A cultural-ecosocial systems view for psychiatry

While contemporary psychiatry seeks the mechanisms of mental disorders in neurobiology, mental health problems clearly depend on developmental processes of learning and adaptation through ongoing interactions with the social environment. Symptoms or disorders emerge in specific social contexts and involve predicaments that cannot be fully characterized in terms of brain function but require a larger social-ecological view. Causal processes that result in mental health problems can begin anywhere within the extended system of body-person-environment. In particular, individuals' narrative self-construal, culturally mediated interpretations of symptoms and coping strategies as well as the responses of others in the social world contribute to the mechanisms of mental disorders, illness experience, and recovery. In this paper, we outline the conceptual basis and practical implications of a hierarchical ecosocial systems view for an integrative approach to psychiatric theory and practice. The cultural-ecosocial systems view we propose understands mind, brain and person as situated in the social world and as constituted by cultural and self-reflexive processes. This view can be incorporated into a pragmatic approach to clinical assessment and case formulation that characterizes mechanisms of pathology and identifies targets for intervention.

Integrating neuroscience in psychiatry: a cultural-ecosocial systemic approach

Psychiatry has increasingly adopted explanations for psychopathology that are based on neurobiological reductionism. With the recognition of health disparities and the realisation that someone's postcode can be a better predictor of health outcomes than their genetic code, there are increasing efforts to ensure cultural and social-structural competence in psychiatric practice. Although neuroscientific and social-cultural approaches in psychiatry remain largely separate, they can be brought together in a multilevel explanatory framework to advance psychiatric theory, research, and practice. In this Personal View, we outline how a cultural-ecosocial systems approach to integrating neuroscience in psychiatry can promote social-contextual and systemic thinking for more clinically useful formulations and person-centred care.

Restoring the missing person to personalized medicine and precision psychiatry

Precision psychiatry has emerged as part of the shift to personalized medicine and builds on frameworks such as the U.S. National Institute of Mental Health Research Domain Criteria (RDoC), multilevel biological "omics" data and, most recently, computational psychiatry. The shift is prompted by the realization that a one-size-fits all approach is inadequate to guide clinical care because people differ in ways that are not captured by broad diagnostic categories. One of the first steps in developing this personalized approach to treatment was the use of genetic markers to guide pharmacotherapeutics based on predictions of pharmacological response or non-response, and the potential risk of adverse drug reactions. Advances in technology have made a greater degree of specificity or precision potentially more attainable. To date, however, the search for precision has largely focused on biological parameters. Psychiatric disorders involve multi-level dynamics that require measures of phenomenological, psychological, behavioral, social structural, and cultural dimensions. This points to the need to develop more fine-grained analyses of experience, self-construal, illness narratives, interpersonal interactional dynamics, and social contexts and determinants of health. In this paper, we review the limitations of precision psychiatry arguing that it cannot reach its goal if it does not include core elements of the processes that give rise to psychopathological states, which include the agency and experience of the person. Drawing from contemporary systems biology, social epidemiology, developmental psychology, and cognitive science, we propose a cultural-ecosocial approach to integrating precision psychiatry with person-centered care.

Dual case study of continued use vs cessation of cannabis in psychosis: a theoretically informed approach to a hard problem

Purpose

Cannabis use in the context of psychosis has been shown to have a negative impact on prognosis and yet it is difficult to treat. Recent randomized controlled trials all have negative findings and novel approaches is sought after. This paper aims to use an embodied cognition framework to add to the understanding of cannabis use in psychosis.

Design/methodology/approach

The paper presents longitudinal, qualitative data on two individuals diagnosed with schizophrenia and using cannabis at least twice weekly prior to inclusion in the study. Factors influencing cannabis use were mapped in dialogue with the participants. Each participant was interviewed six times over the course of a year. The analysis was informed theoretically to describe processes maintaining or ameliorating cannabis use over time.

Findings

This study shows that a systems approach for understanding changes in cannabis use is meaningful; the richness of observations add to the understanding of differences in outcomes. Findings suggest that reductions in cannabis use in psychosis could be dependent on synergistic effects between contextual conditions. Attending closer to the experience of patients may help inform future interventions. However, interventions focusing on single mechanisms may be futile, if an array of individual, formative experiences are a prerequisite for change. A systemic understanding of dual diagnosis calls for tailored, individualized interventions.

Originality/value

The research tests a novel systemic perspective on cannabis use in psychosis by applying it to qualitative longitudinal data. Adding a systemic perspective may help develop future interventions addressing cannabis use in psychosis, which has long been considered a “hard problem” in dual diagnosis treatment.

Why mental disorders are brain disorders. And why they are not: ADHD and the challenges of heterogeneity and reification

Scientific attempts to identify biomarkers to reliably diagnose mental disorders have thus far been unsuccessful. This has inspired the Research Domain Criteria (RDoC) approach which decomposes mental disorders into behavioral, emotional, and cognitive domains. This perspective article argues that the search for biomarkers in psychiatry presupposes that the present mental health categories reflect certain (neuro-) biological features, that is, that these categories are reified as biological states or processes. I present two arguments to show that this assumption is very unlikely: First, the heterogeneity (both within and between subjects) of mental disorders is grossly underestimated, which is particularly salient for an example like Attention Deficit/Hyperactivity Disorder (ADHD). Second, even the search for the biological basis of psychologically more basic categories (cognitive and emotional processes) than the symptom descriptions commonly used in mental disorder classifications has thus far been inconclusive. While philosophers have discussed this as the problem of mind-body-reductionism for ages, Turkheimer presented a theoretical framework comparing weak and strong biologism which is more useful for empirical research. This perspective article concludes that mental disorders are brain disorders in the sense of weak, but not strong biologism. This has important implications for psychiatric research: The search for reliable biomarkers for mental disorder categories we know is unlikely to ever be successful. This implies that biology is not the suitable taxonomic basis for psychiatry, but also psychology at large.

