Treat Systems, Not Symptoms: Defending the Sanity of the Oppressed

From 2013 to 2023, the CDC estimates that the prevalence of depressive symptoms among high school students has gone up from 30% to 40%.¹ Persistent feelings of sadness or hopelessness have also been on the rise during this period, with female and LGBTQ+ adolescents being particularly affected. ¹ Suicidal thoughts and behaviors have also been rising during this period, with 20% LGBTQ+ adolescents, 13% of female adolescents, 10% of Black, and 11% of Hispanic adolescents endorsing these thoughts and behaviors. ¹ This burden in mental health systems is paralleled globally, and yet, the WHO estimates that 35 to 50% of individuals in high income countries like the U.S. do not receive mental health care.² There is a significant treatment gap coupled with global underfunding in mental health care. Most of the healthcare funding is occurring through centralized and private systems, despite recognition that public and preventive services are more cost-effective and equitable.³

The growing burden of mental disorders begs the question: What factors can be targeted for intervention to reduce said burden? In meta-analytic work, trauma experiences are one of the most salient transdiagnostic risk factors for psychopathology.⁴ Adversity more broadly, including poverty and the constellations of other factors that co-occur with each, have also been consistently linked in existing evidence with psychopathology.⁵ Research consistently finds that experiences of oppression (e.g., adversity, trauma, poverty, stress) confer risk for psychopathology. Importantly, much of the literature also finds cumulative effects whereby greater exposure to adversity is associated with an increased likelihood of developing psychopathology. This means that as the frequency, duration, or severity of adverse experiences increases, so does the risk of and severity of psychopathology.

Violence is perhaps the most visible form of oppression, but other faces of oppression (e.g., exploitation, marginalization, powerlessness, and cultural imperialism)⁶ also contribute to accumulated experiences of adversity that produce psychopathology. It should also be noted that experiences of oppression compound intersectionally increasing risk and severity of psychopathology for certain individuals. For instance, having multiple minoritized identities (racial, sexual, gender identity) can lead to multiple forms of oppression and heightened risk for psychopathology emergence and severity.^7,8 Unfortunately, it is these very groups that also have the least and most delayed access to mental health services following symptom onset.⁹

The Psychiatrization of Oppression

Psychopathology, as we see it in the psychiatric and psychological fields in the U.S. (and much of the Western world) can be defined as a “disease” (pathos) of the “mind” (psyche). This conceptualization sets the cause and solution to psychopathology (mental illness) on the individual. From this psychiatrized biomedical lens, illness lies within the individual, and it is shifts to that individual’s psyche (i.e., through cognitive restructuring, individual coping, or medication) that produce recovery from illness. But this framework ignores that what we codify as psychopathology may be a rather normative and sane response to adversity, and that the factors influencing those responses are systemically/externally (rather than individually/internally) caused. Indeed, emerging evidence suggests that it is these macro-level structural determinants, more in alignment with biopsychosocial frameworks, that are causally linked to the development of mental illness.¹⁰

And this further begs the questions: If psychopathology is a normative response to oppression, why have we engaged in a psychiatrization of oppression? In other words, why have the poor and oppressed been dubbed psychologically diseased? The provision of power and economic growth to some, inevitably comes at the expense of the exploitation, disability, distress, suffering, and disenfranchisement of others. This oppressed group, and the responses that are often associated with psychopathology, pose a threat to existing social orders and structures. The pathologizing of mental distress creates an opportunity for more economic growth and benefit to a select few (e.g., through profitable institutions like psychiatry, hospitals, pharmaceutical companies) and as an added benefit dampens the psychological responses that could subvert oppressive systems (e.g., economic exploitation or other forms of injustice).¹¹ This is not to say that psychotherapy and medication are unnecessary or unhelpful. However, our focus on individual intervention while neglecting systemic drivers of mental distress makes these treatments palliative at best and complicit in sustaining the system of oppression at worst.

