The ever-sensible British Neuroscientist we know as Neuroskeptic has a particularly sensible blog post up [How To Avoid Neurohype], tied to his equally sensible Daily Dot commentary [Why we’re living in an era of neuroscience hype].In my view, it’s this sense of “hard” vs. “soft” truth that lies at the root of the craze for neurobullshit. We seem prone to a mind-brain dualism, thinking that the mind is something soft, malleable, and mysterious, whereas the brain is a hard, biological thing open to scientific probing. Therefore, we feel that if we can reframe a “mind” problem as a “brain” problem, then by doing so we’re already halfway to finding a solution. [In fact, the hard/soft, brain/mind fallacy dates back to Greek philosophy, and is known as Cartesian Dualism.]Really, the human brain is no harder or easier to understand than the human mind, because they are ultimately the same thing. So, while it is possible in principle to reframe a “mind” issue as a “brain” issue, it’s often not useful to do so… Why is there so much neurobullshit around today? I think the answer is that neuroscience really has made great advances in the past few decades, and these advances have been very visible…
Ultimately, modern neurohype is driven by the appeal of “hard” or scientific approaches to problems, combined with the modern buzz surrounding brain science. The result is that neuroscience [or something resembling it] has become a selling point — a shiny new coat of paint, both for products and for ideas. Today, while we really do know more about the brain than ever before, our understanding is still very limited. Neuroscience is not yet advanced enough to tell us the answer to life, the universe, and everything.
I had left general psychiatry for a particularly specialized niche, and on returning twenty-five years later, there was a distinct change in the way patients presented. It was a surprise that took some getting used to. Some announced their diagnosis [bipolar, ocd, dissociative disorder]. Many presented their emotional complaint as if it were a disease [depression, anxiety]. And I was supposed to do something with that pronouncement with no further information, as if "I have depression" lead to some specific treatment. Even harder for me was "My antidepressant isn’t working anymore,!" "My depression is coming back," or "I have a chemical imbalance." I had no illusion that I was going to do in-depth case studies in a general charity clinic, but I didn’t anticipate hearing something equivalent to "I found a new mole." And often, taking a real history was hard work. "What’s that got to do with…?"
Many of the patients, even here in the Appalachian Mountains, had adopted this medical model [in the scorned usage]. At first I thought it was something learned from their doctors or the tv ads, but it was more than that. It was something they had maybe initially picked up that way, but it was maintained by many because… [don’t know the because]. And it’s in the culture now "My neighbor, see she’s bipolar and…". The responsibility for improvement was jettisoned to some external locus of control – a new variant of an old psychological defense mechanism. It was enough of a change that I had to relearn how to interview certain people to get the necessary information. There are a lot of things you can do to help people even in the direst of circumstances, but you can’t do them if you don’t know what they are. And you can’t know that without their allowing you to join in a "look around."
So "Therefore, we feel that if we can reframe a ‘mind’ problem as a ‘brain’ problem, then by doing so we’re already halfway to finding a solution" is not just what neuroscientists or some psychiatrists do. Patients do it too. Sometimes it’s a burden handed to patients by their psychiatrists or GPs. And sometimes it’s a thing that patients pick up and carry to extremes – going on a search for an elusive chemical cure instead of making changes in their lives or situations that would make for a more fulfilling visit to our planet. And occasionally, it becomes a place where patients can hide for a very long time to their detriment.
I’m fascinated by neuro-rhetoric in psychiatry. I see it mostly as a way of binding the anxiety that results from inherent uncertainty in our field. (Which leads to the tougher question: why is uncertainty so intolerable now? It wasn’t a few decades ago.) Equating psychiatry with “clinical neurobiology” recalls the old joke about the drunk looking for his lost keys under the lamppost because the light is better there.
Perhaps “all psychiatric disorders are brain diseases” from certain philosophical perspectives. But that smug pronouncement is not an empirical finding; it brings us not an inch closer to actually helping people. I touched on this in a recent post — and received an unexpected teardown by Philip Hickey over at MIA, to which I later responded. Odd, and sad, how pro- and anti-psychiatric extremists are equally afraid of uncertainty.
