The Social World Is Something We Collectively Create
Giulio Ongaro explores what this means for our approach to mental healthcare in a guest post and accompanying Q&A
Giulio Ongaro, PhD, is an Assistant Professor in Anthropology at the Hong Kong University of Science and Technology (HKUST). He conducted long-term ethnographic fieldwork among the Akha people of highland Laos, studying their medical philosophy, shamanic tradition, and system of ritual healing. He focused particularly on how healing rituals work and how people think that they work. In parallel to his anthropological studies, he conducted research within the science of the ‘placebo effect’ in collaboration with an interdisciplinary team from Harvard Medical School. At HKUST, he teaches courses on cultural psychiatry, social anthropology, and global history. Bringing all these strands of research together, he is currently writing a book on the global history of psychiatry.
This post is about a set of 3 papers he published in 2024 in the journal Philosophy, Psychiatry, and Psychology. The papers are open-access.
Outline for an Externalist Psychiatry (1): Or, How to Fully Realize the Biopsychosocial Model
Outline for an Externalist Psychiatry (2): An Anthropological Detour

Taking a course of SSRIs; going through sessions of cognitive-behavioural therapy; finding a job one thrives in—these are all proven means of lifting people out of a condition like depression, effective to varying degrees depending on the case, and often in combination. Psychiatry can offer the first two classes of treatments: the biological and psychological. The third one, the social, lies largely outside its remit, subject to the unpredictability of life events and at the mercy of socio-economic conditions. This observation alone exposes a key limitation of the ‘biopsychosocial’ (BPS) model of health, which survives in truncated form because the treatments available for dealing with the bio and psycho dimensions of illness are nowhere near as developed when it comes to the social. In practice, the ‘social’ in the BPS model is mostly collapsed into the ‘psychological.’
This situation puts psychiatry in a sorry spot vis-à-vis the society that decided to create it. Psychiatry holds little influence over unemployment, housing insecurity, discrimination, class struggle, or social isolation—all factors that, epidemiologically speaking, are major contributors to the cases of mental illness that it must treat in the clinic. Practitioners are thus compelled to treat with bio-psychological means disorders that might be largely social in origin. This process has been termed ‘medicalization’ or ‘psychologization’ of mental illness, depending on the context, and it is, at root, a paradoxical process. It is paradoxical because it exists within a larger social discourse around mental health that privileges methods over outcomes. Imagine a scenario where a newly discovered drug reduces depression rates by, say, 20%. The fact that this (extremely unlikely) event would be hailed as a Nobel prize-worthy breakthrough, while it is much more plausible to achieve the same outcome by way of political action, is eloquent of the lopsided position of psychiatric practice in relation to the society that funds it. The pervasive framing of mental illness as a mind/brain phenomenon prevents this paradox from playing out in public consciousness.
We then come to treat this situation as a natural state of affairs, to the point that it is almost impossible to imagine what a ‘social treatment’ might look like. There are, however, places in the world where the relationship between society and mental healthcare is configured in radically different ways. I suggest that it is worth looking at these places, beyond the orbit of modern psychiatry, as we encounter philosophies of psychiatry that have much to teach us. At the very least, they might be ‘good to think with’ as we deal with the current mental health crisis.
For almost two years, I lived in highland Laos among the Akha, a group of village-based, rice-cultivating, livestock-raising people who have historically escaped the control of the lowland state, while developing a society that is in many ways antithetical to it. They are politically egalitarian rather than hierarchical, animists rather than Buddhists, swidden cultivators rather than permanent farmers, and maintain an oral rather than literary tradition. I quickly realized that many of the ‘social determinants of mental illness’ that are discussed in the sociological literature were either negligible or did not apply to the community I lived in. Unemployment? There is no wage labour. Housing? Guaranteed. Discrimination? While stigma falls on certain categories of people, such as the physically disabled, everyone feels part of the same egalitarian, classless society. Social isolation? It barely exists in a tightly knit community where loneliness is pathologized.
Akha society became for me a living demonstration that by changing what Marx called “material conditions,” one can achieve substantial upward effects on mental health. Proving this systematically is methodologically difficult, but we do have evidence of the presence of cultural elements known to be beneficial to healing and evidence of the absence of elements that are known to be counterproductive. As a growing chorus of anthropological voices suggests, therapeutic outcomes can be better elsewhere (e.g., Luhrmann & Marrow, 2016). In a recent series of papers in Philosophy, Psychiatry & Psychology (Ongaro, 2024a, 2024b, 2024c, 2024d), I sought to identify the key distinguishing element. I argued that it lies in externalism: the (partial) casting of both causes and treatments of mental illness onto the social environment.
