When the world is not ok, how can you, or I, be ok?

seen on Twitter, circa 2020–2021

Why is the ratio of women to men presenting to mental health services with anxiety or depression 2:1?

Why do people from marginalised communities have higher rates of psychosis?

Why do people experiencing socioeconomic deprivation have worse mental health outcomes than people with socioeconomic advantage?

If we don't ascribe to sexism, eugenics, classism, or any other form of simplistic and prejudicial thinking, these questions prompt consideration of the circumstances in which we exist.

Much of the mental health discourse, online or offline, highlights the biological roots of psychological distress and intrapsychic (within oneself — e.g., one's thinking style, personality, coping strategies) and interpersonal (between people — e.g., relationship quality, conflict) factors in mental health. These are undoubtedly significant.

However, the privileging of biological and psychological explanations over social, systemic, and structural ones leads to an incomplete and flawed understanding of causes (aetiology). It also prevents the development of longer-term, more holistic, more systemic remedies — and true prevention.

Maurice in the poisoned aquarium

Imagine a fish (let's name him Maurice, for the sake of whimsy) in an aquarium with poisoned water. For the purpose of our analogy, Maurice has been born and bred in this poisoned aquarium, and now in fish-adulthood is beginning to experience difficulties breathing and irritation on his gills and fins. A vet provides Maurice with medication that works to stop the irritation, and also helps Maurice breathe differently, easing his suffering. Maurice may no longer be distressed by what the poisoned water was doing to him, but he continues to exist in that poisoned aquarium, where the water is pathogenic.

The aim of this imaginary, cartoonish fish analogy is to illustrate the fact that even if we cannot see — or are not directly adversely affected by — the systems and structures around us, these systems and structures are the world we live in, the air we breathe. They shape us continually from our first moments of life unto death. How can we speak or think of mental health, then, without due consideration of said systems and structures?

The systems we breathe

Imperialism, capitalism, patriarchy — what do these three global systems, pillars of the world as we know it, have in common? Each is a system of more for me, and less for thee; of maintaining a status quo where one group benefits at the cost of (an)other group(s) — systems of power and powerlessness, of inequality and inequity.

These don't simply exist as abstract, background ideas. They inform every bit of our lives in often indirect and subtle ways.

Global imperialism is grounded in racism and capitalism ("I get to take from you, who are less worthy and exist for my advantage, for my profit"). It seeps into our lives in the forms of colourism in desi culture, internalised racism, pursuit of proximity to "whiteness", rejection of indigenous ways of knowing and meaning-making in favour of those developed by (mostly) white men from richer, "western", industrialised and developed nations. It manifests as the colonised mind — the identity shaped by the coloniser's gaze and legacy.

Capitalism tells us (ironically, very similarly to Soviet-era communism): "I must contribute to (the profit of) society to be worthy of existing." We must endlessly generate wealth for the 1%, as our survival depends upon it. Our lives are structured around work, which though worthy and necessary for a 'good' life is hardly really 'living'. Living, as I understand it, requires periods of calm and rest that allow for a sense of connectedness with Life itself — experiencing, and being, and creating, without the fear, urgency, and sense of obligation or absence of choice that characterises most work. Capitalism, and its twin consumerism, rob us of opportunities for aliveness.

Capitalism leads to research that speaks of the "global burden" of mental health concerns in economic terms: money lost, days of work reduced, productivity lessened by someone's suffering. The "diseases" with the greatest economic "burden" are then allocated funding for investigation of their causes and "treatments" — getting workers back to work as fast as possible, so as to minimise financial loss.

Patriarchy, present globally, is virulent and overt in the Pakistani context: a woman's entire identity depends on the men in her life (her ID card, passport, driving license, and degrees must all bear the name of her father or husband); male children are still favoured over girls; honour killings and extra-judicial jirgas and their barbaric judgments still exist; women murder and rape victims are still treated to "why was she out at that time? Why was she alone? What was she wearing? Did she lead him on?"; and the sexual abuse of children is still often treated as a dirty little secret to be hidden and ignored by families. Add to this the dehumanising "jokes" about how women are inherently crazy and entitled, and the emotionally illiterate, incel-y masculinity.

The patriarchy claims men as its victims, too. Men can't be emotionally expressive — that's too feminine. Men can't enjoy cooking, the arts, or gentler activities — those are "women-only" roles. Men can't contribute to housework — that's shameful; perish the thought of a self-sufficient man who doesn't expect women relatives to wait on him hand and foot. Men must work, work, work and provide financially only. This, understandably, takes a toll.

Whose questions, whose answers?

As regards mental health, we must ask:

Who, influenced by which systems, creates the theories that decide how we make sense of symptoms of distress?

Who, and which systems, define what is healthy and what is not?

Whose experiences are represented in diagnostic criteria? To use a question from the Power-Threat-Meaning Framework — one of the more social-systems-aware approaches — ultimately, we are asking: how is Power operating in our lives?

Power refers to the social, biological, economic, or interpersonal forces that shape people's lives and may pose threats to the safety and wellbeing of others. Power can have a negative impact when one belongs to a minoritised or marginalised group facing inequality, discrimination, or threat to life and safety (gender-, racial-, or religious-based dangers, for example). Power differentials also exist in social strata, educational differences, being able-bodied or disabled, being an employer or an employee, being a mental health professional or a 'patient', being among those who get to decide what is correct or true versus those expected to obey — and a multitude of other forms.

Some forms of power as summarised by the Power-Threat-Meaning Framework are: ideological (social norms, meanings), economic (wealth), bodily (skin colour, able/disabled, health, valued attributes), coercive (violence), legal (who the law privileges and whom it harms), social capital (access to education, culture), and relational (trauma, abuse). These are not the only forms of power at play — just the ones highlighted by the framework.

This framework, too, is not without its own positionality, having been created by white women in a westernised and industrialised nation. One wonders — what are the implicit biases and assumptions at play here? And how do we find more indigenously congruent ways of making sense of symptoms of distress?

A starting point

Perhaps for now, we may start by reflecting on our experiences of power and powerlessness. How do we experience these? How are we positioned in the world? How does this positioning impact us and others? What are the roots of this, and where does this lead us now? How does it impact the ways in which we make sense of our experiences?