My college’s journal cover http://anp.sagepub.com/content/50/4.cover-expansion – enough said – but also see Psychiatry Under the Influence (Whitaker and Cosgrove 2015) for the detail as to why our colleges / associations have done this.
The irony is that people and doctors find solace in a “brain” problem when “mind” problems are actually more amenable to nontoxic psychosocial intervention. It’s like people finding solace in fibromyalgia. I find no hypothetical comfort in a label that is not understood, has a horrible prognosis and no real cure.
Are we looking for solutions or something to deflect blame and excuse ourselves? There’s no gold at the end of that rainbow. Except maybe some phony sympathy from politicians who pretend to care. It has to be someone in the abstract because actual family and friends will run out of patience.
The 1970 YAVIS who blamed themselves for disappointing parents were a breeze to deal with compared to those who park themselves inside modern neuroscience constructs that may not in fact be valid constructs.
Neuroskeptic is reading my mind, or is it my brain?
The loss of agency is perhaps the greatest unintended harm of the whole broken brain era.
Harrow has written about agency being a predictor of good outcome in his cohort and Ken Kendler is someone whose writings on the brain/mind issue and psychiatry have been so helpful to me (I will try to track down references)
Some of my own musings on this
http://www.madinamerica.com/2014/03/need-see-inside-box/
For me one of the most cogent writers on how we think is Daniel Kahnemann whose work is summarized in his book,”Thinking, fast and slow.” So I am not an expert and maybe I was seduced by his eloquent writing and that whole Nobel prize winner thing. But what is fascinating is that this work was done largely without the use of brain scans. Sure, there is some of that – brought as usual to “confirm” his elegant studies.
Well worth the read.
Unfortunately Kenneth Kendler’s “philosophy” excursions are in truth internally contradictory and logically incoherent, though at a glance appear helpful. I daresay here’s some of what you’re tracking down – What kinds of things are psychiatric disorders. Kendler, Zachar and Craver, Psychological Medicine , 22 Sep 2010 – Toward a Philosophical Structure for Psychiatry. Kendler, AJP 2005 – Philosophical Issues in Psychiatry. 2008 ed Kendler Parnas review by Oyebode in BJP May 2010 – Kraepelin’s concept of psychiatric illness. Kendler and Jablensky, Psychological Medicine, 1 Sep 2010 – Explanatory Models for Psychiatric Illness. Kendler AJP 2008 – An historical framework for psychiatric nosology. Kendler, Psychol Med Dec 09.
Eg from AJP 2005 “Toward a Philosophical Structure for Psychiatry”: This article seeks to sketch a coherent conceptual and philosophical framework for psychiatry that consists of eight major propositions:
1. Psychiatry is irrevocably grounded in mental, first person experiences.
2. Cartesian substance dualism is false.
3. Epiphenomenalism is false.
4. Both brain?mind and mind?brain causality are real.
Please explain – how are points 2. and 4. reconcilable? Points 5 – 8 equally problematic. Reads as very clever, but logically … hmmm.
On the other hand, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2741891/ – also http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1338844/ and finally more recently http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686981/ and coming up to date in this philosophy of science – https://www.researchgate.net/publication/257744287_Contextual_Behavioral_Science_Creating_a_science_more_adequate_to_the_challenge_of_the_human_condition
Sorry for long URL’s and happy phil science reading!
Fascinating dialog here!
Steve,
You’ve made it to Hickey’s Hall of infamy. His hobby seems to be finding that psychiatrists [Pies, Frances, Lieberman, etc] all really either think what he thinks [and don’t know it] or think the wrong things he thinks they think. In either case, It’s an exercise in the creation and maintenance of a straw man extraordinaire. You’re in good company.
As for the Cartesian Dualism, I guess I categorize it as an example for my version of systems theory: “A system is only composed of parts when it’s not working.”
This morning, I rode my magic carpet to work. But some mornings, my magic carpet sputters, and it is instantly transformed into a collection of elements to focus on one at a time, starting with the fuel gauge.
“Therefore, we feel that if we can reframe a ‘mind’ problem as a ‘brain’ problem, then by doing so we’re already halfway to finding a solution”.
