Sanneke de Haan
Erasmus University Rotterdam, Erasmus School of Philosophy (ESPhil), Department Member
- Utrecht University, Ethics Institute, Faculty Memberadd
- I am a researcher in philosophy and psychiatry.
I mainly draw on phenomenology, philosophical anthropology, enactivism, qualitative research, and cognitive neuroscience.edit
‘If I experience X, is it because of the illness, the medication, or is it ‘just me’?’ (Karp 2009). This issue is known as self-illness ambiguity (SIA) (Sadler 2007). In her paper Know Thyself: Bipolar Disorder and Self-concept,... more
‘If I experience X, is it because of the illness, the medication, or is it
‘just me’?’ (Karp 2009). This issue is known as
self-illness ambiguity (SIA) (Sadler 2007). In her paper Know Thyself: Bipolar Disorder and Self-concept, Carls-Diamante (2022) 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/under-reacting?) 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.
‘just me’?’ (Karp 2009). This issue is known as
self-illness ambiguity (SIA) (Sadler 2007). In her paper Know Thyself: Bipolar Disorder and Self-concept, Carls-Diamante (2022) 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/under-reacting?) 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.
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Gilbert et al. (Neuroethics, 2018) argue that the concerns about the influence of Deep Brain Stimulation (DBS) on – as they lump together – personality, identity, agency, autonomy, authenticity and the self (PIAAAS) are due to an ethics... more
Gilbert et al. (Neuroethics, 2018) argue that the concerns about the influence of Deep Brain Stimulation (DBS) on – as they lump together – personality, identity, agency, autonomy, authenticity and the self (PIAAAS) 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.
Research Interests:
In his paper Psychiatry and religion: Consensus reached!, Verhagen advocates the relevance of spirituality and religion for the “origins, understanding, and treatment of psychiatric disorders”. In ...
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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... more
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.
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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,... more
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). 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: a functionalist versus an existential perspective.
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: a functionalist versus an existential perspective.
Research Interests: Psychiatry and Enactivism
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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... more
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 (2006) 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” (Sadler, 2007) seems to be quite an ubiquitous problem in psychiatry (Estroff, 1989; Hope, Tan, Stewart, & Fitzpatrick, 2011; Inder et al., 2008; Karp, 2006; Singh, 2014). It is a very unsettling problem, moreover, and not easy to resolve. Traditionally, philosophical theories of authenticity have recommended individual, mostly reflective strategies to settle authenticity questions. Here I argue for relational authenticity strategies instead.
psychiatric illness, or by the medication you take? Or, as Karp (2006) 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” (Sadler, 2007) seems to be quite an ubiquitous problem in psychiatry (Estroff, 1989; Hope, Tan, Stewart, & Fitzpatrick, 2011; Inder et al., 2008; Karp, 2006; Singh, 2014). It is a very unsettling problem, moreover, and not easy to resolve. Traditionally, philosophical theories of authenticity have recommended individual, mostly reflective strategies to settle authenticity questions. Here I argue for relational authenticity strategies instead.
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What are the respective roles of physiological, psychological and social processes in the development of psychiatric disorders? The answer is relevant for deciding on interventions, prevention measures, and for our (self)understanding.... more
What are the respective roles of physiological, psychological and social processes in the development of psychiatric disorders? The answer is relevant for deciding on interventions, prevention measures, and for our (self)understanding. Reductionist models assume that only physiological processes are in the end causally relevant. The biopsychosocial (BPS) model, by contrast, assumes that psychological and social processes have their own unique characteristics that cannot be captured by physiological processes and which have their own distinct contributions to the development of psychiatric disorders. Although this is an attractive position, the BPS model suffers from a major flaw: it doesn’t tell us how these biopsychosocial processes can causally interact. If these are processes of such different natures, how then can they causally affect each other? An enactive approach can explain biopsychosocial interaction. Enactivism argues that cognition is an embodied and embedded activity and that living necessarily includes some basic form of cognition, or sense-making. Starting from an enactive view on the interrelations between body, mind, and world, and adopting an organisational rather than a linear notion of causality, we can understand the causality involved in the biopsychosocial processes that may contribute to the development of psychiatric disorders.
