1. Introduction
The biopsychosocial model (BPSM) of psychiatric conditions is frequently invoked by researchers and clinicians alike, and it is sometimes regarded as the orthodox account of mental illness. But though it has been explicitly articulated since the late 1970s (Engel Reference Engel1977), many researchers think that it has not been sufficiently taken to heart (Wade and Halligan Reference Wade and Halligan2017). Even when it is taken seriously, the BPSM rarely highlights political conditions separately from social determinants of mental health. Recent advocates of the BPSM in medicine sometimes refer in passing to political factors but seldom detail them, especially when it comes to psychiatry (e.g., Bolton and Gillett Reference Bolton and Gillett2019). A political framing of mental health is not incompatible with other framings (e.g., biomedical, psychological, social), but it emphasizes political conditions as contributing causal factors. To be sure, the political is often subsumed under the social and is not easily differentiated from it, but I will argue that there are distinct advantages to isolating the political dimension and according it separate treatment. There may not be a neat way of differentiating political from social factors, but one way to do so is to say that they concern matters of justice and power. The political sphere is one where injustice, oppression, and exploitation are played out, and where individuals face state power and are subject to control by governments and other authorities. By highlighting political factors, one signals that power structures are causally implicated in these psychiatric conditions in ways that may not be obvious. In fact, I will argue that political framing matters for three reasons. First, when political conditions like oppression, authoritarianism, colonialism, military occupation, and other forms of injustice are explicitly implicated in the causal determinants of mental health, this can help further our understanding of the genesis and provenance of psychiatric conditions. Second, it matters for intervention: Sometimes the most appropriate and effective interventions are ones that target the political sphere or the broader community rather than just the individual. Third, identifying political factors can point to inadequacies in existing psychiatric diagnoses and reorient clinicians and researchers toward alternative categories, which differ from those in conventional psychiatric taxonomies. In this article, I will try to corroborate each of these claims in turn with reference to the case study of the Israeli military occupation of Palestine (West Bank and Gaza Strip). In section 2, I will argue that political framing can advance our causal understanding of psychiatric conditions (section 2.1), help identify effective interventions (section 2.2), and indicate alternative diagnoses (section 2.3). In section 3, I will raise some objections to the political framing approach, before concluding in section 4.
2. Advantages of political framing
2.1. Causal interactions
An obvious advantage of a political framing of some psychiatric conditions is that it highlights the ways in which the broader political environment contributes causally to psychiatric conditions. Emphasizing political factors brings out the fact that many conditions that are conceived of as emanating entirely from the individual are better understood as the result of causal interactions between individuals and their political circumstances. Moreover, it suggests that some of these conditions may be functional responses to regimes of oppression, aggression, and exploitation. Thus, a political framing sometimes situates the pathology or dysfunction not in the patient but in the political (dis)order and may help to explain it as a functional reaction. This is not to say that political conditions are the sole or even the dominant causes of psychiatric conditions, but singling them out for special attention is still warranted if the default view is to see these causes as located solely within the individual. It is also not to say that all psychiatric responses to political circumstances are functional, but there is evidence that some may be.
