'Deep brain stimulation is no ON/OFF-switch': an ethnography of clinical expertise in psychiatric practice.

Despite technological innovations, clinical expertise remains the cornerstone of psychiatry. A clinical expert does not only have general textbook knowledge, but is sensitive to what is demanded for the individual patient in a particular situation. A method that can do justice to the subjective and situation-specific nature of clinical expertise is ethnography. Effective deep brain stimulation (DBS) for obsessive-compulsive disorder (OCD) involves an interpretive, evaluative process of optimizing stimulation parameters, which makes it an interesting case to study clinical expertise. The aim of this study is to explore the role of clinical expertise through an ethnography of the particular case of DBS optimization in OCD. In line with the topic of the special issue this article is a part of, we will also use our findings to reflect on ethnography as a method to study complex phenomena like clinical expertise. This ethnography of DBS optimization is based on 18 months of participant observation and nine in-depth interviews with a team of expert clinicians who have been treating over 80 OCD patients since 2005. By repeatedly observing particular situations for an extended period of time, we found that there are recurrent patterns in the ways clinicians interact with patients. These patterns of clinical practice shape the possibilities clinicians have for making sense of DBS-induced changes in patients' lived experience and behavior. Collective established patterns of clinical practice are dynamic and change under the influence of individual learning experiences in particular situations, opening up new possibilities and challenges. We conclude that patterns of clinical practice and particular situations are mutually constitutive. Ethnography is ideally suited to bring this relation into view thanks to its broad temporal scope and focus on the life-world. Based on our findings, we argue that clinical expertise not only implies skillful engagement with a concrete situation but also with the patterns of clinical practice that shape what is possible in this specific situation. Given this constraining and enabling role of practices, it is important to investigate them in order to find ways to improve diagnostic and therapeutic possibilities.

The affordances of art for making technologies.

With this inaugural lecture as Socrates Professor on the topic of Making Humane Technologies, I aim to show that artistic practices afford embedding technologies better in society. Analyzing artworks made at RAAAF, an art collective that makes visual art and experimental architecture, I will describe three aspects of making practices that may contribute to improving the embedding of technology in society: (1) the skill of working with layers of meaning; (2) the skill of creating material playgrounds that afford free exploration of the potential of new technologies and artistic experiments; and (3) the skill of openness to the possibility of having radically different socio-material practices. I will use images of several RAAAF projects to make these skills involved in making more tangible. It is artistic skills like these that can contribute to a better societal embedding of technologies.

Situated anticipation.

In cognitive science, long-term anticipation, such as when planning to do something next year, is typically seen as a form of 'higher' cognition, requiring a different account than the more basic activities that can be understood in terms of responsiveness to 'affordances,' i.e. to possibilities for action. Starting from architects that anticipate the possibility to make an architectural installation over the course of many months, in this paper we develop a process-based account of affordances that includes long-term anticipation within its scope. We present a framework in which situations and their affordances unfold, and can be thought of as continuing a history of practices into a current situational activity. In this activity affordances invite skilled participants to act further. Via these invitations one situation develops into the other; an unfolding process that sets up the conditions for its own continuation. Central to our process account of affordances is the idea that engaged individuals can be responsive to the direction of the process to which their actions contribute. Anticipation, at any temporal scale, is then part and parcel of keeping attuned to the movement of the unfolding situations to which an individual contributes. We concretize our account by returning to the example of anticipation observed in architectural practice. This account of anticipation opens the door to considering a wide array of human activities traditionally characterized as 'higher' cognition in terms of engaging with affordances.

Metastable attunement and real-life skilled behavior.

