Societal perspectives towards mental health are continually evolving, with sentiments shifting significantly particularly in recent years. It would have been unthinkable even a few years ago to openly discuss taking leave from work for mental health, to share emotional difficulties with friends, or to say with no shame that you are seeing a therapist.
I’d like to consider some of the ways that these perspectives have changed. And while beliefs develop in gradual ways, they are often expressive of more fundamental paradigms. These paradigms can last for decades, until the point when a new paradigm is able to challenge, and eventually replace it. But sometimes we can live with, and in-between, multiple paradigms. Sometimes we’re not aware of the tensions and incompatibilities of the disparate frameworks we’re holding. And sometimes, we’re not aware of what’s left out - what might be missing or why we seem to be caught in between two competing understandings.
It can be easy to forget that the field of psychology is still in its early stages. Common notions of treating mental health conditions from a psychological, and not a physiological perspective have been around for less than 150 years. Of course, before we had the ideas we do about psychology, people still had mental and emotional problems. How were these issues regarded then?
Most often, those suffering from anxiety, depression, post traumatic stress disorder, and the like, were seen as having a deficit in their character, or even morally lacking. Even the phrase “suffering from” is an anachronism. Back then, you weren’t suffering from depression, as if that is something you have externally. Those issues were a part of you. They were seen as expressing a lack of resilience and coping. Having these sorts of problems indicates you are not rational enough, not strong enough, not close enough to God, etc.
I’ll use the phrase character model to refer to this paradigm. This framework makes it a lot tougher to openly acknowledge and seek help for mental health struggles. If having depression means there’s something wrong with you morally, well you’d probably be a lot more averse to admitting you have that problem. And not only to others, but even to yourself. This paradigm is significantly more likely to lead to stigmatization, leading to a back and forth between overwhelming shame and inadequacy, and avoidance and denial. From our modern perspective, most of us would find this model callous and unfairly placing blame on a person who is suffering. This paradigm however is by no means one which is relegated to ancient history. It shows up today, though significantly less common as we progress across generations.
The notion that therapy is for the emotionally fragile persists, particularly in certain cultural circles. There was an entire plotline on the first season of the Sopranos involving the ramifications of Tony being discovered as seeing a psychiatrist. However, developing alongside the character model has been what I’ll refer to as the medical model. Present attitudes predominantly favor the medical model over the character model.
The medical model represented a welcome shift to many. It aims to destigmatize mental health by framing it as a medical condition rather than a moral failing. It offers a more compassionate framework, rejecting the notion of moral wrongdoing in psychological struggles. You couldn't blame someone for a psychological condition any more than you would for physical ailments. If addiction or depression runs in your family, if it's ingrained in your genes, why should that be stigmatized? If the problems with your mood are due to a chemical imbalance, well then why should you feel ashamed about your illness? This paradigm is responsible for an increase in treatment and presenting more of an opening for discussion of mental health in societal discourse.
Yet, for all its merits in reducing blame, I would argue that the medical model leaves a lot to be desired. Most importantly, it’s simply not true. Mental health conditions are not diseases that one is born with, or that arise from purely physical contributors. And while it is beyond the scope of this post to debate the nature vs. nurture debate, there is tons of research showing the effects of environmental conditions - stress, trauma, invalidation, etc., on emotional and mental development. The chemical imbalance theory is rife with numerous methodological flaws, conflating correlation with causation. The discovery of epigenetics, how certain genes are activated or deactivated and passed down to offspring, based on experience, shifts the perception away from genetic determinism.
Putting aside these arguments against the medical model, what I would like to focus on are the ramifications of adopting this paradigm. Because within this orientation lies a paradox—a subtle disempowerment that comes with viewing mental health solely through a medical lens. If you believe you have an illness which you are genetically programmed to have, how can you truly overcome it? The best you can really hope for is learning how to manage your symptoms, perhaps with psychotherapy, more than likely with a lifelong medication regimen. There is little room for an addict to cease being an addict, for someone genetically programmed to have bipolar disorder to truly overcome it. Your disease becomes lifelong and chronic. You have lost personal responsibility, and thus your agency.
Enter the psychosocial model—an emergent paradigm that weaves together the threads of our environment, culture, and experiences. This model focuses on how our thoughts, feelings, social environment, and early developmental history all affect our well-being. It highlights that you didn't choose your past, the challenges your caregivers faced, or the difficulties that can shape your understanding of the world. By acknowledging this complexity and lack of choice, you are better able to understand and empathize with your own struggles as well as those of others. Moreover, this approach emphasizes the capability for change inherent in each human being. Through acknowledging our past wounds, we can begin the process of transformative change and facilitate the journey towards wholeness. This model instills hope and agency by emphasizing that true healing is achievable. This approach recognizes that, unlike with a physical ailment, healing emotional wounds involves active participation on your part, rather than solely relying on medical professionals' instructions.
Unlike its predecessors, the psychosocial model refuses to lay blame at the feet of the afflicted. You didn’t choose your genes, body, and your family history, and thus don’t need to continue carrying the burden of blaming yourself. And most importantly, while struggles may arise along the way, none of these circumstances determine your fate or define your future. We are encouraged to peer into the intricate dance between our internal struggles and the external forces that mold our existence. In doing so, it opens the door to profound compassion and invites us to recognize agency in the face of adversity.
"Between stimulus and response, there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom." - Viktor E. Frankl