The Tension Between Macroculture and Microculture in Psychiatry
The Tension Between Macroculture and Microculture in Psychiatry
Macroculture and microculture describe different levels of cultural analysis, reflecting the scale and scope of cultural influences and behaviors within a society. Both macrocultures and microcultures coexist, interacting and influencing each other within a society.
Macroculture is the overarching or dominant culture in a society or group. It encompasses the shared values, norms, beliefs, practices, and institutions that are widely recognized. It drives major social institutions and is the broad cultural context that shapes the general way of life of a population. Microculture is the culture of smaller groups within a larger society, often distinguished by specific characteristics or practices. It consists of the unique behaviors, beliefs, and practices of subgroups, which differ from the dominant macroculture. Microcultures often have their own norms and values that might coexist with or diverge from those of the macroculture.
has ardently written on his Substack, The Honest Broker, about the growing tension between macroculture and microculture with regards to art, music, entertainment, and journalism. He has predicted, and has subsequently been documenting, the erosion of an increasingly impoverished macroculture by diverse, energetic microcultures. Legacy media is collapsing, and alternative platforms are booming. For example, independent content creators on YouTube are collectively generating revenue at par with or even exceeding that of platforms such as Netflix.In June 2024, Gioia wrote:
“Late last year, I predicted that the Microculture will triumph over the Macroculture in 2024. In other words, indie journalism—operating on Substack, YouTube, Patreon, Medium, and other self-directed platforms—will increasingly shape the cultural dialogue, while legacy media struggles for survival. Even before January was over, this forecast got validated in a series of collapses and downsizings at major media outlets.”
Gioia notes that people leading legacy media institutions seem clueless and uncurious about these developments.
“The most curious part of this is how people working inside the macroculture are the only folks who don’t understand what’s going on…
At this juncture in history, you must fill openings in stagnant old media by hiring people who understand the rapidly growing new media. The data is clear on this—if you want to grow, you need to learn from podcasts, YouTube channels, Substack, Bandcamp, Patreon, and all the other success stories.
But it’s not happening. The macroculture is frozen. It has forgotten how to maneuver. It definitely has forgotten how to learn.”
“Alt media has huge influence on the public in ways most elites can’t even begin to grasp—because they operate in an echo chamber that shuts out this reality.”
Gioia recalls the dominance of macroculture earlier in his life:
“In my childhood, everything was controlled by a monoculture. There were only three national TV networks, but they were pretty much the same… When I went to work in an office, back then, we had all watched the same thing on TV the night before. We had all seen the same movie the previous weekend. We had all heard the same song on the radio while driving to work.
And that’s why smart people back then paid attention to the counterculture.
The counterculture might be crazy or foolish or even boring. But it was still your only chance to break out of the monolithic macroculture.”
“The Internet should have changed all this. And it did—but not much. Even now the collapse in the monoculture is still in its early stages.
But that’s about to change… we still live in a macro culture. But it feels increasingly claustrophobic. Or even worse, it feels dead.”
Thanks to Gioia’s analyses of these developments, I have also been thinking about how the tension between macroculture and microculture plays out in psychiatry, clinical psychology, and the mental healthcare fields.
In the 1980s and onwards, there was a big push towards standardization and quality control in medicine and clinical psychology. A lot of it was driven by economic and political developments, such as the rise of managed care in the US, but a lot of it was also a reflection of the emerging ideal of “evidence-based medicine.” Practice guidelines issued by various associations (such as the American Psychiatric Association and the American Psychological Association in the US) and national institutes (such as NICE in the UK) began to shape and constrain clinical practice. Deviation from the standard of care came with anxieties about liability and malpractice. Official diagnostic criteria in the form of the DSM and ICD dominated clinical training and public education. Evidence-based pharmacological algorithms and evidence-based psychotherapies were heavily promoted. This convergence of the interests of healthcare bureaucracies and ideological trends in medicine created a macroculture in psychiatry and clinical psychology of unprecedented dominance. The influence of macroculture is not absolute, far from it—arguably, the influence of macroculture in psychiatry is still weaker than it is in the rest of medicine—and there remain significant pockets of resistance, and clinicians continue to practice in somewhat idiosyncratic ways driven by the peculiarities of their training and ideological affinities. At the turn of the millennium, the macroculture in psychiatry was still trying to juggle medical-diagnostic thinking and psychodynamic thinking—a struggle beautifully captured in Tanya Luhrmann’s Of Two Minds (2000)—and subsequently, the institutional power of the psychodynamic camp has been further diminished. These shifts in macroculture have created new winners and losers. The resentment of macroculture’s dominance may in fact be a major motivator of the hostility toward the DSM and psychopharmacology seen in many areas of mental healthcare.
