5E Mental Health? Notes on an emerging style of thought

Abstract

A new style of thought is emerging in debates around psychiatry and mental health, which I term ‘5E Mental Health.’ This goes beyond the well-known and much-criticized ‘biopsychosocial’ approach, and entails a fundamental challenge to the deeply socially embedded ‘psychiatric complex.’ It aims to map the biosocial mechanisms through which ‘social determinants’ give rise to the ailments that have become the province of clinical psychiatry. Those ailments are: embodied: brought forth not just by the brain but by the whole organism; extended: realized by the organism in interaction with the material and interpersonal environment; emplaced: always shaped in relation to a specific milieu and what it affords or disaffords; experienced: made meaningful by and to the individual (and to others) in language, meaning, memory, salience; and enacted: not just passively received but shaping an active agentive way of being with others, a form of life. These are the tractable pathways through which adverse social experiences give rise to those ailments conventionally diagnosed and treated in individual clinical encounters. It is possible and plausible to enact small-scale local changes in forms of life that can act on these pathways. This requires mental health professionals to work collaboratively with architects, planners, local and national policy makers, and, crucially, those who have experience of mental distress and psychiatric services. It thus requires a paradigm shift in the work of psychiatrists, mental health professionals, and policy makers that is as radical and fundamental as that entailed in the closure of the asylums.

[it is time to reject] metaphysical reductionism: a style of thought and experimentation that stripped the organism from its environment; separated it from its history, from the evolutionary flow; and shredded it into parts to the extent that a sense of the whole—the whole cell, the whole multicellular organism, the biosphere—was effectively gone.

(Woese, 2004, p. 179)

In place of the intellectual engine cogitating in a realm of detailed inner models, we confront the embodied, embedded agent acting as an equal partner in adaptive responses which draw on the resources of mind, body and world.

(Clark, 1997, p. 47)

Can we put brain, body, and world together again in psychiatry? Can we make sense of our mental afflictions by putting the whole multicellular organism that is the human being back into its place in its biosocial milieu? In this paper I want to suggest that we can detect, from a number of different directions, the emergence of a new style of thought concerning these questions which, over the last century, have come to be understood as the province of psychiatry. ¹ A style of thought, as I use the phrase here, is not a model, though it may give rise to models, nor is it a theory, though it may give rise to theories, nor is it a method or methodology, though it may give rise to these as well. I use the term in a way that is loosely derived from the work of Ludwik Fleck (1979); a style of thought is a way of seeing, acting, and explaining that is shared by a ‘thought community’ or rather taken for granted by them. It is a commitment to a certain way of defining a problem space, rendering problems into thought in a particular way, and establishing and constraining the kinds of explanations that can have the status of truth and the legitimate methods for producing truthful explanations and for judging which kinds of explanations are candidates for truth. Or, to be a bit Foucauldian, one can think of a style of thought as a kind of ‘gaze,’ a way of seeing that makes some things visible and some invisible, a kind of ethos or perspective that renders the world into thought in a particular way. A gaze, in this sense, is intrinsically related to regimes of authority—to those who are able to define and circumscribe the domain of the visible, and the field of explanations that are candidates for the status of truth. Of course, ‘psychiatry’ is no monolith: as I have argued elsewhere, there are many different schools and approaches with different understandings of the origins of mental disorders and different treatment practices, and there are many regional and geographical variations in dominant approaches (Rose, 2018, p. 4). Nonetheless, over the last half century, at least when it comes to psychiatry as taught within the universities in the region conveniently, though misleading, termed ‘the Global North,’ psychiatric thought has been fundamentally shaped by the developments in neurobiology, and the belief that neurobiological anomalies underlie mental disorders has had profound implications for psychiatric explanations, psychiatric research, psychiatric treatment, and much more (Abi-Rached & Rose, 2010; Rose, 2000; Rose & Abi-Rached, 2013, 2014). ² But in this essay I want to suggest that the underlying assumptions of this neurobiological way of thinking about mental disorder are increasingly coming under question, not only because of their internal failures, contradictions, and disputes, but also because of the emergence, gradually, somewhat incoherently, but nonetheless cumulatively, of some new ways of seeing and thinking, and perhaps even of practicing psychiatry (De Haan, 2020; Durt et al., 2017; Fuchs, 2017; Gómez-Carrillo & Kirmayer, 2023; Kirmayer, 2015, 2019; Kirmayer et al., 2015; Rose et al., 2022). Each of these, in its own way, answers to the demands of the two epigrams with which I opened this essay: eschewing metaphysical reductionism, and seeking to put brain, body, and world together again (Clark, 1997; Woese, 2004).

I am, of course, not alone in arguing that a paradigm shift in psychiatry is required in the face of its evident failures to meet the local, national, and global challenges. For example, taking the case of the Unites States, Helena Hansen, Kevin Gutierrez, and Saudi Garcia have written a coruscating critique of the failures and inadequacies of contemporary psychiatric and mental health practices to address the social suffering of those with mental health problems, and have stressed the urgent need for a radical alternative (Hansen et al., 2023). They point to the huge racial inequities in the experience of poor mental health and access to support and treatment, the ‘youth mental health crisis,’ the escalation of ‘deaths of despair,’ and the way psychiatry is intertwined with a criminal justice system characterized by the use of mass incarceration for low-income minority ethnic groups; they argue that psychiatry is itself a source of iatrogenic harm in a ‘profit driven health care system’ (p. 75) where adequate mental health care is inaccessible even for the white middle class. What is needed, they propose, is a transformation that recognizes the ‘sociogenesis’ of mental health and addresses it through supporting and amplifying the work of collective healing developed by social movements of those with ‘lived experience’ of psychiatric diagnoses and mental health services and their communities. This would:

require clinical practitioners to elevate the status of community organizations and nonpharmaceutical interventions at all levels of psychiatric training, practice, and institutions, as well as to directly address the institutional and policy drivers of poor health outcomes through collaboration with community organizations, other public sectors such as schools, parks and recreation, and legal aid organizations, not to mention policy advocacy. (Hansen et al., 2023, p. 86)

