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2020 ART Experiental Neurorehab

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HYPOTHESIS AND THEORY

published: 15 May 2020


doi: 10.3389/fpsyg.2020.00924

Experiential Neurorehabilitation: A
Neurological Therapy Based on the
Enactive Paradigm
David Martínez-Pernía 1,2,3*
1
Center for Social and Cognitive Neuroscience, School of Psychology, Adolfo Ibáñez University, Santiago, Chile,
2
Geroscience Center for Brain Health and Metabolism (GERO), Santiago, Chile, 3 Memory and Neuropsychiatric Clinic
(CMYN), Neurology Service, Hospital del Salvador and Faculty of Medicine, University of Chile, Santiago, Chile

With the arrival of the cognitive paradigm during the latter half of the last century,
the theoretical and scientific bases of neurorehabilitation have been linked to the
knowledge developed in cognitive neuropsychology and cognitive neuroscience.
Although the knowledge generated by these disciplines has made relevant contributions
to neurological therapy, their theoretical premises may create limitations in therapeutic
processes. The present manuscript has two main objectives: first, to explicitly set
Edited by: forth the theoretical bases of cognitive neurorehabilitation and critically analyze the
Heath Eric Matheson,
repercussions that these premises have produced in clinical practice; and second,
University of Northern British
Columbia, Canada to propose the enactive paradigm to reinterpret perspectives on people with brain
Reviewed by: damage and their therapy (assessment and treatment). This analysis will show
Liliann Manning, that (1) neurorehabilitation as a therapy underutilizes body-originated resources that
Independent Researcher, Strasbourg,
France
aid in recovery from neurological sequelae (embrained therapy); (2) the therapeutic
Lucia Maria Sacheli, process is based exclusively on subpersonal explanation models (subpersonal therapy);
University of Milano-Bicocca, Italy
and (3), neurorehabilitation does not take subjectivity of each person in their own
*Correspondence:
recovery processes into account (anti-subjective therapy). Subsequently, and in
David Martínez-Pernía
david.martinez@uai.cl order to attenuate or resolve the conception of embrained, subpersonal and anti-
subjective therapy, I argue in support of incorporating the enactive paradigm in
Specialty section:
rehabilitation of neurological damage. It is proposed here under a new term, “experiential
This article was submitted to
Theoretical and Philosophical neurorehabilitation.” This proposal approaches neurological disease and its sequelae as
Psychology, alterations in dynamic interaction between the body structure and the environment in
a section of the journal
Frontiers in Psychology
which the meaning of the experience is also altered. Therefore, when a person is not able
Received: 15 October 2019
to walk, remember the past, communicate a thought, or maintain efficient self-care, their
Accepted: 14 April 2020 impairments are not only a product of an alteration in a specific cerebral area or within
Published: 15 May 2020
information processing; rather, the sequelae of their condition stem from alterations
Citation:
in the whole living system and its dynamics with the environment. The objective of
Martínez-Pernía D (2020)
Experiential Neurorehabilitation: experiential neurorehabilitation is the recovery of the singular and concrete experience
A Neurological Therapy Based on of the person, composed of physical and subjective life attributes.
the Enactive Paradigm.
Front. Psychol. 11:924. Keywords: enaction, embodied consciousness, experiential neurorehabilitation, cognitive paradigm, cognitive
doi: 10.3389/fpsyg.2020.00924 neurorehabilitation

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Martínez-Pernía Experiential Neurorehabilitation

INTRODUCTION Prigatano, 2013). With the scientific premises of these disciplines,


rehabilitation methodology was constructed to provide clarity on
People who suffer brain injury (stroke, trauma, tumor, the nature of cognitive disorders themselves while implementing
neurodegeneration, etc.) may be left with sequelae lasting days, rehabilitation programs to stimulate specific responses at the
weeks, and years – or their entire lifetime. As the World Health brain level to improve behavior and biopsychosocial recovery.
Organization states, through the international classification Although the knowledge developed in neurorehabilitation –
of functioning, disability and health (ICF) (World Health through the disciplines of cognitive neuropsychology
Organization, 2001), these consequences affect anatomical and cognitive neuroscience – has generated very relevant
structure and physiological and psychological functions (Body contributions to neurological therapy, this manuscript presents
Functions and Structures), the performance of individual tasks a critical analysis of its theoretical premises. The present
(Activity) and social interaction and development (Participation). manuscript has two main objectives: first, to explicitly set
The impact of these sequelae is so great that the person may stop forth the theoretical bases of cognitive neurorehabilitation
taking care of themselves (dressing, eating, walking) and suffer and critically analyze the repercussions that these premises
loss of family, work and social environment. have produced in clinical practice; and second, to propose
The Health Sciences discipline dealing with recovery from the enactive paradigm to reinterpret perspectives on people
brain injury sequelae is called neurorehabilitation, defined as “a with brain damage and their therapy (assessment and
systematic, functionally oriented service of therapeutic activities treatment). The cognitive theory will be shown to have
that is based on assessment and understanding of the patient’s had three central repercussions, termed embrained therapy,
brain-behavioral deficits” (Cicerone et al., 2000, pp. 1956–1957). subpersonal therapy and anti-subjective therapy, each directly
In recovering from sequelae, neurorehabilitation maintains a influencing interpretations of therapy and the clinical resources
multidisciplinary approach where different clinical therapeutic used. Subsequently, and in order to attenuate or resolve the
perspectives work toward biopsychosocial recovery. Mainly, conceptions of the cognitive paradigm in neurological therapy,
disciplines like neuropsychology, physiotherapy, occupational this paper proposes the enactive paradigm as a new theoretical
therapy, and speech/language therapy have field-specific actions model applicable to neurorehabilitation. The therapeutic
for behavioral rehabilitation1 . For example, in neuropsychology, proposal presented here, experiential neurorehabilitation,
behavior is physical action in performing daily activities, or extends the understanding of therapeutic processes to the whole
behavior occurring during a given cognitive task; physiotherapy, living system and its dynamics with the environment, where the
meanwhile, sees behavior as physical action in balancing and subjective experience of the person plays a relevant role.
walking under any condition in which it may occur (automatic,
conscious, or in interference with other cognitive tasks); in
occupational therapy, behavior is physical action in self-care THE INFLUENCE OF THE COGNITIVE
(grooming, feeding, dressing, moving, toilet training); and for PARADIGM IN COGNITIVE
speech and language therapy, behavior is personal ability to NEUROREHABILITATION
appropriately understand and communicate ideas using spoken
and written language. Despite differences, the ultimate goal The cognitive paradigm has influenced neurorehabilitation
of each discipline is “increasing or improving an individual’s through two main models. The first, developed from the field
capacity to process and use incoming information so as to allow of cognitive neuropsychology, sees the mind as the software
increased functioning in everyday life” (Sohlberg and Mateer, of a computer, processing and manipulating information like
1989, p. 3). a program would. This model, known as the “computational
For over two millennia, rehabilitation of people with metaphor” (Boden, 1979), looks to understanding how the
neurological damage was based on the recovery of the mind processes information without referring to the physical
physical structures of the body – without consideration for processes of the brain itself (Coltheart, 2001). Psychologist
mental processes (Martínez-Pernía et al., 2017). With the Ulric Neisser, anticipating the cognitive paradigm, defined the
arrival of the cognitive paradigm during the latter half of mind as a system that processes information in which “sensory
the last century, however, the theoretical and scientific bases of input is transformed, reduced, elaborated, stored, recovered and
neurorehabilitation have been linked to the knowledge developed used” (Neisser, 1967, p. 4) in generating appropriate behavior.
in cognitive neuropsychology and cognitive neuroscience The cognitive neuropsychology approach has been useful in
(McMillan and Greenwood, 1987; Gianutsos, 1989; Sohlberg neurorehabilitation by identifying cognitive deficit, explaining
and Mateer, 2001; Wilson, 2002; Wilson and Gracey, 2009; behavioral problems in terms of information processing, and
predicting behaviors based on these problems (Coltheart et al.,
1
In this manuscript the terms diagnosis, evaluation and treatment are used 1994, 2005; Coltheart, 2002; Wilson and Gracey, 2009). Since the
as follows. Diagnosis is the process developed by physician (e.g., neurologists
and neurosurgeons) to identify neurological conditions and sequelae. Evaluation vision of cognitive neuropsychology was considered insufficient,
refers to instances of therapeutic examination for the purpose of supporting the second of these models introduced a new approach to
diagnosis, treatment planning, and treatment evaluation. The term treatment the mind in neurorehabilitation from the field of cognitive
refers to therapeutic interventions that are aimed at improving, or compensating
neuroscience. This second perspective seeks to reduce the
for, sequelae in those with brain damage. Both the concepts of evaluation and
treatment are related to the disciplines of neuropsychology, physical therapy, complexity of neurological lesions by studying them exclusively
occupational therapy, and speech/language therapy. as alterations in information processing (Wilson, 1997, 2002).

