“A Social Psychiatry Manifesto” Vincenzo Di Nicola , MPhil, MD, PhD, FRCPC, DFAPA Psychiatric Grand Rounds VA Boston Mental Health Care System Harvard South Shore Psychiatry Residency April 4, 2020 at 12:00 PM Eastern Time Purpose Statement To give an overview of the history and current status of Social Psychiatry with some applications of relevance Veterans and their families Several sentences that describe the training. • What is the current knowledge deficit, or gap? A better understanding of the contributions of social psychiatry • How does the information you are presenting fill that gap? By providing the broader context of social psychiatry to understand veterans and their families • How will it benefit Veterans? By providing a broader context, the presenter hopes to inform clinicians and policy-makers of the importance of social context and family and social relationships Objectives The objectives are what the learners will be able to do after attending the training. It is best that each objective has only one item being focused on. At the conclusion of this educational program, learners will be able to: 1. Describe and define Social Psychiatry; 2. List the three main branches of Social Psychiatry; 3. Name two major public health projects of Social Psychiatry; 4. Give at least two examples of the clinical and policy relevance of Social Psychiatry for Veterans and their families.

1. A Social Psychiatry Manifesto
Vincenzo Di Nicola
MPhil, MD, PhD, FRCPC, DFAPA
Psychiatric Grand Rounds
April 22, 2020 - 12:00-13:00 pm
VA Boston Healthcare System
Harvard South Shore Psychiatry Residency
Boston, MA, USA

2. Vincenzo Di Nicola
Professor of Psychiatry
University of Montreal & The George Washington University
Chief, Child & Adolescent Psychiatry
Montreal University Institute of Mental Health
Founder & President
Canadian Association of Social Psychiatry
President-Elect World Association of Social Psychiatry

4. Source: The New Yorker

5. Declaration of Interests
Commitments:
Child & adolescent psychiatry
Family psychotherapy
Community psychiatry
Social and cultural psychiatry
Medical humanities in psychiatry
Financial:
University salary
Mixed remuneration system of Quebec
Speaker fees and publications
Stipend as President-Elect of WASP

6. Isolation vs.
connection

7. V Di Nicola
Review article –
“A person is a person
through other persons”:
A social psychiatry
manifesto for the 21st
century.
World Social Psychiatry
2019; 1(1): 8-21.

8. Dedication
To Giambattista Vico (1668–1744)
Father of constructivist epistemology
which sees knowledge as
a social construction rather than
a discovery of the natural world
Verum esse ipsum factum
“What is true is precisely what is made”

9. Purpose
To give an overview of the history and current
status of Social Psychiatry with some applications
of relevance Veterans and their families
By outlining the broader context of Social
Psychiatry to understand Veterans and their
families
To inform clinicians and policy-makers of the
importance of social context and family and
social relationships

10. What are we missing?

11. Cultural Patterns
When mental health professionals
evaluate children, the influence of
cultural patterns is often
overlooked or attended to much
too briefly.
– Ian A. Canino & Jeanne Spurlock
Culturally Diverse Children &
Adolescents (2000)

15. Objectives
At the conclusion of this educational program,
learners will be able to:
1. Describe and define Social Psychiatry
2. List three main branches of Social Psychiatry
3. Name two major public health projects of
Social Psychiatry
4. Give at least two examples of the clinical and
policy relevance of Social Psychiatry for
Veterans and their families

16. Social Psychiatry’s Principles
Given its role as a bridge between
academic disciplines and distinct
societies, Social Psychiatry's main
principles include transdisciplinarity
and a multicentric world perspective -
not only Western/Northern

17. Values
As an ethical matter, our values
should ensure the dignity of all
those involved in Social Psychiatry's
activities, and
be guided by beneficence

18. Operational criteria
Balance coherence with theoretical
pluralism
Conduct translational research of
social psychiatry's powerful populational
studies
Provide ground-level prescriptions
aimed at prevention, promotion,
intervention, and adaptation

20. What is Social Psychiatry?
Images for Social Psychiatry's disparate
program:
An envelope – a container, a context for
human situations, including problems
A bridge – between the natural sciences
and the human and social sciences
A map of human experience based on
affectionate bonds and family and social
relationships

21. What is Social Psychiatry?
Social Psychiatry is the broadest
envelope for situating human experience
acting as a bridge between fields of
expertise and between personal and
social or relational being, and thus
equipped,
offers a comprehensive map of human
experiences