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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. One commonly assumed 'mind-world topology' (Dreyfus & Taylor, 2015) regards the mind as... more
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. One commonly assumed 'mind-world topology' (Dreyfus & Taylor, 2015) regards the mind as internal and the world as external, and gives the mind the task of properly representing the outer world. From such a perspective, psychiatric disorders appear as problems with internal, cognitive processing. Since the inputs and outputs are in order, the problem must lie in between: in the inner modelling of the outer world. Enactivism offers a very different conception of the nature of mind. Given that on this enactive account mind, body, and world are necessarily interrelated, enactivism provides a promising alternative starting point for an integrative framework of psychiatric disorders.
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This article addresses the integration problem in psychiatry: the explanatory problem of integrating such heterogeneous factors as cause or contribute to the problems at hand, ranging from traumatic experiences, dysfunctional... more
This article addresses the integration problem
in psychiatry: the explanatory problem of integrating
such heterogeneous factors as cause or contribute to the
problems at hand, ranging from traumatic experiences,
dysfunctional neurotransmitters, existential worries,
economic deprivation, social exclusion, and genetics.
In practice, many mental health professionals work
holistically in a pragmatic and eclectic way. Such pragmatic
approaches often function well enough. Yet an
overarching framework provides orientation, treatment
rationale, a shared language for communication with
all those involved, and the means to explain treatment
decisions to health insurers and to society at large. It
also helps to relate findings from different areas and
types of research. In this article, I introduce an enactive
framework that supports holistic psychiatric practice
by offering an integrating account of how the diverse
aspects of psychiatric disorders relate. The article starts
with a short overview both of the four main dimensions
of psychiatric disorders and of the currently available
models. I then introduce enactivism and the enactive
notion of sense-making. Subsequently, I discuss how this
enactive outlook helps explicate the relation between
the four dimensions and what that implies regarding
the causality involved. The article concludes with an
overview of treatment implications.
in psychiatry: the explanatory problem of integrating
such heterogeneous factors as cause or contribute to the
problems at hand, ranging from traumatic experiences,
dysfunctional neurotransmitters, existential worries,
economic deprivation, social exclusion, and genetics.
In practice, many mental health professionals work
holistically in a pragmatic and eclectic way. Such pragmatic
approaches often function well enough. Yet an
overarching framework provides orientation, treatment
rationale, a shared language for communication with
all those involved, and the means to explain treatment
decisions to health insurers and to society at large. It
also helps to relate findings from different areas and
types of research. In this article, I introduce an enactive
framework that supports holistic psychiatric practice
by offering an integrating account of how the diverse
aspects of psychiatric disorders relate. The article starts
with a short overview both of the four main dimensions
of psychiatric disorders and of the currently available
models. I then introduce enactivism and the enactive
notion of sense-making. Subsequently, I discuss how this
enactive outlook helps explicate the relation between
the four dimensions and what that implies regarding
the causality involved. The article concludes with an
overview of treatment implications.
Research Interests:
Gilbert et al. (Neuroethics, 2018) argue that the concerns about the influence of Deep Brain Stimulation (DBS) on-as they lump together-personality, identity, agency, autonomy, authenticity and the self (PIAAAS) are due to an ethics hype.... more
Gilbert et al. (Neuroethics, 2018) argue that the concerns about the influence of Deep Brain Stimulation (DBS) on-as they lump together-personality, identity, agency, autonomy, authenticity and the self (PIAAAS) 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.
Research Interests:
Gilbert et al. (Neuroethics, 2018) argue that the concerns about the influence of Deep Brain Stimulation (DBS) on – as they lump together – personality, identity, agency, autonomy, authenticity and the self (PIAAAS) are due to an ethics... more
Gilbert et al. (Neuroethics, 2018) argue that the concerns about the influence of Deep Brain Stimulation (DBS) on – as they lump together – personality, identity, agency, autonomy, authenticity and the self (PIAAAS) 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.
valuable lessons for a future research agenda.
