|Year : 2020 | Volume
| Issue : 2 | Page : 58-68
Articulating Social Psychiatry and Person-Centered Medicine: Conceptual Bases and International Implications for COVID-19
Juan E Mezzich1, Roy A Kallivayalil2, Rachid Bennegadi3, Michel Botbol4, George Christodoulou5, Doina Cozman6, Afzal Javed7, Marianne Kastrup8, Fernando Lolas9, David Ndetei10, Armen Soghoyan11, Zvi Zemishlany12
1 Department of Psychiatry, International Center for Mental Health, Icahn School of Medicine at Mount Sinai, New York, USA; Hipolito Unanue Chair of Person Centered Medicine, School of Medicine, San Marcos National University, Lima, Peru
2 Department of Psychiatry, Pushpagiri Institute of Medical Sciences, Tiruvalla, Kerala, India
3 Minkowska Center, Sigmund Freud University, Paris, France
4 Department of Child and Adolescent Psychiatry, Western Bretagne University, Brest, France
5 Department of Psychiatry, National Kapodistrian University, Athens, Greece
6 Department of Clinical Psychology, University of Medicine and Pharmacy Iuliu Hatieganu, Cluj-Napoca, Romania
7 Chairman, Pakistan Psychiatric Research Centre, Fountain House, Lahore, Pakistan
8 Specialist in Psychiatry, Frederiksberg, Denmark
9 Interdisciplinary Center for the Study of Bioethics, University of Chile, Santiago de Chile, Chile
10 Department of Psychiatry, University of Nairobi, Nairobi, Kenya
11 Psychosocial Recovery Center, Yerevan, Armenia
12 Geha Mental Health Center, Tel Aviv University, Petah Tikva, Israel
|Date of Submission||18-Jun-2020|
|Date of Acceptance||19-Jun-2020|
|Date of Web Publication||14-Aug-2020|
Prof. Juan E Mezzich
Department of Psychiatry, International Center for Mental Health, Icahn School of Medicine At Mount Sinai, Box 1093, Fifth Avenue and 100th St, New York 10129, USA
Source of Support: None, Conflict of Interest: None
Background: The World Association of Social Psychiatry (SP) and the International College of Person-Centered Medicine (PCM), while having their own background and goals, share some significant interests and concerns, raising hope for collaboration and synergism. Consideration of the COVID-19 pandemic that is severely challenging the world may also offer opportunities for organizations and programmatic perspectives to reflect on and optimize their paths. Objectives: This article is aimed at delineating a pattern of points of conceptual and strategic articulation between SP and PCM as perceived by scholars familiar with these perspectives, and to examine their implications for general health care and for responding to the evolving COVID-19 pandemic. Methods: This is primarily a consultation study involving clinical scholars familiar with the two perspectives at hand around a list of prospective articulation points between SP and PCM based on a selective literature review. The specific methods engaged involved elucidation of prominent SP/PCM articulation patterns through tabular displays of panelist ratings and contrast between such articulation points and recommendations from the UN and WHO for advancing general health care and responding to the COVID-19 pandemic. Results: The initial explorative elucidation of potential articulation points between SP and PCM, including a) Contextualized approach, b) Ethical commitment, c) Humanization of medicine, d) Concern for broad determinants of health, e) Commitment to health care and public health, and f) Contributing to UN SDGs, was supported by the ratings of panelists familiar with both perspectives and the recommendations of authoritative international health declarations (including those focused on COVID-19 response). This was particularly the case for complementary concern for health care and public health, a contextualized person/whole society approach, and ethical commitment to persons' values. Conclusions: The thrust of the results of the present study and their contrast with the emerging professional and scientific literature stimulated by the COVID-19 pandemic affords clarification and validity on the concepts and strategies of SP and PCM and opens new avenues for useful collaboration.
