Context

In the late 1970s and early 1980s, flying became commonplace. Frank White noted, while flying over Washington DC, that a different perspective emerged when looking from the aeroplane at the earth below. Observing buildings and people from a different vantage point led him to develop the concept of the overview effect. This shift in worldview has also been reported by astronauts and cosmonauts during spaceflight, often while viewing the Earth from orbit in transit or from space. ^{Reference White1} The overview effect leads to a transformation of the perspective that the astronauts and cosmonauts hold. Similarly, our perspective of an object can change when we look at it from different angles.

However, White ^{Reference White1} also noted that observation of the Earth from space, in addition to producing a sense of awe, leads to a sense of profound understanding of the interconnectedness of all life and how, in reality, the earth itself is extremely small in the broader perspective of the universe and possibly quite unique with respect to hosting life. Therefore, this observation also invokes a sense of precariousness, and this fragility can lead to a renewed sense of responsibility for taking care of the special environment that we have been gifted. Therefore, the term ‘overview effect’ could perhaps also serve as a concept to help understand and express what is important to people.

For instance, in medicine in general, and in psychiatry in particular, the term can be used to refer to looking at an individual patient not necessarily from a great height or distance but instead examining them within the context in which they live, work, play and exist day to day; it entails taking an overall perspective rather than focusing on phenomenology alone. It could also be used to refer to the traditional way in which the clinical gaze looks at the individual in the context of their functioning – in which external factors including employment, housing, and personal and social achievements play major parts. The overview effect is also applicable to migrants, who often have a different overall perspective on their newly adopted culture. However, the aim of this editorial is to consider what doctors and clinicians need to know and learn, and how they may apply their knowledge to clinical interactions. Specifically, we advocate for the focus to shift to the person rather than being centred on the symptoms, disease or pathology alone. Patients are individuals, but they are usually interested in managing their symptoms in the context of their social functioning and broader cultural self.

Eisenberg ^{Reference Eisenberg2} drew our attention to differences between disease and illness. The concept of dis-ease or disease focuses on symptoms and pathology, and as clinicians we are trained to identify such pathology and learn how to address it. Clinical management and treatment more specifically may include medical, social or psychological interventions or a combination of these, drawing on the biopsychosocial model of aetiopathogenesis and corresponding therapy. Eisenberg’s observation ^{Reference Eisenberg2} was that when these symptoms play a part in distorting a patient’s personal and social world, the condition becomes an illness. Patients are often interested in managing their illness – that is, their social functioning, whereas clinicians are inclined to focus largely on symptoms and disease. Kleinman ^{Reference Klienman3} argued that the person with the disease fits into the clinical framework, which looks at symptoms, whereas the affected individual and their social network and community perceive these symptoms and live with them and respond to disability; this draws our attention to living, the experience of life.

As suggested, the overview effect provides a perspective of patients as human beings, not simply as symptoms or a syndrome, and this somewhat broader gaze is important because it can instil in the clinician a sense of humility. White ^{Reference White1} noted that the overview effect is individualistic, and, in relation to this, he describes the halo experience, which has four components: first, there is a difference between the experience itself and communication of it; second, the experience begins long before the flight and ends, if ever, long after it; third, the experience is relatively private (while the astronaut is in space) but becomes public upon return; and, fourth, the experience is given a meaning that serves societal needs which have little to do with the astronaut’s personal reality. Now, if we apply this effect to the patient first: the patient may or may not be able to communicate their experience, which lasts longer in their memory and also the memories of their family members, partners, formal and informal carers, and community. It is indeed a private experience which becomes public; its labelling may or may not help the patient, but this process of labelling helps society to ‘other’ the patient. If we then apply these four codas to the clinician, in this case a psychiatrist, the communication of the experience and its understanding, memory of dealing with the patient, and the private as well as public nature of the discourse can influence societal needs but also good patient care.

