Belonging is to Social Psychiatry What Attachment is to Child Psychiatry

“[T] he essence of human tragedy (lies in) loneliness, not in conflict” —Frieda Fromm-Reichmann[1] At the WASP/Royal College of Psychiatrists Joint World Congress of Social Psychiatry in London this year, I gave my inaugural address as President of WASP about attachment, family, and social systems, published in this commemorative issue.[2] The connecting thread through all of those systems is belonging which also happens to be the hallmark of social psychiatry. Knowledgeable leaders have informed me that I am among the first, if not the first, child and family psychiatrists to head a major world association of psychiatry that is not specifically dedicated to Child and Adolescent Psychiatry. This focus on attachment, which is the heart of child psychiatry; the family, which is the core constituency of family therapy in all its guises, from structural to strategic to systemic therapies; and social systems, which are the main preoccupation of social psychiatry, arises as an emergent practice of child and family psychiatry and our allied professions in children's mental health as varied as psychology, social work, and nurse practitioners. It was a connection waiting to be acknowledged and I was delighted to contribute to this journal's recent special theme issue on “Child Mental Health and Social Psychiatry.”[3] CENTRIFUGAL VERSUS CENTRIPETAL VALUES In an era of equality, diversity, and inclusiveness, whose recognition is now a transformative goal of Western culture, embraced by cultural psychiatry and the global mental health movement, we are simultaneously living through centrifugal forces of dispersion, disconnection, and divergence – with a consequent fragmentation of identity leading in many quarters to pernicious polarizations. The World Values Survey produces the Inglehart–Welzel World Cultural Map [Figure 1].[4] The map presents empirical evidence of two opposing trends: massive cultural change and the persistence of distinctive cultural traditions. The main thesis is that socioeconomic development confronts the historical expression of distinctive value orientations. Political scientists Ronald Inglehart and Christian Welzel observe two major dimensions of cross-cultural variation in the world: (1) Traditional values versus Secular-rational values and (2) Survival values versus Self-expression values.[4] The Inglehart–Welzel World Cultural Map is also congruent with my characterization of centripetal versus centrifugal trends in the social sciences and in social psychiatry contrasted with cultural psychiatry.[5,6] The traditional and survival values of the World Cultural Map are congruent with the centripetal values of Social Psychiatry whereas the secular and self-expression values reflect the centrifugal impacts of Cultural Psychiatry.Figure 1: The Inglehart–Welzel World Cultural Map 2023[4]PLURALISM – A RAPPROCHEMENT Is a rapprochement between such polarizing contrasts possible? The answer is yes. There is a series of movements worldwide that lean to the political left, meaning a critique of capitalism and social power structures, that have been cataloged in an informative compendium called Pluriverse: A Post-Development Dictionary.[7,8] Its first line is, “The idea of development stands like a ruin in the intellectual landscape.” You might think that “development” would be a welcome notion to a child psychiatrist but I have long been a critic of this notion from the study of children's growth[9] to its application in economics, international relations, and politics.[10] As this volume states, “Development' is a plastic word, an empty term with positive signification.”[7] In a brilliant essay, Poerksen[11] describes plastic words as “context-autonomous” words that “superficially resemble the terms of science, but lack the precisely defined meanings of such terms, and their freedom from associations.” This is as true for how development is deployed in child psychology and psychiatry as it is for economics and politics. This compendium offers a critique of developmentalism along with over 100 essays documenting local alternatives. Although it may seem a mere semantic nuance, I would replace “diversity” which has become divisive with “pluralism” which embraces and warmly welcomes local traditions and smaller communities. In fact, the guiding value in this entire volume is Illich's conviviality, defined as “individual freedom realized in personal interdependence and, as such, an intrinsic ethical value.”[12] SOCIAL PSYCHIATRY'S GUIDING VALUES: BELONGING AND cONVIVIALITY In highlighting belonging as the connecting thread through attachment, family, and social systems, I am arguing for the centripetal trends of convergence, integration, and social solidarity as the guiding values of social psychiatry. Moreover, the vehicle for belonging and its aliases is conviviality, as Illich has defined it.[12] PROPOSED THEMES FOR THE WASP TRIENNIUM 2022–2025 Here are three interlinked themes and tasks for WASP and for social psychiatry: Attachment, family, and social systems “Belonging is to social psychiatry what attachment is to child psychiatry.” Overarching theme: belonging The vagaries of social disconnection and isolation, documented in a prescient article on loneliness in 1959 by Fromm-Reichmann,[1] are the stuff of human tragedy beyond psychiatry's current descriptive nosography. Already in 1890, James limned the outlines of this tragedy: “No more fiendish punishment could be devised … than that one should be turned loose in society and remain absolutely unnoticed by the members thereof.”[13] Thousands if not millions of people in the contemporary world feel this sting of invisibility and its accompanying loss of meaning which may lead to despair or violence. Social psychiatry needs to take this seriously at every level, from the impact of loneliness and social isolation on communities to clinical practice. Attachment theory and systems theory have led to attachment-based therapy and family therapy; both approaches are based on the core social relationships of every society – the parent–child bond and family kinship – and on constructing a therapeutic alliance which mimics those primary relationships. We now need a compelling theory of social structures and systems that will stimulate new kinds of social therapy, modeled on the Brazilian Integrative Community Therapy.[14] Intergenerational transmission of family, communal, and social systems and structures The intergenerational transmission of family, communal, and social systems and structures is now well established with clinical observations and epidemiological and research studies. From trauma studies to epigenetics, we have now amply documented the impacts of adversity and stress across individual lifespans (adverse childhood experience [ACE] study)[15] and across several generations.[16,17] An example was our pioneering study of grandchildren of Holocaust survivors in Montreal.[18] Connecting thread: The mechanisms of such transmissions are represented by the Social Determinants of Mental Health (SDoMHs)[16,17] and ACEs.[15] Social psychiatry can be the integrative and synthesizing approach that situates these intergenerational phenomena into a comprehensive framework. From populations to patients, from social to personal being Methodology: Translational research of SDoMHs and ACEs at ground level. With its populational approach, epidemiological focus, and commitment to community mental health, social psychiatry may be criticized as being distant from individuals and their suffering. Social psychiatry has been “cruising at 35,000 feet.”[19] It's past time to bring social psychiatric research and practice down to ground level – at the clinic (therapy), in the community (outreach), with public information and professional training (education), and for health-care planning (policy making).[17] I call this going from populations to patients and from social to personal being. Moreover, social psychiatry is uniquely positioned to straddle these poles and to forge bridges and syntheses for a more comprehensive, responsive, and responsible 21st-century psychiatry. Acknowledgments The author expresses his gratitude to H. Steven Moffic and Eliot Sorel, two leading social psychiatrists who provided valuable suggestions for this editorial.

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