In their ethnography of psychoanalysis in Palestine, Sheehi and Sheehi (Reference Sheehi and Sheehi2022, 53) quote the head of the Palestine Red Crescent Society, Fathy Flefel, as saying: “[T]he [Israeli military] occupation imposed itself in everything, why would we not think it doesn’t also impose itself psychologically?” The claim that conditions of military occupation impact almost all aspects of life is hard to dispute and is emphasized by other researchers, who draw attention to the fact that restrictions in the occupied Palestinian territories affect individuals’ access to healthcare, education, and social life, among other facets of everyday existence. Some of the measures used by the Israeli military occupation include mass incarceration, house demolitions, live ammunition against protesters, military checkpoints on major roads, curfews, surveillance, and restrictions on movement, as well as limitations on resources such as water, electricity, building materials, and even food (especially in the occupied Gaza Strip) (Amnesty International 2022; B’tselem 2021; Human Rights Watch 2021). In a brief overview of mental health in Palestine, researchers report that “[a]pproximately 40% of the men in the Occupied Palestinian territory have been detained by Israel, often for indeterminate periods for no specific charges and often suffering mistreatment or outright torture while detained” (Jabr et al. Reference Jabr, Morse, El Sarraj and Awidi2013, 174). And in a survey of 3,415 Palestinian high school students in the Ramallah district of the occupied West Bank in 2002–3, researchers found that 80 percent had witnessed a shooting, 28 percent had seen a stranger killed, and 11 percent had seen a friend or neighbor killed. Nine percent of boys reported being tortured, as compared with 1 percent of girls (Giacaman et al. Reference Giacaman, Shannon, Saab, Arya and Boyce2007). An expert on trauma among Palestinians, Shalhoub-Kevorkian (Reference Shalhoub-Kevorkian2010, 6) writes:
Though they may appear on paper as isolated physical events, the trauma caused by a house demolition or a violation of basic rights permeates every aspect of life, irrevocably altering the daily reality of those targeted by this violence. This trauma spirals out and impacts the body, mind, social networks, economic status, etc. of all those involved.
In some discussions of social causation, philosophers have drawn a distinction between initiating and sustaining causes, or triggering and structuring causes (see e.g., Haslanger Reference Haslanger2016; Ross Reference Ross2023; Faller Reference Faller2023). The claim that political circumstances are causally implicated in psychiatric conditions is neutral among these alternatives. In some cases, the surrounding political context can play a role in triggering a psychiatric condition but play no role in its continuation. An episode like imprisonment may trigger a series of psychological effects in the individual, leading to long-term changes. In an extended survey of 128 Palestinian male former political prisoners in the Gaza Strip who had reported various degrees of torture and ill-treatment, Punamäki et al. (Reference Punamäki, Kanninen, Qouta and El-Sarraj2002) identify a wide range of psychological defenses that the men manifested in their subsequent lives, ranging from sublimation and suppression to dissociation and isolation. These defenses are posited to be “processes that help individuals to maintain their integrity in the face of threat and danger” and because most participants had been released over a decade before the survey was carried out, these psychological effects can persist long after the events in question (Punamäki et al. Reference Punamäki, Kanninen, Qouta and El-Sarraj2002, 288). Moreover, imprisonment may have knock-on effects not just on the person who is imprisoned (usually a man and often a head of household), but on their family and others in their social networks. This manifestation of military occupation can be a triggering cause that has persistent effects on mental health and affect a wide circle of people.
In other cases, the manifestations of military occupation might not have played a role in instigating a psychiatric condition but may contribute to its persistence and shape its course. In the ethnographic work quoted in the preceding text, one clinician described a patient as follows:
I had a patient who suffered from delusions in the Old City [of Jerusalem]. He was in his 50s and married. He was born and raised in the Old City, as had his family for generations. He felt that if he left the Old City, if he went out of its walls, he would fly away. You know, he thought he would just float away into the sky. When inside the city, he had some anxiety but was functioning. It’s only when he’d get to a [Old City] gate, he’d get panicked and he’d turn away. Sure, he had schizophrenia. The Occupation…of the Old City was not the cause of his schizophrenia. At least, not directly it seems. But the occupation was the language [in] which his schizophrenia manifested itself. (Sheehi and Sheehi Reference Sheehi and Sheehi2022, 73–4)
In saying that the military occupation did not cause the patient’s schizophrenia “directly,” the clinician may be distinguishing between a triggering cause and a structuring cause, or between a sole cause and contributing cause. Either way, this points to the fact that certain psychiatric conditions that may have emerged under a wide range of sociopolitical conditions may yet be shaped by the military occupation in important ways. One expert on Palestinian mental health observes: “Palestinians are ruled not only with brute force, but also with ambiguity, uncertainty, insecurity, loss of dignity, and deliberate humiliation, all-important consequences of chronic war that need acknowledgment and not merely as a matter of physical survival worthy of assistance and support” (Giacaman Reference Giacaman2018, 16). These conditions may not be reducible to individual incidents or specific events but constitute pervasive conditions. Disentangling causes in these cases is not a trivial matter and it may not be possible in many cases to apportion causal responsibility with confidence, but evidence from patients, clinicians, and researchers often leaves little doubt about the role of the political context.
