How interaction between individuals and external social structures can impact on mental health, trauma and suicidality
By Lorraine Byrne
My name is Lorraine. Upon completing my QQI level 5 in Healthcare I realised that I had a definite interest in pursuing this area further. I am now entering the third year of my BA in Health and Social Care and I am so happy that I have chosen this degree. This course has helped me to realise my passion for this area, allowing me to develop the broad range of skills I will need to pursue a successful career in my chose field.
This is an example of my course work that I have submitted for module SSC110: Exploring Psychosocial Theory.
The objective of this essay is to explore how interaction between individuals and external social structures can impact on mental health, trauma and suicidality. It will view these social influences through the lens of social construction theory, structural functionalism theory and symbolic interaction while also applying the psychological theories of psychoanalysis and cognitive behavioural approaches. It will also explore advocacy for sex workers through the approach of three different feminist perspectives. This essay will maintain that supports and advocacy cannot come solely from a biomedical approach, which seeks to treat illness without recognising any social influences. A more effective method would be the biopsychosocial approach, which acknowledges the impact social factors can have on an individual, treating not just an illness but its causes. A comparison of the themes of nature versus nurture and agency versus structure will also feature throughout this essay, while comparing the role these themes play in many social and psychological theories on mental illness, as well as advocacy work. This essay seeks to argue that the perceived significance and potential of an individual can often by determined by their connection to social structures, and how understanding these connections can provide a greater opportunity towards treatments, supports and advocacy for equality and unbiased social structures.
From the psychodynamic perspective, Freud believed the mind comprised of three parts, the unconscious (id), the subconscious (ego) and the conscious (superego), with the ego maintaining balance between the instinct driven id and the morality driven superego (Boyd and Bee, 2019). According to Freud, the ‘self’ was shaped and influenced in youth by external social forces and that unconscious thought controls behaviour (Daly, 1971). If the ‘self’ was faced with a traumatic event that it believed it was unable to resolve, the ‘self’ shattered and split, using the coping mechanism of forgetting the event and repressing it in the unconscious mind. However, the event did happen and, according to Freud, the repressed memory sometimes presented itself as psychosis. Increased reliance on the stress-diathesis model, which emphasises that mental disorders can be ascertained through interactions of predisposition and environmental stresses, have paved the way for recognition of psychological therapies in treating mental disorders. Though many of Freud’s theories have been discounted by modern psychologists, Alessi & Kahn, (2017) believe that interventions which are rooted in psychoanalytic theory can provide practitioners the necessary skill set to intervene with clients. The repressed memory would be uncovered by a therapist, who would then take receipt of the individual’s unwanted feelings and recreate them in a more acceptable, less overwhelming form, counteracting any sense of dehumanization experienced following the traumatic event.
According to Quist-Adade (2019), symbolic interactionism (SI) defines how individuals interact through use of symbols (including language), creating their social world and identities, under the influence of cultural interpretation. Through the continued process of interaction, it is possible for these identities to be redefined through the process of reflexivity. In SI, language is particularly important in shaping self-awareness as the sense of self is obtained through the perceived appraisals of others and changes through social experiences. This is particularly poignant in the case of women experiencing trauma following domestic abuse or battering relationships. In such cases, men can exert control over a woman by isolating her, removing her from her social identities, leaving only the identity of wife, which she will own with a low sense of self-worth (Anderson & Rouse, 1988). The social stigma attached to being a battered wife or rape victim can become a barrier to the victim seeking help and support to overcome the trauma (Muldoon, 2020). To counteract the damage done by the trauma, a clinician or counselor will endeavor to impress on the victim that the violence done to her was inherently wrong and the blame falls solely on the abuser, not the victim. A counselor would then seek to help positively rebuild the woman’s sense of self, helping her to remember her identity before the abusive relationship and recapture or reconnect with her social identity outside of her marriage while using her competencies to rebuild self-esteem, allowing her to become an individual in society again and not just a ‘victim’. (Anderson & Rouse, 1988).
