Trauma is situational. The situation in which a human being is unable to wind down for a long time because it has been continuously subjected to aversive circumstances is likely to result in distress. There is a growing body of literature that supports this thesis today. Yet the biomedical concepts of mental distress still seem to prevail in the public discourse. This kind of discourse, however, ignores the situatedness of the mental distress in the social context in which it exists, despite a large body of evidence of that link.
Research has found that wide range of social determinants influence mental health. A meta-analysis of 51 prevalence studies, 5 incidence studies and 4 persistence studies mostly from high-income countries has shown that there is a strong association between depressive states and less advantaged socioeconomic position. Financial disadvantage, unemployment, low income, low education or low material standard of living directly impacts mental health.
Childhood trauma and further adverse events in adulthood such as bullying, social discrimination or exclusion, migration or visibly marginalized status may, for example, increase risk of developing what is then labeled as psychotic disorder. Furthermore, research points towards financial difficulties and low income as barriers towards recovery once a person is already manifesting symptoms. These are just a few studies displaying the clear link between mental distress and social determinants, but there are countless others.
How can mental and emotional suffering be approached in a more constructive manner?
The answer lies in the psychosocial approach. The psychosocial approach addresses mental health in the context of the community. It deals directly with the social determinants of mental health and puts emphasis on the lived experience of people who encounter mental distress. However, the institutional power of various proponents of the biomedical role is an institutional barrier when it comes to the spread of psychosocial model.
Consequently, resources offering a psychosocial perspective on emotional distress are still not sufficiently available to the wider public or dominant in the public discourse. Often, in order to research these resources one has to first have epistemological knowledge – to understand how knowledge is constructed socially with power relations being in-built into the concepts. In other words, in order to find other kinds of frameworks one has to first know that the prevailing biomedical framework is just that—a framework. Thus it can be argued that what I will call conceptual tools are needed to understand alternatives to biomedical approach. The psychosocial framework is one such tool. It situates the mental distress within power-operating social environment and understands it as linked to social structures, identifying barriers to recovery and focusing on a way forward towards new orientations instead of the challenges.
There are many psychotherapies that work within psychosocial framework. To have access to them or to acquaint oneself with them, however, requires financial resources. Often, people struggling with mental health issues may be have restricted financial resources, or may suffer social isolation, making it hard for them to have access to these kind of resources. Simultaneously, in the 2021 Mental Health Atlas of the WHO it was found that only 49 countries, which is equivalent to 31% of responding countries or 25% of WHO Member States, reported the integration of mental health into primary care including the provision of psychosocial interventions. Thus barriers to access to psychosocial support are also often institutional and geographical.
In this kind of context, the psychosocial framework is still hard to access for lot of people, both in terms of understanding (epistemologically) and financially, as well as due to its limited availability.
This is why it is particularly important to clearly outline and spread the psychosocial narrative that can offer new ways of understanding of mental distress. It constitutes a conceptual resource—a tool that offers another kind of understanding that is not confined to the malfunction-perspective often emphasized within the biomedical paradigm, which has the danger of functioning as a self-fulfilling prophecy.
Mental distress, within this view, is conceptualized as a reaction to enduring an experience that overpowers the capacities of the organism or exposure to such an experience without adequate support or resources to process it. This can consequently turn into a set of challenging orientations towards the world in which trust, basic safety or the sense of ontological security are hard to access for people suffering. When distress is conceptualized in this manner it is a narrative that opens space towards its symbolic processing.
There is, however, another reason why this kind of narrative is also important. However hard and complex, symptoms are also often a direction sign. Solely focusing on numbing them down, although sometimes or necessary in order to reduce suffering, will not necessarily remove the original source of their emergence. Like in a system of connected vessels, they might reappear once the original symptom has been silenced, but the underlying cause has not been solved. This is why it is sometimes important to also listen to what they are pointing towards. As psychotherapist Branka Jakelić noted in her book, Searching for Oneself, on self-growth and psychological crisis, a crisis can actually be an “enticement towards deeper cure and a step towards oneself”.