Material conditions alone only go so far in shaping a society’s organization—much of it depends on its underlying values and ideology. Something one notices when living among the Akha is that ‘society’, from the Akha point of view, does not only encompass humans but also a plurality of non-human spirits that populate the environment and interact with humans. Conceived largely as disruptive forces, evil spirits can attack people out of spite or for being disturbed (they are imagined as a mirror image of actual lowlanders). Ancestors, on their part, offer protection but also punish moral breach. Health is experienced as intrinsically precarious because it is contingent on maintaining proper relationships with such spirits. Not every illness involves spirit affliction. Akha know that there are diseases, including chronic psychosis, that are not spirit-related and for which only ‘natural’ means, including modern medicine, can offer any hope of treatment. Spirits might merely exacerbate symptoms in this case. Nevertheless, Akha adhere to a BPS model of health where a range of biological (herbal and, recently, pharmacological) and psychological treatments (family-centred support) are integrated into a resourceful system of social treatments. I say ‘social’ because, in animistic contexts, sociality extends to relationships with spirits, who are understood to possess personhood and agency.
When someone falls ill and spirits are suspected, people think causally about what the spiritual source of the illness might be. They do so by connecting a personalized story to an elaborate and commonly shared etiological theory: for example, did she fall sick because she wronged the ancestors in some way? Or perhaps, while walking through the marshes yesterday, she disturbed a spirit living there? Once a spirit is identified as a potential culprit, people arrange a ritual sacrifice of domesticated animals to satisfy the spirit’s demands according to the theory. For instance, the ‘spirit of the rainbow’ may demand the sacrifice of two white chickens near a swampy area, while the spirit of a large tree demands the sacrifice of a dog, performed by using certain leaves, and so on. The theory is elaborate, allowing for many permutations of ritual elements.
If the illness is serious, people might summon the shaman, the person responsible for communicating directly with spirits, and who can appease them, remove the affliction, and restore peaceful relationships. Crucially, among the Akha the afflicted unit is never just the individual—it is the entire household. All family members must adhere to a set of rules and taboos and work together to prepare the shamanic ritual, which can last an entire night and involve the sacrifice of several animals. Relatives from other villages might also join, making the event a celebration of kinship and mutual care. I am loath to call this system a ‘religion.’ It is far more embedded in the social fabric than what the Abrahamic concept of ‘religion’—and its implied separation from the ‘secular’—suggests in the West. Within this culturally integrated system of livestock raising and animal sacrifice, spirits emerge as active agents in the social world, with shamans acting as intermediaries.
We tend to think of the shaman as a rudimentary type of, perhaps even a ‘precursor’ to, the psychotherapist. This assumption conceals profound differences between the two. As Claude Lévi-Strauss once noted, while “the psychotherapist listens, the shaman speaks.” (1963:195) Besides, the shaman speaks to the spirits, not to the person, who, at least in the Akha case, is often found sleeping in another room while the overnight ritual takes place. Shamanism is not primarily a patient-centered phenomenon.
The shaman speaks to the spirits, not to the person, who, at least in the Akha case, is often found sleeping in another room while the overnight ritual takes place. Shamanism is not primarily a patient-centered phenomenon.
We also tend to think that, when any of these rituals work, their effect is simply a ‘placebo effect’. Now, the term ‘placebo effect’ has been notoriously difficult to define. In its broadest sense, it refers to the effect of the psychosocial context on healing, i.e., everything that goes around the patient minus the active principle of the treatment. Except that we never think of describing something like the effect of finding a good job as a ‘placebo effect.’ We think of it as the result of a positive change in one’s social environment. I suggest that, because of the different material and ideological make-up of their society, it is equally misleading to think of the response to an Akha shamanic ritual as a ‘placebo effect.’ From the Akha point of view, these are changes in the person’s social environment.

To the extent that it is attributed to spirit action, illness is socialized rather than psychologized. From what I observed, this system brings two major benefits to the healing experience that we don’t see much within modern psychiatry. First, explaining illness through spirit affliction involves no stigma or epistemic injustice. Insofar as the blame falls on spirits rather than the person, the system preempts stigmatizing narratives associated with diagnosis. In recent years, biomedical psychiatry has been pushing for biogenetic explanations to address this very problem. Unfortunately, while their ability to soften stigma remains unclear, these diagnoses induce essentialist thinking around mental health, which can bring hopelessness and impede recovery (Haslam & Kvaale, 2015). This ‘trapping’ effect of psychiatric diagnosis—here lies the second benefit—is precisely what’s avoided when the disorder is socialized. By casting illness in terms of soul loss, which can be regained through sacrifice, Akha rituals already imply the possibility of healing in their very framing. Understanding illness as a rupture of the human-spirit relationship turns amorphous symptoms into meaningful and actionable experiences. It is not unreasonable to expect better therapeutic outcomes under these conditions.