Muldoon, Haslam, Haslam, Cruwys, Kearns & Jetten (2020), state that traumatic events are associated with actual or threatened risk to life, serious injury or sexual violence. Though both SI and psychodynamic practice different approaches and therapies towards trauma, both recognize that the impact of trauma on the ‘self’, whether through the shattering or splitting of self, and both are united in prioritizing the restoration of ‘self’ at the core of successful therapy. Though Muldoon (2020) observed that positive restructuring of the ‘self’ as a therapeutic intervention, in line with the SI approach, challenging the medical approach to trauma treatment, research shows that alongside therapeutic approaches, there is evidence that bio-medical interventions also have positive outcomes for symptom relief of adults experiencing post-traumatic stress disorders (van der Kolk, Spinozzola, Blaustein, Hopper, Hopper, Korn & Simpson, 2007, Sonis & Cook. (2019). Exploring these different approaches to trauma treatments lends support to the understanding that trauma interventions should always be approached on an individual basis while keeping the impact of external social factors at the heart of any treatment.
Dukheim’s Structural Functionalism theory suggested that people’s mental health can fare better when they are aware of their place within society and the system of interactive bonds which sustains it, i.e., their social facts. Durkheim viewed individualism as detrimental to mental health, observing the influence of external social structure on individuals (Tan, 2011). According to Durkheim, modern society is shaped by capitalism’s drive to promote individualism, while maintaining the power structure, thus weakening the structured bonds of obligation. Cain (2018) believes that neoliberalist societies have a direct impact on psychological distress and mental illness while promoting dependence on the biomedical model. Durkheim (1897) viewed anomie as being adrift, due to the loss of norms and structures that uphold a individual’s ‘social facts’, having a negative impact on mental health, possibly resulting in suicide. An open letter to the Irish Government by the Psychologists for Social Change Ireland, (PSC Ireland)(2020), advocating for those living in direct provision illustrates the detrimental effects on the mental health of people trapped within a system with considerable uncertainty about when their situation will change. PSC Ireland state that “suicide can occur in the context of hopelessness, when the present is unbearable with no end in sight”. Durkheim believed that higher suicide rates were influenced by integration and regulation of society. PSC Ireland believe that detention in direct provision centres was a “primary cause” of this mental health crisis.
Where Durkheim believed social facts shaped individuals, social construction theory posits that individuals have agency, and social actors give meaning to their world through social interactions (Tan, 2011). As speech or language are the primary source of social interaction, it follows that, as individual ideas and perceptions change, so too does interactive discourse that surrounds these ideas, such as the changing attitudes towards mental health and suicide (Tew, 2005). Anthony Giddens’s Theory of Structuration postulates that individuals are shaped within social structures, but, social structures are, in turn, shaped and reshaped by individuals. Tew (2005) believed that it was damaging to socially exclude mental health sufferers, segregating them under the label of ‘other’ or ‘ill’ and providing medical based treatments only. This belief is supported by Rosenhan’s (1973) study On Being Sane in Insane Places, relating how eight volunteers faked mental illness and were admitted into psychiatric facilities, indicating that mental health specialists were unable to accurately diagnose mental health illnesses. There is a real and lasting damage to the shame and stigma that surround mental health and suicide (Tyler, 2020). In recent years, there has been a positive change in attitude and discourse towards poor mental health and suicide. ‘Death by suicide’ is gradually replacing ‘committed suicide’, removing suicide from the association of criminality. Inviting further open and accepting discourse within society, regarding mental health and suicide, may result in further positive changes in attitudes towards those who are still ‘othered’ by society’s perceptions.
According to Scott (2007), research suggests that the biomedical model as a sole treatment of bipolar disorder has been unsuccessful. A growing recognition of the stress-diathesis model in exploring mental disorders has acknowledged the importance of therapies, such as cognitive therapy, in conjunction with the biomedical model of treatment. Beck’s theory of cognitive therapy posited that unhelpful thought patterns were linked to depression and anxiety. He suggested that a depressed person’s negative outlook on themselves, their future and their world was a negative cognitive triad. He also suggested that mania was the mirror image of depression, with overly positive thought patterns creating a positive cognitive triad, and that a person experiencing these two triads was bipolar. According to Scott (2007), while cognitive triggers are better understood in the case of depressive relapse rather than manic relapse, there is very little evidence to support Beck’s cognitive theory to explain the onset of mania. Scott (2007) believed that adding cognitive therapy to the biomedical treatment approach may improve prognosis to bipolar sufferers. According to Swartz & Swanson (2014), there is little evidence to show that cognitive therapy provides more positive results than other bipolar disorder specific therapies. Scott and Swartz both agree that further research is warranted in this area of bipolar treatment.
