Reclaiming the ‘lived-body’: Mind-body dualism, agency & embodiment
In opposition to Western biomedical practice, where the individual is relegated to a ‘passive recipient of care’ (2), creative health – a still nascent field of research and practice – invites a more active, indeed, embodied stance. In prompting action and movement, and encouraging a turning inwards, embodied practices in particular have great potential for restoring agency and thus creating the conditions for health. This essay explores interdisciplinary responses to the dualist paradigm that underpins Western biomedicine, offering much-needed nuanced perspectives on the question of agency and its role for health, leading on to a discussion of the role for embodied practices therein.
Dismantling so ingrained a framework as mind-body dualism, which has, as it were, ‘disappeared under the surface’ of our conscious awareness (3), and shedding new light on the role of agency as it relates to health requires complex lines of inquiry. Interdisciplinary approaches can offer new and different perspectives on, and solutions to complicated problems such as this one, helping to expand upon our understanding of the relationships between health, agency and the body. For the purposes of this chapter, interdisciplinarity is defined as scholarly practice arising from the combination of ‘knowledge, theories, questions, methods, and understandings from more than one disciplinary area’ (4), and which is typically problem-oriented, in that it seeks to reflect external factors (5,4). Despite the ambiguity and confusion often surrounding interdisciplinarity (4), such approaches constitute necessary, ‘countercultural responses’ (6) to long-established, institutionalised, yet likely incomplete and reductionist forms of knowledge, such as the dualist paradigm.
Mind-body dualism and its implications for agency
Although they may appear self-evident, our concepts of health and disease are constructed; they are informed and dictated by an “underlying theory which determines how we define [...] disease [...], and how we see the nature of treatment” (3). At the heart of that ‘implicit theory’ is the mind-body dualism that was formally conceptualised by 17th century philosopher René Descartes, which posits that the mind and body are distinct entities, where the body, unlike the mind, is governed by mechanical laws (7). While Descartes cannot be held solely responsible for “the tendency of western medicine towards a biological-reductionist theory and practice”, his attitudes towards the body have undoubtedly had far-reaching and largely detrimental ramifications for modern biomedical practice (8,9,10). In line with the Cartesian dualism that shaped it, biomedicine views disease as a “malfunctioning of the machine at a biological level” (3), a “deviation from biological norms, caused by some identifiable physical or chemical event”, and requiring intervention by way of “a corrective physical or chemical agent” (10). An inevitable consequence of that stance is that individuals become reduced to their materiality, and thus devoid of agency – where agency is understood as a person’s ability to perceive themselves as influencing their own actions and life circumstances (11,12).
Phenomenologists have been effective at articulating and offering counter-arguments to this dynamic. Erwin Straus argues that the ‘diseased’ body undergoes a process of objectification, whereby the physician neglects the individual’s lived experience (13). That process “is furthered when the patient seeks clinical help”, and thereby “comes to regard his body in an objectified way” (14). Indeed, the power imbalance inherent to clinical spaces demands compliance, requiring individuals to perceive themselves as an ‘object-body’ if their pathology is to be successfully identified and treated, whereby they must relinquish agency. By contrast, Merleau-Ponty’s concept of the ‘lived-body’ (15,16) captures the inherent irreducibility and subjectivity of the body, thereby imbuing it with a lived ‘purposiveness’ that defies the treatment of individuals as passive, malfunctioning objects (8). The ‘lived body’ is, arguably, one and the same as the physiological body (17), such that “subjectivity is always corporeally expressed”, which in turn permits the psychosocial dimension of experience to be accounted for in the understanding of disease (18,19).
Interdisciplinary responses to mind-body dualism & the question of agency
Perspectives from feminist bioethics
Implicit in biomedicine’s myopic focus on biology and its refusal to acknowledge the ‘lived-body’, is an understanding of reality in purely objective terms, one that ignores the relational, interdependent nature of human beings and their surrounding environment. By bringing social, political and economic structures to the fore, feminist bioethics offers valuable perspectives on the question of agency as it pertains to healthcare. Feminist bioethics was born out of efforts to critique and build on discourse within bioethics, an interdisciplinary field that draws on aspects of philosophy, biomedicine, law and theology (20), which arose in the 1970s in response to challenges surrounding medical accountability (21). Feminist ethicist Susan Sherwin’s reimagining of relational theory (22) seeks to reorient and address ethical questions relating to autonomy in ways that are “explicitly attentive to the relational nature of selves” (23).
