- Managing the SelfSome Philosophical Issues
Strijbos and Slors (2020) argue against what they call the “naïve common-sense” view of self-management as taking direct control over one’s mental health conditions. Their argument consists of two steps. First, they claim that self-management is often better understood as a form of facilitation, like a drover steering the herd. The drover is not in the position to directly intervene on the course the herd is taking, but instead manipulates it by exploiting her knowledge of the context-dependency of the herd’s behavior. Second, even though Strijbos and Slors are critical of the “naïve common-sense” view of self-management, they do not want to throw out the proverbial baby with the bathwater. Despite the fact that empirical evidence suggests that short-term intentions are causally inefficacious, long-term intentions do have a causal role to play in mental health-directed interventions. As a rule of thumb, Strijbos and Slors propose that we should help patients to facilitate what they can control and to control what facilitates them. This proposal is circular: to facilitate what they can control, patients need to control this process of facilitation, which in turn requires them to facilitate this control, and so on. However, this circularity is not a problem according to Strijbos and Slors. On the contrary, they point out that it is a key aspect of self-management, which is typically characterized by facilitation-control loops. For example, patients need to control X (going to peer support group) to facilitate Y (keeping motivated) to control Z (self-administering medicine on a daily basis) to facilitate A (stabilizing one’s mood) to control X (going to peer support group), and so on.
What is attractive about this view of self-management is that it proposes a division of labor between management as control and management as facilitation, thereby offering a more nuanced and perhaps more realistic representation of what it means to cope with mental illness. However, one might wonder whether the kind of circularity embraced by Strijbos and Slors is indeed unproblematic. This is because their notion of a facilitation-control loop seems to be based on different and conflicting assumptions about causation. On the one hand, as we saw, Strijbos and Slors argue that self-management interventions should primarily be conceptualized as long-term intentions that facilitate behavior by being causally efficacious via external means. Self-management interventions, in their view, consist of the patient’s active manipulation of her environment such that this environment will facilitate the required behavior, mood, or experience. On the other hand, Strijbos and Slors also point out that the structures underlying mental illnesses typically behave in a non-linear, dynamic fashion with multiple feed-forward and feedback loops. As a result, “surgical” self-management interventions on specific [End Page 371] causal factors are practically impossible. If this is the case, however, then how can we be sure that the long-term intentions that indirectly facilitate behavior are indeed causally efficacious?
To address this worry, Strijbos and Slors need to say more about the notion of causation. Their discussion of mental health problems as complex dynamic systems seems to suggest an interventionist theory of causation à la Woodward (2004). According to this theory, we can establish that X causes Y if there a possible intervention I on X that changes the value of Y. Much of the theory’s work is done by conditions which spell out exactly which interventions qualify as “surgical” rather than “fat-handed.” One of the conditions mentioned by Strijbos and Slors is that any directed path from I to Y needs to go through X. That is, I cannot be a cause of any causes of Y that are distinct from X. Thus, going to a peer support group (I) may have a positive effect on one’s motivation to self-administer medicine (X) and this in turn may seem to cause one’s mood to stabilize (Y). However, to establish that there is indeed a causal relation between X and Y, we need to be able to exclude the possibility that being in...