If the United States exemplifies, in their most extreme form, the multiple ways that the current paradigm fails in advanced economies—the so-called HICs (high-income countries)—it also fails in the so-called LMICs—that is to say in low- and middle-income countries. Thus Vikram Patel and colleagues working in ‘global mental health’ have argued that there is an need for fundamental changes in psychiatric ways of thinking and practicing: “business as usual has failed and will continue to do so” (Patel et al., 2023, p. 656). ‘Business as usual’ can be taken to a mean a practice led by medically trained practitioners, centered on clinical encounter between expert and patient, prioritizing the need for a diagnosis of the patient's troubles, usually framed in the categories of the DSM or ICD, which will then indicate the course of treatment for that individual patient, and provide a narrative of the nature of the ailment to professionals, patients, and others. Patel and colleagues argue that there will never be enough psychiatrists to carry out this work, even in the Global North where numbers of psychiatrists per 100,000 of the population are highly variable between wealthy and poor regions, let alone in LMICs in the ‘Global South.’ ³ Hence they propose task sharing (previously ‘task shifting’), where the therapeutic labor is distributed to non-medical practitioners, community organizations, and others (see also Patel & Rahman, 2023). But if those to whom tasks are shifted largely maintain the individualistic focus of treatment, this will fail to address the fundamental issue: it hardly challenges the conventional psychiatric focus on symptoms as “problems located within individuals, in their psychological dynamics [or] their neurobiology” (Kirmayer, 2024, p. 567). Such an approach fails to address the root causes of the levels of mental distress and social suffering that characterize both HICs and LMICs today. To do so requires us to look beyond the laudable wish to harness the resources of those outside the conventional mental health and psychiatric system, towards what James Kirkbride and colleagues have recently termed “an ambitious but necessary revolution” in addressing the mechanisms and pathways through which social inequities are causally implicated in producing poor mental health (Kirkbride et al., 2024, p. 59): that is to say a fundamental transformation of ‘the psychiatric complex.’

As Foucault argued with regard to the birth of clinical medicine and the ‘clinical gaze,’ the individual clinical encounter is just one small part of a whole psychiatric apparatus (Foucault, 1973 [1963]). This is not just an apparatus of training and credentialization of those who can practice psychiatry, but includes conferences, workshops for further professional accreditation, and an industry of research supported by lavish funding at least for some. Mental health practitioners are also part of a larger profit driven system, for instance involving an array of journals published commercially for profit, yet integral to professional careers, where advancement often depends on producing papers in peer-reviewed journals. Linked to this is a whole commercial apparatus for developing and marketing drugs—still worth over US$20 billion in 2023 (Global Markets Insight, 2023) despite the well-known problems besetting psychiatric drug development—and now other non-pharmaceutical forms of treatment such as deep-brain stimulation (DBS) and transcranial magnetic stimulation (TMS). Psychiatrists and other mental health practitioners have also become integral to many other practices, as consultants and advisers to business, the law courts, the educational establishment, the military, and much more. So a shift in styles of thought entails much more than the success of one kind of theory over others, or the transformation of the clinical encounter so that it is more culturally and structurally competent, but the transformation of this whole ‘psychiatric complex.’ What might that entail?

Beyond critique

Critiques of the ‘medical model’ and ‘biomedical psychiatry’ are well known, as are the criticisms of the ‘biopsychosocial approach’ that is often proposed as an alternative (Borrell-Carrio et al., 2004; George & Engel, 1980; Ghaemi, 2011; McLaren, 1998; Pilgrim, 2002; A. Roberts, 2023). I am not going to repeat those debates here. One rejoinder to those who criticize the ‘biomedicalization’ of psychiatry is that biopsychosocial concerns are already part of what many psychiatrists do in practice. There is certainly some truth in the assertion that while psychiatrists are committed by the nature of their work to the individual clinical encounter, many take into account the social circumstances and life history of their patient in triggering the disorder and in shaping their future wellbeing. It has become quite conventional to argue that such understanding can and should be augmented by ‘cultural competence’ in order to reduce racial and ethnic disparities in health care (Betancourt et al., 2016). Some have developed this argument further, suggesting the need to take account of the cultural shaping of social determinants of mental disorder (Kirmayer, 2012), giving a greater role to advocacy (Kirmayer et al., 2018), and more generally to enhance ‘structural competence’ (Metzl & Hansen, 2014), an approach quite widely taken up in some Latin American countries (Ortega & Müller, 2023). However important these arguments for enhancing and refining psychiatric training and clinical practice to better address the shaping of individual mental distress in the clinical encounter, they remain primarily directed at those individual clinical encounters themselves. To address distal factors seems to demand social and political engagement that is far beyond the remit of psychiatry and psychiatrists.

Yet if the paradigm shift envisaged by Hansen, Kirkbride, Kirmayer, and their colleagues is to be realized, it seems obvious that there is a need to focus our policies, strategies, and priorities not just on improving individual clinical treatment—however much it may be aware of the social circumstances of the individual patient and their consequences—to those distal social and environmental conditions that we know are correlated with higher levels of psychiatric morbidity—to address the conditions at the level of populations that lead to individuals becoming ‘suitable cases for treatment.’ As Laura Samson and Sandro Galea argue:

If we are to extend beyond proximate risk factors … we must broaden our causal models and learn to apply a social-ecological perspective. … a focus on exposures that are pervasive, ubiquitous, and hence difficult to study. Examples include social or cultural norms, urbanization, discrimination, political structures, air pollution, poverty, climate change, or migration patterns … (Sampson & Galea, 2018, pp. 1–3)

But how are we to do this?

What is ‘the social’?

