Social Psychiatry Comes of Age

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SECOND THOUGHTS

In this inaugural column on “Second Thoughts… About Psychiatry, Psychology, and Psychotherapy,” I want to express second thoughts about my profession in a warm and constructive way.

As President of the World Association of Social Psychiatry (WASP), I believe that 21st century social psychiatry offers the psychiatric profession a second chance to recapture the broader human context of our work. The above quote from existential philosopher Jean-Paul Sartre is from his Foreword to a book by Ronnie Laing and David Cooper in which he welcomes what he calls a “truly human psychiatry.”¹ This message was delivered over and over again in the 20th century by psychiatrists themselves—from the outset with Karl Jaspers’ phenomenological psychiatry² and its many offshoots in existential analysis and psychotherapy. The humanistic psychology and psychiatry movement offered another version, as did the community psychiatry and the human potential movements.

Every time there was an effort to embrace the social, community, cultural, or family contexts of psychiatry to expand and enrich the medical model, it came at the cost of creating a separate group or being marginalized from mainstream academic psychiatry, followed by a reactive return to the more traditional medical model in the form of biological interventions such as electroconvulsive therapy (ECT), and the now discredited psychosurgeries such as leucotomies and lobotomies, along with the much more pervasive presence of psychopharmacology. For the record, I had broad subspecialty training in a variety of such approaches, with fellowships in marital and family therapy as well as in child and adolescent psychopharmacology and have conducted psychopharmacological and epidemiological research on eating disorders, mood disorders, and transgenerational trauma in child psychiatry. The problem has never been about the value of each new approach but its overly enthusiastic adoption as an exclusive or superior approach, leading Swiss psychiatrist and medical historian Paul Hoff to decry the history of psychiatry as “a serial collapse into single-message mythologies.”

And what of the vaunted biopsychosocial (BPS) approach? Nassir Ghaemi, MD,³ has written about the “rise and fall of the BPS model” while Steven Sharfstein, MD, American Psychiatric Association (APA) past president, and Allen Frances, MD, chair of the APA’s DSM-IV, observed that BPS became “bio-bio-bio,” giving cover for doggedly biologically-oriented researchers to claim that they were addressing all aspects of psychiatric care. They were not.

To give just 1 example among others that I surveyed in our recent volume on psychiatry in crisis,⁴ the history of eating disorders, first described in the later 19th century in London (1868) and Paris (1873) regularly gets derailed by spurious biological explanations like Simmonds Disease (1914) or Sheehan Syndrome (1939). These medical diseases have nothing to do with eating disorders, merely triggering symptoms related to appetite or weight loss, as do thyroid diseases or diabetes. The point is that these pseudo-explanations favor biological explanations over the more complex and well-documented psychological, social, and cultural aspects of eating disorders.⁵

You may well ask if social psychiatry is not just another “single-message mythology”? We social psychiatrists do not think so. While Norman Sartorius, MD, MA, DPM, PhD, FRCPsych,⁶ a pre-eminent psychiatric leader, asserts that psychiatry is self-evidently social, I argue that we need to make the case for social psychiatry in each generation and in each place.⁷ Why? Until now, it has been harder to demonstrate the social context of psychiatry through robust and compelling research. Two things changed that forcefully: (1) the WHO Commission on the Social Determinants of Health (SDoH)⁸ led by Sir Michael Marmot, the world’s leading epidemiologist, and (2) the salience of epigenetics as a more complex, embracing, and powerful model of human behavior and psychiatric disorders belying the binary opposition of nature versus nurture, or biological versus social psychiatry. The latter is now being led by Dilip Jeste, MD, APA past president and past chair of the APA Task Force on SDoH, who now directs the Global Research Network on Social Determinants of Mental Health and Exposomics.

