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| PERSPECTIVE/VIEWPOINT |
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| Year : 2019 | Volume
: 1
| Issue : 1 | Page : 30-32 |
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Toward an ecosocial psychiatry
Laurence J Kirmayer
James McGill Professor and Director, Division of Social and Transcultural Psychiatry, McGill University; Director, Culture and Mental Health Research Unit, Institute of Community and Family Psychiatry, Jewish General Hospital, Montreal, Quebec, Canada
| Date of Submission | 02-Jul-2019 |
| Date of Decision | 09-Jul-2019 |
| Date of Acceptance | 09-Jul-2019 |
| Date of Web Publication | 27-Sep-2019 |
Correspondence Address:
Prof. Laurence J Kirmayer
Division of Social and Transcultural Psychiatry, McGill University, 1033 Pine Ave West, Montreal, Quebec H3A 1A1
Canada
 Source of Support: None, Conflict of Interest: None  | 47 |
DOI: 10.4103/WSP.WSP_9_19
Social psychiatry is grounded in the recognition that we are fundamentally cultural beings. To advance the field, we need integrative theory and practical tools to better understand, assess, and intervene in the social-ecological cultural systems that constitute our selves and personhood. Cognitive science supports the view that mental processes are intrinsically social, embodied, and enacted through metaphor, narrative, and discursive practices. The circuits of the mind, therefore, extend beyond the brain to include our interactions with others through bodily and verbal communication. This ecosocial view of mind, brain, and culture calls for a shift in perspective from a psychiatry centered on brain circuitry and disorders toward one that recognizes social predicaments as the central focus of clinical concern and social systems or networks as a crucial site for explanation and intervention. The ecosocial perspective insists that we consider the powerful effects of structural violence and social inequality as key determinants of health. Social systems also have their own dynamics which can amplify inequities or provide sources of resilience. These social processes are framed, mediated, and maintained by cultural narratives, models, and metaphors. Hence, cultural analysis and critique must be foundational to social psychiatry. This opens the door to a creative engagement with human diversity in all its forms.
Keywords: Culture, ecosocial, psychiatry
How to cite this article:
Kirmayer LJ. Toward an ecosocial psychiatry. World Soc Psychiatry 2019;1:30-2 |
| Introduction | |  |
Social psychiatry is grounded in the recognition that we are fundamentally cultural beings.[1] Our brains are designed to acquire culture to navigate a social world, find support from others, and cooperate to construct our own ecosocial niche. For the last 50,000 years, we have been co-evolving with those niches, developing a vast array of cultures, languages, and forms of communal life to adapt to the demands of varied environments. This sociality is reflected in the architecture of our brains, which are organized to process social information, but especially in their plasticity, which allow us to acquire culture over decades of development. The brain is remodeled and rewired in response to the ways that we use it, with the result that we carry cultural knowledge, values, and skills within us in our personal storehouse of memory and capacity to respond to situations. However, most of the culture remain without, in the social environment, structured as affordances to which we respond based on our social position, norms, expectations, and aspirations.[2]
Cognitive science increasingly supports the view, first tendered by phenomenology, that mental processes are intrinsically social. The circuits of the mind extend out into the world, through our tools, discourse, practices, and institutions that enable cooperation. The world presents itself to us in terms of its affordances for action and perception, and these affordances are preeminently social and cultural. The collective knowledge, tools, and insights of previous generations are available to us through archives, and we scaffold more complex cognition on this cultural history, which is sedimented in language and present to us in our institutions and practices. In effect, we are able to extend the reach of our thoughts by thinking through other minds.[3] All of this makes social psychiatry not simply an “add-on” or supplement to biological psychiatry, but a necessity if we wish to understand the basic mechanisms of mental disorders and their effective treatment.[4]
This social view of the brain has received new precision through the current work in computational neuroscience, which views the brain as a prediction machine, learning to anticipate change and respond to maximize adaptation.[5] This predictive machinery can be deranged in various ways that correspond to specific forms of psychopathology. Work in 4-E cognitive science and active inference is advancing the vision of the biopsychosocial approach, clarifying the potential for a multilevel mechanistic model of mind, brain, and person that can model the ways in which this prediction machinery can breakdown.[6]
| The Place of Culture in Social Psychiatry | | |
Culture refers to the many ways in which the social world is configured by meaning and tradition. Culture is in the brain and in the world: in embodied skills and dispositions to respond and in social institutions and practices.[7] Local (and global) cultural contexts have their own structures and dynamics. Crucial for psychiatry is the aspects of culture that constitute mind and brain across development and are therefore central to processes of psychopathology and healing, that contribute to discrimination, marginalization, and social disadvantage (and rationalize inequity), and that leads us to fail to recognize the other in the context of their life-world.