Keywords: COVID-19, person centered medicine, social psychiatry
|How to cite this article:|
Mezzich JE, Kallivayalil RA, Bennegadi R, Botbol M, Christodoulou G, Cozman D, Javed A, Kastrup M, Lolas F, Ndetei D, Soghoyan A, Zemishlany Z. Articulating Social Psychiatry and Person-Centered Medicine: Conceptual Bases and International Implications for COVID-19. World Soc Psychiatry 2020;2:58-68
|How to cite this URL:|
Mezzich JE, Kallivayalil RA, Bennegadi R, Botbol M, Christodoulou G, Cozman D, Javed A, Kastrup M, Lolas F, Ndetei D, Soghoyan A, Zemishlany Z. Articulating Social Psychiatry and Person-Centered Medicine: Conceptual Bases and International Implications for COVID-19. World Soc Psychiatry [serial online] 2020 [cited 2020 Oct 20];2:58-68. Available from: https://www.worldsocpsychiatry.org/text.asp?2020/2/2/58/292147
| Introduction|| |
The World Association of Social Psychiatry (WASP) and the International College of Person-Centered Medicine (PCM) have their own roots, purposes, and trajectories. At the same time, they share some significant interests and concerns, as evidenced by some of their publications and the discernible participation of prominent cultivators of these two perspectives in each other events and projects. These observations have raised interest on the relations between their respective conceptual bases and strategies, which may enrich the delineation of their respective tenets, objectives and programmatic profiles and lead to promising collaboration and synergism, particularly as the world enters a new era related to the COVID-19 pandemic when opportunities are emerging for major developments in global health and socio-political systems.
Brief reviews follow of the conceptual bases and strategies of social psychiatry (SP) and of PCM.
A conceptual note on social psychiatry
The founding in 1964 of the WASP was sustained by the theoretical perspectives on SP published by Bierer and Williamson, supported by the delineation of models of madness and models of medicine by Siegler and Osmond. The main focus of their concerns seems to be the Nature of man and his cultures– Prevention and treatment of his vicissitudes and disorders.
Over the years, the focus seems to broaden to promote greater understanding of the interactions between individuals and their physical and human environment (including their society and culture), and the impact of these interactions on the clinical expression, treatment of mental and behavioral problems and disorders and their prevention.
Such a transformational process has been rounded up by Kallivayalil, when as president of the WASP repositioned psychiatry itself “from biological reductionism to a bio-psycho-social perspective.” He appeared to anchor the institution on both practical physician concerns and historical roots, by affirming the importance of understanding the paradigms of health and mental health and pointing out that “the approach in Ayurveda and ancient Greece was person-centered, focused on the quality of life and health rather than disease.” At the same time, he opened up to the future, borrowing the words of Ophelia in Hamlet, We know what we are, but not what we may be.
A conceptual note on person-centered medicine
The historical roots of PCM may be traced to the personalized and holistic notions of health in the earliest Eastern and Western civilizations, including the Andean ones in which personal health was conceived as a harmonious balance among the internal, social and ecological worlds. More recent bases of PCM may be found in Kantian ethical imperative on the person being always a goal and never a means and the French Revolution's Declaration of Human Rights. Instrumentally inspiring PCM in the twentieth century were the contributions of Ortega and Gasset; von Weizsaeker; Rogers', volumes on The Person as a Center and On Becoming a Person; and Tournier.
PCM, as a programmatic movement started in 2005 when the World Psychiatric Association general assembly established the institutional program on psychiatry for the person. Since 2008, this person-centered approach was extended to medicine and health in general through annual Geneva Conferences in collaboration with the World Medical Association, the International Council of Nurses, the World Health Organization and the International Alliance of Patients' Organizations among other similar institutions. In 2009, an International College of PCM was established, which is publishing the International Journal of PCM in collaboration with the University of Buckingham Press and has started a book series with Springer Switzerland (Person-Centered Psychiatry, and Person Centered Medicine, in preparation).