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Martínez-Pernía Experiential Neurorehabilitation

This new focus based on the knowledge of brain biology, became and, therefore, in behavior, may be seen with skepticism
the “brain metaphor” model of neurorehabilitation (Rumelhart among neurorehabilitation researchers and therapists. However,
and MacClelland, 1986), and incorporated cognitive impairment since the cognitive paradigm sees the brain as the only
into the study of rehabilitation to explain the selective activity relevant biological substrate to be rehabilitated and diagnosed
of certain cerebral areas and cerebral cooperation processes in in the person with cognitive impairment, it implies that
performing behavior (Martínez-Pernía et al., 2017). other biological structures are second-class elements. As such,
Although both models make their respective significant the principles that undergird recovery processes in cognition
contributions in explaining cognition, this manuscript presents and associated functionality (walking, feeding, communication,
a critical analysis that equally affects both perspectives, and decision making, etc.) show that corporeality is little, or not at all,
therefore, neurorehabilitation. Three critical analyses of the taken into account.
cognitive premises of neurorehabilitation will be presented Based on the theoretical background of the cognitive
in the next three sub-sections. It will also explain how paradigm, the only relevant biological substratum that
each directly restrict interpretations of sequelae and thus needs to be rehabilitated and diagnosed in a person with
limit therapeutic and scientific approaches. I term these cognitive impairment is located in the brain. Here cognitive
perspectives embrained therapy, subpersonal therapy, and anti- neurorehabilitation has been effective in the recovery of cognitive
subjective therapy. and functional deficits, to the extent that it does rehabilitate
physical and mental events that occur within the brain, as long
as the role of the body is marginal. Under this therapeutic
EMBRAINED THERAPY paradigm, the body and the environment are reduced to a set
of sensory stimuli that send information to the brain and are
A first limitation of the cognitive paradigm within simple pathways for the execution of behavior and body signals
neurorehabilitation is the slight relevance given the body in are not part of the cognitive processing included in deficit
cognitive processing. By situating cognition and its disorders as recovery – they are merely physical or chemical activities which
an exclusive property of the brain, such rehabilitation models lack any type of mental property. Regardless of whether the
consider other body structures physical entities with no mental therapeutic intervention is performed in a hospital room or
properties. Everyday activities such as walking, grooming, with the presence of loved ones, or whether body stimulation is
reading the newspaper, chatting with friends, or planning the performed in exteroceptive or proprioceptive sensory systems,
day’s agenda are cognitive processes that happen exclusively in this paradigm restricts all body and environmental information
the head – and here, events outside the brain structure have no to sensory inputs that travel throughout our biology without
relevance to mental processing or therapeutic recovery. possessing any cognitive property.
Cognitive neurorehabilitation gives so little relevance to the Briefly, and through the above perspective, the stages of
body in rehabilitating cognitive deficits due to its cognitive intervention for behavioral change have been designed as
assumptions, which restrict mental properties to neuronal events follows: (1) environmental and bodily stimuli are transported
located in the head. Indeed, paraphrasing philosophers like to the brain through the subsequent afferent sensory pathways
Shaun Gallagher, cognitive theory reduces the body to the (bottom–up information); (2) this information, purely physical,
reception of environmental stimuli to later be used by cognition changes its properties upon reaching the brain to a functional
or its representation in the somatosensory cortex (Gallagher, brain state which simultaneously possesses physical and mental
1995, 2005). Hilary Putnam affirms that functionalism, a properties – here, in the brain, and not before, cognitive
philosophy supportive of the cognitive paradigm, sees cognition processing and cerebral activity necessary for the rehabilitation
as reductionist, where “the person’s brain (your brain) has been of the person takes place-; and (3), once the processing stage
removed from the body and placed in a vat of nutrients which is finished, the cognitive information is again reduced to purely
keeps the brain alive” (Putnam, 1981, pp. 5–6). In the words of physical, corporeal components through the efferent motor
Lawrence Shapiro, cognition is “envatted” (Shapiro, 2004, p. 169). pathways (top–down information), giving rise to the expected
Giovanna Colombetti furthermore characterizes the cognitive behavior in the subject.
paradigm as brain-centrism, that is, a model where cognition is This argument gives the body little importance as
situated in the processes that happen in the brain (Colombetti, a therapeutic tool in the recovery of cognitive lesions.
2014). In terms very similar to these, neuroscientist Antonio A paradigmatic example of this disinterest can be found in
Damasio affirms that, in this theoretical proposal, the mind is the disciplines of speech/language therapy and neuropsychology,
embodied but only in cerebral terms. To express this idea he in which therapeutic intervention consists of modifying
coined the term “embrained mind” (Damasio, 1994, p. 118). information or neuronal processing produced in the brain2 .
Although many authors across various fields of knowledge
lament the lack of attention given the body following the 2
There are some exceptions to this rule, such as, for example, Trunk Rotation
emergence of cognition, rarely has it been discussed, nor indeed Therapy, in the neuropsychological treatment of hemispatial neglect. This
analyzed, for its impact on clinical application (Martínez-Pernía syndrome is characterized by people unable to report or respond to stimuli from
one side of the body (usually the left) and when such deficits cannot be attributed
et al., 2016). Since many interventions require the stimulation
to a motor or sensory dysfunction but to a cognitive one. The rehabilitation of this
of the body for the stimulation of cognitive function, perhaps cognitive disorder in Trunk Rotation uses body posture to rotate the trunk toward
the assertion that the body has little relevance in cognition the left side, which improves stimuli integration of visual detection, brain activity,

