Ludwig Wittgenstein famously described the philosophical method as ‘therapy’, as a process that produces therapeutic relief by dissolving the linguistic misconceptions that masquerade as philosophical problems. While Sanneke de Haan’s Enactive Psychiatry has no grand Wittgensteinian ambitions of seeing philosophical problems in psychiatry as products of misuse of language, it is nonetheless immensely therapeutic in a somewhat similar sense: it dissolves away many of the dualistic oppositions that have become an ingrained part of how we understand ourselves and the world, oppositions such as mind vs body, internal vs external, subject vs object, real vs constructed, and fact vs value, oppositions which may seem benign but produce much philosophical bewilderment.

Enactivism is a theory of embodied cognition, also described as 4E (or 3E) because of its characterization of mind or cognition as Embodied, Embedded, Enacted, and Extended. In this book, Sanneke de Haan applies insights from enactivism to help conceptualize and navigate the immense complexity of factors that contribute to psychiatric disorders. The book is divided into eight chapters. Chapters 1 and 2 discuss psychiatry’s problem of integrating all the diverse perspectives and dimensions that all are relevant to our mental lives, and the ways in which currently available models fall short of providing an adequate explanation. Chapters 3 to 6 introduce and flesh out the details of the enactive worldview and its relevance to psychiatry. Chapter 7, the crux of the book, articulates and defends the enactive view of psychiatric disorders as disorders of sense-making, and chapter 8 offers a fertile discussion of enactive approach to causes, diagnosis, and treatment of psychiatric disorders.

Coming back to the ‘therapeutic’ function of enactive psychiatry, consider Peter Bieri’s trilemma, which de Haan discusses in the book:

1. Mental phenomena are not physical phenomena.
2. Mental phenomena are causally effective in the domain of physical phenomena.
3. The physical domain is causally closed.

The three propositions cannot all be true without being inconsistent. Something has to give way. Physicalism sacrifices proposition #1. Epiphenomenalism sacrifices #2. Substance dualism sacrifices #3. What is de Haan’s solution? She thinks that the trilemma is not a puzzle to be answered but a puzzle to be dissolved. The bewilderment withers away once we give up on the opposition between the physiological and the experiential, between matter and mind, and once we see the two instead as continuous phenomena, with differences between the two arising from the specific organization of matter rather than the two being radically different and incompatible domains. At the heart of enactivism is the life-mind continuity thesis: mind and matter are not two separate things, rather, aspects of the same, because matter in specific, self-organizing patterns is minded. Enactive ontology is concerned more with relations rather than entities in isolation, and its central unit of analysis is the person in interaction with her world.

Enactivism also takes a similar strategy for other oppositions that arise in the context of metaphysics of psychopathology, such as essentialism-nominalism, objectivism-evaluatism, entities-agents, and causalism-descriptivism. The key move in each case is to resist the polarization and find ways of overcoming it. The result is elegant and exhilarating. It is difficult to do justice to the philosophical nuance and fullness of this work in a review like this, because when described in general terms for the purposes of introduction, the philosophy can sound very much like holistic platitudes and as old wine in new bottles. One has to see the ideas in action to appreciate it for themselves.   

A memorable illustration by de Haan from Enactive Psychiatry is the example of making a cake offered as an analogy for organizational/mereological causality. She writes:

“The important, dualism-defeating move is to resist thinking about the causality of physiological and experiential processes in linear terms and as a two-place event. The causality involved is rather of a mereological, constitutional, or organisational type… Think of the causality involved in making a cake. A cake is made from various ingredients that moreover influence each other. The amount of sugar, for example, will affect not only the overall sweetness of the cake, but it also affects the yeast and thus the structure of the sponge. Adding an extra egg to the dough will affect the sponge – and thereby the cake as a whole… Adding sugar is a local-to-global influence, but there can also be influences the other way around. Consider the temperature of the cake as a whole: putting it in the fridge will have a different effect than putting it in the oven. Again, when we want to describe this effect, this relation between the whole and its parts, we see that it would be a mistake to invoke any linear notion of causality between them. By heating the cake, we change the cake as a whole – including its ingredients… The influence of physiological processes on experiential processes is a local-to-global influence (like the amount of sugar changing the taste of the cake), whereas the influence of experiential processes on physiological ones is a global-to-local effect (like the effect of the temperature of the oven on the overall state of the cake, including its ingredients).” (pages 85-87) 

De Haan returns to this analogy again and again throughout the book and the richness of this analogy in offering us a way out of complex causal dilemmas in psychiatry appears to be inexhaustible! 

The book is very well-written and remarkably accessible. Readers without much philosophical background would nonetheless be able to understand and follow the discussion. De Haan systematically takes the readers through each step of her thought process and presents her ideas with great clarity. Even though de Haan is tackling some of the most complex ideas in philosophy and psychiatry, her writing is simple and graceful, and perhaps for that reason, wonderfully aphoristic and immensely quotable. (Consider, for example: “a cause is only a cause in a certain context”; “a complex system can be stirred in many ways”; “metaphors are never innocent”; “the uniqueness of each patient’s situation is not at odds with the universality of the issues that they may struggle with”; “avoiding dichotomies does not require us to deny all differences”.)

Enactive Psychiatry articulates an impressive vision of what psychiatry can look like when understood through the lens of enactivism. There is, however, little offered in terms of a sustained philosophical or scientific defense of the philosophy of enactivism itself. The principles of enactivism are, relatively speaking, taken for granted in this book, and although it does a terrific job explaining these principles and applying them to psychiatry, critics of the enactive approach or readers who find themselves in fundamental disagreement with enactive assumptions may find this aspect of the book to be somewhat unsatisfactory.

Application of enactivism to psychiatry is proving to be a fertile area of philosophical work; Recently, Kristopher Nielsen, working somewhat independently from de Haan, has also sketched his own framework for an embodied, embedded and enactive concept of mental disorder, which has substantial overlap with de Haan’s framework but also has meaningful differences in emphasis. Nielsen’s ideas are not yet available in a book form, but his PhD thesis on this topic can be accessed online, and I suspect many readers, like myself, will find his discussion of de Haan’s work and exploration of their differences to be quite instructive.

While pluralism has always attracted some of the finest minds in philosophy of psychiatry, the thorny problem of how to meaningfully integrate various perspectives and dimensions into a coherent whole without lapsing into covert reductionism, eclecticism or pseudoscience has been hard to resolve satisfactorily. The popular biopsychosocial model represents that aspiration, but it merely hopes for an integrative answer without necessarily providing us with one. We have seen significant philosophical contributions in recent years to pluralism in psychiatry, for instance by Derek Bolton and Grant Gillett, as well as Ken Kendler and colleagues. De Haan’s book is an admirable addition to this body of work and given the impressive philosophical coherence and depth of the enactive worldview, I venture that it has the potential to dwarf all other competitor explanations. I suspect that years from now when I look back at the development of my own philosophical views of the integration problem in psychiatry, there is a good chance that I would see my discovery of de Haan’s work as a pivotal moment in that history.

Awais Aftab, MD, is a psychiatrist in Cleveland, OH, and clinical assistant professor of psychiatry at Case Western Reserve University. He leads the interview series “Conversations in Critical Psychiatry” for Psychiatric Times; an interview with Sanneke de Haan is forthcoming in the series.

Categories: MentalHealth, Philosophical

Keywords: psychiatry, embodied cognition