|DR. VENKOBA RAO ORATION
|Year : 2016 | Volume
| Issue : 1 | Page : 3-9
Are social theories still relevant in current psychiatric practice?
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||17-Feb-2016|
Prof. Ajit Avasthi
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
Current psychiatric practice is being influenced by advances in the field of molecular biology, genetic studies, neuroimaging, and psychopharmacology and the approach has become "biological." Social theories of mental illness had once revolutionized the field of psychiatry and are currently being somewhat ignored under the dazzle of biological sciences. Main social theories are functionalism, interpersonal theory, attachment theory, stress theory, and labeling theory. Each of these theories had tried to explain the genesis of psychiatric disorders in their own way. However, each theory has its own limitations and critique. Still, for a holistic approach to treat persons with mental illness, it is essential to take a biopsychosocial approach which can only be done if one understands the contribution and relevance of social theories. Nonpharmacological management has been the cornerstone of treatment of any psychiatric disorder and social theories also form the basis of various nonpharmacological modes of treatment. Overall, social theories are still very relevant in current psychiatric practice and should not be neglected. Efforts should be made to integrate social theories with other theories of mental illness for better understanding and treatment.
Keywords: Mental illness, practice, social theories
|How to cite this article:|
Avasthi A. Are social theories still relevant in current psychiatric practice?. Indian J Soc Psychiatry 2016;32:3-9
| Introduction|| |
Psychiatric practice in the current scenario is multiparadigmatic. However, its roots are still largely based on six schools of theories, i.e. psychodynamic, behavioral, cognitive, social, existential, and biological theories. These schools of theories have their own understanding of origin/genesis and management of psychiatric disorders. The followers of each of these schools tend to postulate, understand, and treat patients with mental illness based on the concepts they are inclined to. In spite of various treatment guidelines, psychiatric practice has no standard treatments because of no universally agreed ways of conceptualizing the problems that are to be treated.
The last decade of 20 th century was declared as "Decade of the Brain" during which extensive researches were carried out not only in the field of medicine but also on the neurobiological aspects of psychiatric disorders.  All these researches helped us in a better understanding of mental disorders and redefined mental disorders as "brain disorders" and being caused by disruptions in the neural circuits of developing brain. All these advances (in the field of molecular biology, genetic studies, neuroimaging, and psychopharmacology) have significantly influenced current psychiatric practice. Even more recently, there have been researches to find out specific biomarkers for depression and psychosis. , No doubt it resulted in widespread acceptance of psychiatric disorders in the medical mainstream, but it also had a negative impact. It was observed that the mindset of many psychiatrists has tilted considerably to become totally "biological," and the current generation psychiatrists tend to move away from the age-old traditional psychiatric theories, upon which the base of psychiatry was built.
However, despite the advances in the field of biological psychiatry having improved our understanding regarding the neurobiology, there is always a need to rely on the traditional social theories and try to incorporate them in our day to day psychiatric practice. To explain this notion, I need to answer the question which very commonly arises in the mind of a young budding psychiatrist that whether there is any relevance of the age-old social theories in current practice, or we should just forget them and move on the lines of biological psychiatry.
| How is the Social Perspective Different from Medical Perspective of Mental Illness?|| |
As per the medical model, mental illness is regarded as a disease with an identifiable physical cause and an identifiable course. The positive points as per medical model are that it de-stigmatizes mental illness and helps in identifying at-risk persons/groups. But the negative points are that there are few clear criteria for distinguishing symptomatology, and the threshold for disease is arbitrary. Hence, in short, the medical model of mental illness is a reductionist approach.
Whereas, in turn, the sociological model of mental illness regards mental illness as a deviant behavior which is marked by (1) thoughts, feelings, and behaviors that are defined as a problem by the society and (2) this problem is due to dysfunction of the mind/body. The positive aspect of such model is that it is based on cultural/social context (i.e., not all deviance is "bad") but the negative aspect is that such approach leads to generalization which is often not the case, as individuals vary from one another in many aspects.
The sociological perspective of mental illness can only be understood if we know in detail the various social theories which in some way had explained the genesis of psychiatric disorders.
| Social Theories of Major Psychiatric Disorders|| |
Main social theories which had once revolutionized psychiatric practice are:
- Functionalism theory
- Interpersonal theory
- Attachment theory
- Stress theory
- Labeling theory
- Other theories - social class, migration, and urbanization.