Almost from the beginning of its institutional journey, PCM has been generally defined as an approach that places the person in context as the center of health and as the goal of health care. PCM in the clinical field has been presented as a medicine of the person (of the totality of the person's health, including its ill and positive aspects), for the person (promoting the fulfillment of the person's life project), by the person (with clinicians extending themselves as full human beings, professionally competent, and with high ethical aspirations) and with the person (working respectfully, in collaboration and in an empowering manner with persons presenting for care).
Complementing this, there has been an effort to articulate person-centered clinical medicine and people-centered public health as two sides of the same medal. As a theory of medicine, and in contrast to reductionist perspectives, PCM involves a medicine informed by evidence, experience, and values, and oriented to promote the health and well-being of the whole person.
A major study on the systematic conceptualization and measurement of PCM was undertaken by the International College of PCM with support from the World Health Organization. Through a critical review of the literature and broad international consultations, it elucidated the following as key concepts of PCM: (1) Ethical commitment, (2) Cultural awareness and responsiveness, (3) Holistic scope, (4) Relational and communicational focus, (5) Individualized programming of care, (6) Common Ground among clinicians, patient and family for collaborative diagnosis and shared decision-making, (7) People-centered and integrated organization of services, and (8) Person-centered health education and research. Based on these key concepts, a person-centered care index has been developed. Its metric structure, as well as its applicability, reliability, and content validity, have been appraised through international studies.
This paper is aimed at delineating a pattern of points of conceptual and strategic articulation between SP and PCM, first informally on the basis of the summarized formulation of their existing published conceptualizations, second as emerging informally from an effort to set the bases for an articulation study.
The third and more formal step involved an analysis of the views of consulting panelists on the proposed articulation points. The fourth step consisted in determining the extent to which major international statements on health care in general and on the current situation related to the COVID-19 pandemic touched on the articulation points between SP and PCM.
| Methods|| |
The first two examinations of the potential relations between SP and PCM, as listed under Objectives, being as they were informally presented, they will be assessed as well informally and incorporated into the Discussion section, complementing the comments on the most formal aspects of the study.
As mentioned above, the third and most formal aspect of the study involved gathering and analyses of the views of consulting panelists on proposed SP/PCM articulation points. To this effect, the study organizers (JEM and RAK) elucidated the following six potential points of the conceptual and strategic relationship between SP and PCM, and provided bibliographic references in support of each prospective articulation point, as follows:
- Contextualized approach: Person, family, and community,
- Ethical commitment to persons' values,,
- umanization of medicine and health care,
- Deep concern for the broad determinants of health
- Commitment to health care and public health (person-and people-centered medicine and health),
- Contributing to the United Nations' Sustainable Development Goals.,,,,
Then, ten internationally recognized scholars and clinicians familiar with SP and PCM were invited to participate in a Presidential PanelSession on Articulating SP, and PCM held at the World Congress of the World Association of SP (WASP ) in Bucharest, October 25–28, 2019. In addition, they were invited to reflect on the six potential articulation points between SP and PCM listed above to identify one or more of them as highly relevant to such articulation and to provide a comment or illustration on the points they selected from their own theoretical, clinical or cultural perspectives.
All invited panelists accepted to speak at the Panel Session and to select and identify from the initial set of SP/PCM articulation points those they regarded as most relevant and important. These ten panelists resided in the following countries: Armenia, Chile, Denmark, France (two of them), Greece, Israel, Kenya, Romania, and the United Kingdom. Their contributions in selecting highly relevant articulation points were anonymized for the tabular presentation of results. On the other hand, they are co-authors of this paper as they reviewed and agreed to its content.
The protocol of this more formal study aspect, involving the gathering and analysis of the views of consulting panelists on the proposed articulation points, was submitted for institutional ethics review to the international college of PCM.
| Results|| |
The results presented in this section reveal the degree and patterns of the prominence of the SP/PCM articulation points first in terms of how they are perceived by ten participating panelists, and second in terms of their relationship to three major health declarations issued by top international agencies on general healthy living and well-being, mental health action needed vis-à-vis the COVID-19 pandemic, and broad response to this pandemic, all published between September 2019 and May 2020.