Relational theory ventures beyond the more familiar terrain of informed choice and consent (24), and seeks to challenge liberal, individualistic notions of agency and personhood (25,26). It conceives of autonomy as existing within and being influenced by ‘a web of relationships’, whereby everything from ‘interpersonal relationships, to social, political and economic circumstances, and embodied features of the self’ have implications for ‘the people we are and the decisions we make’ (23). Embedding relational theory into biomedical practice would enable not only a greater sensitivity to the individual as a multi-faceted, ‘lived-body’ to be seen and heard, but a recognition of the wider socio-political forces that so often impinge upon that individual’s ability to act freely, and which contribute towards the social determinants of health (27,28).
The biopsychosocial model and insights from psychosomatic medicine
As well as curbing the individual’s sense of agency within clinical settings, biomedicine’s reluctance to recognise the complex interrelationship between mind, body and environment has led to the role of agency and its own relationship to health being largely overlooked. Nearly 50 years on from George Engel’s proposed biopsychosocial model (29) and the paradigm shift required to integrate such holistic thinking into modern day, Western medical practice is yet to happen (30). Nevertheless, medical science has made great progress with verifying and expanding upon Engel’s holistic model, particularly within psychosomatic medicine. An interdisciplinary area of study and clinical practice that subscribes to a biopsychosocial worldview, psychosomatic medicine is concerned with understanding the “interplay of biologic and psychosocial factors in the development, course, and outcome of diseases” (31), thereby straddling the disciplinary worlds of exact sciences and the humanities (32). Psychosomatic investigations into the nature of illness have revealed that while being deprived of agency can itself be a source of stress and, by consequence, disease, it can also be a catalyst for healing.
If agency is to be defined as someone’s ability to perceive themselves as influencing their own actions and life circumstances (11,12), then agency entails a perceived sense of being in control of those very actions and circumstances. The degree to which individuals experience this, as conceptualised by psychologist Julian Rotter, is understood as having either an ‘internal locus of control’, defined as the belief that one’s life events are within their control, or an ‘external locus of control’, whereby one’s outcomes are determined by factors and forces external to them (33). Researchers examining stress through a biopsychosocial lens have observed that stressful situations are characterised by a lack of information, uncertainty and, crucially, a diminished sense (or ‘external locus’) of control (34,35,36). On a neurobiological level, when such situations persist, leading to chronic stress, the organism comes under ‘allostatic load’ (37) – characterised by physiological states that precipitate disease (38,39). As well as attesting to the deeply interconnected nature of our being, such findings challenge individualistic notions of agency, which operate within a similarly reductionist, isolationist worldview as mind-body dualism, failing to distinguish between internal and external loci of control.
Just as the impairment of agency may lead to disease, its restoration appears to be integral to states of health and wellbeing. An ‘internal locus of control’ has been seen to confer stress-buffering effects, being associated with significantly lower depression and anxiety symptoms following challenging life events (40,41). More remarkably, a reclaiming of one’s agency has been repeatedly linked to cases of spontaneous recovery from cancer, where, alongside shifts towards ‘experiencing a purpose in life’, and a ‘higher quality of social relationships’, an increase in personal autonomy was amongst the psychological changes observed prior to remission (42). Personal autonomy, defined as “the sense of having, within limits, control over one’s situation, behaviour and predicament” (42), is also seen to manifest within such cases as a general sense of defiance and recalcitrance, referred to as ‘bucking the system’ (43). Such behaviour sits in opposition to states of ‘dependency, helplessness and compliance’ (42) – traits that are often desired and expected of patients in biomedical care (44). Although the mechanisms by which such psychological shifts might effect physiological shifts are only beginning to be understood, autonomy does appear to play a role in enabling the drastic lifestyle and attitudinal changes associated with spontaneous remission (45).
