Most illnesses are easy to locate: we break our legs, suffer from headaches, and get arthritis in our hands. But where do mental illnesses happen? In a thoughtful essay in The Wilson Quarterly, Tanya Marie Luhrmann, an anthropologist who studies psychology at Stanford, argues that we’re beginning to answer this question in a new way. During the glory days of Freudian analysis, we tended to see mental illness as something based in family life; more recently, we’ve thought of it as residing entirely in the brain. Now, she writes, we’re transitioning to a new model: “recognizing that social factors are among the causes, and must be part of the cure.” (The article is behind the WQ’s paywall, but you can read it for free using one of their apps for iPad, Android, or Kindle.)



The mathematician John Nash, who suffered from schizophrenia.

Luhrmann’s essay focuses on schizophrenia – a disease, she says, which has been seen from every psychiatric angle. In the mid-twentieth century, psychiatrists thought of schizophrenia as a disease based in “emotional conflict”; it was thought that schizophrenic patients had been raised by “refrigerator mothers” who traumatized their children through emotional fickleness. Then, in the 1980s, brain science took over (“the pain of the [refrigerator mother] mistake,” Luhrmann writes, “still reverberates through the profession”), and schizophrenia started to be approached as a purely brain-based disease, to be treated mainly through medication. “Schizophrenia became a poster child for the new approach, for it was the illness the psychoanalysis of the previous era had most spectacularly failed to cure.”

The intervening decades have seen psychiatrists work tirelessly to cure schizophrenia through medication – but it hasn’t worked, Lurhmann says, because many of the drugs either don’t work or create devastating side effects, like hallucinations or extreme weight gain. Instead, what’s emerged is a more nuanced picture. The brain remains at the center, but it’s caught in a complex web of causes. It’s not just your psyche, and it’s not just your brain – it’s everything, all at once:

[S]chizophrenia now appears to be a complex outcome of many unrelated causes – the genes you inherit, but also whether your mother fell ill during her pregnancy, whether you got beaten up as a child or were stressed as an adolescent, even how much sun your skin has seen…. [S]chizophrenia looks more and more like diabetes. A messy array of risk factors predisposes someone to develop [it]…. These factors are not intrinsically linked. Some of them have something to do with genes, but most do not.

Research from around the world, Luhrmann writes, has shown that social life plays a much larger role than you might think. Immigrants, for example, suffer at higher rates than normal – especially when their social environments are stressful (“One of the more disconcerting findings if that if you have dark skin, your risk of falling victim to schizophrenia increases as your neighborhood whitens”). And changes in one’s social situation can help lessen the impact of the disease. If sufferers are relocated to cleaner, more organized homes, for instance, their symptoms become easier to manage. In India, doctors take a totally different approach to schizophrenia, and end up with better results – patients “had fewer symptoms, took less medication, and were more likely to be employed and married” than their Western counterparts:

No one really knows why Indian patients did so well, but increasingly, psychiatric scientists are willing to attribute the better outcomes to social factors. For one thing, families are far more involved in the ill person’s care in India. They come to all the appointments, manage the medications, and allow the patients to live with them indefinitely. Compared to Europeans and Americans, they yell at the patients less. Indian families also don’t treat people with schizophrenia as if they have a soul-destroying illness…. Many of the doctors didn’t mention a diagnosis. Many of the families didn’t ask. There was a good deal of deception – wives grinding medication into the flour for the daily chapattis they made for their husbands, doctors explaining to patients that they were completely well but should take strengthening pills to protect themselves from the ravages of their youth. As a result, none of the patients thought of themselves as having a career-ending illness, and every one of them expected to get better. And at least compared to patients in the West, they generally did.

It’s not that the drugs don’t help – they remain key to the treatment – but that the “purely biomedical” treatment doesn’t seem like enough; it has to be combined with changes in the sufferer’s social world, too. Psychiatrists, Luhrmann argues, are arriving at a “wiser” understanding of the way mental illness works.

Read more at The Wilson Quarterly – it’s worth the app download, and the Quarterly is a great, under-appreciated magazine.