Soc Theory Health (2019) 17:1–22

https://doi.org/10.1057/s41285-018-00085-7

ORIGINAL ARTICLE

Sociology, biology and mechanisms in urban mental

health

Nick Manning1

Published online: 5 December 2018

© The Author(s) 2018

Abstract  This paper examines the way in which sociology and biology continue
to struggle to understand why urban life creates high levels of mental disorder. The
movement of the world population to be majority urban in recent years adds urgency
to this issue. The paper addresses ways in which sociological analysis and biological
analysis might work together through the identification of mechanisms, imagined
and confirmed through data, of the way in which urban life gets ‘under the skin’. The
argument moves from the use of mechanisms in scientific explanation, to the short-
comings of epidemiology, and the possibility of a new ‘mechanism-rich’ epidemiol-
ogy. It then discusses seven examples of work that might contribute to this effort,
concluding that more careful ethnography is required.

Keywords  Sociology · Biology · Mechanisms · Urban · Mental · Health

Introduction

This paper examines the way in which sociology and biology continue to struggle to
understand why urban life creates high levels of mental disorder. The movement of
the world population to be majority urban in recent years adds urgency to this issue.
The paper addresses ways in which sociological analysis and biological analysis
might work together through the identification of mechanisms, imagined and con-
firmed through data, of the way in which urban life gets ‘under the skin’. The argu-
ment moves from the use of mechanisms in scientific explanation, to the shortcom-
ings of epidemiology, and the possibility of a new ‘mechanism-rich’ epidemiology.

* Nick Manning
[email protected]
1
Department Global Health and Social Medicine, King’s College London, Room BH NE 3.11,
Aldwych, London WC2B 4BG, UK

Vol.:(0123456789)

2 N. Manning

It then discusses seven examples of work that might contribute to this effort, con-
cluding that more careful ethnography is required.

The basic question

The basic question concerns the relationship between urban life and mental disorder,
and the issue is set out clearly by Van Os, who has been wrestling with it for more
than 20 years:
Urban environment is one of the (proxy) environmental risk factors for psy-
chotic disorder. … Candidate mechanisms include higher level of perceived
social isolation in urban areas and greater exposure to social “defeat” occa-
sioned by higher level of competition in cities. (Frissen et al. 2017, p. 2).
This paper, following most research in this field, identifies urban life with social fac-
tors as opposed, for example, to air/noise/light pollution. This is almost universal in
the literature, and we will follow this convention here. Despite many, many studies
that have shown an association between mental disorder and urban life in general,
and indeed between mental disorder and many specific aspects of urban life, it has
been difficult to identify exactly how urban life ‘gets under the skin’. In their review
of the biology/sociology interface using urban mental health as the focus, Fitzger-
ald et al. (2016) suggest a new research strategy, to include thickly textured empiri-
cal research, shared sociological and neuropsychiatric attention, thicker ontology of
urban mental health, and a redrawing of the urban (pp. 151–155). However, it is not
immediately clear how to put this strategy into practice. One common and manifest
problem is what counts as knowledge, argument, indeed good science in biology and
sociology. Since this area of research self-evidently involves both biology and soci-
ology, it follows that we need to work out how our question might be approached
anew between and within these disciplines.

Sociological and biological mechanisms

One immediate issue is the question as to whether explanations developed in these

two epistemic communities are compatible. How is research carried on? There are
a myriad of research questions posed in each discipline, and data collected to throw
light on them. Both disciplines use sophisticated statistical techniques, to identify
patterns and associations, and both disciplines also use individual case studies as
a way of digging into the processes through which particular things work. Each of
these approaches is perceived to have reciprocal strengths and weaknesses. Associa-
tions do not explain why things ‘go together’. Cases are not generalisable. Within
each discipline, there have been strong disputes between these two types of research.
Recently there has been a retreat in both disciplines from the high peaks of ‘cover-
ing laws’, but also from quantitative and qualitative rivalries, to the idea that expla-
nation can be achieved through the identification of ‘mechanisms’ that connect one
Sociology, biology and mechanisms in urban mental health 3