You might be wondering about what the practical relevance of shamanic healing in highland Laos to modern psychiatry really is. For one, the comparison of medical systems illustrates the significance of political economy in shaping mental healthcare. It teaches that however valuable the efforts to reform psychiatry from within may be, these pale in comparison to what can be achieved through political action. In turn, material conditions can shape psychiatry’s theoretical framework. In an important sense, the Akha can afford an entirely different, and arguably more effective, kind of psychiatric system because they take care of primary material conditions first, such as housing and social connections. It would be difficult to frame depression as a spirit affliction if the sick person were a poor disowned homeless—at least not without potent ideological justification.
The Akha system is ‘good to think with’ because it lays bare the principles of externalism: the sick person’s condition should initially be associated with an external phenomenon (spirit) that is taken as its cause, which is then subjected to change (via ritual), which, it is hoped, will affect the course of the illness in turn.
The Akha system is also ‘good to think with’ because it lays bare the principles of externalism. The idea is that the sick person’s condition should initially be associated with an external phenomenon (spirit) that is taken as its cause, which is then subjected to change (via ritual), which, it is hoped, will affect the course of the illness in turn. This general principle needn’t be confined to spiritual phenomena. To imagine a hypothetical scenario, suppose a patient is persuaded to think of their condition as dependent on the success of an election or political movement. If the association is sufficiently strong, and the movement is successful, chances are that the condition will be affected for the better. The treatment does not lie in operating on the patient’s psyche; rather, the core of the treatment consists in making the initial externalized associations and letting the external world accomplish the rest. For this to occur, there must be a meaningful explanatory framework in place—held by a trusted community of people—within which these associations can be made. Belonging to a trusted community of people who share the same epistemic framework is really the key element here. To believe with a group is at least as important as what is believed in.
There are existing approaches that broadly follow these principles. I’ll mention two brief examples. One is liberation psychology in South America, a psychiatric movement designed to be effective in contexts of inequality, oppression, or warfare—all breeding grounds for psychiatric illness (Martín-Baró, 1996). The purpose of liberation psychology is to build narratives around these “social determinants of mental illness” so that they become meaningful social causes patients can use to explain their illness. The underlying premise is that individual transformation goes hand in hand with social transformation, and that linking one’s personal struggles to broader social issues is therapeutic in itself. The movement shares with Fanon (1965) the idea that, to achieve this, one must build collective consciousness among people in the same condition.
An altogether different approach is taken by the ‘Hearing Voices Network’ and associated support groups, which refuse to treat voices as a symptom of a disorder but seek instead to accept, engage with, and find meaning in them. The group’s ethos is based on the rejection of the notion of an objective social reality. The reason this community is therapeutic is that “people can only be supported to recover fully when the reality of hearing voices is also accepted by others and the meaningfulness is explored” (Romme, 2012:164).
Externalism goes hand in hand with denying there is anything ‘natural’ about the social world. Fundamentally, this is because the social world is something we collectively create and, therefore, something we can change.
What brings together these different approaches is a constructivist attitude toward social causation. Externalism goes hand in hand with denying there is anything ‘natural’ about the social world. Fundamentally, this is because the social world is something we collectively create and, therefore, something we can change—starting with addressing material conditions. As Jaime Breilh (2021) noted, the language of “social determinants of mental health” is somewhat misleading here because discussing individual risk factors in isolation (e.g., housing insecurity) risks divorcing them from the broader political processes that produce them. We should be talking about the “social determination of health” instead. Beyond material conditions, constructivism embraces the idea that explanatory narratives around psychiatric illness should be accepted based on the meaning they hold for the patient, regardless of whether they cling onto an objective social reality. In other words, treatments should be evaluated on their (testable) efficacy rather than the scientific ‘validity’ of the causes they aim to address. If social etiology were not confined to naturalistic explanations, we would be able to create externalist psychiatric treatments that are far more effective than the ones we have at present.
Q&A with Giulio Ongaro
Aftab: Giulio, your set of papers in Philosophy, Psychiatry, and Psychology is wonderfully provocative, and gave me a lot to think about. I am also glad that I get to feature and discuss your ideas in Psychiatry at the Margins.
Two things really intrigued me about your PPP articles. The first was your anthropological exploration of how the Akha understand what we call psychopathology to be instances of spirit-affliction that are addressed by elaborate shamanic rituals that are directed at the spirits to appease them. The second was your suggestion that our commitment to naturalism in the clinical psychological realm is a hinderance, that we are doing ourselves a disservice by restricting possible explanations of mental illnesses to natural phenomena, and that our treatments could be more effective if we were to give up that commitment and embrace a constructivist attitude toward social causation.
