Author: Matthew Blakeway

Psychiatrists talk about the “medical model” of mental illness, and yet no such model exists as other scientists would understand it. In science, a model is a hypothetical representation of the relationships between phenomena that permits scientists to make calculations, predictions and comparisons with empirical observations. To illustrate this it is helpful to describe how scientists from diverse disciplines use them.

Meteorologists use models to predict future weather. The inputs are millions of data points including temperature, pressure, wind and tides. The models connect all this data into patterns from which expected future weather systems are extrapolated. The models are complex and messy, in part because generations of meteorologists have tweaked and manipulated them whenever new wrinkles in weather patterns are observed. However, if the predictions are approximately right, everyone is happy.

Physics, by contrast, creates models of sparse minimalism, inputting basic atomic building blocks, such as mass, charge and force, and connecting them using advanced mathematics to explain theories of the universe. A model of particle physics projected the existence and nature of the Higgs Boson long before it had been observed. Its later discovery, complete with the predicted qualities, demonstrated that the theory was likely correct, and the model accurate. Unlike meteorology, approximate accuracy in physics can mean being wrong.

These two modelling approaches represent two ends of a spectrum, but psychiatrists’ “medical model” of mental illness fits nowhere on this spectrum. Perhaps that is why it is usually written with inverted commas.

R W Pies highlights psychiatry’s confusion by describing three different understandings of what the “medical model” represents. The “hard model”, assumes that a mental illness is a brain disease that is a form of physical illness. Pies rejects such a model since it pathologises a wide range of human psychological experience. However, the hard model assumption underlies much of neuroscience’s research into schizophrenia, for example, where they seek correlations with gene or brain abnormalities.

Pies’ second version was set out best by the philosopher Murphy, who described mental illnesses as, “regularly co-occurring clusters of signs and symptoms that doubtless depend on physical processes but are not defined or classified in terms of those physical processes.” This conception, says Pies, is the foundation of the Diagnostic and Statistical Manual. Essentially, this model says that mental illness is like a disease, purely because it has observable symptoms.

The third version Pies mentions is how most practicing psychiatrists understand it. Shah and Mountain ignored biology and focused on treatment as, “. . . a process whereby, informed by the best available evidence, doctors advise on, coordinate or deliver interventions for health improvement.” This view relies on circular reasoning, appearing to state that mental illness follows a medical model purely because doctors treat it.

All these descriptions share one failing: no other scientist would recognise them as models at all. What are the input factors? What are the relationships between phenomena that they describe? There has been no model of psychiatry (medical or otherwise) because there has been no theory. Psychiatry, at its current stage, is comparable to physics before Newton or biology before Darwin, merely describing phenomena without providing explanations. The “medical model” is a forlorn finger pointing in the direction from where it is hoped the explanatory theory will eventually come.

In The Logic of Madness, I described a true model of mental illness that is not medical, but logical. In the syllogism “Fido is a dog; all dogs go meow; therefore Fido goes meow” the initial view is that the second axiom is factually false. Since this is logic, it would naturally follow that the conclusion would be false, and this would appear to be the case if Fido is indeed a dog and not a cat. However, there is a second interpretation: If I am of the belief that the word “meow” is the correct word for the sound that a dog makes, then the second assumption “all dogs go meow” is factually correct, but for an error of language. And since this is logic, it follows that the conclusion is also factually correct, but for that same error of language. If Fido is a dog, it would indeed make a sound that I (and only I) call “meow”.

Putting this into a human context, a psychiatrist might encounter a patient who chews razor blades (to pick an intentionally obtuse example). The patient might say “I want to be happy; chewing razor blades causes happiness; therefore, I will chew razor blades”. A conventional reading is that the idea that chewing razor blades causes happiness is irrational, and the psychiatrist would likely think the patient mentally ill. But what is irrationality? Is it an absence of reason, or could it be that there is a reason that other people cannot see? Here, we can deploy the second interpretation of the Fido syllogism: if the word “happiness” is an error of language, it is possible that the statement “chewing razor blades causes happiness” could be a factually true statement, but for that error of language. This would make the resultant action a rational response to a mis-identification of an emotion. Misunderstanding our own emotion can have bizarre and dramatic consequences.

