Culture is the Solution and the Problem

I intended to write this blog much sooner. However, I’m starting to understand the journey of a PhD is not a simple one. You’d have thought i would have grasped this by now. I’m four years in; nevertheless, here I am. I posted some months ago about writing several blogs about the challenges people face with co-existing mental health and substance (CEMS) needs. This, at the start, was a simple doing. Current literature, such as Christie (2017) and Pinderup (2018), highlights these challenges, and so do the Department of Health policy implementation guides (2002, 2009).

So, I started to write; however, what struck me was that I was regurgitating what others had said. I’m not saying I disagree that training in the field of CEMS is lacking, professional attitudes need to be less stigmatising, and better service provision and funding are required. But, what struck me is that we are focusing on the individual, the (professional) who works tirelessly to help the person with CEMS, who chose this line of work to help and support people. We have been doing this for the last three decades. So, why isn’t anything changing? Why are people with CEMS still having trouble accessing mental health services? I’ll be honest these two questions have significantly impacted how I conceptualised the challenges faced by people with CEMS. So, I did what any ‘nerd’ would do I returned to my data, books and articles. I’d already settled on a theoretical perspective for my PhD: phenomenology alongside social theory. But, this didn’t answer the above questions.

Maybe because it was not meant to – what i mean is a phenomenological approach is all about lived experience and understanding a phenomenon from the perspective of the person it impacts. However, I wanted to know why? Enter critical realism and the work of Margaret Archer – whose theory of Morphogenesis / Morphostasis fascinated me. Archer talks about three elements, culture, structure and agency. At first glance, these appeared simple to define; however, exploring each as an individual element made the task a bit more complex, hence taking so long to write this blog.

I’ll focus solely on culture and agency for this blog as I feel it is the culture of CEMS that is the solution but also the problem to the challenges people face. Culture refers to the unique behaviour patterns and lifestyles shared by a group of people that distinguish it from other groups (Tseng and Streltzer, 2004). However, it can also be conceptualised as an objective phenomenon coterminous, meaning it holds the boundaries in space, time and meaning. Therefore, we are born into a culture. However, it is influenced by agency, which is the idea that people make their own decision and are responsible for their actions.

Consequently, we (people) are all agents of society. So, this got me thinking about the culture of CEMS, firstly the discipline of psychiatry. For hundreds of years, we have seen people with mental health difficulties as different, we have locked them away in asylums, and the medical profession has branded them with disorders of the mind. An example of this was, until 1974, people who were attracted to the same sex we said to have an organic mental disorder, requiring electroshock and sometimes neurosurgery. So was the culture at the time; however, following extensive lobbying, morphogenesis occurred. All I mean is that culture was transformed, and such a diagnosis was removed from the Diagnostic and Statistical Manual (DSM). This transformation is important; it was agents of society effectively that changed the culture. For those born after 1974, being attracted to the same sex would not be considered a mental disorder. So, hopefully, you can see that as agents, we have a complex relationship with culture; we are the producers, reproducers and transformers of culture.

I talk about psychiatry as this is the dominant field when discussing CEMS. However, this is not to say that I am anti-psychiatry, I work within the area and see the good it does at times, but equally the negative and problematic aspects of the field. Doctors of any profession hold a hierarchical position in society and have done for a millennium; like any of us, culture is superimposed on our individual style, personal belief and professional knowledge; this culture shapes the pattern of interaction and communication between doctors and patient. A study of doctors also noted that diagnosis was an integral part of their profession.

Again, this got me thinking about when I go to see a doctor, I want them to give me a diagnosis because i want treatment to make me feel better. However, I want to know that this diagnosis is based on scientific evidence and that the treatment being given to me will make me feel better. But, what if the diagnosis had no scientific grounding at all, and there was no reliable evidence to suggest the treatment would work either? Would you still go to the doctor and take the treatment?

This is the case within mental health; the culture is fixed on the notion of mental health, or mental illness, as a brain disease caused by neurotransmitter dysregulation, genetic anomalies, and defects in brain structures and function. Yet, no scientific evidence identifies any such biological or reliable biomarker for any mental disorder (Deacon, 2013). Equally, we are given psychotropic medication at an alarming rate (NHSBSA, 2020). However, there is no credible evidence that chemical imbalances cause mental disorders or that medicine works by correcting such imbalances (Moncrieff, 2008; Hengartner, Davies and Read, 2019). Yet, rates of mental health disability have almost trebled, and the prevalence of mental health problems has risen fourfold; the classification of mental disorders has increased from 106 in the early 1970s to around 370 today.

Therefore, the culture of mental health is that of the brain disease model and treatment requires pharmacological intervention? The same can be said for those who use substances and have mental health difficulties. Similar to mental health, substance use, commonly described as misuse or addiction, has been posited as a brain disease, Leshner, (1997), but this contradicts how addiction services offer treatment; a person has to show willingness, motivation and determination; it equally contradicts treatment for those with a mental health need as well. All this fails to see the culture of substance use – it may be because the relationship is so complex and dependent on the individual. What i find fascinating is that the disciplinary power of psychiatry and political power conceptualised substance use as an addiction or misuse. However, for hundreds of years, society has used substances; we have been shown how to drink, smoke, and take drugs by family, friends and peers. Tobacco was used and encouraged in the UK from 1670; it was not until 1965 that advertisements on television were banned due to ‘smoking being the greatest single cause of preventable illness and premature death in the UK. However, it took 40 years to ban smoking in all enclosed places. Equally, people have used stimulants and pain- and grief-soothing substances for centuries to enable them to work long hours. Therefore, there is a substance use culture within the UK? However, it’s not until the use of such substance starts to impair our functioning do we seem to care; the moment we can not adhere to the social norms of society, we then misuse the substance.