What, then, if the role of psychiatry was indeed, at least in large part, to address the conditions that cause the individual to become ‘a suitable case for treatment’? Could we demonstrate the existence of tractable mechanistic pathways? Could we show that these ‘biosocial’ pathways were relevant, not only to long-term socio-political change but to the understanding and treatment of individual problems, and that can be addressed in social action in practice in the present? Could we avoid, or rebut, the standard arguments of the critics that the search for ‘biosocial’ mechanisms is in danger of leading down a path of depoliticization, individualization, and ‘biologism’ (Chiapperino, 2023; Meloni, 2023)? This requires us to think more carefully about the question ‘what is the social?’

In much writing on the impact of social conditions on mental health, the social is often transformed into something vaguely termed ‘the environment’ which can in turn be decomposed into factors that seem to be correlated with higher risk of developing particular types of poor mental health: provoking factors (e.g., urbanicity, neighborhood deprivation, ethnic density…) and, more recently, those ‘buffers’ that are postulated to be protective factors for those living in adversity (e.g., Allen et al., 2014). These factors are assumed to work upon individuals, and when framed in neurobiological terms this is often summarized in the misleadingly scientistic formula P = G×E where P is the ‘phenotype’—that is to say whether the individual manifests a mental disorder which is an outcome of the interaction between an underlying biological constitution—predisposing factors usually thought of as genetic, hence G—and an external environment (basically everything that is not genetic) represented by E (e.g., Dunn et al., 2011). While such studies focus on identifying statistically significant population-level correlations between factors or variables, they are only useful to the extent that the variables they utilize make genuine sense in the complex lives of those they are studying, and unfortunately many of the standard variables used in epidemiological research—such as socio-economic status or ethnicity—often do not. Further, despite deploying some statistical methods to disentangle complex causation, such approaches have seldom been able to consider how these intersect to create the heterogeneous milieu in which individuals make their lives (Goodwin et al., 2018). Even when correlations are found, most epidemiological research of this type does not identify the pathways by which these factors—or ‘variables’—‘get under the skin’ and shape mental health for better or worse. Could we do better?

In fact, we can! Recent work from psychiatric epidemiologists and others is making important moves in this direction, seeking to specify and untangle those distal factors—those ‘social determinants of mental health and disorder’—and to postulate ‘mechanistic’ pathways through which they may indeed get under the skin (Anglin et al., 2021; Kirkbride et al., 2024; Weiss et al., 2021). By mechanisms and mechanistic here, I follow Manning (2019) in a non-reductionist use of the term as proposed by Phyllis Illari and Jon Williamson: “A mechanism for a phenomenon consists of entities and activities organized in such a way that they are responsible for the phenomenon” (Illari & Williamson, 2012, p. 132). An understanding of these mechanisms requires us not only to address major issues of social policy shaping adversity and social exclusion for so many of those who experience poor mental health but also to recognize the role of small-scale local and mutable dimensions of everyday social life that can and should be the target of psychiatric concern, intervention, policy advice, and extensive interdisciplinary research. Thus in this essay, I bring together the implications of this work with other cognate developments in ecological and environmental neuroscience, cognitive science, cultural psychiatry, and psychiatric ethnography, and from the emerging work of those who have experienced mental disorder, in order to suggest that a new style of thought is emerging which has radical implications for the ways we understand mental disorders and poor mental health. For simplicity I have called this style of thought ‘5E Mental Health.’

5E approach to ‘mental health’

To elucidate this approach, let us leave to one side, for the present, the essential sixth E, embrained, for mental health certainly involves brains, though not, in this way of thinking, as primary causes enshrined within the secure and impermeable barrier of the skull, or rather, the meninges around brain and spinal cord. If we start with ‘the brain’ all else almost inevitably seems secondary—we just ask ‘how does x affect the brain?’ So let us start elsewhere. The five Es I would like to propose for our analysis are as follows: mental health (I will keep using this rather problematic concept for a while or we won’t get anywhere) is not just embrained but:

Embodied: brought forth not just by the brain but by the whole human being enmeshed in their social and material worlds

Extended: realized by the human being only in and through their relations with the resources available in their material, interpersonal, and social environment

Emplaced: always shaped in relation to specific spaces and places—a specific ecosocial niche and what it affords or disaffords

Experienced: made meaningful by and to the individual (and to others) in language, meaning, memory, and salience

Enacted: not just passively received but shaping an active agentive way of being, a form of life

As will be evident, these terms mirror those used in discussions of 4E cognition (see, e.g., Newen et al., 2018). There are different versions of 4E cognition but basically the argument is that cognition is embodied, embedded, enacted, and extended by way of extra-cranial processes and structures, although the Es in this way of thinking frequently blur into one another (Rowlands, 2010) and this is also the case with my 5Es. However, as we shall see, my use of notions such as ‘embodiment’ differs in important ways from some of those who draw from this framework to think about psychiatry and mental health (for instance in the Introduction to Kirmayer et al., 2020). ⁴