Some of the psychiatric conditions that arise as a result of the political conditions in the occupied territories, whether as triggering or structuring causes, may be construed as functional responses to the surrounding political context. For instance, in the case of the patient whose schizophrenia manifested as panic about leaving the Old City of Jerusalem, the clinician in training states that “the symptom, the fear, assured him that he’d remain in Jerusalem. It kept him near his family,” adding laughingly, “the symptom was a sort of sumud [steadfastness]. You know, he was not going anywhere” (Sheehi and Sheehi Reference Sheehi and Sheehi2022, 75–76). Given that incarceration is ubiquitous, and that exile is a form of punishment adopted by the Israeli security services, there is a certain utility in symptoms that lead a young man to restrict his movements. This is just one illustration of the way in which reactions to conditions of political pathology may sometimes serve as functional responses or coping mechanisms.
2.2. Sites of intervention
A second advantage of specifying and highlighting political circumstances as contributing causes to psychiatric conditions lies in identifying the appropriate site of intervention. In many cases, psychiatric conditions are best treated not by intervening directly on the patient, whether with talk therapies, pharmacological treatments, or otherwise, but in changing the surrounding context, such as an abusive relationship. Highlighting the importance of political circumstances can also have the effect of directing attention to remedies that involve changing broader political realities or intervening on a community-wide level. This theme has been repeatedly voiced by experts on Palestinian mental health. One group of researchers studying the occupied Palestinian territories put it as follows:
To focus on atomized individuals in isolation of what also happens to others, to relationships, and the physical and social worlds that are usually violated or destroyed in war, is to risk focusing interventions on medical or one-to-one therapies and interventions when recovery entails first and foremost the reconstruction of people’s lives and their environments. In the case of Palestinian youth, a community centered social approach as opposed to an individualistic therapeutic one may better help in assisting youth in positively coping with the social suffering of war. In the end, however, recovery is rooted in the attainment of justice and then peace. (Giacaman et al. Reference Giacaman, Shannon, Saab, Arya and Boyce2007, 366)
This quotation brings out the fact that a political diagnosis does not necessarily imply that the only effective intervention consists in the achievement of justice. Although attainment of a just political order should be the ultimate goal, it may be thought to postpone treatment indefinitely for individuals suffering from pressing mental health conditions. Telling patients that they cannot expect relief before freedom from oppression is not an option for those with debilitating conditions. However, recognizing the political causes of their conditions can also help to indicate other forms of relief, particularly ones that emphasize the community and invoke solidarity with others.
Various Palestinian clinicians and mental health practitioners have pointed to different forms of community therapy that are effective in circumstances of military occupation. Thus, psychotherapist Samah Jabr states:
Community mental health care is often effective for us because [it offers] treatment, psycho-social education, and counselling for ‘common’ mental disorders, anxiety, depression, issues of sexuality, domestic life, OCD, and suicide. But also, for us, it involves conditions under which Palestinians live, sharing communal trauma, an understanding of daily violence. (Sheehi and Sheehi Reference Sheehi and Sheehi2022, 102)
Similarly, counseling center director Rana Nashashibi explains the efficacy of group work thus:
When we work with groups, we see how it works systemically, and working within their communities, give them scenarios to think about, not to tell them, think about where they are; get them to be active, not be passively receiving information. They actively think about themselves, in relation to the situation. They start to feel they can breathe. They see themselves in relation to others as opposed to think about themselves as solely as victims. (Sheehi and Sheehi Reference Sheehi and Sheehi2022, 102)
When patients see themselves in relation to others, it provides them with coping strategies that might otherwise not be available. A study involving focus groups in the Gaza Strip in 2012, all of whose members lived in refugee camps and had suffered a serious personal loss in the previous ten years due to the military occupation, identified various coping strategies. Among the five main coping strategies described, two involved an orientation toward the community. One was labeled “moving from individualism to collectivism” and entailed a sense of shared experience on the part of individuals. Participants indicated that their sense that the whole community was targeted and punished gave meaning to collective coping, which in turn enabled their individual survival (Afana et al. Reference Afana, Tremblay, Ghannam, Ronsbo and Veronese2020, 2037). The researchers write that the sense of being in it together “creates community solidarity, kinship support and the ability of individuals to understand the political situation,” adding that “it provides protection against fear, despair and helplessness” (ibid.). Another coping strategy emphasizing the community was labeled “social support and expression of distress” and involved the engagement of immediate and extended families. The reliance on kin networks to support individuals was found to be an important resource for individuals attempting to maintain their psychological integrity. In addition, collective punishment was found to have increased social cohesion and support because it affected the entire community rather than isolated individuals (ibid., 2039).
