Abstract

In lieu of an abstract, here is a brief excerpt of the content:Externalist Psychiatry, Mindshaping, and Embodied InjusticeMichelle Maiese, PhD (bio)Ongaro maintains that although enactivist approaches to psychiatry help to account for the integration of biological, psychological, and social factors, they gloss over an important distinction between patient-centered (bio and psycho) approaches and externalist (social) approaches to mental illness. The central problem is that they lack the means to account for the social causes of illness and do not specify how social determinants can be addressed in the clinic. Since much of an organism’s interaction with the external world is social in kind, the implementation of externalist psychiatry could make the enactivist model truly biopsychosocial and usher in novel forms of treatment.According to Ongaro, this externalist orientation gives rise to an important question about ontology: what are the social causes of psychiatric illness made of, and how can these be conveyed in the clinic to facilitate treatment? A “shared social etiology” would allow for a “rich explanatory framework” that accounts for the social causes of mental disorder. For example, by pointing to spirit affliction as the social cause of mental illness, the Akha transform amorphous pains (which are difficult to capture naturalistically) into meaningful and familiar experiences. Such an approach involves combining a realist understanding of biopsychosocial integration with an anti-realist, social constructivist outlook on social etiology. For them, an illness that is explained as a rupture of a human-spirit relationship is experienced as a ‘problem in living’ that affects the person in an immediate and meaningful way, and can be treated via ritual action.Ongaro then considers social causation in a more familiar context, one where social determinants of mental illness include factors such as employment. Losing one’s job is a significant life event because it signals a change in social status and prompts feelings of uselessness. Ongaro characterizes these feelings of low subjective status as “socially constructed experiences that depend on collectively ingrained ideas about status, value, and self-realization that a person accepts—one could say ‘believes in’—by virtue of living in a particular society.” Because social worlds differ and what counts as social defeat is culturally specific, [End Page 333] social determinants of illness such as unemployment are either negligible or non-applicable in Ahka (non-capitalist) society.To acknowledge the impact of these social constructions, Ongaro maintains, clinical psychiatry should abandon its commitment to naturalism and embrace methodological constructivism instead. Methodological naturalism treats social causes as ‘real’ and holds that the social causes of disorder should be investigated using the scientific method; research focuses on social determinants, social stressors, and social capital. However, despite acknowledging that declining mental health correlates significantly with political and economic factors, Ongaro maintains that methodological naturalism when it comes to social causes will be insufficient to bring about meaningful changes in clinical practice. For one thing, individual psychiatrists lack the political power and economic resources to bring about the sorts of societal changes that are needed to address social determinants of health. Second, social determinants are probabilistic factors rather than definitive causes of mental disorder; psychiatric illnesses often do not have a well-defined cause or a clear-cut social trigger. Third, an explanation that points to ‘lack of social capital’ does “not possess the immediacy, emotional charge, and embodied meaning that could make them therapeutically effective in the same way that Akha explanations for spirit afflictions are.”Philosophically, Ongaro’s embrace of ‘methodological constructivism’ when it comes to social etiology entails a commitment to antirealism about social causation and fictionalism more specifically. Wilkinson (2022) notes that the core tenet of psychiatric fictionalism is that “when we engage in psychiatric discourse... we are not attributing a robust, objective property, but are instead engaging with a useful, perhaps even an indispensable, fiction” (p. 91). For Ongaro, this fiction consists in a meaningful explanatory narrative about the social causes of illness. However, if we take the notion of integration seriously, and characterize this integration naturalistically (as Ongaro does), then questions arise as to how these fictional narratives about social causes can impact people both biologically and psychologically, and thereby have such a powerful impact.I argue that an enactivist approach to treatment will be...