World Social Psychiatry

REVIEW ARTICLE
Year
: 2019  |  Volume : 1  |  Issue : 1  |  Page : 8--21

“A person is a person through other persons”: A social psychiatry manifesto for the 21st century


Vincenzo Di Nicola 
 Department of Psychiatry, Institut Universitaire en Santé Mentale de Montréal (IUSMM); Department of Psychiatry, Université de Montréal; Montreal, Canada; Department of Psychiatry and Behavioral Sciences, The George Washington University, Washington, DC, USA; President, Canadian Association of Social Psychiatry

Correspondence Address:
Prof. Vincenzo Di Nicola
Institut Universitaire en Santé Mentale de Montréal, 7401, Rue Hochelaga, Montreal, Quebec, Canada

Abstract

A critical issue for our field is how to define contemporary social psychiatry for our times. In this article, I address this definitional task by breaking it down into three major questions for social psychiatry and conclude with a call for action, a manifesto for the 21st century social psychiatry: (1) What is social about psychiatry? I address definitional problems that arise, such as binary thinking, and the need for a common language. (2) What are the theory and practice of social psychiatry? Issues include social psychiatry's core principles, values, and operational criteria; the social determinants of health and the Global Mental Health (GMH) Movement; and the need for translational research. This part of the review establishes the minimal criteria for a coherent theory of social psychiatry and the view of persons that emerges from such a theory, the social self. (3) Why the time has come for a manifesto for social psychiatry. I outline the parameters for a theory of social psychiatry, based on both the social self and the social determinants of health, to offer an inclusive social definition of health, concluding with a call for action, a manifesto for the 21st century social psychiatry.



How to cite this article:
Di Nicola V. “A person is a person through other persons”: A social psychiatry manifesto for the 21st century.World Soc Psychiatry 2019;1:8-21


How to cite this URL:
Di Nicola V. “A person is a person through other persons”: A social psychiatry manifesto for the 21st century. World Soc Psychiatry [serial online] 2019 [cited 2022 May 22 ];1:8-21
Available from: https://www.worldsocpsychiatry.org/text.asp?2019/1/1/8/267958


Full Text



 Introduction: What Is Social Psychiatry?



Social Psychiatry is the science of Anthropos

– George Vassiliou and Eliot Sorel (From a dialogue between George Vassiliou and Eliot Sorel following the symposium on “The Role of the Psychiatrist in International Conflict Resolution” at the 8th World Congress of Social Psychiatry in Zagreb, Yugoslavia, in 1981).

As the founder and president of the newly reconstituted Canadian Association of Social Psychiatry, I immersed myself in the rich history and significant achievements of the World Association of Social Psychiatry (WASP) and encountered a recurrent issue: What is social psychiatry? George Vassiliou and Eliot Sorel, two WASP Past Presidents, defined it as nothing less than the science of Anthropos (humanity). In this article, I address this definitional task by breaking it down into three major questions for social psychiatry and conclude with a call for action, a manifesto for the 21st century social psychiatry:

What is social about psychiatry? I address definitional problems that arise, such as binary thinking[1] and the need for a common language[2]What are the theory and practice of social psychiatry? Issues include social psychiatry's core principles, values, and operational criteria; the social determinants of health[3],[4] and the GMH Movement;[5],[6] and the need for translational research. This review establishes the minimal criteria for a coherent theory of social psychiatry and the view of persons that emerges from such a theory, the social self[7]Why the time has come for a manifesto for social psychiatry. I outline the parameters for a theory of social psychiatry, based on both the social self and the social determinants of health, to offer an inclusive social definition of health,[8] concluding with a call for action, a manifesto for the 21st century social psychiatry.

 What Is Social About Psychiatry?



Jules Masserman,[9] a founder and early president (1969–1974) of the WASP, affirmed the social nature of psychiatry:

Humanistic philosophers from Plato and K'ung Fu-Tze (L. Confucius) to Émile Durkheim have taught us that an individual's welfare ultimately depends on the merited support of his or her social group, from family and clan to nation…. We as psychiatrists are … called upon in our triune roles as physicians, cultural ombudsmen and philosophic savants to restore our patients' (L. patient, sufferer) vitality, social adaptation and relative serenity. In the sense that “social” is derived from L. socius, companion, all psychiatry is social.

While Masserman and other social psychiatrists contend that all psychiatry is social,[10],[11] the history of psychiatry shows that this must be demonstrated and continually affirmed. At a time when the community psychiatry movement is losing support, with a return to hospital care, and a large burden of psychiatric care shifting to prisons,[12],[13] the hard-won knowledge and perspective of social psychiatry must be continually integrated into teaching, research and practice, policy-making, and health-care planning.

In my view as a social psychiatrist, different approaches such as systemic family therapy and epidemiological studies are the tools for investigation based on “n greater than 1.” They are tools, nonetheless, not ends in themselves. Mara Selvini Palazzoli, a founder of family therapy, stated this presciently: “Family therapy is the starting point for the study of ever wider social units.”[14] Social psychiatry is the ultimate apparatus for the study of the social context of human predicaments, the widest possible context. Understanding humans out of context is not only limited but also deeply misleading, as many contend,[11] yielding pseudoproblems and the conundrums that psychiatry and the social sciences have created in their descent into the “spiral staircase of the self,” in Montaigne's memorable phrase.

What, then, is social about psychiatry as a branch of medicine and a social perspective on health? A corollary is: what are the roots of our concerns as social psychiatrists?

Social psychiatry – False friends or an odd pair?