In this connection, Palestinian clinicians often use the techniques of activism in their practice, for example, in deploying the method of sumud (steadfastness): “[C]linical practice reproduces the social and psychological processes and practices of sumud by shoring up Palestinian psychological defenses and mental health through connecting them to shared experience, but also by refusing to disavow the ‘madness’ (junun) of their lived experience as settler-colonial subjects” (Sheehi and Sheehi Reference Sheehi and Sheehi2022, 78). Similarly, Afana et al. (Reference Afana, Tremblay, Ghannam, Ronsbo and Veronese2020) point out that some studies from South Africa, Northern Ireland, as well as Palestine, have shown that active participation in or ideological commitment to political struggle can increase resilience and enhance coping strategies. Conversely, some clinicians observe that if it is disengaged from the political context, a certain type of stopgap treatment can amount to a form of collusion with oppressive political conditions. As one clinician observed to Sheehi and Sheehi (Reference Sheehi and Sheehi2022, 81–82): “We can be the tool for oppression, for the oppression that we oppose. Using CBT [cognitive behavioral therapy] to help people ‘adapt’ to their condition. Their condition is not normal though. It is colonialism. It is occupation. It is violence.” This same clinician considered that psychoanalysis allowed clinicians to identify “the psychopathy of the occupation not the patient” (ibid., 82). A colluding attitude is also found in treatments and interventions that understand circumstances of military occupation in relatively apolitical terms, such as “war” or “conflict.” The distortion inherent in this way of framing military occupation points naturally to the limitations of existing diagnoses, which are primarily developed for circumstances that are less pathological or chronic.
2.3. Limitations of and alternatives to existing diagnoses
The third benefit of a political framing is that it can point to the shortcomings of standard psychiatric diagnoses and suggest alternatives. In the context of long-term military occupation in Palestine, clinicians and researchers have proposed diagnostic categories for understanding psychiatric conditions that are quite different from the ones found in standard psychiatric taxonomies such as the DSM-5. In this section, I will survey a few examples drawn from a number of researchers and clinicians.
One psychiatric diagnosis that is often considered to be inapt for individuals in extreme political circumstances is that of posttraumatic stress disorder (PTSD). Even though PTSD is one of the most common psychiatric diagnoses for Palestinians under military occupation, clinician Samah Jabr (Reference Jabr2017) points out that it is far from apposite because “traumatic threats are ongoing and enduring” and there is no post-traumatic safety. But this is by no means the only instance in which clinicians and researchers detect serious gaps and deficiencies in standard diagnostic categories. This is also true for psychiatric taxonomies that are supposedly geared toward “conflict zones.” Sheehi and Sheehi (Reference Sheehi and Sheehi2022, 96–97) quote the Director of the Palestine Counseling Center, Rana Nashashibi as saying: “To deal with international donors, psychological categories of mental health are already prescribed categories—trauma, victim, ‘conflict’ not occupation—so we have to practice away from reactivity and to being more proactive.”
