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Paul Grobstein's picture

The brain and mental health: PG reflections

A very rich semester. Thanks all. I went in thinking that the chaotic state of mental health (both institutionally and individually) could be improved by thinking about mental health in terms of the brain, that doing so would provide a coherent framework for getting things less wrong. And I came out with that feeling reinforced but also with a greater appreciation for some of the problems along this path.

The need for clarification of a working presumption

Perhaps the most general problem that I came to better understand this semester is that its hard to get beyond the idea that "thinking about mental health in terms of the brain" means expecting understandings of and solutions to mental health problems to be found in current research on the brain and/or in future research carried out along the general lines that characterize most of contemporary research (cf Mental health research: future directions?).

My own sense is quite different. We don't yet know enough about the brain to understand, much less develop effective therapeutic procedures for, most mental health problems. And I don't think the situation will be much improved by future work that continues to be rooted in existing, overly simplistic presumptions about what the brain is and how it works.

Yes, the brain is a material entity, but it is not a "machine" whose overall function can be understood by collecting more and more information about the details of its parts, their individual functions, and their interactions. Nor can it be understood by presuming that we already understand its overall function, and need only to figure out how the parts are organized to achieve that function.

The brain is a complex system, one with properties that emerge from the interaction of its parts and that in turn influence the parts and their interactions. Moreover, it is a continually changing system, one that evolves both through its interactions with things outside itself and as a consequence of its own activity, which includes elements of randomness. As such, it requires a comparably sophisticated research approach, one that works from the top down as well as the bottom up, and one that is as open to new understandings of overall functional considerations as the brain itself seems to be.

If, as seems increasingly to be the case, the brain is the material embodiment of what it is to be human, neither its complexity nor the requirement for research sophistication in exploring it ought to come as a surprise. When inquiring into the brain, one is asking nothing less than what are the existing and future potentials of being human.

From this perspective, "thinking about mental health in terms of the brain" very much does not mean asking existing or reasonably anticipated research on the brain to answer age old and indeed probably unanswerable questions. It means instead a commitment to a reciprocal dialogue between those doing research on the brain and those exploring the nature of humanness in other ways, a dialogue in which existing understandings from research on the brain are made use of and tested in broader arenas, with the results in turn influencing the questions and methods of those doing brain research.

The issue is whether we all, those doing research on the brain and those not, can become comfortable with a working assumption that the brain is indeed the material embodiment of humanness, past and future, and with the notion that that working assumption represents opening for future exploration and evolution rather than a denial of important human potentials. Without such a common working presumption, the brain cannot serve as a coherent framework for thinking about mental health. With it, and a more encompassing understanding of what is meant by research on the brain, perhaps it can.

Physical and mental health

I went into the semester with a strong feeling that the traditional "medical model," as it has evolved in the context of "physical health" does not provide an adequate foundation for a coherent approach to "mental health." Here too the semester reinforced my starting position but made me more aware of its complexities.

Inherent in the "thinking about mental health in terms of the brain" idea is a rejection of the distinction between body and mind, replacing it with the notion that "mind" is a characteristic of a material structure, the brain. There are, to my mind, all sorts of advantages to this shift in perspective. Among the more important, from my point of view, is that it could valuably serve to remove the stigma of mental health problems, and the institutional discrimination against those needing assistance with mental health as opposed to physical health issues. Since mental health problems reflect a part of the body, the brain, they should be dealt with in the same terms as problems of other parts of the body.

There are, though, some difficulties with this. That mental health problems should be dealt with "in the same terms" as physical health problems does not mean, for me, that they should be deal with in the terms of the existing "medical model." Destigmatization and parity are important objectives and I would like to see "thinking about mental health in terms of the brain" contribute to achieving them. But there are problems with the current medical model that are particularly acute in the case of mental health. To put it differently, mental health is not the same thing as physical health, as the latter is understood in the medical model.

Problems associated with the brain are different from problems associated with other parts of the body (the kidneys, for example) not because one is mental and the other material but rather because of the distinctive characteristics of the brain as a particularly complex material organ. For many parts of the body, an approach that is based on some ideal concept of structure/function relations, and that assumes a tight correlation between symptom, cause, and effective therapy has been and may well continue to be quite effective.