I would like to briefly explain each of these social theories by keeping "depression" as a prototype of mental illness (the reason being that depression is one of the most common psychiatric disorders and any psychiatrist can easily relate to the social theories of depression).
Functionalism theory was the dominant theoretical perspective in sociology in the 1940s. Emile Durkheim initially proposed this theory, but there were other followers and proponents too (like August Comte, Herbert Spencer, and Talcott Parsons). Durkheim's theory proposes that the behavior in society is structured, and the relationship between different members of the society is organized in terms of certain rules.  It further states that:
- All elements within a society are interconnected and work together
- If one dynamic is changed, it can alter the whole of society
- Society will change to accommodate this change
- Society will always function in harmony as it will accommodate change, by changing itself.
As per Durkheim's theory, when society changes too fast, it enters into a state of anomie or normlessness. An anomic society cannot agree upon collective representations, and so the collective conscience weakens leading to problems in the society. 
In order to explain the genesis of depression from a functionalist perspective, one needs to understand the emotions. Emotions exert bidirectional influences on cognitive processing, social interaction, and physical experience. According to functionalism theorists, emotional processes are evoked with reference to motives and concerns of the developing person and as such undergo a quantitative and qualitative change in development. And hence, any conflict in emotions or emotional processes can give rise to depression.
Functionalism theory is famous for its explanation on various types of suicide. This theory had tried to explain the cause of various types of suicide prevalent in the society. For example: (1) Anomic suicide caused by a weakening of the collective conscience. (2) Egoistic suicide occurs when a person's social bonds are loosened or lost. (3) Altruistic suicide happens when individuals are too strongly bonded to their society, for example, sati (4) Fatalistic suicide results when the collective conscience of the society is so strong that the individual feels helpless, for example, slavery.
The validity of Durkheim's concepts had also been tested and several conclusions have been derived. The important conclusions in brief are: (1) Suicide rates are lower in religious communities and changes in suicide rates could be attributed to changes in the socioeconomic status.  (2) Higher female suicide rates were associated with lower aggregate levels of religious beliefs and less strongly with religious attendance.  (3) Self-immolation for political/ideological self-sacrificial motives (altruistic suicide) has been reported. 
However, the functionalism theory is often criticized because (1) Not all the elements within a society are interconnected, (2) It fails to provide an explanation for wars and conflicts that may arise in particular societies, and (3) It disregards the immediate causes and motivations which are necessary in order to give rise to a phenomenon (i.e., like mental illness) which are purposeless for society.
The main exponents of the interpersonal theory were Adolf Meyer and Harry Stack Sullivan. They elaborated the perspective of the individual as a relationship - seeking social creature.
When, on one hand, Adolph Meyer focused on improvement of current life situation with a belief that individuals' habitual reaction patterns made them more susceptible to specific types of breakdown. On the other hand, Harry Sullivan's theory was fundamentally one of needs and anxiety. Needs are defined as needs for satisfaction and needs for security. Anxiety occurs when fundamental needs are in danger of not being met and is the primary motivator of human behavior.
As per interpersonal theory, social relationships synchronize biological rhythms and interpersonal problems disrupt these biological rhythms which in turn result in changes in somatic symptoms and ultimately leading on to depression.  Evidence in this regard comes from the association between marital functioning and depressive disorders which remain significant even when other dimensions of general interpersonal distress are controlled. Marital discord is associated with the onset as well as relapse of depression. ,
Bowlby proposed the famous attachment theory which brought a significant change in the understanding of the genesis of various psychiatric disorders. Attachment theory posits a human instinct to form strong, persistent affectional bonds. Loss of an attachment bond leads to separation anxiety which gradually becomes intense to revive the lost relationship. Mother-child bond is considered to be the prototype for all subsequent bonds with other objects. On the basis of this bond, Bowlby classified attachment types as secure, insecure-avoidant, insecure-resistant, and disorganized. Attachment shapes the emotional regulation, cognitive schemas, and stress vulnerability of an individual.
As per the attachment theory, working models developed during childhood influence thoughts, feelings, and behaviors in adults. Insecure or disorganized attachment contributes significantly to vulnerability to depression. Insecure attachment is associated with dysfunction of emotion regulation strategies. Disorganized attachment may mediate or moderate the association between early maltreatment and later maladaptation. , Various social hypotheses have been developed based on attachment theory to understand the pathogenesis of depression. Similarly, attachment theory has been postulated in various other psychiatric disorders such as childhood-onset psychosis, autism, and conduct disorder.