thing with another, but under limited circumstances. It is this development which
gives us an opportunity and a strategy for re-examining our core question.
Mechanisms are a core part of explanation in biology, often accompanied by
detailed graphical representation (Bechtel 2013a, b). Indeed, a critical debate about
the general place of mechanisms in explanatory work has been centred on the case
of the Nobel prize winning work of Hodgkin and Huxley (1952) on the way in which
squid neurons fire signals from nerve cell to nerve cell via electrochemical mecha-
nisms (Bogen 2008; Craver 2008; Schaffner 2008; Weber 2008; Levy 2014). Their
series of papers in 1952 is intriguing because the mathematics worked, but with an
incomplete mechanism, parts of which were wrong. However, the “diagram of the
electrical circuit in a membrane and supplemented with details about how mem-
branes and ion channels work, carry considerable explanatory weight. The equations
without such interpretation … do not constitute the explanation”. (Craver 2008, p.
1028). Many other examples for biology are listed by Craver and Darden (2013),
such as cellular transport, cell signalling, DNA repair, and mechanical articulation.
In sociology, the idea of mechanisms is more recent and, at least initially, used in
rational actor models (Hedström and Swedberg 1998). However, a flourishing litera-
ture has challenged these early ideas to sketch out different varieties of mechanism
explanation. Gerring (2008, p. 161) outlines nine different uses in social science, and
Aviles and Reed (2017, p. 728) suggest that ‘‘mechanism warlordism’’ has emerged
between mechanism fundamentalists (prone to reductionism under the guise of par-
simony), and mechanism metaphorists, who prefer nuance and case studies, and see
the social world as ‘‘dappled’’ (Cartwright 1999) where only some causes are best
termed mechanisms. For sociology, the use of mechanism terminology is grow-
ing, with James Mahoney (2001) cataloguing 20 examples from well-known soci-
ologists, reproduced by Margaret Archer in Generative Mechanisms Transforming
the Social Order (2015). A recent example is the extensive use of mechanisms in
Scambler and Scambler (2015) in their critique of theoretical faint-heartedness in
much of the health inequalities literature—yet they offer neither reflection, nor defi-
nition of what they mean by the term ‘mechanism’.
Bechtel and Richardson (1993) argue that decomposition and localisation were
critical to the development of mechanistic models in the life sciences, drawing
examples from cell biology, neuroscience, and genetics. Bunge (2004) similarly
suggests that social science should examine social contexts; break things down into
their composition, environment, and structure; identify relevant levels and exhibit
their inter-relations; and look for mechanisms which enable growth or decay.
However, reductionism is neither ubiquitous nor necessary for mechanism con-
struction; indeed Hodgkin and Huxley’s work on the squid neuron “achieved uni-
fication and simplification in … what might be termed “emergent simplifications”
that transcend the specific workings of the molecular details”. (Schaffner 2008, p.
1018). After all, mechanisms have to be imagined, and do not spring fully formed
from the external world. As Mario Bunge comments “imagination both stimulated
and constrained by data, well-weathered hypotheses … is an art, not a technique”
(2004, pp. 200–201). Recent work on these ideas has thus been to remove reduc-
tionism, stressing the way in which mechanisms might capture the emergent logic
of biological and social processes, and to seek a core, simple and non-reductionist

4 N. Manning

definition for a mechanism, for example, proposed by the philosopher Williamson

(Illari and Williamson 2012): “A mechanism for a phenomenon consists of entities
and activities organized in such a way that they are responsible for the phenomenon”
(p. 132).
It is significant that this ‘turn to mechanisms’ in both biology and sociology
offers a substantial methodological coherence between these disciplines at a time
when both are themselves concerned to bring about a significant appreciation of the
impact of each other’s terrain on their core questions—for example, through epige-
netics and neuroplasticity in biology, and through body and health research in soci-
ology. How can this recent convergence help us in our quest to understand urban life
and mental disorder? What might be the mechanisms?1

Epidemiology, and its limits

Perhaps the first port of call for identifying such mechanisms should be epidemi-
ology, the traditional and still very active unpicking of quantitative associations of
variables, drawn from both biological and social factors. Epidemiology is typically
the collection of population-level data to identify risk and protective factors in rela-
tion to health or illness states, with increasingly small risks and increasingly specific
factors identified through the use of very large samples. The development of ‘big
data’ promises a new round and extension of this strategy.
The original epidemiological work on mental disorder and urban life was
developed in the 1930s by Faris and Dunham (1939). Their Chicago data
showed that schizophrenia was concentrated in the central city area, depression
scattered across the city, with migrants and singletons having specific psycho-
ses. Their hypotheses were that poor social relations lead to mental disorder,
that ‘downward drift’ may make a contribution, and that there might be ‘upward
drift’ of manic depression. In relation specifically to migrants, they suggested
that ‘adjustment difficulties’ were linked to higher rates of mental disorder, that
rates were higher for the mobile and heterogeneous, and that rates varied by race
and by social class. These factors have continued to dominate epidemiological
work, and indeed have been repeatedly rediscovered in later surveys. Density,
ethnic mix and social class have re-appeared regularly, but with little sense that

1
  Bhaskar’s work is not referenced here since it is not really taken seriously, indeed rarely referenced, in
the specialist literature on mechanisms (ie philosophy of science literature) for two reasons. One is that
his later work really moved away from the clearer arguments of his early work. The second is that it is
difficult to operationalise what he meant—hence none of the applied literature on mental health uses him
much either. For example, Pawson (2016) comments that ‘The fundamental difficulty is that Bhaskar was
a philosopher, writing for philosophers about philosophy, with the consequence that he had little com-
mand of the conduct of empirical research (natural science or social science)’ (pp. 49–50). Similarly,
Bhaskar is not referenced at all in Jon Williamson’s key paper “What is a mechanism? Thinking about
mechanisms across the sciences” (Illari and Williamson 2012), nor his latest book (Parkkinen et al. 2018)
Evaluating Evidence of Mechanisms in Medicine, Principles and Procedures.
Sociology, biology and mechanisms in urban mental health 5

