Letting Tourette's be: The importance of understanding lived experience in research and the clinic.

The most common clinical research question regarding Tourette syndrome focuses on tic reduction, which follows from classical 'lack of inhibition' models. Rooted in views about brain deficits, this model suggests that with higher severity and frequency, tics are necessarily disruptive and should therefore be inhibited. However, emerging calls from people with lived experience of Tourette syndrome suggest that this is too narrow a definition. This narrative literature review analyses issues with brain deficit views and qualitative research on tic context and feelings of compulsion. The results suggest the need for a more positive and encompassing theoretical and ethical position on Tourette's. The article puts forward an enactive analytical approach of 'letting be', that is, approaching a phenomenon without forcing preconceived reference structures onto it. We suggest using the identity-first term 'Tourettic'. Prioritizing the perspective of the 'Tourettic patient', it urges attentiveness to the everyday issues diagnosed people encounter and how these are embedded in further life. This approach highlights the strong relationship between the Tourettic persons' felt impairment, their adoption of an outsider's perspective, and feeling under constant scrutiny. It suggests that this felt impairment of tics can be reduced by creating a physical and social environment in which the person is 'let be' but not 'let go of'. WHAT THIS PAPER ADDS: Its theoretical position allows a more holistic view of Tourette's, integrating tics with oft-overlooked complex compulsions. The 'letting be' position also allows us to view why the presentation of Tourette's is likely to vary with gender and age of onset. 'Letting be' is a promising approach to improve a clinical understanding of Tourettic well-being over and above tic severity and frequency. It integrates quantitative research on Tourette syndrome in the neurosciences with qualitative neurodiversity literature in the medical humanities. It integrates ethical frameworks as developed in enactive philosophy with the conceptualization and treatment of tics and compulsions.

Beyond Single-Mindedness: A Figure-Ground Reversal for the Cognitive Sciences.

A fundamental fact about human minds is that they are never truly alone: all minds are steeped in situated interaction. That social interaction matters is recognized by any experimentalist who seeks to exclude its influence by studying individuals in isolation. On this view, interaction complicates cognition. Here, we explore the more radical stance that interaction co-constitutes cognition: that we benefit from looking beyond single minds toward cognition as a process involving interacting minds. All around the cognitive sciences, there are approaches that put interaction center stage. Their diverse and pluralistic origins may obscure the fact that collectively, they harbor insights and methods that can respecify foundational assumptions and fuel novel interdisciplinary work. What might the cognitive sciences gain from stronger interactional foundations? This represents, we believe, one of the key questions for the future. Writing as a transdisciplinary collective assembled from across the classic cognitive science hexagon and beyond, we highlight the opportunity for a figure-ground reversal that puts interaction at the heart of cognition. The interactive stance is a way of seeing that deserves to be a key part of the conceptual toolkit of cognitive scientists.

Seeing and inviting participation in autistic interactions.

What does it take to see how autistic people participate in social interactions? And what does it take to support and invite more participation? Western medicine and cognitive science tend to think of autism mainly in terms of social and communicative deficits. But research shows that autistic people can interact with a skill and sophistication that are hard to see when starting from a deficit idea. Research also shows that not only autistic people, but also their non-autistic interaction partners, can have difficulties interacting with each other. To do justice to these findings, we need a different approach to autistic interactions-one that helps everyone see, invite, and support better participation. I introduce such an approach, based on the enactive theory of participatory sense-making and supported by insights from indigenous epistemologies. This approach helps counteract the homogenizing tendencies of the "global mental health" movement, which attempts to erase rather than recognize difference, and often precludes respectful engagements. Based in the lived experiences of people in their socio-cultural-material and interactive contexts, I put forward an engaged-even engaging-epistemology for understanding how we interact across difference. From this perspective, we see participatory sense-making at work across the scientific, diagnostic, therapeutic, and everyday interactions of autistic and non-autistic people, and how everyone can invite and support more of it.

The precarity of patient participation - a qualitative interview study of experiences from the acute stroke and rehabilitation journey.