Upon further review, that statement makes no sense and is ironically, mindless and brain-dead. I am reminded of similar statements about genetic mapping fifteen years ago. Name one treatment that came out of it for mental disorders. As Dr. Carroll pointed out, we have known the precise genetic defect for Huntington’s for that same period of time.
Brain neurons are post-mitotic. What hypothetical circuit remapping procedure (microsurgery isn’t micro enough) would be more effective than psychotherapy?
File this type of information under interesting but not useful. Way too much time is being wasted in education on this not-ready-for-prime-time science.
Careful Dr N, talking about MIA folk, you know where that leads…
The infamous Mickey snip at the bottom here???
“A system is only composed of parts when its not working”
I love that.
Whilst being aware of your / colleagues enthusiasm for Skinner, and behaviorism (aka a philosophy of science):
Skinner (1961/1972) argues that the physiological inner man is no less problematic than the mental inner man. The validity of a behavioral science need not rest upon, nor reduce to, the “hard facts” of physiology. As Skinner puts it: “The effects of deprivation and satiation on behavior are not the same as the events seen through a gastric fistula… Both sets of facts, and their appropriate concepts, are important -but they are equally important, not dependent one upon the other.
Under the influence of a contrary philosophy of explanation, which insists upon the reductive priority of the inner event, many brilliant men who began with an interest in behavior, and might have advanced our knowledge of that field in many ways, have turned instead to the study of physiology. We cannot dispute the importance of their contributions, we can only imagine with regret what they might have done instead” (Skinner, 1961/1972, pp.325-326).
SUMMARY (of a functional contextualist aka modern radical behaviorist viewpoint)
In this paper, I have argued that adherence to empirical evidence and sharp distinction between constructs and events is a key aspect of the philosophy of science undergirding contemporary behavioral psychology. I have also argued for certain criteria for construct formulation and validation, and that an increase in the potency of this already powerful analysis will be best advanced by adherence to these fundamental principles. The following enumerates what we take to be some of the key points and underlying assumptions of our case:
1. Formulated constructs ought to be continuous with the events within the field of
purported interest.
2. The ultimate validity of constructs is reducible to the extent of improvement in orientation to the field of interest they provide (i.e., enhanced prediction and influence).
3. Constructs ought not be confused with the crude events with which the scientist interacts.
4. Constructs are never attributed ontological validity as result of any operational successes, rather they are maintained as operationally valid. The extent of this validity may be assessed according to the metric described in proposition two.
5. Divergence from the above will at best be superfluous and at worst will draw the investigator’s efforts in directions unfruitful to the advancement of a given field.
My (Rob’s) view – this last sentence encapsulates the problems in both bio-reductionistic, and mentalistic approaches to the study of human behavior. Here’s to a very clear, carefully considered analysis and exposition of the strategies of our science!
Full paper outlining such a carefully considered analysis and exposition is available here http://www.ijpsy.com/volumen1/num2/23.html
Some Notes on Theoretical Constructs: Types and Validation from a Contextual Behavioral Perspective.
Author – Kelly Wilson
Abstract:
Contemporary contextual behavioral analyses take a somewhat different view of theorizing than is commonly held in most of psychology. In formulating a natural science of behavior, theorists such as J. R. Kantor and B. F. Skinner rejected certain varieties of theoretical constructs. This paper divides theoretical constructs into abstractive and hypothetical formulations. It further subdivides hypothetical constructs into three subtypes, including constructs that are (1) in-principle observable, but at some other level of analysis, (2) in-principle unobservable, and (3) in-principle observable, but unobservable for some technical or practical reason. A distinction is made between the ontological and operational validity of theoretical constructs and methods for determining the operational validity of these constructs are discussed. Finally, the selective effects of experimentation and observation on theory development are discussed.
Again, happy philosophy of science reading! btw IMHO foundational stuff
“he calls me a typical psychiatrist when he disagrees with me, atypical and rare when we agree.”
Notable observation.
