Safe enough? Rethinking the concept of cultural safety in healthcare and training.

Refining the cultural safety concept to include an acknowledgement of both the discomfort inherent in training and care and the time needed to overcome multiple layers of oppression may partially buffer the feelings of failure or fraud that often arise from unrealistic expectations regarding equity, diversity and inclusion policies.

Agency, embodiment and enactment in psychosomatic theory and practice.

In this paper, we examine some of the conceptual, pragmatic and moral dilemmas intrinsic to psychosomatic explanation in medicine, psychiatry and psychology. Psychosomatic explanation invokes a social grey zone in which ambiguities and conflicts about agency, causality and moral responsibility abound. This conflict reflects the deep-seated dualism in Western ontology and concepts of personhood that plays out in psychosomatic research, theory and practice. Illnesses that are seen as psychologically mediated tend also to be viewed as less real or legitimate. New forms of this dualism are evident in philosophical attacks on Engel's biopsychosocial approach, which was a mainstay of earlier psychosomatic theory, and in the recent Research Domain Criteria research programme of the US National institute of Mental Health which opts for exclusively biological modes of explanation of illness. We use the example of resignation syndrome among refugee children in Sweden to show how efforts to account for such medically unexplained symptoms raise problems of the ascription of agency. We argue for an integrative multilevel approach that builds on recent work in embodied and enactive cognitive science. On this view, agency can have many fine gradations that emerge through looping effects that link neurophenomenology, narrative practices and cultural affordances in particular social contexts. This multilevel ecosocial view points the way towards a renewed biopsychosocial approach in training and clinical practice that can advance person-centred medicine and psychiatry.

A cultural-ecosocial systems view for psychiatry.

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, we outline 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 be incorporated into a pragmatic approach to clinical assessment and case formulation that characterizes mechanisms of pathology and identifies targets for intervention.

Restoring the missing person to personalized medicine and precision psychiatry.

Precision psychiatry has emerged as part of the shift to personalized medicine and builds on frameworks such as the U.S. National Institute of Mental Health Research Domain Criteria (RDoC), multilevel biological "omics" data and, most recently, computational psychiatry. The shift is prompted by the realization that a one-size-fits all approach is inadequate to guide clinical care because people differ in ways that are not captured by broad diagnostic categories. One of the first steps in developing this personalized approach to treatment was the use of genetic markers to guide pharmacotherapeutics based on predictions of pharmacological response or non-response, and the potential risk of adverse drug reactions. Advances in technology have made a greater degree of specificity or precision potentially more attainable. To date, however, the search for precision has largely focused on biological parameters. Psychiatric disorders involve multi-level dynamics that require measures of phenomenological, psychological, behavioral, social structural, and cultural dimensions. This points to the need to develop more fine-grained analyses of experience, self-construal, illness narratives, interpersonal interactional dynamics, and social contexts and determinants of health. In this paper, we review the limitations of precision psychiatry arguing that it cannot reach its goal if it does not include core elements of the processes that give rise to psychopathological states, which include the agency and experience of the person. Drawing from contemporary systems biology, social epidemiology, developmental psychology, and cognitive science, we propose a cultural-ecosocial approach to integrating precision psychiatry with person-centered care.

Integrating neuroscience in psychiatry: a cultural-ecosocial systemic approach.

Psychiatry has increasingly adopted explanations for psychopathology that are based on neurobiological reductionism. With the recognition of health disparities and the realisation that someone's postcode can be a better predictor of health outcomes than their genetic code, there are increasing efforts to ensure cultural and social-structural competence in psychiatric practice. Although neuroscientific and social-cultural approaches in psychiatry remain largely separate, they can be brought together in a multilevel explanatory framework to advance psychiatric theory, research, and practice. In this Personal View, we outline how a cultural-ecosocial systems approach to integrating neuroscience in psychiatry can promote social-contextual and systemic thinking for more clinically useful formulations and person-centred care.

"Mombrain and Sticky DNA": The Impacts of Neurobiological and Epigenetic Framings of Motherhood on Women's Subjectivities.

The fields of epigenetics and neuroscience have come to occupy a significant place in individual and public life in biomedicalized societies. Social scientists have argued that the primacy and popularization of the "neuro" has begun to shape how patients and other lay people experience themselves and their lifeworlds in increasingly neurological and genetic terms. Pregnant women and new mothers have become an important new target for cutting edge neuroscientific and epigenetic research, with the Internet constituting a highly active space for engagement with knowledge translations. In this paper, we analyze the reception by women in North America of translations of nascent epigenetic and neuroscientific research. We conducted three focus groups with pregnant women and new mothers. The study was informed by a prior scoping investigation of online content. Our focus group findings record how engagement with translations of epigenetic and neuroscientific research impact women's perinatal experience, wellbeing, and self-construal. Three themes emerged in our analysis: (1) A kind of brain; (2) The looping effects of biomedical narratives; (3) Imprints of past experience and the management of the future. This data reveals how mothers engage with the neurobiological style-of-thought increasingly characteristic of public health and popular science messaging around pregnancy and motherhood. Through the molecularization of pregnancy and child development, a typical passage of life becomes saturated with "susceptibility," "risk," and the imperative to preemptively make "healthy' choices." This, in turn, redefines and shapes the experience of what it is to be a "good," "healthy," or "responsible" mother/to-be.

