Abstract

In lieu of an abstract, here is a brief excerpt of the content:Grounding Psychiatry in the Body and the Social WorldLaurence J. Kirmayer, MD, FRCPC, FCAHS, FRSC (bio)The sensing body is like an open circuit that completes itself only in things, in others, in the surrounding earth.—David Abram (2012)Giulio Ongaro has written an interesting set of papers that aim to advance our thinking about ‘externalist’ (i.e., social) approaches to psychiatry by rehearsing an enactivist account of mental disorder and elaborating an ethnographic example of social explanation rooted in a different cultural ontology and system of healing. I am completely onboard with his calls for more attention to the social world in psychiatric theory, research, and practice. What is especially novel in his work is the use of ethnographic research to inform philosophical thinking about psychiatry.Despite my enthusiasm for this effort, I have three concerns with his argument that I can only briefly outline in this commentary: i) the lack of attention to a large body of work in social epidemiology, psychosomatics, and cultural psychiatry that speaks directly to the goals of the biopsychosocial (BPS) approach and that vitiates much of the recent critique of that model; ii) the use of an ethnographic example to idealize an ‘externalist’ system of medicine that patently cannot address the many social structural and sociophysiological processes that psychiatry needs to understand; and iii) most importantly from a philosophical perspective, the fact that the enactivist framework he endorses actually breaks down the distinctions between internalist/externalist psychiatry and naturalist/constructivist ontologies around which he organizes his critique and proposed remedy (Kirmayer & Ramstead, 2017).Integration and the BPS ApproachOngaro’s first paper begins by acknowledging the recent critiques of the BPS approach that claim the BPS leaves vague or underspecified the ways in which the biological, psychological and social domains interact to give rise to mental disorders and how they can be included in systematic case formulation to guide assessment and treatment [End Page 315] intervention. Ongaro notes that current efforts to elaborate an embodied, enactivist approach to psychiatry hold the promise of outlining a more systematic approach to the relationship between levels or domains in the BPS. However, he argues this still leaves psychiatry with excessive emphasis on ‘internalizing’ explanations that appeal to biological or psychological processes within the person to characterize mental disorders. He suggests that this needs to be complemented by an externalizing approach that gives due weight to social processes. The dominant approaches leave the social world underspecified and he notes psychiatry lacks an “ontology of the social.”To some extent, this recent critique—not by Ongaro but by some of the authors he cites—reveals a lack of familiarity or engagement with a rich literature in social epidemiology, psychosomatics and sociosomatics that has long demonstrated the close links between social and physiological processes (Krieger, 2021). This research has produced multiple examples of these relationships detailing their mechanisms and dynamics in ways that do not privilege internal processes. There is no problem identifying many specific instances of these links; for example, research has examined how exposure to racism and discrimination results in increased risk for psychiatric disorders (Kirkbride et al., 2024). We have listed many other such mechanisms related to depression in a recent paper (Gómez-Carrillo & Kirmayer, 2023). This work does not yield a single overarching model or explanation but reveals diverse kinds of mechanisms that interact in a multilevel system that includes both dynamic and linguistic modes (Gómez-Carrillo et al., 2023). Integration occurs in the functioning of this system and cannot be captured in any monolithic theory. This is not a limitation of the BPS, simply a reflection of the complexity of human beings.Can we have a general theory of the links between dimensions or domains in the BPS or will it always remain a piecemeal account that depends on the details of specific systems? Given the many different kinds of processes involved, it seems unrealistic to expect a totalizing theory. If so, both research and clinical work need practical ways to assess the myriad pathways and processes involved in psychiatric disorders in order to formulate cases efficiently, identify a manageable subset of factors to consider in a...