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| PERSPECTIVE/VIEWPOINT |
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| Year : 2021 | Volume
: 3
| Issue : 3 | Page : 146-149 |
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Challenges for Ibero-American Psychiatry from a Moral Standpoint
Fernando Lolas
Department of Psychiatry, University of Chile, Central University of Chile, Santiago, Chile
| Date of Submission | 14-Nov-2021 |
| Date of Decision | 14-Nov-2021 |
| Date of Acceptance | 15-Nov-2021 |
| Date of Web Publication | 23-Dec-2021 |
Correspondence Address:
Dr. Fernando Lolas
University of Chile, Central University of Chile, Santiago
Chile
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/wsp.wsp_52_21
Departing from the notion that psychiatry as a discipline renovates through invention, innovation, and transformation, this paper presents an approach to the syncretic characteristics of Ibero-American psychiatry stressing the essential role of translation in the reception, adoption, and implementation of knowledge and practices developed in other regions of the world. This applies both to scientific and humanistic dimensions of psychiatry, considering that as a praxiology or science of actions deals with embodied persons embedded in cultures that need to be considered in the process of diagnosis, treatment, and prevention. This involves translational humanities considering that basic axioms concerning human nature need a reflective equilibrium between beliefs, constructs and real conditions of practice. The innovations put forward by Ibero-American psychiatry, and expressed through modifications in institutions and concepts, can be studied against the background of the moral determinants of health, a comprehensive concept beyond the usual conceptualization of social determinants. The limitations imposed by scarce resources, shortage of trained practitioners, political instability, poverty, and economic dependence are a reminder that the challenges ahead are not only technical but moral as well.
Keywords: Ibero-American psychiatry, innovation, moral determinants of health, translational humanities
How to cite this article:
Lolas F. Challenges for Ibero-American Psychiatry from a Moral Standpoint. World Soc Psychiatry 2021;3:146-9 |
| The Renovation of Psychiatry | |  |
Three social processes renovate disciplines and practices: invention, innovation, and transformation.[1]
The invention, the creation of new concepts, translates experiences, perceptions, and information into knowledge, which is organized information expressed in concepts or constructs that shape the world of possible action. It increases the input to the societal knowledge system.
Innovation can be described as the process by which a certain set of beliefs or certainties is put to work in a different setting or knowledge applied in ways hitherto untried. New indications for pharmaceuticals, modifications of techniques, novel insights into accepted knowledge are examples of innovation. The output of the knowledge system is expanded, sometimes with added features that enrich the original concepts.
Transformation, the modification of persons, societies, and institutions, is a result of the reasoned and successful combination of invention and innovation. Institutions are reshaped, attitudes of persons may be changed and also society is changed.
It may be said that invention is represented by the process of research, by which disciplines are renovated both in their conceptual basis and in the group of persons engaged in the creation of knowledge, and innovation is usually related to technologies and applied science. However, as can sometimes be observed, “technology breeds technology” and some innovations are made in practice without the intervention of basic research.
These social processes are best characterized as translations: From perceptions and certainties into knowledge, from knowledge into practice, and from practice to social change.
| Psychiatry as a Discipline and a Profession | | |
Psychiatry may be conceived both as a discipline and a profession, guided by concepts and knowledge that aims at transforming society by helping people to find peace in life, enhancing their capabilities, or correcting deviations and impairments.[2] Different streams of thought and practice can be discerned, leading to emphases that privilege the biological foundations of mentation and affect, the social and economic contexts in which psychiatric practice is anchored, or policies contributing to reducing inequalities. Clinical practice, fundamental research, social interventions, advocacy, and public health policies are essential in psychiatric contribution to social welfare. The methodological and practical pluralism of psychiatry echoes the diversity of contexts in which it is developed and practiced, the unavoidable reductionisms that pervade its characteristics in any given tradition, and the need for a holistic approach to its diverse facets.
The contribution of the social and behavioral sciences must be integrated with the results of empirical data from the neurosciences and the reflective equilibrium from philosophical and ethical reflection. Ideas and insights must be confronted with realities and theories grounded on empirical facts if appropriate results and acceptable outcomes are expected from professional intervention.
