Book Review: Embodied, Embedded and Enactive Psychopathology: Reimagining Mental Disorder

Title: Embodied, Embedded and Enactive Psychopathology: Reimagining Mental Disorder.
Author: Kristopher Nielsen
Publisher: Springer Nature, Switzerland

Dr Kristopher Nielsen is a Wellington-based clinical psychologist and graduate of the Victoria University of Wellington clinical training programme. I initially became aware of his work through a shared interest in non-dualistic ways of understanding human functioning. It was with great interest that I recently discovered he had authored a book containing a gestated elaboration of his thinking. Condensing the book’s full scope of ideas into this review would be an impossible task. Therefore, I chose to focus on several key elements in an attempt to capture the essence of Nielsen’s sophisticated and far-ranging thinking.

On the very first page of the book, Nielsen puts his stake firmly in the ground by advocating for a reconceptualisation of how mental disorder is defined and applied. He proceeds by outlining how psychopathology research has traditionally been composed of three tasks: classification, explanation and treatment. Although Nielsen agrees with the importance of these tasks, he opines that this tripartite model is incomplete and would be strengthened by the inclusion of a fourth and more foundational task: conceptualisation. In fact, he sees this task as preeminent as it seeks to answer the question of what a mental disorder is in the first place. From this perspective, classification, explanation and treatment proceed from the foundation laid by conceptualisation.

Nielsen asserts that any conceptualisation of disorder needs to be grounded in a general model of human functioning; that is, we need to know what the disorder is deviating from in the first place. Nielsen offers the theory of 3e cognition as a plausible means of informing this process. His specific contribution is the development of 3e psychopathology, which is an understanding of mental disorder derived from the 3e cognition model. He thereby sets the agenda for the rest of the book: the systematic exposition of the 3e psychopathology model and its application to the tasks of conceptualising, classifying, explaining and treating psychopathology.

The quest to revise conceptualisation begins with a critique of traditional conceptual models. Conceptualisation models attempt to answer the question ‘What are mental disorders?’, and Nielsen highlights two ways that this question is approached. First, structurally-oriented models focus on the physical or causal constitution of mental disorders. Certain structural models are essentialist in nature and have dominated the conceptualisation of mental disorders in the modern era (e.g. the biological essentialism of the serotonergic depression model). These models are criticised as being oversimplistic. As an alternative, Nielsen advocates something akin to the mechanistic property cluster (MPC) framework (Kendler et al., 2011) that allows for a complex ‘fuzzy’ causal structure containing multiple elements held together by a mutually reinforcing network of mechanisms. This flexible network of causal mechanisms can span multiple boundaries of scale and time. This means that physiological, psychological, social, historical, developmental, environmental and cultural causal factors can cohere within a meaningful causal network.

Having decided upon a structurally-oriented tool to guide the conceptualisation process, Nielsen turns his attention to normatively-oriented ways of viewing conceptualisation. While structural models attempt to describe how mental disorders cohere in a physical or causal sense, normative models focus on trying to determine why something should be considered a mental disorder. This brings an evaluative element into the equation, as to label an individual’s thoughts, feelings or behaviour as ‘disordered’ requires ethically-oriented clarity about what does and does not count as disorder. Nielsen begins with a concise critical summary of existing normative models. He then pursues an understanding of dysfunction by attempting to define normative functioning. The 3e cognition/enactivism view is introduced, which considers the mind to be embodied, embedded and enactive. The mind is therefore not understood to be a ‘thing’ outside of the embodied reality of the organism. The embodied mind is embedded in physical and social environments in which it must navigate to survive and thrive. The embodied mind is enactive, as it needs to interact with the environment in which it is embedded.

How does the embodied mind ‘know’ what aspects and elements of the environment to act upon to survive and thrive? This touches on the core problem of normativity; that is, how do organisms embedded in and acting on environments ‘know’ that some states of the world are better or worse for their survival and flourishing? The 3e cognition orientation draws upon ideas such as autopoietic enactivism to answer this. This model highlights the reality that all living organisms need to maintain self-organisation in the context of an external universe that, according to the second law of thermodynamics, tends toward disorganisation. In other words, living organisms must maintain negentropy against the entropic flow of the universe. This is a tremendous feat that requires energy to be sourced from the environment, while also avoiding external threats to ongoing self-organisation. How can this be accounted for without falling into the trap of teleology? The proposed answer is naturalised normativity, a way of understanding normativity as a natural consequence of organisms adapting and maintaining self-organisation. To do this, organisms need to be able to differentiate between what aspects of the world should be approached in the service of maintenance and adaptation, and what aspects are threatening and should be avoided. This distinction leads to differing motivational and behavioural outcomes; the organism approaches what is needed and avoids what is threatening. In this sense even the most basic organisms are ‘survival machines’ (LeDoux, 2019, p. 63), equipped with some form of approach-avoid orientation. Each organism therefore exists in a world that is meaningfully valenced, and its behaviour is purposively oriented to aspects of the world. There are parallels with this and the active inference model of neural functioning (Friston, 2010) that hypothesises the brain is constantly generating inferences about what is ‘out there’ in the world based on both ontogenetic and phylogenetic history, and then testing these inferences against afferent sensory data from the world. It is, in essence, the organism’s way of making sense of the world in which it is embedded based on its personal memorial faculties as well as inherited species memory. Nielsen points out that in humans, this natural normativity attains its most sophisticated expression in culture, the composition of collective structures of meaning woven together over time to facilitate survival and flourishing within the physical and social environments the human organism inhabits.