In the vein of proactivity, some researchers in public health have attempted to develop a vocabulary of psychiatric conditions and mental health that is suitable for the Palestinian cultural context and the political circumstances of military occupation. Giacaman (Reference Giacaman2018, 18) reports that during the Second Intifada (Palestinian Uprising, 2000–5), her team tried to develop measures of health derived from interviewing people and drawing on their experiences. Taking their cue from patients, they identified such factors as humiliation as central to people’s experience and suffering, even developing “a scale to measure humiliation in order to reflect the invisible trauma of war” (Giacaman Reference Giacaman2018, 19). Other measures of well-being drew on the vocabulary used by patients, such as Arabic terms like muhattam and mudammar (literally, feeling broken and destroyed), among a host of others (ibid., 20). Similarly, Sheehi and Sheehi (Reference Sheehi and Sheehi2022, 80–81) note that the Arabic terms khanq and makhnuq (literally, suffocation and suffocating or suffocated) occurred repeatedly in their conversations with Palestinian clinicians. These terms are not ones used in standard psychiatric taxonomies and may shed more light on patients’ subjective states than the canonical diagnostic categories. Additionally, Afana et al. (Reference Afana, Tremblay, Ghannam, Ronsbo and Veronese2020) solicited from their interviewees alternative terms to PTSD and compiled the following list of Arabic words: sadma (shock), faji’ah (calamity), musiba (disaster), balwa (affliction), and nakba (catastrophe).
Some alternative measures of mental health have been precisified and validated, and have been found to be more reliable than some conventional measures and categories. During a multistage study conducted with Palestinians across the occupied territories, in the West Bank, East Jerusalem, and Gaza Strip, a team of researchers attempted to identify types of suffering “not captured in existing mental health instruments” (Barber et al. Reference Barber, McNeely, El Sarraj, Daher, Giacaman and Arafat2016, 1). In the first phase, in the course of group interviews with sixty-eight Palestinians, the participants articulated a form of psychological suffering distinct from the usual constructs of emotional distress discussed in psychiatric science, such as depression, anxiety, grief, and post-traumatic stress (ibid., 5). Researchers reported that “participants elaborated a more existential form of mental suffering: feeling that one’s spirit, morale and/or future was broken or destroyed, and emotional and psychological exhaustion” (ibid., 1). After this first interview phase, the answers from the interviews were used to design questions for a survey administered to a group of 1,788 Palestinians living under military occupation (after first administering a pilot to a representative subsample of 508 people). Because the Arabic words for “broken” and “destroyed,” as well as their close synonyms, were identified as particularly salient in coding the initial interviews, the researchers developed three survey questions based on these expressions. In the quantitative survey phase, they tested the reliability and validity of these expressions of sentiments, finding that the three-item “feeling broken or destroyed” scale had strong inter-item consistency across time, samples, and subgroups within samples, indicating reliability. The same scale also distinguished itself from two conventional measures, “feelings of depression” and “trauma-related stress,” indicating that it was measuring an independent construct, hence validity. The researchers conclude that the form of social suffering measured by their survey questions was not captured by existing mental health constructs because of its political source (ibid., 13). Moreover, according to their participants, this psychological state is “a function of the chronic and burdensome political and economic contexts that plague them” (ibid., 10–11). The researchers also speculate that these constructs may be applicable to other populations that are oppressed or discriminated against (ibid., 14).
Giacaman (Reference Giacaman2018, 19) notes that the development of an alternative vocabulary for mental health is necessary to gauge individual suffering; her team concluded that “dignity or its loss [i.e. humiliation] can be used as one of the indicators of social suffering related to war and for the assessment of well-being.” Like Barber and colleagues, her work focuses on social suffering and its political causes in the context of military occupation. Giacaman (ibid., 22) emphasizes “the need for a reframing of the causes and health consequences of exposure to political violence by placing the concept of suffering at the core of the health paradigm, and by adding a political domain as the ultimate determinant of population health.” Though these attempts in Palestine and in other circumstances of oppression are still at a relatively early stage of development, they promise to suggest additional categories for understanding mental health.
3. Challenges to political framing
In the previous section, I argued that a political framing or reframing of psychiatric conditions has important theoretical and practical advantages, in terms of understanding their causes, intervening on them, and devising alternative psychiatric categories to capture them, specifically in the context of the Israeli military occupation of Palestine. In this section, I will consider two challenges to this account, having to do with the threat of relativizing psychiatric conditions and the complications involved in considering political factors as causal factors in psychiatric practice.
