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Frontiers in Psychiatry 01 frontiersin.org
A cultural-ecosocial systems view
for psychiatry
AnaGómez-Carrillo
1,2* and LaurenceJ.Kirmayer
1,2
1 Division of Social and Transcultural Psychiatry, McGill University, Montreal, QC, Canada, 2 Culture and
Mental Health Research Unit, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada
While contemporary psychiatry seeks the mechanisms of mental disorders
in neurobiology, mental health problems clearly depend on developmental
processes of learning and adaptation through ongoing interactions with the
social environment. Symptoms or disorders emerge in specific social contexts
and involve predicaments that cannot be fully characterized in terms of brain
function but require a larger social-ecological view. Causal processes that result
in mental health problems can begin anywhere within the extended system of
body-person-environment. In particular, individuals’ narrative self-construal,
culturally mediated interpretations of symptoms and coping strategies as well
as the responses of others in the social world contribute to the mechanisms of
mental disorders, illness experience, and recovery. In this paper, weoutline the
conceptual basis and practical implications of a hierarchical ecosocial systems
view for an integrative approach to psychiatric theory and practice. The cultural-
ecosocial systems view we propose understands mind, brain and person as
situated in the social world and as constituted by cultural and self-reflexive
processes. This view can beincorporated into a pragmatic approach to clinical
assessment and case formulation that characterizes mechanisms of pathology
and identifies targets for intervention.
KEYWORDS
multilevel explanation, embodiment, enactment, ecosocial, looping eects, cultural
psychiatry, clinical case formulation, systems theory
Introduction
Current psychiatric research assumes the mechanisms of mental disorders can beunderstood
in terms of neurobiology, especially brain circuitry. However, mental health problems clearly
depend on developmental processes of learning and adaptation through ongoing interactions
with the environment. Human environmental niches are socially and culturally constructed.
Symptoms or disorders emerge in specic social contexts and predicaments that cannot befully
characterized in terms of brain function but require a larger ecological systems view. Causal
processes can begin anywhere in this larger ecosocial system. In particular, individuals’ narrative
self-construals, culturally mediated interpretations of symptoms and coping strategies, as well
as the responses of others in the social world, can play a crucial role in the mechanisms of mental
disorders, illness experience, treatment response, and recovery. In this paper, weoutline the
conceptual basis and practical implications of this hierarchical systems view for psychiatric
theory and practice. Weargue for the importance of adopting a cultural-ecosocial systems view
that understands the brain as situated in the social world and as part of larger, self-reexive
systems that are embodied and enacted through language and other cultural practices (1). is
view builds on work in systems biology, social epidemiology, developmental psychology,
OPEN ACCESS
EDITED BY
Michael Finn,
Independent Psychology Practice,
UnitedStates
REVIEWED BY
Laura Noll,
Northern Arizona University,
UnitedStates
Patrick Bieler,
Humboldt University of Berlin,
Germany
Felix Tretter,
Bertalany Center for the Study of Systems
Science (BCSSS), Austria
Michael Moutoussis,
University College London,
UnitedKingdom
*CORRESPONDENCE
Ana Gómez-Carrillo
ana.gomez-carrillo@mcgill.ca
SPECIALTY SECTION
This article was submitted to
Psychopathology,
a section of the journal
Frontiers in Psychiatry
RECEIVED 29 August 2022
ACCEPTED 08 March 2023
PUBLISHED 13 April 2023
CITATION
Gómez-Carrillo A and Kirmayer LJ (2023) A
cultural-ecosocial systems view for psychiatry.
Front. Psychiatry 14:1031390.
doi: 10.3389/fpsyt.2023.1031390
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TYPE Hypothesis and Theory
PUBLISHED 13 April 2023
DOI 10.3389/fpsyt.2023.1031390
Gómez-Carrillo and Kirmayer 10.3389/fpsyt.2023.1031390
Frontiers in Psychiatry 02 frontiersin.org
anthropology and 4E cognitive science to provide a process-based
view of the dynamic interactions of subjective experience and
social context.
We use the term ‘ecological’ here in a way that is related directly
to ecology [as the study of biological organisms in relationship to
their physical environments (2); see (3, 4)] but with the recognition
that for humans, the environments in which weare embedded are
fundamentally social and cultural. What ows through these
organism-environment systems is not just energy or material (as is
the case in typical ecological analysis) but also information, which
is essentially relational (5). e material and symbolic
(informational) dimensions of our environment are closely related.
Weinhabit socially constructed niches that enable communication
and cooperation (6). Weemploy cultural knowledge and practices
to navigate these niches, which are both local and extended through
time and space. In the process, weboth actively recongure these
niches (7) and are reshaped by them at neurobiological, cognitive
and social levels (8).
e cultural-ecosocial view encourages us to consider how
cognition and experience depend on the dynamics of the system
comprising organism and environment. By emphasizing systemic
processes, this view takes a step away from narrow concepts of
mechanism that assume the total decomposability of a system into its
parts (reductionism), with the recognition that the ways that the parts
or constituents of systems are spatiotemporally arranged and
connected give rise to new dynamics. System dynamics arise from
connectivity, organization and interactions not simply from the
properties of the components. Interactions between components may
change the properties and function of each of the components as well
as the dynamics of local and larger networks.
In the sections that follow, werst provide a brief genealogy of
systems thinking in psychiatry and outline the specic contributions
of the existing frameworks that wedraw from. Wethen discuss the
nature of hierarchical organization in biology before turning to a
discussion of multilevel explanation in psychiatry. e next section
argues that 4E cognitive science can provide a path to multilevel
integration through a cultural-ecosocial systems view. We then
illustrate with a case vignette how this approach can beapplied to
integrative clinical case formulation. e cultural-ecosocial systems
approach includes patient’s experience, self-understanding and
agency, as well as social structural processes, in explanations of
symptoms, disorders and distress. Finally, wediscuss the implications
of our approach for psychiatric practice. Weare calling for a change
in psychiatric theory, research and practice that resists the reication
and over-simplication of mental health problems in terms of discrete
diagnostic entities by focusing on system dynamics that include
individuals’ experience and meaning-making as well as the social-
cultural contexts in which the person is embedded and from which
psychiatric disorders emerge.
Systems thinking in psychiatry
e concept of system is associated with Enlightenment views of
knowledge and has been a central trope in modernity associated with
ideas of order and control (9). However, a more abstract notion of
system has served as of way to identify important analogies and formal
correspondances among diverse phenomena. In this usage, a system
is a structured ensemble of parts or processes (components, actors or
agents) that interact in ways that allow the structure to persist over
time and exhibit distinctive behavior or dynamics. e recognition
that very dierent kinds of ensembles may display similar dynamics
reecting their organization led to the development of general systems
theory (10-12) and cybernetics (13). e application of systems theory
received new impetus with the development of computational
approaches to modelling dynamics. Mathematical analyses and
computational modelling revealed complex dynamics emerging from
even simple systems spawning the development of subelds of
nonlinear systems theory, and popular re-branding under the banners
of “chaos” and “complexity theory” (14–19). e focus on dynamics
supports an ontology in which systems are characterized not in terms
of their constituent parts and structures but rather in terms of
interactional processes (20, 21).
e concepts introduced in general systems theory and
cybernetics were applied widely to modelling behavioral, biological,
ecological and social-economic systems [for overviews see (10, 22,
23)]. Eorts to understand biological processes at genomic and
cellular levels led to the development of systems biology (24). In this
view, the function of components of biological systems like genes,
organelles, cells, tissues and organs can only beproperly understood
by considering their relation to the dynamics of the larger system as a
whole. Understanding these dynamics holds great promise for
improving clinical approaches to the assessment and treatment of
myriad complex medical conditions (25, 26).
Systems thinking has a long history in psychiatry, going back to
the development of the notion of homeostatic regulation of
physiological systems in the work of Walter Cannon (27), and some
of the early applications of systems theory (28). Psychiatrists and
neuroscientists were key gures in the development of cybernetics in
the 1940s and 50s (29). is work aimed to model learning and
adaptation in mechanistic terms and identify forms of pathology with
specic types of dysregulation of adaptive systems. Subsequent work
applying systems thinking to understand psychopathology was
inspired by systems biology (32), the cybernetics of behavioral control
systems (33–36), complexity theory (37, 38), and recognition of the
impact of social-structural determinants of health (39). A recent
version of control systems modelling can be found in the active
inference approach to explaining specic forms of psychopathology
(40). While focused initially on neural processing, active inference can
bereadily extended to consider interactions with the environment and
social networks, (41–44).
Systems theory and cybernetics were central to the development
of family therapy (45–48). Families were viewed as self-regulating
systems comprised of individuals in interaction with each other (49).
ese interactions are inuenced by individuals’ characteristics but
also reect spatial, material and symbolic structures as well as the
social practices, norms, rules, and rituals that constitute family life.
e family system is constituted both by the individuals who are its
members and the community, society or culture that congures and
constrains its structure and identity. e family system thus serves the
needs of its members and of the larger society in which it is
embedded—and these diverse needs may sometimes conict with
each other. While there have been substantial eorts to elaborate sets
of dimensions, typologies, and measures to characterize the structure
and dynamics of families [e.g., (50–54)], to date, none have achieved
wide acceptance or clinical application. e interactional view of
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Frontiers in Psychiatry 03 frontiersin.org
family systems has been extended to consider larger social networks
and structures (55-58) but this is also an unnished project (59).
In the 1970s, second-order cybernetics theory emphasized the
role of recursivity, self-reference and self-construction (autopoiesis) in
living systems (60). is opened the way to a deeper engagement with
social, cultural and linguistic processes of meaning making (39, 61–
63). Agency, subjectivity, and narrativity are given central place in
systems approaches that acknowledge the role of communication,
storytelling and self-reection in human experience (45).
ere are many interconnections among these dierent
approaches to systemic thinking in psychiatry. is reects both their
shared genealogy‚ with common ancestors, and cross-fertilization
among disparate strands. ese lines of work are complementary and
each can address some of the limitations of the others. In particular,
systems neurobiology focuses on multilevel processes in the nervous
system but does not suciently consider the social environment or
treats it simply as a modulator of neural processes rather than as
constitutive of brain function. Systems biology has been extended to
consider biosocial interactions, but this work oen does not specify
the psychological processes of meaning and experience that mediate
bodily and social interactions (64). Krieger’s (65, 66) ecosocial
epidemiology uses the construct of embodiment to emphasize the
biological eects of structural inequities (i.e., how adversity gets
“under the skin”) but also does not clarify psychological processes.
Bronfenbrenner’s (67-68), bioecological psychology emphasizes the
dependence of developmental processes on environmental context but
its application has not always considered the interaction of the
multiple levels of social organization in which individuals and families
are embedded (69). Ecocultural approaches grounded in ethnographic
methods have provided ways to characterize the culturally constructed
meanings and practices that constitute lifeworlds and developmental
pathways (70). e notion of an ecology of mind, introduced by
Bateson (61, 71) views cognition as emergent in loops of individuals
interacting with the environment and through interpersonal
communication with other humans in a social system (72). e many
strands of 4E cognitive science develop this perspective in terms of
processes of embodiment and enactment that involve social
embedding and extension in the world (73–76). e cultural
psychiatric perspective emphasizes the interactions of individual and
collective meaning making and the social-political contexts of
institutional power and practice that create cultural niches and
aordances (77). Computational methods allow us to put aspects of
each of these approaches together in an overarching model that can
reveal system dynamics (78). e novel aspects of our approach that
distinguish our framework from previous work include: the explicit
integration of culture (as embodied background knowledge and
enacted situated practice); the characterization of basic psychological
processes of subjectivity, narrativity, and agency in terms of
embodiment and enactment; and a focus on the dynamics of multi-
level biological, cognitive and sociocultural looping eects as potential
mechanisms of pathology and targets for intervention.
Hierarchical systems theory in biology
Biological systems are hierarchically organized, with components that
are arranged in ways that give rise to stable structures with new properties
and processes (20). For example, the metabolic processes of the cell
depend on the spatial organization of enzymes on its membranes. e
computational functions of the brain depend on its hierarchical structure
of networks and nodes (79). is organizational process is recursive and
new control processes emerge as a result of the hierarchy (34). is
hierarchy includes the social environment which emerges as part of
specic arrangements of relationships with others through social norms,
rituals, institutions, and practices—and which, in turn, shapes the
development and functioning of the individual.
e notion of hierarchy sometimes conjures images of domination
or oppression. However, as weuse it here, hierarchy does not involve
value judgments about degree of importance, power or privilege but
refers to specic forms of organization of systems (80). Some
philosophers are critical of the idea of hierarchy and levels in living
systems because they see this as imposing a misleading model or
metaphor on phenomena that are uid, shiing, or ‘holistic’ (81).
1
Others are concerned about the notion of ‘top-down’ causation,
arguing that causal processes can only involve same-level processes
that are materially linked (83). In reality, top-down causation is
common in complex systems and is central to organismic biology
(84). ere are many types of organization that can bediscerned in
the world or applied to experience and the utility of concepts of
hierarchy and levels depends on the specic question, problem, object
of interest and pragmatic task at hand (85, 86).2
e notion of hierarchy is used in multiple ways in biology that
include subsumption, composition, scale, causality, and control (88, 89).
Hierarchy implies organization into levels, but the signicance of these
levels diers in each of these versions of hierarchy. In biology, each of
these notions of hierarchy is useful but the one that is most important
for an ecosocial systems view in psychiatry is that of control hierarchies.
Subsumption hierarchies are classications in which something is
seen as a member of instance of a larger category. An example is a
Linnean taxonomy of species taxa. e logical relationship between
levels can becaptured by set theory. e elements of progressive levels
are sets of the prior level’s sets. Elements at lower level may beviewed
as concrete instances, while higher levels are abstractions, or each level
may have a kind of ontological identity (90). A lower-level instance
can stand metonymically for the whole. But the way that elements are
1 There is no doubt that notions of hierarchy reflect sociomoral and political
values (73), but this does not vitiate their use as technical concepts in science
or other domains.
2 Of course, there is legitimate concern about the need to recognize
oppressive structures in society but these are not simply due to hierarchically
structured systems. Oppression can arise not only from the dominance of one
group over others but from systemic processes that occur at multiple levels
in the system. For example, collective norms and public discourse can legitimate
discrimination, micro-aggressions and social exclusion with significant eects
on the health of minorities. Hence, it is important to distinguish between
hierarchical structure as an organizational feature of complex, self-organizing,
goal-oriented systems and oppressive processes that make use of hierarchies,
but also other aspects of social structure and everyday practice, to exert power
in ways that create inequity. Ecosystems and social systems might bebetter
characterized in terms of the concept of “panarchy” in the sense that they
exhibit both top-down and bottom-up causation often on dierent spatial and
temporal scales (78). The potential for conflict between these levels of causation
and control leads naturally to a consideration of the dynamics of social power.
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Frontiers in Psychiatry 04 frontiersin.org
grouped into larger sets of sets can provide a conceptual structure,
represented by a graph or lattice that represents the way that the
groupings are based on specic facets or properties of the elements.
Scale refers to the number or the size of the assembly relative to its
components, spatial or temporal span. Scale dierences can
becontinuous or discrete. Some biological and social network-based
phenomena are ‘scale free’; that is, the same structural organization
and dynamics are observed at multiple scales or else scale-up in a
quantitatively predictable way (91, 92, 93). is allows dynamical
system models to be applied in an iterative way to characterize
processes across these networks at multiple scales. However, many
physical and biological phenomena are not scale free; that is, size
matters(94–96). e sheer number of elements, their topological
arrangement or connectivity, and their spatial or temporal extent can
give rise to new dynamics. In this case, the emergence of new
dynamics marks a new level in a hierarchical structure.