In the work of translation, we have the experience of false analogies and ambiguous affinities between languages, what one specialized Italian–English dictionary calls “odd pairs and false friends.”[15],[16],[17] This is a metaphor for the state of social psychiatry today, since the two terms, social and psychiatry, are at times false friends and at others, get along just fine as an odd pair.

If our starting point is Samuel Guze's Why Psychiatry Is a Branch of Medicine,[18]social is a strong counterpoint to psychiatry understood as biomedicine and psychiatric illness as brain disorders, making for a very odd pair. Guze's defense of the medical model in psychiatry now holds sway in North American academic psychiatry to the point that the National Institute of Mental Health (NIMH) established its own Research Domain Criteria based on genomics and neuroscience,[19] airily dismissing a half-century of research and refinements into descriptive psychiatric nosography by the American Psychiatric Association's DSM project as a “mere dictionary.” The translation of psychiatric illness to disorders of the brain elevates neuroscience to the status of a foundational science. In a parallel shift, academic psychology has now become cognitive neuroscience and evolutionary psychology.[20] This has engendered enthusiastic affirmations such as Eric Kandel's psychiatric extrapolations from his Nobel Prize-winning neuroscience research,[21],[22] countered by trenchant criticisms from psychology,[23] philosophy of science,[24] and other branches of medicine.[25] Lolas,[26] WASP Secretary-General and an authority on psychiatric ethics, opines that psychiatry should be a specialized profession rather than a branch of medicine.

On the other hand, if we start with Arthur Kleinman's Social Origins of Distress and Disease,[27] an essay in medical anthropology that widens our understanding of psychiatry to encompass the personal distress and despair and the social suffering that accompany psychiatric illness, we create false friends, an illusion of harmony within psychiatry as a whole. Kleinman exhorts us to “rethink psychiatry,” moving “from cultural category to personal experience.”[28] As an authoritative voice for the social sciences in psychiatry, Kleinman poignantly criticizes the pathologization and the medicalization of human suffering, calling for a “rebalancing of academic psychiatry”[29] to include social, clinical, and community studies within a broader biosocial framework. Yet, the successes of the community mental health movement[30],[31] and the creation of research centers for social and cultural psychiatry, along with the inclusion of cultural competence and the cultural formulation in the DSM, have only sharpened the debate. Sartorius et al.[10] argued that since “all psychiatry is social,” it would be “unimaginable that psychiatry could be practiced or that psychiatric research could be conducted without constant reference to social factors and to the social environment.” Unimaginable but true! The vaunted biopsychosocial (BPS) approach,[32] offering an integration of three domains, became a convenient cover for psychopharmacology and neuroscience research to appear inclusive, yet in practice, as DSM-IV chairman Allen Frances later observed, BPS became “bio-bio-bio.” The social determinants of health,[3],[4] based on populational research that is as robust and durable as anything we have in medicine with powerful implications for health and illness, are discounted or ignored. In this environment, to believe that social is a descriptor for psychiatry today is aspirational. Social psychiatry is, at best, a subfield, like child psychiatry or geriatric psychiatry.

Like other examples of binary opposition, pitting social against psychiatry can lead to polarization and false divisions. Addressing such conundrums, Wittgenstein[33] dismissed them as “pseudo-problems” based on linguistic confusions. How can we move beyond unfruitful divisions, whereby practitioners of subspecialties simply agree to disagree, hiving off into their specialized meetings and journals, while psychiatry as a whole lacks coherence and integration?[34],[35] To anticipate my conclusion, social psychiatry offers the specialty of psychiatry and all of medicine greater coherence through an integration of the biomedical model with the larger context of the social determinants of health and the relational aspects of all human interactions.

Defining social psychiatry

Social psychiatry is concerned with the relationships between mental disorder and sociocultural processes.

– Alexander Leighton[36]

Leighton[36] was a pioneer of psychiatric epidemiology in Canada whose textbook of social psychiatry offers the defining features of the field [Table 1] with a succinct definition that is both theoretical and pragmatic.{Table 1}

Before going further, let us examine the word social. Cultural historians carefully dissect words concerned with the practices and institutions described as “culture” and “society.”[37],[38],[39] Several entries are of interest here: society, social, societal, and sociology and related words such as socialism and solidarity. For our purposes, the lesson is that these terms are plastic and mutable and both social and society, with roots in the Latin, socius – companion, and societas, meaning a union for common purpose, association, community, were transformed from relational descriptions of association and sociability to more abstract meanings, clearly signifying a distinction from the individual, as in “man and society” meaning “the individual in society.” We may conclude that in the Western cultural, lexicon social has moved from a relational description to a kind of ethical prescription.

How did we get here?

How did Western societies move from an ancient world view where divine forces created and controlled the human world to the contemporary vision of humanity and society following natural laws?

“Man in Nature” – The age of reason: From child of nature to the nature of the child

We can reconstruct a history where we see Western cultures moving from a worldview in which humanity is seen within a divine order of things called the Great Chain of Being (Latin, scala naturae), challenged by the Enlightenment and Humanism that created natural philosophy and the origins of modern biological sciences.[40],[41] The concept of Man (which we now call humanity) that emerged in the Enlightenment was “Man in Nature.” And here we see the origins of pedagogy in the work of Jean-Jacques Rousseau, psychology and the construct of mind in thinking about humans as natural beings.[42],[43]

It took a full two centuries before empirical research into what became developmental psychology and developmental psychopathology (child psychiatry) finally studied the adverse events of childhood,[44],[45] demonstrating the consequences of childhood trauma.[8] This is the real birth of a socially informed pedagogy, pediatrics and child psychiatry, and the roots of social psychiatry.

