The Necessary Nuance of Viewing Behaviors Psychosocially

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Public attention to homelessness has increased after an executive order was issued to expand involuntary psychiatric treatment for homeless Americans. Hardly anyone would deny that homelessness has existed in US cities for generations. Yet, should issues like this be solely viewed through the lens of psychiatric disease?

Research suggests that two-thirds of homeless people have mental health conditions and about one-fourth face severe mental illnesses. That said, escalating involuntary admissions at already filled, typically short-term psychiatric hospitals does not durably address the social determinant affecting everyone without housing: the shortage of accessible, stable housing. In contrast, “Housing First” interventions, which provide stability and can be paired with community-based care, are evidenced as highly effective, and cost-effective, in reducing homelessness, including among individuals with mental illnesses.

As a psychiatrist completing specialized training in child psychiatry, I cannot ignore the impacts structural factors have on behavioral health. Housing instability is one example. Half of each week, I work at a state psychiatric hospital for adolescents; invariably, my patients have experienced lives beset with separation, trauma, and social stressors that, together with genetic factors, have contributed to their illnesses. Even when our patients’ most severe symptoms have stabilized, our psychosocial treatment goals necessarily include healing wounded relationships with caregivers and securing safe places for them to return to.

I realize that sociocultural factors contribute greatly to “psychiatric” conditions across ages and identities. For example, a 1998 study of Fijian women exposed to Western beauty norms on TV demonstrated media culture’s profound role in driving eating disorders. Moreover, some research suggests that immigrants have at least twice the risk of developing schizophrenia as non-immigrants, with predisposing contributions from stressful social detachment and isolation. Likewise, prior to the onset of many people’s addictions, substances are often first used to self-medicate anxiety, trauma, and mood symptoms in the shortage of social supports and accessible healthcare.

Often, it feels as if popular media simplistically over-attributes societal tragedies to individual irrationality. Such narratives seem to reduce apparently ill people’s behaviors to idiosyncratic, incomprehensible qualities the rest of us should neither feel any responsibility for, nor bother trying to understand. As with homelessness today, nuanced psychosocial contexts are rarely explained to the public.

Take, for instance, viral videos on social media of road rage. Devoid of context beyond their sensational titles, these clips depict acts of violence as coming out of nowhere, eliciting many viewers’ unopposed disgust, outrage, or even amusement. Some psychologically minded viewers might wonder, but never know for sure, if violent motorists’ behaviors resulted from past collision-related traumatic hypervigilance, sociopathic impulsivity, or substance intoxication.

Rarer yet, very few might immediately think of underlying structural factors that increase the likelihood for road rage to manifest. Psychological contributors can intersect with stressors of congested, inefficient roadways in poorly planned cities, or time-related pressures of busy jobs that require a commute. Depending on where road rage incidents occur, another possible behavioral driver is “honor culture” legitimizing the use of aggression in response to perceived insults by other drivers. There are many possible social causes—and perhaps even ideas for future advocacy—to consider, prior to immediately imposing judgment on drivers.

Other examples of counterproductive decontextualization abound in media. I wonder if what appears to many as isolated cases of individual unwellness could instead be seen as tips of metaphorical behavioral icebergs, replete with submerged social stressors, and topped by surface-level psychological characteristics. Throughout medical training, more times than I can count, I have applied a “biopsychosocial” framework to understanding my patients; yet, even promoting a “psychosocial” viewpoint could expand insight in much of today’s public discourse about people. This means practicing a reflexive openness to considering more than one likely cause for others’ behaviors.

I believe such a nuanced perspective can grow not only our insight but also our compassion for people struggling with mental illness. For some of us, it can even usefully, positively inform our community service and advocacy work. Pathologizing without context has a natural tendency to “otherize” and cast out those we do not personally know. Conversely, I believe, the more we choose to see the intertwined relationships, hardships, and socially normative desires instilled into all of us, the better we can connect with each other across backgrounds. In this hard world, much good can arise from understanding each other more deeply.