anything new has been said about why these factors are associated. Indeed for
some authors, this has suggested an impoverished set of ideas:
We have a clear and strong signal telling us urban birth and urban resi-
dence increases the risk of developing schizophrenia. However, the quality
of the data has not been matched by the quality of the hypotheses. … Let’s
hope that the next decade of research on urbanicity and schizophrenia will
be less ataxic and more focused. (Mcgrath and Scott 2006, p. 246)
Since this comment, the number of studies has certainly grown, but the identifi-
cation of why and how there is an association between urban life and mental dis-
order remains elusive. A sample of recent epidemiological studies and reviews
of factors associated with urban mental disorder includes the following list of
familiar terms: This sample of papers could be multiplied many times over and
extended to include genetic, environmental, psychological and historical factors.
However, in them explanation rarely goes further than statistical association.
There is almost no discussion of mechanisms to be found here, and the ‘social’
is actually measured in some very mundane ways, usually by employment, edu-
cation, income, or social ties, with no real unpacking of what ‘social’ experience
means in any detail.
An example is provided by some work arguably at the forefront of this kind of
analysis (Schofield et al. 2016). This paper examines ‘minority status and men-
tal distress’, using sophisticated statistical analysis. But the data are reduced to
very imprecise categories, for example, ‘occupational social class’ is coded to
a binary variable “advantaged (professional, managerial and technical, skilled
non-manual and skilled manual) and disadvantaged (partly skilled, unskilled and
unemployed) groups”. (p. 3053). The data are subjected to sophisticated quanti-
tative analysis, yet the authors themselves comment that
we were restricted to fairly crude definitions of minority status to achieve
statistical power. Our definition of occupational social class was, by neces-
sity, crude as we had to match classes at individual and area levels meas-
ured on different scales. Also comparison with the social class measure
is hindered by the amount of missing data, 247 (15%) missing responses,
whereas this was negligible for the other measures. Our measure of single
household status is also, by necessity, crude. For example, it could miss
those who effectively live alone but are in shared households, due to eco-
nomic necessity. (pp. 3055–56)
This combination of weak data with sophisticated numerical analysis is common
in this literature.

6 N. Manning

Towards a new epidemiology?

Criticisms have grown of the multiplication of increasingly sophisticated data han-

dling and modelling, but without a concomitant growth in explanation of how typi-
cal risks and protections work in practice. A leading social epidemiologist, Sandro
Galea, comments:
The body of work in the field that has explored how truly large-scale (macro-
level) forces shape the health of populations remains disproportionately lim-
ited….. A concern with the influence of urbanicity must, of necessity, involve
samples that are heterogeneous across urban contexts and involve large sam-
ples that are collected across cities (Galea and Link 2013, p. 844)
He argues that epidemiology devotes too little attention to the mechanisms through
which social factors enter the biological realm. He suggests the successful exam-
ples, smoking and papilloma virus, are rare, and that this is singularly not the
case for urbanicity and mental disorder, which lacks a convincing elaboration of
mechanisms.
(Galea and Link 2013) continues his argument through characterising epidemiol-
ogy as a “black-box” discipline, focussing on factors that “may lead to the isolation
of spurious associations or a chase for associations where there are none”. His alter-
native is a “deeper grounding in a theory of the production of population health that
stands on its own. With a few notable exceptions, epidemiology remains quite poor
in this regard”. (p. 847). More recently (in Keyes and Galea 2017), he has contrasted
traditional epidemiology (seeking to identify whether exposure (e.g. urbanicity) is
associated with disease), with what he terms ‘causal architecture’ (designed to iden-
tify the mechanisms that underlie disease).
In the same vein, the Harvard social epidemiologist Nancy Krieger (2011)
has argued strongly for a move away from the dominant biomedical and lifestyle
approaches in social epidemiology, which emphasise individual-level causes,
towards an ‘ecosocial theory’ which includes the social, ecological and historical
context. In short, epidemiology needs some social theory (Wemrell et  al. 2016).
Wemrell et al. suggest three areas in urgent need of theorisation: macro-social deter-
minants of health and disease, categories of human difference, and embodiment.

Mechanisms: in practice

What work on urban life and mental disorder comes closer to Galea’s causal archi-
tecture by seeking to identify mechanisms? We can review seven strategies.

Strategy 1: Include everything: ‘NEM III R’

How can we link the huge scale differences between urban political economy and
molecular biology that might be involved in urban mental health? The NEM III R
(Network Episode Model) of the causes of mental disorder has been developed by
Sociology, biology and mechanisms in urban mental health 7

sociologist Pescosolido over the last 25 years. Starting from a fairly simple model
of patient networks, demographics and support systems (1991), she has extended it
in NEM II to include the treatment system, and in NEM III to include the biological
system (Pescosolido 2006, 2011; Perry and Pescosolido 2015).
This approach was developed explicitly to integrate the biological and social,
through the specification of four basic requirements:

(1) “Consider and articulate the full set of contextual levels documented to have
impact.
(2) Offer an underlying mechanism or ‘engine of action’ that connects levels.
(3) Employ a metaphor and analytic language familiar to both social and natural
science.
(4) Understand the need for and use the full range of methodological tools”. (Pes-
cosolido 2006, p. 194).

The model broadly includes a time dimension covering an individual’s life course,
and a number of analytic levels, connected by networks, ranging across the bio-
logical, personal, social and system levels. In this sense, it is widely inclusive, but
although the NEM model is strong in sensitising us to all the factors and levels
which might be important, it is less clear about how to determine which mechanisms
are the key ones. This is not just an empirical issue, as it is still not clear where to
look. Pescosolido’s answer is to follow the actors and their networks:
the entire process is dynamic, constituted, and embedded in individuals’ social
networks. What individuals know, how they evaluate the potential efficacy and
suitability of a range of options and providers, and what they do (in what order
and under which “tone”) are fundamentally tied to, negotiated in, and given
meaning through social interactions. (Pescosolido 2011, p. 45)
However, it should be noted that ‘social interactions’ is still biology-light. Actors
here do not include the materialities of molecules, cells, membranes, and biological
systems and structures. Despite her claim to the contrary, Pescosolido’s approach is
really quite thin on biology, and it occupies relatively little space in her work. She
does not follow the actors ‘all the way down’ in the way so notable in actor network
theory (Latour 2005, p. 52).