What seems increasingly clear in practice, and follows from the working assumption of the brain as humanness, is that such a "medical model" approach is both ineffective and inappropriate in the case of the brain. In this case, there is no adequate structure/function ideal, nor any tight correlation among symptoms, causes, and effects. In addition, there is a special need in regard to the brain to acknowledge the significance of story telling, meaning making, and agency (more on these below).

The upshot is that I am optimistic that doing away with the mind/body dichotomy is a promising way to go in terms of eliminating mental health stigma and lack of parity and opening new research directions. It continues though to seem to me important that that movement not be equated with bringing mental health under the "medical model" umbrella. Mental health issues are indeed "physical" problems but they require an approach more sophisticated than that which has characterized the "medical model" to date.

Some key understandings re mental health
What has struck me over the semester is less what we don't yet understand about particular mental health problems and more what the commonalities are across an array of mental health problems, and the understandings that are actually available to us if we choose to notice them (cf The Purposeful Migraine and From the Inside Out: New Insights). The following is an effort to make those explicit, as they seem to me to have emerged from our discussions.
  1. There is no sharp border between health and "illness." Nor any clear criterion to distinguish between functional and "broken" brains. There certainly exist brain states that cause suffering both to people having them and to others, and every effort should be made to ameliorate them. But such problems should be approached from the perspective of facilitating change to lessen suffering rather from the perspective of correcting deficiencies, and with the understanding that all people need help to varying degrees at varying times rather than the notion that people with mental problems are qualitatively different from other people and need a special qualitatively different kind of help. Mental health is not a "state" but a process, one of successively participating in the shaping of one's own life and the lives of others.
  2. All suffering is "in the head." Without brain interpretations, "stories," there would be no suffering. In some cases, disturbing stories can be traced to well-defined problems either in other parts of the body or the brain itself. In the majority of mental health problems, this is not the case and probably never well be. Instead, there is some conflict between existing conscious understandings, the "stories," and unconscious understandings. Conflict itself is generative but persistent unresolved conflicts produce suffering and require external assistance. This requires that attention to "stories" (as per "From the inside") and their interaction with the unconscious be taken as a central element of mental health care.
  3. In addition to stories, issues of self-control, personal autonomy, and meaning are central to most mental health problems. And still more important because of the need to recognize that all three can be compromised not only by external factors but also by internal ones. There is a clear need to better understand the interaction between the unconscious and stories so as to facilitate the ability of individuals to enhance their capabilities of self-control, personal autonomy, and meaning making ability (cf An Exploration into Consciousness and Free Will).
  4. A significant number of mental health problems either derive directly or are significantly exacerbated by interpersonal and social/cultural variables, by conflicts among unconscious understandings, individual stories, and collective stories. Here too conflict is generative but persistent unresolved conflict produces suffering and requires external assistance. In this context, it is particularly important to recognize that the objective should be to relieve suffering by facilitating change, rather than correcting deficiencies, and that change may be needed in societies/cultures as much as in individuals (cf Conquering Culture). Socio-cultural "norms" need to also to be thought about as a central element of mental health care and should not be presumed to be fixed standards to which individuals need to adhere.
  5. The notion of "reality" is an important issue in the mental health context (cf Truth and Reality), and an understanding of the brain has important things to say about it. There is no single "reality" that one can use to evaluate all understandings. Understandings are necessarily and inevitably context and perspective dependent, and so there are multiple realities, both among and within individuals (cf The Folly of Examining Life Rationally). Mental health needs to be understood not as a state of being "in touch with reality," but rather as a process of making creative and productive use of multiple and potentially conflicting realities.

Are these useful understandings, in the sense that they could bring greater coherence to thinking about mental health? in the sense that they raise new questions for further exploration? We'll see ... but I think I at least have a more sophisticated sense of what's at issue then I did at the start of the semester. Again, thanks all. For sharing multiple and potentially conflicting realities. And being wiling/able to see what new things we can make of them.




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