Research Interests:
Research Interests:
Schizophrenic autism, as originally intended by Eugen Bleuler, signifies a pathognomic form of motivated unmooring from the world into a state of asocial fantasy. In this chapter we discuss the unity of the three key aspects of this... more
Schizophrenic autism, as originally intended by Eugen Bleuler, signifies a pathognomic form of motivated unmooring from the world into a state of asocial fantasy. In this chapter we discuss the unity of the three key aspects of this autism: (i) an altered relation to reality; (ii) a distinctive fantasy-involving form of thinking; and (iii) a motivated retreat from the world. Phenomenological psychiatry deepens our understanding of (i) by theorising it in terms of disturbed pre-reflective intersubjective engagement, yet it deprecates the criteria of (ii) fantasy and (iii) motivation. We question the assumptions behind this rejection of (ii) and (iii), retheorising (ii) as withdrawal to a state in which a fantasy/reality distinction is compromised, and reinstating the motivational criterion (iii) through recovering a properly pre-reflective conception of dynamic motivation. The result is a conception of autism which preserves the unity of Bleuler’s concept by unifying phenomenological and psychoanalytical perspectives on the intersubjective constitution of selfhood.
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In his paper Psychiatry and religion: Consensus reached!, Verhagen advocates the relevance of spirituality and religion for the “origins, understanding, and treatment of psychiatric disorders”. In this comment, I argue for the broader... more
In his paper Psychiatry and religion: Consensus reached!, Verhagen
advocates the relevance of spirituality and religion for the “origins,
understanding, and treatment of psychiatric disorders”. In this
comment, I argue for the broader claim that the existential
dimension is important for understanding psychiatric disorders
– of which religion can, but must not necessarily be, part. The
existential dimension refers to our ability to relate to ourselves,
our experiences, and our situation. This evaluative relation can
play an important role in psychiatry: it can co-constitute the
disorder, be affected by the disorder, and/or modulate the course
of the disorder. Given this importance, it makes sense to explicitly
recognize the existential dimension in our explanatory model of
psychiatric disorders. The biopsychosocial model goes a long way
in providing an integrative model, but there is room for
improvement, especially when it comes to integration of its
aspects, and acknowledging the existential aspect. I briefly
introduce the research paradigm of enactivism, and suggest that
an enactive framework is well-suited to incorporate this existential
dimension – along with the traditional dimensions of the
biopsychosocial model.
advocates the relevance of spirituality and religion for the “origins,
understanding, and treatment of psychiatric disorders”. In this
comment, I argue for the broader claim that the existential
dimension is important for understanding psychiatric disorders
– of which religion can, but must not necessarily be, part. The
existential dimension refers to our ability to relate to ourselves,
our experiences, and our situation. This evaluative relation can
play an important role in psychiatry: it can co-constitute the
disorder, be affected by the disorder, and/or modulate the course
of the disorder. Given this importance, it makes sense to explicitly
recognize the existential dimension in our explanatory model of
psychiatric disorders. The biopsychosocial model goes a long way
in providing an integrative model, but there is room for
improvement, especially when it comes to integration of its
aspects, and acknowledging the existential aspect. I briefly
introduce the research paradigm of enactivism, and suggest that
an enactive framework is well-suited to incorporate this existential
dimension – along with the traditional dimensions of the
biopsychosocial model.
Research Interests:
Gilbert and colleagues’ study ('I miss being me: Phenomenological effects of Deep Brain Stimulation') adds much needed data on what patients actually experience regarding changes of the self following DBS treatment. Out of the same... more
Gilbert and colleagues’ study ('I miss being me: Phenomenological effects of Deep Brain Stimulation') adds much needed data on what patients actually experience regarding changes of the self following DBS treatment. Out of the same motivation to gain a better understanding of patients’ experiences, we conducted in-depth interviews with 18 Obsessive-Compulsive Disorder patients on their general experiences (De Haan et al 2013, De Haan et al 2015) and on their experiences regarding personality changes specifically (De Haan et al 2017). We found that most patients felt that they had become more themselves (13) or that they had not changed (4). Only one patient felt less herself. The title of this paper and the terminology of self-estrangement suggests that Gilbert and colleagues found the opposite. Do patients with Parkinson's Disease experience more self-estrangement following DBS than OCD patients?
A closer look at Gilbert et al.'s data, however, reveals a very different picture: the contradictory term ‘restorative self-estrangement’ is used to refer to patients who felt they had become their old selves again. In fact, at least 15 out of 17 patients (88%) either say that they have not changed or that they have become more themselves.