Strategy 2: Cut through on a clear path: SES as a ‘fundamental cause’

NEM excels at bringing all possible factors to bear, but how do we find the network
connections between levels that are active mechanisms? An alternative strategy is to
cut a clear path through the myriad of possible factors with one major explanatory
mechanism. This was proposed by Link and Phelan with the idea of ‘fundamental
cause’.
Urban life is a major multiplier of inequality: just as the world population has
now become majority urban, inequalities grow all around the world (Amin 2007;
Scambler and Scambler 2015). Urban life accumulates both the richest and the

8 N. Manning

poorest. Even a cursory glance at the list of recent epidemiological studies of the
social (Table  1) shows a common theme of disadvantage, deprivation, isolation,
fragmentation, and discrimination. These are overlapping aspects of inequalities of
income, status and power manifest in a variety of ways. Link and Phelan (1995) have
suggested that (unequal) socio-economic status (SES) could be conceptualised as
a fundamental cause (mechanism) of ill health (and of course by definition, good
health). They do not suggest that SES stands in for a number of known and unknown
specific mechanisms, but is in itself a dominant mechanism for understanding the
experience of ill health (including of course mental ill heath). Even if specific dis-
eases and therapies come and go, they argue that SES will continue to exercise dom-
inance, as those with more resources gain disproportionate access to new healthcare
and disproportionately avoid health risks. Resources, they predict, can
help individuals avoid diseases and their negative consequences through
a variety of mechanisms. Thus, even if one effectively modifies intervening
mechanisms or eradicates some diseases, an association between a fundamen-
tal cause and disease will re-emerge. As such, fundamental causes can defy
efforts to eliminate their effects when attempts to do so focus solely on the
mechanisms that happen to link them to disease in a particular situation. (Link
and Phelan 1995, p. 81).
Over the subsequent 20 years, this prediction seems to have held up. Assessing the
evidence that has accumulated in four areas, they suggest (Phelan et al. 2010) that
SES does indeed shape disease outcomes via various risk factors, through the differ-
ential deployment of resources, a pattern which is very stable and reproduced over
time via the emergence and decay of intervening mechanisms. This clearly leads in
exactly the opposite direction from contemporary epidemiological sophistication—
there is little point in identifying more and more (and smaller) risk and protective

Table 1  Social epidemiologies of urban life

Socio-economic status, ethnicity, migration—and their intersection (Goodwin et al. 2017)

Social disadvantage, isolation and function (Morgan et al. 2017)
Socio-economic status and social inclusion (Yi and Liang (2017)
Social isolation and social “defeat” (Frissen et al. 2017)
Social minority status—ethnicity, household, social class (Schofield et al. 2016)
Social disadvantage (Stilo 2016)
Social status, social support, and racial discrimination (Mama et al. 2016)
Social networks, social support, and ethnicity (Smyth et al. 2015)
Social network structure and culture (Perry and Pescosolido 2015)
Social deprivation, social support, discrimination, stress, trust (Wickham et al. 2014)
Social coherence, density of social networks, and population density (Lederbogen et al. 2013)
Social adversity, population density, social fragmentation and deprivation (Heinz et al. 2013)
Social ties, social support, and stress buffering (Thoits 2011)
Socio-economic status, social capital, and social disorder (Kim 2008)
Social fragmentation, social isolation and social inequality (Van Os 2004)
Sociology, biology and mechanisms in urban mental health 9

factors with larger and larger samples, if there is an underlying mechanism gener-
ated by SES that over time continues to reproduce ill health.
As originally defined and subsequently used, the term ‘resources’ is ambiguous.
While Link and Phelan continue to emphasise resources, since wealth and money
income will unequally confer potential and actual agency, it should be noted that
other classical elements of SES, such as power, status, geographical clustering, and
cultural habitus (including language) are likely parts of this mechanism, and indeed
have been partially identified as such in a detailed ethnography exploring a funda-
mental cause analysis of diabetes in the USA (Lutfey and Freese 2005—discussed
further below). In this respect, Link and Phelan’s strategy is a case of “emergent
simplification” mentioned at the beginning of this paper, where Schaffner (2008, p.
1018) discusses how to “transcend the specific workings of the molecular details”.

Strategy 3: Social psychology of small groups

Another strategy has been to try to identify mediators between the social and the
biological levels. Not as rigid as the ‘fundamental cause’ approach, these are the
very small scale interactions that shape capacities and emotions. An example is
research developed from the work of Henry Tajfel (1981) in the 1950s, aiming to
understand stereotyping of Jewish people in WWII though the concept of ‘every-
day’ or mundane categorisation, rather than the personal prejudices of the powerful.
He focussed on the process of prejudice and stereotyping arising from the social
judgements that people are typically hard wired to make in small groups. He showed
that people’s sense of identity is strongly influenced by the group in which they find
themselves, and the way in which groups are categorised. There are similarities here
to Goffman’s (1986) work on stigma, and Scheff’s (1974) work on labelling. In all
three approaches, the individual both creates and receives categorical judgements
about themselves and others in terms of the group context in which they find them-
selves (Phelan et al. 2008).
Indeed it is argued in this ‘self-categorization theory’ (Turner 1987) that there
is a strong desire in people to ask ‘who am I?’ and to answer this through their
perception of the groups they are in. While those making these judgments may
strengthen their own identity in this way, the consequence for people who are so
judged can be considerable. This may range from material exclusion (for example,
from employment, housing), to ‘social defeat’ and shame—a particular experience
for people with mental disorder, migrant status, and ethnic minority status (Reader
et al. 2015). While much work in this area is based on animal studies, Reader et al.
explore a number of ways in which the experience of social defeat ‘gets under the
skin’ and into the brain via the hypothalamic–pituitary–adrenal (HPA) system. The
link to urban mental health would be the way in which cities both destabilise the
fixed social groups of rural life, and in addition multiply the opportunities, divisions
and expectations for those who move to the city.
 N. Manning
10

