Outline for an externalist psychiatry (1): or, how to realise the biopsychosocial model

The biopsychosocial model in psychiatry has come under fire for being too vague to be of any practical use in the clinic. For many, its central flaw consists in lack of scientific validity and philosophical coherence: the model never specified how biological, psychological and social factors causally integrate with one another. Recently, advances in the cognitive sciences have made great strides towards meeting this very ‘integration challenge’. The paper begins by illustrating how enactivist and predictive processing frameworks propose converging accounts of biopsychosocial integration that are far superior to those of previous theories. It argues, however, that the main problem of implementing the biopsychosocial model has less to do with integration than with the lack of a social aetiology. Psychiatric practice leans heavily towards ‘bio’ and ‘psycho’ approaches, without an equally developed set of explanatory and therapeutic resources for dealing with the ‘social’ dimension of illness. This leaves psychiatry essentially internalist in orientation. As illustrated most poignantly by conditions such as functional neurological disorders, internalism comes with the risks of stigma and the curtailment of therapeutic possibilities. The paper argues that the answer to the failings of the biopsychosocial model lies in combining the integration challenge with the development of an ‘externalist psychiatry’, which casts both causes and treatment of psychiatric illness onto the social environment. The following two papers explore the conditions that might make this idea a reality

Outline for an externalist psychiatry (2): an anthropological detour

Philosophical speculation about how psychiatric externalism might work in practice has yet to consider the multitude of actual externalist psychiatric systems that exist outside of modern psychiatry. On the conviction that anthropological insights can inform philosophical debate on the matter, the paper illustrates one such case. The discussion is based on 19 months of first-hand ethnographic fieldwork among Akha, a group of swidden farmers living in highland Laos and neighbouring borderlands. Firstly, the paper describes the Akha set of medicinal, ritual, and shamanic practices, analysing issues of stigma and medical pluralism within it. Secondly, it makes the case that the Akha realise a functioning biopsychosocial system which comes with a well-developed set of resources for treating the social dimension of illness. Externalism among the Akha reframes psychiatric illness as a ‘problem in living’, which becomes manageable as such. The paper claims that, in so doing, the Akha system succeeds in many of the areas where modern internalist psychiatry falls short, and that it does so because Akha society is structured in such a way so that its practitioners can shift the social environment around the patient. As a take-away for philosophers, it suggests that the development of an externalist psychiatry must begin from questioning the accepted ontology of the social causes of psychiatric illness

Outline for an externalist psychiatry (3): social aetiology and the tension between constraints and the possibilities of construction

Any progress in shaping up an externalist psychiatry, so previous discussion suggested, must begin from questions about the ontology of social causation. So far, research and theory have adhered to a naturalistic approach to the social causes of illness, concentrating mostly on the ‘social determinants of mental health’ (inequality, discrimination, housing insecurity, etc.). The paper starts with an assessment of ‘social determinants’ through the lens of epidemiology and critical psychiatry. It illustrates existing practical and political approaches that fight these constraints and it highlights their therapeutic value. It argues, though, that a focus on social determinants is not sufficient for fully realising externalism because a great portion of sociogenic illness remains causally indeterminate. Alongside political action, externalism requires a social aetiology that is established by virtue of the meaning that it holds for patients, rather than by virtue of its capacity to identify objective social causes of illness. This entails abandoning naturalism about social causation and embracing constructivism. The paper shows that this methodological shift is less contradictory and more effective than it is commonly imagined. Drawing from further anthropological evidence, it concludes that only by lending support to projects that balance a focus on constraints with social construction will psychiatry be truly externalist. At stake is a prospect of effective treatment for sociogenic illness for the countless in struggle