For the benefit of readers, can you summarize and restate what you see as the key differences between externalist approaches to psychopathology and contemporary public health and community approaches in psychiatry that focus on social determinants of health?
Ongaro: Thanks a million, Awais, for the opportunity to explain some of the key points from the PPP paper trio here in Psychiatry at the Margins. I’ll start by clarifying that both the public health approaches familiar to us and the kinds of approaches that were the focus of the PPP papers are externalist, as they both identify features of the external environment as the source of illness and the site of intervention. The first addresses the standard ‘social determinants of mental illness’ (e.g., material conditions defined by inequality, social isolation, class struggle, etc.); the second focuses on socially constructed ‘meaning’, which is culturally specific.
Modern social psychiatry has mostly focused on the first. A problem with this narrow focus is that there are many cases of illness that cannot be explained by the common ‘social determinants of illness’ but are still sociogenic in nature and can only be treated through externalist means (I would include many cases of functional neurological disorders into this category). Here, effective externalist treatments are those that bring about changes in the patient’s socially constructed world—a world constituted by collectively held meanings, values, and ideologies that are only indirectly shaped by ‘material conditions.’
Effective externalist treatments are those that bring about changes in the patient’s socially constructed world—a world constituted by collectively held meanings, values, and ideologies.
The two approaches are connected because, while standard public health measures can only go so far in treating the whole spectrum of sociogenic illness, addressing primary material conditions remains a prerequisite for collectively held narratives to emerge and take effect. This is why I speak of a ‘tension’ between material conditions and the possibilities of construction.
Aftab: Say more about why you treat shamanic rituals as interventions designed to change a person’s “social” environment (rather than as spiritual interventions).
Ongaro: Because spirits are one class of social agents. This is salient in contexts like the Akha’s, where spiritual beings are said to have the same defining attributes as humans, such as the soul, intentions, and essentialized roles and powers. At its core, this is the essence of ‘animism’ as defined in the anthropological literature: a way of engaging with the world in which personhood animates a variety of non-human entities that participate in one’s social world (see, e.g., Howell, 1984; Århem & Sprenger, 2016; Sahlins, 2022).
The main reason spirits should be considered part of the social world can be traced to a general human capacity to construct entities that transcend their physicality (Bloch 2013). There are contexts in which we act toward each other not based on how people appear to our senses but on their essentialized properties. We might act toward someone as a ‘professor’ or a ‘queen,’ regardless of the kind of person they are in their day-to-day life. Our engagement with the world is deeply infused with this type of imaginary, whereby we do not relate to physical individuals per se but to their invisible halo of essentialized roles and powers. Seen this way, spirituality is simply an extension of sociality and vice versa.
Among the Akha, this invisible halo extends to a wide range of non-human entities in the environment that people are always interacting with. Their intentions must be factored in on a regular basis: by avoiding certain places known to be spiritually dangerous, by performing offerings for ancestors in exchange for blessing, by leasing a piece of farmable land from the ‘spirit owner’ of that land, and so on. Ritual serves as the primary means of negotiating with them. A healing ritual may accomplish many things, such as bringing the family together, but it is primarily an act meant to restore relationships between humans and spirits—an event that, for the reasons just mentioned, results in a change in the social environment for the sick person.
Ultimately, the ontological distinction between ‘social’ and ‘spiritual’ is more analytical than phenomenological. Historically rooted in the Abrahamic tradition, this separation is alien to most worldviews around the globe. So, I think that speaking of a biopsychosociospiritual model is ethnocentric and misleading. We’d better stick to a BPS framework, while accepting that the nature of the ‘social’ environment can vary remarkably across cultures.
Aftab: Your commitment to a constructivist attitude toward social causation and the idea that “explanatory narratives around psychiatric illness should be accepted based on the meaning they hold for the patient” may give the impression that you are of the view that anything goes in this regard. It seems to me that certain explanatory narratives are going to be more conducive to well-being and flourishing than others, and to the extent that we understand this relationship, we should probably encourage narratives that lead to better outcomes. There is also a difference between making space for the meaning that psychiatric experiences have for a particular patient (no matter how idiosyncratic or ill-informed) and a collective (scientifically informed, one hopes) attitude towards the nature of psychopathology. It is one thing for a patient to believe that they experience mania because Mars is in retrograde and quite another for a society to treat astrology as a legitimate domain of inquiry. I want to hear your thoughts on this issue of creating clinical spaces where patients are encouraged to explore the meaning of their psychiatric experiences in a manner they see fit (e.g., Hearing Voices Network) versus social engineering our collective understanding of psychology and psychopathology in a manner that deviates from our best scientific understanding.