Table 2  Diverse social capitals that affect mental health of young people

Family structure (e.g. number of parents present in the household)

Quality of parent–child relations (e.g. parent–child communication)
Adult interest in the child (e.g. parental involvement with school)
Parent’s monitoring of the child (e.g. perceptions of parental monitoring/control)
Extended family support and exchange (e.g. perceptions of extended family support)
Social support networks (e.g. peer support)
Civic engagement in local institutions (e.g. volunteering)
Trust and safety (e.g. trust in others)
Religiosity (e.g. attendance at religious services)
Quality of the school (e.g. school cohesion and relationship between teachers and pupils)
Quality of neighbourhood (e.g. neighbourhood cohesion and social control) (McPherson et al. 2014)

Strategy 4: Social capital

The expanded conceptualisation of resources to include power, status, geographi-

cal clustering, and cultural habitus (including language), suggested by Lutfey and
Freese (2005) above, is very close to another recent and increasingly common con-
ceptualisation of ‘the social’—social capital. While fundamental cause research
resonates with the gloomy list of disadvantages and deprivations in Table 1, there
is another rapidly growing literature on the mechanisms of social capital that might
protect against mental disorder.
In a parallel development to the fundamental cause literature since the 1990s,
social capital has come to embrace a bewildering variety of aspects of the social
(Moore and Kawachi 2016). In a systematic review of the effects of social capital
on mental health, De Silva et  al. (2005) observe that social capital might include
‘cognitive, structural, bridging, bonding, and linking’ types, drawn from the very
different theoretical traditions of Pierre Bourdieu, James Coleman and Robert Put-
nam. However, in the tradition of epidemiological evidence synthesis these are hap-
pily combined into a review as if they (more or less) extracted elements of a com-
mon underlying reality. Ten years later a further review (focussed on young people)
illustrates the wide range of ideas that have been drawn under the idea of social
capital (Table 2):
McPherson concludes not unreasonably that “It is, therefore, important that
future research seeks to uncover the mechanisms through which social capital may
exert different influences on the mental health” (p. 13).

Strategy 5: Interaction ritual chains

While Pescosolido emphasises what people know and what they do, as the core
aspects of social interactions, and Link and Phelan emphasise the deployment of
resources, and social capital stresses the social context, there is further aspect of
social life which hardly appears in these approaches. This is the point that there are
Sociology, biology and mechanisms in urban mental health 11

important mental health consequence of the emotions generated by the way people
live their lives in close and intimate proximity to one another. For example, stress is
generated by high levels of negative emotional expression in families and, by con-
trast, trauma can result from low levels of emotional expression (e.g. neglect or iso-
lation). There is evidence that both are bad for mental health (Koutra et  al. 2014;
Norman et al. 2012).
Sociological work on mechanisms that might analyse the effect of small/intimate
groups such as families on emotions has been developed by Randall Collins and
others on violence (2009) and ‘interaction ritual chains’ (2005) combining the tradi-
tions of Darwin, Durkheim and Goffman. Collins argues that we are biologically
predisposed to emotional contagion in small group settings through physical and
psychological rhythmic entrainment (resonance) which generates positive (or nega-
tive) emotional states, creating or releasing emotional stress (Fig. 1).
The biological roots of this mechanism he suggests are shared with non-human
animals:
We have things of considerable importance to incorporate from Darwin and
ethology. First and foremost is the proposition that society is subhuman. Many
animals live in groups just as we do. The distinctively human forms of cogni-
tion and communication are built on top of the pre-existing capacity for social
bonds; they are not the basis of it. (Collins 1975, p. 92, italics original)
Goffman, similarly, recognised that sociality is “located in a physical, biological,
and social world” (Goffman 1974, p. 247). However, the biological pathways from
bodies to rhythmic entrainment are not clear from Collins. One interesting possibil-
ity has been suggested by Heinskou and Liebst (2016), through the polyvagal para-
sympathetic part of the autonomic nervous system. This, they observe, is the neural
pathway that regulates a number of internal organs, including the heart. It is phylo-
genetically the most recent subsystem and is connected to social communication,
compared to the second oldest (fight-flight) and oldest (freezing or death feigning).

RITUAL INGREDIENTS RITUAL OUTCOMES

common group assembly group solidarity

acon or (bodily co-presence)
event emoonal energy
(including stereotyped barriers to outsiders in individual
formalies)
mutual focus of symbols of social
transient aenon collecve relaonship
emoonal smulus effervescence (sacred objects)
shared mood
standards of
morality
feedback
intensificaon through righteous anger for
rhythmic entrainment violaons

Fig. 1  Interaction ritual chains (adapted from Collins 2005, p. 48)

 N. Manning
12

In short, they suggest that this mechanism might connect the Collins model with the
polyvagal system, genuinely bringing the biological and social together.