“Man in Society” – 19th Century Social Realism: Society is greater than the sum of its parts

With the rise of cities came the study of “man in society” and sociology as a social science. Its founder, Durkheim studied how society maintained coherence in the face of populational concentration and social dispersion, pioneering methods for studying social currents rather than individuals. He viewed knowledge in social terms and coined the term “collective consciousness.” Durkheim channeled 19th-century social and political concerns into a methodology for studying society as greater than the sum of its parts. He is the forefather of social epidemiological research and the social determinants of health and mental health, with a concern for social justice.

“Man Alone” – 20th Century: Social psychiatry in a time of loneliness

The 20th century witnessed intense contradictions from the traumas of world wars and genocides to the affirmations of humanistic values in opposition to increasing mechanization and speed leading to isolation and marginalization. Many trends converged to create social psychiatry which was motivated to bridge the divides in the society, in medicine, and in psychiatry. Barely acknowledged in medicine and psychiatry were major trends away from the usual power centers – toward the Global South,[46] toward feminism and postcolonialism, in short, toward a multipolar, pluricultural world which made social psychiatry ever more relevant and yet the coming GMH Movement[5],[6],[13],[47],[48] would take center stage.

“Liquid Humanity”– 21st Century: Humanity unbound, social psychiatry without borders

Inheriting the tired term postmodernism from the end of the last century, we now seem to be in a post era – postmodernism, post everything, including truth. In this spirit, the new century heralds a new era, the Anthropocene, in which human activity dominates the planet. That may be true about the natural environment which we are polluting and destroying,[49],[50] but when it comes to the social environment, we are marginalizing our own human capacities in favor of intelligent machines, leading Lanier,[51] the father of virtual reality, to call his manifesto, You Are Not A Gadget.

If some thought leaders in our field worried that the 20th century “lost its mind” (psychologist Cyril Burt)[52] or became “mindless” (child psychiatrist Leon Eisenberg),[53] in the 21st century, we may be “losing our humanity” altogether. Rather than the two 20th-century extremes of fulfilling humanity or ending it, there is talk of the transhuman, modified by bioengineering and digital technology.[54] The best epithet for our century may be “liquid humanity,” a variation of sociologist Zygmunt Bauman's liquid modernity.[55] Rather than overcoming modernity or humanity, it has become liquid. Everything is fluid and subject to change. Never has the Greek philosopher Heraclitus (ta panta rhei, “everything flows”) seemed so relevant as we are fast becoming a century of massive, rapid change.[56] And we need a psychiatry adequate to the task of documenting the consequences. There are crises in all three spheres – the natural environment (climate change and mental health),[49],[50]the built environment (homelessness, the housing crisis),[57] and the social environment (identity, belonging, migration, and massive change).[56],[58],[59]

If social psychiatry is to become a comprehensive, integrative, transdisciplinary field of medicine and social science, we must now concern ourselves with all three spheres, above all with the social impacts of deteriorations and the challenges in these essential environments. Because of such potential social impacts, it is more artificial than ever to compartmentalize health into separate domains due to their porous borders and reciprocal influences. At the same time, our expertise as social psychiatrists allows us to discern the emerging patterns and challenges as we see the social sphere fragmenting into several bubbles. In each bubble, we may perceive a dichotomy or polarization, with both positive and negative impacts.

What does this augur for social psychiatry?

For social psychiatry to maintain its relevance and affirm the claim that “all psychiatry is social,” echoed by both Masserman, a WASP founder,[9] and Sartorius, a WHO leader,[10] we must demonstrate the validity of this general claim in theoretical terms and the specificity of social psychiatry to bolster theory and practice.

Specifically, we must address the binary oppositions not only of psychiatry but also of Western and Northern cultural categories. Ciompi[60] urged pluralism as a philosophical foundation for social psychiatry and Sartorius[61] offered multiple scenarios for the future of psychiatry. We must clarify our principles, values, and operational criteria. We must elucidate a theory of social psychiatry upon which to base a practice of social psychiatry with its integration into teaching, clinical work, research, health-care planning, and policy-making. Moreover, we must set an agenda for social psychiatry in the 21st century.

Binary oppositions

A simple dichotomy of individual and environment is no longer a sufficient concept in understanding the etiology of mental health and illness.

– Michele S. Trimarchi[62]

In This Idea Must Die,[63] a powerful collection of poor theories that block progress, the threads running through many of them are unproductive binary oppositions and false dichotomies. Part of our Western/Northern historical legacy, these include:

Nature versus nurture and its iterations in psychiatry (endogenous vs. exogenous factors, inherited vs. acquired traits)Individual versus collective (individual versus group therapy, individual versus family therapy, clinical psychiatry versus community psychiatry)Subjectivity versus objectivityAnd finally, social versus biological.

Investigations into trauma[1],[64] reveal a dichotomy that is built into all discourses about trauma which expresses itself differently in different fields and times but always founders on the same reductive binary opposition. In trauma studies, I characterize it as the “clinical trauma community” and the “cultural trauma community.”[1] This dichotomy defeats all efforts to change the conversation about trauma. Scholars in the humanities, scientists, and clinicians use similar terms, quote the same literature, and yet arrive at radically different understandings and polarizing conclusions such as whether we should treat or simply witness trauma. That is why we need theory; empirical investigations cannot sort this out. I concluded that psychiatry cannot resolve this dichotomy which is why I resorted to the conceptual apparatus of philosophy to do so.

