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I’ll Have What You’re Having Please – Pain, Psychopathology, and the Enactive-Predictive Turn

By Timothy Cocks Uncategorized, Philosophy of mind 08 Jun 2023

One of the real pleasures, and greatest privileges, of being able to share ideas that excite you, is hearing from and connecting with like-minded explorers. So it was a wonderful surprise to hear from Dr Kristopher Nielsen, a clinical psychologist and researcher from New Zealand, in response to my emails detailing my enthusiasm for ideas such as complexity, prediction, enactivism and embodiment that informed the new course Explore Pain. Kristopher is well down this journey in his field having completed his PhD on the topic of developing an embodied, embedded and enactive approach to psychopathology and recently publishing (what is likely to become) the book on the same topic. I was eager to share Kristopher’s unique experience, research interests and ideas with more people, and delighted when he very kindly agreed to write a blog post for us. Here it is

Standing on the edge of pain science looking in

As a clinical psychologist standing on the edge of pain science looking in, I have to admit to a little bit of jealousy. Over the last few decades, the entire pain field has grappled with fundamental conceptual questions about the nature of pain – including philosophical questions – and has clearly benefitted as a result. From the Biopsychosocial revolution to the current turn towards enactive and predictive approaches, it is clearly a very exciting time to be a pain clinician or pain scientist! Pain science is engaging with cutting-edge developments in neuroscience and the philosophy of mind. What’s more, clinicians from all disciplines are listening and engaged with these developments.

When I compare this to my own field of mental health, something seems lacking on my side of the fence. Don’t get me wrong, conceptual debates regarding our understanding of mental illnesses are occurring all the time. The entire field of philosophy of psychiatry, for example, is dedicated to this. However, compared to the field of pain, clinician engagement with these debates within clinical psychology and psychiatry seems rather low. For example, many mental health clinicians seem to think of conceptual questions such as ‘What is mental disorder?’ or ‘What justifies calling someone’s behaviour disordered?’ as a bit stale, silly, or simply not that useful.

When we look at the study of pain however, it is really clear that engaging with similar conceptual questions has been a vital part of advancing our scientific understanding. It is partially through engaging with conceptual questions such as ‘What is pain?’, ‘Is pain always bad’, and ‘What is the relationship between the pain experience and the body?’ that our understanding of pain has shifted from a linear one, to one that has begun to capture the complexity evidenced by empirical study and patient experience.

The enactive-predictive turn

It is partially through asking such questions, and engaging with other fields of study such as philosophy and neuroscience, that our understanding of pain has advanced so dramatically and at such a pace. Consider the many advances. It has begun to be understood that pain is fundamentally an experiential sort of thing – a feeling. It is now understood that this feeling somehow represents an integration of both sensory information and the evaluation of such information in accordance with past experience and implicit beliefs about the body/potential threat. We now understand that how people conceptualise pain matters to their experience of it, and to their ability to develop agency in the presence of pain. We understand that pain serves a vital evolutionary function and often shapes behaviour in adaptive ways. However, we now understand that pain is not evolved to provide veridical information about the state of the body and damage to it, but that it is rather an imperfect and action-oriented felt prediction about the state of the body and how we should best act – a shift we might call the ‘enactive-predictive turn’.

Relatedly, we now understand that, much like our thoughts and feelings, pain is somewhat plastic – i.e., it is responsive to learning and experience. This comes with huge flexibility and adaptive advantage because it means that our pain, as a ‘felt prediction’, can be informed, not just by evolutionary selection, but by what appears to have worked for us in similar contexts within our own individual histories. We now understand that, unfortunately, this plasticity is also one of the reasons that pain can get stuck in debilitating ways. Many of these advancements in our conceptual understanding of pain would not have happened without clinicians and scientists alike being willing to question their received assumptions about what pain is.

I want some of what you are having

Jealously has a bad reputation, but often serves a function of telling us that we want something. When I look at pain science, I am jealous, and I am ok with this. I want some of what you are having! If the field of mental health could emulate the intellectual courage of pain science and thoroughly question current assumptions about the nature of mental disorder, I would be excited to see what advancements this might bring.

After all, there are a lot of similarities between pain and mental disorder. Just like pain, mental disorders are clearly complex phenomena influenced by factors across the brain, body, and environment. Just like pain, mental disorders do not respect our apparent desire to separate the physical and experiential. Just like pain, it can be difficult to figure out where helpful feelings end and ‘mental disorders’ begin. If genuine field-wide engagement with conceptual questions has been so helpful for our understanding of pain, then there is good reason to suspect that doing the same might be helpful in mental health.

Embodied, Embedded, and Enactive Psychopathology

It is in this spirit that I have recently written a book exploring such conceptual questions regarding the study and treatment of mental disorder. This book starts with some of the same ideas from neuroscience and philosophy of mind that have informed the current enactive-predictive turn in our understanding of pain. These ideas are that human functioning is: embodied (i.e., the mind is not separate from the body, and our cognition is shaped by the kinds of bodies we have), embedded (i.e., human cognition and behaviour involve constant interplay with the environment), and enactive (i.e., the mind is a constant process rather than a thing, emerging from our embodied efforts to make sense of and act in the world).

From these starting ideas I develop a new way of conceptualising mental disorders called 3e Psychopathology. Under 3e Psychopathology mental disorders are understood as recurring and unhelpful patterns in how we make sense of and act in the world, constituted and shaped by factors across the brain-body-environment system. I explore important questions such as ‘What justifies calling these patterns disorders?’ and ‘Are mental disorders the same thing across different cultural contexts?’. Towards the end of the book, I turn to the question of how we should best go about trying to explain mental disorders, exploring this question at both research and clinical levels. As part of this, I reflect on processes of clinical assessment and formulation, considering how one might approach these tasks from a 3e Psychopathology viewpoint.

Being an interested outsider rather than a pain clinician myself, I can’t tell you whether this book will be helpful clinically. However, if you are interested in catching up on current conceptualisations of mental illness and exploring a new way of thinking in this space then you might find it of interest. More about the book, including reviews, can be found here.

– Kristopher Nielsen


Kristopher Nielsen, MSc., PhD., is a clinical psychologist based in Wellington, New Zealand.

He is associated with Te Herenga Waka – Victoria University of Wellington.


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