Hans Selye considered stress as a nonspecific bodily response to any demand caused by either pleasant or unpleasant conditions. The modern conceptualization of stress is that it is the internal state of the individual which perceives threat to physical and mental well-being.  Stress is linked with coping which is defined as the various cognitive or behavioral efforts intended to master or tolerate the internal or external demands which threaten or go beyond the resources of a subject.  Stress has now been established to be linked with almost all psychiatric disorders.
Stress and depression
Brown and Harris (1978) had proved that a linear association exists between the severity of stress and probability of depression onset.  However, the relationship of stressful life events with relapse and recurrence of depression is complex. It has been proposed that after a depressive episode, an individual has both a biological vulnerability and a social vulnerability which influence the further relapse, recurrence, and response to stress.
The outcome of depression has also been linked with stress in the way that severe depression with life stress prior to onset is associated with poor recovery compared to less severe depression. It has also been found that if stressor occurs after the onset of depression, then recovery appears to be delayed considerably.  Stress theory has tried to link biological theories with social theories, i.e. stress leads to over-activity of hypothalamic-pituitary axis and causes decrease in brain derived nerve factor levels which has been found to be low in depression. 
Stress and other psychiatric disorders
Evidence regarding stressful life event as a precipitating agent in bipolar affective disorder has been found strong for first and early episodes but weaker for later episodes which may be explained by "kindling hypothesis." , In the case of schizophrenia, stress has been found to be having a pathoplastic effect rather than pathogenic effect. Stress vulnerability model explains that schizophrenia develops when there occurs combination of high levels of vulnerability with moderate or low level of stress.  Venkoba Rao (1976) reported stressful life events more common in periods preceding relapse.  Stress theory has also been associated with social support coping theory.
Howard Becker proposed the labeling theory in which he mentioned that people labeled as mentally ill are treated as irresponsible, denied access to normal activities, forced to spend time with other deviants and gradually get socialized into the mental-patient culture, and adopting mental patient worldview.  As per Turner, labeling theory has three central propositions, i.e. (1) Deviant behavior by an individual is labeled as deviant by powerful, influential, or significant social groups, (2) People who are labeled as deviant suffer stigmatization, which excludes them from normal interactions and thus converts their behavior into a distinctive one, (3) Behavior that is stigmatized by social labeling becomes amplified because alternative lifestyles and careers are no longer available for the deviant. 
Labeling theory has relevance in current psychiatric practice in the form of stigma attributed to people with mental illness. Across the studies, the telling factor is ignorance. Every psychiatric patient is equated to the unpredictable, violent, disruptive, dangerous, and incurable "schizophrenic." In a study of 608 patients with schizophrenia and 952 family members, it was revealed that stigma had a moderate to severe effect on the lives of the patients in 60% of the interviews.  The critique of this theory is that it does not explain initial causes of deviant behavior and hence has limited usefulness. However, it has sensitized mental health personnel to the dangers of "institutionalization."
Some other social factors/theories
Among the oldest and most consistent relationships in psychiatric epidemiology is the inverse relation between social class and mental illness. Findings are similar across types for schizophrenia, depression, substance abuse, and personality disorders.  Theories which give a special significance to social class are the social causation hypothesis and the drift hypothesis. As per social causation hypothesis, rates of occurrence of mental disorders are higher in low socioeconomic status groups due to higher environmental adversity (like unemployment, poverty, social disadvantage, single motherhood, and homelessness) leading to stress which further leads to mental illness. Whereas, as per drift hypothesis, persons with mental disorders or those with traits probably genetic in origin predisposing to mental disorders, drift down into or fail to rise out of the low socioeconomic status group. ,
Migration, as an important aspect in social theories of mental illness and has been well-established across several studies. Migrants experience losses that affect their mental well-being. Migrants provide an opportunity to study both the pathogenetic and patho-protective aspects of sociocultural variables. Studies since 1932 on migrant population have found increased rates of schizophrenia, depression, anxiety disorders, and other psychiatric disorders than general population. , Several factors like language barriers, concerns about legal status, difficulties related to acculturation, racism, housing, health problems, and isolation increases the risk of mental health problems after settlement in host countries. A possible explanation for the genesis of mental disorders in migrants is feeling of a sense of defeat or dejection, low self-esteem, changing concepts of self, and mismatch between aspirations and achievements. 
