The anti-psychiatry movement and biological psychiatry have an unacknowledged philosophical issue that contributes to the disagreements between them. The issue is the problem of mind.
As is well known, Descartes believed that the mind was in the brain. For Descartes, although the mind was non-material and non-spatial, it resided in the brain, which was composed of matter. The mind interacted with the brain by thinking and willing, and the brain influenced the body to act in such a way as to fulfill the mind’s intentions (1). Descartes’ view of mind has been characterized as the “Ghost in the Machine” (2). Many volumes and articles have been written over the centuries, both criticizing and supporting Descartes’ point of view. His view that the mind is in the brain seems to be the dominant view of mind in the popular imagination as well as in neuroscientific biological psychiatry (3).
DSM-IV-TR and DSM-5 explicitly state that psychiatric disorders are within individuals (4) (5). The belief that psychiatric disorders are within individuals strongly implies that DSM endorses psychiatric illnesses as brain diseases.
Difficulties such as conflicts between family members are specifically excluded from consideration as mental illnesses in the DSM system, and are known in both DSM-IV-TR and DSM-5 as “Other Conditions That May Be a Focus of Clinical Attention: Relational Problems.” Relational problems include abuse, neglect, parent-child problems and other difficulties that occur between people. Because they do not occur inside people’s brains, but occur between people, these problems, according to DSM, do not merit the diagnosis of psychiatric disorders. DSM-5 states, “The conditions and problems listed in this chapter [relational problems] are not mental disorders” (p. 715). DSM-IV-TR has an identical comment.
This odd demarcation between psychiatric mental disorders and problems between people rests upon an acceptance of the philosophic assumption that the mind is in the brain. Problems between people are often the most painful and troubling. A more expansive and accommodative definition of mind might permit problems between people to be given the importance they deserve in DSM psychiatric classification.
There is a great deal of evidence that the mind can be found beyond the boundaries of the human brain. The nurture and development of the infant depends upon the relationship between infant and loving caregiver. The infant’s mind in good part resides in its relationship with its parent. The crucial psychological importance of figures in the external world continues throughout childhood, adolescence and adult development. Erick Erickson appreciated the central importance of culture in the lifelong psychological development of children and adults. Although Erickson did not say this explicitly, his writing strongly suggests that the culture in which people live becomes a part of their minds (6).
Classical psychoanalysis had a difficult time accounting for the influence of the external world on psychological development. Until about age four or five years, the young child was open to the influences of the external world, but with the resolution of the oedipal complex at around age five, external events had no further influence on the child’s psychological development.
Philosophers have struggled at length to develop a theory about mind that resolves the many problems left in the wake of Descartes’ writings. But until recently, the external world played a very small part in their considerations. Noe, in his book, Out Of Our Heads, has written a deceptively simple book for a general audience that argues that neuroscience and neuropsychological experiments can be re-interpreted to include a much wider role for the external world. To Noe, the neuroscience of vision, hearing, and memory can all be more adequately understood by acknowledging the role of the real external world. For Noe, mind is not in the brain but rather a relationship between the brain, the body, and the external world (7).
In mental health, the treatment ideology that best reflects the understanding that mind is outside of the individual is the family therapy or family process movement. Some schools in this treatment ideology explicitly deny an internal mind within an individual and focus exclusively on what takes place between people. This approach began almost fifty years ago; it was a provocative radical departure for its time. Family therapy is now practiced most often by non-medical mental health practitioners; it has been largely abandoned by psychiatry.
For the mental health practitioner, recognizing the salience of relationships in the patient’s life can create opportunities for therapeutic intervention that might otherwise be ignored. For example, a depressed spouse with a bad marriage who does not respond to antidepressant medication or does not want antidepressant medication may respond to marital therapy. The recognition of the importance of human relationships to psychological health and illness creates opportunities to provide more effective treatment, and enhances understanding of mental illness.
Copyright Stuart L. Kaplan, MD, 2013
Stuart L. Kaplan, M.D., is the author of Your Child Does Not Have Bipolar Disorder: How Bad Science and Good