2015 Loebel Lectures in Psychiatry and Philosophy
Professor Steven E. Hyman
Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard
Series title: The theoretical challenge of modern psychiatry: no easy cure
3, 4 and 5 November 2015
All three lectures will take place between 6-8pm at the Grove Auditorium,
Magdalen College, Longwall Street, Oxford OX1 4AU (note venue can only be
accessed via Longwall Street).
Lecture 1: 3 November, 6-8pm
Title: Neurobiological materialism collides with the experience of being human.
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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
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 psychitry 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.
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.
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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.
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.
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: 4 November, 6-8pm
Title: Science is quietly, inexorably eroding many core assumptions underlying psychiatry
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A half-century of stasis in psychiatric therapeutics reflects the enormous scientific
hurdles posed by psychiatric disorders.
However, it also reveals the need for new ways of thinking and a more honest response
to evidence.
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
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.
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.
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Lecture 3: 5 November, 6-8pm
Title: What is the upshot?
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The emerging scientific picture of psychiatric illness and treatment is gaining in truth
value (within the nexus of scientific understandings).
Explanations of distress and psychopathology based on introspection and
phenomenological observations of others generally lacks truth value (from the
perspective of science).
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.
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.
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.
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.
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