The major social determinants of health all depend on culture ideologies and practice to set in place, maintain and, often, hide their structural mechanisms. Cultural practices constitute a social world with positions of advantage and disadvantage, varying exposure to risk and access to resources, giving rise to health inequities.[4]
Culture provides norms, rules, resources, and possibilities which individuals use to construct identities, form groups, and communities to which they belong, and position themselves within and against social constraints. Migration, telecommunication, and globalization ensure that individuals are positioned within and in transaction with multiple cultural worlds, giving rise to hybrid identities and forms of life. Specific kinds of predicaments – like those that arise from racism and discrimination, caste and religious, and linguistic identities and differences – are created by social structures which are normalized, rationalized, and maintained by cultural values, ideologies, and concepts of personhood.[8]
The cultural shaping of expressions of distress occurs at the levels of causes, mechanisms, and modes of expression. Variations in the expression are recognized in the “cultural concepts of distress” in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition which replace the older notion of culture-bound syndromes with a more pragmatic view of how people use local cultural concepts, idioms, and explanatory models to negotiate illness meaning.[9] These modes of interpretation and communication shape how we cope with the symptoms of mental disorders as well as how others respond to our suffering.[10] Stigma and social marginalization or healing, recovery, and integration all depend on the cultural meanings ascribed to behavior and experience. Hence, interventions that aim to change the social context and response to psychiatric disorders, fostering resilience and well-being, must be informed by local cultural models, values, and forms of life.[8],[11],[12]
Beyond engaging with local contexts, attention to culture can advance social psychiatry by revealing both commonalities and variations in the experience and expression of mental disorders. In addition to improving the validity of clinical assessment and the appropriateness of interventions, cross-cultural comparative methods can identify new strategies for adaptation and recovery rooted in local traditions but potentially translatable and transportable to new contexts.
| A Many-Storied Mind | | |
We are narrative beings, fashioning ourselves from the stuff of stories, locating our biographies and life projects in discursive webs of shared meaning. One consequence of this view is that understanding the human capacity to produce, think in, and transact with narrative must play a central role in psychiatric theory and practice.[13] In particular, narrative capacities, skills, practices, and specific content all can contribute to the causes, course, and outcomes of psychopathology as well as to processes of coping, resilience, healing, and recovery.
The mechanisms of the mind are not only biochemical but equally rooted in metaphor and narrative.[1],[6] The brain is a story machine, weaving webs of meaning through language, imagery, and performance. Memory, identity, and action are organized in terms of narratives that locate us in space and time. The narrative allows us to extend the reach of our imaginations to encompass future worlds and possible selves. Mind itself is best understood as largely a narrative capacity: the ability to tell stories about ourselves that explain our conflict, goals, and desires in ways that that recursively guide our own actions through cognition and interaction with others.
The circuits of the mind extend beyond the brain to include our interactions with others through bodily and verbal interaction and communication. Moreover, there can be pathologies of these interpersonal and social circuits.[4],[13] Social psychiatry needs a theory and practical tools to better understand, assess, and intervene in the social-ecological systems that constitute ourselves and personhood. That is where we may find great leverage for therapeutic change.
| An Agenda for World Social Psychiatry | | |
This ecosocial view of mind, brain, and culture has many implications for advancing the field of social psychiatry. Broadly, it calls for a shift in perspective from a psychiatry centered on brain circuitry and disorders toward one that recognizes predicaments as the central focus of clinical concern.
In research, an ecosocial perspective urges us to move an exclusive focus on the brain to consider the developmental trajectories and situations that shape its architecture and function. We may function well in a range of contexts but expect certain resources to be ready-to-hand and find some kinds of situations, especially challenging.[13] Understanding the mechanisms of mental disorders thus requires attention to the world beyond the individual, including families, communities, and networks, both local and global.
In clinical practice, an ecosocial view directs us to consider social context, developing skills of structural competence for a truly person-centered psychiatry.[14] It can guide us to a deeper understanding of resilience, healing, and recovery based not only on internal psychology or biological processes but also equally on social-interactional processes. Culturally, responsive care seeks to integrate the knowledge of the individual's life-world, their family and community as the site of both challenges and resources with which to cope, adapt, heal, and recover.