An enactive account of placebo effects

Placebos are commonly defined as ineffective treatments. They are treatments that lack a known mechanism linking their properties to the properties of the condition on which treatment aims to intervene. Given this, the fact that placebos can have substantial therapeutic effects looks puzzling. The puzzle, we argue, arises from the relationship placebos present between culturally meaningful entities (such as treatments or therapies), our intentional relationship to the environment (such as implicit or explicit beliefs about a treatment’s healing powers) and bodily effects (placebo responses). How can a mere attitude toward a treatment result in appropriate bodily changes? We argue that an ‘enactive’ conception of cognition accommodates and renders intelligible the phenomenon of placebo effects. Enactivism depicts an organism’s adaptive bodily processes, its intentional directedness, and the meaningful properties of its environment as co-emergent aspects of a single dynamic system. In doing so it provides an account of the interrelations between mind, body and world that demystifies placebo effects

Why the extended mind is nothing special but is central

The extended mind thesis states that the mind is not brain-bound but extends into the physical world. The philosophical debate around the thesis has mostly focused on extension towards epistemic artefacts, treating the phenomenon as a special capacity of the human organism to recruit external physical resources to solve individual tasks. This paper argues that if the mind extends to artefacts in the pursuit of individual tasks, it extends to other humans in the pursuit of collective tasks. Paradigmatic cases of extended mind in the original literature are only particular manifestations of the more general capacity for collective intentionality, the unique power of human minds to be jointly directed at goals, intentions, or values. Because this capacity holds developmental and diachronic primacy over human-epistemic artefacts relations, the extended mind should not be seen as a special phenomenon, but as a central aspect of the human condition. The original extended mind thesis carried important implications for how the cognitive sciences should proceed. In a version of the thesis that accommodates collective intentionality, these implications would go far deeper than originally assumed

Patients’ experiences treated with open-label placebo versus double-blind placebo: a mixed methods qualitative study

Background: There is increasing evidence suggesting that open-label placebo (OLP) is an effective treatment for several medical conditions defined by self-report. However, little is known about patients’ experiences with OLP, and no studies have directly compared patients’ experiences in double-blind placebo (DBP) conditions. Methods: This study was nested in a large randomized-controlled trial comparing the effects of OLP and DBP treatments in individuals with irritable bowel syndrome (IBS). We randomly selected 33 participants for interviews concerning their experiences in the parent trial. The data were qualitatively analyzed using an iterative immersion/crystallization approach. We then compared the qualitative interview data to the quantitative IBS severity data assessed during the parent trial, using a mixed methods approach. Results: Two prominent interview themes were identified: (1) the participants’ feelings about their treatment allocation and (2) their reflections about the treatment. Both OLP and DBP participants mentioned hope and curiosity as major feelings driving them to engage with their treatment. However, while DBP participants tended to be more enthusiastic about their allocation, OLP participants were more ambivalent. Furthermore, OLP participants reflected more on their treatment, often involving noticeable cognitive and emotional processes of self-reflection. They offered a variety of explanations for their symptom improvement and were significantly less likely to attribute it to the treatment itself than DBP participants (Χ2 [3] = 8.28; p =.041). Similarly, the participants’ retrospective narratives of symptom improvement were significantly correlated with their corresponding quantitative IBS severity scores only in DBP (p’s ≤.006) but not in OLP (p’s ≥.637). Conclusion: OLP and DBP participants share feelings of hope, uncertainty and curiosity but differ in the extent of conscious reflection. The counter-intuitive OLP prompts more self-examination, ambivalent feelings and active engagement compared to DBP. At the same time, OLP participants are more reluctant to attribute symptom improvement to their treatment. Our findings substantially add to the emerging picture of factors that distinguish OLP and DBP and their potential mechanisms

Notulae to the Italian flora of algae, bryophytes, fungi and lichens: 12

In this contribution, new data concerning bryophytes, fungi and lichens of the Italian flora are presented. It includes new records, confirmations or exclusions for the bryophyte genera Acaulon, Campylopus, Entosthodon, Homomallium, Pseudohygrohypnum, and Thuidium, the fungal genera Entoloma, Cortinarius, Mycenella, Oxyporus, and Psathyrella and the lichen genera Anaptychia, Athallia, Baeomyces, Bagliettoa, Calicium, Nephroma, Pectenia, Phaeophyscia, Polyblastia, Protoparmeliopsis, Pyrenula, Ramalina, and Sanguineodiscus