Thomas Ungar is an associate professor of psychiatry at the University of Toronto and a research consultant with the Mental Health Commission of Canada.
It’s not uncommon in medicine for different approaches to fall in and out of favour. These days in psychiatry, the pendulum toward viewing mental illness as a disease resulting from social determinants has swung too far.
I am observing benevolent physician care providers who are forming professional identities as social justice warriors – when their first and most important responsibility is to practice medicine. It’s the oath they took, and, often, an endeavour supported by taxpayer dollars.
Let me elaborate.
We have moved from a narrower biomedical model of understanding mental illness to a more encompassing approach that touches on three factors: the biological, the psychological and the social. Addressing all three is the secret sauce to best outcomes. But as we progressively attend to social determinants of health, we must not lose sight of the biological and organic (in the body) aspects of mental illness. They are essential to understanding, treatment and care.
Yet, too many of my peers want to throw the baby out with the bathwater. To be “woke” today is to acknowledge the factors that intersect with mental illness, but to ignore the illness itself. It is almost taboo to suggest that social inequities are not the sole cause for the development of mental illness. That angers me because this isn’t a matter of opinion.
It’s suppressing a hard truth.
An exclusive focus on the social is a limited, exclusionary, all-or-nothing mentality that is both reductionist and discriminatory. In fact, I would argue that serious mental illness should be its own stand-alone health disparity, as is it misunderstood and maligned in both society and within healthcare.
If you think I’m exaggerating, consider two scenarios – both involving serious mental/brain illness. Has an emergency alert ever buzzed you awake in the middle of the night after a grandparent living with Alzheimer dementia wanders far from home? It’s certainly happened to me. And I’ve watched with admiration as the media, first responders and community members knit together to mount a search.
Now, ask yourself this. Have you ever seen that same response when a person living with schizophrenia wanders far from home? My answer is no. Nothing. Zip. Zero. Nada. The only response it might elicit is perhaps an unsubtle crossing of the street at the sight of someone visibly unwell meandering in your direction.
The uncomfortable truth is that we readily accept brief news mentions of such individuals freezing to death without so much as a whimper. It’s ironic then, that we reserve our hue and cry to rail against homelessness and poverty, ignoring the severe brain/mental illness that drives many to social marginalization in the first place.
Mental illness has been sloughed off as less real, less tangible – and by extension, less legitimate – while “real” medicine involves the physical stuff. I guess I can lay some of the blame at the feet of René Descartes, whose mind-versus-body segregationist ideas have had dire consequences that continue to reverberate down the generations.
We are content to segregate care for mental illness by building separate hospitals. Let’s not worsen the situation by discounting the legitimate biologic aspects and attribute mental illness solely to social consequences.
Look no farther than the book Hidden Valley Road, a poignant story of an all-American family decimated by schizophrenia – where no fewer than six of the 12 children were struck with the disease. To put it plainly, genetics can be cruel.
Understanding mental illness as organic is very hopeful. It allows it to be something we can observe, study, treat and correct. Arguably, this reduces stigma and discrimination.
In my efforts to recruit and hire psychiatrists over the years, I’ve been impressed by the kindness, compassion and strong sense of social responsibility demonstrated by doctors singularly focused on the social determinants of health.
But the irony of their inclination to run around the streets doing the jobs of social and community workers and saving the world in trendy Chelsea boots is not lost on me. The next time you see your doctor for a bronchitis would you really want them exclusively focusing on building codes and HVAC systems?
For true equity, compassion, and better health outcomes to take root, it’s necessary to delve into the biological and organic aspects of mental illness. The fight for health justice isn’t a glamorous one. It’s often a behind-the-scenes slog to bring approaches, resources and treatments for serious mental illness in line with similar diseases.
The pendulum won’t right itself unless we give it a push.
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