Self-management as management of the self: Future directions for healthcare and the promotion of mental health

In a recent attempt to update the 1948 World Health Organization definition of health as a state of complete well-being and absence of disease, it has now been proposed to change its emphasis to the ability to adapt and self manage in the face of social, physical and emotional challenges (Huber et al., 2011). The question how we should conceptualize such self-management, however, is rarely raised and its theoretical foundations remain largely unexplained. Still, to an increasing extent, scholars, health professionals, researchers, caretakers and policy makers emphasize the great potential of self-management strategies in somatic as well as mental healthcare. Patients, so the argument runs, should not be treated merely as objects of diagnosis and treatment, but as "expert clients", actively involved in the management of their own care. The advantages of this approach are considered twofold: it holds the prospect of more efficient and (cost)effective preventive and care strategies to promote mental health and well-being, and converges with recent research findings which acknowledge that incorporating the patients' subjective perspectives is beneficial to treatment progress.

At the same time, it is clear that self-management in the context of mental healthcare poses profoundly challenging problems (Van Geelen, 2013; Van Geelen, 2014), as we need to take into account that it is often "the self" that is part and parcel of the problem in psychiatric and psychosomatic conditions (Kyrios et al., 2015; Santhouse, 2008; Sadler, 2007). In the context of mental healthcare, then, self-management confronts us with fundamental questions: what is our understanding of this self in psychosomatic and psychiatric settings, and how does that understanding, directly or indirectly, affect diagnoses, treatment plans and nosology in the fields of psychopathology and psychosomatic medicine? Answering such questions will also be of vital importance to a theoretically sound and practically relevant, implementable notion of self-management. Given the complexity of this subject matter, addressing such problems requires an interdisciplinary approach, as we have argued in the introduction (Van Geelen & Franssen, 2017). A conceptual framework for self-management should integrate insights from a variety of disciplines, as it needs to acknowledge the multifaceted character of self-experience – with all its embodied, affective, cognitive, moral and social complexities. It is imperative, in other words, that insights in the structure and characteristics of self and self-experience as developed in humanities traditions – i.e., phenomenology, philosophy of mind and action, ethics, narrative theory – are brought into a dialogue with results obtained in psychiatric and psychosomatic research and practice.

Conceptualizing selfexperience and selfmanagement: From embodiment to metacognition

For this special issue, we asked nine specialists to explicate what they believe to be the fundamental dimensions of self-experience in mental healthcare, and to fully consider the consequences of those dimensions for adequate strategies of self-management in psychiatry and psychosomatic medicine. Their answers are rich and multifarious, as they cover a variety of psychopathologies – anxiety, depression, schizophrenia, unexplained chronic pain – and perspectives to self-management, but at the same time they converge at important points and move in compatible directions.

Heribert Sattel and Peter Henningsen's take on self-management as a "management of the self" starts out from the perspective of contemporary psychosomatic medicine, which aims to integrate biological and psychological with interpersonal and social dimensions in the explanation, diagnosis and treatment of (unexplained) bodily complaints and disorders (Sattel & Henningsen, 2017). In order to conceptualize self-management in mental healthcare, they put forward the concept of the "psychic structure", a developmental model of the self. Psychic structure refers to availability of mental functions for the regulation of the self and its relationships to internal and external objects: metaphorically, it can be understood as the functional capacities of the stage on which the drama of the self unfolds. The quality of the structure is described in terms of levels of integration: well-integrated psychic structures allow for a manifold of mental experiences to coexist and to be perceived differentially, while less integrated structures are characterized by intra-psychic conflicts – limited or...