In everyday situations, and particularly in some sport and working contexts, humans face an inherently unpredictable and uncertain environment. All sorts of unpredictable and unexpected things happen but typically people are able to skillfully adapt. In this paper, we address two key questions in cognitive science. First, how is an agent able to bring its previously learned skill to bear on a novel situation? Second, how can an agent be both sensitive to the particularity of a given situation, while remaining flexibly poised for many other possibilities for action? We will argue that both the sensitivity to novel situations and the sensitivity to a multiplicity of action possibilities are enabled by the property of skilled agency that we will call metastable attunement. We characterize a skilled agent's flexible interactions with a dynamically changing environment in terms of metastable dynamics in agent-environment systems. What we find in metastability is the realization of two competing tendencies: the tendency of the agent to express their intrinsic dynamics and the tendency to search for new possibilities. Metastably attuned agents are ready to engage with a multiplicity of affordances, allowing for a balance between stability and flexibility. On the one hand, agents are able to exploit affordances they are attuned to, while at the same time being ready to flexibly explore for other affordances. Metastable attunement allows agents to smoothly transition between these possible configurations so as to adapt their behaviour to what the particular situation requires. We go on to describe the role metastability plays in learning of new skills, and in skilful behaviour more generally. Finally, drawing upon work in art, architecture and sports science, we develop a number of perspectives on how to investigate metastable attunement in real life situations.

Skilled we-intentionality: Situating joint action in the living environment.

There is a difference between the activities of two or more individuals that are performed jointly such as playing music in a band or dancing as a couple, and performing these same activities alone. This difference is sometimes captured by appealing to shared or joint intentions that allow individuals to coordinate what they do over space and time. In what follows we will use the terminology of we-intentionality to refer to what individuals do when they engage in group ways of thinking, feeling and acting. Our aim in this paper is to argue that we-intentionality is best understood in relation to a shared living environment in which acting individuals are situated. By the "living environment" we mean to refer to places and everyday situations in which humans act. These places and situations are simultaneously social, cultural, material and natural. We will use the term "affordance" to refer to the possibilities for action the living environment furnishes. Affordances form and are maintained over time through the activities people repeatedly engage in the living environment. We will show how we-intentionality is best understood in relation to the affordances of the living environmentand by taking into account the skills people have to engage with these affordances. For this reason we coin the term 'skilled we-intentionality' to characterize the intentionality characteristic of group ways of acting, feeling and thinking.

Optimizing Deep Brain Stimulation Parameters in Obsessive-Compulsive Disorder.

OBJECTIVES: Deep brain stimulation (DBS) is an innovative and effective treatment for patients with therapy-refractory obsessive-compulsive disorder (OCD). DBS offers unique opportunities for personalized care, but no guidelines on how to choose effective and safe stimulation parameters in patients with OCD are available. Our group gained relevant practical knowledge on DBS optimization by treating more than 80 OCD patients since 2005, the world's largest cohort. The article's objective is to share this experience. MATERIALS AND METHODS: We provide guiding principles for optimizing DBS stimulation parameters in OCD and discuss the neurobiological and clinical basis. RESULTS: Adjustments in stimulation parameters are performed in a fixed order. First, electrode contact activation is determined by the position of the electrodes on postoperative imaging. Second, voltage and pulse width are increased stepwise, enlarging both the chance of symptom reduction and of inducing side effects. Clinical evaluation of adjustments in stimulation parameters needs to take into account: 1) the particular temporal sequence in which the various OCD symptoms and DBS side-effects change; 2) the lack of robust response predictors; 3) the limited sensitivity of the Yale-Brown Obsessive-Compulsive Scale to assess DBS-induced changes in OCD symptoms; and 4) a patient's fitness for additional cognitive-behavioral therapy (CBT). CONCLUSIONS: Decision-making in stimulation parameter optimization needs to be sensitive to the particular time-courses on which various symptoms and side effects change.

How mood tunes prediction: a neurophenomenological account of mood and its disturbance in major depression.

In this article, we propose a neurophenomenological account of what moods are, and how they work. We draw upon phenomenology to show how mood attunes a person to a space of significant possibilities. Mood structures a person's lived experience by fixing the kinds of significance the world can have for them in a given situation. We employ Karl Friston's free-energy principle to show how this phenomenological concept of mood can be smoothly integrated with cognitive neuroscience. We will argue that mood is a consequence of acting in the world with the aim of minimizing expected free energy-a measure of uncertainty about the future consequences of actions. Moods summarize how the organism is faring overall in its predictive engagements, tuning the organism's expectations about how it is likely to fare in the future. Agents that act to minimize expected free energy will have a feeling of how well or badly they are doing at maintaining grip on the multiple possibilities that matter to them. They will have what we will call a 'feeling of grip' that structures the possibilities they are ready to engage with over long time-scales, just as moods do.