Strategy 6: Biology led mechanism

Biological mechanisms have so far only been touched on. To move further in that
direction, we can consider mechanisms that place biology more centrally. Pesco-
solido (2006, p. 194) suggested earlier that in seeking mechanisms it might be pos-
sible to ‘employ a metaphor and analytic language familiar to both social and natural
science, so as to facilitate synergy’. Arroyo-Santos (2011) suggests that in biology
‘the metaphor is a tool used to fulfill three major goals: 1) as an epistemic device
seeking to provide a satisfactory explanation, 2) as an inferential device that can help
infer new aspects of the phenomenon under investigation, 3) as an important theory-
construction device’. (p. 89). It has already been noted from Bechtel (2013a, b) that
the mechanisms that are a core part of explanation in biology are often accompanied
by detailed graphical/metaphorical representation—indeed diagrams can be argued
to be part of a full biological explanation. We should start therefore with a comment
on metaphors and images in biology.
Biology has been particularly rich in the use of vivid metaphors and diagrams
as a way of realising possible and actual mechanisms in various fields of its work.
Hodgkin and Huxley represented their mechanism through a mathematical formula
and electrical circuit used as a proxy mechanism for the squid neuron. The vagal
nerve discussed earlier in relation to interaction ritual chains is frequently embed-
ded in diagrams that link brain function to external stress, the HPA system and the
gut microbiome. There are a number of common biological metaphors found in the
literature, of which five are prominent. Table 3 suggests how they might be related
to social and biological mechanisms.
The most common mechanism/metaphor to be found in the biology led literature
on urban life is the proposal that external stressors (trauma, poverty, etc.) are inva-
sive, or at least signal the need for biological changes. The use of this concept of
stress is now almost universal. However, it has not always been so—indeed stress
would be an excellent example of JS Mill’s celebrated warning not “to believe that
whatever received a name must be an entity or being, having an independent exist-
ence of its own” (Mill 1869, footnote 2). In a recent Wellcome project on the history
of stress, Mark Jackson (2012, 2013, 2014, 2015) suggests that although the concept
of stress was used in the late nineteenth century, it only became widely adopted after
the second world war in the UK. Used initially to explain an upsurge in ulcers and
other stomach disorders, it was taken up in psychiatry as war time migration and the
newly established health and social services revealed the kind of lives that poorer
people led.
The classic paper underpinning the modern era of stress research is McEwen and
Stellar (1993), in which stress is described in the first paragraph as “physical stress-
ors such as exertion, heat, cold, trauma, infection, and inflammation; psychologic
stressors such as fear and anxiety, social defeat and humiliation, disappointment, and
sometimes even intense joy” (p. 2093). Significantly, stress is not described in any
Table 3  Five common metaphors found in biological explanations
Metaphor Urban/social mechanism Biological mechanism

Military (e.g. invasion) Life is a battle; war inflicts damage Social defeat causes inflammation (gut microbiome)
Language/signalling/information (e.g. DNA code) Urban form can overload our senses reactions to urban stress shaped by genetic predisposition
Transactional (e.g. competition/collaboration) Social support mitigates stress Good emotions crowd out bad emotions (IRCs and vagal nerve)
Sociology, biology and mechanisms in urban mental health

Machine (e.g. manufacture/assembly) Infrastructure shapes our social ties Psychological therapy reassembles our perceptions (neuroscience)
Plastic/permeable (e.g. adaptive/evolution) Urban context shapes genetic expression Early trauma changes our developmental path (epigenetics)
13
 N. Manning
14

Environmental stressors Major life events Trauma, abuse

(work, home, and neighbourhood)

Individual differences (genes, BRAIN Behavioural responses

development, and experience) Perceived stress (fight or flight)
(threat no threat) (personal behaviour – diet,
(helplessness) smoking, drinking,
(vigilance) exercise)

Physiologic
responses
Allostasis Adaptaon
Allostac load
Fig. 2  How the environment ‘gets under the skin’ (adapted from McEwen et al. 2015, p. T71)

further detail, but summarised as physical or psychological stimulus which threatens

the individual. ‘Allostatic load’ is further defined as the accumulated ‘wear and tear’
of adjusting the natural balance (allostasis) such as heart rate, to threats over time.
However, Jackson’s history raises the question, does stress really exist, and if so,
what is it? The conceptualisation and measurement of stress, and its impact on allo-
static load, is central. However, there is little clear idea of how this accumulation
mechanism actually works, nor the units in which it might be measured. Allostatic
load is now conventionally elaborated to include environment, life events, and early
trauma, such that childhood trauma from many years earlier is added together with
concurrent experiences, such as travelling though the city as measured by moment-
by-moment mobile technology, as illustrated by McEwan here (Fig. 2):
Three approaches have been used to elaborate the evidence for such stress
mechanisms. One is to measure external social stressors and allostatic load
in population surveys. Two comprehensive reviews suggest that this evidence
has yet to be found. Dowd et  al. (2009) conclude on the basis of the 26 studies
they found that “Current empirical evidence linking SES [socio-economic sta-
tus] to cortisol and AL (allostatic load) is weak. Future work should standard-
ise approaches to measuring SES, chronic stress and cortisol to better understand
these relationships”. (p. 1297). (Cortisol level is the standard biomarker used to
measure stress response). In a further recent review of studies since 2009, John-
son et al. (2017) state that “the scope of this review was limited to the biological
internalization of SEP [socio-economic position] and the effects of this stressor
on AL, highlighting AL as a mechanism on the causal pathway between SEP and
health outcomes” (p. 1). The authors report that a total of the 59 different bio-
markers were used in one or more of the 26 studies they found. The number of
biomarkers used to create an AL index ranged between 6 and 25. There were 20
different biomarker combinations observed across the 26 studies included in the
literature review. They conclude by observing how struck they were by the sub-
stantial inconsistency in biomarkers used to operationalise AL, and also by the
lack of fidelity to its original conception as an index of biological response to
Sociology, biology and mechanisms in urban mental health 15