Emotions are biological mechanisms found in social animals: a set of circumstances (for example, danger) triggers a mechanism (fear) that causes an action state (running away) and a behaviour state (a grimace). The action state promotes survival, and the behaviour state is a signalling mechanism to incite similar survival responses from other members of the social group.

The primatologist Franz de Waal observed chimpanzees and recognised that anger is a mechanism for punishing cheaters in social obligations. It is therefore a regulator of animal societies. But observing this in humans is difficult because we use tactical deception with the behaviour. Emotional behaviour may be either suppressed, or affected by individual humans for tactical reasons, and this deception can become habitual. Emotional behaviour in humans therefore does not correlate with biological stimuli, making scientific analysis impossible. This diversity is seemingly so great and random that many humans (including some scientists) think of emotions as mystical.

Ultimately, we can only understand an emotion by observing emotional behaviour, but we all live in a social environment where that behaviour has been manipulated. In essence, most of the behaviour we observe is false data. Observations of manipulated behaviour make us derive a false understanding of our emotions. Understanding how humans can misunderstand their own emotion requires us to consider, in the abstract, how each form of tactical deception changes our understanding into a misunderstanding. The separate forms of misunderstanding can then be tabulated systematically. Elevating this to higher levels of complexity enables us to deduce the misconceptions that result in the anomalous responses that psychiatrist see every day in their patients.

We can construct a true model of mental illness where the inputs are biological descriptions of emotions and evolutionary theory. And the principal analytical method is logic. Deception with emotional behaviour causes misunderstanding of the emotion, and how this will lead to dysfunctional action can be analysed by deduction.

References:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edition. Washington, DC: American Psychiatric Association; 2013.

Blakeway M. The Logic of Madness: A new theory of mental illness. York: Meyer LeBoeuf; 2016.

Darwin C. The Expression of Emotions in Man and Animals. In: Wilson EO. (ed.) From So Simple a Beginning: Darwin’s Four Great Books. New York: WW. Norton & Company; 2005.

de Waal F. Chimpanzee Politics: Power and Sex among Apes. Revised Edition 2000. Kindle Edition. Baltimore and London: John Hopkins University Press; 2007.

Murphy D. Philosophy of psychiatry. In: Zalta EN, ed. The Stanford Encyclopedia of Philosophy. Spring 2017. plato.stanford.edu/archives/spr2017/entries/psychiatry/

Pies, R. W. Hearing Voices and Psychiatry’s (Real) Medical Model.
Psychiatric Times. August, 2017.

Shah P, Mountain D. The medical model is dead – long live the medical model. Br J Psychiatry. 2007;191:375-377. bjp.rcpsych.org/content/191/5/375.full

Allen Frances wrote an Op-Ed in the New York Times ‘An Eminent Psychiatrist Demurs on Trump’s Mental State’ expressing the opinion that Donald Trump does not meet the criteria for narcissistic personality disorder. He bases this view upon the assertion that he cannot have the condition because he does not suffer from distress and impairment. His argument has three flaws:

He claims authority for his view because he wrote the criteria for narcissistic personality disorder for the DSM-IV. This is just a drafting exercise and his claim that he knows what the condition is because he wrote the criteria undermines a vast literature on the subject. The claim is a tautology along the lines of “I know I am right because I said so”.

Secondly, the general criteria for personality disorder requires “distress and impairment in social, occupational, or other important areas of
functioning”. He is no position to claim that Trump does not experience this. Narcissistic personality disorder is usually egosyntonic, meaning that narcissists like the way that they are. They believe that everybody else is also obsessed with obtaining admiration, and if they have achieved this aim then everybody else is envious of them. They rarely seek therapy and, when they do, they resist and manipulate the therapist who they see as undermining what makes them great. Psychiatrists who only treat patients who voluntarily consult them have systemic sample bias–all their patients self-identify as distressed and impaired. If people with egosyntonic personality disorders do not so self-identify, why did Frances include such conditions in DSM-IV at all?