Engaging culture and context in mhGAP implementation: fostering reflexive deliberation in practice.

In 2002, WHO launched the Mental Health Gap Action Programme (mhGAP) as a strategy to help member states scale up services to address the growing burden of mental, neurological and substance use disorders globally, especially in countries with limited resources. Since then, the mhGAP program has been widely implemented but also criticised for insufficient attention to cultural and social context and ethical issues. To address this issue and help overcome related barriers to scale-up, we outline a framework of questions exploring key cultural and ethical dimensions of mhGAP planning, adaptation, training, and implementation. This framework is meant to guide mhGAP activity taking place around the world. Our approach is informed by recent research on cultural formulation and adaptation, and aligned with key components of the WHO implementation research guide (Peters, D. H., Tran, N. T., & Adam, T. (2013). Implementation research in health: a practical guide. Implementation research in health: a practical guide.). The framework covers three broad domains: (1) Concepts of wellness and illness-how to examine cultural norms, knowledge, values and attitudes in relation to the "culture of the mhGAP"; (2) Systems of care-identifying formal and informal systems of care in the cultural context of practice.; and (3) Ethical space: examining issues related to power dynamics, communication, and decision-making. Systematic consideration of these issues can guide integration of cultural knowledge, structural competence, and ethics in implementation efforts.

The Cultural Formulation Interview since DSM-5: Prospects for training, research, and clinical practice.

While social science research has demonstrated the importance of culture in shaping psychiatric illness, clinical methods for assessing the cultural dimensions of illness have not been adopted as part of routine care. Reasons for limited integration include the impression that attention to culture requires specialized skills, is only relevant to a subset of patients from unfamiliar backgrounds, and takes too much time to be useful. The DSM-5 Cultural Formulation Interview (CFI), published in 2013, was developed to provide a simplified approach to collecting information needed for cultural assessment. It offers a 16-question interview protocol that has been field tested at sites around the world. However, little is known about how CFI implementation has affected training, health services, and clinical outcomes. This article offers a comprehensive narrative review that synthesizes peer-reviewed, published studies on CFI use. A total of 25 studies were identified, with sample sizes ranging from 1 to 460 participants. In all pilot CFI studies 960 unique subjects were enrolled, and in final CFI studies 739 were enrolled. Studies focused on how the CFI affects clinical practice; explored the CFI through research paradigms in medical communication, implementation science, and family psychiatry; and examined clinician training. In most studies, patients and clinicians reported that using the CFI improved clinical rapport. This evidence base offers an opportunity to consider implications for training, research, and clinical practice and to identify crucial areas for further research.

Update on the Cultural Formulation Interview.

This article reviews the clinical and research literature on the Cultural Formulation Interview (CFI) since its publication in DSM-5. The CFI is an interview protocol designed to be used by clinicians in any setting to gather essential data to produce a cultural formulation. The CFI aims to improve culturally sensitive diagnosis and treatment by focusing clinical attention on the patient's perspective and social context. Preliminary evidence indicates that the CFI can improve clinical communication by enhancing clinician-patient rapport, allowing the clinician to obtain new, cultural data in a relatively short period, eliciting patients' perspectives on what caused their symptoms, and helping patients to become aware of their problems in more insightful ways. With practice, the CFI takes approximately 20 minutes to complete. The CFI has been evaluated internationally in the United States, Canada, Kenya, Peru, the Netherlands, India, and Mexico and generally has been found to be clinically acceptable and useful in these varied settings. Clinicians receiving as little as one hour of training on the CFI improved their ability to work with culturally diverse patients. The CFI may be more difficult to conduct with patients who have severe symptoms, including acute psychosis, suicidal behavior, aggression, and cognitive impairment. The CFI provides a simple way to begin the process of cultural assessment, and its systematic use can foster a reflective stance and promote systemic thinking in routine clinical practice about the patient's life and experience.

The relationship between causal beliefs and desire for social distance towards people with schizophrenia and depression: Results from a survey of young Ghanaian adults.

This study examines attitudes of the young Ghanaian population regarding the relationship between causal beliefs and desire for social distance from people with symptoms of schizophrenia and depression. Respondents (n = 507) were presented with depression and schizophrenia symptoms using unlabeled case vignettes. A factor analysis examined three factors for causal beliefs, and multiple linear regression analysis on the desire for social distance was conducted. The desire for social distance was higher when symptoms in both case-vignettes were attributed to childhood adversities and overall lower when respondents lived in northern regions of Ghana. Only, for vignettes depicting schizophrenia, mental illness attribution was associated with more desire for social distance. Significant gender effects were found for depression vignettes only: female respondents reported significantly more desire for social distance, whereas female gendered vignettes were associated with less desire for social distance by respondents of both genders.