A recent article published in the International Review of Psychiatry examines the state of psychiatry’s foundational models of the mind, such as “neuroreductionism.” The author, Sanneke de Haan, a philosopher of psychiatry, argues that instead of narrow understandings based primarily on the brain, we could take lessons from enactive philosophy, which attempts to draw links between the body, world, and mind.
“John’s struggles to make sense of his recurrent depressions are not ‘just’ an individual problem. It is a problem that anyone who tries to make sense of the development of psychiatric disorders encounters – whether driven by one’s own experiences, or the experiences of loved ones, or as clinicians or researchers,” the author writes.
“With so many potentially contributing factors of such different natures – e.g., genes, neuronal specificities, (childhood) trauma’s, social and economical disadvantages, existential worries – one of the holy grails in psychiatry is to get clear about how to relate these factors and assess their precise roles. What influences what? What is cause, and what is effect? The answers to these questions are not only important for our (self)understanding, but also for determining how to best intervene in and possibly even prevent the occurrence of psychiatric disorders.”
Multiple authors have recently pointed to “enactive” philosophy as a potential antidote to the medical model’s reductionistic understanding of psychological struggles, such as chronic pain and “schizophrenia.”
Enactive philosophy emphasizes the importance of the body and its activities in the world as the “ground of the mind,” rather than understanding the individual person as an atomistic unit separate from these domains.
The current article argues for an enactive understanding of the bio-psycho-social model, which attempts to account for factors beyond the individual that inform mental distress but is incomplete in how it manages to explain how these three domains interact.
Sanneke de Haan first describes what she calls “reductionist” versus “holistic” models of understanding the person. Reductionist models, often found in psychiatry, propose a “hierarchy between factors with one type of factors being primary.” For psychiatry, the top of the hierarchy is physiological processes.
Reductionist models are simple and “coherent.” They may include complex information, such as neural functioning, but “the overall structure of the explanation is nicely straightforward: all symptoms of psychiatric disorders can be traced back to abnormalities in the brain.”
The author explains that their biggest downside is preferring only one type of factor, citing that clear genetic and neuronal causes for psychiatric disorders have still not been established. Additionally, it is difficult to address personal “meaning” if a “neuroreductionist” model is embraced above all else.
In contrast, more holistic models, such as the bio-psycho-social model, account for multiple factors that contribute to mental distress, not just those at the neural level.
De Haan believes that the bio-psycho-social model needs further development, though citing criticisms of the BPS, such as its lack of a clear account for how the three domains relate causally. She cites enactive philosophy as a potential support for BPS’s theoretical elaboration.
Enactivism, for de Haan, offers a way out of the “integration” problem, or:
“How should we characterize the causal relations between such different factors as someone’s neurotransmitter uptake and release, their tendency to avoid conflicts, and the quality of their friendships?”
She goes on to explain that we are not looking only for a “solution to the mind-body problem,” but rather a solution to the “mind-body-world problem.”
Enactivism is a cognitive science theory informed by biological, developmental systems theory, phenomenology, and dynamical systems theory.
Applied to psychiatry, its insights include pointing out that human beings are “sense-making” creatures—like knowing what is dangerous and what is safe—which is fundamental to our physiological survival.
Therefore, there is no hierarchy with physiology at the top. Instead, physiology and mental sense-making processes, directed toward and constantly interacting with the world, are equally important and perhaps all parts of one domain:
“This means that we cannot properly understand any of the three factors – body, mind, and world – in isolation from each other. They are instead different excerpts of one and the same, complex, dynamical person-in-her-world system.”
The author states that various forms of mental distress can be understood in terms of disrupted sense-making in relation to the world and social relationships. The causality provided by enactivism emphasizes, as well, that these are networked and non-linear relationships that we have between our physiological bodies, sense-making, and social world/world in general.
de Haan uses the example of a cake to illustrate:
“As any baker – or any regular watcher of baking shows – knows, the ingredients affect each other. The amount of sugar, for instance, not only contributes to the sweetness of the cake but also affects the dough’s gluten, thereby affecting the structure of the sponge. So it is not only the precise amounts of flour, eggs, baking powder, milk, and butter that influence the cake’s eventual taste; it also matters how long you knead the dough and at which temperature and how long you bake it.”
She finds it useful to distinguish between “local” and “global” levels. For example, in the cake, adding a few grains of sugar (a local cause) will not change much, but several teaspoons (a global cause) would.
When it comes to psychiatry, this “local-to-global” and “global-to-local” thinking could help in understanding both the local elements of mental distress (neural functioning) as well as the global elements, such as behavior, social relationships, psychological experience, and more.
This extends to causality as well. The causal links between the bio, psycho, and social are organizational. In other words, “global” effects can look similar even when more “local” causes are very different, as in the case of psychiatric medications and psychotherapy, both reducing anxiety.