Nature versus nurture has been an abiding theme of all thinking about childhood as a model of humanity[42] and investigators and clinicians in all disciplines tend to separate into two camps, with few synthesizers in between.[20],[65] In the social sciences, the issue of power has been a dominant theme in the critique of society and the professions, including psychiatry. This includes power issues running through society, including the corrosive myth of racial supremacy. As a social psychiatrist, I believe that power is an illusion and race is a myth. However, as the struggle for power and the discourse on race are social realities, we cannot easily change the subject and need to study how people experience power, race and stigmatization as social phenomena with complex and profound impacts.

Another issue is to differentiate social psychiatry from its cognate fields: transcultural psychiatry, cultural psychiatry, comparative psychiatry, cross-cultural psychology, medical anthropology, medical sociology, and GMH. I see them as tessellated fields of study, each tile having its uses and adding its color and shape to form a larger pattern, but as Sartorius[2] observed, if psychiatry is to have credibility, we need to create an accessible and easily understood common vocabulary. Along with promising studies and new ideas and paradigms, we also need to retrench and redefine and then integrate and synthesize.[66]

What may be a solution? I believe the solution lies in interdisciplinary studies and multi-method research programs working toward a transdisciplinary approach – the very pluralism that Ciompi[60] proposed for social psychiatry. We need more integration and synthesis of what is known with a focus on problems and solutions rather than narrow sectarian interests. The keywords here are a pluralistic philosophy that recognizes that different temperaments will lead to different sorts of questions and methodologies[23],[67] while creating integration and syntheses to refresh the language of biomedical and social sciences.[68]

Psychiatry, fast and slow

If we cannot defeat binary thinking, let us at least put it to good use as a metaphor. Adapting Nobel-winning psychologist Daniel Kahneman's[69] approach to thinking, fast and slow, and my own investigations on slow thinking and slow psychiatry,[70],[71] we can imagine two poles of psychiatry as it is currently constructed: Fast psychiatry and slow psychiatry. This way of looking at modes of thinking, styles of investigation cuts across many disciplines, as in the celebrated essay by Isaiah Berlin[72] contrasting Russian thinkers Dostoyevsky and Tolstoy, characterized as the deeply burrowing hedgehog and the wide-ranging fox [Table 2].{Table 2}

Fast psychiatry yields William James' tough-minded empiricism,[73] converging on solutions,[23] using technocratic algorithms for pragmatic ends,[67] deploying etic or experience-distant approaches with “thin” descriptions,[74] focused on the rapid change to gain mastery within a definitive, uniform research paradigm. Keywords: Fox, empirical, convergent, technocratic, algorithmic, pragmatic impact, rapidity, mastery, paradigmatic/uniform, research.

Slow psychiatry offers James' tender-minded rationalism,[73] pursuing divergent questions,[23] deploying phenomenological heuristics to pursue knowledge,[67] using emic or experience-near approaches, incrementally aiming at comprehensive “thick” descriptions[74] and understanding in a syntagmatic (pluralistic) approach to investigations. Keywords: Hedgehog, rationalistic, divergent, phenomenological, emic/experience-near, heuristic, knowledge accumulation, slowness/incrementalism, comprehension, syntagm/pluralistic, investigation.

Examples of fast psychiatry include behavioral therapy; cognitive-behavioral therapy; brief therapies; solution-focused therapy; psychiatric pharmacotherapy; clinical trials; aspects of psychiatric genetics; and the reductive use of biological psychiatry and neuroscience.

Slow psychiatry includes psychoanalysis and its derivations; aspects of systemic family therapy (on the more phenomenological side);[17],[67] the “narrative turn” in therapy; dialogical methods;[75],[76] transcultural psychiatry (both in its original “classical” version at McGill University[77],[78] and the “new cross-cultural psychiatry” at Harvard, even more clearly focused on emic, experience-near approaches[79]); epidemiological studies;[80] social determinants of health;[3],[4] the human genome project; social neuroscience[81],[82] and mirror neurons[83],[84] to investigate all forms of imitation from empathy to learning to social skills; and, finally, social psychiatry, thus redefined.

 What Is the Theory And Practice Of Social Psychiatry?



Principles, values, operational criteria

Given its role as a bridge between academic disciplines and distinct societies, social psychiatry's main principles should include transdisciplinarity and a multicentric world perspective (not only Western/Northern). As an ethical matter, our values should ensure the dignity of all those involved in social psychiatry's activities, and be guided by beneficence. Our operational criteria need to balance coherence[67] with theoretical pluralism,[60],[61],[85] to conduct translational research of social psychiatry's powerful populational studies, in order to provide ground-level prescriptions (aimed at prevention, promotion, intervention, and adaptation).

What is social psychiatry?

Here are some ways to imagine social psychiatry's disparate program:

An envelope – a container, a context for human situations including medical and psychiatrxic problemsAbridge – between the natural sciences and the human and social sciencesA map of human experience based on affectionate bonds and family and social relationships.

Bringing this together, social psychiatry is the widest, broadest envelope for situating human experience, acting as a bridge between fields of expertise and between personal and social or relational being, and thus equipped, offers a comprehensive map of human experiences. Unlike biological psychiatry[18],[19] or evolutionary psychology[20],[65] which purport to explain human behavior through evolutionary models of brain structures, social psychiatry describes the social context and conditions in which human experiences give rise to psychiatric problems, which I describe as mental, relational, and social problems. I define the difference between social and relational aspects as public and private, the difference between living in the same neighborhood (social) and living in the same household (relational). Biological psychiatry and evolutionary psychology face the same paradoxes and blind alleys that behavioral psychology faced: in an effort to circumvent tough questions about consciousness and social relations, they offer somewhat useful tools while explaining too little.

