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)