Most prominent social psychiatry/person centered medicine articulation points as perceived by participating panelists
[Table 1] displays the SP/PCM articulation points selected by each of the ten panelists along with illustrative comments for each articulation point. All panelists identified as relevant at least one articulation point. The number of identified articulation points approached a normal distribution: three panelists identified one articulation point, five panelists identified two articulation points, and two panelists identified three articulation points.
|Table 1: Articulation points between Social Psychiatry and Person Centered Medicine highlighted by ten panelists and their illustrative comments|
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[Table 2] exhibits patterns of specific articulation points selected by the ten panelists. The most prominent articulation point, selected by six of the ten panelists was “A. Contextualized approach: Person, family, and community.” Illustrative comments included the following: The contextualized approach represents the most important element in the relation between PCM and SP; and the role of the community is crucial concerning resilience and vulnerability.
|Table 2: Patterns of Social Psychiatry-Person Centered Medicine articulation points selected by ten panelists|
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Two other SP/PCM articulation points were next in prominence, each selected by four panelists. One of these two was “B. Ethical commitment to person's values,” which was highlighted with comments such as Person-centered Psychiatry respects personal autonomy but does not exclude societal and public health interests. It recognizes the person in the singular and in the plural (i.e., people in society). It is not necessarily committed to either individualism or communitarianism.); and A practical form of respecting persons' values is to explore the axiological dimension of the person. A graphical depiction-so called axiogram-is a way of contrasting the values of clients and health-care providers.
The other item in the second most prominent pair of articulation points was “E. Commitment to health care and public health.” A couple of illustrative comments offered here were: One needs to attend to both health care and public health; Person-and people-centered medicine and health are complementary.
Relationship between social psychiatry/person-centered medicine articulation points and three major international health declarations
The first international health declaration examined here was the Global Action Plan for Healthy Lives and Well-Being for All published by twelve multilateral organizations on September 24, 2019. [Table 3] shows the recommendations of this Global Action Plan pertinent to each of the six SP/PCM articulation points. It can be seen at the outset that these recommendations touch to various degrees all six articulation points. Among the two articulation points most connected to the Global Action Plan recommendations is “A. Contextualized Approach: Person, family, and community”, illustratively involving recommendations such as Jointly advocate for and provide coordinated support to communities and civil society organizations at country level, including through organizational strengthening, to enable and empower them to strategically mobilize; and Collect and share best practices and guidance on the effective engagement of communities and civil society in the health sphere. Another top involved articulation point is “E. Commitment to health care and public health,” for which illustrative recommendations include: Strengthen emergency capacity through preparedness actions to reinforce health system capacity to prevent and mitigate the impact of health emergencies and natural disasters, and Support countries with fragile settings to better prepare for, prevent, detect and respond to outbreaks.
|Table 3: Recommendations from the Global Action Plan for Healthy Lives and Well-being for All from 12 multilateral organizations, September 24, 2019, pertinent to each of the Social Psychiatry/Person Centered Medicine Articulation Points|
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Next in level of connection with the Global Action Plan was articulation point “D. Deep concern for the broad determinants of health”, as illustrated by recommendations Support countries to mobilize adequate and sustainable revenues through pro-poor and pro-health policies and legislative and regulatory measures, including fiscal measures as appropriate; and Address the determinants of health by action in the different spheres of policymaking that have a bearing on health, health inequities, the relationship between health, poverty and socio-economic development, the number of lives that could be saved and the returns on investment.
The next examined was the United Nations Policy Brief on COVID-19 and the Need for Action on Mental Health, issued on April 13, 2020. It contained recommendations relevant to all six SP/PCM articulation points, but most frequently (seven recommendations) related to “E. Commitment to health care and public health.” Such recommendations may be illustrated by Ensuring uninterrupted in-person care for severe mental health conditions by formally defining such care as essential services to be continued throughout the pandemic; and Making sure that mental health is part of universal health coverage, for example by including care for mental, neurological and substance use disorders in health care benefit packages and insurance schemes.
