The need for a model -- Currently available models in psychiatry -- Introduction to enactivism -- Body and mind - and world -- The existential dimension and its role in psychiatry -- Enriched enactivism : existential sense-making, values, and socio-cultural worlds -- Enactive psychiatry : psychiatric disorders are disorders of sense-making -- An enactive approach to causes, diagnosis and treatment of psychiatric disorders.

In this chapter we give an overview of current and historical conceptions of the nature of obsessions and compulsions. We discuss some open questions pertaining to the primacy of the affective, volitional or affective nature of obsessive-compulsive disorder (OCD). Furthermore, we add some phenomenological suggestions of our own. In particular, we point to the patients’ need for absolute certainty and the lack of trust underlying this need. Building on insights from Wittgenstein, we argue that the kind of certainty the patients (...) strive for is unattainable in principle via the acquisition of factual knowledge. Moreover, we suggest that the patients’ attempts to attain certainty are counter-productive as their excessive conscious control in fact undermines the trust they need. (shrink)

According to the traditional Western concept of freedom, the ability to exercise free will depends on the availability of options and the possibility to consciously decide which one to choose. Since neuroscientific research increasingly shows the limits of what we in fact consciously control, it seems that our belief in free will and hence in personal autonomy is in trouble. -/- A closer look at the phenomenology of Obsessive-Compulsive Disorder (OCD) gives us reason to doubt the traditional concept of freedom (...) in terms of conscious control. Patients suffering from OCD experience themselves as unfree. The question is whether their lack of freedom is due to a lack of will power. Do they have too little conscious control over their thoughts and actions? Or could it be the opposite: are they exerting too much conscious control over their thoughts and actions? -/- In this chapter, we will argue that OCD patients testify to the general condition that exercising an increased conscious control over actions can in fact diminish the sense of agency rather than increase the experience of freedom. The experiences of these patients show that the traditional conception of freedom in terms of ‘free will’ has major shortcomings. There is an alternative, however, to be found in the work of Hannah Arendt. She advocates a conception of freedom as freedom in action. Combined with phenomenological insights on action, Arendt’s account of freedom helps us to get a more adequate understanding of the role of deliberation in the experience of freedom. We argue that the experience of freedom depends on the right balance between deliberate control and unreflective actions. (shrink)

People suffering from Obsessive-Compulsive Disorder (OCD) do things they do not want to do, and/or they think things they do not want to think. In about 10 percent of OCD patients, none of the available treatment options is effective. A small group of these patients is currently being treated with deep brain stimulation (DBS). Deep brain stimulation involves the implantation of electrodes in the brain. These electrodes give a continuous electrical pulse to the brain area in which they are implanted. (...) It turns out that patients may experience profound changes as a result of DBS treatment. It is not just the symptoms that change; patients rather seem to experience a different way of being in the world. These global effects are insufficiently captured by traditional psychiatric scales, which mainly consist of behavioural measures of the severity of the symptoms. In this article we aim to capture the changes in the patients’ phenomenology and make sense of the broad range of changes they report. For that we introduce an enactive, affordance-based model that fleshes out the dynamic interactions between person and world in four aspects. The first aspect is the patients’ experience of the world. We propose to specify the patients’ world in terms of a field of affordances, with the three dimensions of broadness of scope (‘width’ of the field), temporal horizon (‘depth’), and relevance of the perceived affordances (‘height’). The second aspect is the person-side of the interaction, that is, the patients’ self-experience, notably their moods and feelings. Thirdly, we point to the different characteristics of the way in which patients relate to the world. And lastly, the existential stance refers to the stance that patients take towards the changes they experience: the second-order evaluative relation to their interactions and themselves. With our model we intend to specify the notion of being in the world in order to do justice to the phenomenological effects of DBS treatment. (shrink)