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To wit: the gold standard of these disciplines is to perform SUBPERSONAL THERAPY


therapeutic sessions with the patient seated in a chair
(Martínez-Pernía et al., 2016). A great advance of the cognitive paradigm against previous
This is not to suggest that bodily or environmental stimulation mechanistic assumptions was that of opening the “black box.”
produced by the therapist during the session – and transferred Although behaviorism gave a satisfactory explanation of the
to the brain as a sensory signal – does not improve neurological learning of new behaviors, it was never able to account for
damage suffered by the person. Rather, the crux of the discussion the underlying mental processes. The cognitive paradigm, in
is that neurorehabilitation considers that improvements of turn, gave access to the internal processes preceding behavior,
cognitive deficits are exclusively produced in the cognitive which, for cognitive neurorehabilitation, occur in terms of
processing at the cerebral level, obviating corporeal and information processing or brain activity. In spite of such
environmental attributes. While neurorehabilitation disciplines advances, some authors have commented that the approach has
apply a wide range of physical and environmental stimuli in generated new problems in mind research because it produces a
order to improve deficits caused by brain injury, the brain stagnation in certain behavioral precepts. John Searle put it this
representation of these stimuli is reduced to the somatosensory way: “Cognitive science promised a break with the behaviorist
cortex (brain homunculus); nowhere in cognitive explanations tradition in psychology because it claimed to enter the black box
thereof is any detail on how environmental and body information of the mind and examine its inner workings. But unfortunately
have a physical/cognitive brain representation, or what type of most mainstream cognitive scientists simply repeated the worst
cognitive processing is involved.3 mistake of the behaviorists: they insisted on studying only
As seeing appropriate behavior produced through storing, objectively observable phenomena, thus ignoring the essential
filtering, encoding and retrieving information, this intervention features of the mind. Therefore, when they opened up the big
model still lacks an explanation of what specific characteristics black box, they found only a lot of little black boxes inside”
of the environment and the body are incorporated into cognitive (Searle, 1992, p. xii).
and brain processing. Even in ecological therapeutic intervention The “little black boxes” referred to by Searle are the
approaches, where the person performs physical actions in a representation of the mind in terms of events inaccessible to
given environment (shopping in a supermarket, paying bills in a conscious experience. Although the cognitive paradigm managed
bank branch, chatting with several people while walking through to explain what happens in the mind between the presentation
the park, climbing the escalators of a shopping mall, etc.), the of the stimulus and the production of the behavior, its weakness
marginality of corporeality as a whole is still present. lies in the fact that its explanation takes place in terms of
The explanations offered by cognitive neuropsychology processes that are unapproachable by the consciousness. This
and cognitive neuroscience – modular systems of cognitive perspective explains only what type of processing is required by
processing implemented in brain neurobiology-, and therefore the information that enters the system, and the neurobiological
neurorehabilitation practices based thereupon, are insufficient. activity that takes place within it, without requiring individual
It reduces the explanation of clinical improvement to the consciousness information as experienced and expressed.
recovery of cognitive and brain structures, and relegates the Succinctly, the cognitive paradigm considers the mind a
body and the environment to non-mental sensory physical non-conscious process, hidden to the singular and cognizant
events. Borrowing Damasio’s neologism, neurorehabilitation is a perspective of the individual (Dennett, 1969; Sacks, 1985;
therapy embrained. Bruner, 1990; Jopling, 1996). The study of cognition and
In sum, the theory under which neurorehabilitation is its understanding depends on information processing,
governed not only has implications in the way cognition is neurobiological activity, electrical activity, serial information
explained in the rehabilitation of deficits; rather, its assumptions processing, and cerebral blood flow: processes all unintelligible
further generate pre-theoretical determinants in the way therapy to, and inaccessible to, the conscious experience of the individual.
implements clinical intervention. Any therapy based on the In other words, “what makes experience possible in the first
scarce relevance of the body in cognition will be doomed to place is not itself a possible object of direct experience”
generate research models or clinical interventions in which the (Jopling, 1996, p. 158). Dennett (1969) stated that the cognitive
attributes of the body are not taken into consideration or in which paradigm maintains a subpersonal explanation, where personal
it is given scarce relevance. explanations have no relevance, coining the term. That is,
explanation is dependent on patterns of brain activation or
functional organization with no room for the subject’s singular
and daily activities (Spinelli and Di Russo, 1996; Wiart et al., 1997; Manly et al., perspective (belief, desire, thought).
2010). The repercussions of this mental model based on subpersonal
3
Today this view has been largely superseded by some models of social explanations go beyond low-level cognitive processes (attention,
neuroscience and affective neuroscience. These disciplines consider the insular
cortex, or fifth lobe of the brain, relevant to the perception of internal body memory, perception, comprehension of language, etc.). The
signals and environmental stimuli (social context), which are functionally related cognitive paradigm also explains high-level cognitive processes
to areas of the prefrontal and temporal cortices. An example of the importance of (thinking, reflection, decision making, awareness, executive
body states in cognition are given in Antonio Damasio and other somatic marker
function, metacognition) with its model of the unconscious mind
researchers (Damasio et al., 1991; Damasio, 1994; Damasio et al., 1996). The neural
network model of social context, described by Ibáñez and Manés (2012), explains (Reber, 1992). The elements of cognition required for analysis,
the relevance of the social environment in brain processing. interpretation, observation, evaluation or judgment still occur