stress. They argue it is difficult to know what is being measured by AL, or inter-
pret findings about the association between SEP and AL.
The second approach is to induce stress in experimental events, as a proxy for
the stress of ‘urbanicity’, and correlate this with experience of past or current
urban living. A widely used approach is to subject experimental subjects to a
situation of unfamiliarity and perceived social judgement, such as public speak-
ing. This is associated with changes in cortisol levels in the blood, and seems
robust. Using cortisol levels as a measure of stress in studies of mental disorder
has become common—they are fairly easy to evaluate from saliva. However, the
use of cortisol to measure stress raises a very real danger of circularity, in which
stress is itself defined in terms of cortisol, since there is little reflection in the
literature on whether public speaking is the ‘same’ stress as adverse life events,
or childhood trauma, or urban living and whether those get ‘under the skin’ in the
same way.
An example which has recently become widely influential is a study of how urban
living and upbringing affect ‘neural social stress processing’ (Lederbogen et  al.
2011). Two stress measures are used: the “Montreal Imaging Stress Task (MIST),
a social stress paradigm where participants solve arithmetic tasks under time pres-
sure” (p. 498) and a similar test in which “subjects performed two cognitive tasks
(arithmetic and mental rotation) while being continuously visually exposed to dis-
approving investigator feedback through video” (p. 499). This is assumed to be a
model of urban social stress, such that the authors conclude with the “parsimonious
proposal that social stress contributes causally to the impact of urbanicity on the
neural circuits identified” (p. 500). In a final flourish, they suggest that
Beyond mental illness, our data are of general interest in showing a link
between cities and social stress sensitivity. This indicates that an experimen-
tal approach … could be used to characterize further … the effects of finer-
grained quantifiers of individuals’ social networks or individual social experi-
ence in urban contexts. One such potential component is unstable hierarchical
position. (p. 500, italics added).
These findings were not replicated in a subsequent study explicitly linked to the
Lederbogen study, which used two different stress tests (Steinheuser et  al. 2014).
The Trier Social Stress Test asked subjects to “recall a list of 50 previously learned
items in front of an audience” (p. 679). The Socially Evaluated Cold Pressor Test
asked subjects to “immerse their right hand up to and including the wrist for 3 min
(or until they could not tolerate it any more) into ice water”. (p. 679).
It is a long extrapolation from such tests to an argument that the same stress is
produced by an ‘unstable hierarchical position’, and it remains unclear how such
psychosocial components create stress in the field, and how it is to be measured.
A third approach has been the development of a model of the ‘the social brain’
by Cacioppo in social neuroscience, looking at the consequences of social experi-
ence on the brain. The key area for his work has been the consequence of lone-
liness, i.e. the absence of the social, on brain function. Moreover, the key studies
here have been with animals rather than humans, and the definition of the social is
very limited. In a long review of ‘Social Neuroscience: Progress and Implications
 N. Manning
16

for Mental Health’, Cacioppo et  al. (2007, p. 106), for example, define the social
as ‘social behaviour’, which is classified into four subcategories of self-perception,
self-regulation, interpersonal perception, and group processes. However,, the fourth
type, group processes, is dealt with in merely one sentence in this long and detailed
review: “The stigma of physical and mental illness operates at the group or collec-
tive level of analysis” (p. 109). This is a substantial failure to grasp or work with the
reality of human society, and a misleading use of the term social in ‘social neurosci-
ence’ and the ‘social brain’.
In relation to stress, this lopsided approach continues in a recent comprehen-
sive review of stress and the ‘social brain’. Sandi and Halle (2015) open as fol-
lows: “Stress (defined in this Review as the activation of the neurophysiological
stress response) helps organisms to cope” (p. 290). Stress as a concept is thus col-
lapsed into neurophysiological change, rather than separately theorised and meas-
ured. Stress becomes the neurophysiological response, rather than the social expe-
rience. Thus, the conceptualisation and measurement of stress arising from social
life continues to prove elusive in practice. They comment that most of the studies
they review are from animal studies (rodents), and thus stress is read off from small
games and situations created for rodents to react to (p. 292). In common with the
Lederbogen study (above), this is almost exclusively an animal-based review, which
has equivocal findings, yet this has not inhibited the reviewers from concluding with
an unsubstantiated and massive projection into human social life that
If stress that is caused by social disputes — such as war, physical abuse or
aberrant socioeconomic inequalities — exacerbates antisocial dispositions in
individuals, it may be instrumental in the development of spirals of violence
(p. 300) (italics added)

What is to be done?