In this sense, social psychiatry as a map is also the territory of human problems.[86] It does not assume, discount, or reduce any other causes or descriptions. Moreover, the social determinants of health and mental health are among the most robust and durable findings we have in the human sciences. These are now established insights of social psychiatry.

By describing the environments in which problems arise, social psychiatry in the 21st century offers what phenomenological psychiatry in the 20th century promised, but could not deliver: a descriptive nosology of human problems and key examples are the social determinants of health, from a populational, epidemiological perspective, and the social context, from the studies of human relations (including attachment theory, family theory and therapy, and relational aspects of psychotherapy, as well as relational psychology and psychiatry).

The social psychiatry I envision parallels the best intentions of behaviorism in wishing to stay close to observable behavior (without its explanatory overreach in eliminating both mind and brain). My social psychiatry is inspired by such congenial approaches as systems theory which situates human beings in relational contexts called systems and attachment theory which situates human development in the context of parent–child bonds and family-based caregiving. Together, attachment theory and systems theory highlight the crucial, life-defining importance of early childhood growth and lifelong family and social support. Projected onto the larger screen of social psychiatry, these theories become the critical issue of belonging. In a world of complex, competing, and often confusing identities, belonging reminds us that we are first social beings who need to relate to others through family, friendship, and communal relationships.

Social psychiatry has been since its inception, sometimes an approach, closer to an attitude in wishing to place psychiatry in a social context, and sometimes a group of observational studies about that context – all without a coherent, consensual, and compelling theory. Both ends of this spectrum (an approach, observational studies) lack a comprehensive and compelling theory which marshals the evidence and gives it a coherent theoretical framework. Social psychiatry has often generated a group of powerful observations in search of a theory. Two empirically driven social psychiatry models from the Institute of Psychiatry in London where I trained are the expressed emotion paradigm[87],[88] and the social origins of depression in women;[89] both research models initiated by the sociologist George Brown.

As a result, social psychiatry has offered important descriptions accompanied by rather anemic explanations and vague, generic prescriptions. The social determinants of health paradigm and the GMH Movement have taken flight and cruising at 35,000 feet gives them a global reach. What are needed now are prescriptions at the ground level (Schwab called this “clinical applicability”).[90] Competing world views of our field show no reticence to make bold claims. Psychopharmacology, biological psychiatry, neuroscience, evolutionary psychology and psychiatry, and others all want to take our place. Social psychiatry needs a comprehensive theory that asserts its powerful observations in a meaningful way while offering ways of bringing together current practices in line with its core principles, values, and operational criteria.

First, however, let me sound a note of caution. While we should harness the power of research methodologies and promising cognate models and allied approaches to social psychiatric questions, we should resist the reduction of social psychiatry to methodologies or cognate allied fields and subdisciplines that produce data. I call these temptations methodolatry and scientism.[70] Social psychiatry should remain the name of our field and not be subordinated to the limitations imposed by research methodologies or the redefinitions inherent in any kind of reductionism; however, seductive their promise may be. As Sartorius recommended, “If psychiatry is to remain a coherent and socially useful discipline it is essential that it redefine its borders.”[2] Lolas[26] weighed in on this issue, arguing for social psychiatry as a specialized profession. If social psychiatry is to have any meaning, it must define and defend its own domain without being sutured to a methodology, model, or practice.

To be specific, social psychiatry cannot be narrowly defined by the social determinants of health nor can a populational approach alone be our guiding model. Physician-researcher Mukherjee[91] discerned one of the laws of medicine as: “Normals” teach us rules; ”outliers” teach us laws. The epidemiological approach establishes the denominator of our task as physicians – its social distribution. It teaches us about what is or is not normal in a given population and sets out the parameters of health. Yet, it is important to examine outliers – unusual, unrepresentative cases and currents – the numerators that cry out for understanding and intervention. For example, someone had to notice and then describe the first case of anorexia nervosa[92],[93],[94] or self-mutilation[95] as an outlier, something that stood apart from the norm. The clinician is also an investigator, attuned to social context to discern patterns and variations.

That said, we may identify allies and partners in our work. Behavioral approaches and relational approaches are natural allies in the clinic. Public health and epidemiology are natural partners for investigation.[95] Attachment theory is a powerful model that has already integrated a wealth of psychosocial observations and clinical knowledge into a coherent theory; we must use it as a model and integrate it into our own expanded model of social psychiatry for a more encompassing theory of belonging. The studies of life events and stress- and trauma-related disorders are both the heart of social psychiatry as a map of the territory to be studied and of the problems to be treated.

So, bringing it all together, what is 21st century social psychiatry?

Minimal requirements for a theory of social psychiatry

First, we need to articulate requirements for a comprehensive, compelling, and consensual theory:

We need a theory of how humans work – mind, brain, and relations (integrating psychology, neuroscience, and society)We need a theory of psychiatry as both a branch of medicine and a social science embracing other pertinent domains as a descriptive “science of Anthropos” that is congruent and theoretically coherent. Part of this theory of social psychiatry is how human problems arise – mentally, relationally, and sociallyWe need a model of practice, i.e., what do social psychiatrists actually do?.

What model of mind, self, and society emerges from social psychiatry?

At issue: The biggest question in the human sciences today is how to conceive of mind.[43],[96] The 20th century, from philosophy and psychology to neurology, physiology, and psychiatry, staged endless debates over the concept of mind.[43],[97] It opened with two opposing theses: Pavlovian conditioning (based on physiologist Ivan Pavlov's Nobel Prize-winning research) and Freudian psychoanalysis (founded by a neuropathologist), culminating in Watson's behavioral manifesto in academic psychology and a half-century of psychoanalytic predominance in Western psychiatry and mental health care. Intriguingly, none of these leaders were psychiatrists.