A prime example is alcohol, not an illegal psychoactive substance but arguably the most harmful yet the most used in society estimated that around 82% of the UK population drink alcohol, so about 46,166,00 million people equally; it is estimated that 602,391 people are dependent on alcohol, meaning that they have developed a chemical dependency and will often find it difficult to stop without medical support. Yet, alcohol is sold in all most every major supermarket for as little as 19p per unit of alcohol, so 10ml. This is compared to 65p for a bottle of water. Again, there is a substance use culture in the UK?

So, why do people with CEMS struggle to access services? My current stance on this question is that we are not challenging or addressing the underlying culture of CEMS until we start seeking its transformation; culture does not have a form within our daily lives but is always present. Some people act in ways others do not understand, are unable to contribute to the machine of economic efficiency, and act differently from polite social norms. Such people often fall within the labelling framework of psychiatry, subject to diagnostic labelling, which governments have legitimised in order to control psychological abnormality socially. This structural conditioning by powerful agents leads to socio-cultural interaction, cultural elaboration and, in the case of mental health at present, morphostasis. Let me explain:

The belief that mental illness is a brain disease appears logically consistent in that we are told this, and for most lay people, this is what they believe. However, it can not be true because it has a logical contradiction. We’ve ascertained that no biological or neurological evidence exists, so how can it be a disease? Equally, treating mental illness on a pharmacological basis has no reliable evidence-based; therefore, it’s logically inconsistent. Equally, the picture painted of mental illness over the last hundred years has been dangerous, violent, and unpredictable. A leading Noble Prize laureate and Professor of brain science say it’s a biological brain disease. Therefore, it could be argued that culture in this perspective is developed in ways that support the goals and interests of the ruling class. Thus, the existing cultural knowledge provides the basis for the current cultural conditioning of sociocultural interactions.

Sociocultural interactions are an interesting part of the cycle; given that we now know that the above is logically inconsistent, why is it that it remains the dominant approach to mental illness? Perhaps it is because we can that mental health is real; this is evident when people get ‘sectioned’ and sequestrated for observation and treatment in psychiatric hospitals. People continued to be given psychiatric diagnoses despite little biological evidence. However, culture has conditioned us, so when we a person is unintelligible or is distressed, this is immediately, and often without question or reflection, considered to indicate a mental illness. This leads to the hypothesis that sociocultural interactions are influenced by the cultural distribution of power and socioeconomic resources.

Moving to the last phase of the cycle of cultural elaboration, two things can happen here, morphogenesis involves positive change, in which cultural deviations are reinforced and so multiply and expand, or morphostasis, in which innovations are rejected and existing cultural patterns are maintained. I would argue that mental health has been in a state of morphostasis. Albeit, on the face, things appear to be changing; we talk more about mental health now than ever. However, we also prescribe more anti-depressant medication than ever, amidst a four-fold increase in the prevalence of mental health needs. Until we get to a morphogenesis position, this is not to dismiss the field of psychiatry but to suggest a cultural shift away from the area’s dominance.

But, this does not answer why people with CEMS struggle to access services. Well, it does in part. If we return to the cycle of morphogenesis and cultural conditioning – the notion of substance misuse became popular during the First World War and the enactment of the Defence of the Realm Act 1914 (4OB), which enabled the control, manufacture, sale and distribution of cocaine. This was in reaction to claims that solider were using cocaine on leave, which impacted their ability to fight on the front lines. Interestingly some years later, it was found that there was no evidence to support such claims, or at least it was not a severe or noticeable problem. Nevertheless, the concept of misuse was born. Shortly afterwards, in 1920, The Dangerous Drug Act came into force, focused on controlling said dangerous drugs.

During this time, the working-class practice of self-medication with substances stood in diametrical opposition to the aims of the middle-class medical and allied professions due to the person’s inability to function as part of the economic machine when under the influence of a substance. Therefore, social control played an essential role in shaping society’s culture on substance use amidst a growing capitalist industry. The Misuse of Drugs Act (1970) sealed the fate of anyone using a substance that fell into the realms of the Act. Entered the concept of addiction – popularised as medical and insurance industries grew and the idea of an addict was created. Addiction was framed as a brain disease allowing the medical industry to get into the business of treating it. However, as with a mental illness, no biological evidence exists to warrant the disease label. Unlike mental illness, the disease concept of addiction did not appear to inform socio-cultural interactions. The notion of misuse, dangerousness and criminalisation informed sociocultural interactions, thus creating a paradox for the person with CEMS. On the one hand, they have a mental illness that needs treatment but are also misusing a substance and, therefore, told that they must stop it. Consequently, a powerful legislative culture continues to cause morphostasis for people who use substances, directly impacting those with CEMS.

Therefore, using the lens morphogenesis, we need to change the culture of CEMS; the criminalisation of substance use as a method of self-medication is an obstacle, similarly the over-medicalisation of human emotions is an obstacle. It diverts focus from the very real societal causes. However, this is not to say that this is psychiatry’s sole responsibility; it falls to political parties and human agency. We need to see substance use and mental health for what it is, a method of self-medication. Therefore, it is absolutely pointless to treat them separately as is the culture at present. We need to listen to the people with CEMS as they are the experts; the current system has exploratory power but is not addressing the cause. If instead of asking what’s wrong with your brain, ask what’s happened to you. Now I know this might sound idealistic and I’ve probably over-simplified the above, but unless we start somewhere, nothing will change and let’s be honest, nothing is getting better.