In compositional hierarchies, the focus is on part-whole
relationships (97). e parts are building blocks that are arranged in
spatiotemporal structures that create a new level of organization.
Bricks are laid to build a wall; walls joined to build a room; rooms
are concatenated to build a house; houses are arranged to create a
neighborhood. e process of composition may involve dierent
kinds of arrangement at each level and similar processes may
beinvolved in stabilizing the structures (e.g., mortar may beused to
build walls, to join them into rooms, and to join rooms into a house).
However, dierent processes (reecting other properties of the
components or additional components) may stabilize structures at
dierent levels (buildings might bejoined by mortar to build a wall
and walls might bejoined by interleaving bricks at a corner, or by at
angle brackets made of metal). Depending on our focus of study, the
level and processes weneed to explain a phenomenon will shi.
us, if weare looking at the stability of a house wewill beinterested
in the strength of bricks and mortar bonds, and the buckling
properties of columns and frames; whereas, if weare interested in
neighborhood stability, wewill need to consider parameters at other
compositional levels like street layout, greenspace, and social
relationships among inhabitants. However, wemay nd that house
stability and neighborhood stability signicantly aect each other
because of mechanisms that link these through social and economic
processes such as house pricing, gentrication, neighborhood pride
and upkeep.
Compositional hierarchical organization is central to biology and
essential to phylogeny, ontogeny, and adaptation to new environments
because biological systems build on existing structures by preserving,
re-organizing, and re-purposing components (98). In biology, there
are multiple compositional hierarchies, but the main line follows from
the ways that processes are stabilized to create a hierarchy of material
structures (99): molecules are joined to make macromolecules
(through chemical bonds); macromolecules are arranged in space
(with the aid of membranes and other macromolecules) to produce
organelles; organelles are arranged in space (again with the aid of
membranes, macromolecules and other organelles) to create cells
which have metabolic cycles; cells are organized into tissues which
have biomechanical and other functional properties; tissues are
organized in organs which can perform multiple functions related to
their structure and anatomical location; organs form physiological
systems, which have properties related to interactions between the
organs they connect; physiological systems constitute organisms;
organisms form communities; and diverse communities in
environmental context constitute ecosystems.
Causal hierarchies reect arrangements determined by mechanisms
or processes that produce a given eect (100, 101). e directionality of
the link (or irreversibility of the process) establishes an ordering. e
ordering of causes leading to outcomes which are causes of subsequent
outcomes provides a sequential structure that can bedescribed as a chain
of cause and eect. Of course, most processes have multiple causal
contributors that interact and result in dierent partial orderings or lattice
structures that may have a layered or hierarchical structure. Moreover,
multiple causes may independently lead to the same outcome
(equinality), and single causes may lead to multiple outcomes
(multinality), presumably reecting the inuence of other historical or
concurrent causal factors. Finally, the assumption of unidirectionality at
one causal level may not hold when the larger system of relationships is
considered. Most biological systems involve mutual or circular causality
or feedback loops. Indeed, circularity (autocatalysis, self-assembly or
autopoiesis) is essential to what characterizes a system as living (102–106).
rough such circularity and self-reference, biological systems then
instantiate another form of hierarchy that involves self-regulation
or control.
Control hierarchies are dened in terms of successive levels of
regulatory loops (107). e control systems perspective is especially
relevant to understanding biological processes (and psychopathology)
because it leads to a useful way of understanding function and dysfunction
in terms of the goal-oriented nature of behavior and adaptation. A basic
building block is a feedback loop in which a state of the organism or
environment is compared with an expected (or desired) state [what Miller
etal. (34) called a ‘Test-Operate-Test-Exit’ or TOTE unit]; the discrepancy
then drives a compensatory action (either revising the expectation or
acting on the world to make it better conform to the expectation).
Successive levels are loops of loops. ese loops can involve dierent
processes that are best characterized as regulating information (or ‘free
energy’) rather than energy per se (108). is is the kind of hierarchy of
greatest interest in making sense of the dynamics of living systems. For
living systems, these loops are characterized by a fundamental regulatory
goal of maintaining organism integrity and persistence in the service of
reproduction and other goals. e resultant teleodynamics distinguish
living systems from other regulatory systems that lack the capacity to
generate organism-specic goals and norms and to function in ways that
are explicitly informed by future possibility (109, 110).3 In humans, this
process extends to the self-reexive, imaginative and cooperative
processes of agency enabled by language and culture (112, 113).
e general idea of hierarchy then does not imply unidirectional
(top-down or bottom-up) causation, linear dynamics, or reductionism.
In fact, evidence for hierarchical organization is seen in many
emergent phenomena. Emergence involves the appearance of new
levels of organizational structure without implying loss of underlying
structures or component levels (114). ese new levels of organization
have their own dynamic processes. e emergence of new structures
with distinctive properties and of processes with new dynamics
3 We use the term “teleodynamic” in a way similar to Deacon (99), who
contrasts teleonomic systems that can beinterpreted as pursuing a goal state,
from teleodynamic systems that actually pursue goal states as basic to their
structure (see 100, 101).
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Frontiers in Psychiatry 05 frontiersin.org
warrants the use of the concept of levels of organization and
corresponding levels of description.
In hierarchical systems, the function of each level can beexplained
not only through the interactions of its components but in terms of its
relationship with both higher and lower levels. For example, the
genome is a set of structures used by the cell to regulate its activity and
replicate itself; the genome itself is a dynamic system that is regulated
by a network of macromolecules (115). Similarly, the cells of a healthy
multicellular organism serve the priorities and plans of the whole
organism—sometimes to the detriment of their individual survival.4
e functions of any level in a biological system then only make sense
in relation to the dynamics of the larger system, including the
regulatory processes organized at higher levels. e principle of
biological relativity, developed by physiologist Denis Noble (117–119),
argues that in biological systems causal chains can begin anywhere
within the system or hierarchy. is approach to systems biology
recognizes the organizational value of hierarchy but is explicitly anti-
reductionist in the sense that both lower and higher levels of
organization have causal ecacy and contribute to the dynamics of
the system as a whole or the subsystems that constitute brains,
persons, families and communities.
Multilevel explanation In psychiatry
e biopsychosocial (BPS) approach championed by Engel (120,
121) promised a conceptual framework to integrate multiple levels of
analysis in psychiatry based on general systems theory (12). e
motivation for this was a concern to give a place in clinical theory and
practice to the intrapsychic processes characterized by psychodynamic
theory and patients’ own experience and understanding of their
condition (122). But the denition and operationalization of these
level and their exact interplay in cross-level formulations, were le
undetermined. Critics of the BPS, like Ghaemi (123) have argued that
the framework is little more than a placeholder with no real content
to guide diagnostic assessment, formulation and treatment (124). To
a large extent, this claim says more about critics’ failure to engage the
burgeoning literatures of systems biology, psychophysiology, family
systems theory, social epidemiology, and other social sciences, which
can put ample esh on the bones of the BPS model, than about any
inherent limitations of a multilevel systems approach to health and
illness (125, 126. e lack of engagement with this literature is evident
in Ghaemi’s alternative proposal that psychiatry employ mechanistic
biological accounts of disorder complemented by phenomenology and
a humanistic concern for patients’ experience. In this approach, the
causal mechanisms of psychopathology are divorced from the social
world. Subjectivity and social context are acknowledged as important
to ensure a humane engagement with the patient but are not seen as
primary mechanisms of pathology and are taken for granted as aspects
of the patient’s clinical presentation that can beadequately accessed
and assessed with empathy and common sense.
4 Multicellular organisms regulate and “police” their own constituents in ways
that contribute to the survival of the whole organism (through allostasis and
reproduction) at the expense of the viability of individual cells (106).
While Ghaemi’s concern that the BPS leads to “undisciplined
eclecticism” seems to us to beunfounded, more valid concerns
are that in practice the BPS remains mainly descriptive rather
than dynamic, simply enumerating potential risk, causal or
maintaining factors, without detailing causal mechanisms that
could guide intervention. Perhaps this is why, despite its
widespread acceptance, the BPS has failed to prevent or reverse
the adoption of reductive biological explanations in psychiatry.
Moreover, while the BPS was motivated by concerns to include
patients’ lived experience, even mental health practitioners who
claim to use a BPS approach tend to neglect subjectivity and
social-cultural context. This failure may reflect the lack of
interdisciplinary training (127,128), the difficulties of conceptual
integration (81), and the persistence of dualistic thinking (129).
We start from a dierent premise, supported by a wealth of
research in psychosomatics and sociosomatics, that insists that
symptoms and syndromes in psychiatry arise from the interaction of
psychophysiological, cognitive-aective, and sociocultural processes
(77). Psychiatric disorders are complex, multidimensional constructs,
and symptoms are more than just indices of an underlying
neurobiological mechanism that can becaptured by biomarkers (130,
131). Psychiatric disorders emerge within loops that involve the biology
of human adaptation as well as cultural practices of diagnostic labelling,
health care systems and larger discursive formations. Illness experience
therefore does not follow directly from pathobiology but is embedded
in cognitive and social processes that mediate and modulate the
translation of physiological or psychological disturbance into
symptoms and behaviors. is transduction and translation occurs at
multiple levels that involve symptom schemas and their interaction,
interpersonal responses, narrative conventions, social positioning, the
health care system, economic constraints and sociopolitical
processes (132)5.
This perspective is consistent with recent work in symptom
network theory, which suggests that psychiatric disorders result
from the dynamic interaction of multiple symptoms each of
which may have its own pathophysiology or psychopathology
(133), (136). Instead of assuming that a single latent construct
can explain the symptom patterns that characterize psychiatric
disorders, network analysis views disorders as systems of causally
connected symptoms (137). These causal connections can involve
physiology, behavior, experience and interpersonal interaction,
as well as the responses of social institutions and the environment.
5 We use the term ‘translate’ here deliberately, not only to capture the fact
that higher order neurocognitive processes involved in language mediate the
eects of social stimuli on physiology (e.g. 133) but also, because in responding
to symbols and situations the brain must “translate the relations between single
elements of a given situation (stimuli) into wholes”. The dynamics of cognitive
systems involve the regulation of information, which resides in the relationship
of organism to context (134). Human systems have both dynamic and linguistic
modes that require corresponding descriptions. Our self-descriptions, narratives
and metaphors, on this view, participate in the dynamics of adaptive systems
but to do so, they require a translation (i.e. a meaning- and context-sensitive
mapping) from the pragmatic communicative situations of linguistic
communication (and representation) to the dynamics of brain systems and
physiology.
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While some authors consider a network as an inherently
non-hierarchical structure, causal or control hierarchies may
bepart of the mechanisms that constitute and connect symptom
networks, not as a matter of composition (or latent constructs)
but as part of causal chains or loops. The ecosocial systems view
weoutline in this paper extends the idea of symptom networks to
include social-cultural contexts, self-reflection and narration as
active causal processes (1).
ese multiple levels of process reect structures that are
organized hierarchically in the sense that higher organizational levels
involve arrangements of structures at lower levels that give rise to new
processes that require new conceptual vocabularies to describe. For
example, the brain is composed of functional circuits, which are made
up of neurons; the social world is made up of roles, niches and
institutions which are constituted by patterned relationships among
individuals, whose behavior is regulated by cognitive maps, models
and aordances, social positionality, norms, and conventions (138).
Each level enables processes that contribute to the causal mechanisms
that underlie a particular symptom, syndrome or aiction (139).
Experience, behavior, narrative self-understanding, and social
interactions can all contribute causally to the dynamics of psychiatric
symptoms and disorders (140–142).
Even brain-based explanations of mental disorders require an appeal
to multilevel systems dynamics (143). Changes in synaptic function or
neural circuitry alter information processing, which in turn gives rise to
changes in social behavior and experience(144). e process is
bidirectional. Psychotherapy and other psychological interventions have
eects on the brain(145). Changes in social behavior alter brain function
in ways that may beself-sustaining or create knock-on problems in other
brain systems or behavioral functions. Social environments and models
of the self in context inuence neurobiology, immunology and
inammatory processes (142).
Beyond neurobiology, mental disorders also involve cognitive,
aective and attentional processes that emerge from particular
learning histories and narrative modes of recollection and self-
narration, as well as interpersonal interactions with others in one’s
family, community and wider social networks. ese social
interactions have their own dynamics that may aggravate or mitigate
symptoms or create predicaments that present their own challenges to
health and well-being. Social interactions can also feed back into
cognitive and bodily processes in ways that amplify or diminish
symptoms and distress. ese loops correspond to relationships
between dierent aspects of the organism or between the organism
and the environment. Loops may result in cycles of positive and
negative feedback, with eects locally as well as across the
organizational hierarchy. Depending on their structure, parameters
and initial conditions, loops can result in nonlinear dynamics, for
example, growing exponentially, showing discontinuities, bifurcations,
or other complex dynamics (146, 147). To the extent that these loops
have their own dynamics, they can beviewed as specic mechanisms
that need to be considered in diagnostic assessment and case
formulations and that can be the target of clinical intervention.
Moreover, because human adaptive systems involve regulatory or
allostatic processes with specic goals or set points, they may exhibit
equinality, in which, despite variations in initial conditions and
ongoing perturbations, they tend to follow a predictable trajectory.
Identifying these stable patterns or trajectories could provide a
basis for a typology of disorders organized in terms of regulatory
processes that exhibit stable attractors, limit cycles, and nal common
pathways.
6
If these can beidentied and empirically validated, they
could beused as a basis for diagnoses that are prognostic (predicting
outcomes) or that indicate potentially eective treatments, and that
point to specic targets for intervention. is systems-based nosology,
however, will generally be quite dierent than simply identifying
single mechanisms, causal factors, or etiologies for disorders because
it involves dynamic properties of systems with looping eects.
A typology of looping eects (vicious or virtuous) could
complement current diagnostic nosology (149). is enlargement of
frameworks would not completely supplant current nosology, which
has its uses, insofar as it captures salient aspects of illness experience
and can berelated to prognosis or dierential therapeutics. Clinical
assessment routinely goes beyond diagnosis to include a problem
list—some categories of which are included in the ICD and DSM-5
Z-Codes (150, 151)—and case formulation that may note contextual
factors, but this process is unsystematic. Eorts to systematize the
inclusion of social context and determinants of health in assessment
are urgently needed. is needs to go beyond a laundry-list of factors
to include dynamics. Person-centered diagnostic assessment includes
characterizing strengths and resources, risk and protective factors, and
relevant developmental, ecological and meaning-centred contexts
(152). Attention to looping eects could beincorporated into current
practice through case formulation and systemic intervention without
waiting for the development of a systematic nosology. Table1 lists
some of these potential loops both within levels or domains and across
levels using depression as an example.
Although loops are diculty to study, they are composed of causal
arcs that can becharacterized with existing methodologies. Table1 lists
many such causal arcs that linked together would result in ‘loopy’
dynamics. is kind of model is central to cognitive theories of depression
and anxiety (179), which have led to eective treatment interventions and
can readily incorporate cultural-contextual factors (180). ere have been
some notable successes in identifying predictors of dynamics in couple
interactions (181). New experimental methods have been developed to
study the dynamics of dyadic, family, and group interactions (182–184).
