Self,spirituality and social psychiatry

The concept of self and identity are interlinked. Even when people use the identity as a basis of describing who they are, their concepts of the self are important. The identity of the self is very strongly influenced by cultures they are born in, grow up in, work in or play in. These values are often absorbed insidiously and unconsciously. Identity of the self can be fluid and dynamic.

Cultures have been classified as ego-centric or individualistic and socio-centric or collectivist (see Hofstede, 1980/2000). However, that is not to say that every individual born and brought up in one type of culture will have similar characteristics. Throughout one’s physical and psychological development, attitudes, views and behaviours change. People’s responses to na individual’s identity also change according to a number of factors most of which are likely to be social. Fromm (1941, 1947) recognised inner and essential nature of human beings which were identified as ego and Rosenberg (1979) further explored the concepts of self both descriptively and in research studies. In an interesting formulation, Maslow (1954) described the self as a construct of self-awareness but also as experience thus bringing in a behavioural dimension.

Rosenberg (1979, p. 6) differentiated self from the concept of ego in psychoanalytic terms. Symonds (1951) described self as a key set of intellectual processes by which the individual can cope with and manage their own personal reality related to the notions of id (Rosenberg, 1979, p. 7). Self-concept or the concept of the self takes account of totality of an individual’s thoughts and feelings with reference to themselves as an object (Rosenberg, 1979, p. 8) which raises interesting questions about self-perception as an object in relationship with other objects including other human beings. Following on from these concepts, while studying the self, three components have been identified which are clearly related to self-identity and self-perception. These include: the extant self (i.e. how the individual sees themselves), the desired self (how they would like to see themselves) and the presenting self (how they show themselves to others). Building on these, Rosenberg (1979) argued for four principles: reflected appraisals (direct reflection), social comparisons, self -attribution and psychological centrality. Undoubtedly these components are not going to be similar to the same level across cultures and do vary across cultures. Furthermore, the concepts of self and identity also include how one sees others seeing them and how they see others seeing them. This reflection of identity and self-concept varies across cultures but also focusses on individual’s sense of belonging. It is entirely possible that individuals from socio-centric cultures may be better cognisant of their extant self, whereas in egocentric cultures it is possible that presenting self may be more significant. These subtle distinctions are important in the context of clinical social psychiatry and patient engagement, but these may also influence how spirituality comes into the equation in diagnosing and managing psychiatric illnesses. In addition to types of cultures other factors such as gender, religion, race, age, socio-economic status, education, place of work etc provide multiple micro-identities which can be seen as a mosaic of components of identity. Thus, depending upon where the specific focus is, only that part of identity may be shown or seen. These abstract categories of micro-identities can also be liberal, intelligent, kindly, brave, good, knowledgeable, skilled, outgoing and friendly era (Rosenberg, 1979, p. 15). Social identity can be understood in the context of these micro-identities.

Cultural meanings affect and may alter concepts of self (Hofstede, 1980/2000; Morris, 1994). Morris (1994) focusses on the concepts of self which he sees as being strongly influenced by cultural meanings. The perceptions and preservations of the self are very strongly influenced by cultural and social factors of which religion (religious rituals and actions) can be quite an important component in some cases. Personal identity is fused with group affiliation which could include religious affiliations. Morris (1994) points out distinctions between Western concepts of the self from that of the Eastern one. Johnson (1985) sees Western concept as an analytic orientation tending towards the objectification of ‘external’ objects which with self-identity as an object makes us aware of a strong, rigid subject/object dualism. This dualism can be seen similar to spirit and body which are often seen as separate and rigidly defined in Western medicine following Cartesian dualism. This dualism does not exist in some cultures and healthcare systems whereas it takes a somewhat different shape in others. Very often the Western conception of the self is individualistic (egocentric) and materialistic and rationalist (Morris 1994, p. 16). This raises a rather difficult philosophical question as to whether non-Western concepts are thus seen as non-rationalist but again these are very much Western notions. Morris (1994, p. 17 onwards) challenges these perceptions including Cartesian mind-body dualism and argues that class differences may play a role too. In support of Gould (1984) and Grimshaw (1986) he points out the role capitalist system may play in modes of thought and consequently behaviours where gender itself may play an important role (also see Harris, 1989). It must be highlighted that the concept of the West itself is a broad one including Western Europe, USA and Australia and New Zealand. In many parts of the USA, Christian evangelism and other variants appear to be flourishing which challenge some of these assumptions about the self and identity.

Cultures also therefore help mould concepts of spirituality which can be seen as collective or individualistic-whether these activities are conducted by oneself or in a group. Looking at these components of identity in the context of attitudes and values, spirituality can play a major role. This also allows cultural values to be imbibed at an early age.

Spirituality

Religion and spirituality are important in understanding mental illnesses and their implications but also on mental health for a number of reasons. Moreira-Almeida and Bhugra (2021) defined spirituality as the relationship or contact with a transcendent realm of reality that is conceived, sacred, the ultimate truth or reality. They highlight that religion/spirituality are important in managing mental illnesses for several reasons. Partly this is because religion/spirituality are extremely important part of daily lives in many cultures and coping with stress and distress but also in many settings explanatory models may be based on these and first steps in pathways into help-seeking may well be through religious healers or leaders. Religion is understood by these authors as institutional or communal aspects of spirituality as a shared set of beliefs, experiences and practices related to the transcendent and the sacred. They observe that higher levels of religious involvement (attending religious services, participating in religious rituals), positive religious coping and engagement along with intrinsic religiosity show lower rates of some psychiatric disorders such as depression, suicidal ideation, alcohol abuse and have better quality of life. In a meta-analysis of 158 studies, Matthews et al. (1993) were able to show that religion played a positive clinical effect in 77% of studies. Similarly in an interesting study of older adults, it was shown that religious activities such as meditation, prayer and Bible study were associated with better survival rates. These researchers (Helm et al., 2000) pointed out that older adults who participated in private religious activity before the impairment of their daily living started had a survival advantage in comparison with those who did not.

Both clinicians and patients understand and follow that mind and brain are different. Mind is related to soul or spirit which in many cultures have very specific meanings. It has been argued that ‘our bodies are wired to benefit from exercising not only our muscles but our rich inner human core-our beliefs, values, thoughts and feelings’(Benson & Stark, 1996, p. 17). Inevitably all of these are strongly influenced by cultures. These authors see medicine as a three-legged stool: pharmacology, surgery and intentional use of placebo effect. This raises key questions about how and whether this model fits in with psychiatric illnesses. Beauregard and O’Leary (2008) point out that early in the twentieth century, medicine came down firmly against the idea that the mind influenced the body and sought to trace illness to single specific source (p. 233). These authors place significant emphasis on the placebo effect which they also identify as remembered wellness. Religious gap between the health professional and the patient may well influence therapeutic engagement.

Spiritual assessment does not take long in clinical assessment and using cultural contexts and framework can be very helpful in improving therapeutic engagement and ongoing therapeutic adherence. In addition, spiritually integrated therapies can also help better therapeutic outcomes (de Abreu Costa & Rosmarin, 2021).

Psychiatry has recognised and relied upon bio-psycho-social model for assessment and therapeutic interventions. This is not always possible due to demands on resources so perhaps the time has come to invert the model to socio-spiritual-psycho-biological model. Social factors and social determinants affect mental health and in turn are strongly influenced by geo-political determinants. These also influence psychological and biological components of personality, functioning and ill-health. It is crucial that social psychiatry takes the lead in developing and delivering models of care which take concepts of self and spirituality into account using a cultural context.