Biocultural psychopathology as a new epistemology for mental disorders

From methodological to ontological reductionism on biological psychiatry

Psychopathology and its clinical counterparts, clinical psychology and psychiatry, have been criticized for decades for their reliance on an over-reductionist neo-Kraepelinian approach. In the traditional view, mental disorders are understood as disease-like natural kinds that result mainly from pathological changes in brain chemistry and function and, as a result, the best course of treatment is reliance on pharmacological approaches (Tsou, 2016). Criticism targeted at the incapability of previous incarnations of this approach to produce reliable diagnoses were part of the anti-psychiatry movement of the 1970s, and led to the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III), considered by many as a movement of ‘doubling down’ on the neo-Kraepelinian underpinnings of psychiatry (Aragona, 2014; Decker, 2007). While further editions of the DSM were successful in establishing hegemony in the field, there was very little progress in terms of treatment that was based on this approach.

This lack of progress in developing better treatments for psychological distress happened in spite of a great deal of research trying to uncover the neural bases of mental disorders. As the field morphed to biological psychiatry, ignoring Engel’s (1977) call for a more integrative approach and leaving the biomedical model behind in favour of a biopsychosocial model, it adopted an epistemic and methodological stance to understanding mental disorders that were borrowed from early cognitive neuroscience and from the molecular sciences. This epistemic stance treats mental disorders as instantiations of brain diseases, not because they are completely reducible to relatively simple changes in neurochemistry and brain function in principle, but because it is easier to start a progressive research programme by focusing on a few elements at a time. Neuroscientists quickly learned that simple, linearly causal hypotheses were preferred by funders, and rapidly the field moved from an epistemic stance to a statement on ontology – that is, mental phenomena (including mental disorders) are brain phenomena. This was accompanied by the movement towards biological psychiatry and to a pharmacocentric approach to treatment (Abi-Rached and Rose, 2010; Freeborn, 2019; Rose and Abi-Rached, 2014). While this reductionist point of view is still dominant across both neuroscience and biological psychiatry, the lack of success in producing better biological therapies and the realization that the nervous system is far more complex are integrative approaches which include the whole range of interactions and causal loops that can take place within and between levels of biological organization. With contributions stemming from cognitive science, systems biology and philosophy of mind, a more complex view of the brain emerged which understands mental phenomena as emergent properties that are not reducible to lower-level brain processes. In the case of humans and other social animals, this environment includes interpersonal relationships, as well as a broader social environment (Chiao and Cheon, 2012; Choudhury, Nagel and Slaby, 2009). This, however, is very difficult to do:

Any model that wants to avoid reductionism and capture the complexity of multiple processes (potentially) contributing to the development of psychiatric disorders encounters the integration problem. It is a notoriously difficult problem: how should we characterize the causal relations between such different factors as someone’s neurotransmitter uptake and release, their tendency to avoid conflicts, and the quality of their friendships? What we are looking for is not only a solution of the mind-body problem, but of what we could call the ‘mind-body-world problem’: how do body, mind, and world relate? (De Haan, 2021: 473)

This emergentist approach is sometimes associated with three properties of the mind, derived from the cognitive sciences: minds are understood as embodied, in that mental processes are shaped by aspects of the entire body of the organism; as extended, in that some objects in the external environment act as extensions of this embodied mind; and enactive, in that mental processes arise through a dynamic interaction between an acting organism and its environment. While the standard approach in neurosciences assumes that minds are (passive) information-processing mechanisms made by the brain, this approach contends that mental phenomena are activities of bodily organisms in specific environments, and that both different bodies and different environments will result in different experiences (De Haan, 2020b; Fuchs, 2018; Varela, 2017). Thus, brains are seen as systems that are open to the exterior, such as the whole body, and to environmental affordances which support mental processes.

Such an expanded view of the brain leads to a biocultural ¹ approach that can be fruitfully applied to understanding mental distress and psychopathology, leading to an expansion of the purely biomedical model prevalent in psychiatry to a true biopsychosocial model. In what follows, I present some of the characteristics of biocultural approaches proposed by Thomas Fuchs, Sanneke de Haan, Laurence Kirmayer, German Berrios, and Ivana Marková and the possibilities that this approach opens for a biocultural psychiatry.

The biocultural brain, ecosocial niches and circular causality

If individuals produce open-ended interactions and transactions with their environment, it is also useful to understand these environments as more than simple static sources of stimulation. Rose, Birk and Manning (2021: 4) suggest understanding the physical and local socio-cultural environment as ‘ecosocial niches’, defined as:

a zone of living within a milieu that can be occupied by a particular organism with its mode of existence . . . . But rather than thinking of a niche as occupied by a ‘species’, we focus on the diversity of niches – the multiple habitats – of groups of humans differentiated by age, gender, ethnicity, economic resources, housing situation and more which shape their forms of life as biosocial beings.