Symptom network theory and computational modelling provide new
approaches to examining looping dynamics, testing the relative strength
of specic linkages and the sensitivity of network dynamics to changes in
parameters that can bematched with measurable variables in research
and clinical applications [e.g., (185–187)]. In clinical settings, nonlinear
dynamics are commonly observed and putative explanations in terms of
loops could betested by interventions that target specic parameters
(188, 189).
Identifying the feedback loops that may contribute to
psychopathology is dicult. Statistical methods can beused to show time-
lagged autocorrelations and cross-correlations in observational data that
suggest feedback dynamics (190, 191). Experimental methods that
manipulate particular parameters or control the nature of physiological,
perceptual or interpersonal feedback can provide rmer evidence for
feedback mechanisms(192). Computational models can beconstructed
that capture some of the interactions and identify parameters that aect
6 For definitions of these terms and others used to characterize system
dynamics, see: Mainzer (21); for examples of how they may berelated to specific
types of pathology; see: Durstewitz etal. (132).
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TABLE1 Examples of Looping Eects Related to the Mechanisms of Depression and Treatment Response.
Domains System dynamics and looping eects References
Within levels Across-levels
Neurobiological Psychopathology involves self-sustaining loops in
neurobiological, autonomic, endocrine, and other regulatory
systems that are related to reduced stress tolerance and
increased vulnerability to chronic stressors
Depression is linked to HPA dysregulation which
leads to impaired stress response, and to symptoms
including alterations in sleep, appetite, reward
processing, emotion regulation and cognition. ese
alterations aect cognition, coping and interpersonal
interactions in ways that can exacerbate depression
(153)
(154)
Treatments that alter synaptic transmission lead to habituation
or compensatory responses; this might decrease the ecacy of
some medications over time, cause rebound on medication
cessation, and increase the risk of relapse; e.g., denervation
supersensitivity from receptor blockade
Decreased ecacy of medication leads to fear of
relapse, demoralization, decreased self-ecacy, social
avoidance, and, ultimately, less ecacy of medication
Rebound eects of medication contribute to more
challenging withdrawal and continuation of
medication
(155)
Medication works at multiple brain and body sites and aects
systems with multiple functions causing ‘side-eects’ that may
contribute to or undermine therapeutic ecacy
SSRIs can reduce emotional reactivity with impacts on
emotional responsiveness, self-understanding and
ability to connect to others. SSRIs interfere with
sexual function and decrease libido, which may have
negative eects on self-esteem and on intimate
relationships
(156)
(157)
Psychological
Aective Impaired emotion regulation leads to decreased cognitive
exibility, increased irritability, dysphoria, anxiety with
consequences on sleep, cognitive processing including
negative bias and self-appraisal, worry and rumination,
problems with impacts on learning and performance which
reduces stress tolerance and increases emotional distress
Impaired emotional regulation has negative impacts
on goal-directed behavior and can increase perceived
chronic stress which, in turn, is linked to HPA
dysregulation and maladaptive coping (e.g.,
dysfunctional behaviors such as substance use and
social withdrawal)
(158)
(159)
(160)
Emotional distress interferes with functioning, leading to
performance decrements, negative self-appraisal, and greater
emotional distress
Emotional distress is linked to others’ response to
emotional expression and can lead to interpersonal
problems and avoidance of social situations with loss
of social support, and increased experience of
loneliness
(161)
(162)
Mood inuences memory, leading to diculty accessing
mood-incongruent memories, and greater recollection of
mood congruent memories, reinforcing dysphoric mood
Depression alters autobiographical memory, which
leads to negative self-presentation, impaired social
functioning and more negative memories
(163)
Attentional Attention to negative social cues increases sense of threat and
diculty in social functioning
Reduced attention to positive stimuli
Increased attention to negative social cues and signs
of failure exacerbates depressive mood and social
withdrawal; Focusing on positive faces reduces
dysphoria
(164)
(160)
Attributional Attributing sensations to pathology leads to the conviction
that one is ill, increasing the tendency to attribute sensations
to pathology
Attributing sensations to depression leads to
depressed mood
(165)
Embodied
experience
Bodily habitus, stance and facial expression shape experience Slumped posture, frown inuence feelings of
depression
(166), (167)
Social- Micro
Family systems Family inuences development across the lifespan and also
provides a niche and resource for adaptation
Early adverse experiences both in utero and in early
childhood can initiate changes to basal and stress-
related cortisol secretion. is impacts stress tolerance.
Caregiver response in infancy shapes interoception,
self-regulation, ability to attune and attach, also laying
the ground for future interpersonal relationships and
response to perceived stress.
Depression alters family dynamics
(168)
(Continued)
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dynamics (193). However, in practice, these usually are simplied ‘toy’
models that do not include many of the loops and variables present in
real-world contexts. is may lead to mistaken predictions or over-
generalization. ere is a need for an extensive research program of
modelling built on large datasets that include potentially important
individual and contextual variables (194).
Applying computational models in clinical settings poses
additional challenges related to the constraints of clinical epistemology.
e data available for an individual patient may bevery limited and
not include a time-span necessary to reveal dynamics. e
interventions that clinicians make are not really single-subject
experiments because they occur within a context of expectations and
demands that heavily constrain patients’ response. e patient’s own
interpretations and self-construals aect the impact of any
intervention and any subsequent interaction with the clinician. Hence,
we need a circular hermeneutics to complement our models of
circular causality (195). e system of patient and clinician must
beincluded in the model and situated within the larger ecology of
health care and adaptation in social context.
Crucially, the loops relevant to clinical concerns include modes of
self-construal based on cognitive, social and cultural models,
institutions and practices (77). For example, the interpretation of
experiences of pain, fatigue or lack of interest as symptoms of
depression is a culturally shaped attributional process that leads to
particular modes of coping and help-seeking (149). ese attributions
may bere-negotiated in clinical and other social contexts with others
who may validate or contest the views of patient or physician (196).
To the extent these social and clinical responses validate the
individual’s self-construal, they constitute a loop in which the available
categories for symptom interpretation and clinical practices reinforce
TABLE1 (Continued)
Domains System dynamics and looping eects References
Within levels Across-levels
Interpersonal Reactions of others to distress inuences illness experience
and coping
Withdrawal of others leads to emotional distress and behaviors
that prompt further withdrawal by others
Social withdrawal can lead to lack of perspective
fostering feedback and support which may lead to
deepening of dysfunctional behaviors and negative
self-biases in addition to limiting corrective
experiences.
Depressive symptoms lead others to increase social
distance
Social rejection alters neural functioning in ways that
can lead to further withdrawal
Behavioral activation leads to increased social activity
with more rewarding experiences improving mood
leading to greater activity
(169)
(170)
Social- Meso
Neighborhood Neighborhood and community can modulate impacts of
micro and macro-level factors
Sense of belonging and access to a social network/community
contributes to wellbeing and social capital with impact on
opportunities to thrive
Sense of belonging and support impacts sense of
agency and self-identity. Experiences of being
excluded, judged or ostracized as part of a community
can lead to social withdrawal or isolation, self-doubts,
loneliness and induce other dysfunctional behaviors
and impair coping
(171)
(168)
Wor k Job loss impacts self-esteem, social standing, resulting in low
mood, and economic hardship
Low mood and demoralization impede job search,
performance and retention
Others response to job-loss can shape coping
strategies and amplify distress
(172)
Health care system Type and availability of health care services and caregiving
increases the tendency to seek care for specic types of
symptoms or concerns
Distress is shaped by diagnostic categories and
available treatments. Treatment response (which may
include placebo eects) validates diagnostic categories
(173)
(174)
Social- Macro
Economic Poverty increases risk for depression
Financial stress can lead to negative aect and dysfunctional
behaviors that worsen economic adversity
Depression increases risk of poverty
Poor cognitive performance can impact economic
status including status, reputation as well as income
and assets.
(175)
(176)
Transnational Marketing of pharmaceuticals inuences the availability of
specic diagnostic labels and treatments, which are applied to
patients who then become consumers of medications,
increasing economic demand and encouraging further
marketing
Reliance on medications increase sense of
vulnerability and impairs coping
May also impact agency and identity development
(177)
(178)
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each other—an instance of what Hacking (197) has called “the looping
eect of human kinds.” ese loops may beinternal to the individual,
involving bodily attention, interoception, and physiology (examples
of what Hacking (198) termed “biolooping”) or they may primarily
involve cognitive and social-rhetorical processes that recongure the
sense of self (173, 199). Loops also may be irreducibly social or
political, changing the larger environment and available narratives in
which social position and structural adversity determine the causes
and course of symptoms. Psychiatry itself as a social institution
participates in these loops through diagnostic labelling, discursive
practices, and modes of social control that may aggravate or ameliorate
suering (200, 201). e types of problems included within the
purview of psychiatry, the kinds of explanation and interventions
used, and the larger context of practice are all part of the dynamic
system that shapes experience and behavior.
4E cognitive science as a path to
multilevel integration
Contemporary 4E cognitive science points to ways to conceptually
integrate multiple dynamic levels of organizational complexity that
involve neurobiological, social, cultural, and environmental contexts
across spatio-temporal scales (187, 202–205). e 4E cognitive science
approach argues that cognitive processes are embodied, embedded in
social contexts, and involve enactments that extend into the world.
Embodiment refers to the ways in which the body provides a
scaolding for cognition and experience.
7
Enactment emphasizes that
embodied experience emerges through ongoing cycles of action and
perception that engage the environment. Cognition serves adaptation,
and a changing environment requires action to maintain the body and
the person in a healthy, functional state (208). Human adaptive niches
are cooperatively constructed. Action and experience therefore are
embedded in social-cultural contexts. e action-perception cycles of
cognition extend beyond the body to engage with the material and
cultural aordances of a local niche and larger social systems. From a
4E perspective, both the experience and the mechanisms of health and
mental disorders can beapproached in terms of individuals’ dynamic
engagement with the social world.
Dynamic engagement with the social world requires constant
adaptation and resource optimization. e concept of allostasis, which
refers to the ways in which organisms anticipate and adapt to
challenges, focuses on the function of physiological and biobehavioral
systems of stress response and regulation (208, 209). Allostasis
involves the organism’s capacity to allocate resources to maintain an
adaptive balance between coping and recovery in response to adverse
conditions and events. is involves both internal physiological
7 The term embodiment is also used in Krieger’s (188) ecosocial theory in
population health to stand for the ways in which the social environment “gets
under the skin” to aect physiology. These processes are central to
understanding the social determinants of health. However, the notions of
embodiment in 4E cognitive science draw from phenomenology (67) and
cognitive-social psychology (150) to give an account of the process of
sense-and meaning-making that can clarify the nature of illness experience
and coping (1, 186, 189).
processes and behavioral strategies based on appraisal of challenges
and available resources for coping (210). When allostatic regulation is
insucient, various forms of stress-related dysfunction can result
from has been described as ‘allostatic overload’ (211).
e processes involved in allostatic regulation can beviewed from
an enactive perspective as ongoing cycles of action-perception (212).
ey can also bemodelled as Bayesian processes of active inference, in
which the organism predicts and acts on the environment to ensure its
own stability (108). ese cycles occur internally through interoception
and physiological regulation of the internal milieu and externally
through behaviors that act on the body and the environment (213,
214). Cycles of action-perception also underlie our sense of agency
both in terms of the sense of volition and control (215), and the wider
sense of being able to change our social circumstances (216-218). e
action-perception cycles that are constitutive of agency and subjectivity
emerge in and are maintained by social-cultural contexts that involve
other people in dyads or couples, families, neighborhoods and
communities, as well as larger social networks and institutions (219).
ese larger ecological domains contribute to higher-order goals and
plans. Problems in self-regulation and adaptation can originate at any
level in this system, with potential repercussions throughout.
Hierarchical organization of goals is part of healthy functioning and
certain forms of psychopathology may result when stress or allostatic
overload disrupts this organization (220).
Healing practices, therapies and treatment interventions can work
to restore allostatic function where it has been disrupted. e overall
aim of allostasis is to adjust regulatory systems to maintain the health,
survival and reproductive tness of the individual. More proximally,
this includes responding to the challenges and demands of a social
niche in ways that t local cultural norms, roles and expectations. is
may involve changing perceptions (learning new ways to attend to and
interpret sensations from the body or the environment), taking new
actions (enlarging the repertoire of behaviors and changing plans and
priorities), or re-establishing links between action and perception that
have been disconnected (providing feedback from outcomes that can
guide recursive goal setting). Both internal changes and actions on the
world can participate in the same adaptive cycles.
e 4E approach can bereadily extended to include the essential
functions of language in human adaptation (221). Humans are
language animals (113), inhabiting a world that is comprised not only
of physical arrangements but saturated with linguistically mediated
meanings, which provide the content of social norms and conventions
as well as the scaolding for the construction of a narrative self. e
narrative practice hypothesis focuses on how this linguistic capacity
emerges developmentally through culturally prescribed practices of
self-narration, giving rise to folk psychology with its grammar of
motives, plans and intentions that are employed to organize memory
and action, articulate individual goals, and oered to others as reasons
and explanations for one’s behavior (222). Linguistic capacities allow
regulation of systems that are organized in terms of physical dynamics
because narrative construals of self and context organize, constrain
and modify lower-level action plans both within individual cognition
and in communicative interactions with others. Language is self-
referential and recursive and, through metaphor and narrative, is used
by individuals and groups to construct novel multilevel hierarchies
that regulate complex cognition and behavior. is is a key facet of the
ways that culture permeates human cognition and functioning. Of
course, language and culture reach deeper to reshape cognition,
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perception and action in ways that are nonconscious, implicit and
automatic (167, 207, 223, 224).
roughout the lifespan, culture shapes the human nervous
system, allowing us to navigate socially constructed environments,
engage in cooperative activities, and pursue our goals through
embodied knowledge, skills, habits and dispositions (225). But much
of culture remains outside the individual, distributed among others
with specic expertise, residing in relationships, reproduced in
institutions or practices, and present in social niches that provide
cultural aordances for action and perception (226). ese cultural
aordances are part of the extended context on which human
cognition and adaptation depend. Central to this context are
interactions with other people, texts, and institutions. Werely on these
interactions inlocal niches and relationships or larger networks to
scaold cognition, guide behavior and augment our capacities by
“thinking through other minds”—whether in ongoing cooperative
interactions with others or by consulting the vast archives of human
knowledge and experience (44).
In summary, current elaborations of 4E cognitive science oer an
account of human function in dynamical systems terms as embodied
(coupling bodily physiology and experience), enacted (involving
sensorimotor loops that give rise to agency), embedded (context
sensitive), and extended into the environment (dependent on cultural
aordances). By tracking the ways that processes of organismic self-
regulation and experiential learning emerge from ongoing cycles of
interaction between the individual and the social-cultural
environment, this framework can integrate physiology, cognitive
processes, including individual agency and self-construal, and
participation in cooperative meaning-making. is allows us to recast
basic processes of symptom production, distress, coping and
adaptation as well as the response to interventions in terms of
multilevel dynamical systems. is systemic view opens the way
toward a conceptual approach that considers how the co-constituted
systems of body, mind and person are in transaction with larger
interpersonal, social and cultural systems.