In clinical assessment, and as part of anamnesis, the overview effect relies on the psychiatrist taking a position from which they can see the patient at the centre of several concentric rings, which include family, community, society, cultural and national worlds, and international context. These influences may be concentric, but they do not necessarily operate at the same level, degree or depth. At various personal levels, social determinants of mental health have been identified as having a major impact on individual well-being. These determinants include poverty, overcrowding, unemployment and lack of green spaces. At the national and international levels, determinants leading to mental ill health include geopolitical factors such as political and commercial determinants, natural disasters, and man-made disasters such as wars and conflicts.

Bearing in mind the biopsychosocial model of aetiology, it is worth recognising that biology is affected by social factors. It has been shown convincingly that various attachment patterns in childhood, as well as adverse childhood experiences, affect the development of brain structures and subsequent brain functioning; ^{Reference Leblanc, Dégeilh, Daneault, Beauchamp and Bernier4,Reference Hidalgo, Muetzel, Luijk, Bakermans-Kranenburg, El Marroun and Vernooij5} it is also likely (and unsurprising) that emotional distress has an impact on brain biology and its neural processing. ^{Reference Malhi, Das, Outhred, Bryant and Calhoun6}

The overview effect has been compared to a spiritual experience, although it has not been identified as a universal phenomenon. However, it highlights that the clinician may need to look at spiritual aspects of the individual when indicated. Concepts of self are strongly influenced by culture, and many individuals with psychiatric illnesses express distress through somatic symptoms. This mind–body dualism has its problems, in that because of stigma against mental illnesses, patients and indeed clinicians may highlight medicalisation of symptoms, where mind is also influenced by environment. Cultures influence our development and worldview, and this relationship, or abnormalities in it, can influence kinships, relationships, economic freedoms and technology, all of which are influenced directly or indirectly by political ideologies which do not take the overview effect into account.

White ^{Reference White1} observed that the overview effect is about our observations and functioning. Interestingly, he speculates that if politicians were taken to space for a summit, they would make different decisions, because there are no political boundaries in space, and the relative insignificance of the planet comes into focus. However, for people on earth, their personal views remain important in the same way that patients’ observations are significant for them. The clinician needs to be with the patient but also needs to have an overview. The lack of geographical borders and boundaries in space furnishes the observer with a different and welcome perspective. These same principles are applicable when we look at factors such as migration and the needs of those seeking refuge and asylum.

White ^{Reference White1} defined planetary management as emerging from the recognition that if the whole can be perceived, it can be the focus of practical and abstract interest. If we apply this view to looking at an individual who is presenting with distress, it can help us to rise above their symptoms and immediate distress and see the person as a whole with an individual identity and a purpose in their functioning. This more complete and meaningful perspective will allow us to both improve clinical engagement and strive for worthwhile outcomes. In clinical settings, an overview system often exists, but it tends to focus on systems and structures rather than on the individual experiencing and expressing distress (which is what any clinician ought to be doing). There is no doubt that systems and structures are important, but, as White ^{Reference White1} pointed out, an overview system is a pattern of organised self-awareness in which the whole is perceived as is the context of all the parts contained within it. This overview perspective – the gestalt – appears to have diminished in clinical psychiatry. The shift of attention to symptom checklists has taken us away from patient experiences, for which narratives are crucial in understanding phenomenology. ^{Reference Klienman3,Reference Carel7–Reference Bhugra and Ventriglio9} To improve patient outcomes, we must focus on patients’ narratives and those of their care partners in the context of their cultures.

The achievement of an overview, be it on a personal, social or societal, or even planetary level is essential to self-definition and self-differentiation, seeing the self as whole and complete and at the same time a part in relationships with other systems. ^{Reference White1} This perspective could be spelled out in basic clinical training and built into doctor–patient relationships. Furthermore, it enables clinicians to have a broad geopolitical perspective, which may in turn influence public and personal mental health. Understanding the living circumstances and ecosystems of our patients is critical. The overview effect provides a shift to a more system-based approach, in which clinicians and their patients and care partners must be seen as key parts of the system. Systems theory relies on maintaining some sort of equilibrium. This could become a helpful tool in patient engagement and working with families.