INTRODUCTION: Active patient participation is an important factor in optimizing post-stroke recovery, yet it is often low, regardless of stroke severity. The reasons behind this trend are unclear. PURPOSE: To explore how people who have suffered a stroke, perceive the transition from independence to dependence and whether their role in post-stroke rehabilitation influences active participation. METHODS: In-depth interviews with 17 people who have had a stroke. Data were analyzed using systematic text condensation informed by the concept of autonomy from enactive theory. RESULTS: Two categories emerged. The first captures how the stroke and the resultant hospital admission produces a shift from being an autonomous subject to "an object on an assembly line." Protocol-based investigations, inactivity, and a lack of patient involvement predominantly determine the hospital context. The second category illuminates how people who have survived a stroke passively adapt to the hospital system, a behavior that stands in contrast to the participatory enablement facilitated by community. Patients feel more prepared for the transition home after in-patient rehabilitation rather than following direct discharge from hospital. CONCLUSION: Bodily changes, the traditional patient role, and the hospital context collectively exacerbate a reduction of individual autonomy. Thus, an interactive partnership between people who survived a stroke and multidisciplinary professionals may strengthen autonomy and promote participation after a stroke.

Embodiment, tailoring, and trust are important for co-construction of meaning in physiotherapy after stroke: A qualitative study.

BACKGROUND AND PURPOSE: Physiotherapy, with an emphasis on high intensity, individually tailored, and person-centered treatment, is an effective route for recovery after a stroke. No single approach, however, has been deemed paramount, and there is limited knowledge about the patient experience of assessment, goal-setting, and treatment in physiotherapy. In this study, we seek to report patient experiences of I-CoreDIST-a new physiotherapy intervention that targets recovery-and those of usual care. The purpose is to investigate how individuals with stroke experience the bodily and interactive course of physiotherapy during their recovery process. METHODS: A qualitative study, nested within a randomized controlled trial, consisting of in-depth interviews with 19 stroke survivors who received either I-CoreDIST or usual care. Data were analyzed using systematic text condensation, and this analysis was informed by enactive theory. RESULTS: Interaction with the physiotherapist, which was guided by perceived bodily changes, fluctuated between being, on the one hand, formal/explicit and, on the other, tacit/implicit. The experiences of participants in the intervention group and the usual care group differed predominantly with regards to the content of therapy sessions and the means of measuring progress; divergences in levels of satisfaction with the treatment were less pronounced. The perception of positive bodily changes, as well as the tailoring of difficulty and intensity, were common and essential features in generating meaning and motivation. An embodied approach seemed to facilitate sense-making in therapy situations. In the interaction between the participants and their physiotherapists, trust and engagement were important but also multifaceted, involving both interpersonal skills and professional expertise. CONCLUSION: The embodied nature of physiotherapy practice is a source for sense-making and meaning-construction for patients after a stroke. Trust in the physiotherapist, along with emotional support, is considered essential. Experiencing progress and individualizing approaches are decisive motivators.

Embodiment in online psychotherapy: A qualitative study.

As a result of the COVID-19 pandemic, many therapists and patients have been required to switch to online sessions in order to continue their treatments. Online psychotherapy has become increasingly popular, and although its efficacy seems to be similar to face-to-face encounters, its capacity to support the implicit nonverbal and embodied aspects of the therapeutic relationship has been questioned and remains understudied. OBJECTIVES: To study how embodied and intersubjective processes are modified in online psychotherapy sessions. DESIGN: Taking the enactive concept of participatory sense-making as a guiding thread, we designed an interpretative phenomenological analysis to examine the experiences of embodiment in online therapy. METHODS: We conducted phenomenological semi-structured interviews with patients and therapists who have recently switched from face-to-face encounters to online modality. RESULTS: Adjustments in verbal and nonverbal behavior, gaze behavior, management of silences, and displacements of non-intentional and pre-reflective patterns onto reflective ones are reported as necessary to compensate for changes introduced in the online modality. CONCLUSIONS: From an enactive perspective, such adaptations manifest regulatory processes aimed at sustaining interactive dynamics and coordinating the primordial tension between relational and individual norms in social encounters. PRACTITIONER POINTS: We examine different aspects of embodiment that practitioners should take into account when switching from face-to-face to online encounters with their clients. Online communication systems can alter aspects of the therapeutic relationship, such as its structure, its fragility, and its significance. Video calls afford new forms of intervention such as integrating the experience of patients with their self-image, incorporating information about their habitual environment into the process, and adopting less confrontational therapeutic styles.

