Enactivism as a New Framework for Psychiatry
How we think about the mind affects how we think about mental disorders: about what they are, how they develop and how we should best treat them. How we think about the mind and its relation to both body and world will typically be implicit though. One commonly assumed 'mind-world topology' (Dreyfus & Taylor, 2015) regards the mind as internal and the world as external, and gives the mind the task of properly representing the outer world. This leads to a division of labor in which perception provides input from world to mind, cognition processes this input and generates output from mind to world in the form of actions (i.e., Hurley's  "sandwich model of the mind"). From such a perspective, psychiatric disorders appear as problems with internal, cognitive processing. Since the inputs and outputs are in order, the problem must lie in between: in the inner modeling of the outer world.
It is easy to see how this model of the mind meshes with a neuroreductionist model of psychiatric disorders as brain diseases. For if the mind is inner, and its job is to process sensory input and generate bodily output, it seems natural to turn to the brain as the place where the magic happens—and where the internal mechanisms that have broken down in psychiatric disorders may be found.
Enactivism offers a very different conception of the nature of mind. Enactivism stresses how mind emerges from embodied beings interacting with their environment. Living beings rely on constant exchanges with their environment to maintain themselves, and therefore need to make sense of their surroundings to distinguish what is edible from what is not, what is dangerous from what is safe, and so on. Mind or cognition is this sense-making: an embodied and embedded activity of an organism interacting with its environment.
Given that on this enactive account mind, body, and world are necessarily interrelated, enactivism provides a promising alternative starting point for an integrative framework of psychiatric disorders. It is attractive for those who are dissatisfied with neuroreductionist accounts which ignore non-neurological factors, yet who also find the biopsychosocial model too vague.
This special issue comprises one general article on an enactive approach to psychiatry (De Haan) and three articles focused on specific pathologies: anxiety disorders (Glas), schizophrenic delusions (Fuchs), and ego boundary disturbances in schizophrenia (Gipps). Each article is commented on and these comments are again replied to. The comments on Glas's and De Haan's articles and their replies will appear in a subsequent issue of PPP.
De Haan's article outlines how enactivist ideas can throw new light on our conception of the [End Page 1] nature of psychiatric disorders, in particular the notion of sense-making. Sense-making is central to living, is affective, and implies some basic form of values. De Haan argues that sense-making can be reflexive, that is, self-relating, too; marking a transition from basic organismic sense-making to human existential sense-making. On an enactive account, psychiatric disorders can be understood as structurally disordered patterns of sense-making. One of its strengths is that offers a solution to psychiatry's 'integration problem' of how to relate the diverse factors—patients' experiences, physiology, existential stances, and sociocultural influences—that are at play in psychiatric disorders. By adopting an 'organizational' rather than a linear account of causality, an enactive approach neither reduces all factors to one 'underlying' factor nor merely juxtaposes them.
Glas discusses what an enactive approach could add to the science and treatment of anxiety disorders. Current theories of anxiety have difficulties accommodating anxiety's contextuality and self-referentiality. Anxiety is shaped not only by person-related factors (e.g., coping skills, personality) but also by contextual factors (e.g., education, socialization). And anxiety is self-referential in that it reveals something about the person having the anxiety. By regarding anxiety and anxiety disorders as enacted, an enactive approach is particularly suited to do justice to both characteristics. From an enactive perspective, anxiety is neither an automatic reaction of the body to an external stimulus, nor an inner mental state, but rather results from the ongoing interaction between a self-concerned person and her environment. This better captures the complex dynamics of the development of symptoms of anxiety than the biomedical model that regards them as mere expressions of underlying dysfunctions.
In his article on the nature and development of schizophrenic delusions, Fuchs challenges the common view on delusions as faulty information-processing within an individual's brain and instead analyzes them as disturbances of the enactive, intersubjective constitution of a shared reality. Drawing on phenomenological and enactive theories of perception, he argues that the objectivity of perception depends on a two-level process of a) sensorimotor interaction with the environment and b) social interaction with others. Both types of interaction attest that my own current perspective is only one among many. This twofold decentering of the subject constitutes the experience of reality's independence. The formation of delusions can now be understood as an increasing subjectivization of perception. In beginning psychosis, derealization and self-centrality go hand-in-hand: objects seem strangely unreal, as if they are only for the patient. Delusions subsequently provide an alternative sense for these experiences—but one that is fundamentally decoupled from our shared world.
Finally, Gipps provides an enactive re-theorization of the conception of ego boundary disturbances in schizophrenia. In line with classical psychopathology, Gipps argues that the diversity of schizophrenic symptoms can be unified as a self-disorder. Focusing on that self's boundaries, Gipps notes how these are often understood unhelpfully either as some sort of entity (metaphysical view) or as something experienced (epistemological view). By contrast an enactive perspective sees them as enacted. The boundary between self and world is not pre-given, but co-arises with experiential encounters with the world. This enactive perspective captures the ontological depth of schizophrenic self-disturbance (contrast the epistemological view), while remaining within a naturalist frame (contrast the metaphysical view). Gipps then shows how this conception of ego boundaries not only helps connect various schizophrenic psychopathology such as thought insertion, hearing voices, and disturbed bodily experiences, but also helps to understand the restabilizing effect of various therapies.
All articles show how an enactive view on the mind and its relation to body and world allows for a conceptualization of mental disorders that regards physiological processes, experiences, and environmental processes as fundamentally intertwined. As such, an enactive approach offers a solid theoretical grounding of a holistic approach to psychiatric disorders. As Glas points out, the next steps would be to apply enactivist insights to empirical research and translate such research into clinical practice.
Sanneke de Haan works as a postdoctoral researcher at Tilburg University. Her main research interests are philosophy of psychiatry, phenomenological psychopathology, and enactivism. She currently works on relational authenticity in psychiatry. Recent publications include The existential dimension in psychiatry: an enactive framework (Mental Health, Religion & Culture 2017) and Becoming more oneself? Changes in personality following DBS treatment for psychiatric disorders: Experiences of OCD patients and general considerations (PLoS ONE 2017). In the spring of 2020 her book Enactive Psychiatry will appear with Cambridge University Press.