In this article we offer a two-part commentary on Bolton and Gillett’s reconceptualization of Engel’s biopsychosocial model. In the first section we present a conceptual and historical assessment of the biopsychosocial model that differs from the analysis by Bolton and Gillett. Specifically, we point out that Engel in his vision of the biopsychosocial model was less concerned with the ontological possibility and nature of psychosocial causes, and more concerned with psychosocial influences in the form of illness interpretation and presentation, sick (...) role, seeking or rejection of care, the doctor-patient therapeutic relationship, and role of personality factors and family relationships in recovery from illness, etc. On the basis of this assessment, we then question Bolton and Gillett’s restricted focus on accounting for biopsychosocial causal interactions. The second section compares Bolton and Gillett’s account with a recent enactivist account of mental disorder that tackles similar conceptual problems of causal interactions. Bolton and Gillett’s utilize elements of the 4E cognition, but they combine these proto-ideas with an information-processing paradigm. Given their explicit endorsement of 4E approaches to mind and cognition, we illustrate some key ways in which a more fleshed out enactive account, particularly one that doesn’t rely on notions of information-processing, differs from the account proposed by Bolton and Gillett. (shrink)

Research in the philosophy of addiction commonly explores how agency is impacted in addiction by focusing on moments of apparent loss of control over addictive behavior and seeking to explain how such moments result from the effects of psychoactive substance use on cognition and volition. Recently, Glackin et al. (2021) have suggested that agency in addiction can be helpfully analyzed using the concept of affordances. They argue that addicted agents experience addiction-related affordances, such as action possibilities relating to drugs, drug (...) paraphernalia, and drug-related activities, as aberrantly salient motivations for action. Building on this approach, we present a novel two-tiered affordance model of addiction. In doing so, we suggest that what is significant about the addicted person’s world is not simply what affordances are experienced as salient, but also the way in which the addicted person’s world is shaped by a dominant concern. It is not only that addiction-related affordances become more prominent as addiction progresses but that one’s plurality of concerns become monopolized by and funneled through addiction. Our model endorses Glackin et al.’s idea that addiction-related affordances become aberrantly salient, while proposing why they become and remain so. This way of viewing agency in addiction also brings to light important implications for recovery and treatment. For, if an addicted person adopts a new, even “socially approved”, dominant concern, there is a risk that the shape of addiction is preserved, even though the content changes, leaving an individual at the risk of addiction substitution or relapse. (shrink)

In this commentary on Anneli Jefferson’s book “Are Mental Disorders Brain Disorders?,” I offer an overview of her central thesis, and then propose my own modified account of when we are justified in calling mental disorders as “brain disorders.” In doing so, I draw on recent work in neuroscience that understands the relationship between brain and behavior in complex, dynamic, and computational terms. In particular, I disagree with Jefferson’s criterion of sufficiency, that a particular brain process should always realize a (...) psychological dysfunction. I propose that a psychiatric disorder can be said to be a brain disorder if there are empirically identifiable systematic brain differences associated with it and if these associations are contextualized within a scientifically robust theoretical understanding of the relationship between brain and behavior. I conclude by preliminary reflections on whether the issue of “mental disorder” versus “brain disorder” comes down to “the language of psychology” versus “the language of neuroscience,” and the degree to which the former can be expressed in the latter. (shrink)

Questions are currently being posed concerning the implications of the clinical uptake of psychedelics. While enthusiasm surrounds the potential therapeutic benefits of psychedelics and critique surrounds their appropriation to commercial ends, limited attention has been given to the role of psychedelics in generating social transformation. Herbert Marcuse contended radical change requires ‘new imaginaries of liberation’. We consider whether clinical uptake of psychedelics may produce the perceptual shifts necessary to generate social transformation surrounding contemporary alienating conditions. Economic structures contributing to these (...) alienating conditions are highly resistant to change and may neuter psychedelics’ revolutionary potential. We illustrate how psychedelics may be instrumentalised: regulating individuals into unjust systems; redirecting psychedelic usage away from therapeutic ends towards productivity; distracting or diverting attention from systemic forms of control; usurping non- ordinary states into the domain of self-care; and fetishistically commodifying psychedelic experience as a consumable. There are, however, reasons to believe that psychedelics, in raising consciousnesses, may prove resistant to co-option. In particular, psychedelics induce perceptual experiences that: challenge the paradigmatic assumptions of industrial society by provoking alternative epistemologies and meta- physics; generate expanded or ecological constructions of selfhood, thereby offering resignifications of meanings, desires, and life potentials; and offer the enriched phenomenological insight into self, other, and world called for in combating ubiquitous social alienation. In this way, psychedelics may induce the revolution in perception necessary to imagine liberatory potentials and spark the desire for collective emancipation. (shrink)