Lastly, he criticises those psychiatrists who breach the ethical constraints against diagnosing celebrities at a distance. And yet he is also doing this. He supposes that Trump does not suffer distress, but he cannot know this without examining him. Narcissism is a defence mechanism that conceals an inner state of rage, emptiness and intense envy. His assertion that Trump does not experience this is diagnosing at a distance. He also cannot say that Trump is not impaired. Trump is unique among narcissists in that his wealth has enabled him to purchase the admiration that he craves, and he has been able to mask his impairment by acquiring unlimited sycophants and fixers. But his brief career in politics is already revealing that his unreasonable belief that he knows more about foreign policy than the State Department and more about security threats than the CIA is leading to undeniable severe impairment.

Link to referenced Op-Ed

Imagine you are teaching a small child a word for an emotion. You might start by saying when the child is naughty “your mother is angry”, and when you do this you refer the child to an attribute of the mother, namely a behaviour state. On another occasion, you might ask the child “why are you angry?” when it displays that same behaviour state. Without the behaviour state, we could not know that another person was angry. The ability to compare our behaviour with that of others is necessary for the process of giving a name to it, but that is not the reason for the behaviour.

Charles Darwin explored this in his least read book “On the Expression of the Emotion in Man and Animals”. Emotional expression exists in many mammals, particularly social mammals and serves as a signalling mechanism that enables animals to communicate intentions, desires, warnings, etc. This is very necessary in social mammals that don’t have language. Humans have evolved language, but still retain the emotional expression.

Later, you might ask the same child “are you feeling angry?” and piece-by-piece the child builds a concept of anger that we could describe with the following diagram:

We can separately think about how a scientist and a child each understand this. The scientist can draw upon evolutionary theory, the study of this in animals such as chimpanzees, and observations of humans. I drew the “feeling state” in a dotted line box to indicate that no scientist understands its nature. It is a state of consciousness and this remains a thorny philosophical problem. I also drew the associated arrow as a double headed dotted line because nobody knows which direction the causality flows. Strangely, anger is much easier to understand in chimpanzees: I groom your fleas; you do not reciprocate; I jump up and down and scream at you. This simple point is difficult to determine in humans because they manipulate anger behaviour tactically, often suppressing it in particular circumstances. From a scientist’s perspective the link between causal trigger and the behaviour state is patchy at best and immeasurable at worst.

A child understands this within the context of their family. However, it is clear that anger is a mechanism for punishing those that cheat in social obligations and is essential for regulating the interactions of social animals. For the child, it is a mechanism for teaching it what is and is not permitted, and for the child to make it clear when others are cheating.

Let us now consider how this works in a family that habitually suppresses the behaviour associated with anger. If the behaviour is the only means of identifying the emotion, then that identity is uncertain. However, the child will only suppress the behaviour itself when it is trained to do so, so initially it will display the behaviour. Imagine that a parent reacts by saying “Such behaviour is shameful!” Two things are happening here: firstly, the parent is training the child to suppress the behaviour; and secondly, they are suggesting the name of another emotion, shame, in circumstances where the child is lacking behavioural clues for the emotion because he or she is living in a family of anger suppressors.

If this happens for two emotions separately, then it is possible that the child can grow up mistakenly recognising anger as shame, or some other mistaken pairing. How will this affect them in adulthood?

A chimpanzee reacts to a stimulus and has a limited ability to second-guess that reaction. But a human has a number of capabilities that the chimpanzee does not have: naming emotions (possibly incorrectly); manipulating behaviour tactically; and predicting future emotion (also possibly incorrectly). Actually, a chimpanzee has a limited ability to suppress behaviour, but probably no ability to affect it. This enhanced ability to understand our emotions (and therefore to misunderstand them) creates all sorts of complications for humans. Human reason depends upon an ability to predict the future and understand how we will react to it. The invention of agriculture required us both to predict that food would be scarce in winter and to understand that this would mean that we would be hungry. A chimpanzee won’t seek food until it is hungry, but a human predicts future hunger and calculates the action it needs to undertake now to avoid its future occurrence. This could mean planting seeds or going to the supermarket.

