Gerrit Glas

The article investigates the concept of self-illness ambiguity (SIA), which was recently re-introduced in the philosophy of psychiatry literature. SIA refers to situations in which patients are uncertain about whether features (symptoms, signs) of their illness should be attributed to their illness or to their ‘selves’. Identification of these features belongs to a more encompassing process of self- definition and -interpretation. The paper introduces a distinction between the notions of self-relatedness, self-referentiality (or: implicit self-signification), self-awareness and self-interpretation. Each of these notions offers a different perspective on SIA, but these perspectives do not exclude one another. A further distinction will be developed between primary, secondary and tertiary forms of self-referentiality. The practical and conceptual relevance of these distinctions will be illustrated with case vignettes. Throughout the paper our findings will placed in the context of other philosophical work on the self, especially in the field of narrative theory (Ricoeur), phenomenology (Ratcliffe) and philosophy of mind. The article closes with a brief discussion about the appropriateness of the term ambiguity and the potential of SIA as concept in the context of clinical psychiatry. Directions for future work will be indicated.

This work provides an overview of attempts to assess the current condition of the concept of creation order within reformational philosophy compared to other perspectives. Focusing on the natural and life sciences, and theology, this first volume of two examines the arguments for and against the beauty, coherence and order shown in the natural world being related to the will or nature of a Creator. It examines the decay of a Deist universe, and the idea of the pre-givenness of norms, laws and structures as challenged by evolutionary theory and social philosophy. It describes the different responses to the collapse of order: that given by Christian philosophy scholars who still argue for the idea of a pre-given world order, and that of other scholars who see this idea of stable creation order and/or natural law as redundant and in need of a thorough rethinking. It studies the particular role that reformational philosophy has played in the discussion. It shows how, ever since its inception, almost a century ago, the concepts of order and law (principle, structure) have been at the heart of this philosophy, and that one way to characterise this tradition is as a philosophy of creation order. Reformational philosophers have maintained the notion of law as 'holding' for reality. This book discusses the questions that have arisen about the nature of such law: is it a religious or philosophical concept; does law just mean 'orderliness'? How does it relate to laws of nature? Have they always existed or do they 'emerge' during the process of evolution?

Understanding lone actor grievance-fueled violence remains a challenge. We believe that the concept of grievance provides an opportunity to add an engaged, first-person perspective to the assessment of lone actor extreme violence. We propose an enactivist philosophical approach that can help to understand the why and how of the pathway from grievance to violent extremism. Enactivism sees grievance as a dynamic, interpersonal, and context-sensitive construct that indicates how offenders make sense of the world they live in and how under certain circumstances it fuels violent behavior. Hence, grievance should not be understood as a given thing, but as an unfolding experience that involves sense-making through interaction with the environment. This relational and ecological understanding requires another approach than looking at demographic factors or life histories, only from an outsider’s perspective. Enactivism invites us to look at such risk factors as external indices of an ongoing process of active self-regulation and sense-making, and in some cases spiraling toward extreme violence. To understand the mindset of the offender we need to look more in depth at the processes that shape this mindset: why does this person, with this history, in this context, and at this point in time, proceed to use violence? The enactivist approach to the mind offers a complementary framework that may help us to understand the dynamics of grievance as a possible precursor to violent extremism. It also helps to appreciate why the relative unpredictability of the pathway toward lone actor extreme violence is not necessarily a sign of empirical weakness but a matter of principle due to the non-linearity of the processes involved. We end by summarizing how enactivism could contribute to the prevention of extremist violence and research and how it can help to avoid reinforcing stigmas and re-establishing a confirmation bias.

In this paper, we explore the conceptual problems arising when using network analysis in person- centered care (PCC) in psychiatry. Personalized network models are potentially helpful tools for PCC, but we argue that using them in psychiatric practice raises boundary problems, i.e., problems in demarcating what should and should not be included in the model, which may limit their ability to provide clinically-relevant knowledge. Models can have explanatory and representational boundaries, among others. We argue that we can make more explicit what kind of questions personalized network models can address in PCC, given their representational and explanatory boundaries, using perspectival reasoning.

