Lebanon has witnessed a slow but steady fight against the stigmatization of mental illness. Local non-profit organizations like the Institute for Development, Research, Advocacy and Applied Care (IDRAAC), networks like the Lebanese Psychological Association and Embrace, as well as governmental actors like the Ministry of Health have led powerful and creative initiatives that have shifted the way we deal with and talk about mental illness in Lebanon.
While such initiatives are proving to be successful in removing barriers to help-seeking behavior, such as stigma and lack of knowledge about mental disorders, it is also important in this process to re-think our basic understanding of mental illness and of mental health practice. This article opens the discussion on the need to tackle the root systemic causes of mental illness and bring politics into the therapy session to empower those suffering from their socio-economic and political realities. To do so, we revisit our understanding of abnormality and highlight the powerful role that psychotherapists can play in pushing individuals forward to make societal change.
How does a therapist differentiate between a client’s ‘normal’ reaction to losing a job, for example, and a full-blown depressive episode? And how should a therapist approach individual psychological issues when they are clearly caused by systemic problems?
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5th edition[1]) explicitly distinguishes between normal and abnormal mental functioning through three necessary criteria of abnormality commonly referred to as the 3Ds. Unlike a triggered stress reaction, a disordered condition is Deviant, Distressing, and Dysfunctional.
The DSM’s criteria of abnormality have been subject to debate, and are still amenable to change. What is of particular interest for us here is the American Psychiatric Association’s understanding of Dysfunction. If a client is unable to meet “social, school, and work obligations” (DSM, p.301), or engage in “professional or family obligations” (p. 367), over certain periods that differ across disorders, he or she is by definition experiencing dysfunction.
Thus, embedded in our understanding of mental illness are assumptions about the contributions an individual should ‘normally make’ to societal, economic, and familial systems. Based on those expectations, we tend to put the burden of change and adaptability on the individual, instead of questioning the system or context in which the individual exists.
If a client has sleeping patterns that do not fit the 8:00 to 5:00 work shift, if they do not have the attention span or willingness to spend stretches of time on tasks they perceive to be devoid of meaning, we are quick to advise them to seek professional help. Yet if we contextualize our notion of ‘normal functioning’ by zooming out of the individual to consider the effect of macro-level factors on people’s subjective experiences, we might realize that our expectations of the ‘average’ student or employee are today increasingly difficult to meet.
A common and still potent criticism of psychotherapy is that it rarely factors in these macro level factors into the therapy session. The focus is instead on the individual. The client is encouraged to look inwards and shy away from external issues such as political concerns or social structures. If the client happens to mention political themes or concerns during a consult, the topic of discussion is on how this relates to them, and why they are responding to or perceiving the situation in that particular way.
Most therapists actively refrain from contributing to their client’s political development and political action. In fact, a bulk of research on psycho-politics explains why therapists have historically shifted away from any political engagement with their clients in the mid- 1900s[2]. Although the initial intention of therapists in such person-centered forms of therapy is to empower the client, more often than not, they tend to do just the opposite.
The social, political, and economic situation in Lebanon today and the state of the world in general, is likely to create a pervasive state of worry and helplessness. Thinking about one’s future and the future of loved ones can become a significant source of stress. A recent study by Maalouf and colleagues showed that anxiety disorders are the most prevalent among Lebanese youth residing in Beirut (Maalouf et al., 2016[3]). Would it not be empowering for clients to address the systemic issues affecting their constant worrying, instead of focusing on how they should adapt to an unpredictable and competitive environment? Considering the context, are the increasing rates of anxiety not a normal reaction to social, political, and economic problems?
Still, political concerns expressed during therapy are either avoided or used by the therapist to discuss symptoms and coping skills. The focus becomes on reading true feelings and/or opinions as symbolizing internal individual states, rather than recognizing a profound need to talk about the issue. Psychotherapy as a field is not equipped to respond to major issues affecting patients’ lives, such as continual exposure to gender inequality and violence, economic and financial concerns, near constant fear of war that creates a perpetual state of uncertainty, concerns about environmental disasters, etc. It is only normal for such an uncertain economic and political climate to increase in levels of anxiety in a given population.
In these instances, it is a sign of mental health that such concerns would hinder an individual from functioning and going through their daily routine. In fact, it is precisely because people remain functional in times of local or international crises that social problems propagate. Yet in not being able to cope, most people might blame themselves, feel like a failure, and fall into a state of a prolonged learned helplessness. Is the role of the therapist in this context to work on the client’s coping skills to adapt to a failed economic and political system? When does the problem stop being about individual response patterns, and become about a status quo creating increasingly more prevalent symptoms of “mental illness”?
In our current context, a depoliticized psychology only serves to propagate the status quo and reinforces the unspoken assumption of personal responsibility and failure in one’s inability to adapt. An apolitical, objective, and neutral psychotherapist is, knowingly or unknowingly, complicit with an unjust and oppressive system. Focusing on the individual’s responses to a given situation without addressing the ways in which the client can change the external world frames the external situation as an inherently unchangeable reality.
We call on mental health practitioners to engage in conversation with clients if and when clients express the need to discuss political issues. These could range from frustrations about governmental decisions, to frustration about workplace interactions. In so doing, therapists have the power to turn their client’s distress into a refreshing vital force capable of instigating change. In a recent New York Times article, psychotherapist Richard Brouillette eloquently reminds his colleagues that the integration of political issues into the therapy session is not the sole responsibility of a social worker (Brouillette, 2016[4]):
“You would be surprised how seldom it occurs to people that
their problems are not their fault. By focusing on fairness and justice,
a patient may have a chance to find what has so frequently been lost:
an ability to care for and stand up for herself. Guilt can be replaced with a clarifyinganger,
one that liberates a desire — and a demand — to thrive,to turn outward toward others rather than inward,
one that draws her forward to make change.”
[1] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.
[2] For a review, see Totton, N. (2000). Psychotherapy and politics. Sage.
[3] Maalouf, F. T., Ghandour, L. A., Halabi, F., Zeinoun, P., & Tavitian, L. (2016). Psychiatric disorders among adolescents from Lebanon: prevalence, correlates, and treatment gap. Social psychiatry and psychiatric epidemiology, 51(8), 1105-1116.
[4] Brouillette, E. (2016). Why therapists should talk politics. The New York Times.
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