Comparatively speaking, there has been a considerable standardization of the manner in which patients are diagnosed and treated in the clinic. The reality of the care provided falls well short of the aspirations, due to various structural constraints and a general lack of resources and time. The care provided is relatively uniform but also relatively impoverished.
Just as smart people working within mainstream media pay attention to countercultural trends, smart people in the psy-fields pay attention to various microcultural trends in the field, ideological pockets where people are challenging the macroculture. Some microcultures have gone on to acquire considerable public and professional influence, and aspects of these microcultures have been integrated into the macroculture. Think of trauma-informed care, neurodiversity, EMDR, Internal Family Systems therapy, psychedelic treatments, nutritional psychiatry, etc.
Macroculture in medicine has managed this integration process through an insistence on randomized clinical trials for new treatments and through a tight control of research funding (thereby determining what gets studied and who gets to accumulate evidence). Professional disagreements in macroculture have also been mostly managed via academic journals under editorial scrutiny and peer review.
The result has been that microcultures in healthcare remain limited in their ability to shape the macroculture. Tactics that work in other cultural and political spheres have limited ability to create large shifts in the macroculture of clinical practice unless they are also able to recruit the medical training and research funding apparatus to their advantage (pharmaceutical companies were exceptionally successful in pulling this off).
What has often been described in terms of “paradigm shift” in psychiatry and psychology may be better understood in terms of shifts in the dominant macroculture (some would argue that we are still scientifically pre-paradigmatic in psychiatry and clinical psychology).
We must also distinguish the macroculture within psy-professions, reflected by practice guidelines and clinical practice on the ground, from broader societal trends and developments that intersect with healthcare. We often see large shifts in public opinions and attitudes. This happens through the usual channels of sociocultural commentary: books, films, social media, TikTok, etc. Think of the popularity of books such as The Body Keeps the Score or Brain Energy, or content related to autism and ADHD on TikTok. People who work at the medicine-society interface are acutely aware of such trends, but average clinicians may be blissfully ignorant.
The internet has energized the dynamics of microculture and facilitated the development of vocal communities of people with shared experiences or ideological views. The harmed patient and psychiatric survivors communities exist as microcultures, as do critical psychiatry, neurodiversity, and Mad in America. The development of blogs, newsletters, podcasts, etc. has snatched some power from academic institutions when it comes to the process of critique, commentary, and opinion formation. “Weird nerds” are being driven out of academia (see
’s analysis of this here and here) but they remain active commentators through various online platforms. Some of the most astute scientific commentary and critique I come across these days is not in peer-reviewed academic journals but on X/Twitter and Substack. Folks such as Scott Alexander ( ) have been very successful in building influential microcultures around them.The collective goal should be to find a healthy dynamic between macroculture and microculture. Microculture is the site of creativity, diversity, innovation, and speculation. But microculture is also the site of quackery, pseudoscience, conspiracies, misinformation, and ideological dogma. There are large online communities around, for example, nutritional interventions, psychedelics, and shamanic healing operating in parallel to healthcare institutions. The fact that online communities of thousands of people help each other through the process of complicated or protracted withdrawal from psychotropic medications on their own reflects the practical influence of microculture.
In medicine and clinical psychology, where the stakes are high, it is to be expected that ideas should make their way from microcultures to macroculture through a process of filtration and vetting. This process of filtration and vetting has been stifled, perhaps even corrupted, but wise people in the field are paying attention to microcultures devoted to scientific scrutiny of evidence, uncovering fraud, iatrogenic harm, service-user activism, psychedelic experimentation, sociopolitical examination of disability, neuroscientific speculation, and conceptual commentary, among others. There is a flourishing of microcultures, with all the good and the bad that accompanies it, and if the hollowed-out macroculture is to regenerate, it must look to and learn from microcultures.
See also:
Insightful analysis, that the pharmaceutical companies were able to capture the macro-culture of psychiatry, because they captured the medical training and research funding. They will continue to hold psychiatry to their agenda, because there always is a supply of chemicals that they can hype up and make billions in profit, despite marginal, or non-existent benefit (ketamine is the latest example). Given their vast wealth, they will always be able to co-opt training and funding.
“The result has been that microcultures in healthcare remain limited in their ability to shape the macroculture. Tactics that work in other cultural and political spheres have limited ability to create large shifts in the macroculture of clinical practice unless they are also able to recruit the medical training and research funding apparatus to their advantage (pharmaceutical companies were exceptionally successful in pulling this off).”
I’d agree, but I think digital can really shake this up. Relatively small and low-resource organisations (compared to pharma companies, anyway) have the ability to develop and roll out new therapeutic interventions rapidly and at scale. But establishing a meeting of minds between academia, clinicians, and tech is the challenge.