Ongaro: I was assuming a strong correlation between the positive meaning of the therapeutic narrative and its effectiveness for the patient, as far as social treatments are concerned (see Moerman, 2002). In this sense, my position could be rephrased as: anything goes as long as it is effective, regardless of whether the method aligns with psychiatry’s current standards. Certainly, some narratives will be more effective than others because of their different meanings. For example, DSM categories are partly considered as socially constructed due to their poor validity. However, these make for poor healing narratives because, being internalizing and non-etiological, they fail to provide patients with meaningful explanations for their condition.
I accept the distinction you make between individual and collective attitudes toward psychopathology. In the terms I laid out in the PPP papers, this would reflect a distinction between ‘psychological’ and ‘social’ approaches. In a way, a movement such as the Hearing Voices Network bridges the two because it is a collective effort to support individual explorations without stigma. To be clear, I am fully in favor of the development of novel psychological approaches in psychiatry (as well as biological ones). What I have been highlighting is the near absence—and the simultaneous necessity—of social ones.
Which brings me to your point about whether social approaches should be ‘scientifically informed.’ I think this depends on what you mean. If by ‘scientifically informed’ you mean applying to the social world the same naturalistic framework that is applied to the natural world then I disagree, on the grounds that there is a significant epistemological difference in how these two should be approached. As David Graeber would say to illustrate the distinction: if you managed to convince everyone on earth that you can breathe underwater, you would still drown if you tried, but if you convinced everyone that you were the King of France, then you would actually become the King of France. The takeaway is that the ‘social’ cannot be studied in the same way as the ‘natural’ because it is collectively constructed to various extents (Bhaskar, 2000; Tuomela, 2013). With notable exceptions, such as that of Collective Medicine in Latin America (Breilh, 2021), biopsychosocial psychiatry hasn’t really grappled with this distinction.
If by ‘scientifically informed’ you mean tested for efficacy, then I am entirely on board. It would be great to develop more sophisticated methods for evaluating therapeutic effectiveness. This is especially true for ‘transformative’ therapies (Waldram, 2013), where the main purpose, in the impossibility of eliminating the illness, is to fundamentally change the person so that they learn how to live with it. The methodological and theoretical question here is how to determine the appropriate criteria for defining the effectiveness of these therapies.
Aftab: I think we can say with a high degree of confidence that psychopathology is not caused by spirits. The Akha are wildly off the mark here as far as the truth of the matter is concerned. I also have some reservations regarding the efficacy of shamanic rituals, but I’ll assume that they are indeed reasonably effective. The question then arises: what explains the benefit? The way I see it, the explanation would have to be some combination of expectancy effects, participation in rituals of healing that make sense within one’s metaphysical worldview, a strong show of social support, optimism, etc. (What else could it be?) In your discussion, you seem to imply that there is an important difference between interventions directed at the person and interventions directed at something in a person’s social/spiritual world that is thought to be a cause of the condition. But if I am correct and what matters is expectancy and beliefs around the nature of the ritual, then efficacy should not depend on what the intervention is directed at but on what is believed to be the case by the person and the society.
Let me present you with a thought experiment. Imagine that one society believes that mental illness is caused by spirits. They have developed a ritual in which, in a room next to a severely depressed person, they place a dummy as a representative of the spirit, and all the family gathers together, a shaman says a prayer, and then they pass an electric current through the dummy to cure the person’s spirit affliction. In our world, we have rituals of our own in healthcare. Imagine a person receiving blinded sham-electroconvulsive therapy. They are cared for by nurses and doctors in their medical gowns and white coats. They undergo assessments. They believe that they are about to receive a powerful treatment. They go under anesthesia. Family members are in the waiting room. They receive a sham electric shock. They wake up and are told they have successfully received the treatment.
I would expect both procedures to be similarly effective on average, since the expected mechanisms of improvement in both cases are pretty similar—ritual, expectancy, support, etc. As we know from sham-controlled trials of ECT, improvement can be quite substantial in cases of sham-ECT. Do you have any reason to believe that a ritualized administration of electric current to a dummy to treat putative spirit affliction would outperform sham ECT administered to a patient? If so, why?
Ongaro: This is a great question because it allows me to clarify the core principles of an externalist psychiatry. Before getting to the gist of it, let me comment on your statement that the Akha are ‘wildly off the mark’ in explaining illness as a spirit affliction. It will also allow me to wrap up my answer to the previous question.
As you qualify your statement, the Akha are wildly off the mark if the truth of the matter is concerned. This is a big ‘if.’ An anthropologist working on the Akha in Thailand once remarked that, “For the Akha, truth and falsehood are not an issue” (Tooker, 1992:805) when it comes to spiritual customs. What matters is the correct practice of these customs. As for the metaphysical status of spirits—well, that remains open to debate.