This study clarifies the need for a renewed account of the body in physiotherapy to fill sizable gaps between physiotherapeutical theory and practice. Physiotherapists are trained to approach bodily functioning from an objectivist perspective; however, their therapeutic interactions with patients are not limited to the provision of natural-scientific explanations. Physiotherapists’ practice corresponds well to theorisation of the body as the bearer of original bodily intentionality, as outlined by Merleau-Ponty and elaborated upon by enactivists. We clarify how physiotherapeutical practice corroborates Merleau-Ponty’s (...) critical arguments against objectivist interpretations of the body; particularly, his analyses demonstrate that norms of optimal corporeal functioning are highly individual and variable in time and thus do not directly depend on generic physiological structures. In practice, objectively measurable physical deviations rarely correspond to specific subjective difficulties and, similarly, patients’ reflective insights into their own motor deficiencies do not necessarily produce meaningful motor improvements. Physiotherapeutical procedures can be understood neither as mechanical manipulations of patients’ machine-like bodies by experts nor as a process of such manipulation by way of instructing patients’ explicit conscious awareness. Rather, physiotherapeutical practice and theory can benefit from the philosophical interpretation of motor disorders as modifications of bodily intentionality. Consequently, motor performances addressed in physiotherapy are interpreted as relational features of a living organism coupled with its environment, and motor disorders are approached as failures to optimally manage the motor requirements of a given situation owing to a relative loss of the capacity to structure one’s relation with their environment through motor action. Building on this, we argue that the process of physiotherapy is most effective when understood as a bodily interaction to guide patients towards discovering better ways of grasping a situation as meaningful through bodily postures and movements. (shrink)

In this paper I explore health and illness through the lens of enactivism, which is understood and developed as a bodily-based worldly-engaged phenomenology. Various health theories – biomedical, ability-based, biopsychosocial – are introduced and scrutinized from the point of view of enactivism and phenomenology. Health is ultimately argued to consist in a central world-disclosing aspect of what is called existential feelings, experienced by way of transparency and ease in carrying out important life projects. Health, in such a phenomenologically enacted understanding, (...) is an important and in many cases necessary part of leading a good life. Illness, on the other hand, by such a phenomenological view, consist in finding oneself at mercy of unhomelike existential feelings, such as bodily pains, nausea, extreme unmotivated tiredness, depression, chronic anxiety and delusion, which make it harder and, in some cases, impossible to flourish. In illness suffering the lived body hurts, resists, or, in other ways, alienates the activities of the ill person. (shrink)

Enactive approaches to psychiatry have recently argued for an understanding of psychiatric conditions based within relational interactions between individuals and their environments. A central motivation for these enactive approaches is the goal of social integration: the integration of a naturalistic approach to psychiatric conditions with their broader sociocultural dimensions. One possible issue, however, is whether appeals to the autonomy and authenticity of relationally constituted enactive individuals can provide a means of adjudicating between harmful and beneficial social constraints upon individual behaviour. (...) This paper seeks to provide enactive approaches to psychiatry with a possible means of evaluating normative influences of social contexts beyond direct interactions with relationally constituted individuals. Some of the most significant influences of the sociocultural dimension of psychiatric conditions consist not in direct interaction with individuals, but in setting the terms for interactions and interactants alike. Insofar as some social influences precede and predefine dyadic relations between individuals and their social context, these cannot be accounted for as features of interactions, but must be assessed as independent structures of the sociocultural dimension. I will provide one potential means for enactive models to assess social norms using Canguilhem’s distinction between health and pathology. I will argue that Canguilhem’s conceptualization of health in terms of adaptive normative structure provides a potential tool for social integration which strongly complements enactive approaches to psychiatry. (shrink)

