3E Approach to Psychopathology: Kristopher Nielsen, PhD

CONVERSATIONS IN CRITICAL PSYCHIATRY

Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

Kristopher Nielsen recently completed his PhD in Psychology at Victoria University of Wellington, New Zealand. His thesis “What is Mental Disorder? Developing an Embodied, Embedded, and Enactive Psychopathology” (accessible here) concerned the development of a conceptual model of mental disorder grounded in embodied enactivism, and explored how we might explain mental disorders from this perspective. He is currently completing his final year of clinical psychology training, after which he hopes to split his time between clinical work and continued research in theoretical psychopathology.

This interview with Kristopher Nielsen, PhD, is second of a pair of interviews on the topic of enactive psychiatry; you can read the first interview with Sanneke de Haan, PhD, here.

Dr Nielsen’s framework for an embodied, embedded, and enactive (3E) concept of mental disorder^1,2, explored in detail in his thesis, has substantial overlap with Dr de Haan’s framework but also has meaningful differences in emphasis. In this interview, we discuss how he applies the 3E conceptual framework to psychiatry, and how his approach differs from Dr de Haan’s.

Aftab: Doctoral theses do not normally make it to my reading list, but I am very glad that yours did. It is a remarkable and impressive work, and I look forward to your ideas making a big splash in the field of philosophy of psychiatry. You develop your account of psychopathology within the 3E (Embodied, Embedded, and Enactive) framework, and conclude that mental disorders are dysfunctions in the behavioral and experiential processes of striving organisms, constituted by relatively stable dynamic patterns (networks of phenomena) within the brain-body-environment system. How would you describe this understanding of mental disorders in a language that would be accessible to clinicians?

Nielsen: Thank you, that is very kind. And thanks also for inviting me to do this interview. I was blown away when you asked me and feel very privileged.

To put it in plain language, I think that mental disorders are patterns of behavior that individuals get stuck in, despite that pattern not working for the individual. I want to note here that when I say “behavior,” I am referring to everything the organism does, including the enaction of emotions and thoughts. I have to say, that central description you highlighted is embarrassingly wordy! What I was trying to do there was to sum up and link the reader back to 3 core ideas I had explored earlier in the thesis. Let me briefly go through the description in reverse and try to pull these three ideas out.

Awais Aftab, MD

Kristopher Nielsen, PhD

Firstly, we have the idea of mental disorders as occurring within a brain-body-environment system. From the developed perspective, seeing mental disorders as “in the brain,” “in cognition,” or “in society” does not really cut it. The work of those such as Ken Kendler highlights that mental disorders are complex, with causes littered across scales of explanation from genes to culture. The developed perspective encompasses this and does not require that all these causes be mediated by some change within the brain for the disorder to be seen as “real.” Rather, a mental disorder is conceived of as a pattern existing across the brain, body, and environment, with no a priori explanatory privilege given to causes at any particular scale.

Secondly, we have the idea that these patterns are “relatively stable.” While the constituent phenomena fluctuate, mental disorders are remarkably inflexible. We have a pattern of behavior, thought, and emotion that, by definition, is not working for the person-in-context, yet the person has great difficulty moving away from it. In a potentially contrived sense, then, mental disorders themselves almost appear to parasitically self-maintain within the agential processes of the organism. Another way I like to refer to this idea is that, at both an individual and across-individual level, mental disorders can be seen as “sticky.” This is an idea I have explored in this communication piece for Aeon recently.³ The developed perspective tries to capture this quality, and (as I explore later in the thesis) I think this has important implications for how we should seek to explain mental disorders.

Finally, I started that central description by saying that mental disorders are “dysfunctions in the behavioral and experiential processes of striving organisms.” Here I am trying to remind the reader that these patterns (while we might be able to model them as “complex networks of phenomena”) are occurring within the lives of real people. These people are doing their best to survive and adapt to their circumstances yet are somehow ending up acting against this purpose. I am trying to acknowledge that the view developed is essentially a functionalist one, but that it is also strongly agential. It basically holds that a mental disorder is when someone inflexibly acts in a way that is against their own interests as an organism. To put this another way, under the developed view, mental disorders are both natural (ie, they are real patterns in the world) and normative (ie, we can define them as “disorder” in reference to the natural functional normativity of an individual organism trying to survive and adapt). This also has the consequence of reserving the label of “disorder” for patterns of behavior that are themselves working against the person.

The biggest lesson here is that I should have tried to squeeze less into that description! But hopefully this gives a working sketch of the framework that can be filled out a bit as we go.

Aftab: What are some of the ways in which your account of mental disorders differs from the enactive account of mental disorders developed by Sanneke de Haan, PhD?

