Martin Seager argues that the scientific paradigm underpinning our mental health culture is deeply flawed. The medical model, with its emphasis on the physical and material, has been allowed to dominate our understanding of mental health and illness at the expense of the mind. Instead of being factored out as subjective and therefore ‘soft’, the mind should be factored in to scientific research. Seager argues for a marriage of mind and body, of the objective and subjective, in a genuinely holistic approach to researching and finding ways to help people who have been psychologically damaged. We need a new science that gives equal weight to meanings and relationship and the work of counsellors and psychotherapists alongside medical treatment.
Bad science and good mental health
It is, sadly, rarely even noticed that the whole scientific paradigm underpinning our public mental health culture is deeply flawed.
This goes much deeper than the so-called medical model. After all, if there were a medical ‘model’, we would be constantly testing it against other models, wouldn’t we? The truth is, we don’t hypothesise that the suffering we call ‘mental’ has a physical basis; we simply assume it. But what if the whole medical paradigm were completely and demonstrably false? This is not anti-psychiatry revisited but a much deeper and broader questioning of the science.
The reason why the medical model of human suffering continues to thrive unquestioned is that it is part of an even bigger physical, materialist model that prevails, at least in the Western world. In the West, we think that the universe is made up of quantifiable or tangible matter and that mind, if it exists at all, is just a by-product of matter. Why matter would need such a by-product in a wholly physical universe is ignored. We still believe either that our minds are located physically inside our brains or that our minds and our brains are the same thing. We also think that subjectivity (mental life) is a dirty word: an obstacle to the ‘objective’ (physical) truth that must be ‘factored out’ of science.
In the West, we imagine we can stand back from the universe and discover what everything looks like ‘objectively’, from the outside in.
This depersonalising or ‘mindless’ assumption creates an irreparable rift between what is seen as ‘hard’ (brain) and ‘soft’ (mind) data on mental health. But what if this assumption is wrong? What if, far from being factored out of science, the mind needs to be factored in? In the East, thinkers have been more likely to look at themselves (and their minds) as an integral part of the natural world; their perspective looks from the inside out.
Physicists are beginning to realise that you cannot study matter or energy without taking account of the mind dimension. For example, the different ways in which light is observed produce different results. Light can be a wave and a particle at the same time. Something can also have the value of one and zero at the same time. In other words, the universe is not a simple binary tale of definite objects and the spaces between them (something that Western science has believed since the early Greek philosophers).
All observation has, by definition, to be subjective. No human theory, thought, judgment or conclusion can be free of the mind. There is no such thing as a purely physical science, independent of psychological factors. As was so beautifully described in Persig’s Zen and the Art of Motorcycle Maintenance,1 quality can never be reduced to quantity. Subjectivity, far from being an unwanted bias, is at the core of all our understanding. Any attempt at objectivity always depends on subjectivity. Whether ‘mind’ is then an energy force, a dimension of the universe, dark matter or even the recently detected Higgs boson, it is not reducible to physics; it is a core factor that we need to include in our calculations about the universe.
This is not a Cartesian split or compromise but recognition that all science has a mind dimension, or a meaning dimension. Science itself is a mental and meaning-based activity. Meaning (mind) can never be reduced to mechanics, or vice versa. For example, the meaning of words goes beyond their physical forms, which are arbitrary; the meaning of a piece of music goes beyond the physical arrangement of the notes; the experience (meaning) of the colour yellow could never be derived just from an understanding of light and retinal cells. Human minds can therefore never, by definition, be directly measured quantitatively or ‘objectively’. A mind can only be measured by another mind (empathy). This means honouring subjectivity, not factoring it out. By studying the brain we learn almost nothing about the mind, regardless of the correlations between the two.
So, far from being identical, mind and brain are working on different levels. Although clearly interconnected, the one can never be logically inferred from the other.
How much more, then, should the mind be directly at the centre of research into problems that we actually label ‘mental’? Once the mind is factored in to science, we can begin to do exciting things such as (re)connecting science to art and religion. We can also arrive at a properly integrated scientific model of the human condition that is hinted at these days in the terms ‘holistic’ and ‘bio-psychosocial’.
Flaws in the mental illness model
Once we look at the broader science in this way it becomes easier to spot the massive flaws in the medicalised assumptions behind the evidence base that we are increasingly being forced to follow in our public mental health services.
IAPT itself (the Improving Access to Psychological Therapies programme) reflects the bad science endemic in our traditional mental health culture, which is itself full of mind-blindness. For example, IAPT:
- treats mental conditions as if they were separate entities instead of addressing the universal needs of the human condition
- ignores the core value and impact of the meanings and relationships that are formed in the mental health system
- emphasises surface differences between therapy brands rather than their deeper commonalities and universalities (for example, that empathy and relationship factors predict therapeutic outcomes much better than therapy brands or techniques)
- manualises therapies as procedures and protocols and prescribes them in doses like drugs rather than recognising that people need to form personalised relationships
- assumes that medical care only works for medical reasons and not for psychological ones
- assumes that psychological care and love do not change the human brain.