Returning to the example of the service user John, de Haan argues that a bio-psycho-social approach might understand his depression in terms of interacting genetic, psychological, and social factors like upbringing and stressors.
An enactive approach would instead focus holistically on John’s “relation to his world” as one complex system with local and global elements.
This includes a great deal of interactivity with the world. John’s social and developmental experience informs a lot of his behavior. Personality traits can reflect strong patterns of behavior or those ingrained modes of interaction with the world. These patterns make neurological changes in the brain, and the brain (local) can also affect future behavior and personality (global).
For de Haan, this more nuanced understanding of a sense-making person in the world could assist in psychiatrists being less likely to focus exclusively on the brain, as in much of traditional psychiatry.
The author concludes:
“A sound holistic model helps us resist the temptation to a priori single out one type of process as ‘the’ defining matter of psychiatric disorders and to unquestioningly assume that there are such things like ‘underlying’ causes or mechanisms of psychiatric disorders.
A sound holistic model does justice to psychiatry’s complexity in a manageable way and offers us (self)understanding. And importantly, it supports the holistic practice of cooperation in interdisciplinary teams of social workers, psychologists, psychiatrists, nurses, and other professionals, and as such, supports optimal care. Enactive psychiatry is such a view.”
De Haan, S. (July 04, 2021). Bio-psycho-social interaction: An enactive perspective. International Review of Psychiatry, 33(5), 471-477. (Link)
“With so many potentially contributing factors of such different natures – e.g., genes, neuronal specificities, (childhood) trauma’s, social and economical disadvantages, existential worries – one of the holy grails in psychiatry is to get clear about how to relate these factors and assess their precise roles. What influences what? What is cause, and what is effect?”
Psychiatry doesn’t care about etiologies of distress, especially when it comes to child abuse.
Quite to the contrary, if they want to get paid, they must misdiagnose all child abuse survivors with the other billable DSM disorders.
I agree, “all symptoms of psychiatric disorders can be traced back to abnormalities in the brain.”
Psychiatry’s problem is that their ADHD drugs and antidepressants can create “abnormalities in the brain” or symptoms that look like the “bipolar” symptoms to the “mental health” workers. And the antipsychotics/neuroleptics can create symptoms that look like the positive and negative symptoms of “schizophrenia,” via anticholinergic toxidrome and neuroleptic induced deficit syndrome.
“The author explains that their biggest downside is preferring only one type of factor, citing that clear genetic and neuronal causes for psychiatric disorders have still not been established. Additionally, it is difficult to address personal ‘meaning’ if a ‘neuroreductionist’ model is embraced above all else.”
Very true, but dismissing a client’s real life concerns and “personal ‘meaning'” does seem to be the very point of defaming people with the DSM disorders. The supposed “life long, incurable, genetic” DSM disorder becomes the problem, rather than the person’s actual concerns being addressed.
“In contrast, more holistic models, such as the bio-psycho-social model, account for multiple factors that contribute to mental distress, not just those at the neural level.”
But the problem lies in the fact that even those who call themselves “holistic, Christian talk therapists” are required to defame people with the “invalid” DSM disorders, in order to get paid.
And, at least in my ex-religion, those “holistic, Christian talk therapists” are “partnered with” the religions. So instead of working for the person paying them, the “holistic, Christian talk therapists” function as the child abuse covering up arm of the religion.
Ultimately leading to the bishops of such a religion also becoming systemic child abuse cover uppers, too.
Oh, I guess we can go further. Since all this systemic child abuse covering up by psychologists, psychiatrists, pastors, and bishops also functions to aid, abet, and empower the pedophiles and child sex traffickers. This has left us all living in a “pedophile empire,” with child sex trafficking running amok.
This systemic problem is known as “the dirty little secret of the two original educated professions,” according to an ethical pastor of a different religion. We truly need psychologists, psychiatrists, pastors, and bishops to get out of the child abuse covering up and profiteering business. And we need the police to start arresting the pedophiles.
All of this consensual thinking is very nice, if not a bit vapid.
The problem is that there is no proof at this day that neurology and genetic is involved (in a causal way) in mental/emotional suffering.
Ergo, there is no place for psychiatrists in the care of those suffering.
Is not it incredible that this class of “carers” is accepted and even put in a dominant position, when they have not YET DEMONSTRATED THEIR LEGITIMACY.
Why not include plumbers or economists at this rate?
More holistic is nice, but its just another model, that is to say another subsuming of people in the abstract cake of people who are dangerously interested in epistemic aesthetics, rather than the wholesome and muddy battlefield of people souls.
Do we really need a model?
A model is just a set of boundary. It limits and humans are to prone to make models artefacts of power.
A model is useful only to the degree that it correctly explains predicts the effects of actions we take into the future. The psychiatric model explains nothing, obscures real causes, and fails to predict even the success or failure of its own interventions. Therapy models to date similarly fail to account for observable facts nor are they able to predict the outcomes of their own interventions. I’ve got nothing against models, but they need to work!