I think this is correct and reflects my ethnographic observations as well. Over the two years I spent among the Akha, I met many people who, when discussing spirits in the abstract, were outright skeptical about their actual existence independent of people’s minds. They would ridicule the very idea or say that spirits exist only if people think they exist. That the very same people summoned a shaman to fend off spirits whenever they got sick was not lived as a contradiction. They could easily act ‘as if’ spirits existed—an ability to shift between “multiple orderings of reality” (Tambiah, 1990) that remains underappreciated in a modern context of all-encompassing naturalism (Seligman et al., 2008)
So, the Akha are wildly off the mark if we consider what they say about spirits to be akin to scientific theories, but doing so would be like comparing apples with oranges. Few anthropologists these days would agree that statements about spirits are truly statements about the factual nature of the world. Defining what they actually are has proven more challenging. Plenty of interpretations exist. One that I find illuminating involves placing them alongside statements about our own society, which, being deeply ingrained in common discourse, often escape the same level of theoretical scrutiny despite being similar in nature. For example, isn’t it extraordinarily commonplace in our own society to say things like, ‘Anyone who’s sufficiently determined and genuinely believes in themselves can become rich and successful,’ despite the obvious reality that, even if every single person woke up one morning determined to become the next Elon Musk, society is so arranged that there would still have to be bus drivers, janitors, and nurses? (Graeber, 2015). Clearly, such statements are not aimed at scientific truth. They reinforce norms, values, and ideology. They are about the social world and its main constituents. Arguably, the same can be said about many ‘apparently irrational beliefs’ anthropologists hear around the world (despite the fact that these, too, can sometimes be subjected to naturalizing ideologies (Haslanger, 2012; Kirmayer, 2024)).
Having noted this point, let me address the question of what explains the alleged benefit of a shamanic ritual. I agree with you that these benefits must result from ‘some combination of expectancy effects, participation in rituals of healing that make sense within one’s metaphysical worldview, a strong show of social support, optimism, etc.’ What else could it be? But it strikes me that no one ever feels the need to explain, for example, healing from depression that comes after finding a partner, a good job, or financial security as being the result of expectancy effects or other psychological variables. Insofar as these require an explanation at all, we typically attribute them to a positive change in the social environment. I think the same perspective should be applied to Akha rituals. This is because spirits—who are dealt with during rituals—constitute essential elements of the Akha social environment. To understand the nature of a treatment, we cannot view it in isolation; we must always consider to the social context in which it is embedded.
It seems to me that the issue of social context is precisely what is missing in your thought experiment. There is a key difference between an Akha ritual and a sham ECT. The difference lies in the fact that while ideas about spirits make up the Akha social world, ideas about ECT are nowhere near as relevant to the social world of patients undergoing ECT. An anthropologist who studied another ‘animistic medical system’ once wrote that, for such systems, “the elementary aspects of social life are the essential background to medicine” (Glick, 1967:39). This means that medical action in these contexts accomplishes a kind of social change. The same can’t be said of modern psychiatry, whose ideas, by contrast, form a compartmentalized sphere of knowledge that is mostly privy to therapists and do not constitute elementary aspects of the social life of the patient. For these reasons, I argue that the healing effect of a ritual among the Akha is more similar to the healing effect of finding a respectable job in our own society—i.e., a meaningful change in one’s social world—than it is to the effect that follows a placebo treatment. It’s not a psychological effect but a social one, from the Akha point of view.
The healing effect of a ritual among the Akha is more similar to the healing effect of finding a respectable job in our own society—i.e., a meaningful change in one’s social world—than it is to the effect that follows a placebo treatment.
This is not to say that the former is necessarily more effective than the latter. The appeal of the BPS model lies in its ability to tell apart between three distinct dimensions of illness, each of which may be more or less salient depending on the case. In some instances, psychological or biological interventions may prove more effective than social ones, and vice versa (as discussed in Paper 1). The central predicament of modern psychiatry is that the social dimension is recognized only in marginal ways.
Aftab: If I am right about the therapeutic power of rituals (they combine expectancy and social support in synergistic ways), then it is also natural to wonder about how far we can expect such effects to go. We already know that such effects can be substantial—we see them in placebo/sham groups in ECT, accelerated TMS, in deep brain stimulation, ketamine/esketamine trials, etc., but they are also generally inferior to active treatments. I wish we had a dedicated research program that was aimed at better understanding and optimizing the effects of medical rituals. I do think such a research program would yield important insights and would be clinically beneficial, but at the same time, how much more benefit can we realistically expect over current placebo/sham treatments, especially over the long-term and especially in serious and persistent mental illness?