The Ecological-Enactive Model of Disability: Why Disability Does Not Entail Pathological Embodiment.

In the last 50 years, discussions of how to understand disability have been dominated by the medical and social models. Paradoxically, both models overlook the disabled person's experience of the lived body, thus reducing the body of the disabled person to a physiological body. In this article we introduce what we call the Ecological-Enactive (EE) model of disability. The EE-model combines ideas from enactive cognitive science and ecological psychology with the aim of doing justice simultaneously to the lived experience of being disabled, and the physiological dimensions of disability. More specifically, we put the EE model to work to disentangle the concepts of disability and pathology. We locate the difference between pathological and normal forms of embodiment in the person's capacity to adapt to changes in the environment. To ensure that our discussion remains in contact with lived experience, we draw upon phenomenological interviews we have carried out with people with Cerebral Palsy.

Skill-based engagement with a rich landscape of affordances as an alternative to thinking through other minds.

Veissière and colleagues make a valiant attempt at reconciling an internalist account of implicit cultural learning with an externalist account that understands social behaviour in terms of its environment-involving dynamics. However, unfortunately the author's attempt to forge a middle way between internalism and externalism fails. We argue their failure stems from the overly individualistic understanding of the perception of cultural affordances they propose.

Embodying addiction: A predictive processing account.

In this paper we show how addiction can be thought of as the outcome of learning. We look to the increasingly influential predictive processing theory for an account of how learning can go wrong in addiction. Perhaps counter intuitively, it is a consequence of this predictive processing perspective on addiction that while the brain plays a deep and important role in leading a person into addiction, it cannot be the whole story. We'll argue that predictive processing implies a view of addiction not as a brain disease, but rather as a breakdown in the dynamics of the wider agent-environment system. The environment becomes meaningfully organised around the agent's drug-seeking and using behaviours. Our account of addiction offers a new perspective on what is harmful about addiction. Philosophers often characterise addiction as a mental illness because addicts irrationally shift in their judgement of how they should act based on cues that predict drug use. We argue that predictive processing leads to a different view of what can go wrong in addiction. We suggest that addiction can prove harmful to the person because as their addiction progressively takes hold, the addict comes to embody a predictive model of the environment that fails to adequately attune them to a volatile, dynamic environment. The use of an addictive substance produces illusory feedback of being well-attuned to the environment when the reality is the opposite. This can be comforting for a person inhabiting a hostile niche, but it can also prove to be harmful to the person as they become skilled at living the life of an addict, to the neglect of all other alternatives. The harm in addiction we'll argue is not to be found in the brains of addicts, but in their way of life.

General ecological information supports engagement with affordances for 'higher' cognition.

In this paper, we address the question of how an agent can guide its behavior with respect to aspects of the sociomaterial environment that are not sensorily present. A simple example is how an animal can relate to a food source while only sensing a pheromone, or how an agent can relate to beer, while only the refrigerator is directly sensorily present. Certain cases in which something is absent have been characterized by others as requiring 'higher' cognition. An example of this is how during the design process architects can let themselves be guided by the future behavior of visitors to an exhibit they are planning. The main question is what the sociomaterial environment and the skilled agent are like, such that they can relate to each other in these ways. We argue that this requires an account of the regularities in the environment. Introducing the notion of general ecological information, we will give an account of these regularities in terms of constraints, information and the form of life or ecological niche. In the first part of the paper, we will introduce the skilled intentionality framework as conceptualizing a special case of an animal's informational coupling with the environment namely skilled action. We will show how skilled agents can pick up on the regularities in the environment and let their behavior be guided by the practices in the form of life. This conceptual framework is important for radical embodied and enactive cognitive science, because it allows these increasingly influential paradigms to extend their reach to forms of 'higher' cognition such as long-term planning and imagination.

Effective Deep Brain Stimulation for Obsessive-Compulsive Disorder Requires Clinical Expertise.