This book focuses on two important, interlinked themes in psychiatry, i.e., the relation between self (or: person), context and psychopathology; and the intrinsic value-ladenness of psychiatry as a practice. Written against the background of scientistic tendencies in today’s psychiatry, it is argued in Part I that psychiatry needs a clinical conception of psychopathology alongside more traditional scientific conceptions; that this clinical conception of psychopathology must be based on a fundamental rethinking of the interaction between illness manifestations, contextual influences and the patient as person, such that psychopathology is conceived as the product of this interaction rather than as the outward manifestation of a broken mechanism within the patient. In Part II, it is shown that self- and context-related factors have a large impact on who one is as a professional. I argue that an analysis is needed of the normative aspects of the relations that sustain and frame professional role-fulfilment. This analysis culminates into a so-called normative practice model (NPM) which distinguishes between qualifying, conditioning and foundational principles (or: rules, norms). The normative practice model helps to locate and resist scientistic defenses of the legitimacy of psychiatry and to replace them by a positive account that provides clinicians (and scientists) the conceptual tools they need to justify what they do in broader contexts. The main thrust of the argument is to show that psychiatry needs a value-sensitive account of its legitimacy, in which other normative dimensions are recognized than those that sustain the expert role. Psychiatrists should in other words not defend the legitimacy of their profession by referring to the expert role solely but provide a broader account in which justice is done to the broader social, legal, and economic contexts of professional activity. The analysis of this inherent normativity begins within clinical practice, it extends to the concept of disease as well as to wider domains of psychiatric care and the sociology of professions, and, finally, amounts into an analysis of the value-ladenness of interactions between healthcare institutions, the government, professional organizations and patient groups.

Borsboom and colleagues have recently proposed a “network theory” of psychiatric disorders that conceptualizes psychiatric disorders as relatively stable networks of causally interacting symptoms. They have also claimed that the network theory should include non-symptom variables such as environmental factors. How are environmental factors incorporated in the network theory, and what kind of explanations of psychiatric disorders can such an “extended” network theory provide? The aim of this article is to critically examine what explanatory strategies the network theory that includes both symptoms and environmental factors can accommodate. We first analyze how proponents of the network theory conceptualize the relations between symptoms and between symptoms and environmental factors. Their claims suggest that the network theory could provide insight into the causal mechanisms underlying psychiatric disorders. We assess these claims in light of network analysis, Woodward’s interventionist theory, and mechanistic explanation, and show that they can only be satisfied with additional assumptions and requirements. Then, we examine their claim that network characteristics may explain the dynamics of psychiatric disorders by means of a topological explanatory strategy. We argue that the network theory could accommodate topological explanations of symptom networks, but we also point out that this poses some difficulties. Finally, we suggest that a multilayer network account of psychiatric disorders might allow for the integration of symptoms and non-symptom factors related to psychiatric disorders and could accommodate both causal/mechanistic and topological explanations.

Alterations in consciousness are among the most common transdiagnostic psychopathological symptoms. Therefore clinical practice would benefit from a clear conceptual framework that guides the recognition, comprehension, and treatment of consciousness disorders. However, contemporary psychopathology lacks such a framework. We describe how pathology of consciousness is currently being addressed in clinical psychology and psychiatry so far, and how the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and International Classification of Diseases, Tenth Edition (ICD-10) refer to this subject. A brief review of the literature on consciousness is then given. After describing psychological perspectives on consciousness and discussing theoretical issues involved in exploring consciousness, we offer a practical clinical working definition of consciousness and we illustrate its connections with a variety of diagnoses. Making use of Jean-Paul Sartre’s distinctions among: states, functions, qualities, and structure, provide a conceptual framework to understand consciousness, to refine diagnostics and to guide the development of therapeutic possibilities in clinical practice.

When we first anticipated the research project concluded with this special issue, about 8 years ago, it seemed timely and appropriate to investigate the opportunities and the challenges of self-management in mental health care. At the time self-management was well on the rise in general health care, offering both empowerment to patients and efficiency and cost-effectiveness to the health care system. It seemed a most promising approach in an era that celebrates individualistic self-reliance. And we were sure about our insight that self-management in mental health care would deserve comprehensive investigation because “the self” that was supposed to do the management would itself be the core problem in psychiatric...

We thank Sanneke de Haan for her thoughtful response. We agree with what she says and consider it as a further specification of our intentions. We particularly endorse the two main points she raises, that is, that dealing with self-illness ambiguity requires a relational perspective; and that relying on reflection solely is problematic since it plays an only modest role in the resolution of self-illness ambiguity. We discuss both points in reverse order.With respect to the role of reflection, we have, as a matter of fact, been very explicit: “we should not overemphasize the importance of reflection”; and “self-ambiguity is more likely to be a diachronic process”, with a “back and forth between narrative...

In the context of theistic religions, God representations are an important factor in explaining associations between religion/spirituality and well-being/mental health. Although the limitations of self-report measures of God representations are widely acknowledged, well-validated implicit measures are still unavailable. Therefore, we developed an implicit Attachment to God measure, the Apperception Test God Representations. In this study, we examined reliability and validity of an experimental scale based on attachment theory. Seventy-one nonclinical and 74 clinical respondents told stories about 15 cards with images of people. The composite Attachment to God scale is based on scores on two scales that measure dimensions of Attachment to God: God as Safe Haven and God as Secure Base. God as Safe Haven scores are based on two subscales: Asking Support and Receiving Support from God. Several combinations of scores on these latter subscales are used to assess Anxious and Avoidant attachment to God. A final scale, Percentage Secure Base, measures primary appraisal of situations as nonthreatening. Intraclass correlation coefficients showed that the composite Attachment to God scale could be scored reliably. Associations of scores on the ATGR scales and on the explicit Attachment to God Inventory with scores on implicitly and explicitly measured distress partly confirmed the validity of the ATGR scales by demonstrating expected patterns of associations. Avoidant attachment to God seemed to be assessed more validly with the implicit than with the explicit scale. Patients scored more insecure on the composite Attachment to God scale and three subscales than nonpatients.

