Friday, March 27, 2020

The importance of the existential dimension in understanding psychiatric disorder

Sanneke de Haan makes a case for incorporating the existential dimension into the understanding of psychiatric disorders. As she says, the "existential stance of relating to oneself, to others, and to one’s situation is crucial for understanding psychiatric disorders." We can suffer from alienation when we do not coincide with ourselves and with our present situation, and this alienation may go on to develop into psychiatric disorders. How patients relate to their experiences and their disorder is likely to co-determine the course of their illness, and of their lives in general.

I'm not sure that I agree that Engel's biopsychosocial model does not do justice to patients' subjective experience. Nonetheless, I do like the idea of enactivism as a way of moving on from cognitive science (eg. see my book review). Cognition is a fundamentally embodied and embedded form of action and needs to incorporate the sense-making activity of a person in context. To understand psychiatric disorders, we should look at persons in interaction with their worlds. The evaluative interactions of a person with their world go astray in psychiatric disorders. When a person's sense-making goes astray, it is not appropriate to, or insufficiently grounded in, their situation and the person may well find it difficult to adjust their sense-making. In physical illness, sense-making may be secondarily affected as an effect of the illness but in psychiatric disorders these relations are directly implicated.

The term 'existentialism' was explicitly adopted as a self-description by Jean-Paul Sartre. There is a direct link with the work of R.D. Laing in that Laing & Cooper (1964) wrote an exposition together in english of Sartrean terms related to dialectical rationality. Laing (1964) said in New Society, that he thought there was a revolution happening at the time that was changing the clinical point of view in psychiatry to one that is both existential and social. It's taken a while to happen, maybe because Laing eventually became more interested in personal liberation and spiritual growth, including, for example, developing 'birthing' as a component of his practice following the technique of Elizabeth Fehr. There is an existentialist tradition in psychotherapy but enactive psychiatry seems wider than psychotherapy, and I look forward to finding out more about it.

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