Nielsen: I want to say from the get-go that I love Dr de Haan’s work. We have developed our perspectives essentially in parallel to each other, although reading Enactive Psychiatry (Cambridge University Press, 2020) in the last 6 months of my thesis did push me to extend my ideas, as I have acknowledged in the thesis. Initially I was disappointed that we did not find each other’s work earlier. Now, I am actually rather excited that it happened this way. We now have these 2 perspectives that can enrich each other through comparison. All the better for the continued development of an enactive approach in this area!

Probably the most important difference between our perspectives can be illustrated in our central descriptions of mental disorder. Mine is chunky as previously noted, and hers is: “Mental disorders are biases in sense-making.” Beyond the obvious differences in parsimony and elegance (hers being vastly superior in this regard) I think there is a difference in our intentions here that may relate to our respective professions. De Haan is a philosopher, with interests in lived experience. On an enactive view, mental disorders represent differences in the way we perceive, understand, and act in the world. Her description puts words to this beautifully, capturing the agential and experiential nature of mental disorders. My domain is psychology, and I see myself as a theoretical psychopathologist. I want my conceptual model to inspire new ways to understand, classify, explain, and treat mental disorders. While my approach is certainly against eliminativist or wholly reductionistic approaches, I wanted to explicitly leave room for methodological pluralism. As such, while still recognizing the experiential, agential, and dynamic nature of disorder, I also tried to put words to how we can simultaneously understand mental disorders in an entitative and more mechanistic way. I do believe, however, that while we emphasize different qualities, de Haan and I are describing the same—or at least a very similar—concept. I understand this through Fuch’s notion of dual aspectivity⁶; de Haan’s is a more first-person view, and mine a more third-person view, but I think we are ultimately looking at the same thing.

There are also differences in the way our frameworks demarcate the disordered from the benign; how we separate between significantly dysfunctional behavior/sense-making one the one hand and the functionally normal on the other. I focus more on what it means for behavior to be dysfunctional and talk a lot about functional/natural normativity. This is an area that de Haan leaves relatively unexplored. Instead, de Haan focuses more on the qualities that disordered sense-making has, and thereby how we might recognize it. This is actually an area that I explicitly left unexplored in my thesis. Given these complimentary lacunae, I think there is huge potential for our frameworks to support each other.

Aftab: I was really struck by a line in your thesis because of its eloquent, aphoristic quality, and it has stayed with me ever since: “. . . the central tenant of enactivism—that meaning is built upon precariousness and thus at least distantly rooted in biological functionality.” Am I correct in understanding it as a rephrasing of sorts of the life-mind continuity thesis?

Nielsen: Yes, absolutely that is what I was referring to. Recent developments in enactivism are pushing towards there being (more or less) partially autonomous levels of meaning within the human condition—for example, the possibility that humans can have meaningful values that transcend our biology. In the section you are referring to, I was exploring a further difference between de Haan’s perspective and my own regarding her notion of “existential values.” On my reading of her work, de Haan leans more toward a transcendental view than I do, although she is very mindful of overstepping the bounds of embodiment and prefers the word “transformation” to “transcendence.” At times she seems to have an aversion to the idea that human values might be explainable in reference to biological functionality. While I can understand why some might hold this view, I actually see great beauty in the idea that values and meaning structures, handed down through our respective cultures, represent ways of surviving and thriving in the physical and social environments of our ancestors. For me, this holds closer to the life-mind continuity thesis at the heart of enactivism.

Aftab: As you well aware, the very notion of characterizing some psychological/behavioral states as “disorders” has been challenged in certain critical circles, and there is a popular sentiment that psychiatric conditions are understandable reactions to life circumstances and structural forces. Such criticisms are coupled with a tendency to think of “disorder” as being an inherently “medical” concept and that to label a condition as a disorder is to label it as a medical problem. How do you see the relationship between your understanding of disorder and the medical model? The impression I get is that your account is inclusive of and consistent with the medical model, but at the same time does not see mental disorder as an intrinsically medical concept.

Nielsen: That sounds like a reasonably fair assessment of my view. Ultimately, I do not see mental disorder as a medical concept. In a sense it is much more than that. While developing my perspective, I attempted to carve out a conceptual object that served the needs of psychology/psychiatry better than analogies to disease or injury.

