Precision medicine promises a new era of highly targeted treatments akin to precision strikes in warfare, aimed at ‘combating’ disease at the most individual, localised level. Hailed as the future of mental health care, it conjures images of medical interventions as carefully planned and executed military operations, striking with lethal accuracy at the heart of mental suffering while minimising collateral damage.
Yet, beneath this veneer of exactitude, precision mental health harbors myths and inherent dangers that undermine some of its promise. One of the most prevalent of these is that mental health is genetically determined and can be largely understood and treated by identifying specific genetic markers. Another is its emphasis on pharmacogenomics (how genes affect one’s response to drugs), which emphasises medication as the primary means of intervention.
In areas like cancer and certain chronic diseases, where treatments and medications have been developed to target specific genetic mutations, precision medicine has shown promise. As Sally Satel points out, the precision model has been effective in treating cystic fibrosis because it located the single dominant gene mutation that drives the pathology and developed a medicative response, disarming the harmful product of that mutation. But what about the use of precision ‘targeting’ in other fields like psychiatry and psychology, where there is little evidence of causal genetic mutations to take aim at? How effective can a personalised approach to mental health be in a context wrought with widespread systemic deficiencies in access to basic care?
The promise of precision medicine is that it can safely mark and neutralise the underlying causes of mental suffering, giving diagnostic clarity and accuracy in a way that more generalised medicine cannot. What this metaphor of ‘combatting’ mental illness through precision strikes does is to reduce mental health to a series of targeted attacks on specific disorders. Sickness is thus understood not in psychological, social, or environmental terms, but in terms of biological markers and data points, mainly genetic predispositions and neurobiological characteristics, which are then taken to be the underlying causes of a person’s mental suffering.
Mental health is not a battlefield
The language used to describe suffering carries significant weight. For instance, the practice of characterising a patient as a ‘fighter’ battling a disease, or viewing an illness as an ‘enemy’, is deeply ingrained. This connection between mental health and the use of battlefield and warfare metaphors has meaningful implications for how people perceive and cope with mental health conditions, influencing how care goals are set and treatment plans are designed.
By blurring the lines between the literal and figurative, battlefield metaphors do more than explain similarities, they also construct them. As Dhruv Khullar observes, terms like ‘fighting’ or ‘battling’ tend to create a perception of health as adversarial, setting a confrontational tone. This framing can affect both the patient and the public’s understanding of suffering, often oversimplifying the complex nature of mental health conditions. As Khullar elaborates, this suggests a scenario where suffering can only have two perceived outcomes: victory or defeat.
Such a binary outlook adds further pressure to those suffering, making them feel as if they must constantly wage war against their conditions. What’s more, the notion of fighting a health condition implies that success depends on individual effort and resources, which can marginalise those with limited access to healthcare resources, including the uninsured or underinsured. New diagnoses or changes in regimens become retreats or advances, relapses and institutionalisation are battles lost, costly bills pilling up as the war rages on.
What these militarised metaphors do is amplify the threat in a certain way, superimposing a conflict narrative over a person’s lived experience of mental health. Illness is the enemy. Drugs are weapons on the battlefield of the body. Sufferers must soldier on, lest they be perceived as ‘not fighting hard enough’, which can further intensify stress and isolation. According to Peter Hodgkin, the operational logics of such ‘medicine is war’ metaphors are primarily centered around reinforcing the notion that ‘taking action’ is a virtue, viewing patients as passive, with doctors, diseases, and medical and technical ‘weapons’ as the main protagonists.
The idea of being in a constant battle is exhausting because it implies that health is a matter of personal effort while also relegating sufferers to a passive role in their mental health care. Feelings of failure or weakness become issues for anyone who does not experience their mental health in a narrow sense of triumph over the enemy within. The prevailing atmosphere of guilt, inadequacy, and self-blame that arises from this ‘war on mental health’ approach can exacerbate the challenges faced by those dealing with mental health conditions.
Genetic determinism and biological fatalism
The allure of precision medicine lies in its promise to pinpoint the genetic causes of mental conditions and tailor treatments accordingly. The quest for identifying genetic biomarkers in schizophrenia exemplifies the pitfalls and limits of this approach. This search, deeply rooted in 19th century concepts of eugenics, assumes a simplistic causation model where genetics are seen as the primary determinant of complex mental health conditions and outcomes. As a result, it not only overlooks the nuanced interplay of environmental and social factors but also imposes stigmatising narratives around ‘deviant’ genes and bodies.