Imagine that the child in our example is calculating the action it needs to take to avoid future anger, but it is misidentifying that emotion as shame. It will calculate the wrong response to that predicted future; most probably it will withdraw for fear of doing something that prompts the disapproval of others. You might imagine that this would only happen occasionally, but this is a person who suppresses anger and therefore lacks a mechanism for punishing the asocial actions of others. They are therefore likely to be the target of them more and to have no means of dealing with it. Therefore, they feel its consequence more severely.

They convert the anticipation of asocial actions of others into the avoidance of the disapproval of others. This is a set of symptoms approximating avoidant personality disorder.

There is no scientific hypothesis as to the cause or structure of personality disorder. But if this logical hypothesis is correct, that would not be surprising. The deviant actions of the patient are triggered by an anticipation of a future emotion––something that a scientist cannot see or measure. We cannot ask the patient why they are reacting as they do because the reaction is to a misidentified emotion. There is no empirical way of determining that the patient is doing this because the only evidence of an emotion is someone else is behaviour. And this patient is suppressing it both for the emotion being misidentified and for the emotion that they think it is. All the causal elements are invisible and a scientist without data is like a fish out of water.

Many emotions drive the rectification of a bodily need – for example, hunger drives seeking nutrition. Nutrition is a finite upside and the strength of the urge is proportional to the urgency of fulfilling that need. There is very little that science can say on this because it is impossible for a scientist to measure the strength of the urge. That can only be seen in the consciousness of the urged. When two urges that drive seeking a finite upside coexist (say you are hungry and tired) then the relative strength of each urge determines in which you order you will seek to rectify the respective bodily need. We could say that the greater urge is dominant.

Some urges drive escaping an imminent infinitely negative outcome that we usually call death. If two urges coexist, where one drives seeking a finite upside and the other drives escaping an infinitely negative downside (say you are tired whilst fleeing a predator), then the former can never dominate the latter. And the simplest way to ensure that this does not occur is to switch off all emotions that drive actions with finite upsides. I speculate that this switch is a primary function of dopamine in the human brain.

When you experience the dopamine rush that you get on a rollercoaster, it might feel like a euphoric positive emotional experience, but it probably arises through the simultaneous switching off of all negative emotions (hunger, tiredness, pain, etc.). Your brain interprets the steep drop down the initial swoop of the rollercoaster as a near-death moment, and it responds by switching off all awareness of such negative emotional experience. It is quite difficult to come up with an explanation of the evolutionary origin of a positive emotion.

Humans seek emotional fulfilment through acts of pure imagination (e.g. imagining being in bed with the object of your sexual fantasy, or having an imaginary friend). Another seemingly paradoxical way to achieve this might be to imagine a near death experience. It is conceivable that, by doing this, you could train yourself to trick your brain into releasing dopamine, and you could do this at will. This would achieve a euphoric emotional rush – the best conceivable emotional outcome. If human wellbeing is measured in emotional outcomes, then it is rational to do this. In fact, once you had perfected the technique, it would be rational to do it for all your waking hours. People who are not psychotic tend to imagine that the manic phases of someone with psychosis must be hell. But imagining hell may be the whole point. If that is the case, then psychosis is a motivated self-deception with the rational objective of seeking a favourable emotional outcome. Psychotics often say that they only feel truly alive when manic.

It is a source of frequent frustration for psychiatrists and family members of psychotics that they relapse by refusing to take their medication. But if this model of psychosis is correct, then it is even rational to stop taking your meds, since the “cure” is cutting off an avenue to positive emotional experience. Only the psychotic can know whether this is a price worth paying or not.

The French philosopher and economist Jacques Attali[1] predicted in the 1970s that the music industry would collapse. He was proved right within twenty years. If something is freely or cheaply replicable, then economic theory will predict that its value will trend towards zero. Even before the digitisation of music, we were able to record our friends’ vinyl LPs on cassette, and the ability of musicians to earn a living from recorded music was doomed. So it turned out to be. And musicians today earn less and less from selling recorded music. As a writer, I am acutely aware that it is getting harder to make a living, even in a world where people are reading more.