Cognitive science and shifts towards embodied understandings of self and agency
Advancements in cognitive science, an ‘interdisciplinary matrix’ integrating aspects of neuroscience, cognitive psychology, linguistics, and philosophy (46), have contributed irrefutable evidence towards establishing the interconnection between mind and body as fact. Research within embodied cognition, which arose from explorations into the body’s role in mental processes, challenges long-held, top-down understandings of the mind as the seat of cognition – referred to as the computational paradigm (47). Embodied cognition radically posits that ‘perception and action are integrated with cognition through bidirectional pathways’, such that bodily and emotional experiences are intimately interlinked with cognitive processes (48,49).
Neuroscientist Antonio Damasio, one of the foremost figures within cognitive science, has stated that “the self is a repeatedly reconstructed biological structure” (50). His ‘somatic marker’ hypothesis illustrates the interconnectedness between mind and body, and their reliance on environmental inputs to establish a sense of self and inform behaviour (51). Damasio suggests that perception brings about bodily responses, which operate as somatic markers – or “feelings of knowing”, which in turn orient action and decision-making, and contribute to our understanding of self (52). If, as Damasio states, the body is the vehicle through which consciousness arises and our sense of self is formed, then it must also play a vital role in endowing us with a similarly felt sense of agency.
Phenomenologist Shaun Gallagher describes the “consciousness of oneself as an immediate subject of experience” as the bodily or ‘minimal’ self, a term adopted by cognitive science (12). The minimal self comprises both a sense of ownership (of one’s body or mental processes) and a sense of agency (12,53). Recent discourse and research within embodied cognition (54,55) suggests these two components of the minimal self may be reliant on the awareness of arising internal bodily states – what’s known as interoception (56). Interoceptive sensitivity in young children has been observed to correlate with ‘improvements in sensorimotor mapping, such as hand-to-mouth touch’, a signifier of bodily ownership, and ‘goal-directed reaching’, which might be understood as intentional action deriving from a sense of agency (55,57).
Moreover, interoceptive sensitivity appears to have implications for wellbeing, being correlated with an ability to detect and regulate one’s emotions, and a broader susceptibility to mental illness (58). Just as agency, a constituent part of the minimal self, is shaped by interoception, interoception itself can be dampened by a diminished sense of agency. Research has shown that interoception can be negatively affected by stressful experiences (themselves associated with an ‘external locus of control’), thereby ‘altering our capacity to tune into and regulate our own emotions’ (59). Regardless of the causal, directional mechanisms underlying the relationship between interoception, agency and emotional regulation, interoception is malleable (60), and it suggests the body itself may offer internal pathways to regaining a sense of agency and establishing an ‘internal locus of control’ that are associated with enhanced states of health.
The role of the body in (re)claiming agency and supporting health
Despite the mind-body dualism that prevails within Western biomedicine, interests in the embodied phenomena have witnessed a revival across disciplinary and interdisciplinary fields (61). Nevertheless, far from academia, ‘embodiment’ has been and continues to be central to both traditional and modern movement and body-centred practices. As Christine Caldwell defines it, embodiment is characterised by “awareness of and attentive participation with the body’s states and actions” (62). Hence, embodied practices seek to enable the unity of mind and body through bottom-up, felt approaches. Despite the recent enthusiasm surrounding the mind-body benefits of such practices in the West, they carry with them a long, Eastern tradition of conferring ‘knowledge through experience’ (63). Ancient Eastern philosophies and practices, such as yoga, have long advocated a ‘corporeal understanding’ of reality (64), treating the body as a tool of inquiry and self-knowledge, enabling ‘skilful’ or ‘easeful action’ (65), such that we may cease to be governed by our habitual thought-patterns and unconscious conditioning.