BACKGROUND: Deep brain stimulation (DBS) is an innovative treatment for severe obsessive-compulsive disorder (OCD). Electrodes implanted in specific brain areas allow clinicians to directly modulate neural activity. DBS affects symptomatology in a completely different way than established forms of treatment for OCD, such as psychotherapy or medication. OBJECTIVE: To understand the process of improvement with DBS in patients with severe OCD. METHODS: By means of open-ended interviews and participant observation we explore how expert clinicians involved in the post-operative process of DBS optimization evaluate DBS effects. RESULTS: Evaluating DBS effect is an interactive and context-sensitive process that gradually unfolds over time and requires integration of different sources of knowledge. Clinicians direct DBS optimization toward a critical point where they sense that patients are being moved with regard to behavior, emotion, and active engagement, opening up possibilities for additional cognitive behavioral therapy (CBT). DISCUSSION: Based on the theoretical framework of radical embodied cognitive science (RECS), we assume that clinical expertise manifests itself in the pattern of interaction between patient and clinician. To the expert clinician, this pattern reflects the patient's openness to possibilities for action ("affordances") offered by their environment. OCD patients' improvement with DBS can be understood as a change in openness to their environment. The threshold for patients to engage in activities is decreased and a broader range of daily life and therapeutic activities becomes attractive. Movement is improvement.

Trusted strangers: social affordances for social cohesion.

How could the paradigm shift towards enactive embodied cognitive science have implications for society and politics? Translating insights form enactive embodied cognitive science into ways of dealing with real-life issues is an important challenge. This paper focuses of the urgent societal issue of social cohesion, which is crucial in our increasingly segregated and polarized Western societies. We use Rietveld's (2016) philosophical Skilled Intentionality Framework and work by the multidisciplinary studio RAAAF to extend Lambros Malafouris' Material Engagement Theory (2013) to the social domain. How could a landscape of social affordances generate change in the behavioral patterns of people from different socio-cultural backgrounds? RAAAF is currently imagining and planning an ambitious intervention in the public domain that could really change existing socio-cultural practices and aims to contribute to social cohesion. An animation film it made introduces a landscape of social affordances. We will present and discuss this Trusted Strangers animation film, which is a thinking model for new public domain all over the world. Tha animation film visualizes how a well-designed landscape of social affordances could invite all sorts of interactions between people from different socio-cultural backgrounds.

Obsessive Compulsive Disorder: A Pathology of Self-Confidence?

A striking change OCD patients repeatedly describe following treatment with deep brain stimulation (DBS) of the ventral anterior limb of internal capsule (vALIC) is an immediate increase in self-confidence. We show how the DBS-induced changes in self-confidence reported by our patients can be understood neurocognitively in terms of active inference.

Reconceiving representation-hungry cognition: an ecological-enactive proposal.

Enactive approaches to cognitive science aim to explain human cognitive processes across the board without making any appeal to internal, content-carrying representational states. A challenge to such a research programme in cognitive science that immediately arises is how to explain cognition in so-called 'representation-hungry' domains. Examples of representation-hungry domains include imagination, memory, planning and language use in which the agent is engaged in thinking about something that may be absent, possible or abstract. The challenge is to explain how someone could think about things that are not concretely present in their environment other than by means of an internal mental representation. We call this the 'Representation-Hungry Challenge' (RHC). The challenge we take up in this article is to show how hunger for representations could possibly be satisfied by means other than the construction and manipulation of internal representational states. We meet this challenge by developing a theoretical framework that integrates key ideas drawn from enactive cognitive science and ecological psychology. One of our main aims is thus to show how ecological and enactive theories as non-representational and non-computational approaches to cognitive science might work together. From enactive cognitive science, we borrow the thesis of the strict continuity of lower and higher cognition. We develop this thesis to argue against any sharp conceptual distinction between higher and lower cognition based on representation-hunger. From ecological psychology, we draw upon our earlier work on the rich landscape of affordances. We propose thinking of so-called representation-hungry cognition in terms of temporally extended activities in which the agent skilfully coordinates to a richly structured landscape of affordances. In our framework, putative cases of representation-hungry cognition are explained by abilities to coordinate nested activities to an environment structured by interrelated socio-material practices. The RHC has often figured in arguments for the limitations of non-representational approaches to cognitive science. We showcase the theoretical resources available to an integrated ecological-enactive approach for addressing this type of sceptical challenge.

Free-energy minimization in joint agent-environment systems: A niche construction perspective.