Embodied

Of course, there has been a very significant debate around the question of embodiment, especially in ‘materialist’ feminist thought, which I cannot review here (see, e.g., Fraser & Greco, 2020). Most relevant for this essay are the proposals in 4E cognition that use the term to stress the ways that the features that constitute what we commonly think of as minds—awareness, thought, volition, feeling, memory, cognitive and emotional phenomena, and the like—are not matters of a brain alone but of a whole brain-body complex. These features thus accord a key role for ‘interoception,’ that is to say sensory information from the interior of the body itself—the peripheral nervous system—internal organs, gut, muscles, skin and so forth, hormones—as well as being intrinsically intertwined with sensory input from the sense organs—vision, smell, taste, and so forth. But what is meant by ‘cognition’ in these arguments? I will restrict myself to humans here, although there are many important issues raised in relation to cognition in non-human animals (Osborne & Rose, 2024; Tomasello, 2022). There is a tendency to think of human cognition in narrow terms as thinking, reasoning to solve a problem, perhaps even modeled on the extremely limited notion of intelligence as problem solving. But as evolutionary biology and neuroscience make clear, cognition is not a cold, rationalistic process; thought, whether conscious or non-conscious, entails feelings and desires; it is always loaded with affect and intentionality (Damasio, 1999; Ginsburg & Jablonka, 2019), and is inextricably bound up not just with a central nervous system but with the sensations from peripheral nerves, muscles, skin, and all the highly enervated internal organs of the body, not least the gut. From this perspective of evolutionary biology, cognition ‘in the wild’—that is to say outside the reductionist environment of the laboratory—there is no thought without feelings and desires, and intentionality. ‘Thinking,’ in the real lives of humans, entails the active engagement of a whole organism, in the sensori-motor regime of the person, in ways of seeing, experiencing, being present in the world, in forms of self-understanding, and in relations with material and interpersonal milieu, all, of course, bound up with language and regimes of meaning. It is also important to stress that cognition should not be confused with consciousness; our ways of being in the world are made possible by a host of non-conscious habits and routines of life that govern the management of bodily functions, help shape actions and conduct, infuse will and desire, and much more (Bennett, 2023; Bennett et al., 2021). Thus, for William James, habit is a “second nature” grounded in the “plasticity of the living matter of our nervous system”:

I believe that we are subject to the law of habit in consequence of the fact that we have bodies. … Ninety-nine hundredths or, possibly, nine hundred and ninety-nine thousandths of our activity is purely automatic and habitual, from our rising in the morning to our lying down each night. (James, [1890] 1981,Ch. VIII)

Recent work on habit agrees: the non-conscious habits that enable us to manage our way in the world are fundamentally embodied (e.g., Graybiel & Grafton, 2015). We are then speaking less about embodied cognition than about embodied minds.

Extended

Minds are not only embodied; they are ‘extended.’ What we call ‘thinking,’ for example, entails multiple feedback loops through which the organism is coupled with its milieu (Clark, 1997): thinking with eyes and hands as Bruno Latour put it (Latour, 1986), extended by the use of ‘inscription devices’ (although I do not think this Latourian term is often used in this context) such as written texts and instruments that create material traces external to the body, together with tools and other artefacts, as well as relations with others. And what is true of ‘thinking’ is true more generally, for what Ian Hacking has termed ‘mental events’—“beliefs, emotions, feelings, thoughts, intentions, thinking, reasoning, reflecting, imagining, choosing, deciding” (Hacking, 2005, p. 59). David Chalmers, one of the central figures in 4E approaches to cognition, puts it as follows: “A subject's cognitive processes and mental states can be partly constituted by entities that are external to the subject, in virtue of the subject's sensori-motor interaction with these entities” (Chalmers, 2019, p. 15). This is a key recognition for understanding the experience of mental distress—these experiences do not occur in a space delimited either by the skull or the skin, demarcated by the boundaries of the individual organism. They are ‘transdermal’: extended through extra-cranial—material, social, interpersonal, discursive—processes and structures, enabled, supported, shaped, and constrained by features of an individual's milieu: the variable and highly inequitable network of material and social supports—the sedimented configurations of power and injustice that are so often glossed as ‘social determinants’—within which they make their lives.

We will return in a moment to these material and social supports when we turn to the dimension that is usually termed ‘embedded.’ But first, there are many implications for mental health in the growing recognition that mental events are constituted by the inescapable enmeshing of the human organism in its specific material and social milieu. Clearly, it problematizes the belief that these aspects of mental life, of mind, are capacities of an isolated individual brain, that can be understood by studies in the purified environment of the brain scanner or in seemingly highly controlled experimental situations. These may be ‘non-places’ from the perspective of the researcher, but they are very real situations for the researched! But I would like to bring this idea of the embodied and extended mind into conversation with another idea of embodiment, of the ways in which living organisms embody their milieu. Nancy Krieger long ago argued that:

embodiment … refers to how we, like any living organism, literally incorporate, biologically, the world in which we live, including our societal and ecological circumstances … [It] entails consideration of more than simply “phenotypes,” “genotypes,” and a vaguely defined (and implicitly external) “environment” eliciting “gene-environment” interactions. We live embodied … embodiment necessarily is a process, for it entails the temporal transformation of bodily characteristics as a consequence of animate beings’ terms of engagement in their world. (Krieger, 2005, p. 350)

Krieger was not specifically thinking of the dynamics of mental health, but her argument stands in this domain as well: thoughts, feelings, and beliefs are not merely functions of brain activity, not just ‘in the brain’ but of the engagement of a brain-body-environment assemblage: an ‘extended network’ entailing a dynamic interaction between brain, body, and resources in the world. These are not merely ‘external’ as in social network theories that map out the connections of individuals to one another and to their material and social environment, such as those charted by Bernice Pescosolido (e.g., Pescosolido, 2006). Rather, as postulated in the idea of ‘affordances’ developed by James J. Gibson (J. J. Gibson, 1979) and E. J. Gibson (E. J. Gibson, 1969), these dynamic networks between brain, body, and milieu actually constitute the possibility of mind and shape cognitive, affective, and volitional capacities. This question of affordances, often implying a non-representational, action-oriented conception of human psychology, has been much developed and contested in recent work in ‘ecological psychology’ (Heft, 2001; Uskul & Oishi, 2020). However, as I argue elsewhere, Kim Sterelny's notion of ‘scaffolding,’ which I discuss presently, is much less limited in its understanding of the ways in which human capacities are constituted through transdermal relations (Osborne & Rose, 2024; Sterelny, 2010; on the relation of affordances and scaffolding, see also Ramstead et al., 2016; Veissière et al., 2020). Perhaps we can best understand the relevance of this approach here by considering my next E—embedded.