I thank Giovanna Colombetti and Dan Stein for their careful reading and thoughtful comments.Colombetti is right when she suggests that in enactivism there are no 'mere physiological states.' She criticizes the following quotation: "If there is no self-referentiality, even after attempts at clarification, the putative emotion is just a physiological state or a sensation." My formulation, she says, echoes traditional, disembodied cognitivist accounts of emotion, according to which bodily arousal and bodily sensation, without accompanying intentional evaluations and judgments, are mere physiological happenings. Enactivism rejects the dichotomy between cognitive appraisals and bodily arousal.I agree that I could (and...

Enactive approaches to emotion are rare and to anxiety and anxiety disorder even more. This article aims to show how an enactive paradigm might be helpful in solving some problems in the clinical and scientific understanding of anxiety and anxiety disorder. I begin by pointing at a number of relevant clinical features of anxiety and anxiety disorder and by sketching how and why anxiety theories have difficulties with doing justice to these features. I specifically focus on two themes: a) how to conceptualize anxiety as the expression of a dynamical interaction with the environment instead of as just a reaction to the environment (or to...

Translation as philosophical program: An explorative reviewWhat does the concept of translation mean in the expression ‘translational neuroscience’? What are the different steps, or components, in the translation of neuroscientific findings to psychiatry? There are serious concerns about the validity and productivity of the traditional idea of a translational pipeline, starting in the fundamental sciences and ending in the practice of clinical medicine, including psychiatry. The article defends the thesis that the difficulties in the traditional approach result, at least partially, from insufficient reflection on the philosophical premises upon which the concept of translation is based. The linear pipeline model is strongly determined by the traditional biomedical approach to disease. The translation crisis signifies some of the limitations of this approach, especially in the realm of clinical practice and patient experience. The biomedical model suggests that illness manifestations should be conceived as causally determined expressions of an underlying biological derailment or dysfunction. This model lacks the language and conceptual tools to address the role of contextual and person-bound factors in the manifestation of illness. It is only recently that personalized and context-sensitive approaches to psychopathology have gained scientific attention. In the wake of this conceptual and practical reform, network-like approaches to translation have emerged. These network approaches are based on a different conception of transdisciplinarity. They address all stakeholders, by asking them what kind of translation they need. Stakeholders are not only scientists and clinicians, but also patient- and family support groups; and parties that are responsible for the institutional embedding, the financial and logistic infrastructure, and the legal frameworks that support psychiatric care. It is the interaction between science and the contexts that are supposed to benefit from this knowledge, that should be put at the centre of conceptual reflection. The degree and fruitfulness of this interaction will be decisive for the future of both psychiatry and clinical neuroscience. Philosophy can play an important role in this interaction, by making explicit underlying logical and practical tensions and ambiguities in this interaction.

One of paradoxes of current mental health care is that we never have known more about mental disorder and at the same time been more uncertain about the conceptual basis—and, therefore, the legitimacy—of psychiatry.This is remarkable. Psychiatry as a science flourishes. Over the last three decades, there has been an enormous increase in empirical research on the genetic, neurobiological, psychological, and social determinants of mental disorder. At the same time, mental health care has improved a lot, at least in most Western countries. Reform in legislation and in the organization of care has led to more autonomy of the patient, more control on the process and outcome of therapy...

Over the last years, self-management has become a central value in the practice of mental health care. Patients are positioned as expertclients who are actively involved in the management of their disease. Some of the ideas that are implied in the concept of self-management may raise important and intriguing questions. For instance, in the context of psychiatry impaired agency and altered self-experience are often part of the psychopathological process itself. The capacity to manage oneself may be impeded by the very problem that needs to be managed. Therefore, how should self-management be conceived in...

This is the second of three articles on the relationship between science, religion and professional practice in psychology and psychiatry. The first article pointed out that the weakness of the integration debate consists of lack of awareness of the epistemological distinction between everyday knowledge, professional knowledge, scientific knowledge and philosophical assumptions. This article shows how the integration debate gains new impetus by relating knowledge to practices and by investigating the intrinsic normative nature of professional practices. In the first part of the article I will analyze the structure of professional practices (psychiatry; psychotherapy), in order to gain insight into the role of norms and values in these practices. In the second part I show how the notion of integration can be elaborated upon along the dimensions of structure (levels; functions) and direction (opening-up; disclosure). It appears that the I-self relationship plays a crucial role in the conceptualization of the relation between these two dimensions