- Two Enactive Approaches to Psychiatry: Two Contrasting Views on What it Means to Be Human
Shared Sources and Different Aims
The relevance and potential value of insights from enactivism for the field of psychiatry have been recognized for some time now. Recently, two overarching frameworks have been proposed, one by Nielsen (Nielsen, 2020; Nielsen & Ward, 2018, 2020), and one by me (De Haan 2017; 2020a; 2020b; 2020c).1 As mentioned by Nielsen (2021), we developed our approaches largely in parallel: I was not aware of Nielsen’s work, and he only became aware of my work in the last phase of his PhD. Nielsen (2021) compares our approaches and concludes that our frameworks are ‘largely compatible, do different work to one another, and are best understood as complimentary’ (p. 175). I think, however, that the differences between our positions run much deeper, so that they are, in fact, incompatible. These differences result from fundamentally opposed views on what it means to be human. But before I get into our differences, let me acknowledge what we share.
Nielsen and I are attracted to enactivism2 for similar reasons. We are both critical of neuroreductionist views that depict psychiatric disorders as internal problems in individual brains, and instead stress the relevance of taking the individual’s whole body and larger (sociocultural) context into account. In enactivism, we find a framework that spells out how the mind is fundamentally tied to the body and to interactions with the environment (Thompson, 2007; Varela, Thompson, & Rosch, 1991). More specifically, ‘mind’ refers to the sense-making activities of an organism interacting with its environment, which it depends on for its survival. Enactivism, furthermore, argues that the organism in its environment is best described as a complex, dynamical system. Applied to psychiatry, enactivism offers a) an integrative perspective on the relation between body, mind, and world;, and b) a complex systems approach which acknowledges causal complexity without ascribing a priory primacy to any of the processes involved.
Our aims—what we use enactivism for—are different though. My aim is to solve psychiatry’s integration problem, that is, the problem of how to relate the heterogeneous factors that are at stake in the development and persistence of psychiatric [End Page 191] disorders. Even though many people would be willing to embrace the (potential) influence of biological, psychological and social factors, the proof of the pudding will be in providing a proper explanation of how these factors work together and how (causal) interaction between them works. Enactivism provides an excellent basis for explaining such interactions, without resorting to either reductionism or dualism (de Haan, 2020a). As such it can offer an extended and improved version of Engel’s (1977, 1980) biopsychosocial model (de Haan, 2020c). My enactive approach to psychiatry is thus clearly not a ‘first person or phenomenological approach,’ as Nielsen (2021) calls it. Personal experiences are indeed vital when trying to understand and explain psychiatric disorders—but so are (neuro) physiological processes, sociocultural influences, and existential considerations. The purpose of my account is precisely to relate personal experiences to these other processes and explain how these four heterogeneous dimensions affect one another. Enactivism’s thesis about the continuity of life and mind and its concept of sense-making are useful to explicate how ‘matters of the mind’ are necessarily also matters of the body and matters of the world too (de Haan, 2020a, 2020b).
Nielsen, in contrast, is primarily interested in solving the demarcation problem between mental health and mental illness, or: ‘why some behaviors should be considered disordered’ (Nielsen & Ward, 2018, p. 801). This should in turn help to carve out psychiatry’s ‘diagnostic entities’ (Idem, p. 813) and classify mental disorders accordingly. Nielsen mainly draws on enactive ideas to ‘naturalize normativity’ (Nielsen & Ward, 2020, p. 121) as he calls it. Because mere statistical rarity is not enough to establish a phenomenon as ‘disordered’, we need to adopt some norms to distinguish between ‘dysfunction and functionality’ (Nielsen & Ward, 2018, p. 811). Nielsen appeals to the enactive idea of organismic self-maintenance to establish such norms. Being alive is a precarious condition that requires constant, adaptive interaction...