Pregnant Agencies: Movement and Participation in Maternal-Fetal Interactions.

Pregnancy presents some interesting challenges for the philosophy of embodied cognition. Mother and fetus are generally considered to be passive during pregnancy, both individually and in their relation. In this paper, we use the enactive operational concepts of autonomy, agency, individuation, and participation to examine the relation between mother and fetus in utero. Based on biological, physiological, and phenomenological research, we explore the emergence of agentive capacities in embryo and fetus, as well as how maternal agency changes as pregnancy advances. We show that qualitatively different kinds of agency have their beginnings already in utero, and to what extent fetal and maternal movement modulate affectivity and individuation in pregnancy. We thus propose that mother and fetus are both agents who participate in pregnancy. Pregnancy then emerges as a relational developmental organization that anchors and holds its developing participants. We end the paper with reflections on ethical implications of this proposal, and suggestions for future research.

The co-creation of meaningful action: bridging enaction and interactional sociology.

What makes possible the co-creation of meaningful action? In this paper, we go in search of an answer to this question by combining insights from interactional sociology and enaction. Both research schools investigate social interactions as such, and conceptualize their organization in terms of autonomy. We ask what it could mean for an interaction to be autonomous, and discuss the structures and processes that contribute to and are maintained in the so-called interaction order. We also discuss the role played by individual vulnerability as well as the vulnerability of social interaction processes in the co-creation of meaningful action. Finally, we outline some implications of this interdisciplinary fraternization for the empirical study of social understanding, in particular in social neuroscience and psychology, pointing out the need for studies based on dynamic systems approaches on origins and references of coordination, and experimental designs to help understand human co-presence.

What does the interactive brain hypothesis mean for social neuroscience? A dialogue.

A recent framework inspired by phenomenological philosophy, dynamical systems theory, embodied cognition and robotics has proposed the interactive brain hypothesis (IBH). Whereas mainstream social neuroscience views social cognition as arising solely from events in the brain, the IBH argues that social cognition requires, in addition, causal relations between the brain and the social environment. We discuss, in turn, the foundational claims for the IBH in its strongest form; classical views of cognition that can be raised against the IBH; a defence of the IBH in the light of these arguments; and a response to this. Our goal is to initiate a dialogue between cognitive neuroscience and enactive views of social cognition. We conclude by suggesting some new directions and emphases that social neuroscience might take.

We can work it out: an enactive look at cooperation.

The past years have seen an increasing debate on cooperation and its unique human character. Philosophers and psychologists have proposed that cooperative activities are characterized by shared goals to which participants are committed through the ability to understand each other's intentions. Despite its popularity, some serious issues arise with this approach to cooperation. First, one may challenge the assumption that high-level mental processes are necessary for engaging in acting cooperatively. If they are, then how do agents that do not possess such ability (preverbal children, or children with autism who are often claimed to be mind-blind) engage in cooperative exchanges, as the evidence suggests? Secondly, to define cooperation as the result of two de-contextualized minds reading each other's intentions may fail to fully acknowledge the complexity of situated, interactional dynamics and the interplay of variables such as the participants' relational and personal history and experience. In this paper we challenge such accounts of cooperation, calling for an embodied approach that sees cooperation not only as an individual attitude toward the other, but also as a property of interaction processes. Taking an enactive perspective, we argue that cooperation is an intrinsic part of any interaction, and that there can be cooperative interaction before complex communicative abilities are achieved. The issue then is not whether one is able or not to read the other's intentions, but what it takes to participate in joint action. From this basic account, it should be possible to build up more complex forms of cooperation as needed. Addressing the study of cooperation in these terms may enhance our understanding of human social development, and foster our knowledge of different ways of engaging with others, as in the case of autism.

Embodiment and sense-making in autism.

