Year : 2019 | Volume
: 1 | Issue : 1 | Page : 25--26
The Importance of the Social in Psychiatry
Thomas K J Craig
Emeritus Professor of Social Psychiatry, King's College London, Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London SE5 8AF, UK
Prof. Thomas K J Craig
King's College London, Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London SE5 8AF
|How to cite this article:|
Craig TK. The Importance of the Social in Psychiatry.World Soc Psychiatry 2019;1:25-26
|How to cite this URL:|
Craig TK. The Importance of the Social in Psychiatry. World Soc Psychiatry [serial online] 2019 [cited 2022 Oct 1 ];1:25-26
Available from: https://www.worldsocpsychiatry.org/text.asp?2019/1/1/25/267963
Di Nicola sets out a compelling case for the revitalization of social psychiatry in the 21st century offering psychiatry “….greater coherence through an integration of the biomedical model with the larger context of the social determinants of health and the relational aspects of all human interactions.” In this short commentary, while agreeing with this biopsychosocial perspective, I argue that it is the study of social data that has made the most significant contribution to the understanding of mental illness; but, paradoxically, it has been less exploited than these insights would suggest.
The Diagnostic Challenge: Discrete Category or a Continuum Response
As a branch of medicine, psychiatry has long been committed to the notion that a careful definition of what constitutes a pathological condition is an essential first step in the search for mechanisms. However, evidence that categorical reification has really helped the search is hard to come by. It is increasingly clear that the phenomena classified as symptoms of disorder exist on a continuum, shading off into everyday experiences in the general population, so that many psychiatric conditions are based on a somewhat arbitrary threshold above which an experience is considered pathological. The case of depression is an interesting example. Constituent symptoms exist on a continuum of correlated axes from mild to severe, fleeting to enduring, and with varying impact on occupational and social functioning. When George Brown and Tirril Harris reported findings of their studies of depression in women in the general population, there was tremendous pushback from some psychiatrists who held that the depression they saw in hospital clinics was qualitatively different: not just more severe but a more “biological” subtype for which life stress was at best a nonspecific trigger. However, as research moved on, it became clear that stressful life events play a causal role not only in community “cases” but also in hospitalized patients with melancholia. Furthermore, the relevant events were not only just losses such as bereavement but also those that involved socially excluding experiences of shame and humiliation.
Social Causes of Biological Dysfunction
The tired debate about “reactive” and “endogenous” forms of depression took place quite a long time ago, and the findings of Brown and Harris seem far less surprising today. What remains is more nuanced, and attempts to account for the fact that only some of those who experience one of these life events go on to develop depression, thus implying some individual vulnerability. A key candidate is maltreatment in childhood that has a strong association with adult mental disorders. Such early adversity has an impact on brain development affecting networks and circuits involved in appraising threat and regulating emotions. Structural brain changes include volume reductions in the corpus callosum, hippocampus, and prefrontal cortex (PFC) and altered functional activity in the amygdala, PFC, and the striatum, areas that are involved in processes important for social interaction including how individuals understand and respond to the social environment. The involvement of the striatum is of interest in the light of the evidence for dopamine dysfunction in schizophrenia. Increased striatal dopamine is seen following maternal separation in animals, and this increase is further maintained if the animal is returned in a position subordinate to other members of its social group. In humans, poor-quality maternal care in childhood is associated with higher dopamine release in the presence of a social stressor, such data providing intriguing suggestions of how early trauma may lead to later psychopathology. Unfortunately, although the data are tantalizing, the link of these changes to later disorder is far from robust. The changes are not always seen and even when present also appear in resilient maltreated people who do not have any psychopathology. Reviewing this literature, Teicher et al. suggest that some of the changes may even be adaptations that facilitate resilience and survival.