In this paper I argue that thinking in terms of process metaphysics and seeing the mind and mental disorders as processual in nature allows for a more complete understanding of mental disorders than is allowed by non-processual frameworks, while it also allows us to incorporate what we currently know about them. In addition, it can address problems in psychiatry that arise when we ask the wrong kinds of questions that naturally arise within a non-processual metaphysical framework. In this paper I (...) address the problems of reductionism, essentialism and dualism. -/- . (shrink)

Participatory sense-making is already an established concept within enactivism. It is used to define the participatory nature of cognitive relations, designating that humans and other organisms make sense of their surrounding environments not just on their own. They build cooperative networks, working together, to create ways of making sense of the world. However, so far little attention has been paid to how enactive concepts, such as participatory sense-making, may apply to the field of bioethics, understood here as health care ethics. (...) In this paper, I examine health care practices cases of participatory sense-making. The paper aims to show that relations between patients and health care providers (HCPs) can be understood as participatory sense-making relations. To make my case, I discuss the so-called phenomenological interview, as proposed technique in health care. I argue that this interview technique has essential features that can be viewed also as features of participatory sense-making. More specifically, the phenomenological interview is an open-minded, a critical, and pro-active dialogue between patient and health care provider that is meant for the patient to raise self-awareness of their body and medical condition, as well as of the social conditions that may affect that experience and condition. I will argue that phenomenological interviews are exemplary cases of patient-health care provider relations in which both parties actively work together to make sense of what the patient is going through and to find adequate medical responses to that experience. I will conclude by proposing normative guidance based on my analysis of health care practice as participatory sense-making. I argue that viewing patient-HCP relations as participatory sense-making may be helpful for both patients and health care providers in that it shows that health care practice is not just a technical exercise or routine task, but essentially relational and patient-oriented. (shrink)

La psiquiatría a lo largo de su historia y fundamentalmente desde la publicación del DSM-5, enfrenta diversas críticas por la falta de confiabilidad y validez en las clasificaciones de los trastornos mentales, esto debido a su incapacidad para integrar adecuadamente el conocimiento científico y la complejidad de las experiencias individuales. Este análisis, inspirado en la filosofía de Hegel, propone una nueva perspectiva que valora cada caso clínico como una entidad única, desafiando el enfoque reduccionista y promoviendo un entendimiento más profundo (...) y respetuoso de la psicopatología, enriquecido con una integración dialéctica del conocimiento científico y el concepto del universal concreto. (shrink)

In 2020, M. Summa developed a promising approach to understanding the concept of illness. This approach combines a theory of organisms with Responsive Phenomenology to gain a concept of illness. Following on from this, the present article shows that the normative presuppositions can be further explicated and justified by drawing on the theoretical resources of Aristotelian naturalism as propounded by Michael Thompson. Aristotelian naturalism does provide a theoretical option to grasp the normative foundations of human life. However, this article argues (...) that Aristotelian naturalism requires another criterion besides human nature to make the concept of illness intelligible. Following John McDowell’s critique of Aristotelian naturalism, it will be shown that this criterion consists in the capacity for autonomy. From this a concept of illness is developed which describes an impairment of the self-regulated and autonomous realisation of the human form of life. (shrink)

Ecological psychology (EP) and the enactive approach (EA) may benefit from a more focused view of lived temporality and the underlying temporal multiscalar nature of human living. We propose multiscalar temporality (MT) as a framework that complements EP and EA, and moves beyond their current conceptualisation of timescales and inter-scale relationships in organism-environment dynamical systems. MT brings into focus the wide ranging and meshwork-like interdependencies at play in human living and the questions concerning how agents are intimately entangled in such (...) meshworks, utilising them as resources for skilful living. We develop a conceptual toolkit that highlights temporality: Firstly, we address lived temporality. We use a case study from psychotherapy to show how a person’s skilful engagement with the world is best described as adaptive harnessing of interdependencies of constraints residing across a wide range of timescales. We call this skill time-ranging. Secondly, the case study provides a proof of concept of the integration of an idiographic approach to human conversing and a more general theory of emergent organisation rooted in theoretical biology. We introduce the existing concept of constraint closure from theoretical biology and scale it up to human interactivity. The detailed conceptualisation of constraint interdependencies constitutes the backbone of the proposal. Thirdly, we present a heuristic mapping of what we call organising frames. The mapping guides the conceptualisation of the emergence of inter-scale relationships and serves as an epistemic tool that brings together nomothetic and idiographic approaches. Finally, we combine new ideas with re-interpretations of existing EP and EA concepts and elaborate on the need of a fresh new look at the implicit and sometimes missing conceptualisations of temporality in the EP and EA literature. (shrink)