Mechanisms connecting urban life to mental disorder are both everywhere and elu-
sive. Hundreds of papers are being produced looking at dozens of different vari-
ables, measured in different ways. Is there progress? And if so, what might this
mean? How can we know more about urban life and mental disorder?
The key concept of stress is variable and unstable in its definition, and the social
aspects of urban life are poorly articulated. While the proposal from Galea of a more
theorised causal architecture is the right direction in which to move, this requires
that the elements are clear; yet we see that in the literature to date too much of it
either under- or miss-specifies both the nature of stress and the ‘social’. The archi-
tecture, to continue that metaphor, requires a more careful scaffolding. Wimsatt
(2014), for example, suggests three types of ‘scaffolding’ are necessary to underpin
such concepts and their interrelations. He defines scaffolds as the “means through
which other structures or competencies are constructed or acquired by individuals
or organizations … scaffolding for individuals, scaffolding for organizations, infra-
structural scaffolding” (pp. 86–87). For example, individuals live their lives in a
myriad of small face to face groups, such as families, friends, schools, associations,
Sociology, biology and mechanisms in urban mental health 17

work teams, churches; they are also embedded in legal and administrative contexts,
travel and distribution networks, and work organisations; underpinning all of which
are infrastructures such as language, travel networks, information sources, shopping
centres, networks for gas, water, power, telephone and waste removal. All of these
are aspects of the social context within which stress is experienced. Yet very lit-
tle of this kind of scaffolding appears in the papers reviewed so far, which could
be applied not only to the lived experience of being in the city, but also the ways
in which possible biological sub-systems work. As Krieger has put it more bluntly,
“psychosocial analyses accord less attention, theoretically and empirically, to who
and what generated psychosocial insults and buffers” (p. 198).
A key issue here is the idea that mechanisms are not merely aggregates of fac-
tors, or elements of scaffolds, but that they capture ‘emergent’ properties that are
organised in very specific ways. Craver and Tabery (2017) distinguish between
mechanistic (or organisational) emergence, whereby elements are arranged together
in quite specific ways, and epistemic emergence, meaning that it is not possible to
predict the properties of wholes from properties of the parts. In both cases, we need
to seek out the relationship between urban lives, stress, and mental disorder in terms
of mechanisms which are more than an aggregate of factors identified through statis-
tical associations.
Given the under-specification of stress and the social, we suggest that detailed
ethnography is now necessary to access urban experience which is associated with
mental disorder, keeping an open mind as to what the lived experience of people
might be. An example is Lutfey and Freese’s (2005) ethnography of diabetes as an
elaboration of the fundamental cause mechanism discussed earlier. In some ways,
diabetes could be a proxy for mental disorder: it is a major cause of morbidity and
mortality, with prevalence increasing dramatically; it is a long-term illness whose
treatment depends heavily on patient self-management; it is related to SES; com-
plications are known about. This simplifies the work of identifying potential mech-
anisms within an ethnographic inquiry (ibid, pp. 1332–1333). Their own model
is (Fig. 3):

Central locus Aributed Perceived disposional

of mechanism locaon Impediments

Inside the Connuity of care

In-clinic educaonal resources
clinic (I) Division of labour among physicians

External (II) Financial limitaons

Occupaonal constraints
Social support networks

Outside Apparent Costs of compliance

Relave magnitude of
clinic movaon (III) lifestyle adjustments
Disposional
Apparent Interaconal differences
Capacies as praccal
cognive ability (IV) achievements

Fig. 3  An ethnography of diabetes mechanisms (adapted from Lutfey and Freese 2005, p. 1339)
 N. Manning
18

Their goal is to use ethnography to “articulate some of the mechanisms by which

the inverse relationship between SES and health outcomes might be produced
among persons with diabetes” (p. 1361).
Knowing that migration, ethnicity, poverty, density, pollution, noise and so on
might be sources of urban stress, we have set up a major ESRC-funded ethnography
of migrant workers in Shanghai to see what we might understand about the scaffolds
surrounding their urban life and mental (di)stress. Our aim is to create a novel deep-
surveying instrument for wider use on the (global) social epidemiology of urban
mental health, and to inform strategies to address development priorities. Examples
of such ethnography in support of innovative epidemiology can be found for hygiene
(Larrea-Killinger et al. 2013), teen pregnancy (Béhague et al. 2008) and health seek-
ing (Freidenberg et al. 1993).

By way of a conclusion

In an open letter to the actor Stephen Fry, who discussed frankly on television his
own struggle for mental health, Richard Bentall (2016) wrote
a wide range of social and environmental factors increase the risk of mental ill
health …
poverty, urban environments, migration, ethnicity, early separation from par-
ents, childhood sexual, physical and emotional abuse, bullying in schools,
debt, unhappy marriages, demanding work, unemployment, to name but a few.
And he concluded that the “biggest cause of human misery is miserable relation-
ships with other people, conducted in miserable circumstances”.
But where does this leave us? It is far easier to question the factors, elements,
mechanisms, associations etc. of others than to create something new. What is
stress? Social capital? Socio-economic status? How do the microbiome, vagal
nerves, and the HPA axis interact? What is and how does trauma work? Even if we
understood these processes completely, what could we do? One way we might think
about this is by turning in the other direction, away from the damages that urban
life inflicts, towards an “urban utopianism based around four registers of solidarity
woven around the collective basics of everyday urban life. These are ‘repair’, ‘relat-
edness’, ‘rights’ and ‘re-enchantment’ (Amin 2006, p. 1009). Perhaps these could be
the inspiration for new ways of thinking.

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Sociology, biology and mechanisms in urban mental health 19

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