While the biological pathways to adult disorder remain puzzling, social and psychological pathways are more consistent, showing associations of early abuse with difficulties in later social relationships including early sexual pairing with multiple partners, atypical adult attachment styles, and turbulent personal relationships that are often the source of the socially humiliating experiences that immediately precede the onset of major depression.,
The Relevance of Social Therapy Keeps Getting Lost
Perhaps the biggest contribution of social psychiatry in the last century was the closure of the hospital asylum and the introduction of community care. This has not been an unqualified success. Expectations that community care should lead to better social integration were met in early hospital closure programs in England but have not been sustained; many patients are now living impoverished lives in sheltered environments with little social contact and little to do in the day. The economic recession of 2008/2009 was followed by protracted economic austerity that has had a profound impact on the provision and delivery of social care. This happened alongside a move in mainstream politics away from communitarian policies that aimed to create a more equal society toward an emphasis on self-reliance, tax breaks for the very rich, and hoped-for “trickle down” economics. The psychiatric profession has followed this trend by increasing its focus on mental illness as the individual's problem, “fixable” by changing their brain function (biological psychiatry) or their mind (psychological therapy) but heaven forbid, not their social environment. Gone are the milieu therapies, family psychoeducation (offered to around 10% of eligible families in England), and day care in favor of “easy-in easy-out” time-limited treatments that seem more aimed at reducing costs than improving outcomes.
Given the importance of social factors in the cause and maintenance of mental disorder, it is surprising that so little is done by way of prevention. Here, there is a need for effective policies to reduce poverty, improve education, and improve housing conditions that are the source of the more specific psychosocial risks to health. Ensuring the best-quality perinatal care, promoting good-quality parenting and reducing bullying at school can be achieved and are well evidenced, especially where the interventions are sustained and involve parents, children, and teachers. This harks back to the principles of community care – psychiatric services need to reach beyond the traditional hospital clinic, to work with schools, workplaces, prisons, and refugee settings. The scale of the challenge means that additions to existing professional models of care are needed including what can be delivered by less skilled (and expensive) staff.
Psychiatry is the branch of medicine in which disorders of interpersonal and wider group relationships are the key, not only in terms of understanding the etiology of disorder but also in the delivery of treatment. Interventions that target the social outcomes that are desired by patients are at the heart of recovery practice and are possibly better indicators of successful treatment than symptom reduction alone.
To quote Di Nicola again “…we are social beings who…… need to relate to others through family, friendship, and communal relationships.” Achieving that is a vital target for social psychiatry.
|1||Di Nicola V. A Person is a person through other persons: A social psychiatry manifesto for the 21st century. World Soc Psychiatry 2019;1:8-21.|
|2||Brown GW, Harris TO. Social Origins of Depression: A Study of Psychiatric Disorder in Women. London: Tavistock Press; 1978.|
|3||Kendler KS, Hettema JM, Butera F, Gardner CO, Prescott CA. Life event dimensions of loss, humiliation, entrapment, and danger in the prediction of onsets of major depression and generalized anxiety. Arch Gen Psychiatry 2003;60:789-96.|
|4||Teicher MH, Samson JA, Anderson CM, Ohashi K. The effects of childhood maltreatment on brain structure, function and connectivity. Nat Rev Neurosci 2016;17:652-66.|
|5||Dube SR, Felitti VJ, Dong M, Giles WH, Anda RF. The impact of adverse childhood experiences on health problems: Evidence from four birth cohorts dating back to 1900. Prev Med 2003;37:268-77.|
|6||Brown GW, Craig TK, Harris TO, Handley RV. Parental maltreatment and adulthood cohabiting partnerships: A life-course study of adult chronic depression-4. J Affect Disord 2008;110:115-25.|
|7||Burstow P, Newbigging K, Tew J, Costello B. Investing in a Resilient Generation: Keys to a Mentally Prosperous Nation. Birmingham: University of Birmingham; 2010.|
|8||Bouras N, Ikkos G, Craig T. From community to meta-community mental health care. Int J Environ Res Public Health 2018;15. pii: E806.|