Research into embodied practices supports the view of Eastern traditions, providing evidence for the ways embodiment might engender internal bodily and mental shifts that are salutogenic, empowering individuals by restoring their sense of agency. Trauma research has been a rich area for exploration into embodied practices, where yoga – an ancient mind-body postural and breathing practice originating in the Indian subcontinent – has been a focus. Yoga can enable a “positive process of relearning to inhabit the body with agency”, through movements and actions that counter the feelings of helplessness and decreased internal locus of control resulting from trauma (66,67). As well as improving emotional regulation (68), yoga has been observed to bolster self-efficacy – defined as the belief in one’s capacity to act in the ways necessary to achieve a desired goal (69), while increasing feelings of control, security and confidence (70). Moreover, interoceptive awareness, an integral part of the minimal self’s sense of agency, which tends to be weakened in victims of trauma (71), can be fine-tuned through embodied practices (72), in turn enhancing one’s ability to act on internal cues, thus contributing to psychological wellbeing (73).
Yoga is among a number of embodied practices that have been observed to promote health and wellbeing, spanning an array of different contexts and populations, including trauma, addiction (74), respiratory diseases (75) and neurological conditions (76). And yet, depending on the nature of the body one inhabits, whether it is perceived as non-normative or ‘othered’ for its skin colour, gender or ability, the process of embodying may not be as straightforward. Carla Sherrel argues that the term embodiment, as conceived in modern Western societies, has been appropriated by whiteness, in that it fails to appreciate the challenges sometimes posed to being ‘embodied’ (77). Embodying her black female body at all times would be threatening to those around her and therefore risk her safety, meaning she must move between states of embodiment and disembodiment in order to ‘navigate racism effectively’ (62).
While wider structural change is needed to dismantle the systems of oppression requiring many to dissociate in order to survive, embodiment can still offer opportunities, as Christine Caldwell states, to “practice activism at its most basic level”, by moving purposefully to effect change – whether internal or external (62). Embodiment can therefore support social justice, for individuals truly attuned to their internal states are “more likely to keep track of their rights as an embodied being, value the rights of others, and feel empowered to stand up for them effectively” (62). Hence, reaffirming one’s own agency might, in turn, support the restoration of others’ agency.
Angelica Paez, Daffodil Dance (Collage, 2016)
Conclusion
Interdisciplinary perspectives, such as those offered by feminist bioethics, psychosomatic medicine and cognitive science, do greater justice to the complexity of human experience and its implications for health than what narrow, disciplinary perspectives might afford. The comprehensive nature of such approaches is analogous to the irreducible, subjective nature of our species. While imperfect, they are able to hold a more accurate mirror up to reality – one that accounts for its relational and interdependent dimensions.
Thus, interdisciplinarity is crucial to challenging inaccurate, institutionalised forms of knowledge such as that held by biomedicine, in its adherence to outdated, dualist understandings of mind and body. The approaches discussed in this chapter shed new light on the question of agency, revealing it to be subject to a number of internal and external factors, and proving to be at once susceptible yet powerful, thus holding untapped potential for health outcomes. In asserting the connections between agency, health and the body, such understandings might support the role of embodied practices and embodiment more broadly within creative health, so that their agency-restoring capacities are brought to the fore, while encouraging greater attention and energy be devoted to the spaces and structures that impinge upon agency.
Additionally, interdisciplinarity succeeds in lending nuance to binary narratives surrounding agency, long shaped by dualist notions of mind and body. Embedded in such narratives are “moral judgements of blame and responsibility”, whereby we are held accountable for events thought to lie within our conscious control, and excused for those deemed to befall us, such as illness (78). Ascribing such weight to agency, as this chapter seeks to do, by no means equates to laying blame on individuals, or claiming they bear conscious responsibility for the state of their health.
Rather, if health is to be understood as occurring within a complex mind-body system, then our understanding of agency must also be reformulated. It must be conceived within a relational context, and involve the recognition that disease, whether physical or mental, does not arise in a vacuum, but rather constitutes natural responses to unnatural conditions (79,2). To enact agency therefore entails taking ownership over what does lie within our control, being associated not with blame but with what physician and author Gabor Mate refers to as ‘response ability’ (2). That is, the ability to respond appropriately and effectively to both our internal and external environment, to bring about change – both internal and external. That very impulse, one might argue, is central not just to embodied practices, but to creative health more broadly.
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