
Though these many stressors or risk factors were very strongly present in clinical data, they proved difficult to systematically describe and clearly link since they involve complex interactions between social, psychological and biological variables. Nevertheless, they provided compelling policy direction for progressive governments. Proposals like the guaranteed annual income to provide basic dignified economic security to all, a series of “well-family” clinics located in schools and staffed by teams of mental health professionals, infant parenting support programs, an expansion of social housing availability, early intervention programs to support families in crisis, and other initiatives sought to target the identified risk factors and to provide early assistance and remediation to vulnerable segments of the population.
Optimism that we were on the threshold of positive strides in the prevention and treatment of mental disorders was further enhanced by the move to community psychiatry in the 1960s and 1970s, and the closure of most custodial mental hospitals. Scandals about the mistreatment of patients, irresponsible and dangerous drug and surgical research on incarcerated patients without the informed consent of either patient or family, court cases confronting the removal of psychiatric patients’ rights as members of civil society, and the poor treatment outcomes made custodial mental hospitals increasingly indefensible. The clinical evidence was clear: such facilities had little success in treatment and cure, and had become dumping grounds for individuals abandoned by their families and by society, serving what often amounted to life sentences of incarceration without the right of appeal.
The move to community psychiatry looked good on paper—-it still does. Patients would be discharged to community-based programs staffed by social workers, psychiatric nurses, psychologists, psychiatrists, and a variety of counsellors. Rather than simple custodial care and the management of symptoms so typical of mental hospital treatment regimes, the afflicted would be involved in ongoing and aggressive therapeutic programs in the community, where they would remain rooted. The future seemed promising.
But only the first (and easiest) step was ever taken. Governments across Canada closed mental hospitals and discharged patients, but the necessary accompanying investment in community psychiatry never occurred. The discharged patients were simply dumped from institutional custodial care onto the welfare rolls. The only treatment made available to most was the simple management of symptoms through psychoactive drugs, buttressed by the odd underfunded drop-in centre. Those patients who remained difficult to manage often ended up incarcerated in provincial jails and federal penitentiaries rather than mental hospitals. Indeed, it’s no exaggeration to say that today“šÃ„ôs asylum for large numbers of the seriously mentally disordered is the prison.
“The biomedical consensus became so widespread that individuals increasingly medicalized all their problems of living.”
The rise of the biomedical model
THE COLLAPSE OF THE COMMITMENT TO COMMUNITY psychiatry, and to the social model of explanation and intervention, occurred in the context of the triumph of a biological determinist model of mental illness. This model asserted that social and psychological factors may play a secondary role in the development of mental disorders, but that the fundamental and primary cause and cure was to be found in the realm of biology. Diagnosis, treatment and cure of mental illness, therefore, were seen to require a biomedical approach.
Through the conflation of diverse events and social forces, the biomedical model became the dominant paradigm, and has remained so for the past 30 years. The great advances in psychoactive drugs, which made it possible to manage even the most extreme symptoms of psychiatric illness, and which had made the closure of mental hospitals feasible, contributed to a conviction that perhaps the secrets of cause and cure would be the next great breakthrough of biomedical science.
A powerful consensus thus emerged to push the biomedical model. Pharmaceutical companies, already fattened by huge profits from the sale of psychoactive drugs, aggressively pushed the biomedical approach. As governments reduced their commitment to funding independent medical research, these companies moved in to become the primary source of research funding, and were thus able to shift research priorities to focus primarily on the biological causes and cures of psychiatric illness. Governments, for their part, were delighted to avoid the huge costs involved in social models of prevention and treatment, and enthusiastically joined the biomedical chorus.
Many of those suffering from psychiatric disorders, meanwhile, desperately wanted to believe they were suffering from a biomedical condition that could someday be cured like some infectious disease. Not only did this shift give hope to the often hopeless, but the stigma of mental illness was significantly reduced when it was viewed as a biological phenomenon rather than some inadequacy in personality, willpower, or upbringing. Many families of psychiatric patients leapt on the bandwagon as well, now free of the burden of guilt implied by social and psychological explanations, and hopeful that a medical cure was just one biological breakthrough away. Finally, several prominent scientists argued that advances in genetic research, including the mapping of the human genome, would finally solve the mysteries of mental illness and lead us to more successful interventions.
The biomedical consensus became so widespread that individuals increasingly medicalized all their problems of living, seeking the correct biomedical diagnosis and the proper drug to provide instant alleviation of conditions ranging from anxiety to loneliness to job stress. The research documenting the social sources of madness, meanwhile, disappeared down the memory hole, and those who persisted in promoting it were ignored and swept aside.