Deep Brain Stimulation (DBS) is a relatively new, experimental treatment for patients suffering from treatment-refractory Obsessive Compulsive Disorder (OCD). The effects of treatment are typically assessed with psychopathological scales that measure the amount of symptoms. However, clinical experience indicates that the effects of DBS are not limited to symptoms only: patients for instance report changes in perception, feeling stronger and more confident, and doing things unreflectively. Our aim is to get a better overview of the whole variety of changes that (...) OCD patients experience during DBS treatment. For that purpose we conducted in-depth, semi-structured interviews with 18 OCD patients. In this paper, we present the results from this qualitative study.We list the changes grouped in four domains: with regard to (a) person, (b) (social) world, (c)characteristics of person-world interactions, and (d) existential stance. We subsequently provide an interpretation of these results. In particular, we suggest that many of these changes can be seen as different expressions of the same process; namely that the experience of anxiety and tension gives way to an increased basic trust and increased reliance on one’s abilities. We then discuss the clinical implications of our findings, especially with regard to properly informing patients of what they can expect from treatment, the usefulness of including CBT in treatment, and the limitations of current measures of treatment success. We end by making several concrete suggestions for further research. (shrink)

Psychiatry is enormously complex. One of its main difficulties is how to connect the wide diversity of factors that may cause or contribute to the problems at hand, factors ranging from traumatic experiences, dysfunctional neurotransmitters, existential worries, economic deprivation, and social exclusion, to genetic bad luck. Interventions are also diverse, with options including chemical or electrical treatment, therapies aimed at behavior change and those promoting insight. Much is still unknown: what are the causal pathways, which interventions work best for which (...) patients and why?In practice, many mental health care professionals work holistically in a pragmatic and eclectic way. Without using any explicit... (shrink)

Does DBS change a patient’s personality? This is one of the central questions in the debate on the ethics of treatment with Deep Brain Stimulation (DBS). At the moment, however, this important debate is hampered by the fact that there is relatively little data available concerning what patients actually experience following DBS treatment. There are a few qualitative studies with patients with Parkinson’s disease and Primary Dystonia and some case reports, but there has been no qualitative study yet with patients (...) suffering from psychiatric disorders. In this paper, we present the experiences of 18 patients with Obsessive-Compulsive Disorder (OCD) who are undergoing treatment with DBS. We will also discuss the inherent difficulties of how to define and assess changes in personality, in particular for patients with psychiatric disorders. We end with a discussion of the data and how these shed new light on the conceptual debate about how to define personality. (shrink)

Gilbert et al. argue that the concerns about the influence of Deep Brain Stimulation on – as they lump together – personality, identity, agency, autonomy, authenticity and the self are due to an ethics hype. They argue that there is only a small empirical base for an extended ethics debate. We will critically examine their claims and argue that Gilbert and colleagues do not show that the identity debate in DBS is a bubble, they in fact give very little evidence (...) for that. Rather they show the challenges of doing research in a field that is stretched out over multiple disciplines. In that sense their paper is an important starting point for a discussion on methodology and offers valuable lessons for a future research agenda. (shrink)

We propose to understand social affordances in the broader context of responsiveness to a field of relevant affordances in general. This perspective clarifies our everyday ability to unreflectively switch between social and other affordances. Moreover, based on our experience with Deep Brain Stimulation for treating obsessive-compulsive disorder (OCD) patients, we suggest that psychiatric disorders may affect skilled intentionality, including responsiveness to social affordances.

Psychiatric disorders involve changes in how you feel, think, perceive, and/or act—and the same goes for psychotropic medication. How then do you know whether certain thoughts or feelings are genuine expressions of yourself, or whether they are colored by your psychiatric illness, or by the medication you take? Or, as Karp nicely sums up the problem: “if I experience X, is it because of the illness, the medication, or is it “just me’?” Such “self-illness ambiguity” seems to be quite an (...) ubiquitous problem in psychiatry. It is a very unsettling problem, moreover, and not easy to resolve.In their... (shrink)

The notion of embodiment is central to the phenomenological approach to schizophrenia. This paper argues that fundamental concepts for the understanding of schizophrenia have a bodily dimension. We present two single cases of first-onset schizophrenic patients and analyze the reports of their experiences. Problems such as loss of self, loss of common sense, and intentionality disorders reveal a disconnectedness that can be traced back to a detachment from the lived body. Hyperreflectivity and hyperautomaticity are used as coping mechanisms, but reflect (...) the same problem of the split between body and mind. It is argued that the sole focus on cognitive impairments leads to a distorted image of schizophrenia, and that the acknowledgment of its fundamental bodily roots enables one to see the coherence between the diverse symptoms. As for the practical implications of the phenomenological approach, further research is needed to investigate if and how body- and movement-oriented therapies might strengthen the embodiment of schizophrenic patients. (shrink)

