Challenging the Behavior Paradigm and Moving Towards A Socio-Structural Understanding of Mental Health in a COVID world

May 5, 2022

Michaela Z. Whitley

Mental illness has received increasing attention as a public health concern since the emergence of COVID-19. Amidst a pandemic landscape in which we must grapple with grief and an ever-changing world, we have begun to consider how mental health intersects with our push for social justice as well as how mental illness stems from socio-structural determinants including racism. While the COVID-19 pandemic has impacted the mental health of many, it has also created an opportunity to discuss mental illness more openly and through a health equity lens, considering the ways in which systems of oppression contribute to mental illness. This includes opportunities to challenge patterns within the field of mental health care that perpetuate such inequities, including the prevalence of what I have come to call the behavior paradigm. 

What is the behavior paradigm? Mental health and illness are often approached from an internal perspective: that in order to treat mental illness, we must treat the individual, independent of the outside world. Therapy, psychiatry, and even concepts like self-care and the recovery model prescribe individual behavior change as the quintessential element of mental illness treatment. It operates on the assumption that if your mental health is poor, you simply haven’t done enough to make it better. This behavior paradigm does not acknowledge the ways in which our world, and most importantly systems of oppression, shape our mental health. Much of our modern mental health care system focuses on such individual or behavioral interventions, so much so that these services are often referred to as behavioral health. However, there is significant data to support that socio-structural determinants have more influence on health outcomes and mortality than does individual behavior. 

It is imperative that we acknowledge how racism and income inequality have contributed to the ongoing mental health crisis, and understand how the history of psychiatry perpetuates inequitable and poor mental health care. Psychiatry has a long history of upholding racism: to name a few examples, psychiatry was used to justify segregation, contributed to harmful stereotypes of Black bodies, and utilized violence under the guise of treatment for racial and ethnic minorities. Whites continue to hold much of the power in our systems of care: in 2015, an appalling 86% of psychologists in the US were white. In 2021, an estimated 77% of therapists are white. With the racist history of psychiatry and therapy unacknowledged, the prevalence of white practitioners in the two disciplines, and insufficient training in acknowledging the experience and impacts of racism on their patients’ wellbeing, there is a clear lack of safety and trust for people of color in seeking mental health care. To be effective, mental health services must be affirming for all races and ethnicities. Harrell et. al describes how all forms of racism have psychological manifestations, mediated through a reduced sense of well-being, anxiety and ruminations, suppression, alienation, and generally negative effects. This description has striking similarities to the symptoms of many mental health conditions and demonstrates why addressing the accessibility of affirmative, diverse, and racially-conscious mental health care should be a social justice priority. 

The mental health trends associated with the pandemic are concerning; issues of equity are being exacerbated and vulnerable populations are at increased risk both for contracting the virus but also worsening mental health symptoms. Overtaxed healthcare systems have been unable to meet the increasing demand for mental health care; additionally, these systems are not designed to address socio-structural determinants. Without urgent attention to socio-structural causes, we could anticipate a continuous trend of increasing mental health crises: globally, nationally, and locally. In addition to seeing a trend of worsening mental health, the pandemic’s impact on people of color is a concern, with Black and Latinx adults in the United States reporting more symptoms than whites while also having more difficulty accessing care. A study of over 19,000 people across 7 countries showed an increased risk of COVID-19 mortality among those living with severe mental illness, enough so to consider a severe mental health condition as a high-risk factor for COVID-19, which is especially troubling when understood through a health equity lens.

We should begin to consider interventions such as universal healthcare, guaranteed housing, a universal basic income, police and prison abolition, and attention to socio-structural determinants as forms of preventative mental health care and suicide prevention. The COVID-19 pandemic has illustrated just how much outside circumstances shape our mental health and our ability to access the tools needed to obtain mental wellbeing. As people lost loved ones, jobs, insurance coverage, and their sense of safety and stability, our collective mental health began to deteriorate. No amount of therapy or self-care alone can address the fundamental ways in which our lives have changed since March of 2020. Neither can they counter the socio-structural determinants of mental illness, especially when these determinants mean services and practices are out of reach for so many. Our behavior doesn’t guarantee a change in circumstance, nor does it eliminate the oppressive systems we are subject to based on our race, ethnicity, gender, sexuality, or disability status–the behavior paradigm only serves to mask the ways in which societal injustice negatively impacts mental wellbeing. 

For these reasons, I refuse to use the term “behavioral health”.  In renouncing this term, we can give full attention to the ways in which our societal structures and inequity influence mental health, a much-needed shift for those of us working in the field. We can begin to move away from the harmful narrative of individual responsibility for our mental wellbeing, and consider the ways in which our society and its many-layered systems of oppression contribute to mental illness. Acknowledgment of these systems and the inequities they produce is an important first step toward radically changing how we understand and treat mental illness, and toward creating a world where affirming and safe mental health care is accessible to all. 

Michaela Z. Whitley is an MPH candidate at Simmons University studying the intersections of severe and stigmatized mental illness with mass incarceration and policy, with an interest in social and public histories. She is the recipient of Simmons’s Future Leaders in Health Equity Scholarship, and identifies as bipolar, a psychiatric survivor and mental health advocate. Michaela is from the Boston area and currently lives in Colorado with her rescue dog Huck.