We have entertained some false starts on defining mind: just as mind is not reducible to behavior (Chomsky vs. Skinner), the mind is not a computer (Fodor vs. Pinker) and “you are not a gadget” (Lanier vs. Silicon Valley), Social Psychiatry holds that the mind is not simply the brain (Kagan, Tallis vs. Guze, NIMH). Until we have a consensus on the matter, we should consider competing theories, without accepting reductionist and simplistic claims. Let us accept a levels approach, whereby we name the domains of human activity:[17],[67]

Biomedical science (biology and medicine)Cognitive science (cognitive psychology and neuroscience)Critical thinking (social science and the humanities)Relational psychology (from dialogism to social psychology and from relational psychoanalysis to family therapy).

The key feature of such a levels approach is not how each level works as much as what are the rules of translation between levels and how their integration works in reality. What social psychiatry may offer with its encompassing, pluralistic approach is precisely such an integration.

 Why The Time Has Come For A Manifesto For Social Psychiatry



I outline the parameters for a theory of social psychiatry, based on both the social self[7],[67] and the social determinants of health,[3],[4] to offer an inclusive social definition of health,[8] concluding with a call for action, a manifesto for 21st-century social psychiatry.

Why social psychiatry needs a theory now

Without theory, blind empiricism produces data without an explanation, observations with no goal. A theory can bring cohesion and coherence to apparently unrelated phenomena and data. Attachment theory, for example, brought together a wide range of clinical observations and studies from psychoanalysis to René Spitz's hospitalism that are given coherence and meaning to create a rich explanatory model. Two great theorists constructed modern psychiatry – Emil Kraepelin with his classification of the psychoses and Karl Jaspers who brought phenomenology to psychiatry, the greatest coherence brought by a single theorist in the field. Theory brings coherence and meaning to seemingly disparate facts, observations and studies – what we have called since Jaspers the clinical phenomenology of psychiatry.

Social psychiatry has harnessed powerful methodologies from epidemiology and adopted some compelling community and social principles (often in reaction or resistance to institutional psychiatry), yet a comprehensive, compelling, and consensual theory eludes the field. The best we have are statements of social psychiatry's principles and values, thoughtfully expressed. Each of the three definitions cited in this article – Leighton's epidemiological model,[36] Vassiliou's and Sorel's embracing “science of Anthropos,” and Ciompi's (1995) philosophical pluralism wedded to community psychiatry[60] – brings us closer to a mission statement but none of them explicitly formulates a theory of social psychiatry.

Practical implications of social psychiatry

Together, three branches of social psychiatry signaled a shift in psychiatry:

Epidemiological studies, where the shift is away from the individual and the clinic, and populations became the focus of researchCommunity psychiatry, where the shift is away from the individual in the institution, and the community became the locus of interventionRelational therapies (marital, family, and group therapies), where the shift is from the individual to relationships, and relations became the praxis, the object of study and intervention.

In contrast to the characterization of Jung's work as “depth psychology,” I describe social psychiatry as a psychiatry of breadth – expanding the range of observations from the individual to the family and group (relational therapies), to the community (community psychiatry), and to populations (psychiatric epidemiology).

What we need now is translational research to bring these solid findings to the ground level and start converting them to programs for health promotion, illness prevention, and therapeutic interventions, and to harness them to well-established principles of community psychiatry and relational therapies to make these other branches compelling not only as values but backed up by studies demonstrating their utility.

Translational research needs to address four domains: service (models of practice), training and teaching (bridging all the other domains and transmitting a coherent theory to the field and the next generation), health-care planning (utilitarian questions about efficacy, reliability and utility), and values-based medicine (ethical questions about validity).[94],[98]

Qualities of the 21st-Century Social Self – the self-in-relation

After the atomized individual, alienated by industrial progress in the late 19th century and early 20th century, succumbing to the “lonely crowd” by mid-century,[99] and the “saturated self”[100] by century's end, what kind of self can social psychiatry conjure up in the 21st century? The social self that emerges from such studies is: porous, relational, and quick.

Porous

”Porosity” is a quality of incompleteness, “a work in progress” and of loosely defined margins.[101] It is closely allied to liminality and threshold persons described in Victor Turner's anthropology.[102] This is Bauman's “liquid modernity”[55] harking back to the Heraclitan flux. A positive experience of being comfortable with porosity and liminality is “flow,” a deep, fluid immersion into activities.[103]Cognate ideas: Liminality,[102] interdependence,[17] liquid modernity,[55] flow.[103]Contrasting ideas: Coherence, homeostasis, stability.[67]

Relational

The social self is relational, drawing on Bakhtin's[75],[76]dialogism and Levinas' face-to-face encounter.[104] Relational is more than social, it implies a greater degree of mutual exchange, knowledge, and intimacy. In this view, culture is a border that runs through everything in society.[105] Society is an interface and human relations at their best are face to face. Richard Mollica's[106] groundbreaking work on trauma reminds us that trauma is “a story that must be told” (dialogical) and I would add, it must be told to another person (face to face) as opposed to being written or deposed as a document. Cognate ideas: Dialogism, face-to-face encounter, narrative therapy.[75],[76],[104] Contrasting ideas: Agency, individuation, solitude.

Quick

This is a quality of the social self-inspired by Italo Calvino's reflections on literature,[107] meaning alertness, responsiveness, and economy of expression. Think of the quickness of the fox rather than the velocity of cars as in the “dromology” of Virilio.[108]Cognate ideas: Adaptability, cleverness. Contrasting ideas: Lingering, digression, slowness;[71] development; speed/dromology;[108] the deeply burrowing hedgehog and the wide-ranging fox.[72] These contrasts are brought together in the Latin maxim, Festina lente, “hasten slowly.”