Nielsen is now able to answer the question of why something should be considered a disorder. He defines normal function and deviations therefrom from the perspective of naturalised normativity. Normal functioning is thereby understood to emerge from the needful relationship between the organism and its environment. Functional norms develop organically from this embedded and deeply contextual relationship. These norms guide ongoing survival, adaptation and self-organisation by directing the organism to engage with the world in ways that have been adaptive in some way in the history of both the individual and the species. From this perspective, mental dysfunction or disorder is a recurrent pattern of action that works against these naturalised norms of self-maintenance and self-organisation.

At this point in the book, based on the structural and normative concepts he has woven together, Nielsen is able to formally define mental disorder as a ‘recurring pattern in sense-making that runs counter to the individual’s functional norms to a significant or atypical degree, disrupting their wider mode of functioning in the world’ (p. 120). The latter part of the book examines the implications of Nielsen’s model for the classification, explanation and treatment of mental disorder. For the sake of brevity, I have focused on the content deemed most applicable to clinical practice.

First, we are invited to adopt an attitude of humility and openness to pluralism in our clinical work. This stems from the fact that as previously outlined, the 3e psychopathology model allows for complex causal networks held together across the brain-body-environment system. This allows for a more fluid continuity in causal attribution, and permits the adoption of a stance towards classification that departs from psychological, biological or sociocultural essentialism. It deftly promotes the idea that dysfunction exists in the relationship between the organism and their environment without favouring or prioritising any particular biological, psychological or social causal factor. We are invited to adopt an attitude of epistemic humility, holding lightly the confidence we have in our chosen ways of understanding causality while remaining open to alternative views, and able to conceptualise how these can cohere meaningfully within an MPC-like structural framework.

With regard to generating case formulations in clinical practice, Nielsen asserts that the 3e psychopathology model does not prescribe any singular formulation approach, but has implications for the overall process of formulation. Recall that the model seeks to delineate dysfunctional patterns of thought, feeling and behaviour that have emerged over time across the brain-body-environment system of an individual embedded in the world. The task of a formulation becomes the explication of these patterns and their ongoing dysfunctional effect on the individual’s ability to live well in their current context. Nielsen presents the ‘sense making spiral’ as a clinical tool to assist clinicians and clients to identify consistent enactive patterns between the client and the world in which they are embedded. This can be used in the construction of the case formulation, and can also be used therapeutically as a treatment tool. Through the consistent use of the sense making spiral, clients can cultivate metacognitive awareness and insight. Deliberate and systematic use of the tool also invites the client to reflect on alternative ways of enactive engagement (e.g. reorienting attention, regulating emotional activation, choosing different behavioural responses). In addition to its here-and-now applicability, the tool can be used to explore the history of how recurring patterns may have been shaped over time. For example, the client can come to see how a pattern may have emerged in reaction to particular historical events, and that the pattern may have been useful in reacting to the particular situation at that time, but has become anachronistically entrenched. This can lead to agentive shifts, with the client being guided to consider ‘updated’ ways of being-in-the-world that are potentially better aligned with their core needs and values.

The last chapter of the book reviews and summarises the territory covered in the preceding chapters. Nielsen then returns to the central question he invited the reader to ponder at the start of the book: ‘What is a mental disorder?’ Along the way he has lucidly and progressively articulated his answer to this, which he now presents in full as follows.

Under 3e Psychopathology, mental disorders are understood as recurring patterns in the way that someone makes sense of and engages with the world that work against that person’s ability to survive, flexibly adapt to changing circumstance, and to fare-well by their own embodied standards. These patterns are understood to be supported by a complex network of causal factors across the person’s brain-body-environment system, holding them stuck in behaviors (sic) and ways of thinking and feeling that do not work for them. (p. 228)

Nielsen’s development of 3e psychopathology is praiseworthy. He embeds it within a model of normative functioning that transcends the limits imposed by traditional conceptual models. I was particularly impressed by Nielsen’s articulation of the structural and normative composition of his 3e psychopathology model. I have begun to use these ideas in my own thinking as it provides a meaningful way of understanding complex and ‘fuzzy’ causal networks across the brain-body-environment system and across multiple temporal frames.

I highly recommend this book for its thoroughgoing and rigorous exploration of the conceptualisation of mental disorders. I was unfamiliar with 3e cognition and appreciated Nielsen’s critical review of that literature. I was struck by the points of concordance with other areas I have been exploring, particularly the literature on active inference, predictive processing and the Bayesian brain hypothesis. I look forward to further pursuing the links between 3e cognition and these ideas.