Embedded, emplaced (and exposed)

In 4E approaches, cognition is understood as embedded in the environment of the living organism. In a sense, the idea of embeddedness is already implied by the discussion above. It amounts to the view that cognition is both afforded and constrained by the milieu inhabited by the organism, that external artefacts play a constitutive role in matters of the mind. In his early discussion of the situated nature of thought and action, in a chapter entitled ‘The Situated Infant,’ Andy Clark points out that the developmental psychologists such were “probably among the very first to notice the true intimacy of internal and external factors in determining cognitive success and change” (Clark, 1997, p. 35). Among those he mentions—from Piaget and Vygotsky to Bruner, the name of James Gibson stands out, and Clark acknowledges his debt to Gibson's now popular and much-debated concept of ‘affordances’ in the emergence of ‘action loops’ in which infants learn about the world by acquiring knowledge related to specific contexts of action (J. J. Gibson, 1979). James Gibson, as is well known, was very hostile to the notion that humans—or indeed non-human animals—find their way in the world because they develop complicated internal representations or maps of that world that they somehow consult in navigating their environment. Clark too seeks to lighten the cognitive load that such internal representations would entail, although he does not dismiss them altogether. However, he argues that they must be ‘action oriented’—which implies a rather limited notion of the internal representations that an organism has of its milieu, as we shall see presently. Nonetheless he follows Gibson in arguing that affordances are “nothing other than the possibilities for use, intervention, and action offered by the local environment to a specific type of embodied agent” (Clark, 1997, p. 50). But his example shows the limits of this idea, in its universalizing framing. He remarks that “a human sees a chair as ‘affording sitting,’ but the affordances presented by a chair to a hamster would be radically different” (Clark, 1997, p. 50). But the issue is rather more significant than that throwaway remark suggests: a chair only affords sittings for some humans, with some bodily configurations, in some situations, in some historically and locally specific forms of life into which they have been ‘encultured’ (cf. Ramstead et al., 2016). That is to say, even mundane objects such as chairs in a human-constructed milieu are highly normative in their assumptions about human bodily forms and in their assumptions about the forms of life and the specific situations in which a chair—or to use Gibson's favorite example, a ‘post-box’ (Gibson, 1979, p. 130)—would afford anything at all.

Of course, these weaknesses in James Gibson's hypothesis, about which much ink has been spilt, do not render the idea of affordances useless. We do not, here, need to enter into the ‘representation wars’ in the 4E community—the heated debates about the existence or role of internal representations (see the discussion in Kiverstein, 2018)—but I will simply assert here my agreement with those like Kim Sterelny (Sterelny, 2003) who argue that humans, in the course of the evolution of their neocortex under selection pressure, have evolved the capacity to create ‘decoupled’ internal representations of their world. Hunger may be a ‘drive’ but planning and cooking a meal requires extensive ‘off-line’ representation, imagination, and perhaps mental simulation, discussion and so forth before action. That is to say, humans have the capacity to introduce a gap between desired ends and available means. This enables them not to respond immediately to an ‘affordance’ for action (as implied in a Gibsonian perception-action loop), but to reflect upon potential responses ‘off-line’ in order to work out the best way to solve the problems that are salient to them in a socially appropriate way. Each developing human being, tacitly, through imitation or through conscious teaching and learning, is initiated into ways of being and acting in a complex, human-constructed, material and interpersonal scaffolding (Sterelny, 2010). ⁵ These ‘affordances’ are thus highly normative; they embody certain norms of thought and action for those humans ‘trained up’ in a particular form of life, and in practices of interaction with others, but in so doing they privilege some ways of being a person, some forms of thought and action, and delimit and constrains others (Dokumaci, 2017, 2020, 2023). Reminding ourselves of the previous brief discussion of habit, this is not solely, or even mainly, a matter of conscious, skilled action, or the exercise of agency as affordance theorists such as Rietveld and Kiverstein (2014) seem to suggest, for much if not most of what conducts us through our hourly, daily, weekly passage through the niches we inhabit is habitual. Thus, it is not only the case that mind is embedded, but as a moment's sociological thought reminds us, it is always embedded in particular situations in specific forms of life (Goffman, 1964), situations that are, as any social scientist knows, highly differentiated across time and space, and by generation, sex, age, race, class, and so forth.

That emplacement of individual, groups, and populations in a specific milieu of inhabitation has corporeal consequences which are, to my knowledge, not much considered in the debates around 4E cognition. They are, however, partially captured in the idea of ‘the exposome.’ As Christopher Wild defined it in 2012, “The exposome is composed of every exposure to which an individual is subjected from conception to death. Therefore, it requires consideration of both the nature of those exposures and their changes over time” (Wild, 2012, p. 24). Wild made a threefold distinction in his original formulation. One set of exposures were internal to the organism but shaped by its emplacement—such as hormones, lipid levels, or gut microflora which are acutely sensitive to factors ranging from feelings of threat to composition of diet. A second were ‘specific external’ exposures, such as exposures to radiation, contamination, pollution, and ingestion of alcohol or tobacco. In relation to mental health and mental disorder, we might consider here work on the consequences of air pollution (e.g., Buoli et al., 2018) and recent work on the microbiome and the gut-brain axis, which are highly sensitive to external exposures, diet, and more but where there remains much debate over the significance of research findings (Dowd & Renson, 2018; Falony et al., 2019; Hoisington et al., 2015; Logan et al., 2016). ⁶

Wild's third category of exposures were what he termed ‘general external’ factors, such as those which would commonly be thought of as ‘variables’ in epidemiological research on the social determinants of health, including social capital, education, financial status, psychological and mental stress, urban or rural environment, and climate—the list usually ending with an enigmatic ‘etc.’ These classic ‘social determinants’ are included in the scope of exposome research, and have been the focus of a number of recent explorations (Neufcourt et al., 2022; Vineis & Barouki, 2022). They have also been discussed in thoughtful essays by Michelle Kelly-Irving and her group on risk for chronic diseases such as cancer and heart disease; structurally patterned social variables across the life course are taken to include experiences of racism, lack of job security, and other ‘policy actionable factors’ (Kelly-Irving & Delpierre, 2021). As James Kirkbride and colleagues argue, there is a need to “fully integrate a social determinants perspective into the biopsychosocial model of mental health and illness”—to establish the extent to which such “social determinants are causally implicated in producing poor mental health … and understanding the mechanisms and pathways through which these outcomes emerge” (Kirkbride et al., 2024, pp. 59–60). And that, as I shall argue in this essay, requires us to understand not simply correlations between variables but the ways in which those ‘social determinants’ are actually experienced and lived by individuals and social groups in societies structured by inequality, adversity, and precarity in almost all aspects of existence from conception and birth to illness and death.