Ongaro: As it happens, I’m currently writing a paper on this very topic—about the ‘reach’ of placebo effects. I think that the question of placebo power is best addressed by considering illness from an etiological point of view; that is, not in terms of symptoms or mechanisms, but in terms of its causes. All the evidence we have seems to indicate that placebo effects can be powerful to the extent that they act on components of illness that resulted from prior nocebo-like causes. However, they remain ineffective in reversing the proximate effects of bottom-up, physiological causes (see e.g. Benedetti et al., 2014). In other words, even when we witness strong placebo effects, this occurs because the condition in question was previously influenced by significant nocebo-like forces—cultural narratives, negative expectations, culturally specific ways of attending to the body, etc.—that amplified symptoms.
At first, this conclusion might seem to diminish the significance of placebo effects. However, it does not, once we recognize the extent to which we are inescapably exposed to cultural narratives, media messaging, myths, cultural schemas, explanatory models of illness, metaphors, interpersonal interactions, bodily forms of attention, and so on—all of which can potentially exacerbate symptoms through nocebo-like mechanisms, which the ritual helps to address. So the therapeutic ritual is always a vital component of treatment. This is further demonstrated by experiments showing that when treatment is administered to patients surreptitiously, without their awareness of being treated, outcomes are significantly lower (Benedetti et al., 2011; see also Ongaro & Kaptchuk, 2019).
One thing that strikes me, going back to the anthropology, is that many healing philosophies around the world express ideas about the power of rituals that, in their own idioms, parallel this view. Of course, the concept of ‘placebo’ is specific to the West, but the idea—central to Akha philosophy and many others—that healing rituals can only reverse spirit affliction but are helpless against natural causes of illness shows intriguing parallels with what we now know about the power and limitations of placebo effects.
Aftab: Anthropological work seems to suggest that sociocultural understanding of mind influences how psychotic phenomena such as voices are interpreted. A spiritual worldview allows for the possibility that non-physical entities—such as spirits, deities, and ancestors—have mental states and intentions that can influence individuals. In collectivist societies, the self is also thought to be more relational, with porous boundaries between oneself and others (including spirits). This facilitates a less distressing, less stigmatizing, and more spiritual and meaning-laden view of psychotic experiences. In the Western world, with an understanding of self as discrete and autonomous, with rigid boundaries separating the individual from external influences, hearing voices takes on a more intrusive, alien, and threatening quality that seems to contribute to both more distress and stigma. What are your thoughts on how we can develop social narratives that normalize psychiatric symptoms while recognizing psychopathological states and how we can offer individuals with serious mental illnesses non-stigmatizing meaningful identities and roles?
Ongaro: In the PPP papers, I have merely explored the gap that exists between the limitations of our own internalist system and the strengths of externalist ones. How to move from one situation to the other is a different challenge altogether. And, as a non-psychiatrist, I don’t have first-hand knowledge of the immediate practical difficulties psychiatrists may face when attempting to move things in that direction, so I have to be very general.
Still, knowing that this gap exists has several implications in itself. The awareness of alternatives naturally instills the belief that change is possible—and that it must come from a radical standpoint. Reformism within the field is no doubt valuable but is no match for what can be achieved through political transformation. In Paper 3, I argue that political transformation is the precondition for creating the kind of collective explanatory narratives that typify externalist systems. So, the future of psychiatry is political, as you also argued (Aftab, 2023), and a debate on how the discipline can acquire political consciousness now feels more vital than ever.
Another way of moving in that direction—one that feels more within reach—is for psychiatry to begin thinking of disorders etiologically, as most medical traditions do. This means downplaying the focus on symptoms or mechanisms as markers of disorders and instead defining illness as a composition of causes of different natures, which need to be addressed accordingly depending on their degree of influence. This way, the recognition of the biological dimension of illness won’t feel incompatible with the recognition of psychological and social dimensions, as is often the case in today’s psychiatry wars. It will also be far less stigmatizing because any blame falls on the cause rather than on the person to whom symptoms or mechanisms are attached.
Replacing the DSM with an etiology-based, biopsychosocial manual for psychiatric disorders would be a step toward this goal. For everything involving social causation, the next major goal would be to achieve a scenario where, to paraphrase Glick again, “the elementary aspects of social life become the essential background to social psychiatry.” Only in such a scenario can illness become, at least in part, what Szasz termed a “problem of living.” Ultimately, I think this will be more achievable through socio-political transformation rather than actions initiated by psychiatry itself. However, psychiatry can facilitate this transformation by recognizing explicitly that its current framework of scientific naturalism ends at the biological dimension and cannot be applied to the social dimension.
Aftab: Thank you!
See also:
References:
Aftab, A. (2023). The Future Is Political and Transdisciplinary. Philosophy, Psychiatry, & Psychology, 30(1), 5–6. https://doi.org/10.1353/ppp.2023.0002
Århem, K., & Sprenger, G. (Eds.). (2016). Animism in Southeast Asia. Routledge.