Is there a consensual ‘psychiatric model’? Or is there rather both subtly and openly shifting models and interpretations which can be brought out when needed to rationalize some kind of prioritization or course of action? Theory is seldom made explicit in psychiatric thinking which makes it like steering a ship in the dark, I think. Re: model – you can also consider a model as something not concrete enough for doing predictions, but instead as something to bridge different perspectives with. That was probably to intent of the first biopsychosocial model as it was only very vaguely developed…
I would say that there IS a consensual psychiatric model. That model assumes that 1) there are such things as “mental illnesses” which are distinguishable from “normal” conditions. 2) these “illnesses” can be “diagnosed” by “professionals” with sufficient training. 3) there are “treatments” available for these “illnesses” that can “reduce the symptoms” of the “illnesses.” 4) These “illnesses” are essentially physiological in nature and inhere in the person experiencing them rather than in the environment/culture or in the relationship between the environment/culture and the person. 5) That these “disorders” can be described and “diagnosed” using the DSM or the ICD or some other “diagnostic system.” 6) That these are “medical” problems that need to be handled by “services” provided by “medical providers” and paid for by insurance. 7) That sometimes, these “disorders” become so unmanageable that “treatment” must be forced on unwilling participants “for their own good.”
Admittedly, there are plenty of free-floating and irrational interpretations that are pulled out when necessary, but I’d say all of these interpretations are expected to fit into the above. As a former “mental health” professional, I can attest that violating these tenets results in hostility and in some cases even shunning by the system insiders. Not sure how “consensual” it is, but it certainly seems to be expected that people will agree to these basic tenets, and in fact, clients/patients are “diagnosed” as more serious to the degree that they deny the “validity of their diagnosis.” It’s pretty solid in my view.
Yes, there is a “model” but this “model” is dangerous and damages, maims and kills. This “model” is the prime example of how psychiatry has destroyed psychology. And, if you notice, those concepts that exist outside the psychiatry’s framework which sees the human being as a potential for illness rather than health and wellbeing are quickly ostracized, criticized, even censored and cancelled. The real problem with psychiatry, etc. is that if you aren’t “sick” they will make you “sick” to prove their point. Thank you.
At least in Europe there is a wider field, e, g. phenomenological psychopathology a la Karl Jaspers, which is more wary towards physiological explanations. From my point of view the most basic ‘model’ is that mental health is a medical specialty – whatever the psychiatric specialist take that to mean in a certain time and context. Also, I think the diagnostic approach using ICD-10/-11 is la bit less moronic/reflective than DSM – perhaps it has something to do with public healthcare systems too
“The problem is that there is no proof at this day that neurology and genetic is involved (in a causal way) in mental/emotional suffering.”
Absolutely, and since we have the medical proof that the symptoms of the two “most serious” DSM disorders can be created with the psych drugs, we do have the real science, proving the scientific fraud of psychiatry, on our side.
“Ergo, there is no place for psychiatrists in the care of those suffering.” I totally agree, especially since the psychiatric industries are apparently murdering “8 million” innocent, non-criminal, people EVERY year.
But I will say, wow! Our media organizations and/or government are now seemingly deleting all our publicly funded research findings, and the confessions of the former head of NIMH, that I regularly quote. This is a major censorship problem.
“body, mind and world.” What happened to the soul and spirit? When you only consider body, mind and world, you have a totally secular viewpoint. If the reductionist philosophy is singled out as a failure, then this particular concept may be beyond failure. It actually sounds like more of a title for a sitcom on tv than anything that is real. Perhaps, that is the trouble with the holistic viewpoint, is that it is the actual reductionist concept, reducing each unique individual to something even less than an old classic tv rerun on a Saturday afternoon. Until we consider the spirit and soul of the individual, we will not ever reach the body and mind. The is the true, real and only wholism and why psychiatry fails and so much of the 21st century is in disarray. Thank you.
In her book length version of this article, the overall categories are something like: biological/physiological, social/cultural, psychological/experiential and reflective/existential. That gives room for spirituality, I think. No matter what kind of psychiatry or non-psychiatry one supports, or what kind of problems in the world one is concerned with, I think you need to reckon with the tension between thinking holistically vs. reductionistically.
Forgive me for my cynicism – I haven’t read the book, but anyone who is still trying to explain ‘psychiatric disorders’ is still firmly entrenched within the existing paradigm of pathology. There are many and varied forms of emotional suffering, but there is no such thing as a ‘psychiatric disorder.’ This sounds like an all-purpose theory of human experience – ie, it is the result of numerous factors interacting in complex ways. Common sense, really, but with limited explanatory value unless we can specify it more precisely than that. I am seeing increasingly complicated intellectual attempts to retain psychiatry as a legitimate discipline while absorbing enough of the critique to sound reasonable. This sounds like one of those.
Well said Lucy