It’s Not in Your Mind: Addressing Mental Health Through a Social Justice Lens

While academics debate whether smartphones are responsible for the recent surge in depression and anxiety among young people, and state and local governments across the United States experiment with solutions like free access to online therapy, a growing number of clinicians and grassroots advocates are completely rethinking how we approach mental health.

“There is good reason to wonder whether collecting all types of suffering into medicalized mental health disorders is the most accurate or ethical approach when it comes to addressing these crises,” says Dr. Zenobia Morrill, a psychology professor at William James College. The students, she adds, “are so hungry for more complex ways of understanding and doing therapy, but they struggle to find the tools, mentorship, and support in learning these skills.”

Morrill is part of a growing community of psychologists who argue that mental health must be understood in its social context. If anxiety disorders are rising, that is not a sign of a change in human biology; rather, it is a sign of a sicker society.

Why Biomedical Models Are Insufficient

Biomedical models typically treat mental illness as a pathology localized in the brain, without considering how social factors—such as racial discrimination, economic insecurity, and environmental degradation—may have impacted the individual.

If anxiety disorders are rising, that is not a sign of a change in human biology; rather, it is a sign of a sicker society.

Zack Osheroff, a social worker who works with youth, says too much clinical work is concerned with helping people deal with the world as it exists rather than how it could be. “I think it’s important not to lose that,” he says. “But what you don’t want to do is lean so much into helping people cope that what you’re really doing is teaching them to accept the unacceptable—or teaching them to accept injustice.”

When Osheroff was in school, he realized that he wanted to focus not just on the individual and psychology of the inside of the brain but also on the context. In his studies, he became aware of the liberation health model, a framework defined by one of its founders, Dawn Belkin Martinez, as “a theory of human behavior that conceptualizes the problems of individuals and families that cannot be understood in isolation from the economic, political, cultural, and historical conditions which give rise to them.” The objective of the approach is to help people identify factors that have contributed to their distress and change them by engaging in social justice work.

Martinez, now a clinical professor at the Boston University School of Social Work, developed the model over 20 years ago along with some of her social work colleagues at Boston Children’s Hospital, drawing on both Brazilian educator Paolo Freire’s theory of popular education; and liberation psychology, conceived by Spanish/Salvadoran psychologist Ignacio Martín-Baró. These practitioners later formed the Boston Liberation Health Group.

“Boston Liberation Health itself basically exists to train other people to develop the model and then to participate in social justice activities,” says Osheroff. The group got its charter around the same time as the Occupy movement and provided mental health services at the local encampment. Since then, it has supported social movements like the Movement for Black Lives.

“One of the biggest things that Liberation Health does is it explicitly expects you to bring in cultural and institutional factors, where most modes of social work or clinical work just focus on the personal,” Osheroff notes. Using the visual tool of a triangle, he explains that a person identifies the problem in the middle, and the three corners of the triangle represent the personal, cultural, and institutional factors that contribute to the problem. The idea, he emphasizes, is to attend not only to the three corners but to how they interact with each other.

Osheroff offers an anecdote of the triangle from working with a student who had a personal gripe with a teacher. “He felt she was racist, and he felt that she was treating him unfairly,” Osheroff shares. The student used the triangle and realized that, aside from personal issues, there were factors that he and the teacher were both dealing with, like the underfunding of schools, how many students she was teaching, the training or lack thereof, and the overall stress of her job. Afterward, the student considered questions that expanded his horizons about this problem, such as why there were so few Black men teaching in Boston.

Toward Liberatory Mental Health

Boston Liberation Health has become a global hub for the model, Osheroff notes, with their clinical meetings on Zoom drawing practitioners from all over the world.

According to Morrill, students and therapists-in-training often express discomfort with mainstream therapies, seeing them as “putting Band-Aids on social problems or worse, blaming clients.” She points to widely used models like cognitive behavioral therapies as practices that focus on reducing symptoms without addressing the root causes of distress: “We reduce people when we say that any one superficial thing explains it all, and they just need to do that differently.”

As a critical-liberation psychologist who was exposed to the mental health system at a young age, Morrill set out to examine the power imbalances inherent in the psychotherapy process. Her doctoral dissertation research drew on marginalized theories, such as Humanistic-Existential and Feministic-Multicultural psychotherapy, to develop an approach she calls Critical-Liberation Psychotherapy (CLP).

CLP involves reflecting on how sociopolitical dynamics of domination and oppression have shaped our personal lives and experiences. A client is encouraged to explore their lived experience, with the therapist listening for the relational, sociocultural, political, and ideological dimensions of the client’s experiences. Another aim of this approach is for the client to be able to reclaim and recenter knowledge and practices that have been marginalized by society and may provide “more nuanced, expansive, or dynamic ways to understand ourselves,” such as BIPOC, queer, disability, and Global South perspectives.

Historically, Morrill says, mainstream psychotherapy has centered Eurocentric traits—like hyper-individualism—as normal. She offers an example of how CLP works in practice as a counter to that:

“Let’s say your therapy client is a 30-year-old man with Native American ancestry who presents with a depression diagnosis—or meets DSM [Diagnostic and Statistical Manual] criteria for one.” With CLP, she explains, the focus of therapy is to understand patients’ unique experiences in their historical and cultural context. For instance, practitioners “might consider Indigenous values of interdependence to land and nature, not just other people, as knowledge to reclaim and contest hyper-individualism.”

