Inspired by a banner carried by protesters Chile, "it's not depression, it's capitalism” reads this wall in Beirut, Lebanon. December 4, 2019. (Lara Bitar/The Public Source)

Inspired by a banner carried by protesters Chile, "it's not depression, it's capitalism” reads this wall in Beirut, Lebanon. December 4, 2019. (Lara Bitar/The Public Source)

Depressed? You Might Be Suffering from Oppression: On Malaise, Alienation, and Solidarity

Day 43: Thursday, November 28, 2019

While dining with friends in Beirut recently, some at the table discussed feeling distress, worry, and general unhappiness, with no apparent identifiable reason other than general concern about the unrest. Given that I am a mental health professional who works in mental health and conflict, I was asked if this was “depression.”  I am always alarmed by the casual way people use depression to describe a general sense of unease. Depression is a specific clinical diagnosis; it has a long course, involves particular issues, and often requires the help of a professional. Depression does not capture what many in Lebanon have been expressing since October 17 in different settings, including in the mental health stands that popped up in public spaces in Beirut, Jal al-Dib, and Tripoli. Staffed by mental health professionals, these spaces were open to anyone to discuss how the situation was affecting their individual and collective mental health. When I attended the discussions, it was clear that many were not describing clinical depression or anxiety, but a general sense of malaise.

Malaise, in the standard definition of the word, is “a vague sense of mental or moral ill-being.” For mental health professionals, malaise is the consequence of coping with everyday life stressors. People don’t tend to notice their malaise; it is hidden under the veil of common sense, or the sensation that “this is how it is supposed to be.” Once malaise interferes with daily functioning and manifests with other symptoms that overwhelm a person’s capacity to deal with them, it becomes clinical and needs to be addressed.

The extent to which individuals are aware of the symptoms, and the degree to which these symptoms interfere with functioning, is highly dependent on social context. Societies that develop malaise are ones where one group (aligned by class, race, religion) oppresses other groups and their means to gain actual and social capital. Oppression — the systemic and institutional abuse of power by one group at the expense of others and the use of force to maintain this dynamic — has clear mental health consequences: being a victim of discrimination, poverty, violence, and prejudice deteriorates your mental health and wellbeing.

It is hardly a new idea that social environments affect the way people feel. It was in 1977 that the biopsychosocial model proposed that social factors could be as crucial as medical or psychological ones in determining health and development outcomes. Yet the model is problematic; it is unclear which social factors count or what to do about them. Often, the ones included are life’s immediate worries and uncertainties, and the solutions prescribed are personal: think differently, think harder, take a break, meditate, talk or, finally, take a pill. While this may work for clinical syndromes, it is counterproductive or at least partially effective for general malaise.

Focusing on the structural/collective level of human psychology, [liberation psychology] emphasizes that structures of power and oppression (rather than childhood experiences) create daily stressors of uncertainty, insecurity, and violence that negatively affect our mental wellbeing.What do we do when people are suffering from malaise, which cannot be addressed through individual fixes? What if what we are seeing is not clinical depression en masse, but people reacting in a rational way to losing their sense of security, meaning, or belonging? How can we reconcile the struggle to get one's inner psychological life in order with the effort to meet one's daily needs and secure one's savings and future? What is the role of mental health professionals in a system (call it capitalism, neoliberalism, or any other name) designed to have the majority of the population living perpetually in fear and insecurity?

Traditional psychology predominantly espouses an individual-based, Eurocentric view of the self as a universal fact. And if all you have is a hammer, everything looks like a nail; if our primary tool is an individual-based diagnosis, then everyone is seen as suffering from an anxiety disorder due to personal circumstances. The danger of reducing complex social problems to individually-focused ones is that the solutions adopted will also be individually-based. The conversation revolves around how to increase mental health treatment through stigma reduction, psychoeducation, or improving access to the services, rather than whether we need to think about what the population needs at large.

Enter liberation psychology, a tradition developed in Latin America in a social context resembling that of Lebanon and the region today. Focusing on the structural/collective level of human psychology, it emphasizes that structures of power and oppression (rather than childhood experiences) create daily stressors of uncertainty, insecurity, and violence that negatively affect our mental wellbeing. But awareness of an exploitative system is not enough to achieve more significant control over one’s life. One cannot be liberated through awareness alone. As one writer put it: “I personally can’t afford to wait until after capitalism has been abolished to be happy, and I doubt you can either.” According to liberation psychology, the solution must be the transformation of these structures, which can only be done through the collective action of the oppressed not through individual effort.

We can categorize the psychological processes that lead to liberation into three domains: personal, relational and political. The personal domain is the focus of traditional mental heal: treating mental illness through individual efforts regarding the self. In our current context, this approach includes psychological first aid tents and mental health awareness discussion groups.

The relational domain refers to how oppressive structures pitch groups against one another as competitors over resources. Today in Lebanon, we see daily fights in banks between customers and staff who are likely in the same boat, or confrontations between people blocking roads and those who want to open them. What is needed is solidarity. This entails rejecting the fragmentation of suffering (“Christians face discrimination,” “Shi‘a are not being treated fairly”), and forging cross-sectarian and cross-regional networks to break the monopoly of those who benefit from keeping oppressed groups at odds with each other. This sense of possibility was felt in the first weeks of the protests across public spaces in downtown Beirut as the area transformed into one where people from different backgrounds could spend time, meet others, discuss, and even be entertained, all without the need to consume exorbitantly.

Collective work is crucial for developing critical consciousness; it encourages both a common awareness of the problem and our collective capacity to change it.As for the political domain, liberation psychology espouses a broad view of political action; any activity done to challenge the power structure counts. But to be effective, it must be grounded in conscientization, or “the process whereby individuals and groups achieve an illuminating awareness of the socioeconomic, political, cultural, and psychological factors that determine their lives and their capacity to transform that reality.” The ability of the oppressed to develop this critical consciousness depends primarily on how much they have internalized the oppressive framework to explain  suffering and misery, such as belief in an inferior identity, deference to dominant groups, groupthink, or legitimizing myths. Collective work is crucial for developing critical consciousness; it encourages both a common awareness of the problem and our collective capacity to change it. In Lebanon, open discussions in the squares led people to organize into groups for more productive work in the squares and beyond.

Addressing systemic issues does not come naturally to the mental health profession, founded in large part on individually-based approaches. But any approach to mental health today must recognize that if the world we live in is making us sick, then it is not enough to change ourselves. Through collective efforts against isolation and alienation, we need to promote social healing by changing the system responsible for our malaise. For ultimately, what is mental health work if not a desire for people to exercise greater agency and improve their well-being?