In lieu of an abstract, here is a brief excerpt of the content:Social Psychiatry Inside-OUTGiulio Ongaro, PhDA heartfelt thanks to all commentators on this trio of papers. The idea that animates these papers is that placing modern psychiatry in a comparative perspective lays bare its weaknesses, for it shows that some of the problems that dominate our contemporary discussions in journals such as Philosophy, Psychiatry & Psychology (e.g., the problem of diagnostic validity, the demarcation challe…
Read moreIn lieu of an abstract, here is a brief excerpt of the content:Social Psychiatry Inside-OUTGiulio Ongaro, PhDA heartfelt thanks to all commentators on this trio of papers. The idea that animates these papers is that placing modern psychiatry in a comparative perspective lays bare its weaknesses, for it shows that some of the problems that dominate our contemporary discussions in journals such as Philosophy, Psychiatry & Psychology (e.g., the problem of diagnostic validity, the demarcation challenge, stigma on mental illness), do not actually exist elsewhere, at least not to the same degree or in the same form. I believe this should raise the question of why certain healthcare systems manage so differently and what, if anything, might modern psychiatry learn from them. My proposed answer is externalism: the development of a set of conditions that allow people to place the causes and treatment of psychiatric illness out of the psyche and into the social world. The contributors offer important insights and critiques regarding these conditions.Derek Bolton’s (2024) commentary is a good place to start since his focus on the biopsychosocial (BPS) model is also the starting point of the tryptic. I began with it because, I felt, previous attempts at externalism (I am thinking here of the cluster of approaches often referred to as ‘anti-psychiatry’) were skewed precisely by the absence of a model of BPS interaction. This has led to a lot of binary thinking between biological and social explanations of illness (Aftab, 2020) that fly in the face of the “interacting causal pathways, including feedback and feedforward mechanisms, within and between [bio, psycho and social systems]” (Bolton, 2024, p. 321), which frameworks such as enactivism and predictive processing bring to light. So, when Bolton says that there need to be no deep cuts in the BPS model, I agree entirely. The vignette he presents from Morocco shows that, when the will to recover trumps any ideological commitment, people act pragmatically, and tend to flexibly move across different kinds of therapeutic resources in a way that is compatible with our picture of BPS integration.Nothing in all this is at variance with what I describe in Ongaro (2024b). As I note, pragmatism and pluralism are the norm among the Akha as well. Akha shamans might encourage sick people to visit the hospital if they feel there are no more spiritual causes to address. I should have mentioned that the relatives of the young man with psychotic symptoms that I discussed on p. 13 (Ongaro, 2024b) even asked me if I have medicine ‘for his brain,’ much like Bolton’s Moroccan acquaintances did to him.But although I agree we should posit no deep cuts in the use of therapeutic resources, there are [End Page 341] clear cuts between the types of resources people can flexibly avail of. The therapeutic effects of cognitive-behavioral therapy—psychological, internalizing—are different in kind from those of finding meaningful work or housing security—social, externalizing. In Ongaro (2024b), I argue that Akha rituals are more similar to the latter than to the former, and that Akha society is structured in such a way that social affordances can be easily mobilized. There is a resourceful externalist framework in place. When viewing modern psychiatry from a broad anthropological perspective, it is the absence of anything like this externalist system that stands out, at the detriment of therapeutic efficacy. If anything, Bolton’s incisive point that even our ‘social determinants of health’ tend to be psychologized underscores this contrast.In the end, I resist the dichotomy Bolton draws between ‘small’ and ‘homogeneous’ societies and ‘large,’ ‘diverse,’ and ‘complex’ societies, along with the implicit suggestion that one cannot speak to the other. The Akha carve their own community within a rather complex and ethnically diverse environment in the Lao highlands. In turn, Akha shamans carve their own within Akha society. Conversely, I discussed in Ongaro (2024c) examples of therapeutic movements that achieve ‘collective effervescence’ in modern ‘complex’ contexts. Evidence of superior recovery rates in spiritually treated psychosis comes from megaci-ties like Chennai. The challenge of developing an externalist framework for psychiatry is, therefore, cultural and political. A tall order, no doubt, but there is nothing about ‘modernity,’ ‘scale,’ or ‘complexity’ that inherently...