I think the pragmatic response to the “mind problem” versus “brain problem” issue is to eschew grand schemas and to ask instead, Where is the best leverage for helping the person? Engaging in polarized philosophical arguments is not helpful. Ignoring options because of a conflict between guilds is even worse.
It may be helpful to recall the discipline/antidiscipline framework of science here. E.O. Wilson introduced the constructs of disciplines and antidisciplines to describe the relations between cognate sciences. Thus, physics is the antidiscipline of chemistry; chemistry is the antidiscipline of biology, and so on. Likewise, neurobiology is the antidiscipline of psychology, and psychology is the antidiscipline of sociology. We see emergent complex properties at each progressive level, but no discipline violates the principles of its antidiscipline.
Back to the theme of pragmatism, the topic of suicide can illustrate these points. The related disciplines of sociology through psychology to neurobiology all bear on suicide. Each is a discipline in its own right. Nothing in psychology invalidates Durkheim’s insights into suicide; nothing in neurobiology invalidates Beck’s psychological insights into suicide. Interventions to protect individuals and populations against suicide can come from all 3 levels. Social policy can restrict access to the means of suicide – drugs on the street, firearms, and carbon monoxide cooking gas in homes. Social change also can mitigate predisposing factors like homelessness, unemployment, chronic disease, and poverty. Psychological interventions for suicide risk are well known. Antipsychotic drugs reduce the rate of suicide in patients with schizophrenia. For some groups of patients lithium and clozapine will reduce the rate of suicide. In the clinical setting there need never be any argument over which of these approaches to adopt. We adopt all of them as appropriate to the case at hand, and we don’t engage in pointless guild arguments.
That is true also for what I call the A-list disorders – conditions like psychosis, melancholic depression, mania, crippling anxiety, obsessive compulsive disorder, dementia. From a discipline/antidiscipline perspective, we aim to use every point of leverage. None is privileged over the others but equally none can be withheld for ideological reasons. So a patient with a diagnosis of bipolar I disorder will be managed optimally with medications plus psychoeducation plus psychotherapy plus social rhythm therapy. She will not be told that the medications are optional or a bad idea, any more than she will be told that she doesn’t need to pay attention to her behavior and sleep patterns, social feedback on her perceived mood, or her alcohol intake.
Dr. Mickey referred to the issue of agency versus victimhood in relation to illness, and also to the issue of internal versus external locus of control. That is an area where we need to tread carefully for the A-list disorders. Sadly, psychiatry has a history of misplaced attribution of agency for illness – the refrigerator mother; the schizophrenogenic mother; falsely suggested recovered memories. In the A-list disorders, responsibility for improvement does usually require recognition of an important external locus of control – as in, take your prescribed meds! You didn’t make yourself this way and there is no bootstrap solution for you on your own. Just be sure you don’t add to your burden with new maladaptive behaviors like substance misuse. And don’t make impulsive decisions to stop your meds before discussing that with your psychiatrist.
In some measure, the enthusiasm that Neuroskeptic spoke of for framing a “mind problem” as a “brain problem” derives from impatience with the pace of discovery and clinical innovation in psychology and social psychiatry. Basically, those disciplines had no competition from neurobiology for centuries, yet when the neurobiological approaches began around 60 years ago those older disciplines had made little progress in sweeping away the A-list disorders. That is why the new approaches were taken up so enthusiastically. It is ironic now that some in those guilds are so eager to badmouth the clinical exploration of physical treatments in psychiatry. The lesson of the discipline/antidiscipline framework is that none of the levels of analysis is complete in itself, so our patients deserve all we can offer, no matter the source.
Discovery of a cause isn’t the rational midpoint to any kind of cure. In the case of scurvy, the discovery of a cause meant instant easy cure (limes). There is basically nothing that tidy in mental health on the horizon. How much closer are we to a cure for Rett’s now that the cause has been identified?
These kind of statements are made either to or by people who don’t understand how discovery of treatment works historically.
It’s not an organized top down process. Sometimes, it’s a complete happy accident out of the blue (sulfa) or related to a completely different experiment (lithium). Sometimes it’s centuries of frustration.
