restricted access 20. Embodiment and Enactment in Cultural Psychiatry
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20  Embodiment and Enactment in Cultural Psychiatry Cultural psychiatry aims to understand the implications of cultural diversity for psychopathology , illness experience, and intervention. The emerging paradigms of embodiment and enactment in cognitive science provide ways to approach this diversity in terms of bodily and intersubjective experience and narrative practices. In turn, cultural psychiatry provides striking examples of how cultural variations in ways of life and social contexts shape embodied experience. While evolutionary history reaches all the way up from brain circuitry to cultural forms of life, culture reaches all the way down to neuroplastic circuitry and epigenetic regulation; hence, human biology is fundamentally cultural biology and human environments are social environments, constituted by relationships with others and with cooperatively constructed institutions and practices. The implication for psychiatry is that current efforts to explain the mechanisms of mental disorders in terms of brain circuitry must be complemented with models of the social interactions that shape both the content and process of psychopathology. Recent work has begun to apply embodied and enactivist approaches to understanding mental disorders (Colombetti 2013; Fuchs 2009; Fuchs and Schlimme 2009; Zatti and Zarbo 2015). We believe that cultural psychiatry stands to gain a great deal from these new paradigms . This chapter will outline an approach to the cultural neurophenomenology of mental disorders that focuses on the interplay of culturally shaped developmental processes and modes of neural information processing that are reflected in embodied experience, narrative practices that are structured by ideologies of personhood, culturally shared ontologies or expectations, and situated modes of enactment that reflect social positioning and selffashioning . Research on metaphor theory suggests ways to connect the approaches to embodiment and enactment in cognitive science with the rich literature on the cultural shaping of illness experience in current medical and psychological anthropology. The resulting view of cultural enactment has broad implications for psychiatric theory, research, and practice, which we will illustrate with examples from the study of the phenomenology of delusions. Laurence J. Kirmayer and Maxwell J. D. Ramstead 398 L. J. Kirmayer and M. J. D. Ramstead 1  The Perspectives of Cultural Psychiatry Cultural psychiatry calls on the resources of cognitive and social science to provide a more comprehensive model of normal functioning and affliction that can include the wide variations in illness experience seen across cultures and communities. Accounting for this variation requires theory that spans individual neurobiology, psychology, and sociocultural processes (Kirmayer and Gold 2012; Kendler 2014). Older models have tended to approach culture and social context in terms of lists of individual traits, internalized representations, or beliefs. The emerging paradigms of embodiment and enactment provide new ways to think about the influence of context on behavior and experience. In particular, they offer approaches to organism-environment interaction that emphasize the co-emergence of mind and culture over evolutionary, developmental, and everyday timescales (Leung et al. 2011; Seligman, Choudhury, and Kirmayer 2016). A key element of these processes for psychiatry is the intersubjective grounding of experience through modes of embodied interpersonal interaction, cooperation, and collaboration (Fuchs and De Jaegher 2009). The engagement with cognitive science can work in the other direction as well. Cultural psychiatry can contribute to the study of intersubjectivity by providing compelling examples of pathology that reveal some of the taken-for-granted, implicit assumptions of regnant theories , and expose the fault lines in the everyday construction of reality (Gold and Gold 2014). A specific symptom or syndrome can provide a focus for interdisciplinary analysis. Attention to cultural variation serves to foreground social context and encourages theorists to test models against the diversity of human experience. Of course, psychiatry not only provides privileged access to uniquely instructive kinds of experiences but, as a clinical discipline, also presents a set of tasks with their own epistemic challenges and social consequences. The clinical engagement with suffering brings with it the urgent imperative to acknowledge and respond to the other—their face, voice, presence, or perspective—in an ethics of intersubjective encounter (Kirmayer 2015a). The mandate to take helpful action requires tracing the effects of theoretical models through clinical and social practices to their impact on individuals and communities. Ethnographic research and intercultural clinical work have found both commonalities and substantial variability in the ways that people experience and express mental disorders (Kirmayer 2006; Larøi et al. 2014). This has sometimes been framed in terms of a distinction between pathogenesis, involving putative underlying mechanisms of mental disorder that are assumed to be based on universal aspects of human neurobiology, and pathoplasticity , the...