Throughout human history, it has been common for certain behaviors to be considered normal and others abnormal. And yet, such distinctions have not always been made on the basis of medical knowledge, as they often are today. A new research paper, published in the Annual Review of Clinical Psychology, traces some of the ways that explanations for mental distress have changed over time, setting a historical context to think about how biomedical explanations for behaviors have become so popular.
Specifically, the article examines how biomedical characterizations of mental disorders—e.g., thinking about distress as ‘mental illness’—relate to beliefs and attitudes about those who have received a diagnosis. According to the two authors, led by Matthew Lebowitz from the Center for Research on Ethical, Legal, and Social Implications of Psychiatric, Neurologic, and Behavioral Genetics at Columbia University Medical Center, a biomedical explanation of mental disorders can be understood as:
“An account of the nature of mental disorders that casts them as medical diseases with biological roots, such as in genes or neurobiology,” adding that such explanations “are often seen as being in competition with other explanatory frameworks, such as those that conceptualize psychiatric symptoms as reactions to environmental factors or as traceable to early childhood experience.”
The authors situate their study within a growing body of literature that suggests that mental health clinicians are more likely to assume psychological distress is caused by biological factors than other possible explanations. Their paper argues that privileging biology over other causes has significant consequences for clinical decision-making practices, while also affecting how diagnosed individuals understand themselves through their diagnoses.
This comes at a time when criticism of biomedical approaches to mental health care is steadily mounting, with even members of the United Nations expressing concerns. Likewise, this publication comes on the heels of recent research suggesting biomedical explanations for psychological distress can stigmatize individuals, especially young people, who elect to use mental health services.
Lebowitz and Applebaum focus primarily on four different areas of research about how mental distress and abnormal behaviors tend to be understood: 1) a history of changing explanations for psychological distress, 2) theoretical and conceptual issues underlying biomedical explanations, 3) empirical evidence about the effects of biomedical explanations, and 4) developing strategies for countering the negative social consequences of the now dominant biomedical paradigm.
As is common in historical accounts of Western psychiatry, the authors trace the current biomedical model to the ancient Greek physician, Hippocrates, and his theory of humors. His framework, they suggest, offered a set of natural explanations for deviant thoughts and behaviors in lieu of the supernatural ones that were most popular up until that point.
With the Renaissance period of European history, they explain, came a revitalization of supernatural explanations, whereby “people exhibiting mental or behavioral disturbances were once again viewed as under the influence of demons or were even executed as practitioners of witchcraft.”
Later on, around the turn of the nineteenth century, trends reversed course yet again as “other areas of medicine were being revolutionized by biological discoveries, and psychiatry was suffering from diminished standing as a profession because of its failure to make similar advances.”
Going further, they outline how:
“[a]long with frustration over the lack of efficacy of existing treatments, this may have helped set the stage for the field’s twentieth-century embrace of psychobiological treatments that are now seen as barbaric, such as prefrontal lobotomies, the removal of healthy ovaries to quell hysteria, and the use of insulin-shock therapy as a treatment for schizophrenia.”
Despite being no longer deemed appropriate forms of treatment, such practices remain important historical footnotes insofar as they served to legitimize the profession of psychiatry in the eyes of the broader public. This trend toward the biomedicalization of psychological life continued across the twentieth century, hitting a high point with the emergence of psychopharmaceutical interventions in psychiatry.
Citing “data from nationally representative surveys in the United States,” for instance, the authors note that during “1998 most patients undergoing mental health treatment received psychotherapy, either alone or in combination with medication; however, by 2007 the majority received only medication.”
Today, the use of pharmaceuticals as interventions for psychological distress has been challenged increasingly by general practitioners, clinicians, and clinical researchers. Research approaches like Research Domain Criteria (RDoC), however, indicate renewed attempts to ground explanations for deviant behaviors in biology and medicine.
Drawing on a large body of research, the authors underscore how the biomedical model of mental health care can sometimes increase stigma for diagnosed individuals in the following four ways: 1) marking a clear dividing line between those with a diagnosis and without one, 2) stereotyping those with a diagnosis as inherently more dangerous, 3) positioning those with a diagnosis as part of a certain ‘out-group,’ and 4) leading to discrimination and socioeconomic disadvantage for those so diagnosed.
