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Mind-Brain Dualism and Its Place

in Mental Health Care^23

Eric Matthews

Contents

Introduction. Descartes, Dualism, and Medicine Arc Menial Disorders Illnesses?. The Brain and Mental Disorder An Alternative Account of Brain-Mind Relations. References.

345 346 348 351 354 357

I

Abstract This chapter begins by setting out and explaining the doctrine of "substance dualism", according to which the mind and the brain are distinct and mutually independent "substances". It then examines the merits and deficiencies of dual- ism, in comparison with those of alternative theories, in answering questions about the nature and treatment of'rnental disorder. its similarities and differences from bodily Illness, and the relation between mental disorder and brain dysfunc- non. The alternative theories considered are the mind-brain identity version of materialism, and Merleau-Ponty's conception of human beings as "embodied subjects".

Introduction

The nature of human mental life and its relation to biological life, and especially the operations of the brain, is a central theme in general philosophy. Since health care is concerned with maintaining and restoring human well-being. both mental and

E Matthews (P:) The School of DIvinity, History and Philosophy, University of Aberdeen, Aberdeen, UK e-mail. e.matthcws@abdn ac.uk

( Spnnger SctencetBusmess Media Dordrecht 2017 T. Schramme, S. Edwards (eds.), Handbook of/he Philosophy of Medicine, 00110.1007/978-94-017·8688-1_

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23 Mind-Brain Dualism and Its Place in Mental Health Care (^) 347

arguing that from the fact that one may doubt the existence of one thmg but may not doubt the existence of another, it does not follow that the existence of the latter is not dependent on that of the former), In the tennmology that he used, that meant that the thinking self was a distinct "mental substance," where "substance" meant a being which could exist independently of anything else. Conversely, he concluded that all the objects that he could think about, including his own body, constituted an entirely separate substance, "material substance," since their existence does not require the presence of a thinking substance. A human being, therefore, was a composite of two quite independent substances, mental and material, or "mind" and "body." This is the doctnne known as "substance dualism," the conception of the world, including ourselves, as made up of two types of stuff - mental and matenal. In order to be logically independent in their existence, two substances must be different in their "essences": that is. they must each have defining characteristics which are peculiar to them and not found in the other substance. Descartes argues that the essence of mental substance is thought, reason, or consciousness; that of material substance is extension, or the property of occupying space - havmg a spatial location, being able to move from one such location to another, having spatial dimensions, etc. Because these are distinct essences, nothing mental can have, say, a spatial location (e.g., a thought cannot be 2 cm from another thought); and nothing material can have any property which depends on thought (a boulder, for instance, cannot have a purpose in rolling downhill). Thus, the explanation of mental life must be different in kmd from that of processes in the material world. We can explain why someone felt angry at someone else by giving his reasons for feeling that way (he found the other's words insulting, say): but the brain processes which occurred when he felt angry - the electrochemical movements in his neurons, for instance, cannot, for the dualist, be any pan of the explanation of his anger. Equally, however, the feeling of being insulted cannot be part of the explanation of why Just these brain processes occurred then: for that, according to dualism, we need a more "mechanis- tic" explanation 10 terms of purely physical and chemical processes. One main reason which Descartes had for seeking reliable foundations for science was his conviction of the need to establish medicine on a sounder, more scientific, basis. The maintenance of health, he says in his best known work, the DIscourse on the Method, is "the chief good and the foundation of all the other goods in this life" (Descartes 1985, p. 143). If wc had a medicine which was based on a reliable understanding of the causes of the diseases and infirmities of body and mind, therefore, we could use it to free ourselves of these infirmities, and so make human beings "wiser and more skilful than they have been up till now" (Descartes 1985, p. 143). As far as the mfinnities of the body were concerned, reliable understanding, according to the argument given above, required seeing them as like the dysfunc- tional performance of a machine - a clock which could not tell the time correctly, for instance. The human (or animal) body was, after all, according to dualism, a part of matter or material substance, whose movements could be explained "mechanisti- cally," as the result of the purposeless movements of particles of matter from one position in space to another - Just like the movements of clockwork. Bodily

