Mental distress is today often perceived as something devoid of context, as an individual medical condition or a failure instead of a human condition linked to the social context one exists in. This has great consequences for how we handle that distress. It can, for example, make it devoid of meaning, which can foster feelings of hopelessness.
How can the acknowledgment of context give distress more meaning and serve as a starting point for a wider conversation?
We are often not aware of the lenses through which we perceive the world. Often what we think influences us is based on societal expectations and “common-sense knowledge.” Sometimes this construction becomes so “solidified” that it seems like an objective, unchangeable reality. This reality then defines the way we think about something and the solutions we see as existing. The “common-sense knowledge” of mental distress is no exception to this.
The prevalent social perspective of today sees mental distress as an individual medical problem, rooted in features ascribed by birth, such as biological deficiencies. This understanding of it, which has somehow now become a “common-sense knowledge,” is fully separated from context and thus also separated from the power relations within the social system that people live in. Instead it is seen in terms of deviation from normative functioning as determined by society, and treatment is then often seen as restoration of functionality. Solutions are often looked for within the current economic and technological system, which emphasizes profit and effectiveness. This often results in “quick fixes” such as medicines becoming the only solution offered.
We are so accustomed to this way of looking at things that it is almost as if we are not aware that this is one way of thinking and not all possible ways of thinking. As sociologists Ulrich Beck and Elizabeth Gernsheim-Beck have so picturesquely proposed, the characteristic of contemporary society is to seek biographical solutions to the systemic problems. This means that in contemporary post-industrial society, where feelings of community are on decline, individuals are increasingly asked to independently construct their own lives. It is according to this way of thinking that interpretations of life-events occur. Deviations from norm are now seen without connection to economic, social, or cultural perspectives or with the importance of these perspectives undervalued.
These economic and social resources can, however, greatly constrain or open up possibilities of one’s social existence. For example, studies show that people who are born in poor socioeconomic conditions acquire a worldview which reduces the likelihood of engaging in behaviors that might help them get out of poverty. A similar logic applies to personal resources, such as coping strategies which one has been lucky enough to acquire or not to acquire in early stages of life.
There is also the current social context one lives in. Without taking all of this into account, we are ignoring the reality of human existence, which is always grounded in social context. The complexity of the human condition is reduced to a set of genes, and any deviation from the norm is, in this perspective, seen as something wrong, a pointless error. This is a very mechanistic way to look at a human being.
The data that shows that at least 10% of the world is affected by some kind of “mental, neurological and substance use disorder” and that 20% children or adolescents are suffering from some mental distress makes it clear that a change in perspective is needed. These numbers can be seen as a reflection of our sense that something is wrong with our system.
In the 21st century, we seem to have a lot of problems which we should have gotten rid of by now, given our technological and economic advancement. For example, growing economic insecurity in a global neo-liberal capitalist system, which on its path of purposeless economic growth demands more flexibility than ever. This can be linked to the increase of precarious jobs and social inequalities.
Further, disparity between those holding the power and economic resources and those lacking even basic resources is rapidly increasing. On top of all of that, the current COVID pandemic, with its lockdowns, increased rates of unemployment, and health concerns, can be linked to increased uncertainty about the future. It would be outright crazy not to see distress as something linked to these experiences, as they are concerns we live with every day.
Further, defining mental distress in individualized terms can often be problematic for the sufferer. Why? Because the definition that we impose on a certain phenomenon limits existing solutions as well as our ability to envision new ones. Individualized ways of thinking offer only solutions at the individualized level. Furthermore, the way in which we think about things can become a “self-fulfilling prophecy.” In other words, viewing something as a failure can result in a subjective feeling of failure. There are other more constructive ways of looking at mental distress, which include the context within which it is happening.
Let us remind ourselves what those are.
According to the existential traditions of philosophy and psychotherapy, the most important thing for a human being in his or her life is meaning. Meaning is seen as basic connectedness or openness to the world around us and as the primary motivation for living. It is also what helps human beings to endure suffering.
Furthermore, existentialist approaches put an emphasis on the meaning a certain event has for a person, not the event itself. Consequently, mental distress is often linked to the loss of meaning in one’s life or to traumatic events to which one hasn’t been able to ascribe meaning. It is also linked to situations in which one’s capacities have been so overwhelmed that one has lost the ability to meaningfully connect with the environment or feel any dignity. This was very well known to Viktor Frankl, an Austrian psychiatrist who survived Auschwitz and established logotherapy, one of the branches of existential therapy, based on his own experience.
So let us try to apply this to the lived experience of today’s world in order to understand how context can make a difference in understanding mental distress. For example, let us take a fairly common situation: precarious or insecure employment that is not meaningful. Maybe the person in this position feels disconnected from meaning, which is, according to existentialists, the primary motivation for living. But there is still rent to be paid, family to be fed, and perhaps in an increasingly insecure and competitive market, lack of other well paid jobs.
The person in our story suppresses their feelings of frustration with their circumstances and continues to work. However, maybe they feel so disconnected from meaning that after some time they feel a lack of energy or will to get up and go to work. Everything starts to seem meaningless. Maybe the person goes to see the therapist then and is – guess what? – diagnosed with depression. However, did the therapist look at the context of the person’s distress?