We challenge Gallagher’s distinction between the sense of ownership and the sense of agency as two separable modalities of experience of the minimal self and argue that a careful investigation of the examples provided to promote this distinction in fact reveals that SO and SA are intimately related and modulate each other. We propose a way to differentiate between the various notions of SO and SA that are currently used interchangeably in the debate, and suggest a more gradual reading of (...) the two that allows for various blends of SO and SA. Such an approach not only provides us with a richer phenomenology but also with a more parsimonious view of the minimal self. (shrink)

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, and one by me.1 As mentioned by Nielsen, 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 compares our approaches and concludes that our frameworks are ‘largely compatible, do (...) different work to one another, and are best understood as complimentary’. I think, however, that the differences between our... (shrink)

In their target article, Moore and colleagues offer a valuable overview of the various ambivalence-related phenomena that may impede swift clinical decision-making. They argue that patients...

This article is based on an online ethnographic study of Dutch women who use YouTube as a medium to document their contested illness experiences. During 13 months of observations between 2017 and 2019, we followed a sample of 16 YouTubers, and conducted an in-depth analysis of 30 YouTube videos and of 7 interviews. By adopting a ‘praxiographic’ approach to social media, and by utilising insights from phenomenological theory, this study teases out how bodies are ‘done’ in (the making of) these (...) YouTube videos. We describe three types of bodies: (1) inert bodies, (2) experienced bodies, and (3) authentic bodies. Ultimately, this study shows how vlogging about contested illness is a practice in which bodies are continually (re)configured, and through which the ‘invisibility’ of a sufferer’s condition can obtain social visibility. (shrink)

We whole-heartedly agree with Mecacci and Haselager(2014) on the need to investigate the psychosocial effects of deep brain stimulation (DBS), and particularly to find out how to prevent adverse psychosocial effects. We also agree with the authors on the value of an embodied, embedded, enactive approach (EEC) to the self and the mind–brain problem. However, we do not think this value primarily lies in dissolving a so-called “maladaptation” of patients to their DBS device. In this comment, we challenge three central (...) claims of the authors on the basis of our direct experience with psychosocial effects of DBS in 45 obsessive- compulsive disorder (OCD) patients treated at the AMC in Amsterdam, The Netherlands, and our indepth qualitative interviews with 18 of them (de Haan et al. 2013). We end our comment by sketching out our perspective on the practical merits of an EEC approach to DBS. (shrink)

ABSTRACT‘If I experience X, is it because of the illness, the medication, or is it ‘just me’?’ (Karp 2009) [Is it me or my Meds? Living with Antidepressants. Harvard University Press]. This issue is known as self-illness ambiguity (SIA) (Sadler 2007) ["The Psychiatric Significance of the Personal Self." Psychiatry: Interpersonal and Biological Processes 70 (2): 113–129]. In her paper Know Thyself: Bipolar Disorder and Self-concept, Carls-Diamante (2022) [“Know Thyself: Bipolar Disorder and Self-Concept.” Philosophical Explorations, 1–17] offers a taxonomy of different (...) ways in which Bipolar Disorder can be related to one’s self and self-concept. In contrast to the essentialist model of mental disorders she seems to adopt, I propose a different outlook on SIA, following an enactive approach to psychiatric disorders as disorders of sense-making. One’s way of making sense of the world and/or oneself can become stuck in a rigid pattern that is stronger than oneself and at odds with how one would want to be. I argue that it is helpful to distinguish between the experiential SIA of specific experiences (Am I over/underreacting?) and the long term concerns of existential SIA (How to live my life in accordance with what matters to me despite/while having certain vulnerabilities?). I conclude that knowing oneself is not an intra-individual matter, nor primarily a matter of reflection: it is rather a relational and material practice of trying to live your life in accordance with what matters to you. (shrink)