So, for example, what is labelled as depression can also be thought of as shutting down of the organism which has either functioned too long in a situation of insecurity or scarcity and/or which does not know how to get out of the cycle of scarcity and/or not seeing options. It might be excruciating and seem like the collapse of organism that comes out of nowhere. However, if it is researched, usually subjective negative experiences are found that were not acknowledged or not listened to. Further, questioning the above mentioned link of the scarcity within the social context is also important. It is important to educate people on how to process the pain in a constructive manner, how to give oneself more options or how to find more options in scarce circumstances.
Further, it is important to understand states of anxiety as states of being caught in the tension of trying to suppress emotions and feeling them. Emotions erupting in the face of solving what seems unsolvable can result in the inability to breathe. When the human being does not have resources to process them in adequate manner, he or she will often compartmentalize emotions and when they rise this might result in shaking and trembling or a loss of breath. It is important to understand this is pointing towards something that is not attended to and it should be because it has emotional significance for the person. States of anxiety should also be examined within the frameworks of power, particularly institutional ones, or the socioeconomic circumstances people live within.
It also has to be understood that mania can be explained by the overly reactive fight-flight mechanism and stress response of the organism and how adequately addressing the perceived source of stress that one sometimes hides from oneself or not letting oneself feel feelings because of fear might be connected to its regulation. How can recognizing the winding up of the organism and attending to its well-being contribute to regulation in these initial phases of the emergence of this kind of state?
Symptoms of psychosis can be a reaction linked to distressing or traumatic events during a person’s childhood that affects the way in which person experiences things as an adult. People who are sensitive enough and have had adverse or traumatic experiences in childhood are at significant risk to develop different ways of engaging the world or reactions to stress. It is important to raise the awareness that there is a way of “making sense of voices” in some areas offered within hearing voices networks. People can also be educated on how to recognize the early onset of stressful situations that make them prone to the emergence of voices.
Then there is complex PTSD, which can be due to the lack of attunement from caregivers in the developmental phase or shock which is overwhelming for the organism that is unable to process it, resulting in a hypervigilance, problems with safe attachment or arousal regulation due to the compromising of neurobiological systems which are involved. Within this context it is necessary to teach people about re-training of their neurological mechanisms and feelings of safety and how to work with their triggers and process unprocessed emotions.
This is just a brief overview of some of the states and how they can be thought of alternatively. It is important to note the empowerment that this approach brings. The idea is not to underemphasize the challenges of mental distress, but the emphasis is also not put on the solidifying of states into an unchangeable block, as it is in the biomedical paradigm.
The emphasis is instead put on detection of challenging orientations towards the world, their disentanglement into smaller blocks which are understandable, explorable and in which there exists a possibility of working with them or their processing. The work can also consist of re-training of the organism towards new orientations. It also involves thinking of the social context and power relations.
It is important on multiple levels to put an effort into promoting and teaching this kind of alternative psychosocial aetiology and conceptual framework. It gives people conceptual tools to understand and name their experiences, so-called mentalization—the sense-making of one’s own experience. This simultaneously gives room for the processing of emotional suffering. It also provides an orientation towards meaning. If this epistemological conceptual framework and interventions following this framework could be scaled to be widely accessible, it is likely this could also mean a difference for the sustainability of the mental health system.
Namely, this kind of approach can offer a sense of agency for the person suffering. Instead of a helpless position where interventions lowering distress come only from an outside position of power (built into the very premises of the biomedical model), the psychosocial approach puts an emphasis on equality between the help-seeker and the help-provider, and thus the co-creation of the process. This brings with it a sense of agency and ownership of the process which could, it is safe to assume, result in a different kind of motivation for finding new orientations.
Thus, having this kind of conceptual tool at our disposal could mean a difference for the person encountering mental distress, but also for the mental health support system as a whole.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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