In this article, I sketch an enactive account of autism. For the enactive approach to cognition, embodiment, experience, and social interaction are fundamental to understanding mind and subjectivity. Enaction defines cognition as sense-making: the way cognitive agents meaningfully connect with their world, based on their needs and goals as self-organizing, self-maintaining, embodied agents. In the social realm, the interactive coordination of embodied sense-making activities with others lets us participate in each other's sense-making (social understanding = participatory sense-making). The enactive approach provides new concepts to overcome the problems of traditional functionalist accounts of autism, which can only give a piecemeal and disintegrated view because they consider cognition, communication, and perception separately, do not take embodied into account, and are methodologically individualistic. Applying the concepts of enaction to autism, I show: How embodiment and sense-making connect, i.e., how autistic particularities of moving, perceiving, and emoting relate to how people with autism make sense of their world. For instance, restricted interests or preference for detail will have certain sensorimotor correlates, as well as specific meaning for autistic people.That reduced flexibility in interactional coordination correlates with difficulties in participatory sense-making. At the same time, seemingly irrelevant "autistic behaviors" can be quite attuned to the interactive context. I illustrate this complexity in the case of echolalia. An enactive account of autism starts from the embodiment, experience, and social interactions of autistic people. Enaction brings together the sensorimotor, cognitive, social, experiential, and affective aspects of autism in a coherent framework based on a complex non-linear multi-causality. This foundation allows to build new bridges between autistic people and their often non-autistic context, and to improve quality of life prospects.

The interactive brain hypothesis.

Enactive approaches foreground the role of interpersonal interaction in explanations of social understanding. This motivates, in combination with a recent interest in neuroscientific studies involving actual interactions, the question of how interactive processes relate to neural mechanisms involved in social understanding. We introduce the Interactive Brain Hypothesis (IBH) in order to help map the spectrum of possible relations between social interaction and neural processes. The hypothesis states that interactive experience and skills play enabling roles in both the development and current function of social brain mechanisms, even in cases where social understanding happens in the absence of immediate interaction. We examine the plausibility of this hypothesis against developmental and neurobiological evidence and contrast it with the widespread assumption that mindreading is crucial to all social cognition. We describe the elements of social interaction that bear most directly on this hypothesis and discuss the empirical possibilities open to social neuroscience. We propose that the link between coordination dynamics and social understanding can be best grasped by studying transitions between states of coordination. These transitions form part of the self-organization of interaction processes that characterize the dynamics of social engagement. The patterns and synergies of this self-organization help explain how individuals understand each other. Various possibilities for role-taking emerge during interaction, determining a spectrum of participation. This view contrasts sharply with the observational stance that has guided research in social neuroscience until recently. We also introduce the concept of readiness to interact to describe the practices and dispositions that are summoned in situations of social significance (even if not interactive). This latter idea links interactive factors to more classical observational scenarios.

Can social interaction constitute social cognition?

An important shift is taking place in social cognition research, away from a focus on the individual mind and toward embodied and participatory aspects of social understanding. Empirical results already imply that social cognition is not reducible to the workings of individual cognitive mechanisms. To galvanize this interactive turn, we provide an operational definition of social interaction and distinguish the different explanatory roles - contextual, enabling and constitutive - it can play in social cognition. We show that interactive processes are more than a context for social cognition: they can complement and even replace individual mechanisms. This new explanatory power of social interaction can push the field forward by expanding the possibilities of scientific explanation beyond the individual.

Social understanding through direct perception? Yes, by interacting.

This paper comments on Gallagher's recently published direct perception proposal about social cognition [Gallagher, S. (2008a). Direct perception in the intersubjective context. Consciousness and Cognition, 17(2), 535-543]. I show that direct perception is in danger of being appropriated by the very cognitivist accounts criticised by Gallagher (theory theory and simulation theory). Then I argue that the experiential directness of perception in social situations can be understood only in the context of the role of the interaction process in social cognition. I elaborate on the role of social interaction with a discussion of participatory sense-making to show that direct perception, rather than being a perception enriched by mainly individual capacities, can be best understood as an interactional phenomenon.