The free-energy principle is an attempt to explain the structure of the agent and its brain, starting from the fact that an agent exists (Friston and Stephan, 2007; Friston et al., 2010). More specifically, it can be regarded as a systematic attempt to understand the 'fit' between an embodied agent and its niche, where the quantity of free-energy is a measure for the 'misfit' or disattunement (Bruineberg and Rietveld, 2014) between agent and environment. This paper offers a proof-of-principle simulation of niche construction under the free-energy principle. Agent-centered treatments have so far failed to address situations where environments change alongside agents, often due to the action of agents themselves. The key point of this paper is that the minimum of free-energy is not at a point in which the agent is maximally adapted to the statistics of a static environment, but can better be conceptualized an attracting manifold within the joint agent-environment state-space as a whole, which the system tends toward through mutual interaction. We will provide a general introduction to active inference and the free-energy principle. Using Markov Decision Processes (MDPs), we then describe a canonical generative model and the ensuing update equations that minimize free-energy. We then apply these equations to simulations of foraging in an environment; in which an agent learns the most efficient path to a pre-specified location. In some of those simulations, unbeknownst to the agent, the 'desire paths' emerge as a function of the activity of the agent (i.e. niche construction occurs). We will show how, depending on the relative inertia of the environment and agent, the joint agent-environment system moves to different attracting sets of jointly minimized free-energy.

The anticipating brain is not a scientist: the free-energy principle from an ecological-enactive perspective.

In this paper, we argue for a theoretical separation of the free-energy principle from Helmholtzian accounts of the predictive brain. The free-energy principle is a theoretical framework capturing the imperative for biological self-organization in information-theoretic terms. The free-energy principle has typically been connected with a Bayesian theory of predictive coding, and the latter is often taken to support a Helmholtzian theory of perception as unconscious inference. If our interpretation is right, however, a Helmholtzian view of perception is incompatible with Bayesian predictive coding under the free-energy principle. We argue that the free energy principle and the ecological and enactive approach to mind and life make for a much happier marriage of ideas. We make our argument based on three points. First we argue that the free energy principle applies to the whole animal-environment system, and not only to the brain. Second, we show that active inference, as understood by the free-energy principle, is incompatible with unconscious inference understood as analagous to scientific hypothesis-testing, the main tenet of a Helmholtzian view of perception. Third, we argue that the notion of inference at work in Bayesian predictive coding under the free-energy principle is too weak to support a Helmholtzian theory of perception. Taken together these points imply that the free energy principle is best understood in ecological and enactive terms set out in this paper.

Becoming more oneself? Changes in personality following DBS treatment for psychiatric disorders: Experiences of OCD patients and general considerations.

Does DBS change a patient's personality? This is one of the central questions in the debate on the ethics of treatment with Deep Brain Stimulation (DBS). At the moment, however, this important debate is hampered by the fact that there is relatively little data available concerning what patients actually experience following DBS treatment. There are a few qualitative studies with patients with Parkinson's disease and Primary Dystonia and some case reports, but there has been no qualitative study yet with patients suffering from psychiatric disorders. In this paper, we present the experiences of 18 patients with Obsessive-Compulsive Disorder (OCD) who are undergoing treatment with DBS. We will also discuss the inherent difficulties of how to define and assess changes in personality, in particular for patients with psychiatric disorders. We end with a discussion of the data and how these shed new light on the conceptual debate about how to define personality.

Situating the Embodied Mind in a Landscape of Standing Affordances for Living Without Chairs: Materializing a Philosophical Worldview.

Sitting too much is unhealthy, but a widespread habit in many societies. Realizing behavioral change in this area is hard. Our societies promote being seated via the way its places are structured: they are filled with chairs for example. How can we make healthier environments that invite people to move around more? This article shows how philosophical research in the area of embodied/enactive cognitive science let to a built vision for the office of the future, of 2025. Multidisciplinary studio RAAAF [Rietveld Architecture-Art-Affordances] and visual artist Barbara Visser built this world without chairs, titled The End of Sitting. This large rock-like landscape integrates many affordances for standing. Affordances are the possibilities for action provided by the environment. This landscape of standing affordances allows people to work standing while being supported by the material structure of the environment. This unorthodox working landscape is both an enactive art installation and the materialization of a philosophical worldview that understands people as embodied minds situated in a landscape of affordances. It stimulates reflection on the way built environments can naturally invite more active and healthy behavior.