(^348) E. Matthews

processes, both normal and abnormal, are just physicochemical processes governed by the laws of nature, that is, according to Descartes, the laws of mechanics (see Descartes 1985, p. 139). A good example of this, which impressed Descartes greatly, was the discovery by his English contemporary, William Harvey, of the circulation of the blood. This phenomenon could be explained mechanistically, Descartes reasoned, if one regarded the heart as a pump which pushed blood round the body. Then, certain kinds of heart disease could be seen as analogous to the failure of such a pump to be able to fulfill this function. This failure will itself be mechanically caused: so, if we can discover these causes, we can hope to devise methods of curing or preventing such maladies (see Descartes 1985, p. 316). Descartes talks also of mental illness, but his account of the nature of mind makes

it hard to explain what It consists in, how it can be explained, or how it can be treated.

Mental substance, according to dualism, does not operate mechanistically: our bodies may be machines, but our minds cannot be. Their operations cannot be explained by the laws of physics, but only by reason. If we are to speak of mental

illness, therefore, it must consist in failure to operate rationally. Does it make sense,

however, to speak of a person as having reasons to think, feel, desire, or behave irrationally? In his Fourth Meditation, Descartes tries to explain why, despite the goodness of God, who does not wish us to be deceived and has given us the power of reason to discover the truth, we can nevertheless make mistakes. This is because, he says, "the scope of the will is wider than that of the intellect" (Descartes 1984, p. 40). We are, that is, inclined to rush to judgment about things that we do not fully understand. The will, however, is part of our minds and so governed by reason: how can we have rational grounds for rushing to form irrational beliefs? We could, perhaps, fail to use our powers of reasoning properly, especially about issues which require hard thought, and so get into difficulties, which could be described as mental disorders. Such disorders, however, could surely not qualify as illness in any medical sense, that is, in any sense where professional medical help is needed to help us overcome the difficulties. They require the help not of a doctor but of an educator (and some willingness on our part to make the effort to thmk more rationally).

Are Mental Disorders Illnesses?

We might, of course, simply deny that this is a problem: some would wish to deny, anyway, that there is such a thing as "mental illness," as opposed to difficulties which we may get into in our lives and which we may need help in dealing with - though not medical help. One of the best known of these "deniers" was the American psychiatrist, Thomas Szasz (1920-2012). In the book which first made him famous, The Myth of Mental Illness (1961), he proposed (as his title implies) that the whole idea of mental illness was a "myth." He had various reasons forthis view. One of the most relevant, from the present point of view, was the claim that, according to ordinary usage, a condition could only be described as an "illness" ifit is a deviation

350 E. Matthews

considered bizarre in one society, for example, are considered perfectly normal in

another. Nothing objective. like the possibilities of survival of a species. seems to depend on whether people, for instance, deludedly believe in witchcraft. If correct,

this argument implies that what we call "mental disorder" is determined not by

scientifically establishable facts but by purely subjective value judgments - by what people in any particular society generally regard as "bizarre" beliefs, or behavior, for instance. Another possibility is to say that at least some recognized mental disorders are illnesses in exactly the same sense as bodily disorders, because they represent biologically harmful dysfunctions. One much discussed version of this view was proposed in the 1970s by the psychiatrist Robert Kendell (1975). Kendell defined an illness as a deviation from normality which conferred "biological disadvantage" [Kendell 1975, p. 310). Obvious examples of biological disadvantage, he thought, were increased mortality and reduced fertility, but "other impairments" (loc. cit.) might also be included. So any failure of normal functioning, bodily or mental, which could be shown to confer such disadvantages constituted an illness. To call something a "biological disadvantage" is, of course, to make a value judgment, though one with which most human beings in all cultures would probably agree. To say that some dysfunction confers biological disadvantage is thus to say something which is objectively (scientifically) verifiable. The rest of Kendell's argument consists in giving examples of recognized mental disorders which can allegedly be shown to confer biological disadvantage and so to qualify as "illness" in a straight-

forward medical sense, Schizophrenia, for instance, can, he claims, be shown to lead