García’s and Oblak’s reviews of my book Enactive Psychiatry open up some fundamental debates with regard to my use of the term “enactive” for the kind of approach that I develop. Is my account still properly “enactive” (García) and how does my approach compare to the extended mind theory on the one hand and to constructivism on the other hand (Oblak? In this response, I argue that (a) adding an existential dimension to enactivism is necessary to do justice to our (...) way of being in the world and our specific sense-making and its problems; and (b) that this dimension can be incorporated within enactivism without giving up on either enactivism’s commitment to naturalism or the enactive life-mind continuity thesis. My “existentialized” enactivism is very much enactive in that it adopts the thoroughly relational perspective that forms the core of enactivism. This relational perspective is also what distinguishes enactive theory from both extended mind theory and constructivism. Erratum: In §1, the name of the first commentator is misspelled: Her name is “Enara García” rather than “Elena García.”. (shrink)

How we think about the mind affects how we think about mental disorders: about what they are, how they develop and how we should best treat them. How we think about the mind and its relation to both body and world will typically be implicit though. One commonly assumed 'mind-world topology' regards the mind as internal and the world as external, and gives the mind the task of properly representing the outer world. This leads to a division of labor in (...) which perception provides input from world to mind, cognition processes this input and generates output from mind to world in the form of actions. From such a perspective, psychiatric... (shrink)

Auditory verbal hallucinations (AVHs) are a highly complex and rich phenomena, and this has a number of important clinical, theoretical and methodological implications. However, until recently, this fact has not always been incorporated into the experimental designs and theoretical paradigms used by researchers within the cognitive sciences. In this paper, we will briefly outline two recent examples of phenomenologically informed approaches to the study of AVHs taken from a cognitive science perspective. In the first example, based on Larøi and Woodward (...) (Harv Rev Psychiatry 15:109–117, 2007 ), it is argued that reality monitoring studies examining the cognitive underpinnings of hallucinations have not reflected the phenomenological complexity of AVHs in their experimental designs and theoretical framework. The second example, based on Jones (Schizophr Bull, in press, 2010 ), involves a critical examination of the phenomenology of AVHs in the context of two other prominent cognitive models: inner speech and intrusions from memory. It will be shown that, for both examples, the integration of a phenomenological analysis provides important improvements both on a methodological, theoretical and clinical level. This will be followed by insights and critiques from philosophy and clinical psychiatry—both of which offer a phenomenological alternative to the empiricist–rationalist conceptualisation of AVHs inherent to the cognitive sciences approach. Finally, the paper will conclude with ideas as to how the cognitive sciences may integrate these latter perspectives into their methodological and theoretical programmes. (shrink)

Although the enactive approach has been very successful in explaining many basic social interactions in terms of embodied practices, there is still much work to be done when it comes to higher forms of social cognition. In this article, we discuss and evaluate two recent proposals by Shaun Gallagher and Daniel Hutto that try to bridge this ‘cognitive gap’ by appealing to the notion of narrative practice. Although we are enthusiastic about these proposals, we argue that (i) it is difficult (...) to see them as continuous with the enactivist notion of direct coupling, and (ii) the failure to account for folk psychological action interpretation suggests that the enactive approach should adopt a broader notion of coupling. (shrink)

I. Tijdperk vam Cartesius tot Kant -- II. De strijd tussen idealisme en naturalisme in de negentiende eeuw.

I am tasked with addressing philosophical hazards in the neuroscientific study of religion. As a philosopher concerned with the well-being of neuroscientists studying religion, I am inclined to begin with the philosophical hazards of philosophy. I am well aware of the extraordinary difficulties of both tasks, for the hazards are many and it is easy to miss the forest for the trees or the trees for the forest. Instead of focusing on one issue in great detail, I shall hang a (...) number of warning signs around a forest of issues that identify various philosophical hazards which deserve particular caution when it comes to neuroscience and religion. Since I am aiming for breadth over depth, my brief remarks on each issue shall be synoptic, non-exhaustive, contentious and suggestive for additional consideration and reflection. To redress such deficits, I have provided references for further reading. (shrink)

I argue that culpable ignorance can be irreducibly collective. In some cases, it is not fair to expect any individual to have avoided her ignorance of some fact, but it is fair to expect the agents together to have avoided their ignorance of that fact. Hence, no agent is individually culpable for her ignorance, but they are culpable for their ignorance together. This provides us with good reason to think that any group that is culpably ignorant in this irreducibly collective (...) sense is non-distributively collectively responsible for subsequent unwitting acts and consequences. (shrink)