Second, in the level of pertinence, this UN Policy Brief encompassed four recommendations pertinent to SP/PCM articulation point “A. Contextualized Approach: Person, family, and community.” Among illustrative recommendations were: including mental health and psychosocial considerations in national response plans across relevant sectors, for example supporting learning and nurturing environments for children and young people who are confined at home; and Responding proactively to reducing pandemic-related adversities that are known to harm mental health, for example, domestic violence and acute impoverishment [Table 4].
|Table 4: Recommendations from the UN Policy Brief on COVID-19 and the Need for Action on Mental Health, 13 May 2020, pertinent to Social Psychiatry/Person Centered Medicine articulation points|
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The third and final authoritative international health statement examined involved the 2020 World Health Assembly Resolutions on COVID-19 Response, May 19, 2020. It encompassed considerations and recommendations related to all six SP/PCM articulation points, but most prominently (three considerations and four recommendations) to “E. Commitment to health care and public health.” The relevant recommendations may be illustrated by: Put in place a whole of government and whole of society response implementing a national, cross-sectoral COVID-19 action plan that outlines both immediate and long term actions with a view to sustainably strengthening their health system and social care and support systems; Maintain the continued functioning of the health system in all relevant aspects, in accordance with national context and priorities, necessary for an effective public health response to the COVID-19 pandemic; and Calls for the universal, timely and equitable access to and fair distribution of all quality, safe, efficacious, and affordable essential health technologies and products including their components and precursors required in the response to the COVID-19 pandemic as a global priority.
The next SP/PCM articulation point frequently related to the 2020 WHA Resolutions (four considerations or recommendations) was “B. Ethical commitment to person's values.” An illustrative recommendation follows: Implement national action plans by putting in place, according to their specific contexts, comprehensive, proportionate, time-bound, age- and disability-sensitive and gender-responsive measures across government sectors against COVID-19, ensuring respect for human rights and fundamental freedoms and paying particular attention to the needs of people in vulnerable situations, promoting social cohesion, taking necessary measures to ensure social protection, protection from financial hardship and preventing insecurity, violence, discrimination, stigmatization, and marginalization.
In third place concerning pertinent 2020 WHA considerations or recommendations was SP/PCM articulation point “F. Contributing to the UN Sustainable Development Goals.” An illustrative recommendation here was: Continue to work with the United Nations Secretary-General and relevant multilateral organizations, including the signatory agencies of the Global Action Plan for Healthy Lives and Well-Being, on a comprehensive and coordinated response across the United Nations system to support Member States in their responses to the COVID-19 pandemic in full cooperation with governments, as appropriate [Table 5].
|Table 5: Considerations and recommendations of the 2020 World Health Assembly Resolutions on COVID-19 Response, 19 May 2020, pertinent to Social Psychiatry-Person-Centered Medicine articulation points|
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[Table 6] pointedly displays the frequencies with which the recommendations of the three authoritative international health declarations (one on healthy lives and well-being and two focused on COVID-19),, were pertinent to the SP/PCM articulation points. It appeared that the international health declarations included variable and sizable numbers of recommendations relevant to each of the six SP/PCM articulation points. In effect, the articulation points with the highest numbers of pertinent recommendations from the international health declarations were “E. Commitment to health care and public health” (with a total of 18 recommendations) and “A. Contextualized approach” (with 10 recommendations). In third place was the articulation point “B. Ethical commitment” (with 7 recommendations), conceptually connected to “C. Humanization of medicine and healthcare” (5 recommendations). Frthermore, third was the articulation point “D. Concern for broad determinants of health” (7 recommendations), conceptually close to “F. Sustainable Development Goals” (6 recommendations).
|Table 6: Frequency of Recommendations from three Authoritative International Statements found relevant to six Social Psychiatry-Person Centered Medicine Articulation Points|
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| Discussion|| |
One could say that the present study on the conceptual bases of SP and PCM and their international implications related to the COVID-19 pandemic has had a telescopic course. It started by looking at the conceptual backgrounds of these two institutional and programmatic perspectives and finding that the profile of the WASP has been evolving from a straightforward “social” focus towards a comprehensive anti-reductionist bio-psycho-social perspective. This conceptual broadening, as well as its concern for positive health (i.e., a concern not restricted to disease) seems to position the WASP closer to PCM, keeping in mind that the framework of WASP is the psychiatry/mental health field, while the broader framework of PCM involves general medicine and general health.