In this comment, I first argue that the authors’ interpretation of their data in terms of ‘self-estrangement’ is misleading. Secondly, I present findings from our study on two different ways in which patients understood what it means to be ‘changed as a person’; leading to different answers to describe a similar experience. I show how this may shed new light on the data presented here. I end by discussing the clinical relevance of the concepts ‘personal identity’ and ‘authenticity’.
A closer look at Gilbert et al.'s data, however, reveals a very different picture: the contradictory term ‘restorative self-estrangement’ is used to refer to patients who felt they had become their old selves again. In fact, at least 15 out of 17 patients (88%) either say that they have not changed or that they have become more themselves.
In this comment, I first argue that the authors’ interpretation of their data in terms of ‘self-estrangement’ is misleading. Secondly, I present findings from our study on two different ways in which patients understood what it means to be ‘changed as a person’; leading to different answers to describe a similar experience. I show how this may shed new light on the data presented here. I end by discussing the clinical relevance of the concepts ‘personal identity’ and ‘authenticity’.
Research Interests:
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... more
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.
Research Interests:
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... more
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 in- depth 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.
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... more
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.
Research Interests:
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... more
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.
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.
Research Interests:
Research Interests:
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... more
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.
(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.
Research Interests:
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... more
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.
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.
Research Interests:
De existentiële dimensie verwijst naar het gegeven dat mensen zich verhouden tot zichzelf en hun situatie. Deze verhouding speelt een belangrijke rol in de psychiatrie: zowel in het ontstaan en verloop van psychiatrische stoornissen, als... more
De existentiële dimensie verwijst naar het gegeven dat mensen zich verhouden tot zichzelf en hun situatie. Deze verhouding speelt een belangrijke rol in de psychiatrie: zowel in het ontstaan en verloop van psychiatrische stoornissen, als wat betreft de behandeling. Huidige modellen voor de psychiatrie geven onvoldoende rekenschap van deze dimensie. Enactivisme biedt een algemeen denkkader dat uitgaat van de samenhang tussen biologie en betekenis, tussen lichaam en geest, en tussen persoon
en omgeving. Een enactivistische benadering kan recht doen aan de existentiële dimensie en maakt bovendien de samenhang inzichtelijk tussen de existentiële, de sociaal-culturele, biologische en experiëntiële dimensies van de psychiatrie. De verschillende dimensies kunnen we zien als verschillende uitsnedes uit het gehele systeem van een persoon in interactie met haar (sociale) omgeving. Zonder de verschillen uit het oog te verliezen, benadrukt een enactivistische benadering de samenhang tussen
de dimensies, en biedt daarmee grip op de complexiteit van psychiatrische aandoeningen.
en omgeving. Een enactivistische benadering kan recht doen aan de existentiële dimensie en maakt bovendien de samenhang inzichtelijk tussen de existentiële, de sociaal-culturele, biologische en experiëntiële dimensies van de psychiatrie. De verschillende dimensies kunnen we zien als verschillende uitsnedes uit het gehele systeem van een persoon in interactie met haar (sociale) omgeving. Zonder de verschillen uit het oog te verliezen, benadrukt een enactivistische benadering de samenhang tussen
de dimensies, en biedt daarmee grip op de complexiteit van psychiatrische aandoeningen.
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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... more
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.
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.
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It is often assumed that the exercise of free will depends on the ability to consciously decide between available options. Consequently, the more conscious control one has over one’s actions, the freer one is. Since neuroscientific... more
It is often assumed that the exercise of free will depends on the ability to consciously decide between available options. Consequently, the more conscious control one has over one’s actions, the freer one is. Since neuroscientific research shows the limitations of what we in fact consciously control, it seems that our free will is in trouble.
A closer look at the phenomenology of Obsessive-Compulsive Disorder (OCD) gives us reason to doubt this concept of freedom. OCD patients feel unfree. They do things they do not want to do, or think things they do not want to think. In order to regain control, they deliberate or pay extra conscious attention to what they do. Paradoxically, their recourse to conscious control often makes matters worse, resulting in a diminishment of the experience of freedom.
