Matrix Medicine: How Psychiatry can Adapt Personalized Insights about Culture into Scalable Interventions

As a physician, I am interested in how we make explanations of all the possible things that come into the clinic. How do we choose whether some phenomena is a derangement of biology or environment?

Psychiatric MD’s like me, interested in the complex interplay between the environment and mental health, particularly involving complex questions of place, heritage, and individual identity, have most recently been called “cultural psychiatrists.”  The relative contribution of culture to thinking about psychiatric issues is in flux as fads about causation work their way through the decades and fields, but it is safe to say that the most recent thinking about the role of culture and environment only came with the decline of classical psychoanalysis in the 1950’s and 1960’s and also with movements in the United States and Canada like social and community psychiatry, which identified the source of mental illness in derangements in community (and made those sites the area of intervention).  

So what’s not to like?  The main problem with cultural psychiatry in my opinion, was the creeping misapplication into medical education as “cultural competence.” Although the goals around reducing poor health outcomes for minority groups, immigrants, and the poor were laudable, cultural competence simply reinforced stereotypes about ethnic groups and behavior.  Instead of expanding understanding about the complex interplay of culture, environment, behavior, and mental health, cultural competence robbed the field of vitality and its historically personalized nature. 

Fast forward to 2013 and personalized medicine is the buzzword in medicine.  By personalized medicine, in general, I mean taking specific insights tailored to individuals to decide on maximally efficacious treatments and therapies.  

However, personalized medicine in application has become closely related to genomics, the analysis of DNA signatures to determine optimal therapies.  While this reductive biological model seems promising for certain disorders, (for example, certain kinds of cancers), not only does it ignore other potential applications of personalized medicine it seems challenging to apply to the complex, chronic behavioral disorders (like obesity) that are responsible for huge medical costs and involve complex interplays between genome and environment.   These highly personal intricacies were, in my opinion, consistent with the original focus of cultural psychiatry, and in fact should pave the way future for its evolution out of cultural competence. 

This does not imply a ideological war between biology and environment.  Indeed, single minded explanations of complex phenomena with simplistic explanations should be labeled for what they are -- dogmas.  Certain methodologies can free us from these restrictions, however.  Psychiatric pluralism, an approach advocated by certain traditions within psychiatry, allows us to pick and choose, on the individual level, the relative contributions of environmental causation in a single patient (this is in contrast to psychiatric eclecticism, the dominant model by some measures today, where every explanation is granted a fair showing).  

Armed with pluralism we can then begin to develop a classification system of problems in the clinic based on a combination of simple pattern recognition and patient’s individual subjective experience.  Although every individual is unique, we should start to see patterns among subjective experience that may offer a path toward greater generalization.