2.3 Social Factors in Psychological Disorders

We exist in a world filled with social forces: our relationships with family, friends, colleagues, and neighbors; the messages we receive through the media; the norms of our culture. These social forces help to shape who we become. They can help to protect us from developing psychological disorders, or they can make us more vulnerable to or exacerbate psychological disorders. Social forces begin to exert their influence before adulthood, and they can affect each generation differently, as a culture changes over time. For instance, the more recently an American is born, the more likely he or she is to develop a psychological disorder (Kessler, Bergland, et al., 2005), perhaps because of social trends such as the increased divorce rate, an increased sense of danger, and a diminished sense of local community (Twenge, 2000).

Consider Big Edie and Little Edie. The social factors that influenced them include their relationships with other members of their family, their financial circumstances, the prevailing community and cultural standards of appropriate behavior for women—and the discrimination they encountered. Let’s examine in more detail each type of social factor—family, community, and culture—as well as the stress they can create.

Family Matters

Certain aspects of family life form the basis for the type of attachment a child has to the primary caregiver, which influences how a child comes to view himself or herself and learns what to expect from other people. Other family-related social factors include the style of interaction among family members, child maltreatment, and parental psychological disorders. All of these factors can contribute to the emergence or persistence of psychological disorders.

If family members exhibit hostility, voice unnecessary criticism, or are emotionally overinvolved, then the family environment is characterized by high expressed emotion. Based on what we know of the Beale women, their family environment would likely be classified as high expressed emotion. Consider these typical comments by Big Edie to her daughter: “Well, you made a rotten breakfast,” followed moments later by, “Everything is perfectly disgusting on account of you” (Maysles & Maysles, 1976). Big Edie and Little Edie were also clearly overinvolved with each other: They spent virtually all their waking hours together, participated in all aspects of each other’s lives, and responded to each other in exaggerated ways.

British researchers found that among people with schizophrenia, those whose families showed high expressed emotion were more likely to have the disorder recur; the same association between high expressed emotion and relapse has been found in other studies in the United States and China (Butzlaff & Hooley, 1998; Yang et al., 2004). This may be because high expressed emotion is associated with family members’ belief that the patient has the ability to control his or her symptomatic behaviors, which sometimes leads the family members to push the patient to change (Miura et al., 2004). Unfortunately, these exhortations may well backfire: Instead of encouraging the patient to change, they may produce the sort of stress that makes the disorder worse! When family members are educated about the patient’s disorder and taught more productive ways of communicating with the patient, relapse rates generally decline (Miklowitz, 2004).

High expressed emotion is not associated with relapse in all cultural or ethnic groups; members of different groups interpret such emotional expression differently. Among Mexican American families, for instance, the family member with schizophrenia is more likely to have a recurrence if the family style is the less common one of being distant and aloof; high expressed emotion is not related to recurrence (Lopez et al., 1998). And among African American families, high expressed emotion is actually associated with a better outcome (Rosenfarb et al., 2006). One possible explanation is that in African American families, confrontations are interpreted as signs of honesty (Rogan & Hammer, 1998) and may signal love and caring.

Although high expressed emotion is associated with relapse in a European American family member with schizophrenia, this is not true among Mexican Americans; the likelihood of relapse of a patient with schizophrenia in a Mexican American family is higher when family members are emotionally distant. The family shown here does not appear to be emotionally distant.

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Child maltreatment comes in various forms—neglect, verbal abuse, physical abuse, and sexual abuse—and is associated with a higher risk for a variety of psychological disorders (Cicchetti & Toth, 2005; Green et al., 2010; Naughton et al., in press), including personality disorders (Battle et al., 2004; Bierer et al., 2003). Child maltreatment exerts its influence indirectly, through the following:

• An altered bodily and neurological response to stress. For instance, children who have been maltreated have higher baseline levels of cortisol than do children who have not been maltreated. Such alteration of the stress response in those who have been maltreated continues into adulthood (Tarullo & Gunnar, 2006; Watts-English et al., 2006).
• Behaviors that are learned as a consequence of the maltreatment. Maltreatment may result in a type of learned helplessness, so the children are more likely to be victimized as adults (Renner & Slack, 2006).
• Biases in discriminating and responding to facial expressions. For instance, children who have been physically abused are more likely to perceive photographs of faces as conveying anger than are children who have not been physically abused (Pollak et al., 2000).
• Difficulties in attachment. Children who have been maltreated are less likely to develop a secure type of attachment than are children who have not been maltreated (Baer & Martinez, 2006).
• Increased social isolation. Children who have been physically abused report feeling more socially isolated than children who have not been physically abused (Elliott et al., 2005).