I appreciate Bernard Carroll’s caveat as far as “agency” vs. “victimhood.” The history of psychiatry is full of groundless life-experience theories with brutal consequences, especially for the parents of patients (and the young patients torn from their families). Not to mention neo-behaviorist or “tough love” programs (minus the love, usually) that effectively frame emotional disorders as “bad choices” by the patient.
But where is the tolerance for complexity, and paradox? We need to be mentally flexible enough to say, No, you did not get yourself into this hole, but yes, you can play a pretty big role in getting yourself out. Or at least far enough out of the hole to have a life worth living. It’s more often true than not.
I have seen well-meaning shrinks and other mental health staff, transfixed by the medical model, actively work to extinguish any idea their patients may have that their recovery is in ANY sense in their own hands. I have also seen them insist that there is ZERO overlap — none whatsoever — between the pain felt by patients who Have Depression or Have Anxiety, and the “normal” emotional distress of their non-diagnosed family and friends.
(I actually felt a bit sorry for Ted Cruz recently. Weird, I know. He wrote some smarmy-ass thing about his spiritual goals for Lent, which were to work on letting go of his impatience and anxiety about the future. Whereupon various “mental health advocates” fell upon him shrieking about having Stigmatized the Mentally Ill by his heedless use of the A-word. How DARE he compare his ordinary troubles to the sufferings of patients who Have Anxiety? They would LOVE to choose to let go of their pain, Mr Cruz — but unlike you they have NO CHOICE! Because they have a DISEASE.
These are dreadfully disempowering lessons that strip us of all hope. They are also just flat-out wrong. If a pill can help someone cope with distress that comes from life experience — even make it all feel better for a short while — why can’t words or deeds help someone cope with a constitutional disorder?
Johanna, I see little distance between us. I have not personally met psychiatrists who, “transfixed by the medical model, actively work to extinguish any idea their patients may have that their recovery is in ANY sense in their own hands.” The main point of my comment was to underline the need for all interventions appropriate to the person at hand. Can “words or deeds help someone cope with a constitutional disorder?” Sure they can, up to a point. They can bring about cognitive reorientation, improve self-image, stabilize marriages, and strengthen resiliency, not to mention educate the person about risk in relation to his own behavior. These benefits can help the person with bipolar I disorder, say, navigate the currents in life on a more even keel. But they can’t be counted on to protect against tidal events like a manic relapse. Those often have little relationship to life events or to patient agency. So, when you rightly call for tolerance of complexity and paradox, that needs to work in both directions. The discipline/antidiscipline framework may help to promote the kind of flexibility you mentioned, while dialing back the pointless guild conflicts.
Re: agency vs victimhood. But isn’t agency involved in many medical diseases as well? A Type 2 diabetic benefits from medication, but s/he also does best when s/he take charge by eating an appropriate diet.
EastCoaster,
Many people with diabetes, particularly Type 2, stopped being a victim when they started ignoring conventional advice by many in conventional medicine such as certified diabetic educator to eat around several grams of carbohydrate at every meal. They found from their glucometer readings that following this advice was causing their blood sugar to severely spike according to the glucometers and that they weren’t improving. Many were able to get off medication with a high fat, low carb diet.
Unfortunately, I can’t give you pub med links that provide proof of these anecdotal experiences. But in my opinion, there isn’t any better evidence than what the meter says regarding various foods.
Thanks to Bernard Carroll for the thoughtful reply! No real argument there. My experience with psychiatrists has not been all bad by any means. Will always be grateful to the one who finally realized that, no matter how “endogenous” my problem, the most urgent thing was for me to stop pouring whisky on top of it. And had faith in my ability to quit. And insisted I go to AA. It did not turn my life into a suburban fairy tale by any means, nor did it prove my “mental illness” to be a myth. But it was my second lease on life.
Weird that in order to do this he had to turn his back on most of what he’d learned in his residency program … and only after I had “failed ECT” as well as “heroic” doses of every drug on the market. It wasn’t that the program directors and senior authorities failed to recognize that my drinking was playing a very negative role. They just really did not believe me capable of taking any major positive action until they had first brought my Illness under control. Till then, they figured it was like telling a person with a shattered femur to Arise and Walk.