The first challenge gives rise to some familiar questions in the philosophy of psychiatry concerning the reality of psychiatric conditions. If psychiatric conditions are reframed as resulting from political circumstances, then this raises the specter of relativism when it comes to these conditions. I have argued that psychiatric conditions can be triggered or structured, or both, by political conditions. This means that they might not exist, present in a certain way, or take a certain course were it not for the ambient conditions of injustice or oppression. But does this mean that political circumstances are constitutive of these psychiatric conditions, which must be relativized to them, or just a causal factor in their genesis or sustenance? In response, I would point out that I have been arguing that the relation is causal. Even though sustaining causes might sometimes be considered constitutive because they are necessary for the continued existence of their effects, this does not imply that the very same individual, if transplanted from one political context to another, might thereby automatically cease to have a psychiatric condition. However, it may mean that such an individual, had they developed in alternate circumstances or were those circumstances to change, may not have acquired or may not maintain the same mental condition, respectively. Moreover, if conditions of military occupation were to cease, it is not inconceivable that some of those suffering in the former circumstances would have relief from their symptoms. That is just what would be expected if political factors are sustaining causes, and it does not imply that psychiatric conditions are relative to a political perspective or point of view.
A second challenge to this case for political framing has to do with the apparent unwieldiness and impracticality of identifying political causes of psychiatric conditions and intervening on them. It might be said that therapists and psychiatrists are professionals trained in diagnosing patients and treating them individually on a one-by-one basis, not in curing the problems of the world. They cannot be expected, in the course of diagnosis and treatment, to factor in the entire sociopolitical context. The response to this objection is primarily a concession rather than a rebuttal. It can be admitted that taking this reframing proposal seriously does require addressing a broader range of issues and problems in the larger sociopolitical context. But this should not be too surprising. After all, it is a truism among many physicians, therapists, and social workers that there is a need to take into account the larger picture when treating patients, and this encompasses not just the family unit, school, workplace, and circle of friends and acquaintances, but also society at large. Approaching psychiatry from this vantage doubtless makes both diagnosis and treatment more daunting, but many mental health professionals already recognize the necessity of such a holistic approach. Moreover, when it comes to treatment, although many professionals who take political framings seriously acknowledge that ultimate relief may only be achieved by a wholesale overhaul of the political context, many also propose other social and political therapies that fall short of that, as seen in section 2.2. While recognizing that the end of military occupation and justice for Palestinians is ultimately required for mental health, many practitioners in Palestine adopt community-oriented and other sociopolitical interventions that they regard as especially suited for the context, though they obviously cannot be a substitute for liberation.
4. Conclusion
This defense of a political framing of psychiatric conditions is based on the case study of military occupation in Palestine. The conclusions may not be widely applicable to other cases, but there are indications that some of the lessons are transferable, when it comes to ascertaining etiology, identifying sites of intervention, and developing alternative diagnoses, as mentioned in previous sections. Despite the fact that political framings may complicate our attempts to understand and treat psychiatric conditions, an appreciation of the political context is necessary, particularly when there is clear evidence that power differentials and injustice are part of the complement of causes. As others have argued, individual dysfunction is not always an appropriate framework for understanding psychiatric conditions (e.g., Lilienfeld and Marino Reference Lilienfeld and Marino1999; Garson Reference Garson2022). If there is disorder or pathology at all, it is often in the political order rather than internal to the individual, who may be responding in self-defense against extreme injustice and oppression.
Acknowledgments
For very helpful comments on this article, I am grateful to Justin Garson and Şerife Tekin, as well as the participants and audience at a symposium on alternative framings of mental illness at the Philosophy of Science biennial conference in New Orleans, November 2024. I am especially indebted to the organizers, Justin Garson and Sera Schwarz, who invited me and encouraged me to work on this topic.
Funding statement
None to declare.
Declaration statement
None to declare.