For Lebowitz and Applebaum, underscoring how these associations are made is important because there is a long history of mental health professionals assuming naively that biomedical explanations always decrease stigma for those diagnosed. Such a belief is summarized by the following quote from Eric Kandel, a psychiatrist who was part of anti-stigma efforts organized by the Brain and Behavior Research Foundation in 2013: “Schizophrenia is a disease like pneumonia. Seeing it as a brain disorder de-stigmatizes it immediately.”
Attempts to link psychosocial distress to biological causes are often pursued under the assumption that this will help remove responsibility from the diagnosed individual similarly as it would for other physical diseases. For the authors, this is closely connected to the presumption of categorical essentialism, defined as the“belief that underlying essences (e.g., genes, neurobiology) define categories (e.g., social groups) and deterministically cause surface-level similarities among category members.”
According to Lebowitz and Applebaum, however, a growing number of studies suggest a much more complicated relationship between essentialism, biomedical explanations, and social stigma. As they describe, not only do “biomedical explanations of mental disorders show a small but significant association with increased perceptions of dangerousness,” they likewise tend to “evoke essentialist biases and lead to the assumption that mental disorders are relatively immutable and unlikely to remit.”
These conceptual links can have consequences well beyond how the general public perceives diagnosed individuals. They also affect how clinicians interact with such individuals during treatment.
In one study overviewed by the authors, for instance:
“When clinicians were given a biomedical explanation of a patient’s symptoms, the clinicians consistently rated psychotherapy to be less effective, and with one exception (schizophrenia, for which ratings of the effectiveness of medication were about equally high regardless of the explanation provided), they rated medication to be more effective.”
In other words, even clinicians were more likely to assume that pharmaceutical intervention is the best option when biomedical explanations are the only ones offered for observed symptoms. This has clear implications for thinking through why particular treatments become more popular than others in general.
While clinician’s beliefs about diagnostic categories are undoubtedly important, the authors affirm that “people’s attitudes and beliefs about their own disorders are likely the most clinically meaningful of all.” And yet, they suggest research linking self-stigma to biomedical explanations appears inconsistent, at best, depending mainly on how each person internalizes such explanations.
The authors remain clear on the fact that beliefs in genetic predispositions for psychiatric diagnoses, overarching essentialism, and self-blame reinforce each other in ways that harm diagnosed individuals. They also expressed optimism that “[e]ducation about the nondeterministic role of biological factors in the etiology of mental disorders appears to mitigate some of the negative effects of biomedical explanations.”
Likewise, while they concede that “economic considerations and other factors clearly play a part in the selection of treatments,” they stress the importance of understanding “whether the recent ascendancy of biomedical explanations for mental disorders might be encouraging the use of pharmacotherapy and the rejection of psychotherapy.”
This last point, however, can be read as a notable limitation of the perspective taken by the authors of this article. Many researchers today would consider it impossible to understand how psychotherapy and psychiatry operate socially apart from capitalism and neoliberal policy. For instance, contemporary mental health markets in America unavoidably cater to insurance companies and pharmaceutical industries, which unavoidably structure how services are provided.
With mental health treatments increasingly shifting online, moreover, the relationship between mental health care and capitalism is likely to be reinvented in more complex forms—leading to new markets for clinical data and advertising for mental health services.
Lebowitz and Applebaum’s hesitation in rejecting biomedical explanations wholesale appears to be based on their commitment “to the promise of biomedical advances for aiding the field’s understanding of psychopathology.”
This reveals an overarching belief on their part that biomedical approaches in psychology and psychiatry can be useful for reasons other than legitimizing psychopharmaceutical treatment. Regardless of their position on this particular issue, however, their article underscores important conceptual links between how psychological distress is framed linguistically and how those who receive services are treated socially.
Lebowitz, M. S., & Appelbaum, P. S. (2019). Biomedical Explanations of Psychopathology and Their Implications for Attitudes and Beliefs About Mental Disorders. Annual Review of Clinical Psychology, 15(1), 555–577. (Link)