In this new world, where borders are porous and identities are fluid, the quickness and alertness of the fox offer survival skills while the single-mindedness of the hedgehog maintains coherence and stability. Slow thought[71] is a “counter-method” that counsels a strategic pause for reflection before precipitating into action in response to the challenge of rapid change.

 A Global Agenda for the 21St-Century Social Psychiatry



An agenda that is coherent with a theory of social psychiatry and responsive to its dual clinical and populational mandate needs to be articulated. The agenda of social psychiatry should address three environments or spheres of human activity:

Natural environment: Climate change; disaster psychiatryBuilt environment: Homelessness; crowding; worker safety; child labor; and exploitationSocial environment: Rapid, massive change; social class, culture change; the Global South; global epistemologies; migration and borders; stigmatization; crime and violence; and mass murder and suicide

The still hidden injuries of class

Despite social class having been set aside for theoretical reasons, the rise of cultural psychiatry with its emphasis on culture as a primary focus means that the “hidden injuries of class”[109] have become invisible to academics. In fact, these injuries are still present yet hiding in plain sight. We have become inured to their presence, especially in mid to large cities, where, sadly, we can ignore poverty, homelessness, and urban violence through social segregation. The discourse of social class has been essentially replaced by issues related to culture such as migration and racism. This means that social psychiatry for a time was eclipsed by cultural psychiatry. We must reopen the discussion about social segregation and health-care equity, as the WHO CSDH recommends.[3]

Rapid, massive change

These are two different issues: radical change and the acceleration of everything. Social psychiatry is uniquely positioned to take stock of rapid and massive cultural and social change.[42],[92],[93] The debate on migration and borders in many countries has become polarized. Accusations of racism and xenophobia on one side and fear of lawlessness and loss of sovereignty on the other abound. These are the wrong questions which generate wrong answers. In another era, people studied history to understand cycles and social changes in order to cope with the massive disruptions associated with disasters and wars. From this, they created strategies to deal with them. Most societies deal with rapid, massive change with difficulty and this may be exploited for short-term gains or planned wisely to deal with its implications and opportunities. For example, many complex economies now require a highly skilled workforce which their home populations cannot sustain; hence, immigration is not only desirable but also necessary to maintain their levels of economic productivity and social stability.

That said, rapid social change may generate many adaptational problems.[56],[110] In the early literature of transcultural psychiatry, much attention was given to culture-bound syndromes, but I have argued for the study of culture-change syndromes, notably among the youth, in whom the rates of selective mutism and anorexia nervosa are greatly elevated in first-generation immigrants.[42],[92],[93],[111] My clinical practice as a child psychiatrist demonstrates that these problems are still treated as passing phases or transitional problems (e.g., adjustment disorders), rather than serious mental health issues that can become chronic.[42]

Psychiatric problems are socially constructed

Human problems, including psychiatric disorders, broadly conceived, are richly contextual in which even genetics (via epigenetics) are now known to be socially situated. This means that the cross-cultural distribution and historical evolution of psychiatric disorders not only reflect dominant models of mind, self, and society, but are constantly changing. Across cultures and over time, psychiatric disorders are themselves porous, under construction, and are not easily codified.[42],[92],[93] The complex evolutionary basis and neurophysiological substrates teach us that mind and brain reflect the plasticity of adaptation and the porosity of human identity. Social neuroscience is a bridge between brain and mind and not a reductive science.[81],[82],[83],[84]

A priority should be integrating descriptive populational studies with ground-level prescriptions through translational research. The social determinants of health, the ACE Study, and key ideas such as the social gradient of health and treatment gaps identified by the GMH Movement should serve as blueprints for wise and responsive health-care planning and practice.

Moving beyond binary oppositions

Above all, social psychiatry needs to:

Create a synthesis of populational research with ground-level programsMove beyond dichotomies such as personal/social and individual/groupAccept that domains of inquiry reflect different temperaments among the investigators, addressing different sorts of hypotheses[23],[67]Acknowledge that we need both phenomenological and technocratic approaches, divergent and convergent methods, to properly define and thereby solve social problems. Nowhere is this more clear than in the emerging fields of transgender health,[112],[113],[114] part of whose message is to move beyond binary identities.

The global south and southern epistemologies

In order to be inclusive and responsive to social realities in different societies around the world, we need to move beyond Western and Northern epistemologies to embrace the Global South[46] and “southern epistemologies.”[115]

Migration and borders

The global flow of migrants and refugees is an international problem that must be recognized as a global, transnational priority.[116] As Nail[58],[59] argues in his work, there are two implications. First, global migration is not a mere uptick or a passing crisis to be imagined as an exception, it is rather the rule in human history. Human history is the history of our migrations. Second, such a perspective implies that we need to rethink everything, from what Nail calls kinopolitics – a politics based on movement and migration, which challenges current notions of borders and sovereignty, to kinopsychology – the psychology of migrants and refugees, which challenges our conceptual models of human behavior.[111]

Social Psychiatry's Public Works: Health promotion, human rights, destigmatization

The foci of social psychiatry's public works projects are health promotion, human rights, and combatting stigmatization of psychiatric illness[117],[118],[119] and the traumatic consequences of disaster, war, and conflict.[120] An emerging allied field is disaster psychiatry.[121]

 The Language of Social Psychiatry



Finally, a new model requires a refreshed vocabulary.[67],[68] After centuries of situating human being in a social context and more than a half-century of WASP, social psychiatry is now in a position to develop its own lexicon of keywords.[2] Social psychiatry has numerous “plastic words”[38] that are polysemic and whose professional meanings are at odds with general usage. Life events, stress, and trauma are three examples. These terms have expanded to mean almost anything and researchers have had to coin more specific notions with stricter criteria to represent their impacts on health, e.g., “Complex PTSD” to differentiate serious cases from the now generic “trauma.”[1]

Social self

The self is best imagined as a social self, a self-in-relation. In this view, the concept of “self-esteem” is understood as social esteem.