A pseudo-science has taken root, creating ‘objective’ guidance that belies most of our daily subjective experience of troubled people. NICE guidance makes the unsupported core assumption that people suffer mentally from discrete, diagnosable medical conditions rooted in genetic vulnerability and triggered by stress, requiring discrete evidence-based treatments. Below are four illustrations that refute this irrational belief system.
Mourning was something that Freud long ago recognised as the psychological blueprint for all mental distress. Grief can and does literally kill people when those whom they love very dearly are taken from them. How many older people die soon after the loss of partners with whom they have shared many years, or after the death of children whom they have outlived? But what is the science behind this? How can it be explained biologically? In biological terms, the body of the mourner has not been directly damaged or affected by the death of the loved one. Equally, bereavement is an independent event that cannot be causally attributed to anything going on in the DNA of mourners. What physical mechanism can be invoked to explain this sudden deterioration in the mind and body of the bereaved person? What physical explanation could there be for the loss of the will to live in many of those who grieve? Quite obviously, it is the meaning of the loss that is so powerful and critical.
Similarly, orphans who are fed and clothed but not loved can fail to thrive and so die. This effect can also be seen in old age, where loneliness and emotional neglect may hasten death. Unless we work with the meaning of human attachments, we cannot truly help those who suffer any loss or unhappiness. The meaning of loss can only be measured on a mind dimension by empathy in a relationship and this requires attunement, or subjective resonance, between one mind and another. Such attunement cannot be achieved simply by the use of a textbook, prescriptive protocol or evidence-based brand of therapy.
Similarly, biology cannot provide a causal mechanism to explain why something that does not hurt us physically can hurt us so badly emotionally and lead to serious changes in our health, both mental and physical. Again, it is not so much the physical properties of a trauma or shock (eg the noise and image of being shot at) that cause this major change in our health; it is the meaning of those physical events. The same physical events could indeed be simulated by actors with nothing like the same level of trauma or distress, because the meaning would be different for the participants.
Our society is beginning to allow for a vague concept of emotional abuse and emotional damage in childhood and in later life. For example, we recognise that verbal (including cyber) bullying can lead to a state of depression and even suicide in some cases. However, the massive scientific implications of this are not yet being followed through. There is a distinct lack of curiosity as to how, if mental health is ultimately biological, words and social meanings can be more powerful than the proverbial ‘sticks and stones’. The reality is, of course, closer to being the other way around. Words and meanings cause brain chemistry to change more than brain chemistry dictates our meanings and communications. This is why the whole research paradigm that separates and compares drugs and talking treatments is poor science. Talking and the meanings conveyed by talking change neurotransmitter activity and brain chemistry. Equally, drugs can never be prescribed without a relationship context that has a meaning and a psychological impact.
The biggest and most obvious problem for a biological model of mental health is its inability to explain why people defy their survival instinct by destroying their own bodies, either as an act of self-sacrifice for others or simply as an end to personal existence. Biology can only offer the inadequate explanation that people who kill or sacrifice themselves have evolved to do so for the protection of others with whom they share genes or DNA. This selfish gene theory2 cannot explain the majority of suicides, where no one else is protected. Nor can it explain the majority of human self-sacrifice, which takes place for wider religious and political causes, rather than for the protection of small families, groups or tribes who might share gene material. Evolutionary biology simply cannot explain the meaning and the spiritual dimension of human acts.
Nature and nurture
We can go further and state that the brain itself, the core plank of biological mental health theory, although built physically from a blueprint in our DNA, has evolved primarily for the psychological functions of learning and adapting. Gene expression, brain development and brain process are all highly dependent on experience. If the brain was already hard-wired to make us act, think and feel in particular ways, there would be no point in our species evolving a lengthy period of childhood and education across all cultures.
The whole point of the brain is to learn from experience. This means that nurture and nature are interwoven, not opposites. Experience, however, can only be measured at the level of mind, not brain. In mental health, therefore, talking is the ‘royal road’ to change because only communication and relationship can change meanings. Psychotropic chemicals can play a valuable role by acting directly and quickly on the brain when someone is overwhelmed and unreachable verbally, but drugs can only create short-term relief while they are present in the blood stream; they cannot alter the longer-term meaning of a person’s life. This means that long-term medication treatment for mental health conditions will often lead to addiction or dependency, rather than cure or change.