Social functionalism views the increase of mental illnesses as the result of the deterioration of supportive social structures, while social construction considers mental health illness through the interpretations of individuals, during social interaction and discourse, within respective societies and cultures. Beck’s cognitive theory views mental health illnesses as the result of negative thought patterns that can be triggered by external factors. Though each theory views mental illness through a different lens there are some similarities. Each theory suggests society has an impact on mental health, either through lack of social supports, societal opinions and views or external triggering factors and recommends that mental health illness should be addressed using a biopsychosocial approach. According to PSC Ireland (2020) hopelessness and uncertainty, arising from imposed social structures, can have a detrimental effect on mental health. Structural functionalism suggests that ongoing, changing perceptions towards mental health in society, proposing that mental illness should be removed from the sole lens of psychiatry (Rosenhan, 1973). Beck’s cognitive theory, however, has not withstood the test of time with cognitive therapy being more useful in treating mental illness than cognitive theory is at explaining the onset of mental illness (Scott, 2007). There is growing awareness that the imposition of social structures that result in hopelessness and uncertainty to individuals can have long-term detrimental effects on mental health (PSC Ireland, 2020, Cain, 2018). Continuing advocacy and dialogue can challenge society’s ideas and harmful perceptions of mental health illness to promote equality and acceptance.
According to Beegan & Moran (2017), the approach to advocacy for sex workers is a contentious topic which has splintered feminist groups for decades. Radical feminists view sex workers as universally suppressed, coerced and exploited by a patriarchal society, while liberal feminists view sex work as a choice where suppression arises from a lack of social freedom, placing them in the role of ‘other’. Post-modernist feminists view that suppression occurs when an individual’s choice to partake in sex work is criminalised. (Beegan & Moran, 2017). Radical feminists favour legislation based on ‘The Nordic Model’, on which Irish legislation of prostitution is based. This model criminalises the purchasers of sex rather than the sellers. (Beegan & Moran, 2017). Liberal and post-feminists agree that business transactions between consenting adults should not be criminalised as criminalisation can do more harm than good to the sex worker. Post-modern feminists further believe that sex workers should have the same equal rights and recognition as any other worker. Platt et. al. (2018), research shows that criminalisation of sex work can be detrimental to the health and safety of sex workers, increasing their exposure to violence and unsafe sex while disrupting peer support groups and services. However, Beegan & Moran (2017) state that the decriminalisation of sex work in New Zealand has not decreased the violence or stigma aimed at women engaging in sex work. Therefore, negative attitudes towards sex workers mainly arise from society’s perceptions towards them. Advocacy for sex workers should address not only the legal position that promotes negative attitudes towards sex workers, but society’s attitudes that attribute stigma and shame to sex workers, making them easier targets for violence while denying them the rights and dignity afforded to other workers.
This essay has sought to explore some of the complex social interactions and structures that influence different therapeutic approaches to mental health and, also, three different feminist advocacy approaches to sex work. The holistic, biopsychosocial model is the favoured approach to treating mental health illness, especially in the case of cognitive therapy. Different therapeutic approaches can have long-term, positive outcomes if the effects of contributing, external social factors are acknowledged, explored and considered in every case. Advocacy, whether in the case of mental health, direct provision, sex work or other social issues, for the promotion of equality and dignity of all, must also raise awareness to the stigma and dehumanisation that arises from political, legal and social structures, which can further contribute to difficult circumstances. Adjunct to advocacy, open and honest discourse could change social perceptions, giving every individual, regardless of their mental health, employment choice or social standing, the support and opportunity to become a valued and respected member of an equal, inclusive society.
Alessi, E.J. & Kahn, S. (2017). Using psychodynamic interventions to engage in traumatic-informed practice. Journal of Social Work Practice. DOI:10.1080/02650533.2017.1700959. Available at: http://www.researchgate.net/publication/321655980_Using_psychodynamic_interventions_to_engage_in_trauma-informed_practice [Accessed on 20 April 2021]
Boyd, D. & Bee, H. (2019). Lifespan Development, Global Edition, Pearson Education Limited.
