The Dynamics of IntentionalityIntentionality

Fig. 5.1

The two moments of choice , in the example of patient adherence and nonadherence, to adjust the insulin dose or not. Reproduced from Reach (2000). Copyright © 2000 Elsevier Masson SAS. All rights reserved

The daily choice and the primitive choice of being adherent in the future by getting into the habit of performing the therapeutic act, making the daily choice useless. Repeated actions can favor the formation of habit, which is shown by the double arrow; it also makes the need for reasoning less pressing. But it also has the advantage, by leading to the phenomenon of habituation described by Pierre Livet , to limit the force of emotions (fear ) that were present during the announcement of the illness and to combat anxiety stemming from the impossibility of following the change of preferences represented by the primitive choice. At the right of the figure, a reminder that according to Davidson the results of the action do not depend on the agent but on nature “that takes care of the rest”.

In this model of changing priorities, we again find Livet ’s process of revision by which emotion arises from perceived differences between how we imagine things to be, and how they really are. In the case of habit formation, the initial decision to take care of oneself introduces just such a disequilibrium: Previously, one thought all was well, or at least well enough; but in the new frame of self-care, one sees work to be done. Livet’s model should not be understood as implying that cognition precedes emotion; but that our beliefs (cognitions) and emotions are tightly coupled—Livet himself notes that changes in beliefs may even be unconscious:

most of the time , we don’t think about revising our beliefs , [until] one day we notice that we no longer feel the emotion, or only in a weakened form, and that our preferences have changed. The revision can be largely unconscious (Livet 2002, 75).

The revision of preferences allows one, over time and through the phenomenon of habituation, to channel the force of emotions and avoid the anxiety stemming from a state of perpetual indecision. A patient may not know exactly where her determination to take care of herself stands; to put this in terms of Prochaska ’s helices of change, for example: She can progress imperceptibly on the path towards adherence; a conscious change in beliefs is neither necessary nor sufficient.

Clinical experience shows that this revision is, nevertheless, often a conscious process. It can be an authentic rational choice reached at the conclusion of true deliberation. Many former smokers can give the date of their last cigarette ; recovering alcoholics routinely report the date of their last drink. Other aspects of adherence seem to be similarly conscious: Three years ago, having “considered all things”, I finally decided to be reasonable and stop arguing and opposing those who sought to counsel me; I hadn’t even gotten to the specifics of my unreasonableness, but I had decided to lower my guard and stop fighting.

We shall soon see that George Ainslie suggests a similar solution to fight weakness of will (Ainslie 1999): Unify one’s choices into a single, momentous decision ; he calls it ‘bundling’: It is the creation of personal rules. Good habits are the armor of the weak -willed: They sometimes allow the person who has firmly decided to stop smoking to indulge in a good cigar after dinner without putting the future of the decision at risk , creating exceptions that confirm one’s commitment to the rule.

One may now understand the wisdom of taking a break once in a while, as is advised by the Stoic Seneca , for whom “there is a great difference between simple living and slovenly living”, the latter leading to the risk of falling back into bad habits . Ainslie also shows that the strict use of personal rules is not without danger if we do not once in a while ‘take a break’ (Ainslie 1999). Exceptionally rigid adherence can, at least sometimes, lead to disastrous failures.

5.4 Intention , Decision, Resolution, and Willpower

Context is all-important. Facts are facts unchangingly, but meanings depend vitally on context—and it is meanings which drives behavior , not facts. We are dealing with much more than just performing the action of ‘taking the pill’: The patient must have the intention to take care of herself. In some way, the successful patient must engage in the action because it has a meaning for her. Meaning is not a prerequisite to action, and it needs not be static over the course of treatment, and it is not even always clearly articulated—but it is always present in successful therapy.

In Prochaska ’s model (Prochaska and DiClemente 1983), the individual goes from the pre-contemplation stage, where there is not even a problem to be solved, to the stage of contemplation, where the person becomes conscious of the problem and considers resolving it. This is when the intention to adopt a health behavior is formed. The next step is to pass beyond preparation, to decide to adopt the behavior. The maintenance stage may then depend on the patient ’s resolve to treat herself (Fig. 5.2). An analysis of the mental states of intention, decision and resolution will allow us to better understand this model.