The preparation of the consultation panel as the core of the present study led to the marshaling a selective literature review to substantiate the formulation of a set of promising points of articulation between SP and PCM. While the engaged bibliographic references may have afforded an outlook of reasonableness in principle, they would not guarantee their solidity to articulate the relationship between SP and PCM. Examining the support for such articulation (or lack of it) was reserved for later phases of the study.
The results obtained from the participating panelist ratings as well as from the assessment of correspondence and relevance between the SP/PCM articulation points and the recommendations of three authoritative health declarations (two related to COVID-19) issued by United Nations and the World Health Organization bodies revealed two discernible patterns. One was that largely across the board, the most prominent articulation points involved a contextualized approach, the complementariness of healthcare and public health, and ethical commitment. The other emerging pattern was that the other three articulation points (concern for medicine and health care humanization, broad determinants of health, and SDGs) were not far away in value and relevance and enjoyed the substantial conceptual closeness to the top articulation points.
A broader interpretation of the above findings may be facilitated by the rapidly burgeoning professional and scientific literature stimulated by the COVID-19 pandemic. The thrust of this literature is revealing that the scope and consequences of the pandemic seem to extend beyond a global health crisis. Fassin has unpacked that life is a fact of nature and also a fact of experience. And thus, he emphasized that our task is to uncover the biographies of those who have lived and died with COVID-19, to resist the restrictive biologization of this disease, and to insist on a social and political critique of COVID-19.
Dalglish has documented that the COVID-19 has given the lie of presumed global health expertise, with some of the dominant purveyors of advice now exhibiting dismal responses to the pandemic. She presses cogently for more democratic, more multipolar, more networked, and more distributed understanding and operation of global health. In line with this, Chiriboga et al. addressing health inequities during the pandemic call for ethical global leadership. A pertinent initiative that comes to mind is that from the New Zealand government recently proposing a national budget aimed to enable all people to lead lives of purpose, balance, and meaning.
In another promising line of thinking, the Group on Healthier Societies for Healthier Populations, is urging the fulfillment of the aspirations of the Alma Ata Declaration (WHO, 1978) through joint renewed efforts of all stakeholders. This has been also the plea of the Astana Declaration (WHO, 2018), particularly through the call for action from the WHO Regional Office for the Americas. As Hare has recently pointed out, what is now needed is a new social contract, affirming the interdependence and interconnectedness of efforts at local, national, and global levels. The well documented devastating vulnerability of ethnic minorities, migrants, and refugees to COVID-19 makes this call patently urgent.
The above insights and developments happen to be also relevant to the evolving concepts and strategies of SP and PCM. For example, Cash and Patel have examined the proper ways in a pandemic of observing the key principles of global health, i.e., that context matters, that social justice and health equity are crucial goals, and that the engagement of persons and the whole society is fundamental. These three requirements square well with the SP/PCM articulation concepts of a contextualized approach, ethics commitment, and complementariness of clinical health care and public health (i.e., person-and persons-centered health actions).
| Conclusions|| |
Clarification has been gained on the intersecting conceptual tenets of SP and PCM through literature reviews, expert consultations, and contrasts with authoritative international health recommendations (including some related to COVID-19). The elucidation of prominent points of articulation between SP and PCM affords a measure of convergent validity to their basic concepts, particularly those involving ethical commitment, comprehensive and contextualized approaches, and person-and persons-centered health actions. At the same time, they open up promising avenues for collaboration among SP, PCM, and like-minded organizations.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]