However, not everyone who experienced maltreatment as a child develops a psychological disorder (Haskett et al., 2006; Katerndahl et al., 2005).

Another family-related factor that may contribute to psychological disorders is the presence of a psychological disorder in one or both parents (Pilowsky et al., 2006). It is difficult to pinpoint the specific mechanism responsible for this association, however, because it could be due to any number—or combination—of factors. For instance, a parent may transmit a genetic vulnerability for a psychological disorder to a child. Alternatively, the specific patterns of interaction between an affected parent and a child may lead to particular vulnerabilities in learning, mental processes, cognitive distortions, emotional regulation, or social interactions—any or all of which can increase the risk of a psychological disorder as the child grows older (Finzi-Dottan & Karu, 2006).

What is clear is that the association between a parent’s having a psychological disorder and the increased risk of the child’s later developing a psychological disorder isn’t solely a result of genetic vulnerability. For instance, when depressed mothers received treatment, their symptoms improved, and so did their children’s symptoms of anxiety, depression, and disruptive behaviors. The more positively a mother responded to her treatment, the less likely her children were to continue to have symptoms (Weissman, Pilowsky, et al., 2006; Wickramaratne et al., 2011). And consider children of women who had depressive symptoms: When such children went to preschool, they had fewer emotional and behavioral problems than did the children who spent their preschool years at home with their mothers full time (Herba et al., in press.)

Community Support

Social support—the comfort and assistance that an individual receives through interactions with others—can buffer the stressful events that occur throughout life (Silver & Teasdale, 2005). Conversely, a lack of social support can make people more vulnerable to various psychological disorders (Scarpa et al., 2006). College students who experience high levels of stress, for instance, are less likely to be depressed if they have relatively high levels of social support (Pengilly & Dowd, 2000).

Social support can lessen the detrimental aftereffects of a stressful event such as an untimely death. People who do not have such support have a higher risk of developing a psychological disorder.

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The Beale women did not have much social support in their extended family or community, but they had each other, which clearly played a role in limiting whatever distress they may have felt about their lifestyle and circumstances. Little Edie noted, “My mother really was the most extraordinary member of the family. She was always singing…. I was happy to be alone with mother because we created the sort of life we liked, and it was very private and beautiful” (Wright, 2007, p. 17). Had the Beale women not supported each other and shared good times, the symptoms of psychological disorders that they displayed might have been worse.

Social Stressors

Living in poverty is associated with a higher rate of psychological disorders. Another social factor associated with psychological disorders is discrimination. Let’s examine these two factors—socioeconomic status and discrimination—in more detail.

Socioeconomic groups are defined in terms of education, income, and occupational level; these indicators are sometimes referred to collectively as socioeconomic status (SES). People from low SES backgrounds have a higher rate of psychological disorders than people from higher SES backgrounds (Costello et al., 1996, Mittendorfer-Rutz et al., 2004; Ramanathan et al., 2013). Socioeconomic factors may contribute to the development of psychological disorders in several ways. One theorized mechanism is through social causation: socioeconomic disadvantages and stress cause psychological disorders (Freeman, 1994). Specifically, the daily stressors of urban life, especially as experienced by people in a lower socioeconomic level, trigger mental illness in those who are vulnerable. For instance, living with inadequate housing, very limited financial means, and few job opportunities corresponds to the stress component of the diathesis–stress model discussed in Chapter 1 (Costello, Compton, et al., 2003). Case 2.1 describes Anna, whose depression was precipitated by financial stressors.

Another mechanism that may be responsible for the connection between psychological disorders and low SES is social selection, the hypothesis that those who are mentally ill “drift” to a lower socioeconomic level because of their impairments (Mulvany et al., 2001; Wender et al., 1973). Social selection is sometimes referred to as social drift. Research suggests that the relationship between psychological disorders and SES cuts both ways: Low SES both contributes to disorders and is a consequence of having a disorder (Conger & Donnellan, 2007; Fan & Eaton, 2001; Johnson et al., 1999).