Relational disorders

Many human problems have their roots in social contexts, starting with attachment and family process, which are relational processes. Renewed attention must be given to relational disorders understood through relational psychology and social psychiatry with an emphasis on relational interventions and therapies.

Psychiatric problems

The problems we treat are psychiatric problems, which include problems with many complex causes, from more genetically loaded ones such as bipolar disorder to brain, behavioral, emotional, cognitive, and relational disorders. All of these exist in evolving social contexts which are often determinant of the expression of symptoms. Many thoughtful psychiatrists would add ethical, moral and spiritual domains to this enlarged vision of psychiatry.[26],[67],[122] “Mental illness” focuses exclusively on the mind and was first challenged by behaviorists, who eschewed any reference to mental processes and consciousness, and now many neuroscientists, for whom mind equals brain.

Patients

Our concerns are with preventing disease, attenuating illness, and improving the social health of patients, an ancient term that speaks to suffering, as Masserman observed.[9] Calling them “clients” and “consumers” implies a commercial exchange, not a medical or therapeutic relationship. When addressing “n greater than 1,” especially outside the clinic, we should refer to the appropriate relational or social group, e.g., family, community, culture, and society. In policy and health-care planning, the term population is appropriate but more distancing.

Psychiatry

Our field is psychiatry, not “mental health” which conflates the nuances among disease, illness, health, and well-being. Above all, I am arguing for an enlarged vision of medicine to include psychosocial and sociocultural perspectives in the integrated view of human health we call social psychiatry.

Health is first social

Sartorius[2] affirmed that health is “a dimension of human existence which remains present in disease and in spite of impairments which diseases may cause.” Lewis[123],[124] concurred that, “Health is a single concept: It is not possible to set up essentially different criteria for physical and mental health.” Instead, health may be fruitfully imagined as a series of contextual envelopes – physical, mental, relational, and social – the largest, broadest, and most encompassing of which is social.[8] Just as we can recast self-esteem as social esteem, we can understand the social self in illness and health through its social contexts. Today, understanding the social determinants of health leads us to formulate health as first social – where identity is porous and plural, expression is dialogic in face-to-face encounters, and community action is relational and social.[8]

 Conclusion: from Society to Self – “a Person Is a Person Through Other Persons”



Being is always “being with,” “I” is not prior to “we,” and existence is essentially co-existence.

– Jean-Luc Nancy[125]

Social psychiatry upends much of the Western tradition that reasons from self to the society. Employing other strands in the Western tradition and supported by much wisdom and cultural traditions in other societies,[30],[126],[127],[128],[129],[130] Social psychiatry reasons from society to self. We are born with the capacity – properly nurtured – to become fully human, as we construct that notion in different places and different times. Social psychiatry focuses on attachment, on the caregiver bond, and lifelong social relations to create a sense of self and of belonging in the human community. Self emerges from social relationships and this social self is most properly seen as a self-in-relation. The “self-made man” is a myth that found its avatar in the work of Ayn Rand where the heroic individual is responsible to no one. In the solipsistic Randian universe, social relations count for nothing, only the endless affirmations of the heroic self.[131]

Because of the binary thinking built into our now globally dominant Western/Northern culture,[132],[133],[134] we cannot take the social for granted in psychiatry. In fact, bringing the two words together in the field of social psychiatry makes for an odd pair which demands explanations and a theory. Social psychiatry, thus redefined, is not only a context for understanding the self and its relations, but offers two critical things for medicine and the society. It is an embracing definition of health as first social that enriches and expands the field of biomedicine, and a theory of humans as social beings, with diverse methodologies and observational studies that follow from it, as well as the practices it inspires. Out of all my training, research, teaching, and practice over more than four decades, it is social psychiatry that encompasses and unites them as an abiding concern and a guide for practice.

In the end, we must find ways of continually suturing the individual to the society and for the society to respond to the individual's uniqueness. So while the social is our heuristic, our path forward, social psychiatry must try to bypass the binary opposition between the individual and the community, as William James so wisely put it: (Source: Plaque at the entrance of William James Hall at Harvard University)

The community stagnates without the impulse of the individual.

The impulse dies away without the sympathy of the community.

In Africa's Ubuntu philosophy, personhood is not innate but acquired through experience, as the Zulu saying, Umuntu Ngumuntu Ngabantu, captures it – “A person is a person through other persons.”[135] This is the slogan for a manifesto of social psychiatry that reaches for more than a methodology to a social theory of human being, the science of Anthropos.

Acknowledgments

I am grateful for ongoing dialogs with WASP Past President (1996–2001) Eliot Sorel on the history and definition of social psychiatry, WASP Past President (1988–1992) Guilherme Ferreira on the history of WASP, WASP President-Elect Rachid Bennegadi on information technology, Jack Drescher on transgender health, and Lise Van Susteren on climate change and mental health. Dedicated to Giambattista Vico (1668–1744), the father of constructivist epistemology that sees knowledge as a social construction rather than a discovery of the natural world– Verum esse ipsum factum, “What is true is precisely what is made.”

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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