In a 2016 study published in Nature, researchers proposed some potential biological origins of schizophrenia, receiving widespread coverage with headlines indicating significant breakthroughs in understanding the condition. However, as Noel Hunter points out, the study’s actual impact and findings were far less profound than suggested by the media. Rather than a decisive step forward in the precision targeting of specific ‘irregular’ genes, the actual content of the study highlighted the need for a more nuanced, comprehensive approach to understanding and treating the complex, multi-factorial nature of mental health conditions like schizophrenia.
By framing studies like this as breakthroughs without adequately discussing its limitations or the complexity of schizophrenia, the media perpetuates a misleading narrative that mirrors the genetic determinism of precision medicine in mental health diagnostics and treatment. This reductionist framing is further intensified by current trends in pharmacogenomics, which presume that a person’s response to psychiatric medication can be finely tuned based on their genetic makeup. Exposing patients to a range of side effects, some of which can be severe and long-lasting, this approach often leads to a trial-and-error method of prescribing high-dose medications or a cocktail of drugs, hoping to hit that elusive genetic target.
Describing drugs as a ‘weapons’ or ‘magic bullets’ encourages more aggressive treatment strategies. It also normalises an entirely data-driven healthcare landscape, where the complexity of mental health is reduced to a series of inputs and outputs—cause-and-effect relationships determined largely by genetics. Bolstered by the aggressive marketing of pharmaceuticals as precise tools targeting specific genetic markers, pharmacogenomics risks fuelling a cycle of dependency just as debilitating as the mental health conditions they aim to treat.
Moreover, the emphasis on genetic determinism in precision mental health perpetuates a sort of biological fatalism. Sufferers and their families are left with the impression that mental health conditions are predetermined and unchangeable, locked in one’s genetic code. This narrative diminishes the role of social support systems, and reifies societal misconceptions about ‘mental deviance’, further alienating those who suffer from these conditions.
Mental health as a garden
Couched in a technical, deterministic, confrontational mode of thinking about mental health that implies a battle against an internal enemy, precision medicine neglects the complex reality of mental health conditions, which are deeply embedded in personal histories, socio-cultural contexts, and lived experiences. This neglect is symptomatic of the market-driven nature of precision mental health care.
As I highlight in a previous piece on ‘high-functioning anxiety’, mental health diagnostics and treatment in a capitalist system operate within a framework that prioritizes efficiency, competition, and profit. Combat metaphors like ‘fighting illness’ align well with this ethos because they portray health as a battle to be won, emphasising individual responsibility and resilience. At the same time, the heavy reliance on data-driven solutions and pharmacological interventions in precision medicine renders sufferers as passive recipients of care dependent on medical technologies and drugs to wage their internal war.
James Tabery’s work in Tyranny of the Gene uses a historical perspective to shed light on how we got into this paradox. By examining the competition between genetic and environmental research at the National Institutes of Health since the late 1990s, Tabery highlights how precision care’s fundamental approach can be misleading and distracts from more impactful research into how factors such as racism and socio-economic conditions affect mental health. In doing so, it often diverts resources away from basic care to access, broadening and legitimating health disparities framed across a binary of winning or losing.
Ultimately, any metaphor—combat or otherwise—is not inherently good or bad. They serve as a means through which to express and understand suffering within a given social context. If the metaphor of precision imposes damaging language and practices on patients and practitioners, then there’s a pressing need to reframe and reimagine our understanding of mental health care beyond the narrow confines of this battlefield.
Rather than a war to be fought within individuals, we should envision mental health as a garden to be carefully nurtured. In this ‘garden’ model, mental health is seen as a collective, dynamic cultivation process. Here, environmental influences, social connections, and personal factors interact synergistically, much like the roots, soil, and water in a thriving garden. The emphasis shifts from targeting isolated genes to nurturing the complete well-being of individuals within their environments.
This holistic approach recognizes the intricate interplay of elements that contribute to mental wellness and underscores the importance of comprehensive, preventative care. Such a model requires substantial investment in community-based mental health initiatives, bolstering social support networks, and tackling systemic issues such as poverty, inequality, and social injustice. It also means empowering individual sufferers to play a more engaged, participatory role as active gardeners of their mental landscape.
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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