Psychiatrization, institutionalization, and even incarceration can function as profitable necessary illusions (a term borrowed from Noam Chomsky) that occlude root causes of suffering: the prioritization of power, profit, and growth for a select group. As psychiatrists and psychologists, we indirectly become complicit in cognitively restructuring, encouraging acceptance, and medicating. The preservation of suffering itself outside of these institutions is also profitable. When individuals experience insecurity in basic needs (e.g., physiological needs like adequate nutrition, water, safety, warmth, sleep; security needs like safety, employment, financial assets; social needs like family, friendship, intimacy, belonging; esteem needs like self-worth, accomplishment, confidence; and self-actualization needs) they become susceptible to fabricated needs and rampant overconsumption to fill those voids which further drives economic profit.

Call for a Paradigm Shift

On the road towards economic growth and profit for a few individuals and nations, humanity has not been the only collateral damage. To sustain this privilege, power, and growth, there has been a pillaging of nature on a global scale, with vulnerable and oppressed communities most affected. For the profit of select individuals, nations, and corporations, we are facing large-scale environmental destruction and intensified social inequality. There is growing evidence of deforestation, depletion of rare earth elements, displacement of peoples and seizure of communal lands, toxic waste disposal in targeted regions (e.g., Southeast Asia, Africa, and the Caribbean), increasing pollution, and a corresponding growing burden of disease in affected communities.

If we hope to reduce the burden of psychopathology, the evidence is pointing us towards restoring ecological balance and justice. We cannot continue to prioritize economic productivity at all costs, because the costs will be humanity and our planet. The oppressed are not insane, the definition of mental illness cannot continue to be expanded until it encapsulates most of the modern world. Pathology by its very nature is a deviation from the norm. Insanity is not a psychological term; it is a legal term invoked as a part of an insanity defense. It establishes that an individual should not be held criminally responsible for their actions, because they lacked the capacity for rational intent or moral reasoning. So, who is insane by this definition? One could argue that it is those with privilege and power that have lost sight of moral reasoning, equity, justice, and the rational thought that accompanies it. Perhaps it is the oppressors that are insane.

References

1. Centers for Disease Control and Prevention (CDC). (2023). Adolescent and school health: Mental health. U.S. Department of Health and Human Services. https://www.cdc.gov/healthyyouth/mental-health/index.htm
2. World Health Organization (WHO). (2022, June 17). WHO highlights urgent need to transform mental health and mental health care. https://www.who.int/news/item/17-06-2022-who-highlights-urgent-need-to-transform-mental-health-and-mental-health-care
3. Jomo Kwame Sundaram, “Finance healthcare, not insurance premia”, Inter Press Service, 26 June 2024.
4. Hogg, B., Gardoki-Souto, I., Valiente-Gómez, A., Rosa, A. R., Fortea, L., Radua, J., … & Moreno-Alcázar, A. (2023). Psychological trauma as a transdiagnostic risk factor for mental disorder: an umbrella meta-analysis. European Archives of Psychiatry and Clinical Neuroscience, 273(2), 397-410.
5. Lee, A. H., Kitagawa, Y., Mirhashem, R., Rodriguez, M., Hilerio, R., & Bernard, K. (2024). Do dimensions of childhood adversity differ in their direct associations with youth psychopathology? A meta-analysis. Development and Psychopathology, 1-31.
6. Young, I. M. (2008). Five faces of oppression. In Geographic thought(pp. 55-71). Routledge.
7. Rankin S, Blumenfeld WJ, Weber GN, Frazer S. State of higher education for LGBT people. Campus Pride; 2010.
8. Williams, M., Osman, M., & Hyon, C. (2023). Understanding the psychological impact of oppression using the trauma symptoms of discrimination scale. Chronic Stress, 7, 24705470221149511.
9. Murali, V., & Oyebode, F. (2004). Poverty, social inequality and mental health. Advances in psychiatric treatment, 10(3), 216-224.
10. McAllister, A., Fritzell, S., Almroth, M., Harber-Aschan, L., Larsson, S., & Burström, B. (2018). How do macro-level structural determinants affect inequalities in mental health?–a systematic review of the literature. International Journal for Equity in Health, 17, 1-14.
11. Monbiot, G. (2017). Out of the wreckage: A new politics for an age of crisis. Verso Books.
12. Logan, J., & Karter, J. M. (2022). Psychiatrization of resistance: the co-option of consumer, survivor, and ex-patient movements in the global south. Frontiers in Sociology, 7, 784390.