The search for the holy grail of a genetic basis for mental disorders is therefore doomed. Ironically, it continues primarily for reasons of tradition, prejudice, professional status, economic profit and blind faith rather than science. It is also conveniently forgotten that most physical disorders do not have a clear-cut genetic basis. Whether we get or do not get physically ill depends largely on a whole array of environmental factors and experiences to which we are exposed both during the developmental period and in adult life. Returning to grief again, the rates of cancer are much higher in the bereaved than the non-bereaved when matched for age and other variables. This in itself should tell us all we need to know scientifically about the direction of causation of human disease and suffering. Even our immune systems are dependent on our state of mind and our state of mind (even our very will to live) is dependent on the meanings that our lives have for us.
All this means that Abraham Maslow’s famous hierarchy3 is, if anything, the wrong way round. Maslow argues that, once we have achieved bodily wellbeing, we can then concentrate on the meaning of our lives and our spiritual wellbeing. If this were true, then suicide would be almost unheard of; it would be a fundamental violation of the primary survival instinct. It is truer to say that if our mental and spiritual needs are not met then a mere physical existence is not enough for our species. Great physical hardship can be endured if there is a spiritual purpose, but without such a purpose a physical existence is often given up. Of course, the whole idea of a hierarchy is probably false in any case. Body, mind and spirit are interwoven.
In 2006 I was invited by the Department of Health to lead an advisory group to explore the universal psychological needs that underpin the human condition, so that these might begin to inform standards of care in our mental health services for all professions, not just psychological therapists. I recruited a group of eminent colleagues from a broad range of psychological approaches (including cognitive-behavioural, psychoanalytic and systemic/family) precisely to delve deeper than therapy brand differences, into the core science of human mental wellbeing. We came up with a paper in 2007 that identified five universal and core psychological needs of the human condition:4
- to be loved (attachment)
- to be heard (empathy)
- to belong (home, family, identity)
- to achieve (fulfillment)
- to have belief in something and hope for the future (meaning).
If these needs were not met, any one of us would deteriorate mentally. This is not because we would contract a mental condition but because we are subject to the human condition. Clearly, these needs are particularly critical during the developmental years, but they need to be maintained in adulthood too.
Once we accept these fundamental psychological needs, it becomes obvious why art and religion have always played such a huge role in all human life and culture. Nearly all songs are love songs. All novels, plays and films invite us to empathise and identify with fictional characters. All religions, at their best, invite us to empathise with other minds and to recognise that our fellow humans also share these same needs. If mind is a valid dimension of the universe and not simply a fictional by-product of our brains, then the spiritual nature of our species can be said to tap into a wider spiritual dimension of the universe itself. Whatever the exact configuration, therefore, art and religion cannot be regarded as ‘soft’ subjects, outside a true science of the human condition. Rather, they provide a rich source of data for that science.
Counselling and talking therapies have a special place in the science and practice of mental health care, because they tap directly into the psychological needs of the human condition for people who have been psychologically damaged and disadvantaged. Carl Rogers, one of the fathers of counselling, originally identified the highly important triad of empathy, warmth and genuineness. This is indeed what babies need from birth and we all continue to need throughout our lives. It is important therefore for counsellors to retain belief in the human value of what they are doing every day, as well as the scientific.
However, the implications of this go much further. If we are able to identify universal human psychological needs then we should not be waiting to address them reactively in our clinics and mental health services. We should be using this knowledge proactively to inform our vision and policies on how to build healthy families, communities, schools, businesses and societies. One of my personal heroes is John Snow, the 19th century public health doctor who, instead of trying to cure people falling sick with cholera, sought out the source of the epidemic. By simply removing the handle from the public water pump in Soho, he prevented people catching the disease in the first place. In the same way, we can use these psychological principles to prevent epidemics of poor mental health in our fragmented society. Once we realise that love attachments are the building blocks of human wellbeing, we are able to take a more psychologically-minded view of how best to support parents, teachers and other adults in society to nurture future generations of happier children.
Martin Seager is a clinician, lecturer, campaigner, broadcaster and activist on mental health issues. He studied at Oxford University, Edinburgh University and the Tavistock Clinic and has worked in the NHS for nearly 30 years. He is currently also an adviser to the central London and national Samaritans. This article is based on a presentation to the BACP Healthcare division conference in York, May 2012. Martin would welcome reader’s responses: email him at firstname.lastname@example.org
1. Pirsig RM. Zen and the art of motorcycle maintenance. New York: William Morrow & Company, 1974.
2. Dawkins R. The selfish gene (2nd revised edition). Oxford: Oxford University Press, 1989.
3. Maslow AH. A theory of human motivation. Psychological Review 1943; 50(4): 370–396.
4. National Advisory Group on Mental Health, Safety and Well-Being. Towards proactive policy: five universal psychological principles. Unpublished paper, 2007. Available from the author.