At the levels of public health and policy, the ecosocial perspective insists that we consider the powerful effects of structural violence and social inequality as determinants of health. Social systems have their own dynamics which can amplify inequities or provide sources of collective resilience.[15]
We live on a planet beset by our own exponential growth and arrogation of resources to pursue often short-sighted goals. As a result, we face the existential threat of climate change, which will result in massive increases in the scale and frequency of environmental catastrophes and forced migration. Globalization has created new fault lines and fractures, and media and networking have become not only bridges between communities but amplifiers of disinformation and distrust. Attacks on minorities, racism and discrimination, the erosion of refugee rights, and growing economic inequality are among the challenges we face and among the most powerful determinants of global mental health. These social questions must be central to a social psychiatry that aims not only to help those with mental health problems but to promote the wellbeing and indeed, survival of populations and communities.
We need innovative psychiatric theory, research, and modes of practice, as well as vigorous advocacy to work toward a world of greater equity and humanity. Social psychiatry has a crucial role to play in this – especially when it engages with diversity and recognizes the central place of culture in our being and becoming.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Kirmayer LJ. Re-visioning psychiatry: Toward an ecology of mind in health and illness. In: Kirmayer LJ, Lemelson R, Cummings CA, editors. Re-visioning Psychiatry: Cultural Phenomenology, Critical Neuroscience and Global Mental Health. Montreal: Cambridge University Press; 2015. p. 622-60.  |
| 2. | Ramstead MJ, Veissière SP, Kirmayer LJ. Cultural affordances: Scaffolding local worlds through shared intentionality and regimes of attention. Front Psychol 2016;7:1090. |
| 3. | Veissière SP, Constant A, Ramstead MJ, Friston KJ, Kirmayer LJ. Thinking through other minds: A variational approach to cognition and culture. Behav Brain Sci 2019;30:1-97. |
| 4. | Kirmayer LJ, Gold I. Re-socializing psychiatry. In: Choudhury S, Slaby J, editors. Critical Neuroscience: A Handbook of the Social and Cultural Contexts of Neuroscience. London: Blackwell; 2012. |
| 5. | Kirmayer LJ, Ramstead MJ. Embodiment and enactment in cultural psychiatry. In: Durt C, Fuchs T, Tewes C, editors. Embodiment, Enaction, and Culture: Investigating the Constitution of the Shared World. Boston: MIT Press; 2017. |
| 6. | Kirmayer LJ, Gómez-Carrillo A. Agency, embodiment and enactment in psychosomatic theory and practice. Med Humanit 2019;45:169-82. |
| 7. | Seligman R, Choudhury S, Kirmayer LJ. Locating culture in the brain and in the world: From social categories to the ecology of mind. In: Chiao J, Li SC, Seligman R, Turner R, editors. The Oxford Handbook of Cultural Neuroscience. New York, Oxford: Oxford University Press; 2016. p. 3-20. |
| 8. | Kirmayer LJ, Adeponle A, Dzokoto VA. Varieties of global psychology: Cultural diversity and constructions of the self. In: Fernando S, Moodley R, editors. Global Psychologies: Mental Health and the Global South. London: Palgrave, Macmillan; 2018. p. 21-37. |
| 9. | Kirmayer LJ. The future of cultural formulation. In: Lewis-Fernandez R, Aggarwal M, Hinton L, Hinton D, Kirmayer LJ, editors. DSM-5 Handbook on the Cultural Formulation Interview. Washington, DC: American Psychiatric Press; 2015. p. 267-85. |
| 10. | Kirmayer LJ, Gomez-Carrillo A, Veissière S. Culture and depression in global mental health: An ecosocial approach to the phenomenology of psychiatric disorders. Soc Sci Med 2017;183:163-8. |
| 11. | Kirmayer LJ, Guzder J, Rousseau C, editors. Cultural Consultation: Encountering the Other in Mental Health Care. New York: Springer; 2013. |
| 12. | Kirmayer LJ, Sheiner E, Geoffroy D. Mental health promotion for indigenous youth. In: Hodes M, Gau S, editors. Positive Mental Health, Fighting Stigma and Promoting Resiliency for Children and Adolescents. London: Academic Press; 2016. p. 111-40. |
| 13. | Kirmayer LJ, Crafa D. What kind of science for psychiatry? Front Hum Neurosci 2014;8:435. |
| 14. | Kirmayer LJ, Bennegadi R, Kastrup MC. Cultural awareness and responsiveness in person-centered psychiatry. In: Mezzich JE, Botbol EM, Christodoulou GN, Cloninger CR, Salloum IM, editors. Person Centered Psychiatry. Vancouver: Springer; 2016. p. 77-95. |
| 15. | Kirmayer LJ, Dandeneau S, Marshall E, Phillips MK, Williamson KJ. Rethinking resilience from Indigenous perspectives. Can J Psychiatry 2011;56:84-91. |
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