For me, case histories are the bedrock of medicine and I appreciate your sharing yours with us. We know so little when a case first appears. The longer we can tolerate the ambiguity of what we don’t know, the more likely the possibility of finally coming to know what needs to be known. In your case, the story makes complete sense, but only after you and someone else saw the obvious well down the line. The other part is that either you or that someone or both found your strength, a essential ingredient of any real “diagnosis.”
Great thread.
There are just 2-3 serendipitous discoveries that form the bedrock of biological psychiatry. These have been exploited/generalized inappropriately through relentless marketing of medications, and now devices. We still don’t have even one pathophysiology nailed down – say, for a person who abruptly presents with medically compromising depression. Forget diagnosis or rating scales. What I mean is “medically compromised” – fairly certain disproportionate to any causes – – SADNESS and motor dysfunction etc according to performance status (see ECOG.scales used in cancer research.)
My working bias is that the few clues we have on the biology of mental disorders stem from treatments. That these pertain to orphan diseases – and not all that many. The rest – likely richly maladaptive learning. I feel that just one thing biological (pathophysiological) needs to be nailed down. Anything will do. Having seen “all or none” antidepressant response of barely functional people in 3 weeks – what we’ve found already is jaw dropping. It is also quite rare and we do not understand why it is so.
Let’s say that some of what we’ve been calling mental disorders are chronic recurrent inflammatory diseases. Say, some of these may occur in certain people with propensity to endothelial disease (e.g., heart disease, diabetes) and cause the blood brain barrier to leak where it is most vascularized. Of course these are the striatal areas (globus pallidus, putamen, and adjacnet amygdala, anterior cingulate and the connections with the HPA) So, if then – irrespective of the cause – a blood brain barrier sealer is available we are on our way. (In fact I know of a few very good ones.) This in no way removes the possibility that a person can learn to redirect central blood flow by being in the presence of a compassionate helping person. In fact I’d bet on it – but not in everyone. We need facts – where, what, how? Of course Syphilis is an extreme case in biological psychiatry. But who thinks about that now in terms of biopsych?
A person with a broken left wrist (e.g., my wife right now) can be guided throughout life (or just for a year) to learn how to compensate for permanent loss of function -and this can be done through nearly words alone. It will take a person who understands such things. However, she has just had a plate put in, and will regain full function hopefully in 4 weeks. If not, she will need at least a caring compassionate husband to take out the garbage, and she will need re-education on many things – including how to get me to do this. In fact she will need to understand things she never knew before about how her left wrist participated in her full life.
I am sure all of this is worth a sneer or two. But remember it was not too long ago that we could not conceive that gastric ulcers were caused by infection. And just maybe anxiety promoted that gastric environment and vice-versa – or not. Certain autonomic responses associated with anxiety promote changes in pH and motility that enhance bacterial invasion into deeper layers of mucosa. Now we understand. So, of course some so afflicted with can learn to modulate autonomic nervous activity system through any number of approaches to the psyche. Is that the best way? I don’t think we need dualistic terms. But I do think we need to understand when an antibiotic is needed and worthwhile or not.
While it might not seem so, biological psychiatry has been dumped by big pharma and for good reason. Big pharma stripped off its meat when it began to invent disorders and market them as “Whatever you want or need” in a Pill. Nopt we cannot get signals in clinical trials. This screwed my beloved field for now. But then again we’ve only been at it for 60 or so years.
I think we are seeing the era of biological psychiatry hegemony coming to a close. When it returns in 20 years it will be something entirely different I think – and quite humbling.
Best, Mark
Joanna,
Thanks for sharing that. It was a journey. I have to tell you that my friend and collaborator in my past biopsych escapades – what you’d think she was about the hardest headed person you’d ever want to meet – became my sponsor. She guided my addiction – not to alcohol – but in trying to cure cancer! She never succeeded in the latter, but through AA principles (actually the ones for spouses) helped me live through my premature grief, prioritize my work, and especially to realize a two-way relationship with what can only be called “something higher than oneself ” We are all on quite an amazing journey – that’s really all I can say.
Yes, and Barney is the best.
,
Mark