The range of disorders and deviancies associated with urbanization is enormous and includes psychoses, depression, substance abuse, crime, delinquency, vandalism, family disintegration, and alienation. Link between urban living and schizophrenia has been long debated and proved in many meta-analyses. , Both biological mediators (obstetric complications, low Vitamin D levels, air pollution, and cannabis use) and social mediators (deprivation, neighborhood organization, ethnic composition, and migration) have been postulated in this regard.
| Application of Social Theories In current Psychiatric Practice|| |
After gaining some basic knowledge about these social theories and factors, the question again arises, do we still need to know about all these theories in the current "biological era of science and technology." The answer is yes!!! [Reason of which is depicted in [Figure 1].
|Figure 1: Application of social theories in current psychiatric practice|
Click here to view
Genesis of psychiatric disorders has already been explained on the basis of social factors (as mentioned under the social theories); now I would like to put forward some concepts regarding how social theories are relevant in approach to understanding and treatment of psychiatric disorders.
Social theories in understanding/approach to mental illness: The biopsychosocial model
Engel's biopsychosocial model could explain the relevance of social theories and can be helpful in a holistic approach for understanding of the psychiatric disorder.  In 2013, Basu in his editorial that appeared in the Indian Journal of Social Psychiatry has very rightly put forward the various critiques and current position of this model. Through this model, one can incorporate the three components of reality: External ("biological"), internal ("psychological"), and contextual ("social"). 
In simpler words, in this model it incorporates the biological determinants which are the internal mechanisms of the body, psychological determinants (the psyche of an individual), and sociological determinants (the external factors in the environment or person's social milieu).
A biopsychosocial approach is focused on the current and long-term developmental functioning, health and wellness strengths across all domains, monitoring progress over time, collaboration with other professionals and third parties and the role of risk, protective and compensatory factors in treatment, and behavior change. Overall, a biopsychosocial approach to behavioral health care emphasizes a broad, holistic, systemic, and developmental perspective to understanding treatment.  Constant feedback loops co-exist between biological, psychological, and social determinants. Hence, it can be understood that social factors do play a very important role in genesis, maintaining, and treatment of psychiatric illness.
Biopsychosocial model of each and every psychiatric disorder ranging from depression, psychosis/schizophrenia, addiction, anxiety disorders, and sexual disorders to personality disorders have been postulated and researches have been done on every aspect based on this model. It is beyond the scope of this article to explain how to apply the biopsychosocial model in each of the psychiatric disorders. Hence, to give a general overview, I have tried to explain this concept keeping depression as a prototype of mental illness in [Figure 2].
Perhaps the most important principle to explain to our patients and their relatives is that conditions like depression are influenced by a multiplicity of factors, both physical and psychosocial. When added together, these may lead to illness and therefore successful treatment will frequently depend on a combined physical (biological) and psychosocial approach.  In this regard, psychiatrists who follow a social orientation often make use of a combination of drug treatments, psychotherapy, and socioenvironmental "manipulation" in dealing with a case that might not otherwise yield to just one of these approaches. ,
Social theories in the biopsychosocial model can be incorporated under the general setting factors (culture, race, and socioeconomic status) as well as under the social factors (attachment, parenting, early life trauma, social network, and migration). In short, apart from genetic and psychological factors, social theories can be implicated to a great extent while one tries to understand/approach a patient with mental illness.
A biopsychosocial treatment approach considers etiological factors in the domains of all the three determinants, treatment plan based on the three determinants, and implementation of the same on these three domains. If management includes all the three determinants approach then only it can be said to be holistic and complete. To briefly summarize, again I would like to quote Engel's writings: "A biopsychosocial model is proposed that provides a blueprint for research, a framework for teaching, and a design for action in the real world of health care."  Although the overall role of social factors in the etiology of psychiatric disorder remains "unproven," but it is quite clear now that they do play a significant role in the pathogenesis of psychiatric disorders.
| Social Theories in the Management Perspective|| |
It is now quite evident that pharmacological treatment of psychiatric disorders does not completely cure the illness. Of the several drawbacks of pharmacological treatment some few but important ones are that pharmacological treatment is with limited options of medications, with a burden of adverse side effects and is with very less sustainable benefits. The current era of research is now focusing on the nonpharmacological management of psychiatric disorders, and the nonpharmacological strategies have been found to be more effective with sustainable long-term benefits in many studies including randomized control trials.