Three Branches of Social Psychiatry

After 60 years, social psychiatry has come of age with 3 distinct yet related branches⁷:

1. Epidemiological studies represented by the CSDH⁸ and the Adverse Childhood Experiences (ACE) study⁹ are what I call the “basic science” of social psychiatry.
2. Community psychiatry and the community mental health movement.¹⁰
3. The relational therapies, from relational psychoanalysis to the family therapy movement represented by Italian child psychiatrist and family therapist, Maurizio Andolfi, MD,¹¹ and the community therapy of social psychiatrists like Brazil’s Adalberto Barreto, MD.¹²

In future columns, I plan to detail the unique contributions of each of these branches to the work and progress of social psychiatry.

My vision of social psychiatry is of a comprehensive, integrative, transdisciplinary field of medicine and social science concerned with 3 spheres: the natural environment, the built environment, and the social environment.⁷ All relevant domains from genetic psychiatry and epigenetics to neuroscience and psychopharmacology and from epidemiology to the global mental health movement, not forgetting the relational therapies, must be included. Why a focus on the social, then? Placing all of these approaches in a social context creates the broadest possible framework for our work as psychiatrists, from research and training to clinical interventions and policy-making.

We have been doing this in WASP for 6 decades, since Romanian-born psychiatrist Joshua Bierer, MD, organized the first iteration of our association for social psychiatry in London in 1964¹³—and WASP is now celebrating its 60th anniversary. We are planning to celebrate this significant anniversary in Romania later this year in the country of our founder’s birth. In the fall of 2025, we will be hosting the 25th World Congress of Social Psychiatry in Montreal, Quebec, Canada.

One of the tasks I have set for myself and WASP during my triennium as president is to translate the insights of populational studies—the basic science of social psychiatry—into all the other domains: training, research, and policy-making, but above all in the clinic. On one hand, we need clinicians to consider the social context of our patients, while on the other, we need researchers and policy-makers to put more tools in their hands in order to speak to this larger social context in practical and more effective ways. I hope to answer this question in forthcoming columns with a constructive yet critical perspective, looking at activities as far-flung as Brazil’s integrative community therapy¹² and Zimbabwe’s “friendship bench.”¹⁴

And now for the tough question—what is social psychiatry, after all?

Alexander Leighton, MD, an American pioneer of social psychiatry working in Canada, defined social psychiatry as dealing with n > 1. More specifically, Leighton said that “social psychiatry is concerned with the relationships between mental disorder and sociocultural processes.”¹⁵ There have been many refinements and additions to that simple definition ever since.

Here are mine.⁷ Social psychiatry offers 2 things to medicine and society:

1. Social psychiatry defines health as first social, enriching and expanding the field of biomedicine.
2. Social psychiatry is a theory of humans as social beings with diverse methodologies and observational studies that follow from it as well as the practices that it inspires.

If the slogan of the global mental health movement is “No health without mental health,”¹⁶ then the slogan of social psychiatry must be that “Healthy bodies and minds need healthy societies.”

In future columns in this series, I will comment on and debate some of the assumptions of our work in psychiatry, informed by my perspective as a social psychiatrist and philosopher. I think of myself as a late-career psychiatrist and an early-career philosopher. More about that soon.

For now, here are some WASP resources about social psychiatry:

• WASP Textbook on Social Psychiatry¹⁷: https://academic.oup.com/book/46581
• WASP Website: https://waspsocialpsychiatry.org/
• WASP journal – World Social Psychiatry: https://journals.lww.com/wpsy/pages/default.aspx

Acknowledgements

This column was inspired by H. Steven Moffic, MD’s column in Psychiatric Times and Eliot Sorel, MD, my senior presidential advisor at WASP. I am most grateful for my ongoing conversations with both of them as well as their valuable feedback to improve this inaugural column.

Dr Di Nicola is a child psychiatrist, family psychotherapist, and philosopher in Montreal, Quebec, Canada, where he is professor of psychiatry & addiction medicine at the University of Montreal and President of the World Association of Social Psychiatry (WASP). He has been recognized with numerous national and international awards, honorary professorships, and fellowships, and was recently elected a Fellow of the Canadian Academy of Health Sciences and given the Distinguished Service Award of the American Psychiatric Association. Dr Di Nicola’s work straddles psychiatry and psychotherapy on one side and philosophy and poetry on the other. Dr Di Nicola’s writing includes: A Stranger in the Family: Culture, Families and Therapy (WW Norton, 1997), Letters to a Young Therapist (Atropos Press, 2011, winner of the Camille Laurin Prize of the Quebec Psychiatric Association), and Psychiatry in Crisis: At the Crossroads of Social Sciences, the Humanities, and Neuroscience (with D. Stoyanov; Springer Nature, 2021); and, in the arts, his “Slow Thought Manifesto” (Aeon Magazine, 2018) and Two Kinds of People: Poems from Mile End (Delere Press, 2023, nominated for The Pushcart Prize).