The patterns of interaction with the social and material environment posed by an individual’s niche represent exposure to particular forms of hostile interactions, violence and accidental insults. However, niches also represent possibilities for different activities, ways of life and experiences. In this sense, Rose et al. (2021) propose to expand this conception of niche, bringing it closer to the concept of Umwelt, inspired by the biologist Jakob von Uexküll (2010), reflecting the idea that different human beings inhabit different worlds of experience by adapting the world to themselves:

far from fitting into a given corner of the world . . . it is the [individual] that fits the world to itself by ascribing functional qualities to the things it encounters and thereby integrating them into a coherent system of its own. (Ingold, 2011: 80)

The Umwelt is ‘constituted by a more or less broad series of elements [called] “carriers of significance” or “marks” which are the only things that interest the animal’ (Agamben, 2004: 40). Understood as Umwelten, the niches occupied by individuals provide possibilities for different subjective experiences (emotions, feelings, cognitions), and also provide different biological influences. The concept of Umwelt implies ‘functional cycles’ between the environment and the living organism: ‘receptor and effector possibilities of the living organism and the corresponding characteristics of its Umwelt (environment or perceived environment) are linked in a functional cycle’ (Fuchs, 2018: 88, original emphasis), thus implying an opening to the world and its intensities in a process of co-construction. As a result of this functional cycle of open loops between Umwelt and the living organism, ‘conscious experience can no longer be ascribed to a single section or partial process of the functional cycle. Much rather, it forms the integral of the entire brain– body–environment nexus’ (Fuchs, 2018: 167, original emphasis). So, as well as discussing social determinants of health, Rose et al. (2021) propose tracing empirically the relationship between niches understood as Umwelten (and therefore with an experiential dimension that cannot be ignored) and specific pathways or routes that suggest embodied processes in their material and social environments. In this sense, the niche as Umwelt is fundamentally a biocultural concept.

The concept of the niche as Umwelt and the mental processes as embodied, extended and enactive has important consequences for the idea that mental disorders are brain disorders (Fuchs, 2012). While mental processes and the niches are interlocked in loops of horizontal circular causality, the relationship between levels of biological organization are interlocked in loops of vertical circular causality. Not only are upper-level processes such as emotions and perceptions ‘upwardly caused’ by lower-level processes such as action potentials and synchronized activity across neurocircuits, but these processes also modify the activity of these circuits (‘downward causality’), either by ‘selecting’ or ‘blocking’ certain properties of these components:

[A]n emotional state can, on the one hand, be treated pharmacologically, by influencing the transmitter metabolism in the brain (upward). On the other hand, this can also be achieved psychotherapeutically, by changing the subjective perception of one’s personal situation (downward). . . . As such, subjectivity represents a high or integral systemic level of the organism that feeds back into lower-level physiological processes. The brain functions as a transformer for this vertical circular causality, by converting higher- and lower-level influences on the organism and ‘translating’ them into the other levels of the hierarchy. (Fuchs, 2012: 334, original emphasis)

Fuchs argues that mental symptoms are always first and foremost subjective, and are not merely a secondary reaction to physiological dysfunction:

Mental illness hereby affects the person centrally, namely in their experience of themself and in their autonomy. What is more, the altered experience of and relation to themself, as such, is an effective factor in the further course of the illness. It follows that, independent of its origin, vertical circular causality always plays a decisive role in the illness. . . . The subjectivity of the experience, as a relation to oneself, thus becomes an important component affecting the course of the illness. (pp. 334–5, original emphasis)

While correlations can be traced between neurobiological dysfunctions and subjective experiences of mental distress (that is, one sense of the vertical circular causality), the subjective experience per se (the what-it-is-like-ness and the intentional content) cannot be reduced to physiological descriptions. Every psychopathological experience is characterized by a personal ‘sense-making’ that the patient attributes to it, as well as certain stances that the patient takes towards the experience. De Haan (2017, 2021) starts from the ‘life-mind-continuity thesis’ (Di Paolo and Thompson, 2014; Thompson, 2007: ch. 6) which states that sense-making is central to living beings:

Living beings are special compared to nonliving matter in that they are self-organizing unities: they maintain themselves through a constant exchange with their environment. In order to stay alive, organisms need to take up nutrients and dispose of their waste. Organisms are thus dependent on continuous interactions with their environments. This means that they need to be able to distinguish what is relevant for their survival in their environment: what is food and what is not, what is dangerous and what is safe. Without such an ability to make some basic sense of their environments, living would not be possible. It is in this way that life and mind are continuous: living requires sense-making. (De Haan, 2021: 473)

In agreement with Fuchs (2012, 2018), De Haan (2017, 2021) suggests that an enactive approach to mental phenomena leads to an interpretation of most behavioural transactions in non-human animals as forms of sense-making (e.g. distinguishing and sensing relevant aspects of the environment are basic forms of sense-making). However, De Haan (2021: 473) also says that humans are capable of a reflexive or existential sense-making: ‘We do not only experience things, but we are aware of these experiences, and of ourselves, and of how others see us.’ This is also in agreement with the ‘construction’ process proposed by Berrios and Marková (2015), in which the initial appraisal of environmental stimuli will involve a comparison with templates (‘cognitive and emotional forms already experienced and shared with the culture’; p. 52) that allow the individual to make sense of experiences of change in the ‘normal’ stream of consciousness.

This involves incorporating the sense-making activity of a person in context: the ‘existential stance of relating to oneself, to others, and to one’s situation is crucial for understanding psychiatric disorders’ (De Haan, 2017: 529). Individuals can experience alienation when not coinciding with themselves and with their present situation. How patients relate to their experiences and their disorder is likely to co-determine the course of their illness, and of their lives in general:

[A]n even more crucial reason for this irreducibility [of psychopathological experiences and neurobiological dysfunction] is given by the patient’s relation to themself, which is continually involved in the illness process, influences it positively or negatively, and, as such, bars us from seeing mental illness as purely biological. (Fuchs, 2012: 336)

While vertical circular causality, a property of living bodies (Fuchs, 2018: 94–8), reinforces the idea that reductionist approaches to mental distress are not productive, horizontal circular causality also suggests that mental disorders cannot be seen as ‘purely individual dysfunctions; in other words, as detached from their interpersonal aspects’ (Fuchs, 2012: 336, original emphasis). In one sense, mental distress impairs what Fuchs (2007) calls ‘social responsivity’, the ability to shape social and interpersonal relationships according to one’s needs; this impairment feeds back to influence the development and course of the disorder. In another sense, the individual is in constant co-construction with its ecosocial niche (Rose et al., 2021). Human minds are constructed in socially evolved practices of using linguistic representations (Hutto and Myin, 2013: 151). A unique subset of these representations has to do with the self, and thus with our ability to represent, monitor, reflect on and control our behaviour and subjective experience. Some of these processes involve trying to achieve standards of behaviour, often linked to a sense of our social personhood or our subjective sense of individuality (Kirmayer, 2015, 2019; Seligman, Choudhury and Kirmayer, 2016).

Our sense of subjectivity and self is directly related to the social construction of a ‘personhood’, our selves seen from the outside. In this sense, our behaviour represents emergent levels of organization associated with subjectivity, self-awareness and social roles, as well as the responses of others (Kirmayer, 2019; Langer, 1967: ch. 18). The self, then, cannot be reduced completely to any lower-level structure or representation; even if we can eventually analyse how the self is mapped onto synapses, this does not mean that there is such a thing as a ‘synaptic self’, in the same sense that a map is not a territory (Berrios and Marková, 2015). Similarly, the cultural world is not an aggregate of individual cognitive and neural representations (Ortega and Vidal, 2016).

This does not mean removing agency from the individual, nor does it mean attributing agency to an extra-personal force. But it is important for a neuroscientific psychopathology (or a biological psychiatry) to recognize that individuals are part of dense networks of interpersonal and institutional relations and processes that shape and modulate our psychological development – including psychopathological processes (De Haan, 2021; Fuchs, 2018: 251–5; Rose et al., 2021). These relations and processes are not a passive exteriority in which we locate ourselves and navigate, trying to find who we are, but are themselves determined by political, social and economic interests. These micropolitics influence us because they structure the possibilities of our closest social world – family, friends, education, media – which provide us with the elements for the construction of identity, of the power to act in the world, and of our purposes (Braidotti, 2000; DeLanda, 2006: 73). Moreover, these micropolitics also structure the field of narratives that we use to construct our autobiographical memory and where we situate our sense of self (Berrios and Marková, 2015; Kirmayer, 2015, 2019):

[P]ower relations, social structures and cultural assumptions continuously organize potentials for meaning: by molding the circumstances in which it arises; by shaping the available and legitimate resources with which people make sense of those circumstances; and by directing the valences, inhibitions and expectations that underpin preferences and choices. (Cromby, 2022: 46)

It follows that these micropolitics shape the ecosocial niche as much as the meanings that are built on mental distress. This approach has consequences both at the methodological and the intervention levels.