“Psychoactive drugs are now routinely used to manage troublesome, vulnerable and powerless populations, like overactive and delinquent children, the elderly and those in prison.”
Biopsychiatry’s dubious legacy
TODAY, HOWEVER, SERIOUS CRACKS ARE FORMING in the previously impenetrable biopsychiatric edifice. Quite simply, biopsychiatry, and the biological determinist model generally, have failed to deliver on the great promises made. There is still no psychiatric consensus on diagnosis of many mental illnesses other than the most serious and most common. No genetic cause of a major mental disorder has been found and independently replicated. Although psychoactive drugs have become more numerous and more powerful, they still simply control symptoms and, when successful, allow the sufferer to function reasonably adequately. This is a tremendous contribution, but the early promise of a cure has largely disappeared.
Many clinical trials have documented that most psychoactive drugs are only marginally more effective than a placebo. Some anti-psychotic drugs have serious long-term side effects. Antidepressants often exacerbate apathy and indifference, suicidal thoughts, or flattening of affect and intellectual functioning. Some experts argue that withdrawal from antidepressants has been associated with increased risk of psychosis and of suicide. Some psychoactive drugs contribute to marked obesity and embarrassing physical peculiarities like tics and spasms. These problems with psychoactive drugs often cause patients to discontinue their medication in despair and desperation, leading to serious relapses.
The widespread use of psychoactive drugs has created considerable controversy. Swayed by the biomedical model, patients and families, parents and teachers tend to reject psychological and social explanations of behavioural or mood problems and demand drug treatment. Psychoactive drugs are now routinely used to manage troublesome, vulnerable and powerless populations, like overactive and delinquent children, the elderly and those in prison. And feminist scholars have convincingly documented the overuse of psychoactive drugs to manage the problems many women face in unhappy marriages and dysfunctional families.
It appears, then, that the greatest contribution of biopsychiatry has been to provide chemical (rather than canvas) straitjackets for the mentally afflicted. Indeed, this was a great step forward. Drugs that control symptoms and manage a mental disorder so the sufferer can function even marginally adequately are to be preferred over the asylum, the canvas straitjacket, the restraint chair, and the padded cell. But the promise of finding the biomedical cause and then the cure of mental disorders has not been fulfilled, while efforts to address the social causes of these disorders have been all but abandoned.
Mental illness, in all its frightening and immensely diverse manifestations, results from the complex interaction of social, psychological and biological factors. Research must focus on that interaction, guided by the notion that we need to distinguish between precipitating events, like economic, social and psychological stressors, and predisposing factors, like genetic/biological vulnerability and inadequate early socialization. We were on the threshold of such an approach in the 1970s, but it was shut down by the totalized, unidimensional approach of biopsychiatry, supported by the general hegemony of biological determinist ideology and the demands of free-market capitalism.
There are now indications that faith in biopsychiatry is collapsing, even among the professional leaders of psychiatry. The May 2007 issue of The Canadian Journal of Psychiatry published three articles revealing a crack in the consensus: “Rethinking Social Causes in Psychosis,” “The Contribution of Social Factors to the Development of Schizophrenia,” and “The Social Causes of Psychosis in North American Psychiatry: A Review of a Disappearing Literature.” This may be a case of back-to-the-past, but it is a necessary step if we are to move beyond the intellectual desert of biopsychiatry and biological determinism.
J. F. Conway, a University of Regina political sociologist, holds a Ph.D. in sociology and an M.A. in clinical and social psychology. His past work experience includes a summer as a psychiatric aide at the now-closed Weyburn mental hospital, two summers as a psychologist intern at the Saskatchewan Penitentiary in Prince Albert, and a year working with emotionally disturbed children. He has taught a unit on the sociology of psychopathology for many years.
Endnotes
1. Of course, a demonstrated correlation between a social factor or stressor and a mental disorder does not, in itself, prove a cause-effect relationship. Only over time, as research finds repeated associations between social stressors and particular psychological disorders can a causal relationship be inferred based on a number of strict rules: the sequence must be causal (i.e., the stressor must precede the disorder); the correlation must be very strong; the correlation must be repeatedly replicated by independent researchers; and multiple stressors must exponentially lead to more serious disorders.
2. The definition of social class often varied from study to study, ranging from relationship to the mode of production, to income and occupation, to public perception. Socio-economic status measurements, however, more consistently set a series of criteria by which to rank people, including occupation, income, education and place of residence.