Integrative case formulation
Comprehensive diagnosis and treatment in psychiatry requires
addressing pathology in all its dimensions: biological, psychological,
social, cultural, and environmental. Integrating these into causal
explanations of particular types of problems remains a challenge for
psychiatric theory and practice (126, 227). Approaching these multiple
forms of explanations as independent or even incommensurable ignores
the obvious ways in which processes at multiple levels not only aect but
mediate each other. An ecosystemic approach to integration aims to
identify multiple causal processes or mechanisms within and between
levels of organization and articulate their connections in an
overarching system.
Advancing integrative case formulation requires approaching the
patient as embodied and embedded in an ecosocial niche that presents
an array of inter-related social determinants of health with dierential
constraining and enabling opportunities. e same niche also provides
models for self-understanding, values, aspirations, and aictions that
shape experience, adaptation, coping, and help-seeking behavior, as
well as access to services, educational and vocational opportunities,
and other resources. Individuals’ responses to adversity, symptoms or
disorders, and modes of recovery will beinuenced by the norms,
expectations, and constraints of the sociocultural contexts they inhabit.
To illustrate how this integrative perspective works in clinical
practice, consider the following case vignette8:
A 30-year-old woman presents to a mental health clinic with a
self-diagnosis of depression. On inquiry, she reports feelings of
emptiness, worthlessness, and guilt, as well as irritability,
restlessness, rumination, diculty concentrating, indecisiveness,
early awakening, and fatigue over the past 6 months. Most
recently, she has had increasing loss of interest and pleasure in
ordinary activities and social isolation, as well as thoughts of
death. She has done some online research and comes to the clinic
asking for laboratory tests to conrm her diagnosis and determine
the best treatment. She recently read a blog that mentioned novel
research ndings on the use of brain imaging and
pharmacogenetics in personalized treatment for depression and
presents the clinician with a list of private labs that oer this
service. On further discussion, she reports that she lost her job
three months ago and feels deep humiliation. She also mentions
having diculties in her relationship with her partner, saying that
they are “going through a rough patch.” She explains that she feels
anxious and out of control and at times fears that she is “losing my
mind.” She is prescribed an SSRI antidepressant and experiences
some lessening of her symptoms over the next few weeks, but does
not feel any return of sexual interest, which adds to her worries
about her relationship.
As is increasingly common in mental health care, the person in the
vignette presents clinically with a self-diagnosis of depression and, in this
case, expects treatment with medication for what she views as a brain-
based disorder. She also has ongoing social stressors that may beboth
causes and consequences of her mental state. How she interprets her
symptoms and her feelings of anxiety, hopelessness, humiliation, guilt or
shame will aect both her behavioral and neurophysiological response to
the predicaments of job loss and relationship strain. In addition to
temperamental traits or constitutional predispositions and the
neurobiology of mood regulation (228), a complex interaction of
embodied processes—shaped by previous illness experience, life events,
and the response of others—add reinforcing or attenuating loops that
further complicate the system dynamics that underlie symptoms and
distress. A clinically eective approach to explain and treat distress
therefore must go beyond neural correlates and biomarkers to consider
individual variations in phenomenology and lived experience (229, 230),
developmental processes (231, 232), symptom trajectories (233, 234), and
socio-cultural dynamics, which depend on social structure, institutions
and practices, as well as cultural systems of meaning (218, 235, 236).
In the case of the patient in the vignette, the causal mechanisms
of anxiety, demoralization and depression can (and likely do) start at
many dierent points in the network depicted in Figure 1.
Additionally, each of these processes can interact with potentially
reinforcing or compensatory feedback loops. ese dynamics are
important for adequately characterizing the nature of the problem, its
8 This case vignette is a fictional composite based on the authors’ clinical
experience designed to illustrate cultural-ecosystemic formulation.
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likely course or prognosis, potential interventions, and
treatment response.
Many of the links shown in Figure1 are mediated by personal,
social and cultural processes of meaning making. ese involve bodily
and discursive practices as depicted in Figure 2. While physical
stressors may have direct eects on physiology and elicit responses,
based on past experience, that occur outside of awareness, the impact
of stressors also depends on individuals’ perception and interpretation
of the event. is involves embodied and enactive processes of
meaning-making that build on developmental experiences and draw
from cultural resources (204). e process of meaning-making
includes the person’s appraisal of the level of threat, their coping skills
and resources, and the potential consequences—that is, “what’s at
stake” for the individual and others in their social world (238). For
example, while job loss is likely to bea stressor for most people, the
degree of perceived stress and ability to cope will depend on contextual
factors including the personal and cultural meanings of one’s
occupation and of unemployment, current economic resources, social
supports and mobility.
Shame and humiliation follow from experiences of loss of social
status and failure in performing according to social norms (239). e
experience of humiliation in response to job loss depends on its timing
(e.g., family just moved for the job or has had other resource depleting
stressors), social position, roles, norms and expectations (e.g., father
expects to bea breadwinner). Social validation of perceived stress can also
contribute to self-regulation and reduction of perceived stress through
process of feeling understood, supported and protected, as well as helping
the individual to shi perspectives, mobilize problem solving strategies,
and access stress-reducing resources.
Perceived stress can prompt multiple maladaptive behaviors that
feedback in loops that lead to resource depletion. For example, drug
consumption for symptom control, relaxation and or escape can lead
to emotional lability and irritability that challenge relationships. In
favorable constellations however, response to perceived stress may
lead one to develop new skills or positive schemas, overcome
engrained biases, rescript self-understanding narratives, expand one’s
aordances, deepen social relationships and improve coping.
In the ecosocial systems view, interpersonal dynamics, work
stress, gender discrimination, and cultural knowledge and practices
for dealing with distress—all of which depend on or reside primarily
in social interactions—may contribute to the patient’s distress, coping
strategies and process of recovery. Applying an integrative perspective
in case formulation requires considering how these processes unfold
over time in the individual’s life trajectory. Moreover, the processes
related to each of these levels and dimensions interact in ways that can
give rise to feedback loops that exacerbate symptoms and result in a
FIGURE1
Ecosystemic Embedding of Depressive Symptoms. The figure illustrates some of the many links between symptoms, processes and experience that
constitute the ecosocial system of the patient described in the vignette. The arrows represent causal influences mediated by diverse mechanisms.
Closed loops can give rise to feedback amplification, resulting in vicious cycles of symptom exacerbation or, when regulatory mechanisms are
sucient, can lead to allostatic changes that contribute to resilience and recovery. For the links marked with asterisks, the mechanisms of influence
depend on nonverbal and linguistic communication through embodied and enactive loops that give rise to intersubjectivity, positionality and ongoing
negotiations of meaning as depicted in Figure2. Based in part on (237).
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depressive disorder or other syndrome, which may then bemaintained
through similar looping mechanisms (237). ese loops are not only
internal to the brain and its circuits but extend beyond the body to
social interactions with other people and social institutions—all of
which aect the development and course of psychiatric disorders.
e cultural-ecosocial approach is fundamentally relational. e
relationships it considers involve material, informational and
symbolic-communicational interactions between the individual and
the environment. ese relationships can bemapped by causal loop
diagrams (CLD) that aim to capture the links between observable
processes (240). ese maps can beused to develop formal quantitative
models to reveal dynamics and test the potential impact of
interventions, including changes in the conguration of systems—e.g.,
by altering individual biology or cognition, family interactions, health
care systems or other social contingencies (241, 242).
In the ecosocial view, humans are embedded in and dependent on
culturally constructed environments that include physical
arrangements as well as a web of relationships with other people and
social institutions. e 4E perspective insists that interactions with the
environment are part of the dynamics that constitute the individual.
In human ecology, however, the distinctions between individual and
environment are phenomenologically, psychologically, morally and
politically important. Hence, drawing the boundary between ‘inside’
and ‘outside’ (organism and environment or system and subsystem)
varies with the clinical question and the way welocate the relevant
dynamics (243). ere can beprincipled and practical reasons for
drawing a boundary in a particular way both because it highlights
crucial dynamics and constitutes a useful way to organize case
formulation and guide intervention. ese reasons may include the
system’s topology, the feasibility of specic interventions, and the
ethical imperative to privilege the patient’s perspective (244).
Integrating the patient’s
self-understanding
A key element in an ecosocial systemic approach is recognizing
the role that the person’s own understanding of and response to
symptoms and suering play in the dynamics of mental disorders,
coping, help-seeking, treatment response and recovery. In the case
vignette presented in the previous section,the patient’s self-diagnosis
and explanatory model of her symptoms follow closely from the
prevailing brain-centric model of depression widely disseminated in
popular culture. is model portrays depression as a condition related
to specic neurotransmitters and explains the ecacy of medications
by their eects on corresponding receptor sites. More recent versions
of this explanatory model go beyond synaptic mechanisms to consider
brain circuitry (245–247). Other patients may present explanations
that draw from sociomoral or religious understandings of suering
and view illness as a consequence of moral transgression or failing
(248). ese modes of explanation and attributions inuence ways of
coping and help-seeking but they may also participate in the vicious
circles that aggravate dysphoria, self-deprecation, social withdrawal,
and other symptoms of depression (249).
FIGURE2
Embodied and Enactive Processes of Meaning Making. The figure outlines the cyclical processes of embodiment and enactment that give rise to
meaning and experience. Experience emerges through developmental processes and engagement with others in particular social-cultural contexts.
There is two-way trac between bodily processes and individual experience mediated by cognitive processes of metaphoric thinking, imagery and
imagination. Similarly, there is trac between experience and social discourse mediated by interpersonal communication and narrative practices. All of
this occurs in a field of cultural aordances provided by local niches and larger social contexts (Adapted from Figure20.1in (204); originally published
in Embodiment, Enaction, and Culture: Investigating the Constitution of the Shared World, edited by Christoph Durt, Thomas Fuchs, and Christian
Tewes, reprinted courtesy of The MIT Press).
Gómez-Carrillo and Kirmayer 10.3389/fpsyt.2023.1031390
Frontiers in Psychiatry 13 frontiersin.org
e patient’s illness narrative, which emerges in dialogue with
available cultural models and in clinical encounters, also shapes the
process of meaning-making and illness experience (238). e models
used by clinicians — which borrow from both technical literature and
dominant cultural narratives — also shape patients’ experience and
expectations (173). In this case vignette, the patient adopted a simple
biological model of depression even before speaking to the doctor,
setting aside her challenges of job loss and relationship problems as
secondary issues. In so doing, she focused her expectations in
consulting the clinician on receiving a specic medication. While this
ts squarely with psychiatrists’ competence, it may require negotiation,
because her self-diagnosis may not beaccurate and her requested
treatment may not beappropriate, and, even if it does address an
important facet of her current problem, medication may not
besucient to resolve other aspects of her predicament (250, 251).
e eects of adopting a neurobiological explanation go beyond
a narrow focus for clinical assessment and treatment to also
inuence the patient’s sense of self-ecacy and participation in the
process of recovery as well as broader features of her identity. A
simplied, brain-centric model of depression makes antidepressant
prescription seem a straightforward, necessary, and sucient clinical
response. Of course, beyond pharmacogenetics, kinetics, and
dynamics, our mechanistic knowledge of drug action remains
limited (252). Antidepressant treatment may have dierent
eectiveness based on the individuals’ expectation of ecacy (253)
or their socioeconomic status (254), requiring the clinician to
consider the interaction of the type of treatment and the patient’s
context when collaboratively designing a care plan (255). Moreover,
prescription is inevitably a social and symbolic act, and taking
medication has meaning and consequences for psychological self-
regulation and social identity (256, 257). Rose (258) has drawn
attention to the ways that biomedical diagnosis and treatment of
mental disorders lead to narratives of “neurochemical selves” with
consequences for individual coping as well as for mental health
policy and practice. ere is increasing recognition that good
practice in psychopharmacology requires paying attention to the
personal and cultural meanings of medication and patients’ own
values and priorities (259). A cultural-ecosocial view can inform
existing approaches to shared decision making and collaborative
prescribing or deprescribing of medication (255).
An ecosocial systems approach to
person-centered clinical practice
Psychiatric practice employs multiple ways of knowing that have
been characterized as verstehen (understanding), erklären (explaining)
and einfühlung (empathic, embodied co-presence/being/knowing)
(260). ese ways of knowing have dierent epistemic bases and
constraints and are sometimes in tension, conict or competition. In
contemporary psychiatry, this tension is seen between the divergent
approaches of precision psychiatry (which characterizes the person in
terms of biological parameters) and person-centered psychiatry (which
emphasizes experience, values and context) (261, 262). Although
advocates of each approach supercially acknowledge the other, in
practice their respective research programs and modes of
implementation reect the persistence of an underlying dualistic
ontology (129, 218). Bringing erklären, verstehen, and einfühlung
together in clinical formulation means integrating explanatory models
and mechanisms across levels, including molecular, physiological, neural
circuitry, cognitive, and social. Including the social level requires
knowledge of social and cultural history and current context as well as
biographical trajectories. Because our institutions and practices are
embedded in these same contexts, a social-cultural perspective requires
self-reective consideration of the clinician’s positionality and interaction
with the patient and others in the co-construction of clinical narratives
(260). e cultural-ecosocial systems approach oers a frame that can
encompass these dimensions of psychiatric practice through a dialogical
process of meaning-making that recognizes culture and context.
Human ecological niches are fundamentally social—with socially
constructed contexts and relationship providing the essential matrix
of development from inception—and cultural, with shared meanings,
values and practices shaping cognition and experience across the
lifespan. e notion of ecosystem builds on work in ecological systems
theory in developmental psychology (68), which emphasizes the
embedding of the individual in multiple, nested environmental
contexts, dened by socio-relational and spatio-temporal scale and
composition to include: micro (immediate family and friends,
community and work-school setting); meso or exo (neighborhoods,
wider networks, and larger community); and macro (society, nation,
transnational) contexts. (See: Table 1), e idea of a niche highlights
the interactive and dynamic nature of such sociocultural embedding.
Social context, structural, economic and political forces aect
individuals and groups dierentially as a result of individual and
collective past histories, biology, and current positionality (263).
To unpack the notion of niche in a way that can serve a person-
centered clinical approach, the ecosocial systems view needs to
consider the intersections and interactions across at least four over-
lapping domains: (1) lifespan developmental history; (2) social
structure and positioning; (3) cultural meaning, norms, values and
aordances; and (4) individual biography and self-understanding
(which draws selectively from each of the other domains). ese
domains can provide a temporal dimension to clinical formulation
that points both to adaptive challenges and resources for helping,
healing and recovery. Eorts to develop models that incorporate
social context and lived experience are underway, but they face
multiple obstacles, including lack of collection of data representative
of population variability and high levels of context dependence as
well as ethical and pragmatic issues related to the use of such data
(264). We need better conceptual, research and clinical tools to
characterize niches—their demands, aordances, and constraints as
well as their embedding in larger ecosystems (6). e theory of
syndemics provides one approach to exploring the multilevel
interactions that give rise to mental health problems (265, 266).
While the notion of niche points to the immediate environment that
an individual inhabits, in reality, human niches are subsystems of larger
social systems. An ecological view encourages us to examine this larger
network of relationships and how they interface with local niches. It is a
virtue of the ecological perspective that it allows us to think systematically
about the relationships between our most proximal and intimate relational
networks and the larger networks with which weare coupled. e nature
of this coupling depends on local arrangements and interpersonal
interactions, which are extended by population migration as well as
information and communication technologies that allow connections
with distant others but that also create virtual environments that we
increasingly inhabit (267, 268).