Benedetti, F., Carlino, E., & Pollo, A. (2011). Hidden administration of drugs. Clinical Pharmacology & Therapeutics, 90(5), 651–661.
Benedetti, F., Durando, J., & Vighetti, S. (2014). Nocebo and placebo modulation of hypobaric hypoxia headache involves the cyclooxygenase-prostaglandins pathway. Pain, 155(5), 921–928. https://doi.org/10.1016/j.pain.2014.01.016
Bhaskar, R. (2000). The possibility of naturalism: A philosophical critique of the contemporary human sciences (3. ed., reprinted). Routledge.
Bloch, M. (2013). In and out of each others’ bodies: Theory of mind, evolution, truth, and the nature of the social. Paradigm Publishers.
Breilh, J. (2021). Critical epidemiology and the people’s health. Oxford University Press.
Fanon, F. (1965). The wretched of the earth. Grove Press.
Graeber, D. (2015). Radical alterity is just another way of saying ‘reality’: A reply to Eduardo Viveiros de Castro. HAU: Journal of Ethnographic Theory, 5(2), Article 2. https://doi.org/10.14318/hau5.2.003
Haslam, N., & Kvaale, E. P. (2015). Biogenetic Explanations of Mental Disorder: The Mixed-Blessings Model. Current Directions in Psychological Science, 24(5), 399–404. https://doi.org/10.1177/0963721415588082
Howell, S. (1984). Society and cosmos: Chewong of peninsular Malaysia. Oxford University Press, USA.
Kirmayer, L. J. (2024). Grounding Psychiatry in the Body and the Social World. Philosophy, Psychiatry, & Psychology, 31(3), 315–319. https://doi.org/10.1353/ppp.2024.a937775
Lévi-Strauss, C. (1963). The Effectiveness of Symbols. In Structural Anthropology (pp. 181–201). Anchor Books.
Luhrmann, T. M., & Marrow, J. (Eds.). (2016). Our most troubling madness: Case studies in schizophrenia across cultures. University of California Press.
Martín-Baró, I., & Corne, S. (1996). Writings for a Liberation Psychology (A. Aon, Ed.; Reprint edition). Harvard University Press.
Moerman, D. E. (2002). Meaning, medicine, and the ‘placebo effect’. Cambridge University Press.
Ongaro, G. (2024a). Outline for an Externalist Psychiatry (1): Or, How to Fully Realize the Biopsychosocial Model. Philosophy, Psychiatry, & Psychology, 31(3), 269–284. https://doi.org/10.1353/ppp.2024.a937772
Ongaro, G. (2024b). Outline for an Externalist Psychiatry (2): An Anthropological Detour. Philosophy, Psychiatry, & Psychology, 31(3), 285–300. https://doi.org/10.1353/ppp.2024.a937773
Ongaro, G. (2024c). Outline for an Externalist Psychiatry (3): Social Etiology and the Tension Between Constraints and the Possibilities of Construction. Philosophy, Psychiatry, & Psychology, 31(3), 301–314. https://doi.org/10.1353/ppp.2024.a937774
Ongaro, G. (2024d). Social Psychiatry Inside-OUT. Philosophy, Psychiatry, & Psychology, 31(3), 341–346. https://doi.org/10.1353/ppp.2024.a937780
Ongaro, G., & Kaptchuk, T. J. (2019). Symptom perception, placebo effects, and the Bayesian brain: PAIN, 160(1), 1–4. https://doi.org/10.1097/j.pain.0000000000001367
Romme, M. (2012). Accepting and making sense of voices. In M. Romme & S. Escher (Eds.), Psychosis as a personal crisis: An experience-based approach (pp. 153–165). Routledge.
Sahlins, M. (2022). The new science of the enchanted universe: An anthropology of most of humanity. Princeton University Press.
Seligman, A. B., Weller, R. P., & Puett, M. J. (2008). Ritual and Its Consequences: An Essay on the Limits of Sincerity (Illustrated edition). Oxford University Press.
Tambiah, S. (1990). Magic, Science and Religion and the Scope of Rationality: 1984. Cambridge University Press.
Tooker, D. E. (1992). Identity Systems of Highland Burma: ‘Belief’, Akha Zan, and a Critique of Interiorized Notions of Ethno-Religious Identity. Man, 27(4), 799–819. JSTOR. https://doi.org/10.2307/2804175
Tuomela, R. (2013). Social ontology: Collective intentionality and group agents. Oxford University Press.
Waldram, J. B. (2013). Transformative and restorative processes: Revisiting the question of efficacy of indigenous healing. Medical Anthropology, 32(3), 191–207.