I do think there is an important parallel between a medical disease/disorder and the concept of mental disorder. Just as medical disorders represent something “not working for the organism” at the physiological scale, mental disorders represent something “not working for the organism” at the level of thought, emotion, and behavior. However, this difference of domain/scale is no small thing. At the level of physiology, it seems there are only so many ways that humans can work, making it easier to infer the functionally normative from the statistically normal at this scale. For example, small changes to someone’s cardiovascular system can be disastrous. The inference from statistical abnormality to dysfunction thus seems reasonable at the scale of physiology, especially if deviation from the norm can be associated with risk. I do not think we can safely make the same inference when considering behavior. The variation in ways of living across individuals and across cultures is proof enough of this. Thus, I think the conceptual basis for labeling a pattern of thought, emotion, and behavior as dis-ordered has to be very different to that of physiological disorder.

You couched this question in reference to deflationary-type views that want to move away from the concept of mental disorder altogether, and I feel like I should briefly address that side of things. I am well aware that those who hold such views may accuse me of begging the question in that I assume a realist position at all. I don’t know, there is a lot we could talk about there. It is extremely frustrating that the realist and the deflationary positions tend to talk past each other so much. There is much that we can agree on. Most obviously, for the purposes of formalizing diagnostic concepts for study, and for diagnosing psychiatric disorders in a way that can inform treatment, the DSM isn’t cutting it. We are almost all on board with this. We are just looking for solutions in different ways and using different languages. We need to find a way to talk to each other more productively.

Aftab: Reading your discussion of “functional norms” and the emphasis on how some patterns of behavior contribute to “faring well of the individual” and some do not, I was somewhat reminded of the notion of eudaimonia (flourishing) as it exists in virtue ethics. Do you also see a relevance? Do you think one could develop a naturalized account of virtue using the notion of functional norms?

Nielsen: You have stumped me a bit there. Some of that sounds familiar from my undergrad philosophy, but to be honest I do not know enough about virtue ethics to comment. The concept of eudemonia does sound like it overlaps with the notion of faring well I had in mind. I believe I borrowed the term from the work of Michelle Maiese.⁷ In whatever way we consider it, I think it is important that “faring well” be a flexible notion, so as to be applicable across cultures.

Aftab: The distinction between mental and somatic disorders is a major focus of my interview with de Haan. What do you make of this distinction within your framework?

Nielsen: I think there is a meaningful difference between somatic and mental disorders, but they are probably continuous with each other. My intuition is that this continuity follows directly from the principle of embodiment. In my thesis I briefly consider the distinction between Parkinson disease (PD) and depression as an example. Both involve behavioral and cognitive phenomena, and yet we understand 1 as a neurological disorder and 1 as a mental disorder. This makes sense to me because of the known hub of causal connections situated within the brain through which the process of developing PD flows. I am not a neurologist, but my understanding is that we can sufficiently account for PD using an essentialist-type model of this hub. Despite a lot of trying, we cannot do that with depression.

This is not to say that the wider pattern of difficulties that people with organic/somatic diseases experience cannot be fruitfully analyzed though a system-wide and embedded lens. I assume that, even with a somatic disorder like PD, such an analysis would likely highlight a complex network of causal relations across body and environment that impinge on or alleviate a patient’s well-being (ie, PD is more than “just” a neurological/medical disorder). However, we can visualize the network in this instance as much more centralized around a core pathogenic process in the brain—as being denser in the middle if you will. It seems very likely that the network supporting depression and other mental illnesses is more diffuse (although there may well be hubs of causal connections to be discovered, within the brain or elsewhere). This leaves room for different disorders to be more or less diffuse in their causal structures, and this is what I mean when I suggest that, structurally, mental disorder and physical disorder seem reasonably continuous. As mentioned earlier, I do think the normative basis is somewhat different.

Aftab: Sigmund Freud wrote in Civilization and its Discontents, “But there is a question which I can hardly evade.⁴ If the development of civilization has such far-reaching similarity to the development of the individual and if it employs the same methods, may we not be justified in reaching the diagnosis that, under the influence of cultural urges, some civilizations, or some epochs of civilization—possibly the whole of mankind—have become ‘neurotic’?” Given that we can also meaningfully talk about the behavior of societies and how that behavior can at times work against the self-maintenance and adaptation of the societies, do you think we can also, in some sense, talk of societies being disordered?

Nielsen: That is a big question! I am no Freud scholar, but what you are suggesting does make some sense to me under my framework, although I am not sure the direct analogy holds. I think a relevant question here is, what is the purpose of a society? Is it to self-perpetuate the society itself, and what would this mean? In my view, societies (are meant to) exist to support the individuals that constitute them. When they fail to do that, we need to be careful to place the blame at the appropriate level rather than pathologizing struggling or oppressed individuals. This seems to require that “dysfunction” can exist at a social level.