Gómez-Carrillo and Kirmayer 10.3389/fpsyt.2023.1031390
Frontiers in Psychiatry 14 frontiersin.org
In the current moment, relationships on the planetary scale are
increasingly present and consequential in the lives of individuals
through the impacts of climate change (269, 270). ese interactions
occur in material ways, but they are also present in self concepts,
imagination and orientation toward the future with signicant mental
health impacts. True to its name, an ecosocial view, encourages us to
think about mental health as dependent on these wider networks and
modes of interdependence. Coming to terms with the impact of our
changing environments requires considering not only strategies for
individual adaptation, but the larger, social structural arrangements
that account for global disparities and that constrain the options of
individuals and groups across the globe (271, 272). Ultimately, mental
health theory and practice must consider not only the private
challenges of individuals, but the larger dilemmas faced by our species
and the planet weshare with others (273).
Conclusion
Although psychiatry conventionally locates mental health
problems in the individual, systems thinking encourages to see
the ways in which health and the wide range of problems seen in
clinical settings arise from interactions at multiple levels from the
biological to the cognitive and social. Recognizing patients’
agency and restoring their health requires that clinical care
consider the range of systemic processes that contribute to
suffering and impairment (274). Addressing problems that derive
from social structure may require interventions that go beyond
individual clinical care to include advocacy and social-network
interventions. Advocacy is not limited to efforts to change policy
and institutional practices but includes actions that aim to
counter oppressive circumstances and create habitable
environments and niches for individuals (275).
Eorts to provide multilevel systems explanations of health
problems are oen challenged as “too complex” for practical
application. Systems dynamics may bedicult to think through and
require specic training to apply. Complex systems can exhibit
counterintuitive properties, but qualitative understanding is oen
sucient to guide practice (276–279). Quantitative models of specic
problems could allow clinicians to examine the eects of potential
interventions on system dynamics to guide treatment and predict
outcomes. Crucially, these models can include clinician-patient
interaction and other social processes as part of the symptom network.
Innovative computational methods can capture multilevel system
dynamics if the relevant data are collected (264). e resultant models
could beused as decision tools or used by clinicians and patients to
foster mutual understanding and motivate interventions. e models
weoer to patients are themselves interventions that may guide self-
reection and elicit new behaviors. ey may also function as self-
fullling explanations that foreclose the search for better answers. How
this plays out depends on the ability of the clinician to apply dynamical
systems models while closely attending to the patient’s experience so
that the model can berened and care remains patient-centered.
e application of dynamical systems models in psychiatry,
though actively pursued for decades, has been slow to advance and has
had limited uptake. ere are several likely reasons for this, including
that the adoption of systems thinking has been hampered by (i)
continued investment in reductionist models because they are
amenable to study by common scientic methodologies; (ii) the
limitations of clinical decision making, which make it hard to
incorporate complexity and interaction eects; and (iii) economic and
political interests that favor short-term treatment and pharmacological
interventions rather than approaches that challenge entrenched
systems. However, new computational modelling methods that can
beimplemented in clinical settings to support patient education and
real-time decision making oer the hope of signicant progress.
e challenges associated with complexity reect the real-world
dynamics of human problems (280, 281). Recognizing this complexity
should urge on us humility and the need to frequently recalibrate our
clinical response to respond to patients’ experience. It underscores the
need for idiographic methods of case formulation, which may include
characterizing networks of relationships among symptoms and related
biological, cognitive, and social processes (194, 282). Finally, it points to
the importance of self-reexivity, in which clinicians interrogate their own
assumptions and practices to rethink case formulations and
potential interventions.
e cultural-ecosocial view includes practitioners, clinical
settings, health care systems and the local and international
institutions of psychiatry itself — both as material and discursive
practices— as part of the systems in which patients and practitioners
are embedded and which oer them aordances, norms and
constraints. ese need to befactored into practice in general and into
the formulation of specic cases. A literature in critical psychiatry has
considered some of the ways in which psychiatry colludes with larger
structures of oppression (201, 283). is is more likely to occur when
psychiatric practice is narrowly conceived as the identication and
treatment of discrete disorders without attention to patients’ lived
experience, values, and lifeworlds as well as to practitioners’ tacit
assumptions. By giving an explicit place to the meaning-making
process in clinical encounters as well as in institutional and wider
social contexts, a cultural-ecological systems view opens the door to
more self-reective and critical thinking that can uncover power
dynamics and counter potentially oppressive practices.
An ecosocial systems view oers a way for clinicians to organize
the multiple explanatory models needed to capture the complexity and
heterogeneity of psychiatric disorders and illness experience. Based
on a view of psychiatric disorders as involving complex system
dynamics, an ecosocial systems approach allows clinicians to use
multiple languages of description to assess processes within and across
levels of organization of an overarching ecology of mind and to
prioritize those that oer the greatest therapeutic leverage and optimal
use of resources for person-centered practice.
Data availability statement
e original contributions presented in the study are included in
the article/supplementary material, further inquiries can bedirected
to the corresponding author.
Author contributions
AG-C and LK contributed equally to conceptualizing the manuscript.
AG-C wrote the rst dra. LK wrote sections of the manuscript. All
authors contributed to the article and approved the submitted version.
Gómez-Carrillo and Kirmayer 10.3389/fpsyt.2023.1031390
Frontiers in Psychiatry 15 frontiersin.org
Funding
Work on this paper by AG-C was supported by a Banting
Fellowship from the Canadian Institutes of Health Research. LK
received project support from the McGill-CFREF Healthy Brains for
Healthy Lives Program through a grant for the development of a
Canadian Framework for Brain Health (3c-KM-61).
Acknowledgments
We thank Kenneth Fung and Roberto Lewis-Fernández of the
GAP Committee on Cultural Psychiatry for helpful comments on
early drafts of this paper and Elizabeth Anthony for
editorial assistance.
Conflict of interest
e authors declare that the research was conducted in the
absence of any commercial or nancial relationships that could
beconstrued as a potential conict of interest.
Publisher’s note
All claims expressed in this article are solely those of the
authors and do not necessarily represent those of their affiliated
organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article, or
claim that may be made by its manufacturer, is not guaranteed or
endorsed by the publisher.
References
1. Kirmayer LJ. Toward an ecosocial psychiatry. World Soc Psychiatry. (2019) 1:30. doi:
10.4103/WSP.WSP_9_19
2. Justus J. e philosophy of ecology: An introduction, New York: Cambridge
University Press (2021).
3. Tretter F, Löer-Stastka H. e human ecological perspective and biopsychosocial
medicine. Int J Environ Res Public Health. (2019) 16:4230. doi: 10.3390/ijerph16214230
4. Tretter F, Loeer-Stastka H. How does the ‘environment come to the person? e
'ecology of the person' and addiction. World J Psychiatry. (2021) 19:915–36. doi: 10.5498/
wjp.v11.i11.915
5. MacKay, DM. Information, mechanism and meaning. Cambridge, MA: MIT Press
(1969).
6. Manning N, Birk R, Rose N. Niche sociality: approaching adversity in everyday life.
Sociology. (2023) 57(1):72–95. doi: 10.1177/00380385221094
7. Bister MD, K lausner M, Niewöhner J. e cosmopolitics of ‘niching': rendering the
city habitable along infrastructures of mental health care In: A Blok and I Farías, editors.
Urban Cosmopolitics: Routledge (2016). 187–205.
8. Rose N, Birk R, Manning N. Towards neuroecosociality: mental health in adversity.
eory Cult Soc. (2022) 39:121–44. doi: 10.1177/0263276420981614
9. Siskin C. System: e shaping of modern knowledge. Cambridge, MA: MIT Press
(2017).
10. Hammond D. Exploring the genealogy of systems thinking. Syst Res Behav Sci.
(2002) 19:429–39. doi: 10.1002/sres.499
11. Miller JG. Living systems: the organization. Behav Sci. (1972) 17:1–182. doi:
10.1002/bs.3830170102
12. Von Bertalany L. General system theory. New York: George Braziller (1968).
13. Wiener N. Cybernetics: Or, control and communication in the animal and the
machine. Cambridge, MA: MIT Press (1948).
14. Aubin D, Dalmedico AD. Writing the history of dynamical systems and chaos:
longue durée and revolution, disciplines and cultures. Hist Math. (2002) 29:273–339.
doi: 10.1006/hmat.2002.2351
15. Kellert SH. In the wake of chaos: Unpredictable order in dy namical systems. Chicago:
University of Chicago Press (1993) doi: 10.7208/chicago/9780226429823.001.0001.
16. Mitchell M. Complexity: A guided tour. New York: Oxford University Press (2009).
17. Ruelle D. Chance and chaos. Princeton: Princeton University Press (1993).
18. Wolfram S. A new kind of science. Champaign: Wolfram media (2002).
19. Strogatz, SH. Nonlinear dynamics and chaos with student solutions manual: With
applications to physics, biology, chemistry, and engineering. New York: Routledge (2018).
20. Dupré JA, Nicholson DJ. A manifesto for a processual philosophy of biology In: .
Everything ows: Towards a processual philosophy of biology. Oxford: Oxford University
Press (2018). 416.
21. Morin E. e concept of system and the paradigm of complexity In: M Maruyama,
editor. Context and complexity: Cultivating contextual understanding. New York:
Springer-Verlag (1992). 125–36. doi: 10.1007/978-1-4612-2768-7_6
22. Guastello SJ, Koopmans M, Pincus D, (Eds.). Chaos and complexity in psychology: e
theory of nonlinear dynamical systems. Cambridge: Cambridge University Press (2008).
23. Mainzer K. inking in complexity: e complex dynamics of matter, mind, and
mankind. Berlin: Springer (1997) doi: 10.1007/978-3-662-13214-2.
24. Noble D. e aims of systems biology: between molecules and organisms.
Pharmacopsychiatry. (2011) 44:S9–S14. doi: 10.1055/s-0031-1271703
25. Ahn AC, Tewari M, Poon CS, Phillips RS. e limits of reductionism in medicine:
could systems biology oer an alternative? PLoS Med. (2006) 3:e208. doi: 10.1371/
journal.pmed.0030208
26. Ahn AC, Tewari M, Poon CS, Phillips RS. e clinical applications of a systems
approach. PLoS Med. (2006) 3:e209. doi: 10.1371/journal.pmed.0030209
27. Cooper SJ. From Claude Bernard to Walter Cannon. Emergence of the concept of
homeostasis. Appetite. (2008) 51:419–27. doi: 10.1016/j.appet.2008.06.005
28. Tretter F. “Systems medicine” in the view of von Bertalany's “organismic biology”
and systems theory. Syst Res Behav Sci. (2019) 36:346–62. doi: 10.1002/sres.2588
29. Ashby WR. An introduction to cybernetics. London: Chapman & Hall (1956) doi:
10.5962/bhl.title.5851.
30. Pickering A. e cybernetic brain. Chicago: University of Chicago Press (2010).
31. Marmor, J. Systems thinking in psychiatry: Some theoretical and clinical applications.
e American Journal of Psychiatry. (1983) 140:833–8. doi: 10.1176/ajp.140.7.833
32. Tretter F, Gebicke-Haerter PJ, Mendoza ER, Winterer G. Systems biology in
psychiatric research: From high-throughput data to mathematical modeling. Weinheim:
Wiley-Blackwell (2010) doi: 10.1002/9783527630271.
33. Mansell W. C ont rol theory and psychopathology: an integrative approach. Psychol
Psychother eory Res Pract. (2005) 78:141–78. doi: 10.1348/147608304X21400
34. Miller GA, Galanter E, Pribram KH. Plans and the structure of behaviour. New
York: Henry Holt & Co. (1960).
35. Powers WT. Behavior: e control of perception. Chicago: Aldine Publishing Co (1973).
36. Tretter F, Löer-Stastka H. Steps toward an integrative clinical systems psychology.
Front Psychol. (2018) 9:1616. doi: 10.3389/fpsyg.2018.01616
37. Tschacher W, Junghan U. Psychopathology In: SJ Guastello, M Koopmans and D
Pincus, editors. Chaos and complexity in psychology: e theory of nonlinear dynamical
systems. Cambridge: Cambridge University Press (2009). 307–34.
38. Tschacher W, Schiepek G, Brunner EJ. Self-organization and clinical psychology:
Empirical approaches to synergetics in psychology. Cham: Springer Science & Business
Media (2012).
39. Beck TJ. From cybernetic networks to social narratives: mapping value in mental
health systems beyond individual psychopathology. J eor Philos Psychol. (2020) 40:85.
doi: 10.1037/teo0000127
40. Friston K. Computational psychiatry: from synapses to sentience. Mol Psychiatry.
(2023) 28, 256–268. doi: 10.1038/s41380-022-01743-z
41. Constant A, Clark A, Kirchho M, Friston KJ. Extended active inference:
constructing predictive cognition beyond skulls. Mind Lang. (2022) 37:373–94. doi:
10.1111/mila.12330
42. Short, SE, and Mollborn, S. Social determinants and health behaviors: conceptual
frames and empirical advances. Current opinion in psychology. (2015) 5:78–84.
43. Tison R, Poirier P. Communication as socially extended active inference: an
ecological approach to communicative behavior. Ecol Psychol. (2021) 33:197–235. doi:
10.1080/10407413.2021.1965480
44. Veissière SP, Constant A, Ramstead MJ, Friston KJ, Kirmayer LJ. inking through
other minds: a variational approach to cognition and culture. Behav Brain Sci. (2020)
43:1–97. doi: 10.1017/S0140525X19001213
Gómez-Carrillo and Kirmayer 10.3389/fpsyt.2023.1031390
Frontiers in Psychiatry 16 frontiersin.org
45. Carr A. e evolution of systems theory In: TL Sexton and J Lebow, editors.
Handbook of family therapy. New York: Routledge (2015). 13–29.
46. Ferguson KT, Evans GW. Social ecological theory: family systems and family
psychology in bioecological and bioecocultural perspective In: BH Fiese, M Celano, K
Deater-Deckard, EN Jouriles and MA Whisman, editors. APA handbook of contemporary
family psychology: Foundations, methods, and contemporary issues across the lifespan:
American Psychological Association (2019). 143–61.
47. Guttman HA. Systems theory, cybernetics, and epistemology In: AS Gurman and
DP Kniskern, editors. Handbook of family therapy, vol. 2. New York: Routledge (1991).
41–62.
48. Watzlawick P, Weakland JH. e interactional view. New York: Norton (1977).
49. Cox MJ, Paley B. Understanding families as systems. Curr Dir Psychol Sci. (2003)
12:193–6. doi: 10.1111/1467-8721.01259
50. Moos RH. Conceptualizations of human environments. Am Psychol. (1973)
28:652–65. doi: 10.1037/h0035722
51. Cummings EM, Bergman KN, Kuznicki KA. Emerging methods for studying
families as systems In: SM McHale, P Amato and A Booth, editors. Emerging methods
in family research, vol. 4. Cham, Switzerland: Springer International (2014). 95–108.
52. Epstein NB, Baldwin LM, Bishop DS. e McMaster family assessment device. J
Marital Fam er. (1983) 9:171–80. doi: 10.1111/j.1752-0606.1983.tb01497.x
53. Manseld AK, Keitner GI, Dealy J. e family assessment device: an update. Fam
Process. (2015) 54:82–93. doi: 10.1111/famp.12080
54. Moos RH, Fuhr R. e clinical use of social-ecological concepts: the case of an
adolescent girl. Am J Orthop. (1982) 52:111–22. doi: 10.1111/j.1939-0025.1982.
tb02671.x
55. Moos, RH. Conceptualizations of human environments. Am Psychol. (1973)
28:652–65. doi: 10.1037/h0035722
56. Olson, DH. Circumplex model of marital and family systems. Journal of Family
erapy. (2000) 22:144–67.