to reduced fertility. One problem with this kind of argument, however, is that it is easy to find examples of recognized mental disorders which do not seem to confer any of the biological disadvantages which Kendell lists, though they do confer what

may be regarded in some cultures but not others as social or psychological

disadvantages. A more philosophically sophisticated attempt along the same lines is to be found in a number of articles published in the I990s by the American philosopher Jerome Wakefield. Wakefield defines a disorder as a "harmful dysfunction." "Functions" here mean "biological functions," which are said to be "designed by nature" in a sense determined by Darwinian natural selection: that is, an "internal mechanism" is said to perform its function in so far as it tends to ensure individual and species survival, Success or failure in performing functions can thus be verified by objective scientific evidence (see, e.g., Wakefield 1992, 2000, 2009). The question then is whether recognized mental disorders can be fitted in to this analysis. To do so would involve showing that generally accepted examples of such disorders can be explained by the failure of some internal mechanism(s) to perform their functions as designed by nature (in the sense explained above). To do this, however, would involve abandoning mind-brain dualism of the Cartesian kind, since that is incompatible with the existence of any kind of mental "mechanisms" which might be accounted for by natural selection. To proceed any further, therefore, we need to return to the general philosophical issue of the nature of our mental life and

its relation to the brain.

23 Mind-Brain Dualism and Its Place In Mental Health Care (^) 351

The Brain and Mental Disorder

An objection to dualism which emerged very early (and was in a way admitted by

Descartes himself) is that we cannot ultimately separate "mind" and "brain," because many of our mental operations depend in one way or another on the normal functioning of the brain. Brain damage, for instance, leads to loss of memory or even a change in personality. Many of the symptoms of mental illness, such as delusions, can equally be the result of problems in brain functioning. As scientific understanding of the brain has developed over the last three centuries, more and more such interactions between brain functioning and the character of our thoughts, feelings, desires, and behavior have been discovered. The very possibility of such reactions, however, seems to be ruled out by the dualist view that our "minds" are a separate "substance," with a distinct essence, from our "bodies," including our brains. To account for them, therefore, seemed to require a philosophical shift from thmking of a human being as composed of two substances, mind and body, to thinking of ourselves as composed of a smgle substance: our mental functioning, it seems, must be just part of our bodily or biological functioning - in particular the operations of our brains. This is the position known as "classical materialism." One advantage of materialism was that it seemed to chrnmate the dualist problem of interaction: the influence of mind on body and body on mind became not the unintelligible influence of one substance on another but simply the influence of one part of a substance on another part of the same substance. Our "minds" could then be liable to disease or illness in exactly the same sense as, say, our hearts or livers. In effect, so-called "mental illness" would be just one kind of bodily illness. This view IS made exphcit in the Introduction to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders: "anachronism of mindlbody dualism unfortunately implies a distinction between "mental" disor- ders" and "physical" disorders that is a reductionistic anachronism of mind/body dualism" (American Psychiatric Association 1994, p. xxi). A connected benefit of abandoning dualist conceptions of menta! disorder was

believed to be that it made it possible to bring psychiatry into line with the scientific

approach of the rest of modem medicine. If the mind is equated, not wuh some immaterial substance distinct from anything else m the created universe but with the brain and its operations, then it seems possible to explain mental disorder as the harmful outcome of a dysfunction In "internal mechanisms" operating in the brain and nervous system. The philosopher Dommie Murphy even defines psychiatry as "a branch of medicine dedicated to uncovering the neurological baSIS of disease entities" (Murphy 2006, p, 10). This approach to psychiatry is often labeled "bio- logical psychiatry." These brain dysfunctions can then be related, in much the same way as heart dysfunctions, to biochemistry, genetics, and other sciences, to form part of the unified scientific picture of the world which modern science is believed to aspire to. Descartes had proposed such a unified science for the physical world, but excepted the mental sphere from it: materialism goes further, to mclude the mental sphere in the physical world. The philosopher Paul Churchland, an advocate of "eliminative materialism," according to which our common-sense (essentially

