‘Mental illness’ isn’t all about brain chemistry: it’s about life

There are many pieces to the mental health puzzle: and it isn’t all about the brain. stephenphampshire

Do you believe ‘mental illness’ is all about brain chemistry? It wouldn’t be surprising if you did, because this is the message we regularly receive about various forms of troublesome feelings, thoughts and behaviour.

The publication of the latest Diagnostic and Statistical Manual (DSM-5) reinforced this picture. David Kupfer, chair of the manual’s taskforce, declared:

In the future, we hope to be able to identify disorders using biological and genetic markers that provide precise diagnoses that can be delivered with complete reliability and validity.

The fact the US National Institute of Mental Health (NIMH) recently announced that it would be steering research away from DSM categories doesn’t change the overall picture. It has stated that “mental disorders are biological disorders involving brain circuits”.

What may be surprising is how limited the evidence for this assumption is. Kupfer also said that the promise of the science of mental disorders was disappointingly distant. “We’ve been telling patients for several decades that we are waiting for biomarkers,” he said. “We’re still waiting.” And the NIMH admitted that it could not design a new diagnostic system based on biomarkers because it lacked the data.

Does this mean we’ve made no progress in understanding mental and emotional problems? Far from it. Researchers have produced a great deal of evidence that what we think of as mental disorders are strongly, consistently and meaningfully related to our life circumstances, especially loss and bereavement, ill-health, loneliness, child abuse, domestic violence, bullying, unemployment, poverty, discrimination and family conflict. This is true even for the most serious problems such as psychosis.

Why do we hear more about the promise of brain research than about the reality of what research tells us about how people’s lives affect mental health? Partly because brain research seems to offer a simple, good news solution to complex and troubling problems. It flatters our belief in the power of technology while seeming to avoid difficult questions of blame and responsibility.

But it also silences us, so its limitations remain hidden. Which of us knows the important questions to ask about genetic linkage or brain imaging research? And there’s a great deal of money at stake - presenting mental distress as illness suggests drugs as a treatment. By contrast, social and psychological research can make us feel helpless and is unwelcome to governments whose policies are implicated. This has also led to accusations of “blaming families”, which can make researchers uncomfortable about discussing their findings.

This emphasis on brains rather than lives matters because it creates a kind of institutionalised ignorance about how our social and personal contexts relate to how we feel, think and act. Psychologist David Smail has described how people’s distress is compounded when they can’t understand how it relates to what’s happening in their lives. John Read and colleagues have shown that focusing on supposed brain malfunction can increase stigma. It can also limit thinking about intervention and prevention.

Perhaps this is too pessimistic. Perhaps the promise of brain research will be fulfilled and we will soon understand the fundamental causes of mental suffering.

But it doesn’t work like that. Take just two examples. Hearing voices is often seen as a symptom of schizophrenia. But it’s quite a common experience, related to bereavement, prolonged solitude, and personal crises and also to intense religious experiences. Most voice hearers never seek help and some find the voices positive, offering comfort and guidance. But voice hearing is also related to child sexual and physical abuse, when voices may be more distressing, negative and hostile. Research suggests that the content of voices and people’s reaction to them can tell us about their relationships with others, for example about feelings of powerlessness. Certainly, the content of voices often reflects people’s actual experiences.

Similarly, in research for her book, Women and depression: recovery and resistance, psychologist Michelle Lafrance found that many women’s feelings of depression were inseparable from their struggles to be “a good woman”, focused on others, while their recovery was inseparable from their eventual rejection of idealised notions of femininity.

None of this is revealed by people’s biology or by a diagnostic label, yet all of it is vital to understanding distress and getting appropriate help.

The British Psychological Society’s Division of Clinical Psychology has issued a statement calling for a paradigm shift in the way we think about distress, away from the notion of mental distress as similar to physical illness. This doesn’t mean ignoring biology. We are, after all, social and biological creatures.

It does mean not assuming that biological research can provide fundamental answers to mental suffering. Certainly, it seems time to refocus our attention to the abundant evidence that mental and emotional problems and their solutions are inextricably linked with the conditions of our lives.