57. Skinner, HA, Steinhauer, PDS-B, and J., e family assessment measure. Canadian
Journal of. Community Mental Health. (2009) 2:91–103.
58. Sluzki CE. Personal social networks and health: conceptual and clinical implications of
their reciprocal impact. Fam Syst Health. (2010) 28:1–18. doi: 10.1037/a0019061
59. Speck RV, Attneave CL. Family networks. New York: Vintage Books (1974).
60. Lebow JL. Attending to the larger system in systemic therapy and family research.
Fam Process. (2021) 60:1079–82. doi: 10.1111/famp.12729
61. Bateson G. Steps to an ecology of mind. New York: Ballantine Books (1972).
62. Clarke B, Hansen MBN. Emergence and embodiment: New essays on second-order
systems theory Duke University Press (2009).
63. Tilak S, Glassman M, Kuznetcova I, Pelfrey GL. Applications of cybernetics to
psychological theory: historical and conceptual explorations. eory Psychol. (2022)
32:298–325. doi: 10.1177/09593543211053804
64. Fletcher JR, Birk RH. e conundrum of the psychological interface: on the
problems of bridging the biological and the social. Hist Hum Sci. (2022) 35:317–39. doi:
10.1177/09526951211070503
65. Krieger N. eories for social epidemiology in the 21st century: an ecosocial
perspective. Int J Epidemiol. (2001) 30:668–77. doi: 10.1093/ije/30.4.668
66. Krieger N. Embodiment: a conceptual glossary for epidemiology. J Epidemiol
Community Health. (2005) 59:350–5. doi: 10.1136/jech.2004.024562
67. Maturana, HR, and Varela, FJ. Autopoiesis and cognition: e realization of the
living. Dordrecht: D. Reidel (1980).
68. Bronfenbrenner U. Developmental ecology through space and time: a future
perspective In: P Moen, ElderGH Jr and K Lüscher, editors. Examining lives in context:
Perspectives on the ecology of human development. Washington, DC: American
Psychological Association (1995). 619–47. doi: 10.1037/10176-018
69. Scarpa MP, Trickett EJ. Translating ecology: similarities and dierences in the
ecological images of Bronfenbrenner and Kelly. Trans Issue Psychol Sci. (2022) 8:185–96.
doi: 10.1037/tps0000315
70. Weisner TS. Ecocultural understanding of children's developmental pathways.
Hum Dev. (2002) 45:275–81. doi: 10.1159/000064989
71. Bateson G. Mind and nature: A necessary unity. New York: Dutton (1979).
72. Ruesch J, Bateson G. Communication: e social matrix of psychiatry. New York:
W.W: Norton (1951).
73. Gallagher S. Enactivist interventions: Rethinking the mind. Oxford: Oxford
University Press (2017).
74. Hutchins E. Cogn Ecol Top Cogn Sci. (2010) 2:705–15. doi: 10.1111/j.1756-8765.20
10.01089.x
75. Newen A, Gallagher S, De Bruin L. 4E cognition: historical roots, key concepts,
and central issues In: A Newen, L De Bruin, S Gallagher (eds.) e Oxford handbook of
4E cognition. Oxford: Oxford University Press (2018).
76. Varela FJ, ompson E, Rosch E. e embodied mind: Cognitive science and human
experience. Cambridge, MA: MIT Press (2016).
77. Kirmayer LJ. Re-visioning psychiatry: toward an ecology of mind in health and
illness In: LJ Kirmayer, R Lemelson and C Cummings, editors. Re-visioning psychiatry:
Cultural phenomenology, critical neuroscience and global mental health. New York:
Cambridge University Press (2015). 622–60.
78. Constant A, Badcock P, Friston K, Kirmayer LJ. Integrating evolutionary, cultural,
and computational psychiatry: a multilevel systemic approach. Front Psychol. (2022)
13:763380. doi: 10.3389/fpsyt.2022.763380
79. Pezzulo G, Parr T, Friston K. e evolution of brain architectures for predictive
coding and active inference. Philos Trans R Soc B. (2022) 377:20200531. doi: 10.1098/
rstb.2020.0531
80. Pattee HH. Hierarchy theory. e challenge of complex systems. New York: Braziller
(1973).
81. Gallagher S. Integration and causality in enactive approaches to psychiatry. Front
Psychol. (2022) 13:870122. doi: 10.3389/fpsyt.2022.870122
82. Agre PE. Hierarchy and history in Simon’s “architecture of complexity”. J Learn Sci.
(2003) 12:413–26. doi: 10.1207/S15327809JLS1203_4
83. Campbell D. T. (1974). ‘Downward causation’ in hierarchically organised biological
systems. In F. J. Ayala and T. Dobzhansky (Eds.). Studies in the philosophy of biology:
Reduction and related problems (pp. 179–186). Berkeley: University of California Press.
84. Ellis GF, Kopel J. A realistic view of causation in the real world In: S Wuppuluri
and I Stewart, editors. From electrons to elephants and elections: Exploring the role of
content and context. Cham: Springer (2022). 117–33. doi: 10.1007/978-3-030-92192-7_8
85. Kendler KS, Woodward J. Top-down causation in psychiatric disorders: a clinical-
philosophical inquiry. Psychol Me d. (2021) 51:1783–8. doi: 10.1017/S0033291721001811
86. Woodward J. Levels: what are they and what are they good for? In: KS Kendler, J
Parnas and P Zachar, editors. Levels of analysis in psychopathology: Cross-disciplinary
perspectives. Cambridge: Cambridge University Press (2020). 424–49.
87. Allen CR, Angeler DG, Garmestani AS, Gunderson LH, Holling CS. Panarchy:
theory and application. Ecosystems. (2014) 17:578–89. doi: 10.1007/s10021-013-9744-2
88. Hilgetag CC, Goulas A. ‘Hierarchy’ in the organization of brain networks. Philos
Trans R Soc B. (2020) 375:20190319. doi: 10.1098/rstb.2019.0319
89. Salthe SN. Hierarchical structures. Axiomathes. (2012) 22:355–83. doi: 10.1007/
s10516-012-9185-0
90. Rousseau D, Billingham J, Calvo-Amodio J. Systemic semantics: a systems
approach to building ontologies and concept maps. System. (2018) 6:32. doi: 10.3390/
systems6030032
91. West G. Scale: e universal laws of life, growth, and death in organisms, cities, and
companies. New York: Penguin (2018).
92. West GB, Brown JH. e origin of allometric scaling laws in biology from genomes
to ecosystems: towards a quantitative unifying theory of biological structure and
organization. J Exp Biol. (2005) 208:1575–92. doi: 10.1242/jeb.01589
93. Fields, C, and Levin, M. Scale-Free Biology: Integrating Evolutionary and
Developmental inking. BioEssays. (2020) 42:1900228.
94. Anderson PW. More is dierent: broken symmetry and the nature of the
hierarchical structure of science. Science. (1972) 177:393–6. doi: 10.1126/
science.177.4047.393
95. Auray C, Noble D, Nottale L, Turner P. Progress in integrative systems biology,
physiology and medicine: towards a scale-relative biology. Europ Phys J A. (2020)
56:1–24. doi: 10.1140/epja/s10050-020-00090-3
96. Keller EF. Revisiting “scale-free” networks. Bio Essays. (2005) 27:1060–8. doi:
10.1002/bies.20294
97. Eronen MI. e levels problem in psychopathology. Psychol Med. (2021)
51:927–33. doi: 10.1017/S0033291719002514
98. Simon HA. e architecture of complexity In: . e sciences of the articial.
Cambridge, MA: MIT Press (1969). 192–229.
99. Dupré J. e metaphysics of biology. New York: Cambridge University Press (2021).
100. Glennan S. e new mechanical philosophy. Oxford: Oxford University Press
(2017).
101. Machamer P, Darden L, Craver CF. inking about mechanisms. Philos Sci.
(2000) 67:1–25. doi: 10.1086/392759
102. Kauman SA. A world beyond physics: e emergence and evolution of life, Oxford
University Press (2019).
103. Maturana HR, Varela FJ. Autopoiesis and cognition: e realization of the living
Springer Science & Business Media (2012).
104. Nurse P. What is life?: Understand biology in ve steps. New York: W.W. Norton
(2020).
105. Pross A. What is life?: How chemistry becomes biology. Oxford: Oxford University
Press (2016).
Gómez-Carrillo and Kirmayer 10.3389/fpsyt.2023.1031390
Frontiers in Psychiatry 17 frontiersin.org
106. Ramstead MJD, Badcock PB, Friston KJ. Answering Schrödinger's question: a
free-energy formulation. Phys Life Rev. (2018) 24:1–16. doi: 10.1016/j.plrev.2017.09.001
107. B echtel W. Top-down causation in biology and neuroscience: control hierarchies
In: MP Paoletti and F Orilia, editors. Philosophical and scientic perspectives on
downward causation: Routledge (2017). 203–24.
108. Parr T, Pezzulo G, Friston KJ. Active inference: e free energy principle in mind,
brain, and behavior. Cambridge, MA: MIT Press (2022).
109. D eacon TW. Incomplete nature: How mind emerged from matter. New York: WW
Norton & Company (2011).
110. García-Valdecasas M. On the naturalisation of teleology: self-organisation,
autopoiesis and teleodynamics. Adapt Behav. (2022) 30:103–17. doi:
10.1177/1059712321991890
111. Dennett DC. Aching voids and making voids. Q Rev Biol. (2013) 88:321–4. doi:
10.1086/673760
112. De Luca Picione R, Martino ML, Troisi G. e semiotic construction of the sense
of agency. e modal articulation in narrative processes. Integr Psychol Behav Sci. (2019)
53:431–49. doi: 10.1007/s12124-019-9475-9
113. Taylor C. e language animal. C ambridge, MA: Harvard University Press (2016).
114. Emmeche C, Køppe S, Stjernfelt F. Explaining emergence: towards an ontology
of levels. J Gen Philos Sci. (1997) 28:83–117. doi: 10.1023/A:1008216127933
115. Davidson EH. e regulatory genome: Gene regulatory networks in development
and evolution. Burlington, MA: Elsevier (2010).
116. Stencel A, Suárez J. Do somatic cells really sacrice themselves? Why an appeal
to coercion may bea helpful strategy in explaining the evolution of multicellularity. Biol
eory. (2021) 16:102–13. doi: 10.1007/s13752-021-00376-9
117. Noble D. A theory of biological relativity: no privileged level of causation. Inter
Focus . (2012) 2:55–64. doi: 10.1098/rsfs.2011.0067
118. Noble D. Dance to the tune of life: Biological relativity. Cambridge: Cambridge
University Press (2016).
119. Noble D. e principle of biological relativity: origins and current status In: K
Voosholz and M Gabriel, editors. Top-down causation and emergence. Cham: Springer
(2021). 117–33. doi: 10.1007/978-3-030-71899-2_6
120. Engel GL. e biopsychosocial model and the education of health professionals.
Ann N Y Acad Sci. (1978) 310:169–81. doi: 10.1111/j.1749-6632.1978.tb22070.x
121. Engel GL. e clinical application of the biopsychosocial model. J Med Philos.
(1981) 6:101–24. doi: 10.1093/jmp/6.2.101
122. Saraga M, Fu ks A, Boudreau JD. George Engel's epistemology of clinical practice.
Perspect Biol Med. (2014) 57:482–94. doi: 10.1353/pbm.2014.0038
123. Ghaemi SN. e rise and fall of the biopsychosocial model: Reconciling art and
science in psychiatry. Baltimore: Johns Hopkins University Press (2010) doi: 10.1353/
book.3501.
124. Benning TB. Limitations of the biopsychosocial model in psychiatry. Adv Med
Educ Pract. (2015) 6: 347–52. doi: 10.2147/AMEP.S82937
125. Bolton D. Looking forward to a decade of the biopsychosocial model. BJPsych
Bull. (2022) 46:228–32. doi: 10.1192/bjb.2022.34
126. Bolton D, Gillett G. e biopsychosocial model of health and disease: New
philosophical and scientic developments. New York: Springer Nature (2019) doi:
10.1007/978-3-030-11899-0.
127. Gilbert, P. Psychotherapy for the 21st century: An integrative, evolutionary,
contextual, biopsychosocial approach. Psychology and Psychotherapy: eory, Research
and Practice. (2019) 92:164–89.
128. Kirmayer LJ, Worthman C, Kitayama S. Epilogue: Interdisciplinarity in the study
of culture, mind and brain In: LJ Kirmayer, C Worthman, S Kitayama, R Lemelson and
CA Cummings, editors. Culture, mind and brain: Emerging concepts, models, applications.
New York: Cambridge University Press (2020). 494–512. doi: 10.1017/9781108695374.028
129. Miresco MJ, Kirmayer LJ. e persistence of mind-brain dualism in psychiatric
reasoning about clinical scenarios. Am J Psychiatr. (2006) 163:913–8. doi: 10.1176/
ajp.2006.163.5.913
130. Berrios GE, Marková IS. Towards a new epistemology of psychiatry In: LJ
Kirmayer, R Lemelson and C Cummings, editors. Re-visioning psychiatry: Cultural
phenomenology, critical neuroscience, and global mental health. New York: Cambridge
University Press (2015). 41–64.
131. Kendler KS. e structure of psychiatric science. Am J Psychiatr. (2014)
171:931–8. doi: 10.1176/appi.ajp.2014.13111539
132. Tramonti F, Giorgi F, Fanali A. Systems thinking and the biopsychosocial
approach: a multilevel framework for patient-centred care. Syst Res Behav Sci. (2021)
38:215–30. doi: 10.1002/sres.2725
1 33. Eisenberger, NI, and Cole, SW. Social neuroscience and health: neurophysiological
mechanisms linking social ties with physical health. Nature Neuroscience. (2012)
15:669–74.
134. Fuchs, T. Mind, meaning, and the brain. Philosophy, Psychiatry, & Psychology.
(2002) 9:261–4.
135. Pattee, HH. Dynamic and linguistic modes of complex systems. International
Journal of General Systems. (1977) 3:259–66.
136. Borsboom D, Cramer AO. Network analysis: an integrative approach to the
structure of psychopathology. Annu Rev Clin Psychol. (2013) 9:91–121. doi: 10.1146/
annurev-clinpsy-050212-185608
137. Borsboom D, Cramer AO, Kalis A. Brain disorders? Not really: why network
structures block reductionism in psychopathology research. Behav Brain Sci. (2019)
42:1–63. doi: 10.1017/S0140525X17002266
138. Badcock PB, Friston KJ, Ramstead MJ, Ploeger A, Hohwy J. e hierarchically
mechanistic mind: an evolutionary systems theory of the human brain, cognition, and
behavior. Cogn Aect Behav Neurosci. (2019) 19:1319–51. doi: 10.3758/
s13415-019-00721-3
139. Povich M, Craver CF. Mechanistic levels, reduction, and emergence In: . S.
Glennan and P. Illari, editors e Routledge handbook of mechanisms and mechanical
philosophy. London: Routledge. (2018). 185–97.
140. Bouizegarene N., Ramstead M., Constant A., Friston K., Kirmayer L.J. (2020).
Narrative as active inference.
141. Branchi I. Recentering neuroscience on behavior: the interface between brain
and environment is a privileged level of control of neural activity. Neurosci Biobehav Rev.