Affordances are possibilities for action offered by the environment. Recent research on affordances holds that there are differences in how people experience such possibilities for action. However, these differences have not been properly investigated. In this paper I start by briefly scrutinizing the existing literature on this issue, and then argue for two claims. First, that whether an affordance solicits action or not depends on its relevance to the agent’s concerns. Second, that the experiential character of how an affordance solicits (...) action depends on the character of the concern to which it is relevant. Concerns are conceived of as bodily forms of responsiveness, and solicitations are experienced through this responsiveness. The main aim of this paper is to make clear that an understanding of experiential differences in solicitations has to be based on a phenomenological appreciation of how one experiences one’s responsiveness to those solicitations. In the remainder of the paper I show how such a phenomenological appreciation reveals several characteristics of our responsiveness and I briefly explore three of them: valence, force and mineness. In the final section I discuss the self-referentiality of affordances in light of the current proposal, and argue that this self-referentiality is broader than is typically acknowledged. (shrink)

This paper aims to show that genders are enacted, by providing an account of how an individual can be said to enact a gender and explaining how, consequently, genders can be fluid. On the enactive-ecological view we defend, individuals first and foremost perceive the world as fields of affordances, that is, structured sets of action possibilities. Fields of natural affordances offer action possibilities because of the natural properties of organisms and environments. Handles offer graspability to humans because of physical-structural properties (...) of handles and the anatomical-physiological properties of humans. Although humans live in fields of bodily, action, and cultural affordances, our work focuses on cultural affordances, where action possibilities are offered to individuals because of the normative responses of individuals in that culture. Knocking on a door affords entrance because knocking provides cultured individuals on the other side of the door an affordance to which they themselves behave normatively. Usually, behaving normatively in response to cultural affordances brings about sequences of perception-action loops, which we will call “scripts”: for instance, closed doors afford knocking, which affords the individual inside opening the door, which affords an interpersonal meeting, which afford entrance. Although the notion of script has a strong cognitivist flavor, one of the aims of the paper to provide an ecological account of scripts, to show that what cognitivists viewed as representations are in fact environmentally structured perception-action loops. On our account of gender, gendered cultures build and maintain gendered cultural affordance landscapes, that is, landscapes in which the action possibilities individuals face are normed according to a specific body type or situation; most often biological sex. Individuals enact a given gender when they come to perceive the affordances reserved for one gender by their culture and respond in the culturally normative way, thus enacting gendered sequences of perception-action loops. With the shifting landscapes of cultural affordances brought about by several recent social, technological, and epistemic developments in some cultures, the gendered landscapes of affordances offered to individuals in these cultures have become more varied and less rigid, thus increasing the variety and flexibility of scripts individuals can enact. This entails that individuals in such cultures have an increased possibility for gender fluidity, which may in part explain the increasing number of people currently identifying outside the binary. (shrink)