In the Latin American context, the necessary integration of these discourses must be harmonized within political and ideological constraints. Social inequities and scarce resources make it imperative to reflect upon the ethical background of societal practices, characterized by institutional instability and attempts to replicate results from other, more scientifically minded societies. The challenge ahead lies in recognizing the diversity and arriving at “culture fair” decisions against the background of developmental challenges. A few examples provide support for the assertions and suggestions derived from praxis at the interface of ethics, politics, and technology.
| Defining Features of Ibero-American Psychiatry | | |
Ibero-American psychiatry, as depicted in numerous publications, combines many features, extensively studied by different scholars.[3],[4] The “globalization turn” aided by fast communications and the hegemony of the ideas and practices originating in certain areas of the world tend to obscure the particularities of local traditions. In no other field, is more necessary to remind practitioners that to “think globally” must be accompanied by an “act locally” stance. Since practical psychiatry relies heavily on language, an added layer of complexity is provided by the linguistic differences in which humans express distress or request help. A “global psychiatry” must consider the contributions of different traditions and cultures.
In this regard, Ibero-American psychiatry can and must contribute to the discipline by demonstrating how relevant the social milieu is for the conceptualization of mental health. Health, etymologically speaking, alludes to wholeness and wellbeing. However, with vast populations subject to deprivation, war, migration pressures, hunger, and lack of resources any universalism sounds utopic. Placed between the highly developed scientific advances and the complex theoretical approaches of North American and European traditions, the main contribution of the Ibero-American world has been to stress the social dimension and develop models for integrating the neuroscientific and the philosophical discourses within a frame of reference that accommodates the felt needs of underserved populations.
| Technologies in Psychiatry | | |
In the professional field of psychiatry, different technologies are used.
Productive technologies can be identified with the generation of desirable conditions for people. Since health is a personal construction, interventions and policies provide only means and tools for its attainment. Moreover, psychiatry - as medicine in general or any other helping profession - is a praxiology, a science of actions; its efficacy cannot be ascertained by a “thing” of “object” created by their practitioners but, instead, by the “good” performance, the correct ministration of resources and the satisfaction of the populations.
Semiotic technologies deal with the creation and generalization of appropriate indicators for people to recognize the quality of professional work, to distinguish between good and bad service, and to respect the practitioners. They are sometimes associated with technologies of identity which help recognize the different types of professionals involved in mental health and their respective competencies within the healthcare team.
Undoubtedly, communicative technologies are essence of the work in mental health. Their correct appreciation, development, and teaching are some of the contributions of the social and humane sciences to the armamentarium of psychiatry as a service profession.
| Innovation in Ibero-American Psychiatry and the “Translational Challenge” | | |
Innovation means, in this ambit of technologies, to perfect and improve the techniques and resources used, and to train practitioners in its correct application depending on context and circumstance.
Ibero-American psychiatry has been diligent in the creation of substantial reforms in terms of social participation, the creation of institutionalized resources, the establishment of community services, and the expansion of care to populations. It must be noted, however, that shortage of qualified professionals has been a hindrance to universal coverage and that institutional support has been lacking for adequate use of resources.
The dialogue between Anglo-Saxon, German, and in general, American or European psychiatry poses various challenges relevant to the issue of innovation in Ibero-American psychiatry. One of the most important challenge seems to be the language barrier.[5] While referential content may be translated with the usual tools of accredited translators versed in the language and the discipline, the contextual use of words and expressions needs an understanding of the culture-or ontology-in which they are used. The attempts to standardize diagnostic categories have implied, for instance, that usage of terms differ widely and lack of understanding of what a diagnosis really “means” in a given society may lead to false attempts at replication of studies or misguided treatment options. Efforts should be made to resort to transdiagnostic categories, labels, or qualifiers that help in the process of translating not only the terms in which pathologies are framed but also the social implications and connotations these labels may possess in certain communities.
This challenge, of course, is not unique to psychiatry but, in practice, this profession relies heavily on verbal and written communication and the very notion of wellbeing is a linguistic artifact dependent upon socio-facts and mind-facts that are inscribed into the culture.[6] Cultures, like languages that express some of their cardinal features, are collective creations inherited generation after generation. For their correct appreciation, some kind of training is needed. Probably not the specialized knowledge of anthropologists, but certainly the key notion of cultural relativism and the acceptance that any culture achieves its goals and ends differently by different processes of sense-giving and sense-making of what humans perceive or accept.[7] The hermeneutical approach is essential for deciphering these sense and meaning-related dimensions, implicit in societal life. Persons are embodied human beings embedded in traditions, customs, rituals, and beliefs. Their “forms of life” (Lebensformen) are expressed in “language games” that need to be understood, comprehended, and interpreted to single out what is “normal” suffering (pathic) and what is “abnormal” (pathological) because it alters life and prevents human persons from flourishing and developing their potential.