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outside of a subject’s conscious experience. It is only the end mental representations and manipulates them, it bears repeating,
result of cognitive processing a person has access to, not the via subpersonal cognitive processing. A clinical example is asking
cognitive process itself. Miller, expressed that consciousness “is patients the sum of 11, 17, and 24. In order to obtain the answer
the result of thinking, not the process of thinking, that appears to this question, the patient must manipulate the different mental
spontaneously in consciousness” (Miller, 1962, p. 56); Mandler, contents that appear in their head in order to be able to carry out
that “the analysis of situations and appraisal of the environment the task effectively.
goes on mainly at the non-conscious level. There are many Whereas the two systems described by Daniel Kahneman
systems that cannot be brought into consciousness, and probably differ substantially, both in terms of neurobiology and
most systems that analyze the environment in the first place have patient perception, therapeutic intervention models developed
that characteristic. In most of these cases, only the products of therefrom take similar approaches. Neurorehabilitation under a
cognitive and mental activities are available to consciousness.” subpersonal framework ignores personal and individual positions
(Mandler, 1975, p. 245); Neisser expressed that constructive on how to solve cognitive tasks. These therapeutic interventions
processes “themselves never appear in consciousness, their cannot access the possibility of implementing strategies related
products do” (Neisser, 1967, p. 301); and Alexander Luria, father to individuality, and exclude meaningful learning, divergent
of modern neuropsychology – and who believed the study of thinking, creativity, emotionality or exploration of new
the mind was being reduced to questionnaires, mathematical behaviors. The perspective assumes that the person (i.e., in this
schemes, and devices that measured brain activity (Jopling, 1996; case, the brain) correctly performs the cognitive task through
Good, 2000) – stated that “the reality of human conscious activity natural qualities necessary to solve the problem. During clinical
was being replaced by mechanical models” (Luria, 1979, p. 176). intervention, the subject is not expected to learn through certain
Transferring this analysis to the discussion of how subpersonal individual dispositions that may allow them to face the task from
models have influenced neurorehabilitation, these precepts for their own position. Rather, the subpersonal laws of neurobiology
understanding, investigating, and exploring mental phenomena expect the patient to resolve the proposed cognitive task in which
and conscious experience reduce rehabilitation intervention the qualities of the physical world are innately present, with no
models to focus purely on cognitive processing and brain sign of subjectivity. An example of the therapeutic strategies
activity via determinants of automatic cognitive processes and governed under this subpersonal model is errorless learning,
the ability to self-referentially manipulate symbols. In showing tirelessly repeating the same semantic or phonetic tracks in
that cognitive neurorehabilitation assumes the ontology of the order to automate learning, stimulate senses, and generate
mind as a subpersonal process, let us discuss this precept’s habits and routines.
influence on neurorehabilitation, both research and therapy,
below. To do so, I distinguish two models of subpersonal Subpersonal Therapy Sensu Lato
therapy neurorehabilitation. The first is “subpersonal therapy While it is true, as shown above, that the cognitive paradigm
sensu stricto”; and the second, “subpersonal therapy sensu lato.” does not take personal perspectives into consideration, there is
yet a paradox: a multitude of research paradigms (cognitive tasks)
Subpersonal Therapy Sensu Stricto and clinical interventions (assessment and treatment) require
Psychologist and Nobel Prize in Economics Kahneman (2011) participant self-awareness4 . Under this high-level cognitive
described thinking as system 1 and system 2. System 1 process, the participant self-explores their own mental contents
includes all mental processes that operate quickly, automatically, through introspection. This is subpersonal therapy sensu lato,
stereotypically, unconsciously and implicitly; and system 2, slow, where the therapeutic effect appears once the person appropriates
infrequent cognitive processes that require effort on the part their mental contents and discovers an element of which he or she
of the subject, are conscious, and have a logical or calculating was previously unaware.
character. In terms of cognitive domain, system 1 is attributed Although cognitive neurorehabilitation, from its subpersonal
low level cognitive functions such as attention, perception, proposal, affirms that self-consciousness is the final product of
comprehension of language, memory or visual construction, cognition and that, therefore, “it could not be a cause of anything”
among others. On the other hand, system 2 is related to high- (Bruner, 1990, p. 9), under this therapeutic methodology it is
level cognitive processes such as sequencing, planning, decision- affirmed at the same time, although implicitly, that the personal
making, reflection, thinking, working memory and impulse dimension is a relevant factor implied in the person’s recovery
control, among others. mechanism. It is in the very act of “awareness” where the
Taking Kahneman’s analysis to a personal context, low-level explanation of cognition as a subpersonal process is insufficient
information processing is so fast that the person spontaneously and where the subjective and personal discovery of a new element
produces the output of the task “automatically.” For example, in the consciousness and for the consciousness appears as a
when a person is shown the image of a lion and asked what necessary mechanism of the recovery process.
that animal is called, suddenly, and without being able to explain Unlike other high-level cognitive processes in the previous
how, they find in their head the mental content “Lion.” On the section, it is in this intervention based on awareness that is
other hand, perception of high-level cognitive processing varies 4
In contemporary neurorehabilitation literature, the term awareness or self-
substantially, in which it is assumed that the person is capable
awareness is defined as “the capacity to perceive the ‘self ’ in relatively ‘objective’
of handling and manipulating symbols once all unconscious terms while maintaining a sense of subjectivity” (Prigatano and Schacter, 1991,
processing has finished. That is, a person symbolically handles p. 13).

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found in subpersonal therapy sensu lato. From this methodology model has contributed significantly to neurorehabilitation.
the therapy can no longer be explained in terms of subpersonal Notwithstanding, it remains reductionist in the understanding of
processes and needs the very act of self-awareness to make consciousness. It limits the rich spectra of mental attributes and
the therapeutic change understandable. In other words, the the potential diversity of clinical therapy interventions.
process of characterizing the subjective cannot be reduced
to any other level of explanation. Examples of this type of
intervention include feedbacks (verbal, visual, audiovisual), ANTI-SUBJECTIVE THERAPY
drawing a performance graph, declarative presentations of
personal deficits, writing strengths and weaknesses of performed The third ontological repercussion presented in this work refers
tasks, real world experiences, positive reinforcement, the use of to the restriction of attributes with which the mind is defined
non-confrontational discussions (patient and therapist) about or characterized. In order to delve deeper into this idea, I will
the performance of the task, and self-evaluation systems (Lucas now explain how neurorehabilitation understands subjectivity in
and Fleming, 2005; Cheng and Man, 2006; Fleming and a person with neurological lesions, and what repercussions such
Ownsworth, 2006; Ownsworth et al., 2006; Toglia et al., 2011; premises have on therapeutic intervention.
Schrijnemaekers et al., 2014). One of the great philosophical criticisms against the cognitive
While the conceptual understanding of subpersonal paradigm is centered on its definition of the essence of what
therapy sensu lato allows for a better understanding of the is human (e.g., Gallagher, 2005; Gallagher and Zahavi, 2008;
characteristics of awareness-based therapy, its intervention Colombetti, 2013). Even at its earliest, this paradigm was
model still carries certain cognitive premises that limit criticized by many for its concept of mind, here, lacking
therapeutic processes. Below, I briefly explain three types of attributes that relate cognition to the existence of a unique
awareness therapy reductionisms from traditional cognitive and singular individual. The development of the theoretical and
neurorehabilitation methodologies. scientific program of cognitivism abandoned subjective attributes
for information processing and brain activity. This model of
Mental Content cognition redefines the qualities that make us “human,” and
Therapeutic interventions meant to modify mental content in has been harshly criticized by philosophers and neuroscientists
participants focus efforts on the individual discovering their for legitimizing subpersonal processes without reference to
mental content in order to acquire new content endowed personality, identity, consciousness, emotion, belief, desire,
with characteristics that minimize sequelae. This cognitive volition, motivation, or meaning. The philosopher David Jopling
paradigm, however, reduces consciousness to a construct found explained it in the following way: “The postulated entities
in the mental image, and does not explore the possibility that and systems forming the explanans of sub-personal theories
consciousness may be constituted of processes present before the bear none of the familiar identifying marks of consciousness,
elaboration of the mental content or underlying it. selfhood or personality: the systems are anonymous, impersonal
and thin” (Jopling, 1996, p. 159); and Matthew Elton argued
Introspection that “Consciousness is a product of certain capacities that are
This neurorehabilitation methodology looks to access mental intelligible only at the personal level, capacities that are neither
content through introspective acts; that is, the subject must present at the sub-personal level of brain mechanism nor present
turn their mind toward themselves (re-flection, or turning in ‘sub-persons”’ (Elton, 2000).
into oneself) to understand their mental content, which In addition to these criticisms from the basic sciences,
reduces alternatives for exploring one’s own experience. different therapy professionals have harshly criticized the anti-
Therapeutic success is measured by the exercise applied during subjective cognitive model. Thus, for example, the post-
therapeutic sessions (speaking, evaluating, comparing, drawing rationalist psychologist Juan Balbi explained it in the following
performance), and does not include the processes themselves terms: “The computational conception of the mind does not
involved in accessing or creating mental content. contemplate its subjective and intentional character and excludes
the possibility of a scientific explanation of human consciousness
Rationality and self-awareness. By adopting as a computational ‘metaphor
Neurorehabilitation assumes that recovery is subsumed to a of mind’ model, cognitive psychology has turned toward a
rational mind accessing its mental contents. Patient ability for new kind of anti-mentalism, more subtle and technologically
awareness is placed under the domains of rationality and, as such, equipped and, perhaps, even more vigorous than the previous
strategies work to help the patient logically understand the mental [behaviorism]” (Balbi, 2004, p. 184). Another important and
events to which they do not have access (thinking, believing, remarkable figure in cognitive psychology who strongly criticized
reflecting, arguing, evaluating, comparing). This proposal is the anti-subjectivist vision was Alexander Luria. Although Luria
reductionist by not including a pre-reflective look at the was one of the most influential psychologists in the theory of
constitution of consciousness, i.e., at the point where personal cerebral organization and behavior with his works on aphasia
knowledge is created by events prior to the conformation of (Luria, 1970) and higher cognitive functions (Luria, 1966),
their rational world. his particular therapeutic vision saw an important limitation
Based on the rational mind, introspection, and access to in the cognitive proposal vis-à-vis its abandonment of the
mental content, it is unquestionable that this clinical intervention study of subjectivity. To quote a letter from Alexander Luria