Here, we combine Arendt’s conception of freedom in terms of action with phenomenological insights to get a better understanding of the role of deliberation in the experience of freedom. We argue that this experience depends on the ability to rely on our skills as much as on our ability to deliberate. This implies that the dichotomy between automaticity and freedom in the current debate, is a false one.
A closer look at the phenomenology of Obsessive-Compulsive Disorder (OCD) gives us reason to doubt this concept of freedom. OCD patients feel unfree. They do things they do not want to do, or think things they do not want to think. In order to regain control, they deliberate or pay extra conscious attention to what they do. Paradoxically, their recourse to conscious control often makes matters worse, resulting in a diminishment of the experience of freedom.
Here, we combine Arendt’s conception of freedom in terms of action with phenomenological insights to get a better understanding of the role of deliberation in the experience of freedom. We argue that this experience depends on the ability to rely on our skills as much as on our ability to deliberate. This implies that the dichotomy between automaticity and freedom in the current debate, is a false one.
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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... more
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.
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We challenge Gallagher’s distinction between the sense of ownership (SO) and the sense of agency (SA) as two separable modalities of experience of the minimal self and argue that a careful investigation of the examples provided to promote... more
We challenge Gallagher’s distinction between the sense of ownership (SO) and the sense of agency (SA) 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.
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Schizophrenic autism, as originally intended by Eugen Bleuler, signifies a pathognomic form of motivated unmooring from the world into a state of asocial fantasy. In this chapter we discuss the unity of the three key aspects of this... more
Schizophrenic autism, as originally intended by Eugen Bleuler, signifies a pathognomic form of motivated unmooring from the world into a state of asocial fantasy. In this chapter we discuss the unity of the three key aspects of this autism: (i) an altered relation to reality; (ii) a distinctive fantasy-involving form of thinking; and (iii) a motivated retreat from the world. Phenomenological psychiatry deepens our understanding of (i) by theorising it in terms of disturbed pre-reflective intersubjective engagement, yet it deprecates the criteria of (ii) fantasy and (iii) motivation. We question the assumptions behind this rejection of (ii) and (iii), retheorising (ii) as withdrawal to a state in which a fantasy/reality distinction is compromised, and reinstating the motivational criterion (iii) through recovering a properly pre-reflective conception of dynamic motivation. The result is a conception of autism which preserves the unity of Bleuler’s concept by unifying phenomenological and psychoanalytical perspectives on the intersubjective constitution of selfhood.
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This paper addresses the integration problem in psychiatry: the explanatory problem of integrating such heterogeneous factors as cause or contribute to the problems at hand, ranging from traumatic experiences, dysfunctional... more
This paper addresses the integration problem in psychiatry: the explanatory problem of integrating such heterogeneous factors as cause or contribute to the problems at hand, ranging from traumatic experiences, dysfunctional neurotransmitters, existential worries, economical deprivation, social exclusion, and genetics. In practice, many mental health professionals work holistically in a pragmatic and eclectic way. Such pragmatic approaches often function well enough. Yet an overarching framework provides orientation, treatment rationale, a shared language for communication with all those involved, and the means to explain treatment decisions to health insurers and to society at large. It also helps relate findings from different areas and types of research.
In this paper I introduce an enactive framework that supports holistic psychiatric practice by offering an integrating account of how the diverse aspects of psychiatric disorders relate. The paper starts with a short overview both of the four main dimensions of psychiatric disorders and of the currently available models. I then introduce enactivism and the enactive notion of sense-making. Subsequently I discuss how this enactive outlook helps explicate the relation between the four dimensions and what that implies regarding the causality involved. The paper concludes with an overview of treatment implications.
In this paper I introduce an enactive framework that supports holistic psychiatric practice by offering an integrating account of how the diverse aspects of psychiatric disorders relate. The paper starts with a short overview both of the four main dimensions of psychiatric disorders and of the currently available models. I then introduce enactivism and the enactive notion of sense-making. Subsequently I discuss how this enactive outlook helps explicate the relation between the four dimensions and what that implies regarding the causality involved. The paper concludes with an overview of treatment implications.
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The preface and table of contents from my book 'Enactive Psychiatry'.