There does seem to be an important distinction to be made though, between labelling a society as disordered and certain patterns in society being dysfunctional. I think I would tend to avoid the evocative language Freud employs there, regarding a “neurotic civilization.” Although, perhaps when society begins to serve itself, serving the perpetuation of ideas (such as money) rather than people, perhaps that is an example of a society level disorder . . . I don’t know. These are just my unqualified ideas, and it is certainly an interesting question.

Aftab: What are some implications of your framework regarding the practice of psychiatry?

Nielsen: Practicing as an intern clinical psychologist this year, I have been thinking about this a lot. It also happens to be the sort of directly practical question that caught me totally off guard in my PhD defense! There are 3 prongs to my thoughts in this area.

Firstly, I think this framework supports what is already recognized as gold-standard practice under something like the biopsychosocial model. We need to be considering factors across brain, body, and environment, and trying to get a 360-degree view of the patient. I think it does push us slightly further than this though. While best practice already encourages us to think about presenting problems both diagnostically (ie, a recognized label for the problem) and in terms of formulation (ie, a tailored explanation of the problem), I think an embodied enactive view also asks us to approach from a third angle. This third angle is something like, “What is this patient’s mode of functioning?” How has this patient learned to survive and thrive in the world, and could this provide a richer and potentially less pathologizing way of thinking about the presenting problem.

Secondly, an embodied enactive perspective affords a way of understanding therapy as a collaborative exercise in “sense-making about sense-making.” This does not change anything necessarily (at least not at this stage of my thinking), but I think it provides a nice frame for considering therapy. A key task for therapist and client under this view is to collaboratively consider how the client perceives, understands, and acts in the world—and whether this is contributing to the problem at hand. This is a very nascent train of thought for me, but I like it because it provides a certain creative freedom when considering solutions, and highlights how important the therapist-patient relationship is to the therapeutic endeavor.

Lastly, delusions of grandeur aside, I do not ultimately think this conceptual-level work is going to radically change practice. It is a new way of thinking about things that I think has some significant advantages. But as much as I hate to admit it, most clinicians are not actually interested in philosophy of psychiatry. This is why, in my thesis, I really tried to push towards practical implications at a research level. Within 1 of the later chapters, I developed a meta-methodological framework called the Relational Analysis of Phenomena—“The RAP” for short. I have overviewed the approach in this communication piece for Scientific American.⁵ One of the greatest challenges in practice is that our diagnostic concepts are too large and unstable to reliably provide an epistemic bridge back to the research base. One person with “depression” is so different from another with “depression,” but our diagnostic categories do not capture this. Consequently, when we try to be “evidence based,” we end up treating with broad strokes (such as “behavioral activation” or “antidepressants”), making it harder to be responsive to the person in front of us. The RAP, while still acknowledging the existence of wider and somewhat unstable syndromes/patterns, shifts explanatory focus to the relationships between clinical phenomena or something I label “phenomena complexes.” If this sort of research model was taken on board (probably wishful thinking), I think this would genuinely have a big impact on practice. The nature of our evidence-base, and the way clinicians can access it would potentially become more tailored and flexible.

Aftab: Thank you!

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of Psychiatric Times.

Dr Aftab is a psychiatrist in Cleveland, Ohio, and clinical assistant professor of psychiatry at Case Western Reserve University. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the Psychiatric Times Advisory Board. He can be reached at awaisaftab@gmail.com or on twitter @awaisaftab. Dr Aftab and Dr Nielsen have no relevant financial disclosures or conflicts of interest.

References:

1. Nielsen K, Ward T. Mental disorder as both natural and normative: Developing the normative dimension of the 3e conceptual framework for psychopathology. Journal of Theoretical and Philosophical Psychology. 2020;40(2):107-123.

2. Nielsen K, Ward T. Towards a new conceptual framework for psychopathology: Embodiment, enactivism, and embedment. Theory & Psychology. 2018;28(6):800-822.

3. Nielsen K. Think of mental disorders as the mind’s “sticky tendencies.” Aeon. May 2020. Accessed October 14, 2020. https://aeon.co/ideas/think-of-mental-disorders-as-the-minds-sticky-tendencies​

4. Freud S. Civilization and its Discontents. Translated by Strachey J. Norton. 2005 (Originally published 1930). p 152.

5. Nielsen K. A New Way to Think about Mental Illness. Scientific American. November 2019. Accessed October 14, 2020. https://blogs.scientificamerican.com/observations/a-new-way-to-think-about-mental-illness​

6. Fuchs T. Ecology of the Brain: The Phenomenology and Biology of the Embodied Mind. 2017. Oxford University Press.

7. Maiese M. Embodied Selves and Divided Minds. 2016; Oxford University Press.