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Martínez-Pernía Experiential Neurorehabilitation

addressing the eminent neurologist Oliver Sacks, in which he clinical practice and reduces therapeutic intervention to
clearly criticizes the anti-subjective therapy model: “There are no subpersonal process determinants. Even strategies based on
prescriptions in a case like this. Do whatever your ingenuity and self-awareness, which implicitly assume the existence of a
your heart suggest. There is little or no hope of recovery in his personal level, suffer from this subjective dimension. From
memory. He has feeling, will, sensibilities, moral being. Matters the perspective of an awareness task, subject access to their
of which neuropsychology cannot speak. And it is here, beyond mental content is recorded as a binary (yes/no), disregarding any
the realm of an impersonal psychology, that you may find ways to personal accompaniment to the experience (frustration, anger,
touch him, and change him. Neuropsychologically, there is little happiness, neglect).
or nothing you can do, but in the realm of the Individual, there
may be much you can do” (Sacks, 1985, p. 32). The Impersonal
In the field of neurorehabilitation, anti-subjectivity has Impersonal therapy, instead of showing the individual as an entity
impacted therapeutic methodology and the concept of the full of “internal,” personal experiences, describes them as a set
patient during the therapeutic intervention. To this end, let of cognitive processes sans subjective qualities. Whatever the
us explore what the denial of the attributes of subjectivity personal explanation presented, it is never in terms of individual
consists of in the person who turns to neurorehabilitation (“the attributes or personal qualities, but rather of how the subject is
anti-subjective person”); and, then, with what type of attributes able to organize and elaborate information and behavior – an
neurorehabilitation replaces subjectivity in its participants (“the explanation based on the impersonality of the person with brain
impersonal”). damage. Under this therapeutic approach, the person ceases to
be a subjective entity and becomes an impersonal entity. It is
The Anti-subjective Person an explanation that does not need any reference to individuality,
As in subpersonal therapy, the cognitive paradigm only considers where everything is expressed in terms that disregard subjective
therapeutic strategies as useful when they act at the level of life attributes of the person.
unconscious processing. Patient recovery is based on strategies By causing the person with brain injury to be seen not as a
focused on neuronal stimulation, brain plasticity, the generation sentient entity loaded with attributes that make them unique,
of new information processing routes, or the recovery of but as a logical entity that processes information in an efficient
information that, until now, had not been available. They make and objective manner – a function of computational algorithms
use of tools based on a methodology that omits any reference in cerebral/subpersonal systems – the cognitive interpretation
to the personal characteristics of the patient, such as the will, of the human being is logical, rational, and objective. Cognitive
eagerness to overcome, responsibility, anger, hope, spirituality, neurorehabilitation has incorporated this as its impersonal
faith, motivation, morality, etc. All of these are unique and therapeutic model, where there is only room for attributes
singular attributes of each human being which may facilitate or constructed under scientific rationality, reducing cognition to
impede quality of life, biopsychosocial recovery, and success in attention, memory, perception, language, visual construction,
the rehabilitation program. praxis, locomotion, and executive function5 . This approach of
All therapeutic disciplines of cognitive neurorehabilitation neurorehabilitation has developed a corpus of knowledge that
(physiotherapy, occupational therapy, speech therapy, denies subjective attributes and replaces them with a rational and
psychology) apply interventions whose purpose is to restructure objective vision of the therapeutic process and cognition: this is
the cognitive and cerebral system, regardless an individual’s exemplified in neurorehabilitation diagnoses.
personal history, the experiences that shape their present, Indeed, diagnosing these domains implies accepting an
or elements that will make their look at the future hopeful intellectualist vision of the patient’s world, a vision of reality
or heartbreaking; intervention is reduced to influencing and therapy mediated by rules, norms, and laws that avoid any
unconscious subpersonal processes, where the person with reference to the interiority of the person (self, consciousness,
brain damage is subordinate to therapy. Under these anti- self-awareness, volition, motivation, emotion, meaning). This
subjective premises, cognitive neurorehabilitation considers therapeutic discipline perspective maintains an intellectualistic
that the learning process is produced by means of constant and vision of the world, where people must adopt an impersonal
repetitive stimulation of cognitive processes in the consolidation attitude regarding the task assigned to them. For example, the
of which the subjective experiences of the patient have no verbal fluency “P” test requires enunciating a minimum of words
repercussion whatsoever. Neurorehabilitation overlooks in beginning with “P.” A person successful in the task is able to
its theory of learning those elements that for the patient are shift between different strategies in searching for words. Another
deeper or more full of personal meaning, learning loaded example of assessment is the clock test, where a person is asked
with a subjective quality that could facilitate the process of to draw a clock with their face and 12 numbers in their correct
therapeutic recovery. position. Processing this cognitive-motor task correctly suggests
This model of intervention may have dramatic consequences. their visual perceptive ability is unharmed.
An anti-subjective approach dismisses suffering, will, personal
5
improvement, dignity in the face of illness, or the shame of feeling Today in the basic sciences, especially in social and affective neuroscience, it
is accepted that there are other cognitive domains that could be closer to the
ill. Neurorehabilitation abandons central aspects of our existence,
non-rational aspects of the subject, such as creativity, empathy, social cognition,
making it a therapeutic model far removed from our humanity. recognition of emotions, and morality. However, in the clinical field, these
This devaluation of the subjective dimension undermines cognitive domains are practically unexplored.