The idea, Morrill elaborates, is to “understand how power has constrained us, how it’s been carried forward in our lives, and therefore, where it can be renegotiated or reconfigured.”

How Peer-Based Models Can Be Manipulated

In recent years, the World Health Organization (WHO) has emphasized the need for noncoercive, community-based mental health services. In the document Guidance on community mental health services: Promoting person-centred and rights-based approaches, the WHO endorses peer support. This approach arose from the psychiatric survivors movement of the 1970s that protested human rights violations within the mental health system.

Originally, peer support was widely understood to mean grassroots people supporting one another, but state mental health officials have co-opted the term to refer to people with psychiatric diagnoses working as “peer specialist” employees in conventional settings.

Despite this, many genuine peer-support programs exist worldwide, led by and for people with lived experience, operating outside the conventional system and centering self-determination and mutual aid. “A lot of folks are struggling under the weight of oppression, and the power imbalances in the mental health system are really extreme,” says Caroline Mazel-Carlton of Wildflower Alliance, a nonprofit that operates peer-run support centers in western Massachusetts.

Mazel-Carlton, who first became involved in psychiatry as a patient at the age of eight, says a lot of the care she received from conventional mental health institutions didn’t work for her. At one point her treatment included being put on a 15-minute check when she was identified as a suicide risk at a hospital. This meant that every 15 minutes, a large man with a clipboard and a flashlight would enter her bedroom and shine a flashlight to determine that she was still alive. “That is what suicide prevention looked like at that institution. For me, as a sexual trauma survivor, having a large man enter my bedroom was really distressing.”

Fifteen years ago, Mazel-Carlton began working professionally as a peer specialist in formal mental health settings. She recalls being “around folks with advanced degrees, who would wield certain power.” She was told that if anyone mentioned suicide to her, she had to report this, in which case the person would be assessed and often hospitalized against their will. After years of this, she began to experience what she describes as “moral injury.”

The breaking point came when someone with whom she’d previously lived in a group home came to stay at the psych hospital where she worked. “We had been friends, but because of the power differential, our relationship changed.”

While in the hospital, this person attempted suicide. When Mazel-Carlton asked her friend why she hadn’t told her how much pain she was in, her friend told her that she “was afraid to talk to [Mazel-Carlton] because she knew that if she had, I would have to notify an authority.” After this, Mazel-Carlton decided she could no longer work in organizations with these protocols, leading her to move 900 miles to work with Wildflower Alliance.

Creating Genuine Peer-Based Care

Today, as director of training at Wildflower Alliance, Mazel-Carlton facilitates and trains others to facilitate support groups known as Alternatives to Suicide, where people can share openly about suicidal thoughts without the risk of being institutionalized involuntarily. This approach was originally developed by the nonprofit in 2008. “It is at its heart an approach that’s about harm reduction and centering real-life supports that work, that are based on real people’s experience,” says Mazel-Carlton.

The groups, which are 90 minutes long and cofacilitated by people who have been suicidal themselves, are free to attend and don’t require any clinical referral or diagnosis. It is a confidential space for people to share their stories without documentation.

“A lot of folks are waking up and wanting to do things differently.”

Alternatives to Suicide groups, Mazel-Carlton explains, ask open-ended questions like, “What’s going on in your life right now? What do you need right now to get through this moment?” There are no diagnostics and no force or coercion. Facilitators validate people’s fears and concerns—and share some of their own experiences. “Alternatives to Suicide is about figuring out what supports that person has in the community, or what community connections we could build,” she says.

The model also aims to de-professionalize conversations about suicide. At the conventional service providers where she previously worked, Mazel-Carlton says it was assumed someone needed a graduate degree and license to be allowed to talk about suicide.

“Alternatives to Suicide challenges that notion because there are a lot of problems with it. One being, it’s not necessarily true that people need to have academic knowledge to support each other. What happens under capitalism in particular—when you create this professional class—is sometimes they become an agent of the state that controls people.” A lot of clinicians, she notes, say that talking about suicide with their patients almost always leads to the patient being committed to an institution, which creates a feedback loop where people in severe distress won’t talk about suicidal thoughts for fear of being hospitalized against their will.

Wildflower Alliance conducts training for people wanting to start Alternatives to Suicide groups in settings like colleges, spiritual spaces, and maximum-security prisons. Mazel-Carlton herself has given talks in other regions that have led to groups starting in the midwestern United States, Canada, and Australia.

And the broader field of psychiatry is starting to take notice. In 2023, the WHO and the UN Office of the High Commissioner for Human Rights offered a scathing assessment of modern psychiatry with their joint publication Mental health, human rights and legislation: Guidance and practice. The exhaustive document calls for preventative measures like addressing inequalities in housing and income, a perspective that Dainius Pūras, a former special rapporteur for the UN Human Rights Council, articulated in 2017 when he wrote, “There is a need of a shift in investments in mental health, from focusing on ‘chemical imbalances’ to focusing on ‘power imbalances’ and inequalities.”

For his part, social worker Osheroff believes that to set the foundation for improved mental health, it will be crucial to direct more public funds toward meeting people’s basic needs. “Instead of going to war, it needs to go to housing, nutrition,” he says.

More and more, Mazel-Carlton says she’s been invited back to conventional mental health settings to talk with clinicians experiencing the same moral injury she did. “I think a lot of folks are waking up and wanting to do things differently,” she observes. “They’re reaching out to folks with lived experience and saying, ‘Help me envision what would be more helpful.’”