(2022) 138:104678. doi: 10.1016/j.neubiorev.2022.104678
142. Koban L, Gianaros PJ, Kober H, Wager TD. e self in context: brain systems
linking mental and physical health. Nat Rev Neurosci. (2021) 22:309–22. doi: 10.1038/
s41583-021-00446-8
143. Geschwind DH, Konopka G. Neuroscience in the era of functional genomics and
systems biology. Nature. (2009) 461:908–15. doi: 10.1038/nature08537
144. Chen, P, and Hong, W. Neural circuit mechanisms of social behavior. Neuron.
(2018) 98:16–30.
145. Linden, DE. How psychotherapy changes the brain–the contribution of
functional neuroimaging. Molecular psychiatry. (2006) 11:528–38.
146. Kaplan D, Glass L. Understanding nonlinear dynamics. Cham: Springer Science
& Business Media (1997).
147. May RM. Simple mathematical models with very complicated dynamics. Nature.
(1976) 261:459–67. doi: 10.1038/261459a0
148. Durstewitz D, Huys QJ, Koppe G. Psychiatric illnesses as disorders of network
dynamics. Biol Psychiatry. (2021) 6:865–76. doi: 10.1016/j.bpsc.2020.01.001
149. Kirmayer LJ, Sartorius N. Cultural models and somatic syndromes. Psychosom
Med. (2007) 69:832–40. doi: 10.1097/PSY.0b013e31815b002c
150. Torres JM, Lawlor J, Colvin JD, Sills MR, Bettenhausen JL, Davidson A, et al. ICD
social codes: an under-utilized resource for tracking social needs. Med Care. (2017)
55:810–6. doi: 10.1097/MLR.0000000000000764
151. Walsh J. e utility of the DSM-5 Z-codes for clinical social work diagnosis. J
Hum Behav Soc Environ. (2016) 26:149–53. doi: 10.1080/10911359.2015.1052913
152. Mezzich JE, Salloum IM, Cloninger CR, Salvador-Carulla L, Kirmayer LJ,
Banzato CE, et al. Person-centred integrative diagnosis: conceptual bases and structural
model. Can J Psychiatr. (2010) 55:701–8. doi: 10.1177/070674371005501103
153. Beck AT, Bredemeier K. A unied model of depression: integrating clinical,
cognitive, biological, and evolutionary perspectives. Clin Psychol Sci. (2016) 4:596–619.
doi: 10.1177/2167702616628523
154. Sanacora G, Yan Z, Popoli M. e stressed synapse 2.0: pathophysiological
mechanisms in stress-related neuropsychiatric disorders. Nat Rev Neurosci. (2022)
23:86–103. doi: 10.1038/s41583-021-00540-x
155. Fava GA. May antidepressant drugs worsen the conditions they are supposed to
treat? e clinical foundations of the oppositional model of tolerance. erap Adv
Psychopharmacol. (2020) 10:2045125320970325. doi: 10.1177/2045125320970325
156. Baldwin DS, Foong T. Antidepressant drugs and sexual dysfunction. Br J
Psychiatry. (2013) 202:396–7. doi: 10.1192/bjp.bp.112.110650
157. Fisher HE, omson JA Jr. Lust, romance, attachment: do the side eects of
serotonin-enhancing antidepressants jeopardize romantic love, marriage, and fertility?.
In: SM Platek, JP Keenan and T. Shackleford, editors. Evolutionary Cognitive Neuroscience.
Cambridge, MA: MIT Press. 245-284/. (2007) 245
158. Kalia V, Knauft K. Emotion regulation strategies modulate the effect of
adverse childhood experiences on perceived chronic stress with implications for
cognitive flexibility. PLoS One. (2020) 15:e0235412. doi: 10.1371/journal.
pone.0235412
159. Park C, Rosenblat JD, Lee Y, Pan Z, Cao B, Iacobucci M, et al. e neural systems
of emotion regulation and abnormalities in major depressive disorder. Behav Brain Res.
(2019) 367:181–8. doi: 10.1016/j.bbr.2019.04.002
160. Vanderlind WM, Millgram Y, Baskin-Sommers AR, Clark MS, Joormann J.
Understanding positive emotion decits in depression: from emotion preferences to
emotion regulation. Clin Psychol Rev. (2020) 76:101826. doi: 10.1016/j.
cpr.2020.101826
161. Storms MD, McCaul KD. Attribution processes and emotional exacerbation of
dysfunctional behavior. New Dir Attrib Res. (1976) 1:143–64.
Gómez-Carrillo and Kirmayer 10.3389/fpsyt.2023.1031390
Frontiers in Psychiatry 18 frontiersin.org
162. van Kleef GA, Côté S. e social eects of emotions. Annu Rev Psychol. (2022)
73:629–58. doi: 10.1146/annurev-psych-020821-010855
163. Joormann, J, and Siemer, M. Memory accessibility, mood regulation, and
dysphoria: Diculties in repairing sad mood with happy memories? Journal of abnormal
psychology. (2004) 113:179.
164. Dandeneau SD, Baldwin MW, Baccus JR, Sakellaropoulo M, Pruessner JC.
Cutting stress o at the pass: reducing vigilance and responsiveness to social threat by
manipulating attention. J Pers Soc Psychol. (2007) 93:651–66. doi:
10.1037/0022-3514.93.4.651
165. Nolen-Hoeksema S. Responses to depression and their eects on the duration of
depressive episodes. J Abnorm Psychol. (1991) 100:569–82. doi:
10.1037/0021-843X.100.4.569
166. Finzi E, Rosenthal NE. Emotional proprioception: treatment of depression with
aerent facial feedback. J Psychiatr Res. (2016) 80:93–6. doi: 10.1016/j.
jpsychires.2016.06.009
167. Gibbs RW Jr. Embodiment and cognitive science. New York: Cambridge University
Press (2005).
168. Belsky J, C aspi A, Mott TE, Poulton R. e origins of you: How childhood shapes
later life. Cambridge, MA: Harvard University Press (2020).
169. Elmer T, Stadtfeld C. Depressive symptoms are associated with social isolation
in face-to-face interaction networks. Sci Rep. (2020) 10:1–12. doi: 10.1038/
s41598-020-58297-9
170. Fossati P, Hinfray S, Fall A, Lemogne C, Rotge J. Emotional and cognitive
consequences of social rejection: an entry door to major depression In: BT Baune and
C Harmer, editors. Cognitive dimensions of major depressive disorder. Oxford, UK:
Oxford University Press (2019). 211–23.
171. Richardson R, Westley T, Gariépy G, Austin N, Nandi A. Neighborhood
socioeconomic conditions and depression: a systematic review and meta-analysis. Soc
Psychiatry Psychiatr Epidemiol. (2015) 50:1641–56. doi: 10.1007/s00127-015-1092-4
172. van Eersel JH, Taris TW, Boelen PA. Grief reactions, depression, and anxiety
following job loss: patterns and correlates. Eur J Psychotraumatol. (2021) 12:1905348.
doi: 10.1080/20008198.2021.1905348
173. Kirmayer LJ, Bhugra D. Culture and mental illness: social context and explanatory
models In: IM Salloum and J Mezzich, editors. Psychiatric diagnosis: Patterns and
prospects. Chichester: Blackwell (2009). 29–37.
174. Magaard JL, Seeralan T, Schulz H, Brütt AL. Factors associated with help-seeking
behaviour among individuals with major depression: a systematic review. PLoS One.
(2017) 12:e0176730. doi: 10.1371/journal.pone.0176730
175. McIntyre RS, Cha DS, Soczynska JK, Woldeyohannes HO, Gallaugher LA,
Kudlow P, et al. Cognitive decits and functional outcomes in major depressive disorder:
determinants, substrates, and treatment interventions. Depress Anxiety. (2013)
30:515–27. doi: 10.1002/da.22063
176. Ridley M, Rao G, Schilbach F, Patel V. Poverty, depression, and anxiety: causal
evidence and mechanisms. Science. (2020) 370:eaay0214. doi: 10.1126/science.aay0214
177. Kirmayer LJ. Psychopharmacology in a globalizing world: the use of
antidepressants in Japan. Transcult Psychiatry. (2002) 39:295–322. doi:
10.1177/136346150203900302
178. Ecks S. Living worth: Value and values in global pharmaceutical markets. Durham:
Duke University Press (2022).
179. Everaert J, Koster EH. The interplay among attention, interpretation, and
memory biases in depression: revisiting the combined cognitive bias hypothesis In:
T Aue and H Okon-Singer, editors. Cognitive biases in health and psychiatric
disorders: Neurophysiological foundations. New York: Academic Press (2020).
193–213.
180. Ryder AG, Chentsova-Dutton YE. Cultural-clinical psychology In: LJ Kirmayer,
R Lemelson and CA Cummings, editors. Re-visioning psychiatry: Cultural
phenomenology, critical neuroscience, and global mental health. New York: Cambridge
University Press (2015). 400–33.
181. Gottman JM, Murray JD, Swanson CC, Tyson R, Swanson KR. e mathematics
of marriage: Dynamic nonlinear models. Cambridge, MA MIT Press (2005).
182. Bolis D, Dumas G, Schilbach L. Interpersonal attunement in social interactions:
from collective psychophysiology to inter-personalized psychiatry and beyond. Philos
Trans R Soc B. (2023) 378:20210365. doi: 10.1098/rstb.2021.0365
183. Girme YU, Overall NC, Simpson JA. Introduction to the special issue: nonlinear
eects and dynamics in close relationships. J Soc Pers Relat. (2022) 39:2991–3000. doi:
10.1177/02654075221119427
184. Tognoli E, Zhang M, Fuchs A, Beetle C, Kelso JS. Coordination dynamics: a
foundation for understanding social behavior. Front Hum Neurosci. (2020) 14:317. doi:
10.3389/fnhum.2020.00317
185. Bringmann LF, Albers C, Bockting C, Borsboom D, Ceulemans E, Cramer A,
et al. Psychopathological networks: theory, methods and practice. Behav Res er. (2022)
149:104011. doi: 10.1016/j.brat.2021.104011
186. Cramer AO, Van Borkulo CD, Giltay EJ, Van Der Maas HL, Kendler KS, Scheer
M, et al. Major depression as a complex dynamic system. PLoS One. (2016) 11:e0167490.
doi: 10.1371/journal.pone.0167490
187. De Beurs D, Bockting C, Kerkhof A, Scheepers F, O’Connor R, Penninx B, et al.
A network perspective on suicidal behavior: understanding suicidality as a complex
system. Suicide Life reat Behav. (2021) 51:115–26. doi: 10.1111/sltb.12676
188. Hayes AM, Andrews LA. A complex systems approach to the study of change in
psychotherapy. BMC Med. (2020) 18:1–13. doi: 10.1186/s12916-020-01662-2
189. Hofmann SG, Curtiss JE, Hayes SC. Beyond linear mediation: toward a dynamic
network approach to study treatment processes. Clin Psychol Rev. (2020) 76:101824. doi:
10.1016/j.cpr.2020.101824
190. Haslbeck J, Ryan O, Robinaugh DJ, Waldorp LJ, Borsboom D. Modeling
psychopathology: from data models to formal theories. Psychol Methods. (2022)
27:930–57. doi: 10.1037/met0000303
191. Hollenstein T. is time, it’s real: aective exibility, time scales, feedback loops,
and the regulation of emotion. Emot Rev. (2015) 7:308–15. doi:
10.1177/1754073915590621
192. Dumas G., and Fairhurst M.. Reciprocity and alignment: quantifying coupling
in dynamic interactions. Royal Society Open Science. (2021) 8(5):210138.
193. Smith R, Khalsa SS, Paulus MP. An active inference approach to dissecting
reasons for nonadherence to antidepressants. Biol Psychiatr y. (2021) 6:919–34. doi:
10.1016/j.bpsc.2019.11.012
194. Burger J, van der Veen DC, Robinaugh DJ, Quax R , Riese H, Schoevers RA, et al.
Bridging the gap between complexity science and clinical practice by formalizing
idiographic theories: a computational model of functional analysis. BMC Med. (2020)
18:1–18. doi: 10.1186/s12916-020-01558-1
195. Kirmayer LJ. Improvisation and authority in illness meaning. Cult Med
Psychiatry. (1994) 18:183–214. doi: 10.1007/BF01379449
196. Norrmén-Smith IO, Gómez-Carrillo A, Choudhury S. “Mombrain and sticky
DNA”: the impacts of neurobiological and epigenetic framings of motherhood on
women's subjectivities. Front Sociol. (2021) 6:653160. doi: 10.3389/fsoc.2021.653160
197. Hacking I. e looping eect of human kinds In: D Sperber, D Premack and AJ
Premack, editors. Causal cognition: A multidisciplinary debate. Oxford: Oxford
University Press (1995). 351–83.
198. Hacking I. e social construction of what? Cambridge: Harvard University Press
(1999).
199. Gold I, Kirmayer LJ. Neuroscience as cultural intervention: reconguring the self
as moral agent. AJOB Neurosci. (2010) 1:53–5. doi: 10.1080/21507740.2010.514884
200. Brinkmann S. Diagnostic cultures: A cultural approach to the pathologization of
modern life. London: Routledge (2016).
201. Rose D, Rose N. Is ‘another’ psychiatry possible? Psychol Med. (2023) 53:46–54.
doi: 10.1017/S003329172200383X
202. de Haan S. Bio-psycho-social interaction: an enactive perspective. Int Rev
Psychiatry. (2021) 33:471–7. doi: 10.1080/09540261.2020.1830753
203. Fuchs T. Ecology of the brain: e phenomenology and biology of the embodied
mind. Oxford: Oxford University Press (2017).
204. Kirmayer L, Ramstead MJ. Embodiment and enactment in cultural psychiatry
In: C Durt, T Fuchs and C Tewes, editors. Embodiment, enaction, and culture:
Investigating the constitution of the shared world. Cambridge, MA: MIT Press (2017).
397–422.
205. Nielsen K, Ward T. Towards a new conceptual framework for psychopathology:
embodiment, enactivism, and embedment. eory Psychol. (2018) 28:800–22. doi:
10.1177/0959354318808394
206. Krieger N. Ecosocial theory, embodied truths, and the people's health. New York:
Oxford University Press (2021).
207. Kirmayer LJ. e body's insistence on meaning: metaphor as presentation and
representation in illness experience. Med Anthropol Q. (1992) 6:323–46. doi: 10.1525/
maq.1992.6.4.02a00020
208. Sterling P. What is health?: Allostasis and the evolution of human design.
Cambridge, MA: MIT Press (2020).
209. McEwen BS. Stressed or stressed out: what is the dierence? J Psychiatry Neurosci.
(2005) 30:315–8.
210. Lazarus, RS, and Folkman, S. Stress, appraisal, and coping. New York: Springer
(1984).
211. Fava GA, McEwen BS, Guidi J, Gostoli S, Odani E, Sonino N. Clinical
characterization of allostatic overload. Psychoneuroendocrinology. (2019) 108:94–101.
doi: 10.1016/j.psyneuen.2019.05.028
212. Colditz IG. A consideration of physiological regulation from the perspective of
Bayesian enactivism. Physiol Behav. (2020) 214:112758. doi: 10.1016/j.
physbeh.2019.112758
213. Nave K, Deane G, Miller M, Clark A. Wilding the predictive brain. Wiley
interdisciplinary Reviews. Cogn Sci. (2020) 11:e 1542. doi: 10.1002/wcs.1542
214. Seth AK, Friston KJ. Active interoceptive inference and the emotional brain. Philo
Trans R Soc B: Biol Sci. (2016) 371:20160007. doi: 10.1098/rstb.2016.0007
215. Juarrero A. Dynamics in action. Cambridge, MA: MIT Press (1999) doi: 10.7551/
mitpress/2528.001.0001.