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Cognitive assessment is based on the fact that the patient must development of life and cognition (Varela et al., 1993; Thompson
approach the cognitive task under the premises of objectivity, and Varela, 2001). In opposition to the cognitive paradigm, which
planning, sequencing, reflection and evaluation, all of which are prioritizes the brain over any other biological dimension, the
characterized by the absence of the subjective quality of the enactive paradigm affirms that the body, the environment and
participant within the task posed, and replaced by an impersonal the brain are constituted by a structural coupling that cannot
vision of the world that surrounds them. be divided or sectioned in its study and in which all of them
have equally shared responsibility for the emergence of the
mind (McGann et al., 2013). Therefore, the living organism,
THE ENACTIVE PARADIGM mind and environment are indissolubly intertwined properties in
cognition that require simultaneous research (Thompson, 2007).
In the previous section, the repercussions of the cognitive The enactive paradigm, and therefore a neurorehabilitation based
paradigm on neurorehabilitation were presented. First, it was on that paradigm, proposes to abandon the concept of the
argued how neurological therapy underutilizes interventions body as an empty substance and identify it with an existential
focused on corporeality and an explanatory model that focuses biology, a biology with meaning and personal sense. From this
exclusively on cognitive and cerebral processing. Next, it was perspective, the concept of cognition as a subpersonal process
shown how neurorehabilitation assumes as possible variables of disappears and is replaced by a model of consciousness based on
the therapeutic and research process those that are inaccessible to the philosophical current of phenomenology (Varela et al., 1993;
the consciousness of the patient and the therapist or researcher. Gallagher, 2005; Thompson, 2007; Colombetti and Thompson,
Finally, and directly related to a subpersonal explanation model, 2008; Gallagher and Zahavi, 2008; Rowlands, 2010) where bodily
it was argued that neurorehabilitation lacks a therapeutic model correlates are in turn subjective correlates.
in which there is room for a therapy based on subjectivity. Given
these three repercussions, which in the light of this manuscript
restrict the assessment, therapeutic, investigative and recovery EXPERIENTIAL
process of the person with brain damage, this section will present NEUROREHABILITATION: A
the enactive paradigm as an ontological proposal that could THERAPEUTIC PROPOSAL BASED ON
minimize or overcome the limitations previously mentioned.
Currently, enaction is considered a new paradigm in THE ENACTIVE APPROACH
cognitive sciences (Stewart et al., 2010) constituted by different
The purpose of this section is to move the discussion from the
approaches. Following the categorization of phenomenologist
enactive paradigm to the field of neurorehabilitation. I show the
Shaun Gallagher these approaches are called “the 4e approaches
clinical implications for addressing neurological disorders from
of the mind” and where cognition is considered to be Embodied,
enaction, and how therapy is transformed under its premises.
Enacted, Embedded, and Extended (Rowlands, 2010). The
An element to which I would first like to draw attention is
enactive paradigm has been widely applied in various fields
that this approach – which has been given different names in the
of knowledge such as neuroscience, philosophy, education,
basic sciences6 , is here termed “embodied consciousness” in its
psychology and artificial intelligence, among others (Damasio
concrete application to the therapeutic sciences. The conceptual
et al., 1991; Varela et al., 1993; Brooks, 2003; Gallagher, 2005;
precision on which neurological therapy is based is not minor
Shapiro, 2011; McGann et al., 2013). However, in the field of
and, in itself, is a declaration of intent. Currently, research
neurorehabilitation few studies have been developed from this
carried out under the enactive paradigm has predominantly been
perspective (Martínez-Pernía and Ceric, 2011; Øberg et al., 2015;
from the fields of the basic sciences (Gallagher, 2005). In those
Hay et al., 2016; Martínez-Pernía et al., 2016; Repetto et al., 2016;
disciplines, while research has mainly focused on demonstrating
Cardona, 2017).
the entanglement among brain, body, and environment, there
The theoretical position that defends the enactive paradigm,
has yet to be a genuine effort to study the new characteristics
as opposed to the cognitive paradigm, is the denial that the mind
of the mental associated with this paradigm (Gallagher and
can be explained from a materialistic reductionism that limits
Zahavi, 2008). This oversight is not irrelevant: the neurological
any explanatory construct to the physical mechanisms and/or
therapy based on the embodied consciousness approach requires
cognitive processes that are located in the head. From the enactive
understanding how a person is conscious of their experience.
perspective, the body ceases to be understood as a secondary
Unlike the basic sciences, where the main variable for studying
process of the mind. The body is not limited to being a mere
cognition is biological, the therapeutic sciences necessarily call
physical entity that sends and transmits information from the
studying conscious experience where the biological response
world to the brain. The enactive proposal converts the body
(third-person view) and the subjective experience (first-person
into the necessary substratum from which consciousness emerges
and from where attention, memory, reasoning, consciousness, 6
Some examples are embodied cognition, enaction, extended mind, embedded
emotion, subjectivity, etc., take shape (Gallagher, 2005). It is a mind, or affective mind (Varela et al., 1993; Clark and Chalmers, 1998; Gallagher
perspective from which the “states of the body modify states of and Zahavi, 2008; Ward and Stapleton, 2012). Each approach has unique
characteristics; some emphasize the importance of environment in cognition,
the mind” (Wilson and Golonka, 2013, p. 1). This is how the
while others give greater relevance to body structure (Rowlands, 2010). The current
dynamic interactions between the physiology of the organism, literature considers these approaches logically independent from each other, but
the sensorimotor schemes and the environment allow the are sometimes also combined (Ward and Stapleton, 2012).

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view) are fundamental elements in rehabilitating a person which they left, and is even able to pedal standing on the bicycle
with neurological damage. Currently, different authors of the without any support from the saddle. The cognitive paradigm
enactive paradigm emphatically and explicitly defend that the explains away this phenomenon by stating that the person has
study of the mind in this paradigm is based on the precepts retained motor schema related to that part of the physical activity
of phenomenology7 (e.g., Varela et al., 1993; Gallagher, 2005; intact. Experiential neurorehabilitation, on the other hand, offers
Thompson, 2007; Colombetti and Thompson, 2008; Gallagher a more versatile perspective regarding variations of neurological
and Zahavi, 2008; Colombetti, 2014). sequelae through its contextual and changing approach to
In order to make use of a vocabulary that distinguishes this disease. Under this perspective, patient symptomatology is a
therapeutic model from others, I propose the term “experiential dynamic process that changes according to the body’s interaction
neurorehabilitation” to designate neurological therapy based with the environment and its subjective experience, in such a way
on the embodied consciousness approach. Continuing with that said neurological sequelae are expressed differently between
conceptual clarifications, “experiential,” as applied here, is far walking down a hospital corridor and pedaling a bicycle up the
removed from the panpsychist proposals of some therapeutic street. Experiential neurorehabilitation conceives of neurological
approaches (e.g., humanistic-existential therapy). Rather, in the pathologies and consequences not only as exclusively individual-
context of a therapy based on embodied consciousness, the cerebral disorders, but depending upon the temporal immediacy
term “experiential” refers to the constitution of a human being of brain, body, environmental, and subjectivity dynamics.
who is in the world – natural and social – with corporeal and Another alternative in implementing experiential diagnosis
intentional attributes. considers corporeality as a dynamic of sensorimotor interactions
If I transfer the embodied consciousness approach to the very with others; that is, neurological disease is explained by analyzing
definition of neurological injury and the consequences it has in body dynamics of intersubjective interaction, and not just “in
the life of the person (body functions and structures, activity, the head.” Thus, for example, Hanne De Jaegher describes the
and participation) important contributions are observed under pathology of autism as the relationship that a person maintains
the proposal of embodied consciousness. Under this perspective, with their social environment from their embodied experience
the neurological disorder and its consequences are not only associated with their particular environment (De Jaegher, 2013);
alterations in the processing of information or deficits in the while McGann et al. (2013, p. 206) affirm that “a person
patterns of brain activity that underlie the behavior. In addition, with autism often functions better in some types of situations
this proposal states that brain damage and its consequences than in others. It may be just as plausible to characterize the
are a disorder that is situated in the process of dynamic person-environment situations as problematic, describing the
interaction between the body structure and the environment that engagement or the interaction as ‘disordered’, and not just the
surrounds it. And where the subjectivity of the agent is part individual.”
of this dynamic. Therefore, when a person is not able to walk, In order to deepen the therapeutic perspective from the
communicate or maintain an efficient self-care, their deficits enactive paradigm, the next section will explain a possible
are not only a product of the alteration of a certain cerebral way to interpret experiential neurorehabilitation. For this, I
area or the functional state of the brain. The sequelae of his rely on the proposal developed by Shaun Gallagher on the
condition are caused by the alteration of the dynamics of the structure of body experience (Gallagher, 1995, 2000, 2005;
body–environment and in which the meaning of the experience Gallagher and Zahavi, 2008).
is also altered.
To illustrate the importance of an paradigmatic shift in the
neurorehabilitation from cognitive to embodied consciousness THERAPEUTIC PRINCIPLES BASED ON
perspective, let us see how Parkinson’s disease is defined THE STRUCTURE OF BODY
according to each, using as a case in point the following visual EXPERIENCE
recording of a person with advanced stage Parkinson’s disease
(Snijders and Bloem, 2010). The first part of the video shows Experiential neurorehabilitation, in line with its theoretical
a traditional gait assessment setting, where the person has premises, considers the co-existence of two entities that must be
enormous difficulties in walking a few meters along a hospital taken into account simultaneously during clinical assessment and
corridor. From the cognitive paradigm, this symptomatology is therapeutic intervention. These two entities are structured into
a product of the death of dopaminergic nervous cells in the the “prenoetic structure” and the “intentional project” (Gallagher,
pars compacta substantia nigra (Kalia et al., 2015). The second 1995, 2000, 2005; Gallagher and Zahavi, 2008).
part of the video shows a totally different phenomenon related
to Parkinson’s symptoms – the same person, this time pedaling
a bicycle down the street, turns to return to the point from PRENOETIC STRUCTURE
7
The cognitive sciences present various proposals for third and first-person Those aspects of consciousness that have no intentional content
data joint research, such as neurophenomenology (Varela, 1996), the affective and are inaccessible to conscious experience are prenoetic
neuro-physio-phenomenology (Colombetti, 2013), and the cardiophenomenology
structures. These emphasize the importance of the interaction
(Depraz and Desmidt, 2018). Some of this research has been conducted in clinical
contexts (e.g., Price and Aydede, 2005; Petitmengin et al., 2006; Petitmengin et al., between the environment and corporeality for the formation
2007). of consciousness and cognition. This concept understands

