Loebel Lectures 2015

Lecture 1 of 3:  Neurobiological materialism collides with the experience of being human  

i. The mechanistic explanations of neuroscience pose, in a new form, an age-old challenge to our ineluctable experience of the freedom of our ideas and intentions and their causal efficacy.

a. This is not simply an academic debate

b. This collision plays out with real consequences in systems of criminal justice and in psychiatry.

i. Courts have resisted expansion of mechanistic explanations because Western justice is based on a concept of moral agency that requires freedom of choice and action. 

ii. Nonetheless, increasingly sophisticated mechanistic understandings are slowly gaining traction

ii. Psychiatry poses a more complex case: Mechanistic explanations of thought, emotion, and behavior have been both welcomed and reviled. 

a. Mechanistic explanations have been seen as a path to better understanding and treatments and as freeing the mentally ill from unfair attributions of moral weakness. 

b. Others see the same explanations as dehumanizing. 

c. By offering new views on strange and frightening behaviors neurobiology has been seen as destigmatizing. Conversely neurobiology has been seen to create a picture of a hopelessly different brain, thus contributing to new forms of stigma. 

d. Proponents and antagonists of neurobiology in psychiatry give very different answers to the central questions of how a person came to be a certain way and what can be done to make things better.

iii. Psychiatrists are not immune to the cognitive distortions invited by intuitive Cartesian dualism.

a. Too often conditions that are simplistically attributed to genetic or other strong biological causes are falsely seen through a filter of determinism and hopelessness: “you can’t change your genes”. Conditions attributed simplistically to lived experience are seen, often falsely, as more malleable.

b. Conditions ascribed to biological causes are often wrongly thought to be treated best with medicines or neuromodulation. Conditions ascribed to lived experience are often thought to be treated best with psychotherapy.

iv. The credibility of psychiatry has been damaged by premature claims of mechanistic understandings and by closed minded resistance to the implications of genetic and neurobiological discoveries.

a. Unyielding theoretical stances put patients at risk of poor clinical decision-making

b. The use of patients as theoretical cudgels was illustrated by some notorious cases and, in the U.S., law suits during the 1970’s and 1980’s.

v. Currently clinical pragmatism has become increasingly dominant in psychiatry, to the benefit of clinical care. 

a. However, emerging science is significantly disconnected from the clinic.

b. Moreover, the theoretical underpinnings of psychiatry remain weak, dealing poorly with the intersection of mechanistic views with human intuitions and experience. I will address this weaknesses in the third lecture.

Lecture 2 of 3:  Science is quietly, inexorably eroding many core assumptions underlying psychiatry 

i. A half-century of stasis in psychiatric therapeutics reflects the enormous scientific hurdles posed by psychiatric disorders. 

ii. However, it also reveals the need for new ways of thinking and a more honest response to evidence. 

iii. Psychiatry has yet to grasp the complexity that lies at the heart of human cognition and behavior as well as psychopathology.

a. There are few, if any, main effects in the genesis of psychopathology

i. Hundreds, perhaps thousands of genes, contribute small incremental to the pathogenesis of mental illness

ii. Current ‘candidate’ gene by environment approaches are still reductive heuristics, not explanations of psychopathology.

b. Overly reductive pharmacologic and endocrine models persist in academic research despite contrary evidence, as do failed animal models rejected by industry.

c. Linear, causal psychological narratives may be comforting, even helpful, but are not veridical

i. Motivation and decision-making are opaque to introspection (as Freud knew, but lacked the tools to investigate).

ii. Cognitive and computational neuroscience are beginning to draw a better picture

d. The DSM classification, based on drawing a large number of fictive categories, has proved damaging to science 

iv. Epochal technological advances (genomics, computation, stem cell biology, genome engineering, microscopy, and brain-machine interfaces) are fundamentally changing the science relevant to psychiatry; new ideas are following from technologically enabled observations.

v. The complexity is humbling, but the emerging picture of psychopathology will be one of biological mechanisms, whether of molecular targets within protein complexes (cellular machines) affected by drugs, or synapses and circuits affected by cognitive therapies, adaptive therapies, or neuromodulation.

Lecture 3 of 3:  What is the upshot?

i. The emerging scientific picture of psychiatric illness and treatment is gaining in truth value (within the nexus of scientific understandings).

ii. Explanations of distress and psychopathology based on introspection and phenomenological observations of others generally lacks truth value (from the perspective of science).

iii. The problem for psychiatry is that it must make diagnoses and administer treatments for problems that are deeply involved in subjective experience, introspection, and personal narratives.  Psychiatry fails if patients (and their families) are expected to see themselves as machines.

iv. I would add that human subjective narratives and intuitions of agency qualify as more than ‘mere’ illusions: The experience of lacking agency is a well validated and measurable stressor or in other cases a psychotic delusion.

v. Psychiatry must find a way to be better rooted in science, which it should see as provisionally true (in the sense that we will learn more) and to recognize the implications of complexity. At the same time clinicians must also empathize with the human beings who are their patients, and respect their whose direct subjective experience of illness. Unlike the psychiatry of the late 20th century, we must not choose sides; all patients the best outcome of being objects of science and human beings with subjective experience.

vi. I will present a theory that does not elide the differences between mechanistic neurobiology and subjective human narratives, but that requires clinicians to switch their gaze as the situation demands and as they can.

One-day Workshop

This workshop aimed to provide commentaries and discussion of the themes of Professor Steven Hyman's Loebel Lectures, 'The theoretical challenge of modern psychiatry: no easy cure', which took place on the evenings of 3, 4 and 5 November 2015.

Thank you to our workshop speakers for their commentaries and reflections on Prof Hyman’s lectures.

We gratefully acknowledge the support of our sponsors, the Society for Applied Philosophy and the Oxford Martin School.

Programme

09.30-10.00 Arrival and Registration
10.00-10.45 Barbara Sahakian
10.45-11.00 COFFEE BREAK
11.00-11.45 Tim Thornton
11.45-12.30 Liz Meins
12.30-14.00 LUNCH (a sandwich lunch will be provided)
14.00-14.45 Derek Bolton
14.45-15.30 Sanneke De Haan
15.30-15.45 COFFEE BREAK
15.45-16.30 Jonathan Glover
16.30-17.00 Open Q&A with Hyman