Gómez-Carrillo and Kirmayer 10.3389/fpsyt.2023.1031390
Frontiers in Psychiatry 19 frontiersin.org
216. Buhrmann T, Di Paolo E. e sense of agency–a phenomenological consequence
of enacting sensorimotor schemes. Phenomenol Cogn Sci. (2017) 16:207–36. doi:
10.1007/s11097-015-9446-7
217. Kirmayer l. J., Langlois-Therien T., Gómez-Carrillo A., Gold I. Culture, self
and agency: an ecosocial view In: LJ Kirmayer, C Worthman, S Kitayama, R
Lemelson and CA Cummings, editors. Culture, mind and brain: Emerging concepts,
models, applications. New York: Cambridge University Press. (2020) 244–71. doi:
10.1017/9781108695374.012
218. Kirmayer LJ, Gómez-Carrillo A. Agency, embodiment and enactment in
psychosomatic theory and practice. Med Huma nit. (2019) 45:169–82. doi: 10.1136/
medhum-2018-011618
219. Gómez-Carrillo A, Kirmayer LJ, Aggarwal NK, Bhui KS, Fung KPL, Kohrt BA,
et al . Integrating neuroscience in psychiatry: a cultural–ecosocial systemic approach.
e Lancet Psychiatry, (2023). 10, 296–304. doi: 10.1016/S2215-0366(23)00006-8
220. Goekoop R, de Kleijn R. How higher goals are constructed and collapse under
stress: a hierarchical Bayesian control systems perspective. Neurosci Biobehav Rev. (2021)
123:257–85. doi: 10.1016/j.neubiorev.2020.12.021
221. Di Paolo EA, Cuari EC, De Jaegher H. Linguistic bodies: e continuity between
life and language. Cambridge, MA: MIT press (2018).
222. Hutto DD. Folk psychological narratives: e sociocultural basis of understanding
reasons MIT Press (2012).
223. Bargh JA. What have webeen priming all these years? On the development,
mechanisms, and ecology of nonconscious social behavior. Eur J Soc Psychol. (2006)
36:147–68. doi: 10.1002/ejsp.336
224. Hutto DD, Gallagher S, Ilundáin-Agurruza J, Hipólito I. Culture in mind.
An enactivist account—not cognitive penetration but cultural permeation In: LJ
Kirmayer, C Worthman, S Kitayama, C Cummings and R Lemelson, editors.
Culture, mind, and brain: Emerging concepts, models, applications. New York:
Cambridge University Press (2020). 163–87.
225. Kirmayer LJ, Worthman C, Kitayama S. Introduction: co-constructing culture,
mind and brain In: LJ Kirmayer, C Worthman, S Kitayama, R Lemelson and CA
Cummings, editors. Culture, mind and brain: Emerging concepts, models, applications.
New York: Cambridge University Press (2020). 1–49.
226. Ramstead MJ, Veissière SP, Kirmayer LJ. Cultural aordances: scaolding local
worlds through shared intentionality and regimes of attention. Front Psychol. (2016)
7:1090. doi: 10.3389/fpsyg.2016.01090
227. Kendler KS, Parnas J, Zachar P. Levels of analysis in psychopathology: Cross-
disciplinary perspectives. New York: Cambridge University Press (2020).
228. Ladouceur CD, Versace A, Phillips ML. Understanding the neural circuitry of
emotion regulation: white matter tract abnormalities and psychiatric disorder In: LJ
Kirmayer, R Lemelson and C Cummings, editors. Re-visioning psychiatry: Cultural
phenomenology, critical neuroscience and global mental health: Cambridge University
Press (2015). 236–72.
229. Fuchs T. e circularity of the embodied mind. Front Psychol. (2020) 11:1707.
doi: 10.3389/fpsyg.2020.01707
230. Nelson B, McGorry PD, Fernandez AV. Integrating clinical staging and
phenomenological psychopathology to add depth, nuance, and utility to clinical
phenotyping: a heuristic challenge. Lancet Psychiatry. (2021) 8:162–8. doi: 10.1016/
S2215-0366(20)30316-3
231. Johnston T, Edwards L. Genes, interactions, and the development of behavior.
Psychol Rev. (2002) 109:26–34. doi: 10.1037/0033-295X.109.1.26
232. Lux V, Non AL, Pexman PM, Stadler W, Weber LA, Krüger M. A developmental
framework for embodiment research: the next step toward integrating concepts and
methods. Front Syst Neurosci. (2021) 15:672740. doi: 10.3389/fnsys.2021.672740
233. Ellis RE, Seal ML, Simmons JG, Whittle S, Schwartz OS, Byrne ML, et al.
Longitudinal trajectories of depression symptoms in adolescence: psychosocial risk
factors and outcomes. Child Psychiatry Hum Dev. (2017) 48:554–71. doi: 10.1007/
s10578-016-0682-z
234. Sharp PB, Miller GA, Dolan RJ, Eldar E. Towards formal models of
psychopathological traits that explain symptom trajectories. BMC Med. (2020) 18:1–8.
doi: 10.1186/s12916-020-01725-4
235. Kirmayer LJ, Gómez-Carrillo A. Culturally responsive clinical psychology and
psychiatry: an ecosocial approach In: A Maercker, E Heim and LJ Kirmayer, editors .
Cultural clinical psychology and PTSD. Boston: Hogrefe Verlag (2019). 3–21.2018
236. Kirmayer LJ, Gómez-Carrillo A, Veissière S. Culture and depression in global
mental health: an ecosocial approach to the phenomenology of psychiatric disorders.
Soc Sci Med. (2017) 183:163–8. doi: 10.1016/j.socscimed.2017.04.034
237. Wittenborn AK, Rahmandad H, Rick J, Hosseinichimeh N. Depression as a
systemic syndrome: mapping the feedback loops of major depressive disorder. Psychol
Med. (2016) 46:551. doi: 10.1017/S0033291715002044
238. Kleinman A. e illness narratives: Suering, healing, and the human condition.
New York: Basic Books (2020).
239. Fessler, D. Shame in two cultures: Implications for evolutionary approaches.
Journal of Cognition and Culture. (2004) 4:207–62.
240. Lane A. A review of diagramming in systems practice and how technologies have
supported the teaching and learning of diagramming for systems thinking in practice.
Syst Pract Action Res. (2013) 26:319–29. doi: 10.1007/s11213-012-9254-8
241. Crielaard L, Uleman JF, Châtel BDL, Epskamp S, Sloot PMA, Quax R. Rening
the causal loop diagram: A tutorial for maximizing the contribution of domain expertise
in computational system dynamics modeling. Psychological Methods: Advance online
publication (2022) doi: 10.1037/met0000484.
242. de Pinho H. Mapping complex systems of population health In: AM El-Sayed
and S Galea, editors. Systems science and population health. New York: Oxford University
Press (2017). 61–76.
243. Ramstead MJ, Kirchho MD, Constant A, Friston KJ. Multiscale integration:
beyond internalism and externalism. Synthese. (2021) 198:41–70. doi: 10.1007/
s11229-019-02115-x
244. de Boer NS, Kostić D, Ross M, de Bruin L, Glas G. Using network models in
person-centered care in psychiatry: how perspectivism could help to draw boundaries.
Front Psychol. (2022) 13:1769.
245. Heshmati M, Russo SJ. Anhedonia and the brain reward circuitry in depression.
Curr Behav Neurosci Rep. (2015) 2:146–53. doi: 10.1007/s40473-015-0044-3
246. Spellman T, Liston C. Toward circuit mechanisms of pathophysiology in
depression. Am J Psychiatr. (2020) 177:381–90. doi: 10.1176/appi.ajp.2020.20030280
247. Wil liams LM. Precision psychiatry: a neural circuit taxonomy for depression and
anxiety. Lancet Psychiatry. (2016) 3:472–80. doi: 10.1016/S2215-0366(15)00579-9
248. Pulcu E, Zahn R, Elliott R. e role of self-blaming moral emotions in major
depression and their impact on social-economical decision making. Front Psychol.
(2013) 4:310. doi: 10.3389/fpsyg.2013.00310
249. Kirmayer LJ, Jarvis GE, Gómez-Carrillo A. Depression across cultures: an
ecosocial approach In: C Nemero, AF Schatzberg, N Rasgon and SM Strakowski,
editors. Textbook of mood disorders. Second ed. Washington: American Psychiatric Press
(2022). 837–67.
250. Iniesta R, Hodgson K, Stahl D, Malki K, Maier W, Rietschel M, et al.
Antidepressant drug-specific prediction of depression treatment outcomes from
genetic and clinical variables. Sci Rep. (2018) 8:5530. doi: 10.1038/
s41598-018-23584-z
251. Wigmore EM, Haerty JD, Hall LS, Howard DM, Clarke TK, Fabbri C, et al.
Genome-wide association study of antidepressant treatment resistance in a population-
based cohort using health service prescription data and meta-analysis with GENDEP.
Pharm J. (2020) 20:329–41. doi: 10.1038/s41397-019-0067-3
252. Serretti A. e present and future of precision medicine in psychiatry: focus on
clinical psychopharmacology of antidepressants. Clin Psychopharmacol Neurosci. (2018)
16:1–6. doi: 10.9758/cpn.2018.16.1.1
253. Leuchter AF, Hunter AM, Tartter M, Cook IA. Role of pill-taking, expectation
and therapeutic alliance in the placebo response in clinical trials for major depression.
Br J Psychiatry. (2014) 205:443–9. doi: 10.1192/bjp.bp.113.140343
254. Elwadhi D, Cohen A. Social inequalities in antidepressant treatment outcomes:
a systematic review. Soc Psychiatry Psychiatr Epidemiol. (2020) 55:1241–59. doi: 10.1007/
s00127-020-01918-5
255. Gupta S, Miller R, Cahill J. Deprescribing in psychiatry. New York: Oxford
University Press (2019).
256. Choudhury S, McKinney KA, Kirmayer LJ. “Learning how to deal with feelings
dierently”: psychotropic medications as vehicles of socialization in adolescence. Soc Sci
Med. (2015) 143:311–9. doi: 10.1016/j.socscimed.2015.02.034
257. Metzl JM, Riba M. Understanding the symbolic value of medications: a brief
review. Prim Psychiatry. (2003) 10:45–64.
258. Rose N. Neurochemical selves. Society. (2003) 41:46–59. doi: 10.1007/
BF02688204
259. Joshi SV, Martin A. inking about prescribing: e psychology of
psychopharmacology with diverse youth and families. Washington: American Psychiatric
Pub (2022).
260. Kirmayer LJ. Empathy and alterity in psychiatry In: LJ Kirmayer, R L emelson and
C Cummings, editors. Re-visioning psychiatry: Cultural phenomenology, critical
neuroscience and global mental health. New York: Cambridge University Press (2015).
141–67. doi: 10.1017/CBO9781139424745.009
261. Gl as G. Person-centered care in psychiatry: Self-relational, contextual, and
normative perspectives. New York: Routledge (2019).
262. Mezzich JE, Botbol M, Christodoulou GN, Cloninger CR, Salloum IM. Person
centered psychiatry. New York: Springer (2016).
263. Lehman BJ, David DM, Gruber JA. Rethinking the biopsychosocial model of
health: understanding health as a dynamic system. Soc Personal Psychol Compass. (2017)
11:e12328. doi: 10.1111/spc3.12328
264. Gómez-Carrillo A, Paquin V, Dumas G, Kirmayer LJ. Restoring the missing
person to personalized medicine and precision psychiatry. Front Neurosci. (2023) 17:30.
doi: 10.3389/fnins.2023.1041433
265. Mendenhall E, Kohrt BA, Logie CH, Tsai AC. Syndemics and clinical science. Nat
Med. (2022) 28:1359–62. doi: 10.1038/s41591-022-01888-y
Gómez-Carrillo and Kirmayer 10.3389/fpsyt.2023.1031390
Frontiers in Psychiatry 20 frontiersin.org
266. Weaver LJ, Kaiser BN. Syndemics theory must take local context seriously: an
example of measures for poverty, mental health, and food insecurity. Soc Sci Med. (2022)
295:113304. doi: 10.1016/j.socscimed.2020.113304
267. Shields R. The virtual. Psychology Press. (2003).
268. Kirmayer L. J., Raikhel E., and Rahimi S.. Cultures of the Internet: Identity,
community and mental health. Transcultural psychiatry. (2013) 50(2):165–191.
269. Anderson W, Dunk J. Planetary health histories: toward new ecologies of
epidemiology? Isis. (2022) 113:767–88. doi: 10.1086/722308
270. Vergunst F, Berry HL. Climate change and children’s mental health: a developmental
perspective. Clin Psychol Sci. (2022) 10:767–85. doi: 10.1177/21677026211040787
271. Lewis JL. Global mental health, planetary health, and the ethical co-benet In:
AR Dyer, BA Kohrt and PJ Candilis, editors. Global mental health ethics. Cham: Springer
International Publishing (2021). 367–80. doi: 10.1007/978-3-030-66296-7_22
272. Redvers N. e determinants of planetary health. L ancet Planetary Health. (2021)
5:e111–2. doi: 10.1016/S2542-5196(21)00008-5
273. Redvers N, Schultz C, Vera Prince M, Cunningham M, Jones R, Blondin BS.
Indigenous perspectives on education for sustainable healthcare. Med Teach. (2020)
42:1085–90. doi: 10.1080/0142159X.2020.1791320
274. Weiss MG, Aggarwal NK, Gómez-Carrillo A, Kohrt B, Kirmayer LJ, Bhui KS,
et al. Culture and social structure in comprehensive case formulation. J Nerv Ment Dis.
(2021) 209:465–6. doi: 10.1097/NMD.0000000000001346
275. Kirmayer LJ, Kronick R, Rousseau C. Advocacy as key to structural
competency in psychiatry. JAMA Psychiatry. (2018) 75:119–20. doi: 10.1001/
jamapsychiatry.2017.3897
276. Aron DC. Complex systems in medicine: A hedgehog’s tale of complexity in
clinical practice, research, education, and management. New York: Springer Nature
(2019).
277. Chamberlain L, Butz MR. Clinical chaos: A therapist’s guide to non-linear
dynamics and therapeutic change. New York: Routledge (2013).
278. Meadows DH. inking in systems: A primer. White River Junction: Chelsea
Green Publishing (2008).
279. Stanton M, Welsh R. Systemic thinking in couple and family psychology research
and practice. Couple Fam Psychol Res Pract. (2012) 1:14–30. doi: 10.1037/a0027461
280. Apostolopoulos Y, Lich KH, Lemke MK. Complex systems and population health.
Chicago: Oxford University Press (2020).
281. Mitchel l SD. Unsimple truths: Science, complexity, and policy University of
Chicago Press (2009).
282. Wright AG, Woods WC. Personalized models of psychopathology. Annu Rev Clin
Psychol. (2020) 16:49–74. doi: 10.1146/annurev-clinpsy-102419-125032
283. Bracken P, omas P. Reections on critical psychiatry In: BMZ Cohen, editor.
Routledge international handbook of critical mental health. New York: Routledge (2017).
98–106.
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