23 Mind-Bram Dualism and Its Place in Mental Health Care (^353)

claim is that anything mental is necessarily directed toward an object - it is "about" that object. Thus, one cannot thmk without thinking <'?lsomething or that something: a thought might be Identified, for example, as being a thought of Paris or that Paris IS a beautiful city. Similarly, any emotion must be directed toward someone or some- thing: I love my wife; I am afraid of terrorism; J admire bravery. Agarn, one cannot desire without desiring someone or something: J want that picture, I tong for your return, and so on. The argument of the anti-materialists assumes that brain states and processes are not mtentional in this sense: again, a brain state like the firing of a neuron is defined entirely by its physicochemical properties and IS not "intentional," that is, it is not defined by being about anything. We cannot identify my thought that dualism is false, for example, with any particular set of occurrences In my brain (even though 1can't have this, or any other, thought unless something goes on in my brain). What is held to follow from this, if it is correct? From the present point of view, the most important conclusion is that mental disorders (disorders of thought, erno- non, desire, etc.) cannot be completely or satisfactorily explained by brain dysfunc- tion. Brain dysfunctions do not involve subjectivity or intentionality and so cannot explain these essential features of mental disorder. To use a particular example, the mental disorder agoraphobia consists in fear of open spaces, and that fear IS necessarily experienced by someone (it is subjective), and it is defined by what it

is fear of (its intentional object is "open spaces"). It may be the case that someone

experiences agoraphobia only when their brain is In a certain state, hut being agoraphobic involves more than being in that brain state: it also requires that the person as a whole experiences certain emotions about his or her environment. What is required for an explanation of how someone comes to be in any mental state, mcluding one which is disordered in the psychiatric sense, is precisely something which will answer the question why the person is in the relevant subjective state. defined by a certain intentional relation to their world. The state of her brain cannot by itself answer that "why" question. We need also to know about the person's reasons for having these fears about being out of doors. This has implications for psychiatric treatment, since appropriate treatment must depend on the way in which we explain the occurrence of the disorder being treated. Altenng the patient'S brain state (for instance, by administering medication) cannot target the irreducibly subjective aspect of her disorder: only engaging with her reasons for having those problems can hope to do that. This is the essence of the case made by some opponents of biological psychiatry, such as the psychiatrist R. D. Laing (1971, 2010) and the clinical psychologist Richard Bentall (2004, 2009). Laing was mainly concerned with schizophrenia, which he approached from the direction of existential phenomenology, rather than that of clinical psychiatry. His approach concentrates on a sympathetic understanding of the subjective personal experience of the patient. rather than on the biological or chemical causes of the current state of the patient's brain. The patient's condition is seen as expressing an individual response to the problems of his or her existence as a human being, rather than as symptoms caused by dysfunction in his or her brain. Bentall's approach is somewhat different. He is happy to accept the relevance of biological (e.g., genetic)

354 E. Matthews

factors in predisposing individuals to mental abnormality of various kinds; but he attaches more importance to the "environmental" or "psychological" elements in the etiology of mental disorder. The assumption that "mental illnesses are genetically influenced brain diseases" has been, he argues, "a spectacular failure" (Ben tall 2009, p. 264). It has failed, in that it has contributed very little to relieving the suffering of those with the severest forms of mental disorder. A psychological approach, by contrast, would recognize, Bentall argues, "that distress in human beings is usually caused by unsatisfactory relationships with other human beings" (Bentall 2009, p. 265). That is, Bentall, like Laing, maintains that successful treatment of the mental distress of human beings must be based on a conception of that distress as a subjective response to problems which those human beings experience, rather than

as caused by a breakdown in their internal brain mechanisms.