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corporeality as situated in the world prior to perception and INTENTIONAL PROJECT


action, without reducing to its mere biological dimension. Under
such premises, neurorehabilitation abandons the concept of the This approach assumes that, at the personal level, the Subject
body as an empty substance, and rather identifies it with a body is immersed in a universe of meanings. People continually
that contains the meaning of experience without the need for live experiences of personal and cultural meanings, and
any conscious symbolization. It is a body that carries in itself indeed experience the world, full of such meanings, with the
the quality of experience via immediacy. With the experiential ability to reflect on one’s own experience. Unlike cognitive
approach, biology carries meaning in each person: only through neurorehabilitation where experience is reduced to subpersonal
the body does the meaning of experience appear, integrated into and anti-subjective levels, the intentional project holds space
our existence without any reflective process. Bodily existence is for knowledge of a dimension of pre-reflective aspects of
a life full of meaning present, before thought, reflection, or self- experience, as well as of the constitution of the very structures
awareness. of consciousness. Through the concept of intentionality, all
These prenoetic structures function to achieve an adequate experience is susceptible to self-inquiry and self-exploration,
coupling process between the environment and the person, in personal terms. This allows one to go beyond attributes
automatically, without the need for conscious processes. of subpersonal therapy, both sensu stricto and sensu lato.
Applying prenoetic structure constructs in clinical terms has While low and high level cognitive processes are, in cognitive
relevant therapeutic implications. Unlike a cognitive model neurorehabilitation, attributes of the mind under subpersonal
of rehabilitation, where only productions at the level of brain processing, experiential neurorehabilitation refers this concept of
stimulation are relevant, experiential neurorehabilitation mind to the unique and individual vision of each person with
emphasizes a scope of intervention into body–environment neurological impairment.
interaction processes. In other words, while cognitive This phenomenological vision the enriches the analysis and
neurorehabilitation develops a model of therapy where study of consciousness, and, unlike subpersonal therapy sensu
brain stimulation prevails (embrained therapy), experiential lato, experiential neurorehabilitation holds that the mind cannot
neurorehabilitation opens new interpretative paths in be equated to a vision based on the ability of reflexive self-inquiry
therapy by considering the whole body dimension and the of its mental contents; rather, this concept entails an unveiling
environment that surrounds it as relevant, in and of themselves, of how mental contents are constituted from their prenoetic
in recovering from sequelae. Enactive principles have been and pre-reflective bases. From this perspective, experience is
used in therapeutic intervention previously: for example, gait made up of physical, perceptual, temporal, spatial, emotional and
in Parkinsonian patients’ has been rehabilitated with musical meaningful attributes, all of which produce a unique and specific
therapy (musical beat, metronome). Indeed, Schiavio and view of ourselves. These characteristics of the mind go beyond the
Altenmüller (2015) indicate that locomotory rehabilitation reflexive reductionism (introspection) inherent to subpersonal
in a musical environment activates concrete sensorimotor therapy sensu lato.
dynamics, expressed through bodily interaction with the musical The phenomenological perspective in experiential
environment that embeds and creates new world of meanings neurorehabilitation allows for innovation in the types of
for a person. This form of neurological therapy expands upon strategies applied to clinical intervention, especially those that
reductionist explanations of cognitivism, which sees recovery in previously would have made no sense under a framework
walking as a product of cortical sensorimotor network plasticity of cognitive neurorehabilitation. An understanding of the
(Rojo et al., 2011). phenomenological mind within the framework of embodied
By incorporating a new theoretical framework in consciousness introduces narration and description of experience
neurorehabilitation, not only will the understandings of as a therapeutic and assessment strategy in phenomenological
the therapeutic process be broadened to living systems and terms8 . A subject may access their pre-reflective experiences not
their environmental interactions as a whole, so too will the only as a consequence of observations of mental content, but
possibility of generating and creating new therapeutic strategies also through the self-awareness that appears as the participant
based on its theoretical precepts. Thus, for example, the contacts their deeper constitutive reality. A person may
study developed by Martínez-Pernía et al. (2016) investigated narrate their experiences, and that narrative becomes part
differences in behavioral and cognitive performance under of a self-discovery that does not appear merely through the
two different postural settings (sitting on a chair vs. observation of mental content, but rather emerges from a
sitting on a ball). That exploration of patient dynamics in deeper exercise of internal recollection and “intimacy”9 with the
structural coupling between the body and the environment object of knowledge.
in rehabilitative learning showed that neuropsychological
therapy sitting on a ball achieves better cognitive performance 8
In the field of neurorehabilitation, various studies have been carried out in the
and greater behavioral self-regulation than sitting on a chair phenomenological tradition (e.g., Starkstein and Lischinsky, 2002; Howes et al.,
(traditional therapeutic setting). Performing cognitive tasks 2005; O’Callaghan et al., 2006; Owen et al., 2017). There have also been different
on a ball was shown to increase automatic body-balancing rehabilitation programs based on access to consciousness (e.g., introspection) that
prioritize subjective experience (Ernst et al., 2018).
resources (prenoetic structure), aid patient focus on the 9
Francisco Varela used the expression “gaining intimacy with the domain of
task (intentional project), and reduce attention on irrelevant investigation” to refer to the second phase of phenomenological reduction
environmental stimuli. (Gallagher and Brøsted Sørensen, 2006; Olivares et al., 2015).