22. What is Social Psychiatry?
Social Psychiatry as a map is also the
territory of human problems
Does not assume, discount, or reduce
any other causes or descriptions
The Social Determinants of Health
(SDH) and mental health are among the
most robust and durable findings we
have in the human sciences (CSDH,
2008 – WHO study)

23. What is Social Psychiatry?
An approach or an attitude in placing
psychiatry in a social context
Series of observational studies of
psychiatric problems in society
All without a coherent, consensual and
compelling theory that marshals the
evidence and give it’s a coherent
theoretical framework

24. What is Social Psychiatry?
Social Psychiatry generated a series of
observations in search of a theory
Two empirically generated models from
the Institute of Psychiatry (UK) are:
Expressed emotion in schizophrenia
Social origins of depression in women
Both proposed by sociologist George
Brown

25. What is Social Psychiatry?
Result: Important descriptions
accompanied by anemic explanations
and vague, generic prescriptions
SDH paradigm and GMH movement
have taken flight and are cruising at 35K
feet with a global reach
Now – we need prescriptions at the
ground level both for public health and
clinical psychiatry

26. What is Social Psychiatry?
Social psychiatry’s “public works
projects”
Anti-stigma campaign
Suicide prevention

27. Three branches of Social Psychiatry
Three branches of Social Psychiatry
signaled a shift in psychiatry …
Epidemiological studies
Community psychiatry
Relational therapies

28. V Di Nicola (2012).
Family, psychosocial, and
cultural determinants of
health.
In: E Sorel (ed), 21st Century
Global Mental Health.
Burlington, MA: Jones &
Bartlett Learning, pp. 119-50.
Cf.: Cohen, et al. (2013). A
very brief history of global
mental health.

29. Three branches of Social Psychiatry
Social psychiatry is at the interface

30. Three branches of Social Psychiatry
Epidemiological studies
where the shift is away from the
individual and the clinic, and
populations became the focus of
research

31. Three branches of Social Psychiatry
Community psychiatry
where the shift is away from the
individual in the institution, and
the community became the locus of
intervention

32. Three branches of Social Psychiatry
Relational therapies
couple, family, and group therapy,
where the shift is from the
individual to relationships, and
relations became the praxis, the
object of study and intervention

33. Family studies
Family therapy is the starting point
for the study of ever wider
social units.
– Mara Selvini Palazzoli
Self-Starvation (1974)

34. Child & Family Centered
Global Mental Health
“Cultural changelings”

35. Cultural Family Therapy
NY: WW Norton, 1997
Porto Alegre: ArtMed, 1998

36. Cultural Family Therapy
In a world with huge global flows of
migrants and refugees instigated by
conflict, disasters, or for economic
and social reasons, Cultural Family
Therapy offers clinical tools to
understand and treat families
experiencing severe stress due to
rapid and massive culture change

37. A Global Agenda for
21St Century Social Psychiatry
Address three environments or spheres of human
activity:
Natural environment: Climate change – disaster
psychiatry – pandemics
Built environment: Homelessness – crowding –
worker safety – child labor – exploitation
Social environment: Rapid, massive change – social
class, culture change – the Global South – global
epistemologies – migration and borders –
stigmatization – crime and violence – mass murder
and suicide

38. A Global Agenda for
21St Century Social Psychiatry
Some have called for social psychiatry to be called
“Ecosocial psychiatry”
We are creating a new section at WASP with that
name, concerned with the mental health
consequences of:
Climate change
Disaster psychiatry
Epidemics, pandemics and
Other large-scale crises

39. Third culture kids
Third culture kids (TCKs)
“Nomad children”
“Army brats”
Ref: Pollock, D.C., & Van Reken, R.E. (2009). Third
Culture Kids: The Experience of Growing up Among
Worlds. Boston: Nicholas Brealy.

40. Third culture kids
Third culture kids (TCKs)
“Nomad children”
“Army brats”
Ref: Fred Dervin & Saija Benjamin, eds. (2015).
Migration, Diversity, and Education: Beyond Third Culture
Kids. London: Palgrave.

41. Third culture kids
Third culture kids (TCKs) – “Adult TCKs”
“Army brats”
Migration, belonging, language and culture
Identity
Potential exposure to trauma
Ref: Ender, Morten, “Growing up in the Military.” In:
Strangers at Home: Essays on the Effects of Living
Overseas and Coming ‘Home’ to a Strange Land, ed.
by Carolyn D. Smith. New York: Alethia Publications,
1996, pp. 88–90.

42. Military families
Third culture kids (TCKs)
“Army brats”
Migration, belonging, language and culture
Identity
Ref: Florence W. Kaslow, ed. (1993). The Military Family
in Peace and War. Springer.