The psychiatric disorder is one “final common pathway” for a vast array of derangements, which can be subsumed under the headings of physiological, experiential, socio-cultural, and existential etiological factors. The search for strict causal chains between brain disorder and deranged mentation or behavior has occupied researchers for decades, with partial and partly irrelevant success. A “constructivist” position, accepting a kind of organizational or coadjuvant integration of determinations instead of lineal, albeit complex, causalities is assumed, particularly in societies where poverty, hunger, lack of possibilities, and structural inequities may easily be confused with underlying psychopathology-inducing causes. The notion of the psychophysiological triad with which we have worked is precisely the recognition that human states and traits are the conjoint product of physiology, mentation, and overt behavior in a complex “lexical” relationship. Each “text” is a “context” for the others and the result is interpretable only when the full spectrum of meaning is considered. In the same vein, “psychosomatic” alludes to different languages for describing either somatic or mental phenomena, but not the expression of different entities, body and mind, and should be considered aspects of the same unique human reality.[8],[9]
Ibero-American psychiatry represents a syncretic tradition of reception, integration, and creation of a unique system of beliefs and institutions. The shaping of concepts represents an amalgam of influences and the adoption of “culture-fair” constructs. This does not mean only the recognition and study of culture-bound syndromes or the adaptation of diagnostic and treatment alternatives. The challenge lies in an adequate “translation” of ideas and practices that originated in other parts of the world. This, however, is not a minor task. Translational medicine and psychiatry do not only involve the correct application of information and knowledge to novel situations; they also imply a reformulation of the basic tenets on which labels, technologies, and philosophical axioms are based. In this sense, translation not only replicates but adds new shades of meaning and connotations.
In a globalized world, from the economic point of view, it may appear as paradoxical that attempts at maintaining regional, ethnic, or national identities proliferate. This brings to light the need to expand the usual notion of “social determinants” of health to the more inclusive idea of “moral determinants”[10] of well-being since cultures are integrated wholes of traditions, beliefs, ideas, and emotions, their essential character residing more in the ways of justifying good and bad, normal and abnormal, rather than in the use or acceptance of civilization goods such as technologies and political structures.[11] Health, as wholeness and integration, has different meanings for different peoples.
In essence, translation is also comprehension, understanding, and sound re-invention of the basic axioms regarding human nature and its characteristic advantages and failures. Along with translational science, the pressing need for translational humanities is justified in all areas of psychiatric enterprise including the social and humanistic aspects.[12],[13],[14]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Lolas F, editor. Ética e innovación tecnológica (Ethics and technological innovation). In: Centro Interdisciplinario de Estudios en Bioética. Santiago de Chile: Universidad de Chile; 2006.  |
| 2. | Lolas F. Psychiatry: Medical specialty or specialized profession? World Psychiatry 2010;9:34-5. |
| 3. | Alarcón RD, Lolas F, Mari JJ, Lázaro J, Baca-Baldomero E. Latin American and Spanish-speaking perspectives on the challenges of global psychiatry. Braz J Psychiatry 2020;42:77-86. |
| 4. | Lolas F. Psychiatry and human rights in Latin America: Ethical dilemmas and the future. Int Rev Psychiatry 2010;22:325-9. |
| 5. | Lolas F. Editorial: Language, psychiatry, and globalization: The case for Spanish-speaking psychiatry. Asia Pac Psychiatry 2010;2:4-6. |
| 6. | Alarcón RD, editor. Cultural Psychiatry. Basel: Karger; 2013. |
| 7. | De Haan S. An enactive approach to psychiatry. Philos Psychiatry Psychol 2020;27:3-25. |
| 8. | Lolas F. Más allá del cuerpo. In: La construcción Narrativa De La Salud (Beyond the Body. The Narrative Construction of Health). Santiago de Chile: Andrés Bello; 1997. |
| 9. | Lolas F. The basic discipline of psychiatry as metatext. Acta Bioeth 2015;21:61-4. |
| 10. | Berwick DM. The moral determinants of health. JAMA 2020;324:225-6. |
| 11. | Lolas F. Public health and social justice. Toward ethical sustainability in healthcare and research. Acta Bioeth 2003;9:189-94. |
| 12. | Lolas F. Global mental health: Challenges for global ethics. Acta Bioeth 2016;22:9-14. |
| 13. | Pessini L, de Barchifontaine CP, Lolas F, editors. Ibero-American Bioethics. History and Perspectives. Netherlands: Springer; 2010. |
| 14. | Lolas F. Differential ethics in global mental health. JAHR Eur J Bioeth 2015;6:247-54. |
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