Minds are not immaterial

I’ve criticised Ed Bullmore, Regius Professor of Psychiatry at the Institute of Psychiatry, Psychology & Neuroscience at King's College London (see previous post) before for wanting to replace dualism with reductionism (see another previous post). Psychiatry actually needs a non-reductionistic understanding of the relationship between mind and brain by seeing them as integrated in the embodied person (see eg. yet another previous post). Bullmore seems to think the only critique of dualism is reducing mind to brain.

Descartes was the first to apply a natural scientific mechanistic approach to life. Animate and inanimate matter were understood by the same mechanistic principles. Animals were, therefore, seen as machines; and human physiology also understood as mechanistic. Descartes stopped short, though, of including the human mind in this mechanistic framework. The soul was denied any influence in physiology. Descartes, thereby, avoided the materialistic implication that man himself is a machine. The split he created between mind and brain is what is referred to as Cartesianism. 

Living beings, including humans, actually have a purposiveness which cannot be derived from mere physical-chemical processes. This creates a split between organic life and the inorganic, not, as Descartes said, a separation of the mind from the body. An organismic perspective in the life and human sciences forms the basis for an emphasis on psychosomatic medicine, and a focus on clinical medicine rather than the physical sciences. Bullmore doesn’t seem to have a role for psychosomatic medicine. Minds are not immaterial, as he states. He needs to develop his understanding of people as embodied beings.

In his recent book The divided mind: A new way of thinking about mental health, Bullmore builds on his philosophical misunderstandings by describing the development of his psychiatric career to 'shoot down' the concept of functional psychosis. Instead, he still believes schizophrenia is an "organic psychosis, rooted in atypical brain network development". He remains “deeply thrilled by the current pace of change in our scientific understanding of schizophrenia ... [and] highly confident that this force and volume of scientific advances will eventually drive changes in the real world”. This is despite his admission that those real world changes have not yet happened. 

Bullmore believes “we are now well informed about what schizophrenia looks like in the brain” in terms of “changes in connectivity at the micro scale of the synaptic connections between nerve cells and at the macro scale of the hubs of the brain’s myelinated wiring diagram”. He sees some children at increased risk from “interactions between genetic and environmental protagonists” creating a  “trajectory of brain and mind development [which] is atypical from an early age”. This is despite not being able to point to any specific physical causes for schizophrenia. I think he just needs to admit that his life’s work to overturn the concept of functional psychosis has failed. Functional does not mean non-organic, in the sense that mental illness is not mediated by the brain. It’s mere tautology, not a major scientific advance, to say that schizophrenia is mediated by the brain.

Is my brain working differently?

Is it me that is different or is it my brain? Everyone is different, aren’t they? But is it because of my brain?

Many people find the diagnosis of neurodiversity helpful. It seems to explain why they are different from others. Society does need to adapt to the individual differences of people. But to be blaming our brains may not be the best way to look at the issue (see eg. previous post). 

Of course our behaviour, emotions and thoughts are mediated by the brain. But that doesn’t mean they are caused by them. People are more than their brains which is only part of them. The brain is of course socially constructed. It’s not just born ready made. But that doesn’t mean it makes sense to reduce people to their brains, which are only part of them. Descartes looked for the seat of the person in the pineal gland, an endocrine gland deep in the brain. But the brain isn’t the seat of the person. We are all damaged in some way which is what makes us human. We’ve become so obsessed by the neurosciences that we can’t see that it’s us that are alive not our brains. 

Acknowledging the limits of psychiatry

The UK government has set up an independent review into mental health conditions, ADHD and autism (see press release). The aim is to examine what is driving rising demand for services and recommend practical, evidence-based approaches to prevention and early intervention.

Psychiatry itself may have ironically at least contributed to the rising demand for services (see eg. previous post). The limitations of treatment do need to be acknowledged by psychiatry as well as by patients. I’m not being nihilistic about the value of treatment, but social interventions, not just from psychiatric services, may well be as effective at least in dealing with people’s psychosocial problems than either medication or psychological therapy. Believing there are simple solutions to mental health difficulties may be counterproductive (see eg. another previous post).

People are also being misled about the nature of mental illness by psychiatry encouraging them to see their problems as caused by the brain (see eg. previous post). Common mental health problems are not generally caused by the brain. Of course they are mediated by the brain but they have psychosocial not physical causes. Neurodiversity is, at least implicitly, being misunderstood as a brain problem (see eg. another previous post). Mental health assessment tends to focus too much on a single-word diagnosis rather than understanding the reasons for people’s difficulties (see eg. yet another previous post).

When I first trained, mental health services concentrated on what was called severe mental illness. More minor, common problems tended to be managed in primary care. Over the years, NHS secondary mental health services have been opened up to all, particularly with the introduction of Improving Access to Psychological Therapies (IAPT) (see eg. previous post). Despite IAPT being particularly aimed at treating common mental health problems and the proportion of people with common mental health problems reporting receipt of treatment steadily increasing, the number of people actually being identified with a common mental disorder in the community has increased (see previous post). The vast increase in treatment may have been expected to reduce prevalence of common mental disorder but in fact it is associated with the reverse trend.

Until the introduction of IAPT, psychological therapy tended not to be readily available in the NHS. Even within IAPT what tends to be on offer is only short-term therapy or guided self-help. I’m not undermining the value of such treatments as long as people recognise their limitations. It’s important they are not left with frustrations that actually increase demand for services.

How much the review set up by the government will address these issues  remains to be seen. Non-medical services, often provided within the so-called third sector of voluntary organisations, need to be developed to allow more medical services to concentrate on severe mental illness (see previous post). Recovery Colleges are an underestimated valuable means of providing support for some people. Neurodiversity should also be provided for within non-medical services. The time-scale for the review is short, so I doubt it will encroach too much on the conceptual issues I have raised, but it could give a steer towards more patient-centred, therapeutic services for the future.