In an insightful essay in The New York Times titled “Psychiatry’s Mind-Body Problem,” George Makari identifies a deep tension in psychiatry that plays out on the backs, brains, and minds of people struggling with mental illnesses including addiction.
On the one hand, psychiatry treats mental illness as a brain disease best addressed by pharmacological means. This approach tends to reduce mental illness to some physical disorder of pathology of the brain. This reduction may help to lessen the disapprobation and stigma that often accompany the diagnosis of a particular mental disorder.
On the other hand, psychiatry recognizes that mental illnesses are biopsychosocial, which means that multiple causal factors and dimensions overlap and criss-cross, hence avoiding any easy reduction to some physical brain condition.
The Mind-Body Argument
The mind-body problem is one of the perennial problems in philosophy vexing many of the All Time Greats.
Descartes could not abandon the mind-body dualism and now its legacy underpins the tension in contemporary psychiatry. Patients are often caught in this tension and as a consequence may not receive the best – or even merely adequate – care for their health.- Peg O’ConnorRene Descartes in the 1630s advanced the mind-body dualism that has left a powerful legacy. He claimed mind is an immaterial substance having dominion over the physical substance that is the body. Our mind - our immaterial self - is our essence. How the mind controls the body was the question that tormented him to the very end.
Many of Descartes’ contemporaries raised this question, most notably Thomas Hobbes and Princess Elisabeth of Bohemia. While he could never adequately explain how the mind controls the body, Descartes was quite clear that mind doesn’t control the body as a pilot controls a vessel. The pilot-vessel description doesn’t adequately capture the ways the mind experiences the sensations of the body. For all kinds of reasons, Descartes could not abandon the mind-body dualism and now its legacy underpins the tension in contemporary psychiatry.
Patients are often caught in this tension and as a consequence may not receive the best - or even merely adequate - care for their health. This tension manifests in many of the disagreements about addiction - what it is, where’s its locus, how it develops - as well as about treatment - what are the goals and what counts as effective methods. All of this is endlessly complicated by the insurance industry that exerts enormous control over medical practice.
Tension and its Impact on Care
One way to break the tension as it relates to addiction is to move everything metaphysically dodgy or not really real (mind, consciousness, self-awareness, reason, e.g.) to the physical side of the divide. This is just what Nora Volkow attempts to do in her piece, “Addiction is a Disease of Free Will.”
Volkow makes a two-fold reductionist move to the physical. The first is the more familiar one. She regularly refers to addiction as a “chronic brain disease.” She offers an additional claim making a second reductionist move. She writes:
“It isn’t enough to say that addiction is a chronic brain disease. What we mean by that is something very specific and profound: that because of drug use, a person’s brain is no longer able to produce something needed for our functioning and that healthy people take for granted, free will” (emphasis original). The problem she identifies is “the circuits that enable us to exert free will no longer function as they should.”
By defining addiction as a brain disease, the “psychosocial” features of addiction along with economic, cultural, and other “nonphysical” features are secondary to the biological/brain features. This reduction has significant implication for treatment methods. To some degree, this puts all diseases on equal physical footing such that people struggling with addiction should no longer bear special burdens or face additional obstacles in seeking treatment.
Volkow’s claim is that removing the moral stigma will effect better medical treatment; evidence-based treatments using buprenorphine or methadone for opioid addiction, for example, will become standard practice. Will these methods foreclose other methods of treatment available to medical professionals who resist the move to place everything onto the physical side of the dualism? The answer may be “yes.”
Treatment in the Future
George Makari references Dr. John Kane’s psychiatric study of first episodes of psychosis that shows “lower doses of psychotropic drugs, when combined with individual psychotherapy, family education, and a focus on social adaptation, resulted in decreased symptoms ad increased wellness.”
Would insurance companies be willing to pay when certain treatment programs are judged to be not “evidence based?” Stay tuned for how that battle plays out.- Peg O’ConnorThis is an important result that we may not see again because the National Institute of Mental Health now requires that clinical researchers focus on neural circuits or biomarkers. As a consequence, only certain treatment modalities based on a physicalist account will have the opportunity to be “evidenced based.”
It isn’t that the evidence is missing. Rather, it is not encouraging (through financial support) such evidence to be found. This has profound implications for addiction research and treatment. Would insurance companies be willing to pay when certain treatment programs are judged to be not “evidence based?” Stay tuned for how that battle plays out.
Free Will and Addiction
The move to reduce free will to a physical disease of disrupted circuits in the brain is equally troubling. Free will is another one of those perennial problems in philosophy; it is often considered an ability, faculty, or capacity to make choices that are voluntary in the sense of not being compelled by external factors. Discussions of free will tend to revolve around the relationships between motivations, self-control, and best judgment.
Determinism is often understood as the opposite of free will. Determinism in its strongest form entails that voluntariness and choice are illusory at best. Philosophers have been disagreeing whether it is possible for free will and determinism to be compatible in some senses. The stakes are quite high; most of us really do believe and act as if there is free will. On the basis of this belief, we understand ourselves to be free (hence different in kind from other physical objects in the world governed by laws of nature) and operate with conceptions of responsibility we assign in all sorts of ways and in multiple directions.
To say that addicts lack free will entails that we (and our actions) are causally determined by misfiring or hijacked brains. Our physical brain causes or drives our actions without the governor of free will. The disrupted circuits do not allow us to exert our free will. We once had free will but now we have lost it.
But where exactly is this free will located in our brains? That’s a question that has defied answer. Perhaps Volkow has conflated “free will” with “self-control,” which I suspect is the case. But even switching the focus to self-control won’t help matters any. The picture is that addicts lack the self-control to bring their (using) actions into alignment with their best judgment or what should be their best judgment.
Experience shows that many addicts have a great deal of self-control in multiple areas of our lives. The most severe addicts do maintain some degree of self-control even or especially when they need to procure their drug of choice. So when one looks to the brain to determine which circuits managing self-control have been disrupted or compromised, where does one look? And why does a lack of self-control in one area define a person as having no self-control (or free will)?
Defining Will Power
The term “self-control” is often used interchangeably with “will power.” As Baumeister and Tierney argue in their book, Will Power, will power is an ability or resource to resist temptation and pursue certain goals. It is very much an interactive process between person and environment.
Having to resist a series of temptations in one’s environment depletes one’s store of will power. Resisting the candy bowl 99 times is taxing such that on the 100th time, one totally gives over. This shows two important things:
- The first is that this person has will power and self-control.
- The second is that environment plays a crucial role self-control. Self-control has biopsychosocial dimensions, which means a lack of self-control (or will power or free will) cannot be reduced to a physical disease.
This leads me back to one of Makari’s concern - namely that the pendulum has swung far too much on the side of physicalism and pharmacological interventions with mental illnesses. This is harming patients. We need to support treatment programs that yes, target brain receptors but that also make effective use of other treatments that address the psychological and social dimensions of addiction.
In short, we need to jettison an “Either...or” approach and adopt the more robust “Both...and” approach in understanding the causes of addiction and the methods for treating it.
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