What is seen as irrational when viewed independently from context can often be seen as rational when social context is included. Instead of resorting to individualized solutions as the only options—as much as it might be inconvenient for us—it can be useful to look at distress from this point of view: Where has the loss of meaning occurred and why? What are the obstacles to experiencing meaning? What blocks the exercise of free will in this situation?
These are all questions asked by an existentialist approach, which can completely alter the practical approach to someone’s life. When looked at from this position, the situation described above suddenly appears totally differently – as a retreat from a situation which lacks subjective meaning. From this way of looking, the horizon of potential solutions opens. Are there any areas where the exercise of free will could be established? Which areas of meaning can there be found?
Another contextual approach is the psychoanalytic one, today often cast aside because it seems to last too long and (thus) it is costly. However, this is again the system seeking quick solutions. To a psychoanalyst, symptoms of mental distress often function as the messengers of meaning. They appear when they need to be heard or seen and cannot be otherwise transmitted. The subconscious expresses what is not expressed in other ways.
Thus, if the human being is frustrated long enough, but does not know how to express it, or feels unable to express it, that expression is found through the symptoms. It is through the invitation of these expressions to come out, whether through the “talking cure” or some other form of bodily technique, that this distress diminishes.
Newer behavioral approaches such as DBT also partly implement this contextual approach, although coming from a completely different behavioral tradition. However, they still interpret mental distress somewhat contextually and seek solutions within these parameters. Mental distress is here seen as a result of one’s prolonged exposure to contexts within which certain ineffective coping styles, behaviors, and ways of thinking are learned. This results in a lack of resources such as skills or coping strategies for functioning in certain situations.
The solution is to bring context-specific knowledge to the person in the forms of skills and strategies of behavior. The strength of this approach, which is often overlooked by its critics, is that it breaks distress into smaller parts, which makes it seem solvable. This is one example of how the horizon of solutions shifts when the distress is framed differently.
When one shifts towards the context and the function of the symptom in that context, the horizon of potential new questions about the distress emerges – What does it contextually express that fails to be expressed otherwise? How does it function in the context of the wider social network? And what does it do for a person? Does this maybe, within a certain context specific situation of someone’s life, offer an alternative way of taking care of oneself in circumstances which have become unbearable?
In the above example of the person feeling disconnected from meaning, maybe the person did not want to get out of bed to a job he or she hates and in which no meaning is found. Is there a way that not wanting to get out of bed is actually a way of taking care of oneself? A resistance to the soul-crushing labor in a relentless and purpose-lacking system of neo-liberal capitalism?
This way of thinking also opens up new possibilities of working with the situation, such as bringing to awareness alternatives for how a person could take care of herself or himself. Maybe this means exploring which options of meaning-making are possible within this situation. Or maybe just exploring how to support the person in getting out of that context. Or maybe, if this is not possible, to see how to find meaning in changing that context. And one option might be to think about how we can employ community resources to help people navigate this search.
Perspectives emphasizing the importance of context were popular in the 1960s. In the works of Ronald Laing and Gregory Bateson, the wheel of psychotherapy was steered towards looking at human beings within their environment. Mental distress was understood through an ecological way of thinking, not an individualized one.
Within an ecological model, any human issue can be dealt with by looking at the relationships in which it is embedded. This way of thinking eventually led to the development of therapies such as family or systemic therapy. However, the logic underlying this approach got obscured by the individualized logic which expanded in the second half of the 20th century. Individualized logic puts an emphasis on the narrative in which medicines and genes prevail and social context is underemphasized, if not forgotten.
As a global society, we are starting to remember and re-discover contextual thinking, but very slowly. The practice of open dialogue developed and used in Western Lapland in Finland is one example of this. It is the continuation of traditions of family therapy. Since its formation in the 1980s, news of its existence began spreading around the world and in recent years there are attempts at its implementation and accompanying research in the UK, USA, Italy, and some other countries.
Open dialogue sees symptoms or problem behaviors not as irrational individual failures but as meaning-making within a wider system of communication – as being “natural” responses to a difficult situation. The solution is then sought in a form of dialogical practice with the person in distress and his or her communication network. The aim is to find words for the experiences embodied in the symptoms and thus to give voice to them within the wider system.
Of course, approaches that put an emphasis on the context of distress are bound to have some difficulties when they try to be implemented within the culture where individualized thinking is “common-sense.” We are so used to thinking of things in terms of the individual rather than the contextual that it requires great effort even to include this way of thinking within our everyday communication, let alone to implement it into the practices of our society. However, it is important that we remind ourselves that contextual approaches exist and that we foster wider conversation about their use.
Namely, they invite hope where there were feelings of hopelessness. I would even dare to suggest that they give personal suffering an existential meaning. In Ronald Laing’s terms, it is seen as a “normal reaction to abnormal circumstances.” And in line with this, they invite a desperately needed conversation about a struggle to exist in the system of competition and disconnection in which we live today.
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.