We often treat a patient with mental illness with several nonpharmacological strategies, but we have never thought about what actually forms the basis of these treatment approaches. It will be a surprise to know that it is the social theories (as discussed above) which form a broad base or foundation of a majority of nonpharmacological treatment approaches. A list of such approaches is depicted in [Table 1]. All these nonpharmacological approaches, in fact, justify the relevance of social theories in different management perspectives while dealing with patients with mental illness.
Social theories also form the basis of the psychoeducational programs for various psychiatric disorders. These theories focus on the transfer of useful knowledge about psychiatric illness and help in teaching communication and problem-solving skills. Social theories have taken a step forward in reducing stigma due to mental illness and in providing the basis of psychosocial rehabilitation which was previously a neglected component in the management of patients with mental illness. We all know that no treatment is complete without involving the family and community of the patient with mental illness. Therefore, family interventions and environmental modification are the two important aspects of comprehensive psychiatric management. Social theories of expressed emotions and social support have brought these two aspects of care into the central domain of psychiatric management.
It is often said and has been proved time and again true that psychiatric treatment is deficit without psychotherapy. Techniques of psychotherapy have been proved to be beneficial in almost all the psychiatric disorders ranging from neurosis to psychosis. The basic aim of any form of psychotherapy (be it supportive psychotherapy, cognitive behavior therapy, interpersonal psychotherapy, or group therapy) is to improve the functioning of the patient and maintain the same in the long run. A cognitive psychotherapeutic approach may be designed to alter dysfunctional attitudes and beliefs about the value of close personal relationships with others. A social skills training package may be designed to overcome skills deficits that may be restricting an individual from developing or making effective use of more supportive relationships. Interpersonal psychotherapy for depression, by providing the patient with a social relationship that is safe to learn within, may also lead to enhanced skills in obtaining additional sources of support from others. These strategies have also been discussed in relation to helping the lonely and socially isolated.  It will be quite a surprise to know that majority of psychotherapy principles have been derived from the social theories (i.e., interpersonal theory, stress theory, social class, and social support).
Nowadays, preventive mental health strategies are need of the developing countries. Preventive mental health in the form of suicide crisis interventions, early detection of psychosis, social skills training to mentally challenged individuals, problem solving skills for the stressed out adolescents and working class population, self-help groups for increasing social support networks, etc., have been found to be quite beneficial in decreasing the psychiatric morbidity in vulnerable individuals. Moreover, I will not be wrong if I say that social theories have implications in all these preventive mental health strategies.
| Conclusion|| |
From the above description of social theories, it is evident that these age-old social theories are still relevant in the current psychiatric practice in all the domains of mental illness starting from the genesis to approach to treatment. Even though psychiatry has advanced in recent times in all fields of research on neurobiology and psychopharmacology, but still its roots are in the traditional social theories and hence, social psychiatry. It is because the symptoms of mental illness are only expressed in a social context. One should not have a tunnel vision of visualizing a given psychiatric disorder only in its biological aspects. The appropriate approach is to link biology of an illness with its social context. There is a necessity to realize that psychiatric thinking about the mental disorder is not exclusively biological and that there are various biosocial or biopsychosocial models applicable in its practice and in its accounts on mental phenomena. Only then, the approach is of holistic nature and will be beneficial to our patients. Social theories continue to play a major role in our understanding of mental illness and are still very relevant.
I would further like to suggest to the new generation of psychiatrists that they should develop an approach (1) to find the link between the traditionally separate social and biological understandings of mental disorders, (2) to apply the social theories for better management of patients with mental illness, and (3) to understand that psychiatry has its roots in society and cannot prosper without its social theories.
I wish to dedicate this prestigious Oration of Indian Association for Social Psychiatry instituted in the memory of the illustrious late Prof. A. Venkoba Rao to my family and to my teacher Prof. Vijoy K. Varma - who needs no introduction to the fraternity of Social Psychiatry. I deeply appreciate and gratefully acknowledge the contribution of my trusted colleague, Dr. Sandeep Grover (Additional Professor, Department of Psychiatry, PGIMER, Chandigarh), and the young, bright associate - Dr. Swapnajeet Sahoo (Senior Resident, Department of Psychiatry, PGIMER, Chandigarh). This oration is the outcome of dialogue among the three of us.
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Conflicts of interest
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[Figure 1], [Figure 2]