A study by Jane Costello and colleagues (Costello, Compton, et al., 2003) tested the influence of social selection and social causation on psychopathology in children. These researchers tracked more than 300 Native American children between the ages of 9 and 13 for 8 years; the children were seen annually. At the start of the study, over half of the children were living in poverty. Halfway through the study, a casino opened on the reservation, raising the income of all the Native American families and pulling one quarter of them above the poverty line. Before the casino opened, children whose families were below the poverty line had more psychiatric symptoms than children whose families were above it. After the casino opened, the number of psychiatric symptoms among children who were no longer living in poverty was the same as among those who had never lived in poverty. Once the socioeconomic disadvantages and accompanying family stress were removed, children functioned better, and their symptoms improved—an outcome that supports the role of social causation in this setting (Rutter, 2003).

Being the object of discrimination is associated with an increased risk of distress and psychological disorders (Bhui et al., 2005; Chakraborty & McKenzie, 2002; Mays & Cochran, 2001; Simons et al., 2002). Women, for example, may experience sexual harassment and assault, limitations on their freedom (such as a prohibition against working outside the home), or glass ceilings (unstated limits on social or occupational possibilities). Such experiences may lead to increased stress and vulnerability to psychological disorders. Consider that sexual harassment of women in the workplace is associated with subsequent increased alcohol use by those women (Freels et al., 2005; Rospenda, 2002). Similarly, members of ethnic, racial, or sexual minority groups may experience harassment at—or discrimination in—school, housing, or jobs, which can create a sense of powerlessness and lead to chronically higher levels of stress (Bhugra & Ayonrinde, 2001; Mills et al., 2004; Williams & Williams-Morris, 2000), which in turn increases the risk for developing psychological disorders.

The stigma and discrimination encountered by some gays and lesbians can make them—and others experiencing discrimination—more vulnerable to psychological disorders (Herek & Garnets, 2007; Mays & Cochran, 2001).

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In addition, whereas discrimination involves negative behavior toward someone because of his or her status as a member of a particular group (based on ethnicity, race, religion, sexual orientation, or another characteristic), bullying involves negative behavior that may be unrelated to the victim’s membership in an ethnic, racial, or other group. Research indicates that being a victim of childhood bullying can contribute to psychological problems in childhood and adulthood (Arseneault et al., 2008; Copeland et al., 2013; Sourander et al., 2009), and it is particularly likely to lead to internalizing problems.

Finally, war often inflicts extreme and prolonged stress on soldiers and civilian victims. How an individual responds to the effects of war is determined by a variety of factors (discussed at length in Chapter 7), such as proximity to the fighting and the duration of combat. After mandated extended tours of duty for American soldiers in Iraq and Afghanistan, at least 20% of returning troops had symptoms of posttraumatic stress disorder or depression (Tanielian & Jaycox, 2008).

Culture

Every culture promotes an ideal of healthy functioning—of a “normal” personality—and a notion of unhealthy functioning. These ideals differ somewhat from culture to culture and can shift over time (Doerfel-Baasen & Rauh, 2001). Some cultures, such as those of many Asian, Latin American, and Middle Eastern countries, are collectivist, placing a high value on getting along with others; in such cultures, the goals of the group (family or community) traditionally take precedence over those of the individual. In contrast, other cultures, such as those of Australia, Canada, the United Kingdom, and the United States, are individualist, valuing independence and autonomy; the goals of the individual take precedence over the goals of the group (Hui & Triandis, 1986). In either case, if an individual has personality traits that are different from those valued by the culture, other people’s responses to the person may lead him or her to feel humiliated and to develop poor self-esteem, which increases the risk of developing psychological disorders.

GETTING THE PICTURE

Which family immigrating to the United States is more likely to experience stressful acculturation? Answer: The family on the left will probably have a more stressful acculturation; they come from a collectivist culture, with different values. The family on the right comes from an individualist culture (the Netherlands) that has values more similar to those of the United States.

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AP Photo/The Juneau Empire, Michael Penn

In addition, moving from one culture to another often leads people to adopt the values and behaviors of the new culture, a process that is termed acculturation. This can be very stressful and can create tension between parents—who moved to the new culture as adults—and their children, whose formative years were spent in the new culture. As these children grow up, they may be forced to choose between the values and views of their parents’ culture and those of the new culture, which can be stressful and can make them more likely to develop psychological disorders (Escobar et al., 2000). However, the degree to which acculturation is stressful and increases the risk for psychological disorders depends on other factors, such as the degree of difference in values between the native and new cultures, the reasons for leaving the native country (for example, traumatic causes for leaving, such as war and famine, can have strong effects), the change in SES status that results from immigration, and the degree of discrimination encountered in the new culture. In the absence of these other factors, moving to a new culture is not necessarily associated with later psychological disorders (Kohn, 2002).