Beegan, R. & Moran, J. (2017) Prostution and Sex Work: Situating Irelands New Lawa on Prostitution in the Radical and Liberal Feminist Paradigms. Irish Journal of Applied Social Studies. Vol. 17: Iss. 1, Article 6. Available at: https://arrow.tudublin.ie/cgi/viewcontent.cgi?article=1305&context=ijass [Accessed 27 April 2021].
Cain, R. (2018). How neoliberalism is damaging your mental health. https://theconversation.com/how-neoliberalism-is-damaging-your-mental-health-90565 [Accessed on 23 April 2021]
Daly, J. (1971) Freud and Determinism. The Southern Journal of Philosophy, 9(2), pp. 179-188
Goforth, A.N., Pham, A.V. & Carlson, J. S. (eds. Goldstein, S. & Naglieri, J.A.) (2011). Diathesis-Stress Model. Encyclopedia of Child Behaviour and Development. Springer, Boston, MA. Available at https://link.springer.com/referenceworkentry/10.1007%2F978-0-387-79061-9_845 [Accessed on 20 April 2001]
Muldoon, O.T., Haslam, S.A., Haslam, C., Cruwys, T., Kearns, M. & Jetten, J. (2020). The social psychology response to trauma, social identity, pathway associated with divergent traumatic responses. European Review of Social Psychology. 30:1,311-348, Available at:
https://www.tandfonline.com/doi/full/10.1080/10463283.2020.1711628 [Accessed 20 April 2020]
Platt, L., Grenfell, P., &Meiksin, R., Elmes, J., Sherman, S., Sanders, T., Mwange, P & Crago, A. (2018) Associations between sex work laws and sex workers’ health: A systematic review and meta-analysis of quantitative and qualitative studies. PLOS Medicine, 15(12), p.e1002680.
Psychologists for Social Change Ireland (13 August, 2020). Open letter to Taoiseach Michael Martin and Minister for Children, Disability, Equality and Integration, Roderick O’Gorman. Available at: http://www.psychchange.org/blog/open-letter-from-psc-ireland-calling-to-end-direct-provision [Accessed on 23 April 2021].
Rosenhan. D.L. (1973). On Bing Sane in Insane Places. Science, New Series, Vol 179, No. 4070: 250-258.
Scott, J. (2007). Cognitive Theory and Therapy of Bipolar Disorders. Available at psykologtidsskriftet.no/2007/05/cognitive-theory-and-therapy-bipolar-disorders#:~:text=Beck’s%20original%20cognitive%20model%20(1967,called%20the%20negative%20cognitive%20triad). [Accessed on 23 April 2021].
Sonis, J. & Cook, J.M. (2019). Medication versus trauma focused psychotherapy for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Available at: https://pubmed.ncbi.nlm.nih.gov/31690461/ [Accessed on 20 April 2021]
Swartz, H.A. & Swanson, J. (2014). Psychotherapy for Bipolar Disorder in Adults: A Review of the Evidence. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4536930/ [Accessed on 23 April 2021]
Tan, S. (2011). Understanding the “Structure” and “Agency” debate in the Social Sciences. Habitus. Available at: https://www.academia.edu/576759/Understanding_the_Structure_and_ Agency_debate_in_the_Social_Sciences. [Accessed on 23 April 2021].
Tew, J. (2005). Social Perspectives in Mental Health: Developing Socials Models to Understand and Work with Mental Distress. London. Jessica Kingsley Publishers Limited.
Tyler, I. (2020). Stigma: the machinery of inequality. Zed Books. London.
van der Kolk, B.A., Spinazolla, J., Blaustein, M.E., Hopper, J.W., Hopper, E.K., Korn, D. L. & Simpson, W.B. (2007). A Randomized Clinical Trial of Eye Movement Desensitization and Reprocessing (EMDR), Fluoxetine, and Pill Placebo in the Treatment of Posttraumatic Stress Disorder: Treatments Effects and Long-Term Maintenance. J Clin Psychiatry. 68:0. Available at: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.476.4096&rep=rep1&type=pdf [Accessed on 20 April 2021]