Exposome-based approaches are important to the argument about ‘mental health’ because they enable us to think in a different way about the ‘embodied, extended and embedded’ features of human mental life, and bring them into a dialogue with work that conceptualizes the ‘embodiment’ of ‘social determinants’ and ‘environmental factors’ through demonstrable biosocial pathways. Of these, the most discussed is that of ‘stress,’ a term whose meanings and implications have been debated for many decades (Cantor & Ramsden, 2014; Jackson, 2013; C. Roberts & McWade, 2021; Rose & Fitzgerald, 2021). For current purposes it is sufficient to note that stress is now usually understood as a process that begins with an individual, with all their socially shaped beliefs, assumptions, and expectations, perceiving a situation as demanding, frightening, or potentially problematic, which then sparks off a series of hormonal changes, including the production of cytokines, modifying neural circuits, and initiating functional changes in various brain regions, and also producing genetic changes via epigenetics and neurogenesis (McEwen, 2012, 2017; McEwen et al., 2015). Such neurobiological accounts of stress can often appear to be highly individualistic, and dependent on individual subjective perceptions. But it is clear that risks of exposures to stress are not only highly socially patterned but also transindividual and collective: poverty, social adversity in pregnancy and childhood, financial insecurity, racism, violence and the fear of violence, stigma and social exclusion—even ‘loneliness’ arises in a relational space (Cacioppo et al., 2014; Hawkley & Cacioppo, 2010). In this sense, ‘stress’ provides a kind of model for thinking about the ‘transdermal’ character of meaningful experiences and the ways in which, in timescales of seconds, minutes, days, and even years, these shape and reshape bodies and brains—a recognition that underpins McEwen and Stellar's concept of allostatic load (McEwen & Stellar, 1993) and Arline Geronimus's conception of ‘weathering’ (Geronimus, 2023). ⁷

The precise mechanisms and pathways through which such exposures have their effects remain subject to debate, as does the more general hypothesis that what we might call ‘social exposures’ have their most consequential consequences through their cerebral and corporeal consequences, rather than—or perhaps in addition to—their psychological and subjective consequences. Nonetheless, conceptualizing these consequences in terms of their transdermal pathways enables us to relocate sociological arguments within the territory that is currently so much favored in mental health research—the search for ‘mechanistic pathways’ for depression, anxiety, and much more. Or, to put it more positively, they open up the possibility for us to think of the embodied and embrained consequences of the experiences of individuals and groups inhabiting spaces and places—ecological niches—suffused with various kinds of adversity. However, it is crucial to recognize that while living creatures are passive recipients of some exposures—nuclear radiation, air pollution, and so forth—this is by no means always the case. As my colleagues and I have argued (Manning et al., 2023), a niche, for a human being, is not merely a composite of the impact of external ‘exposures’; rather it is a configuration of that which is salient or made salient to the particular human beings who inhabit it in their form of life. ⁸ Organisms such as human beings are constantly making sense of and often reshaping their forms of life in response to their experiences—their perceptions of, and beliefs about, the potential toxicity that impinges on their lives. These experiences are the subject of my next E.

Experience

To be emplaced, to inhabit a place, is not simply a domain of exposures, it is a domain of experience. ⁹ Indeed as I have indicated, for many of the social exposures that might fall under the umbrella of the exposome, what is crucial is not a brute fact of racism or violence, but the subjective experience of actual, feared, anticipated, or remembered racism or violence. ¹⁰ Do all these experiences work in the same way, through the same ‘mechanisms’? This was one of the key arguments in the history of stress research; that whatever the ‘stressor’—whether chemical insult, hunger, overcrowding, fear, or actual attack—the same mechanisms were activated. ¹¹ These are matters for further research. For the moment, let us recognize, as the human geographer Doreen Massey points out:

[Places] are formed through a myriad of practices of quotidian negotiation and contestation; practices, moreover, through which the constituent “identities” are also themselves continually moulded. Place, in other words does … change us . . . through the practising of place, the negotiation of intersecting trajectories. (Massey, 2005: 154 cited in Birk & Manning, 2023; see also, on this dimension, Söderström et al., 2016)

Experience of this myriad of emplaced encounters, then, is my fifth E. But experience should not be understood as some individual raw feeling: the world is rendered experienceable through a grid of perceptibility.

Part of that grid that renders the world experienceable in a certain way is often thought of as cultural: our cultures give us the ways of making sense of our experience, placing it into belief systems, stories, myths, and a repertoire of shared understandings. From my perspective, it is important to recognize that such beliefs and understandings do not just inhere in our symbolic systems but are inscribed in the very material configuration of our ‘niche.’ As Fiona Coward puts it in another context, “Material culture plays a vital role in conveying social information about relationships between people, places and things that extend geographically and temporally beyond the here and now … thereby surpass[ing]the limits to sociality imposed by [our brains] alone” (Coward, 2016, pp. 78–80). That is to say, our houses, our rooms, our furniture and furnishings, our streets and stores, our roads and transport systems, our infrastructures of water, sewage, power, and the like—our very milieu—is highly normative, shaped to make a certain form of life easy, indeed easily habitual, for ‘normal persons’ or ‘majority persons.’ Further, we only have to consider the work of Erving Goffman (e.g., 1964), or of the practice theorists such as Elizabeth Shove (Shove et al., 2012), to grasp the ways in which belief systems are not merely sets of ideas but are stabilized and materialized in interaction rituals and embedded practices that embed and normalize certain modes of interaction among human beings, and between them and their material world (see the discussion in Manning et al., 2023). This ‘scaffolding’ not only enables the non-conscious alignment and resonance between human and milieu; it also enables certain ways of thinking and acting to become habitual, sparked off by the succession of situations in a form of life, the highly normative taken-for-granted machinery that enables and constrains thought and action in certain ways, and difficult, sometimes almost impossible, not only for ‘minority persons’ to conduct their lives, but for anyone to act and think in others. The ways of thinking about ourselves that are active in certain times and places—active not in the sense that they are conscious but precisely the reverse, the unthought of thought, the ‘received wisdom’—shape the ‘scaffolding’—the political technologies—that hold individuals in place, train them in certain ways of being, shape and judge their ways of thinking and acting according to certain norms and the like (Rose, 1999, 2004, 2009).