Fig. 5.2

Intention , decision in the example of patient adherence and Prochaska ’s model

5.4.1 The Notions of Intention and Decision

In the Nature de la volonté (Nature of the Will), Joelle Proust shows how Searle ’s introduction of intention to the philosophical theories of action was remarkably innovative (Proust 2005, 82). Prior to Davidson , the driving force behind action was seen as the conjunction of a desire and a belief . Searle suggests that there is a mental state, the intention, which cannot be reduced to beliefs and desires and which is the true impetus to action. Only if a behavior is caused by an intention can it be qualified as an action. Interestingly, this was Sartre ’s definition of action as well.

We have defined intentional states as mental states that have a content : Intention and decision are particular types of intentional states (Searle 1983, 79–111). And just as belief has a condition of satisfaction , so does my decision. For instance, if I decide to take this pill, the decision is satisfied—completed, brought to a close—when I actually take the pill.

The situation is usually more complicated for intention : I may have the intention of exercising, but I may never realize this intention. I can remain at the stage of contemplation indefinitely. Generally speaking, decision usually leads to an action ; but intention has the potential to linger, sometimes for very long times indeed. It is this deferred intention which characterizes the contemplation stage. On the other hand, when one enters Prochaska ’s preparation stage, the transition to ‘action’ generally occurs usually within one month.

Michael Bratman points out another difference between intention and decision : Intention is linked to a belief , and like belief, intention is independent of context—it is irrational to give up believing that water is wet simply because I have moved from Majorca to Madrid. It is this independence from context that allows intention—and belief—to persist over time . On the contrary, a decision to do something is connected not to a belief, but to acceptance: In this case there was a moment, with an exact date, when I decided that the content of the belief was true. As opposed to belief, acceptance depends on context and is the result of a voluntary action . Consequently, decision, unlike intention, depends on context (Engel 2000; Bratman 1999, 33). Now we can understand the role that external factors play in the Health Belief Model (see Fig. 2.1): It may be a change in context that leads to a patient ’s decision to take care of herself.

5.5 The Dynamics of Intentionality

For Davidson , to form the intention to perform an action at a given moment means, at that moment,

to hold that it is desirable to perform an action of a certain sort in the light of what one believes is and will be the case (Davidson 2001, 100).

Nonetheless, as Michael Bratman notes Davidson gives little information concerning specifically ‘future ’ intentions, the ones that involve actions that will not be performed immediately (Bratman 1999). And yet these ‘future’ intentions play a key role in adjusting means to ends, making future and past projects coherent. Searle makes a similar distinction: Between ‘prior’ intention , for which the condition of satisfaction is the entire action , and the intention ‘in action’, where the condition of satisfaction is the precise bodily movement that I perform at this moment. In the case of patient adherence, then, intending to take care of oneself is a prior intention while intending to take a pill is an intention in action . Here is Searle:

And thus the prior intention causes the intention in action . By transitivity of Intentional causation, the prior intention represents and causes the entire action, but the intention in action causes only the bodily movement (Searle 1983, 95).

Elisabeth Pacherie suggested, with greater precision, that when considering a long-term project there are three types of intentions: Those oriented towards the future (F-intentions), those dealing the present (P-intentions) and motor intentions (M-intentions). These intentions differ in their role regarding the realization of the project, the type of content that is associated with them, temporal constraints to which they are subject, and their dynamics. They intervene successively, and as each one inherits its goal from the preceding intention , their unity in the context of a single project is guaranteed (Pacherie 2003).

5.5.1 To Take Care of Oneself Day After Day: An Interpretation Within the Framework of a Theory of Intentionality

We have defined patient adherence in the case of chronic illness as “the acceptance to perform repeatedly a series of actions prescribed with the objective of long-term health ”. Let us now consider the different phases of the health project of adhering to treatment for a chronic illness, and distinguish the general long-term context from the more up-close events of care . In particular, we have noted the often ‘mechanical’ character of actions such as taking one’s medication each day. Are these mechanical, automatic actions truly actions, or do they differ in some way? Elisabeth Pacherie ’s model suggests that these automatic actions are ‘minimal’ actions. Minimal actions are not preceded by any form of practical deliberation, conscious or otherwise.

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