Infinite Hope, rich with inspirational true stories and breathtaking artwork, will bless you with the kind of hope that never fades and always brightens the darkest paths of life. This is no ordinary hope, but instead a life-transforming hope. It is a hope that will fill you with confidence and inspire you to find peace with yourself and your circumstances. Stories and insights about suffering and the goodness of God, along with illustrations from Joni Eareckson Tada and Jill DeHaan, will (...) give you a richer, deeper love for Christ, the Blessed Hope."--Provided by publisher. (shrink)

Collective moral agents can cause their own moral incapacity. If an agent is morally incapacitated, then the agent is exempted from responsibility. Due to self-induced moral incapacity, corporate responsibility gaps resurface. To solve this problem, I first set out and defend a minimalist account of moral competence for group agents. After setting out how a collective agent can cause its own moral incapacity, I argue that self-induced temporary exempting conditions do not free an agent from diachronic responsibility once the agent (...) regains its moral faculties. For collective agents, any exempting condition is potentially temporary due to the ‘malleability’ of their constitution. Therefore, in cases of self-induced moral incapacity and subsequent wrongdoing, unlike individuals, every collective agent can be (made) morally responsible for its actions even though it did not qualify as a moral agent at the time of wrongdoing. Hence, this is no reason for skepticism concerning corporate responsibility. (shrink)

This paper investigates agents’ blameworthiness when they are part of a group that does harm. We analyse three factors that affect the scope of an agent’s blameworthiness in these cases: shared intentionality, interpersonal influence, and common knowledge. Each factor involves circumstantial luck. The more each factor is present, the greater is the scope of each agent’s vicarious blameworthiness for the other agents’ contributions to the harm. We then consider an agent’s degree of blameworthiness, as distinct from her scope of blameworthiness. (...) We suggest that an agent mostly controls her degree of blameworthiness—but even here, luck constrains what possible degrees of blameworthiness are open to her. (shrink)

There is good reason to think that moral responsibility as accountability is tied to the violation of moral demands. This lends intuitive support to Type-Symmetry in the collective realm: A type of responsibility entails the violation or unfulfillment of the same type of all-things-considered duty. For example, collective responsibility necessarily entails the violation of a collective duty. But Type-Symmetry is false. In this paper I argue that a non-agential group can be collectively responsible without thereby violating a collective duty. To (...) show this I distinguish between four types of responsibility and duty in collective contexts: corporate, distributed, collective, shared. I set out two cases: one involves a non-reductive collective action that constitutes irreducible wrongdoing, the other involves a non-divisible consequence. I show that the violation of individual or shared duties both can lead to irreducible wrongdoing for which only the group is responsible. Finally, I explain why this conclusion does not upset any work on individual responsibility. (shrink)

This paper focuses on the cognitive/computational and evolutionary levels. It describes three proposals to make cognition computationally tractable, namely: Resource Rationality, the Adaptive Toolbox and Massive Modularity. While each of these proposals appeals to evolutionary considerations to dissolve the intractability of cognition, Rich, Blokpoel, de Haan, and van Rooij argue that, in each case, the intractability challenge is not resolved, but just relocated to the level of evolution.

In this paper, we focus on the moral responsibility of organized groups in light of historicism. Historicism is the view that any morally responsible agent must satisfy certain historical conditions, such as not having been manipulated. We set out four examples involving morally responsible organized groups that pose problems for existing accounts of historicism. We then pose a trilemma: one can reject group responsibility, reject historicism, or revise historicism. We pursue the third option. We formulate a Manipulation Condition and a (...) Guarding Condition as addendums to historicism that are necessary to accommodate our cases of group responsibility. (shrink)

I argue that agents can have duties to cooperate with one another if this increases their combined efficiency and/or efficacy in addressing ongoing collective moral problems. I call these duties cooperative duties of efficiency and efficacy. I focus particularly on collective agents and how agents ought to reason and act in the face of global moral problems. After setting out my account, I argue that a subset of cooperative duties of efficiency and efficacy of collective agents are duties of justice (...) in virtue of the roles these agents have taken up. (shrink)