Thus by this E of experience, I want to invoke the ways in which human beings, enmeshed in these ways of thinking and these scaffolds, actively make meaning of their emplaced situation and the ways in which they make sense of their own being in the world and the world in which they are making their lives, the stories that they tell about themselves to themselves and others, the language that they use (possession, repression, trauma, stress …) etc. However difficult it is for those trained in epidemiological styles of thought, this requires us to move away from the idea of ‘the environment’ as decomposable into an array of variables, towards a kind of phenomenology of experiences saturated with meanings molded by languages and narratives, shaped by saliences, populated with memories of dread, fear, pain, delight, hopes, expectations, and much more. Are these ineffable personal ‘experiences’ researchable? Many possibilities present themselves, and here I will focus on just one—experiential maps. Perhaps the idea of making maps of one's experience—focused here on cities—was first developed in the appendix to Kevin Lynch's classic Image of the City (Lynch, 1960) in which people were interviewed about their internal map of various parts of Boston as they walked through it, internal maps which turned out to be based on memories and experiences that were very far from those depicted on the maps that tourists might buy to find their way around. But it was Stanley Milgram, better known for his work on obedience, who seems to have had the idea of psychological maps of urban space, asking individuals to draw their neighborhoods in the light of their own memories and experiences of the different places and objects that surrounded them (Milgram, 1992a, 1992b). These were less geographical maps than examples of the sensory, semantic, affective configurations of the places and pathways we inhabit. These ways of engaging with an individual's ways of rendering their emplaced experience thinkable, along with all the affective resonances that place entails, can be further explored by ‘walk-along’ interviews, in which the researcher walks the streets of an individual's inhabitation, and asks them to reflect on their moods, feelings, and memories as they move through their biopsychosocial niche, mental states whose physiological correlates can also now be mapped using wearable devices that record momentary ecological assessments (for one example of such an approach, see Winz & Söderström, 2020). There is, of course, much more to be said about the possibilities and drawbacks of such approaches, notably the ways in which one might develop them to go beyond individual experiences, working with groups and communities to map the collective nature of such experiences as poverty, racism, risk, and violence, where traps and dangers lie, where lines of escape may form, and where security and protection may be found, where hidden threats lurk, and how, for those living lives of adversity, things are not always what they seem.

Enacted

The notion of enaction here points us to the dynamic and active relationship between a person and their environment. It draws attention to the fact that the organism is not merely a passive receiver of inputs from its milieu but is actively engaged in managing its life within that milieu in a field of threats and possibilities. It stresses the importance of understanding how embodied and emplaced human beings make sense of their worlds and themselves in those worlds, and it is this sense-making dimension that is particularly stressed in the emerging body of work that terms itself ‘enactive psychiatry (De Haan, 2020, 2021; Gallagher, 2022; Kirmayer & Ramstead, 2017; Nielsen, 2020; Thompson, 2006). Michelle Maise captures the idea of enaction well, when she writes:

During perception and action, a living animal is directed toward the surrounding world in and through its body; through the formation of bodily habits, associations, dispositions, and motivations, it shapes its world into a meaningful domain. In cases of “motor intentionality,” the embodied agent makes sense of objects in relation to herself, identifying them pragmatically in relation to her goals, and engages with her surroundings in a “bodily and skillful” way. Likewise, in perception, the agent interprets incoming stimuli selectively and in relation to pragmatic concerns. What is disclosed is partly a matter of what actually exists in the world, and also partly a matter of what the living animal brings to bear, given its specific bodily structure, capacities, and interests. Insofar as intentionality is thoroughly bound up with affectivity and what an agent feels is important … it is inherently evaluative. (Maiese, 2021, p. 970)

Some, notably Sanneke de Haan, suggest that this focus on sense making can help us reconceptualize mental disorders as disorders of sense making, but this is not a line I will pursue here. ¹² Rather, I suggest that to explore the ways in which embodied and emplaced human beings make sense of their world and themselves in it, how they experience and frame their lives in adversity, not as isolated ‘variables’ each with measurable effects but as interacting loops over time, we need to listen to the voice of the (actual or potential) patient.