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In the context of these attributes that, at least from the The experiential neurorehabilitation therapeutic approach
approach of embodied consciousness, constitute experience (i.e., extends the understanding of the therapeutic process to the
the prenoetic structure and the intentional project) – I may whole living system and its dynamics with the environment,
continue to address the discussion that these two attributes where subjective experience plays a relevant role. It furthermore,
should not be understood as isolated entities that shape certain and perhaps more significantly, opens possibilities for creating
aspects of the experience. That perspective would lead to a new new therapeutic strategies through its theoretical precepts. The
proposal of mind–body dualism. Rather, the prenoetic structure paragraphs below will provide more detail into how experiential
and the intentional project are co-constituent elements of each neurorehabilitation and its premises transform the objectives of
experience, modified according to their respective characteristics. cognitive neurorehabilitation.
Experience is not a univocal process of determination, in Prigatano (1999) categorizes cognitive neurorehabilitation
which prenoetic structures would determine an intentional with two different rehabilitation objectives. The first objective,
or conscious project of a subject or the intentional project associated with its disciplinary origins, is related to rehabilitation
would determine how the prenoetic structure will carry out of cognitive functions. To do so, therapeutic strategies under
its functions; instead, both levels of experience co-regulate this paradigm are based on recovery of cognitive deficits or
themselves to form an experience integrated into a dynamic on learning of skills to compensate for damaged cognitive
of structural coupling among environment, embodiment, and functions. In this respect, Barbara Wilson states: “At the most
underlying subjectivity. These two entities are inseparable to fundamental level, people undergoing cognitive rehabilitation
the point that whatever happens in one will also affect the require help to remediate, reduce or alleviate their cognitive
other. For example, although the prenoetic structure functions deficits” (Wilson, 2002). The theoretical precept for this objective,
to achieve an automatic coupling between the environment and and the therapeutic strategies applied from it, is that cognitive
the person, its responses are also delimited by the dynamics learning is sufficient for recovery of the person in their family,
that occur from the person’s intentional project. In other words, social, and work contexts. Some examples of this objective consist
subintentional structures are subject to their own exchanges of people correctly performing cancelation tasks, repeating a
between the body and the environment and, in turn, conditioned sequence of colors, mathematical calculations, writing letters of
to function through the subject’s intentional project, including the alphabet, opening and closing a spastic hand, pronouncing
possible conscious experiences immediate or proximate to the phonemes, or performing agile and fluid flexion and extension
experience underway. Transferring this theoretical vision to knee movements. Over the years, cognitive neurorehabilitation
experiential neurorehabilitation will necessarily integrate the has proven that specific stimulation of cognitive functions
whole living system and its dynamics with the environment is not sufficient for biopsychosocial recovery, and that more
into therapy intervention models. This therapy would include ecological rehabilitation contexts are required (Wilson, 2002);
the prenoetic structure and intentional project as basic elements to be sure, there is a demonstrated need for rehabilitation
of neurorehabilitation (assessment and treatment). Take, for that moves focus away from cognitive impairment recovery
instance, the virtual reality episodic memory rehabilitation as and mental exercises toward aspects more related to activities
proposed by Repetto et al. (2016): sensorimotor interactions of of daily living (Wilson, 1997). Currently, the objectives of
the elderly are increased in a virtual environment (prenoetic neurorehabilitation, as well as therapeutic strategies thereof, are
structure), where the user has the subjective sensation of being based on the main premise of ecological and functional values
“in action” (intentional project), of experiencing the world of therapy. Thus, for example, Sohlberg and Mateer state that
from their spatial-temporal experiences (sounds, sensations, cognitive rehabilitation “refers to the therapeutic process of
perceptions, movements, feelings). Those corporeal experiences, increasing or improving an individual’s capacity to process and
though mediated virtually, will later be central in memory recall use incoming information so as to allow increased functioning
(Wilson, 2002). in everyday life” (1989, p. 3). The aim of this rehabilitation
model is independence in walking, personal autonomy (home
and social), or spoken and written communication. To
CONCLUSION: THE GOALS OF achieve this, therapeutic strategies include walking through the
NEUROREHABILITATION corridors of the rehabilitation center, walking around the city,
cooking a meal, washing the dishes, communicating with other
The first part of the manuscript presented the cognitive people under specific clinical conditions, writing a dictation
assumptions on which cognitive neurorehabilitation is based with the text provided by the therapist, and learning how
as applies to performing neurological therapy, as well as to handle money.
analyses of the consequences that such theoretical assumptions An analysis taken from the perspective of experiential
have for interpretations of neurological disease, its sequelae, neurorehabilitation regarding the objectives and approaches
and therapeutic limitations thereof. Analysis showed that of cognitive neurorehabilitation will inevitably find them
cognitive neurorehabilitation is currently an embrained, insufficient for biopsychosocial recovery. Its objectives are
subpersonal, anti-subjective therapy. The second part of focused on rehabilitating cognitive function and functionality,
the manuscript discussed the enactive paradigm and its and thus abandon any consideration of the subjective attributes
embodied consciousness approach as an alternative proposal that accompany them. Today, we have a cognitive rehabilitation
to overcome the limitations of cognitive neurorehabilitation. whose objective is, for example, allowing people to walk

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Martínez-Pernía Experiential Neurorehabilitation

autonomously in the street, but precludes the sensation of in conversations with others, respecting their turn to speak, and
walking, of holding your partner’s hand or picking up your correctly explaining ideas; rather, it also approaches a recovery of
grandchildren from school. It is a therapy that encourages the happiness one feels when recounting to one’s friends a return
autonomy in the kitchen, but ignores whether a person with brain to work, the feeling of intimacy when reading one’s children a
damage will cook for guests or for their daughter’s school lunch. It story at night, or the low self-esteem one may feel when unable
is a therapeutic model that looks to improve written and spoken to explain oneself as properly as one would like. Recovery from
communication, but disregards whether the person has to write a increased self-care no longer consists only of correctly sequencing
letter of apology to their sister or express nostalgia when talking the steps to make a sandwich; rather, it includes reclaiming the
to their childhood friends. meaning of knowing that the sandwich is for your child to take
Incorporating an enactive paradigm vision into to school, or addressing the frustration and anger you feel when
neurorehabilitation changes the objectives of such therapy. you are not able to do so correctly. The rehabilitation of memory
Given the premises of this paradigm – where corporeality and is not merely recovering a specific life event, but to again feel the
subjectivity are essential constitutive parts of the human being – emotions and meanings that accompany that experience, such
rehabilitation must maintain these precepts as fundamental as the thrill of the day your child was born, or the happiness of
objectives. For experiential neurorehabilitation, disability vacations spent with friends.
is an experience of biological and subjective dimensions,
interdependent, which cannot be reduced or separated from
each other. The essence of the rehabilitation process is to AUTHOR CONTRIBUTIONS
recover the concrete and singular experience of the person
with disability, composed of physical action and its personal The author confirms being the sole contributor of this work and
meaning. Here mobility rehabilitation is no longer just about has approved it for publication.
getting the person to walk autonomously around the city; rather,
it considers overcoming any feelings of fear, of falling to the
ground, replacing it with sensations of walking with a spouse FUNDING
and children in the park, going out with friends to participate
in a life-long football team membership, or strolling across This work was supported by Fondo Nacional de Desarrollo
the countryside in an exercise of solitude and intimacy. Here Científico y Tecnológico (FONDECYT) (iniciación no:
communication rehabilitation is no longer the ability to engage 11190507).

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Occup. Partici. Health 31(Suppl. 1), S53–S60. doi: 10.3928/15394492-201011 Copyright © 2020 Martínez-Pernía. This is an open-access article distributed
08-09 under the terms of the Creative Commons Attribution License (CC BY). The use,
Varela, F. (1996). Neurophenomenology a methodological remedy for the hard distribution or reproduction in other forums is permitted, provided the original
problem. J. Consc. Stud. 3, 330–349. author(s) and the copyright owner(s) are credited and that the original publication
Varela, F., Thompson, E., and Rosch, E. (1993). The Embodied Mind: Cognitive in this journal is cited, in accordance with accepted academic practice. No use,
Science and Human Experience. Cambridge, MA: MIT Press. distribution or reproduction is permitted which does not comply with these terms.

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