Osteopathy is a person-centred healthcare discipline that emphasizes the body’s structure-function interrelationship—and its self-regulatory mechanisms—to inform a whole-person approach to health and wellbeing. This paper aims to provide a theoretical framework for developing an integrative hypothesis in osteopathy, which is based on the enactivist and active inference accounts. We propose that osteopathic care can be reconceptualised under active inference as a unifying framework. Active inference suggests that action-perception cycles operate to minimize uncertainty and optimize an individual’s internal model of the (...) lived world and, crucially, the consequences of their behaviour. We argue that active inference offers an integrative framework for osteopathy, which can evince the mechanisms underlying dyadic and triadic exchanges and osteopathic care outcomes. We propose that this theoretical framework can underpin osteopathic care across the lifespan, from preterm infants to the elderly and those with persistent pain and other physical symptoms. In situations of chronicity, as an ecological niche, the patient-practitioner dyad provides the osteopath and the patient with a set of affordances, i.e., possibilities for action provided by the environment, that through shared intentionally, can promote adaptations and restoration of productive agency. Through a dyadic therapeutic relationship, as they engage with their ecological niche’s affordances—a structured set of affordances shared by agents—osteopath and patient actively construct a shared sense-making narrative and realise a shared generative model of their relation to the niche. In general, touch plays a critical role in developing a robust therapeutic alliance, mental state alignment, and biobehavioural synchrony between patient and practitioner. However, its role is particularly crucial in the fields of neonatology and paediatrics, where it becomes central in regulating allostasis and restoring homeostasis. We argue that from an active inference standpoint, the dyadic shared ecological niche underwrites a robust therapeutic alliance, which is crucial to the effectiveness of osteopathic care. Considerations and implications of this model—to clinical practice and research, both within- and outside osteopathy—are critically discussed. (shrink)

The recommended treatment for dual diagnosis - the co-occurrence of substance use and another mental disorder - requires seamless integration of the involved disciplines and services. However, no integrative framework exists for communicating about dual diagnosis cases across disciplinary or sectoral boundaries. We examine if Enactive Psychiatry may bridge this theoretical gap. We evaluate the enactive approach through a two-step pragmatic lens: Firstly, by taking a historical perspective to describe more accurately how the theoretical gap within the field of dual (...) diagnosis initially developed. Secondly, by applying the Enactive Psychiatry approach to data from a longitudinal study on the trajectory of cannabis use in psychosis disorders. By applying the theory rather than simply presenting it, we position ourselves better to evaluate whether it may assist the purpose of achieving a more expedient pragmatic “grip” on the field of dual diagnosis. In our discussion, we suggest that this may very well be the case. Finally, we consider the enactive approach as one of a small handful of new theories of mental disorders that draw on systems thinking and ecological psychology, and discuss whether they have the potential for a wider progressive problemshift within psychiatry. The case in favor of such potential, we argue, is less strong unless the role of complexity, similar to that seen within the dual diagnosis field, may be demonstrated for other fields of clinical practice. (shrink)

Enactivism has much to offer to moral, social and political philosophy through giving a new perspective on existing ethical problems and improving our understanding of morally ambiguous behaviours. I illustrate this through the case of self-injury, a common problematic behaviour which has so far received little philosophical attention. My aim in this paper has been to use ideas from enactivism in order to explore self-injury without assuming a priori that it is morally or socially wrong under all circumstances, seeking to (...) establish a less implicitly value-laden analysis. Enactivism can help us in making this behaviour more intelligible and contextualising it through examining the relations of individual embodied action and social practices with the help of enactivist theories of habits and affordances. (shrink)

ABSTRACT‘If I experience X, is it because of the illness, the medication, or is it ‘just me’?’ (Karp 2009) [Is it me or my Meds? Living with Antidepressants. Harvard University Press]. This issue is known as self-illness ambiguity (SIA) (Sadler 2007) ["The Psychiatric Significance of the Personal Self." Psychiatry: Interpersonal and Biological Processes 70 (2): 113–129]. In her paper Know Thyself: Bipolar Disorder and Self-concept, Carls-Diamante (2022) [“Know Thyself: Bipolar Disorder and Self-Concept.” Philosophical Explorations, 1–17] offers a taxonomy of different (...) ways in which Bipolar Disorder can be related to one’s self and self-concept. In contrast to the essentialist model of mental disorders she seems to adopt, I propose a different outlook on SIA, following an enactive approach to psychiatric disorders as disorders of sense-making. One’s way of making sense of the world and/or oneself can become stuck in a rigid pattern that is stronger than oneself and at odds with how one would want to be. I argue that it is helpful to distinguish between the experiential SIA of specific experiences (Am I over/underreacting?) and the long term concerns of existential SIA (How to live my life in accordance with what matters to me despite/while having certain vulnerabilities?). I conclude that knowing oneself is not an intra-individual matter, nor primarily a matter of reflection: it is rather a relational and material practice of trying to live your life in accordance with what matters to you. (shrink)