- Dealing with Self-Illness AmbiguityA Rebuttal
We thank Sanneke de Haan for her thoughtful response. We agree with what she says and consider it as a further specification of our intentions. We particularly endorse the two main points she raises, that is, that dealing with self-illness ambiguity requires a relational perspective; and that relying on reflection solely is problematic since it plays an only modest role in the resolution of self-illness ambiguity. We discuss both points in reverse order.
With respect to the role of reflection, we have, as a matter of fact, been very explicit: “we should not overemphasize the importance of reflection”; and “self-ambiguity is more likely to be a diachronic process”, with a “back and forth between narrative self-understanding and unreflective engagement with the world” (p. 350). Maybe we have written somewhat more about the role of reflection than about the informative role of not-yet-understood feelings, images and perceptions for self-understanding. But this does not imply that we consider reflection as the main entry to self-understanding and that we downplay the role of feelings, images and perceptions that are still at the threshold of becoming present to oneself. Self-understanding usually starts in the unreflective world, the world of the images, feelings, intuitions, and the elementary perceptions just mentioned. It is only later in the process, when these feelings, intuitions, and perceptions have become more explicit, that they may become the topic of reflection. This will often give rise to new uncertainties and ambiguities, which in turn are faced and dealt with in the “back and forth” between the raw material (images, feelings, sensations) and the (reflective) space of possible interpretations. That is why we emphasized that psychoeducation is something else than just telling patients what is going on with them; and that we described co-regulation by others as an indispensable element of self-regulation in psychiatric conditions.
This brings us to the second issue, the relational nature of dealing with self-illness ambiguity over against the presumed individualistic tendency of our approach. As a matter of fact, one of the most important ideas behind our project on self-management in psychiatry was our critique on the dominant, individualistic view on self-management in the literature. This view heavily relies on the idea of a reflective and autonomous self that is able to manage itself in case of disease. In clinical practice, this autonomous and individualistic self usually does not exist. The self is not autonomous, because it tends to be affected and disturbed by the emotional, cognitive and/or behavioural turmoil of the psychiatric condition. And this self cannot rely on individual reflection and deliberation, because it is very much in need of getting help of others to regain “itself,” that is, its self-esteem, its stability and its hopes for the future. We recognize our [End Page 353] intentions in de Haan’s plea for relational authenticity and do not recognize the emphasis on the individual. We explicitly state that “self-regulation is not an individual, isolated activity” and that it “occurs in the context of the co-regulating attention, interpretation and intervention of others, among whom the clinician.”
To be honest, we are very much aware that we have only scratched the surface of a range of phenomena that deserve much more refined and nuanced descriptions and analyses. Self-illness ambiguity is not one phenomenon, it shows itself in numerous forms. And its analysis will discern many different patterns. Dealing with self-illness ambiguity requires trust, dialogue, context-sensitivity and ability to listen between the lines. It requires a willingness to engage with people, who often feel stigmatized and treated as outcasts. [End Page 354]
Gerrit Glas is professor of philosophy (Dooyeweerd chair) at the department of humanities at Vrije Universiteit Amsterdam (the Netherlands) and professor of Philosophy of Neuroscience at the VU medical Center (Amsterdam, the Netherlands). He is member of the board of the Abraham Kuyper Center for Science and Religion. He is also a psychiatrist and director of residency training in Dimence Groep (Zwolle, the Netherlands). His work focuses...