From analytic to synthetic-organizational pluralisms: A pluralistic enactive psychiatry

INTRODUCTION

Reliance on sole reductionism, whether explanatory, methodological or ontological, is difficult to support in clinical psychiatry. Rather, psychiatry is challenged by a plurality of approaches. There exist multiple legitimate ways of understanding human functionality and disorder, i.e., different systems of representation, different tools, different methodologies and objectives. Pluralistic frameworks have been presented through which the multiplicity of approaches in psychiatry can be understood. In parallel of these frameworks, an enactive approach for psychiatry has been proposed. In this paper, we consider the relationships between the different kinds of pluralistic frameworks and this enactive approach for psychiatry.

METHODS

We compare the enactive approach in psychiatry with wider analytical forms of pluralism.

RESULTS

On one side, the enactive framework anchored both in cognitive sciences, theory of dynamic systems, systems biology, and phenomenology, has recently been proposed as an answer to the challenge of an integrative psychiatry. On the other side, two forms of explanatory pluralisms can be described: a non-integrative pluralism and an integrative pluralism. The first is tolerant, it examines the coexistence of different potentially incompatible or untranslatable systems in the scientific or clinical landscape. The second is integrative and proposes to bring together the different levels of understanding and systems of representations. We propose that enactivism is inherently a form of integrative pluralism, but it is at the same time a component of the general framework of explanatory pluralism, composed of a set of so-called analytical approaches.

CONCLUSIONS

A significant number of mental health professionals are already accepting the variety of clinical and scientific approaches. In this way, a rigorous understanding of the theoretical positioning of psychiatric actors seems necessary to promote quality clinical practice. The study of entanglements between an analytical pluralism and a synthetic-organizational enactivist pluralism could prove fruitful.

Osteopathy and Mental Health: An Embodied, Predictive, and Interoceptive Framework

Globally, mental and musculoskeletal disorders present with high prevalence, disease burden, and comorbidity. In order to improve the quality of care for patients with persistent physical and comorbid mental health conditions, person-centered care approaches addressing psychosocial factors are currently advocated. Central to successful person-centered care is a multidisciplinary collaboration between mental health and musculoskeletal specialists underpinned by a robust therapeutic alliance. Such a collaborative approach might be found in osteopathy, which is typically utilized to treat patients with musculoskeletal disorders but may arguably also benefit mental health outcomes. However, research and practice exploring the reputed effect of osteopathy on patients with mental health problems lack a robust framework. In this hypothesis and theory article, we build upon research from embodied cognition, predictive coding, interoception, and osteopathy to propose an embodied, predictive and interoceptive framework that underpins osteopathic person-centered care for individuals with persistent physical and comorbid mental health problems. Based on the premise that, for example, chronic pain and comorbid depression are underlined by overly precise predictions or imprecise sensory information, we hypothesize that osteopathic treatment may generate strong interoceptive prediction errors that update the generative model underpinning the experience of pain and depression. Thus, physical and mental symptoms may be reduced through active and perceptual inference. We discuss how these theoretical perspectives can inform future research into osteopathy and mental health to reduce the burden of comorbid psychological factors in patients with persistent physical symptoms and support person-centered multidisciplinary care in mental health.

The Explanation of Eating Disorders: A Critical Analysis

Eating disorders (EDs) are one of the most severe and complex mental health problems facing researchers and clinicians today. The effective prevention and treatment of these conditions is therefore of paramount importance. However, at present our treatments fall short: generally demonstrating only poor to moderate efficacy, and often completely ineffective for severe or chronic cases. A possible reason for this is that the current theories underlying these treatments are flawed. In this paper, we review and evaluate several prominent theoretical explanations associated with current frontline and promising treatments for ED. In doing so, we identify fundamental problems within the construction of current ED explanations and their implications for treatment. In response to these findings, we propose several strategies for the construction of future ED explanations which we believe have the power to ameliorate these problems and potentially help to develop more efficacious treatment downstream.

The Interactive Phenomenal Field and the Life Space: A Sketch of an Ecological Concept of Psychotherapy

Based on the phenomenology of the body and ecological psychology, this paper introduces a series of concepts that enable us to overcome the still prevailing idea of an inner psyche and a corresponding individualistic view of psychopathology. These concepts are the phenomenal field, lived space, intercorporeality, and body memory; they correspond to an embodied, enactive, and ecological view of the mind. On their basis, psychiatric illnesses may be conceived as relational disorders resulting in various restrictions and impairments of the patient's lived space. The main tasks of psychotherapy, then, are to use the interactive phenomenal field as a means of restructuring the patient's relational patterns and to support his or her capacity to engage in more beneficial interactions with others. In this way, phenomenology can valuably contribute to a deeper understanding of the intricate processes of the psychotherapeutic encounter.