At this point I am tempted to add another E—enunciated. That is to say, spoken. How are the voices to be heard of those who are the subjects of those experiences, in particular those who have what is nowadays termed ‘lived experience’ of mental distress, a psychiatric diagnosis and/or psychiatric treatment. Attempts to access ‘the user's voice’—to reference one of the earliest and most influential demands from mental health service users to be heard (D. Rose, 2001)—represent a fundamental shift—and challenge—to the previously prevailing psychiatric orthodoxy. And there is, as is well known, an increasing obligation for those working and researching in the field of mental distress and mental disorder to engage with those who have what is now termed ‘lived experience’ of these conditions. But what is at stake here is not the voice of the lone individual, who may sincerely think or believe that, for example, they have undergone trauma, but something more. Experts by experience make an epistemological claim, a claim to knowledge, not just of the experience of depression, anxiety, hearing voices, and more, but of the experiences that give rise to this mental distress. Enactment, in relation to mental distress and those conditions categorized as mental disorders, obliges us to understand the voice of those with ‘lived experience’ not as just the personal story of a decontextualized individual but as emerging from a collaborative movement of those who have experienced psychiatric treatment or mental distress. The work of Miranda Fricker (2007) points us to the undoubted ‘epistemological injustice’ in the psychiatric apparatus—that is the belief that the voices of those who experience mental distress merely express personal opinions and prejudices, folk psychology, swayed by all manner of beliefs, prejudices, social media narratives, and the like. But the demand for the subjects of psychiatry, for those who experience mental distress, to have a credible voice at the table cannot be so easily dismissed. Almost half a century after the birth of the modern movement of users and survivors of psychiatry, there is now an extensive, credible knowledge base growing out of a wider thought community for what is sometimes termed ‘mad knowledge’—knowledge, here as elsewhere, is grounded within the perceptions of members of a community, however informal (D. Rose, 2022). And the voice of actual and potential patients articulated from within that thought community presents an alternative knowledge basis for understanding how individuals enact their lives in situations of adversity. Closing the gap in what Fricker terms ‘hermeneutic injustice’ requires those ‘experts by experience’ to be seen as credible knowers who can help articulate and ground an understanding of both ‘common’ and ‘severe’ mental distress.

A 5E approach to mental health

The emergent approach that I have been trying to describe, and indeed wishing to advocate, is grounded in social medicine (Pentecost et al., 2021). It takes seriously what some anthropologists of mental health have termed social suffering (Kleinman et al., 1997) and Paul Farmer's insistence on the causal role of structural violence (Farmer et al., 2006). It recognizes that mental distress arises from the actual social and material experience of individuals as they make their lives enmeshed with others in the places they live—their ‘biopsychosocial’ or ‘neuroecosocial’ niches (Rose et al., 2022). A focus on the determinants of mental distress across populations should not lead us to forget that people make their lives in these small-scale worlds, formed, in the words of Doreen Massey quoted earlier, through a multitude of overlapping and intersecting practices, negotiations and contestation which actually shape and reshape identities across time and space. These intersecting and cumulative exposures tend to be effaced in correlational styles of epidemiological thought, and they are erased in those forms of thought—for instance those that focus on Adverse Childhood experiences or ‘the first thousand days’—that suggest that life chances are ‘programmed’ by childhood and even gestational exposures (Pentecost & Meloni, 2020). For those who live in adversity, in poverty, condemned to poor housing and poor schooling, subjected to racism and social exclusion, living lives of precarity and systemic disadvantage, they augment one another, weathering body and soul across days, months, and years (Geronimus, 1992, 2023). But there are alternatives, in the development of collective movements that are creating new ways of thinking and new forms of support and practice in many different regions and situation. We need to listen to the voices of those who experience distress, their collective evidence about what they find pathological, and what might be potentially salutogenic in the reality of their everyday lives—housing, poverty, racism, exclusion, pollution. Their claim to credibility as knowledge makers can no longer be denied if we are to understand the ways in which systematic and structural exposures are actually experienced and lived. We need interdisciplinary research, involving user communities, to clarify the pathways by which these experiences get under the skin, and the tractable targets of policy and practice that might mitigate them, integrating biological and neurobiological insights and methods with older questions about inequality, poverty, exclusion, racism, violence. And psychiatrists and mental health professionals need to become fully involved in those debates, in this interdisciplinary research, in those policy forums and political contestations outside the clinic, working with others, crucially including those ‘experts by experience,’ to develop policies and practices to transform those ‘neuroecosocial pathways’ if they are to treat not only the patient in front of them but all those others who, for good or ill, will never reach their clinics.

Concluding thoughts

Sometimes it seems as if changes can only happen at a large-scale level requiring major transformations in political and economic policies. Major transformations are indeed required. But small and practicable changes can alter the reality of people's lives. We have some evidence already that anti-poverty measures such as unconditional cash transfers or Universal Basic Income can lead to better health outcomes, and we also know that conditional welfare systems augment adversity while unconditional welfare systems address precarity (for one example, see T. C. Rose et al., 2023). Psychiatrists and mental health professionals could take their lead from the great success of antismoking measures in reducing cancer to see what public health measures might address exposures at the population level. They could work with architects and planners to shape milieu that can help support mental wellbeing and to support local scaffolds to mental health, such as safe spaces, local cafes, play areas, and drop-in centers. And when it comes to crises, as will inevitably be the case, they could minimize the use of involuntary confinement—which itself exposes those who experience it to a multitude of pathogenic exposures—by prioritizing the use of short-term crisis houses on the model of those developed in Trieste (Mezzina, 2014; Sashidharan et al., 2019). Working for such changes should not only be the obligation of psychiatrists and mental health professionals, but neither should they consider it to be the responsibility of others. If we are to address the local, national, and global challenges pointed to at the start of this essay, psychiatrists, and the psychiatric complex, must change as fundamentally in all respects as they did with the closure of the asylums.

Radical shifts in styles of thought and practice, paradigm shifts in our understanding and treatment of mental suffering, have happened before, and the cracks in the current paradigm give some hope that they will and must happen again. Psychiatrists can no longer claim to be unaware of the fundamental role of systematic and structural forces shaping experience from birth in increasing vulnerability to mental distress. Some psychiatrists, who are certainly not paid-up members of ‘anti-psychiatry,’ are making important steps to challenge psychiatric orthodoxy. But psychiatrists themselves are working in ‘cramped spaces’—constraints on thought and action that make it difficult in practice to work beyond boundaries of the clinical encounter. Moves towards paradigm shifts are aways resisted precisely because they identify fundamental problems with ‘normal’ science. For the dimensions that I have tried to outline above to be recognized as foundational to the experience of both common and severe mental distress and hence to their mitigation would require a paradigm shift in how psychiatry was taught, practiced, and researched, indeed a radical change in what it is to be ‘a psychiatrist.’ As Thomas Kuhn recognized, the time before a paradigm shift is replete with dangers ….