43. “Cultural changelings”
Culture-bound syndromes
(CBSs)
Culture-change syndromes
(CCSs)
Ref: VF Di Nicola, Anorexia multiforme: Self-starvation in historical and cultural context.
Transcultural Psychiatric Research Review, 1990, 27(3): 165-196;
27(4): 245-286.

44. Anorexia
Nervosa

45. Selective Mutism

46. Trauma

47. Conclusion
In Africa's Ubuntu philosophy, personhood is not
innate but acquired through experience
As the Zulu saying captures it –
Umuntu ngumuntu ngabantu
“A person is a person through other persons”
This is the slogan for a manifesto of social
psychiatry that reaches for more than a
methodology to a social theory of human being
– “the science of Anthropos”

48. Without cultural
understanding,
we build walls
instead
of bridges …

49. “Intimate Strangers”
I see humanity as a family
that has hardly met.
– Theodore Zeldin
An Intimate History of
Humanity (1995)

50. Community/Individual
The community stagnates without
the impulse of the individual.
The impulse dies without
the sympathy of the community.
– William James
The Will to Believe (1897)

51. Acknowledgments
John Bradley, MD
Chief of Psychiatry &
Acting Director for
Mental Health
Associate Professor,
Harvard Medical School
Lynn DeLisi, MD
Chair, Grand Rounds
Committee
Professor of Psychiatry,
Harvard Medical School
Turku, Finland

52. Acknowledgments
VA Boston Healthcare
System
Dr. David Topor
Dr. Margo Funk
Dr. Grace Chang
Amanda Pereira,
Harvard South Shore
Turku, Finland

53. Acknowledgments
VA Education
Tim Walsh, EES Project
Manager
Kimber Polette, Media
Education Technician
David Hines, Media
Education Technician
Turku, Finland

54. Questions
&
Comments

55. Bibliography
Arieti, S. (1976). Vico and modern psychiatry. Social Research,
43: 739-752.
Cohen A, Patel V, Minas H. (2013). A very brief history of
global mental health. In: Patel V, Minas H, Cohen A, Prince MJ,
editors. Global Mental Health: Principles and Practice. Oxford,
UK: Oxford University Press, pp. 3-26.
CSDH (2008). Closing the Gap in a Generation: Health Equity
through Action on the Social Determinants of Health. Final
Report of the Commission on Social Determinants of Health.
Geneva, Switzerland: World Health Organization.

56. Bibliography
Dervin, F. & Benjamin, S. eds. (2015). Migration,
Diversity, and Education: Beyond Third Culture Kids.
London: Palgrave.
Ender, M. (1996). Growing up in the Military. In:
Strangers at Home: Essays on the Effects of Living
Overseas and Coming ‘Home’ to a Strange Land, ed. by
Carolyn D. Smith. New York: Alethia Publications,
pp. 88–90.
Di Nicola, V.F. (1999). Anorexia multiforme:
Self-starvation in historical and cultural context.
Transcultural Psychiatric Research Review, 1990, 27(3):
165-196; 27(4): 245-286.

57. Bibliography
Di Nicola, V (1997). A Stranger in the Family: Culture, Families
and Therapy. New York: W.W. Norton & Co.
--- (2011). Letters to a Young Therapist: Relational Practices
for the Coming Community. New York: Atropos Press.
--- (2012). Family, psychosocial, and cultural determinants of
health. In: Sorel, Eliot, ed., 21st Century Global Mental Health.
Burlington, MA: Jones & Bartlett Learning, pp. 119-150.
--- (2019). Review Article – “A person is a person through
other persons:” A social psychiatry manifesto for the 21st
century. World Social Psychiatry, 1(1): 8-21.

58. Bibliography
James, W. (1897). The Will to Believe.
Kaslow, F.W., ed. (1993). The Military Family in Peace
and War. Springer.
Pollock, D.C. & Van Reken, R.E. (2009). Third Culture
Kids: The Experience of Growing up Among Worlds.
Boston: Nicholas Brealy.
Selvini Palazzoli, M. (1974). Self-Starvation. New York:
Jason Aronson.
Zeldin, T. (1995). An Intimate History of Humanity. New
York: HarperCollins.

59. Further reading
Di Nicola, V. (2020) Review Article – The Global
South: An emergent epistemology for social
psychiatry. World Social Psychiatry, 2(1): 20-26.
--- (2020)“Intimate Strangers.” Aeon Magazine
(online), April 13th. https://aeon.co/essays/there-is-
no-dark-fate-or-bright-destiny-only-things-that-
happen