Many philosophers accept the idea that there are duties to promote or create just institutions. But are the addressees of such duties supposed to be individuals – the members of the citizenry? What does it mean for an individual to promote or create just institutions? According to the ‘Simple View’, the citizenry has a collective duty to create or promote just institutions, and each individual citizen has an individual duty to do their part in this collective project. The simple view (...) appears to work well with regard to – you guessed it – ‘simple’ scenarios but it is riddled with further questions and problems. In this chapter, we raise five problems for the Simple View: (a) We suggest that one cannot develop a view concerning the citizenry’s duty to promote just institutions in isolation from a conception of the ontological relationship between the state and its citizens; (b) We argue that it is not obvious that the citizenry is the right entity to be attributed duties in the first place; (c) We show that a plausible account of collective duties to promote just institutions must not remain silent on the complexities and difficulties amorphous, unorganized group face in vis-à-vis collective action; (d) We contend that without allocation principles for contributory duties amongst the citizenry, or – alternatively – a method for practical deliberation that is action-guiding in collective action contexts, the claim that the citizens have a collective duty to promote just institutions remains moot; and, finally, (e) We demonstrate that the problem of reasonable disagreement is a serious threat to a collective duty to promote or create just institutions – it potentially undermines such a duty altogether and allows for conflicting contributory duties amongst the citizenry. We hope that our discussion will ultimately help improve existing theories and conceptual frameworks with a view to better understanding citizens’ obligations to promote justice under non-ideal conditions. (shrink)

Although the evidence remains tentative at best, the conception of hallucinations in schizophrenia as being underconstrained perception resulting from intrinsic thalamocortical resonance in sensory areas might complement current models of hallucination. However, in itself, the approach falls short of comprehensively explaining the neurogenesis of hallucinations in schizophrenia, as it neglects the role of external attributional biases, mental imagery, and a disconnection between frontal and temporal areas.

This study examines a number of different answers to the question: wheredoes Avicenna demonstrate the existence of God within the Metaphysics of the Healing? Many interpreters have contended that there is an argument for God’s existence in Metaphysics of the Healing I.6–7. In this study I show that such views are incorrect and that the only argument for God’s existence in the Metaphysics of the Healing is found in VIII.1–3. My own interpretation relies upon a careful consideration of the scientific (...) order and first principles of the Metaphysics of the Healing, paying attention to Avicenna’s own explicit statements concerning the goals andintentions of different books and chapters, and a close analysis of the structure ofthe different arguments found in the relevant texts of the Metaphysics of the Healing. I conclude that Avicenna’s explicit goal in I.6–7 is to establish the properties that belong to necessary existence and possible existence, which consists, not in ademonstration of God’s existence, but in a dialectical treatment of the first principlesof metaphysics. (shrink)

According to some collectivists, purposive groups that lack decision-making procedures such as riot mobs, friends walking together, or the pro-life lobby can be morally responsible and have moral duties. I focus on plural subject- and we-mode-collectivism. I argue that purposive groups do not qualify as duty-bearers even if they qualify as agents on either view. To qualify as a duty-bearer, an agent must be morally competent. I develop the Update Argument. An agent is morally competent only if the agent has (...) sufficient positive and negative control over updating their goal-seeking states. Positive control involves the general ability to update one’s goal-seeking states, whereas negative control involves the absence of other agents with the capacity to arbitrarily interfere with updating one’s goal-seeking states. I argue that even if purposive groups qualify as plural subjects or we-mode group agents, these groups necessarily lack negative control over updating their goal-seeking states. This creates a cut-off point for groups as duty-bearers: Organized groups may qualify as duty-bearers, whereas purposive groups cannot qualify as duty-bearers. (shrink)

This study has two goals: first, to show that Avicenna’s account of being and thing significantly influenced Aquinas’s doctrine of the primary notions; second, to establish the value of adopting a mereological construal of these primary notions in the metaphysics of Avicenna and Aquinas. I begin with an explication of the mereological construal of the primary notions that casts these notions in terms of wholes and parts. Being and thing refer to the same entitative whole and have the same extension, (...) but they are distinct in intension according to the different entitative parts they signify. Existence and essence constitute the two most fundamental entitative parts of every entitative whole. Being is taken to mean that which has existence, and thing signifies that which has essence. I then show how this mereological construal of the primary notions clarifies a number of texts in Avicenna and Aquinas. Finally, I address a few arguments against employing this mereological interpretation of the primary notions. (shrink)