Epigenetics and embodied subjectivity

The field of epigenetics – the regulation of gene expression by life experiences – has been lauded as an important bridge between conceptions of the human sciences and those from biology (Jeannerod, Malabou and Rand, 2008: 21–5; Malabou and Shread, 2016: ch. 7). Epigenetic research has shown that not only the biochemistry of nutrition and toxins, but also experiences of social inequality, poverty, trauma and other forms of stress which are commonly associated with mental disorders can affect the shape and structure of chromatin, changing the accessibility of specific genes to transcription (Lappé and Landecker, 2015). Frost (2020: 5) argues that, given the evidence of epigenetic effects of living with racial and sexual discrimination and economic deprivation, ‘the ways our bodies grow and function are deeply and durably susceptible both to the places we live and to our modes of living’.

Methodological consequences

One of the consequences of shifting from the hegemonic model of biological psychiatry to a biocultural psychopathology is the expansion of methods from laboratory-based experimental and quasi-experimental research towards the methods of the human sciences, including deep ethnographies and spatial observational techniques (Hruschka, 2005; Leatherman and Goodman, 2020; Rose et al., 2021) as well as phenomenological research (Fuchs, 2018: 217–19; Slaby, 2010; Thompson, 2007: ch. 2) combined with biological techniques. This has already been proposed in the field of biocultural anthropology, in which biological approaches (e.g. measuring hormone levels) have been combined with ethnographic methods to understand the relationships between stressful contexts, the co-construction of an ecosocial niche, and impacts on particularly sensitive neurobiological substrata (Hoke and Schell, 2020; Hruschka, 2005; Leatherman and Goodman, 2020). Looking at the context in which problem behaviours arise, going beyond a priori theories of distress, is crucial:

[W]e need to learn how to observe and analyse people’s life strategies across all contexts . . . . [We] must attempt to draw together the interdisciplinary studies and methods to observe and think about human behaviours in their social contexts, so we can put mental health ‘symptoms’ into a bigger, or at least broader, contextual frame. It needs to focus on observations of the real contexts from which the behaviours and complaints arise, and not theories and hypotheses which signal to me only that detailed observations were not made. (Guerin, 2017: 35)

An epistemological attitude for biocultural psychopathology involves foregrounding activity, change and relationality over essence, stability and boundedness. This ‘process thinking’ is a consequence of the assumption that an enactive transaction between individuals and their Umwelten is fundamentally dynamic: it should be recognized ‘for example, that over different, overlapping timescales (from the evolutionary, to the epigenetic, to the neural) biology and culture shape each other’ (Cromby, 2022: 44). Thus, the dimension of temporality is central.

In addition to process thinking (Cromby, 2022) and to the use of methodological approaches from the social sciences (Guerin, 2017; Rose et al., 2021) to expand understanding of distress, a third relevant theoretical source for a biocultural approach is phenomenological approaches. While influences from Merleau-Ponty (Merleau-Ponty and Carman, 2013; Merleau-Ponty and Dreyfus, 1992) can be found in most theorists (De Haan, 2020b; Fuchs, 2018; Kirmayer, 2015, 2019), readings of phenomenology from both neurobiological (e.g., Thompson, Lutz and Cosmelli, 2005; Varela, 1996) and sociological (Schutz, 1999) points of view. The material world is always already pre-reflectively imbued with meaning (De Haan, 2017), and that meaning is coloured by bodily reactions that appear before conscious deliberation (Damásio, 2003: 187–91; Fuchs, 2018 ch. 3; Panksepp, 2005):

This general point is of considerable specific relevance to distress, where embodied threat responses – whether relatively dramatic (e.g., dissociation; exaggerated startling to loud noises) or relatively mundane (e.g., sweaty palms; breathlessness) – shape the meanings we involuntarily find in objects, circumstances and events. (Cromby, 2022: 49)

Thus, while biological psychiatry attempted to follow a reductionist epistemology and eliminate both meaning and sociocultural aspects from its explanations, but to realize its potential fully – and therefore to transition from a biomedical to a biopsychosocial model (Engel, 1977) – it must reincorporate these aspects back into its explanatory models. That is, psychosocial determinants must be reincorporated into definitions of mental distress in a way that reconciles the idea that mental disorders have a definite brain basis with the idea that they are, in every sense, social constructions:

If the differences between phenotypes that differ (symptomatologically) are not systematic at the neural or the genetic level, the symptomatological differences must have causes at some other level. If the brain differences that are proximate causes of behaviour and symptoms are heterogeneous— not apt to feature in a natural kind— then to the extent to which the observed phenotypic properties are themselves systematic, they are not fully explained by these brain differences (though, again, neural events are the proximate causes of symptomatology). For this reason, it is overwhelmingly likely that the differences in symptomatology [which are described by different taxonomies] reflect the contribution of the neural, neurochemical, and genetic differences . . . plus differences in higher- level factors: broadly, social and cultural factors. These include (but are not limited to) the ways in which different mental illnesses are conceptualized in a society, the ways in which social roles are assigned and understood, and perhaps idiosyncratic facts about the individual and her history which result in her having beliefs that modulate the form that her illness takes. (Levy, 2020: 103)

Assuming this is not only a methodological stance committed to a more complex and inclusive view of mental distress, but also locked into pragmatic consequences related to treatment (e.g. dispelling issues related to psychotherapy vs. psychopharmacotherapy) and diagnosis.

Consequences for intervention

One source of resistance from biological psychiatry to adopting a fully grown biopsychosocial model is that this move is usually associated with antipsychiatry (Bracken et al., 2012; Lynch, 2006) and therefore with an understanding that this biocultural approach would break the reliance on psychopharmacological approaches. However, it does not follow that psychopharmacology will not be used in a biocultural approach, only that it will require a better understanding and management of the nonlinear causality that connects the individual organism and its environment (De Haan, 2020a, 2021; Fuchs, 2012):

The ‘bio’, the ‘psycho’, and the ‘social’ do affect each other, but through what we might call mereological or organizational causality. By distinguishing between local-to-global and global-to-local causality, we clarify how different interventions have different effects and involve different causal trajectories. Even though at the global level the results may be similar, it is important to recognize that this result is achieved through different causal trajectories. For example, both psychotropic drugs and psychotherapy can reduce someone’s anxiety levels, but they obviously do so in different ways. (De Haan, 2021: 474–5, original emphasis)

In addition to that, if we start to recognize mental disorders as having important social determinants, the focus on interventions at the individual level – either psychotherapy or pharmacotherapy – needs to open space for interventions at the interpersonal level and above (Guimón, 2004: ch. 7, ch. 8).

Perhaps the most important impact that this epistemological turn can have on mental health interventions is that of moving away from understanding mental disorders as ‘natural kinds’ and towards an understanding of distress as a type of construct (Murphy, 2014; Sabbarton-Leary, Bortolotti and Broome, 2014). The dominant view (the ‘natural kind’ view) understands mental disorders as discrete, objective (mind-independent) entities marking a real division in nature between normal and abnormal psychology and between different diagnoses. Different views have been proposed, ranging from calling mental disorders all and only those disorders that have biological causes (with the caveat that there are mental ‘harms’ – ‘para-natural kinds’, so to speak, that should be treated medically and/or psychologically) (Sabbarton-Leary et al., 2014; Stein, Palk and Kendler, 2021), to doing away with understanding distress through disease entities altogether (e.g. Read and Harper, 2022). The dominant view states that dispensing with diagnostic entities leads to a normative conundrum (Sabbarton-Leary et al., 2014) of the kind sketched by Engel (1977: 129):

Psychiatry’s crisis revolves around the question of whether the categories of human distress with which it is concerned are properly considered ‘disease’ as currently conceptualized and whether exercise of the traditional authority of the physician is appropriate for their help functions. Medicine’s crisis stems from the logical inference that since ‘disease’ is defined in terms of somatic parameters, physicians need not be concerned with psychosocial issues which lie outside medicine’s responsibility and authority.

The crisis of diagnostic validity in the 1970s was one of the main motivators of the changes implemented in the third edition of the DSM, and usually interpreted as a move towards biological psychiatry and to the idea that diagnostic entities are natural kinds (Aragona, 2014; Murphy, 2014). However, understanding distress as a type of ‘discourse on suffering’ that is a social construct instead of a natural kind does not entail doing away with biological explanations (Levy, 2020), only that diagnostic entities must capture the neural, neurochemical and genetic differences ‘plus differences on higher-levels factors: broadly, social and cultural factors’ (Levy, 2020: 103). In a sense, this is equivalent to fulfilling Engel’s call for a true biopsychosocial model to a model focused on totality or relationality. Far from refusing the role of the ‘biological’ in this totality, we must move on to understanding the complexity of the relation of biology with interpersonal, social and cultural factors.