An Alternative Account of Brain-Mind Relations

It can be argued that Cartesian dualism and classical materialism, despite their obvious differences. have something important in common and that this common element is responsible for the problems in thinking of the relation between bodily and mental illness which have been raised. Putting it briefly, the common element is a conception of the question to be asked. The question is taken to be this: in saying that human beings have a mind, are we saying that this "mind" is a thing (or "substance") distinct from and independent of the brain, or are we saying it is identical with the brain? Whichever we say, we are assuming that the term "mind" refers to a substance. Descartes's formulation of dualism makes this assumption explicit. Classical materialism is less explicit but clearly implies that "mind" refers to a thing, in identifying the mind with the brain. For this reason, some recent philosophers have called classical materialism "Cartesian materialism." Such critics of a medicalized psychiatry as Laing and Bentall can be seen as dualist in spirit, even if they officially reject Cartesianism and accept that brain states and brain processes have some relevance to the explanation of mental disorder. Their conception of mental disorder, however, rules out attributing any central importance to brain dysfunction. Laing, for example, argues that the issues lived through by

people with schizophrenia "cannot be grasped through the methods of clinical

psychiatry and psychopathology" but "require the ex istential-phenomenological method to demonstrate their true human relevance and significance" (Laing 20 I0, p. 18). In similar vein, Bentall criticizes "biological investigators" for failing to consider the possibility "that their findings might reflect the tribulations oflife, rather than some lesion or genetic scar carried by the victim from birth" (Bentall 2009, p. 152). lfmental disorders are seen in this way, as human responses to certain kinds of problems in life, then It seems we must explain them in terms of patients' reasons for finding certain situations insuperable problems, rather than in terms of the failure of their brains to function in biologically appropriate ways - that is, to offer a dualist or "mentalistic" explanation rather a materialist or "physicalistic" one.

356 E. Matthews

experience someone as a subject, however, is necessarily to experience them as embodied. A subject is a being who relates to the world both in the way material objects do (being spatially and causally related to other objects) and also in experiencing the world - relating to objects in finding them meaningful to him- or herself. A simple example would be that a human being may relate to, say, an apple, not only because the light reflected from the apple causes himlher to see the apple but also in that he or she perceives the apple as having such meanings as "good to eat," "esthetically attractive object," and so on. Being a subject and being embodied are two sides of the same coin: we can only experience the world subjectively because we are embodied in a particular way (we have senses and have a physical location in space and time from which we perceive things) and the way in which we are in the world objectively is not like the wayan inanimate (i.e., "subjectless") object is, because, as active subjects, we find meaning in the objects (including other people) around us. We are thus essentially embodied subjects. Merleau-Ponty's fullest and clearest development of this view can be found in his major work, Phenomenology of Perception (Merleau-Ponty 2012: especially Part One and references in Index to "embodiment/incarnation"). Starting with the notion of human beings as embodied subjects offers the possibility of a totally different way of thinking about mind-brain relationships and their relevance to the treatment of both mental and physical disorders, from that implicit in either Cartesian dualism or Cartesian materialism. In this under- standing, thinking, feeling, desiring, wishing, intending, hoping, remembering, and the behavior, which is explained by them, are activities of neither "minds" nor "brains" but of human beings. Because human beings are embodied, their responses to their environment necessanly involve bodily reactions, especially brain processes, changes in brain chemistry, etc., but these bodily reactions them- selves can be fully understood only as part of the human response. A human being may, for instance, feel suicidally depressed: if so, the serotonin levels in his or her brain would characteristically be lowered. This change in serotonin levels, how- ever, does not explain the depression, on this view: rather, it is part of what has to be explained. To explain why someone feels in such a mood, or any other mental state, requires us to explore what it is about the situation which leads them to see it as they do (e.g., depression may be a response to a dramatic breakdown In a close relationship). Psychotherapeutic modes of treatment would thus be central. At the same time, however, we cannot ignore the fact that depression, in a human being, necessarily involves changes in serotonin levels, so that medications which affect those levels may alleviate depressive mood. This IS also why, it might be suggested, in some cases of what we should normally call "bodily" disorders, we can, for the same reason, cite psychological responses to difficult human situations as playing a significant role, because of our embodiment, in leading to the physical problems involved. An example might be paralysis, as part of a response to psychological trauma. Merleau-Ponty discusses a number of spatial and motor disorders along these lines in Merleau-Ponty 2012, pp. IO<l-148.

23 Mind-Brain Dualism and Its Place in Mental Health Care (^357)

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