References

1. Sartre JP. Foreword. In: Laing RD, DG Cooper. Reason and Violence – A Decade of Sartre’s Philosophy, 1950-1960. Tavistock Publications; 1964.

2. Jaspers K. The phenomenological approach to psychopathology. Br J Psychiatry. 1968;114(516):1313-1323.

3. Ghaemi SN. The Rise and Fall of the Biopsychosocial Model: Reconciling Art and Science in Psychiatry. The Johns Hopkins University Press; 2009.

4. Di Nicola V, Stoyanov DS. Psychiatry in Crisis: At the Crossroads of Social Science, the Humanities, and Neuroscience. Springer Nature; 2021.

5. Di Nicola VF. Overview: Anorexia multiforme: self‑starvation in historical and cultural context. Part I: self‑starvation as a historical chameleon. Transcultural Psychiatric Research Review, 1990,27(3): 165‑196. Part II: Anorexia nervosa as a culture‑reactive syndrome. Transcultural Psychiatric ResearchReview. 1990, 27(4): 245‑286.

6. Sartorius N, Gaebel W, López-Ibor JJ, Maj M, eds. Psychiatry in Society. John Wiley & Sons; 2002.

7. Di Nicola V. “A person is a person through other persons”: a manifesto for 21st century social psychiatry. In: RR Gogineni, AJ Pumariega, R Kallivayalil, et al, eds. The WASP Textbook on Social Psychiatry: Historical, Developmental, Cultural, and Clinical Perspectives. Oxford University Press; 2023:44-67.

8. CSDH. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health Final Report of the Commission on Social Determinants of Health. World Health Organization; 2008.

9. Felitti VJ, Anda RF. The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders and sexual behavior: implications for health care. In: Lanius RA, Vermette E, Pain C, eds. The Impact of Early Trauma on Health and Disease: The Hidden Epidemic. Cambridge University Press; 2010:77-87.

10. Smith M. The First Resort: The History of Social Psychiatry in the United States. Columbia University Press; 2023.

11. Di Nicola V, Andolfi M. Luminaries in Social Psychiatry: A Relational Dialogue with Maurizio Andolfi. Special Issue on Families, Family Interventions and Social Psychiatry. World Social Psychiatry. 2024. In press.

12. Barreto AP, Filha MO, Silva MZ, Di Nicola V. Integrative community therapy in the time of the new coronavirus pandemic in Brazil and Latin America. World Soc Psychiatry. 2020;2(2):103-105.

13. Kallivayalil RA, Kastrup M, Gogineni RR, et al. History of social psychiatry and historical aspects of the World Association of Social Psychiatry. In: RR Gogineni, AJ Pumariega, R Kallivayalil, et al, eds. The WASP Textbook on Social Psychiatry: Historical, Developmental, Cultural, and Clinical Perspectives. Oxford University Press; 2023:9-22.

14. Chibanda D, Bowers T, Verhey R, et al. The Friendship Bench programme: a cluster randomised controlled trial of a brief psychological intervention for common mental disorders delivered by lay health workers in Zimbabwe. Int J Ment Health Syst. 2015;9:21.

15. Leighton AH. An Introduction to Social Psychiatry. Charles C. Thomas; 1960.

16. Prince M, Patel V, Saxena S, et al. No health without mental health. Lancet. 2007;370 (9590):859-877.

17. Gogineni RR, Pumariega AJ, Kallivayalil RA, et al, eds. The WASP Textbook on Social Psychiatry: Historical, Developmental, Cultural, and Clinical Perspectives. Oxford University Press; 2023.