Attali is now making the same predictions about manufactured goods. 3-D printing is still a relatively new technology, but it opens the door to being able to scan any object into a 3-D printable file and to email it. Any manufactured product is now infinitely reproducible, so its value will fall to zero. It isn’t inconceivable that we will soon be able to upload the 3-D printable files for a car or refrigerator that we can print at home and assemble Ikea-style. We could then tweet the link so everybody can have one.

At first glance, this all sounds like an impressive advance of technology. But actually, it is anti-technological – just like music streaming is anti-creative. The incentive to invent a better car or refrigerator is to make money, but if as soon as you have done so the value of the inventor’s work is zero, then all hope that the inventor has of making money evaporates. So what is the point of innovation?

We could argue that the same argument applies to inventing a new music genre. We like to think that people will continue to do this for the love of it. But I remember a time (not long ago) where all waiters and bar tenders in New York City were aspiring actors, musicians or artists. They could survive on three shifts a week and devote the rest of their time to their creative pursuits. But today, it takes six shifts to support subsistent living in a grotty bed-sit, so all those creatives have disappeared. I hope they went to another, better place, but I see a lot of anecdotal evidence that they were all forced to take menial office jobs instead.

If all forms of creative output (artistic or manufactured) will eventually become valueless in economic terms, then the economic constrains upon consumption will evaporate (like it already has with music), but then so will all the manufacturing jobs that create that stuff and so will all the artists and inventors.

There is something else on planet earth that is infinitely and cheaply replicable – and that is humans. During my lifetime, the population of humans on this tiny planet has doubled and, if I survive into my eighties, it will treble. If something is freely and infinitely replicable, then in purely economic terms its value will trend to zero. And that is precisely what is happening across the world. The value of unskilled labour is trending towards subsistence wages, and in a globalised world, nations that value “human rights” are powerless to protect their unskilled workers from the market forces of labour in countries far away that have too many people doing jobs of declining worth. Real wages of American workers have declined even as their productivity has increased[2] . This divergence started in the 1970s, just as economists started preaching the value of globalisation. In the developed world we have been trying to resist this trend by pouring resources into education – attempting to ensure that we have no unskilled workers. But this post started by explaining why the value of the output of skilled creatives is also falling to zero – so this strategy only defers the inevitable.

The logical conclusion of this is that people whose labour has no value will have no economic constraints on the consumption of products that cost nothing to produce. Increased productivity should reduce the need to work, but that is not the experience of workers everywhere who are working harder just to stand still. Playing devil’s advocate, we could argue that goods cost nothing to produce except for the cost of raw materials – but commodity prices are universally declining too.

We need to ask what this means for the future of mankind. But before we can do this, we need to ask what it means for the future of economic theory. It occurs to me that most economic theory doesn’t work in a world where there is an infinite supply of everything and therefore everything costs nothing. If everything costs nothing, money no longer works as a means of allocating access to resources. This sort of argument isn’t trivial, and economists are currently debating different forms of the same thing: they worry about what happens when the conventional tools of economic management (changing money supply, tax rates or interest rates) simply stop having the effect that they used to have. Some governments have already tried negative interest rates after an interest rate of zero was found not to be low enough to stimulate growth and recovery from recession.

The only way to escape this death spiral where ultimately the planet will have billions of economic migrants, is to abandon the idea that all decision making should revolve around money. We need to stop thinking about the monetary value of labour and start thinking about the emotional value of a human life. A good place to start is to consider how much consumption optimises it. Since the advertising industry has been pummelling us with propaganda about how consumption enhances our emotional wellbeing, it seems likely that we need a lot less consumption than most of us currently think. Then we can start to consider how much consumption this planet can support. And it then becomes easy to compute how many humans we can fit on this planet before it bursts. If economics is going to have any role in working this all out, then it is going to have to go cold turkey on its addiction to converting everything to a monetary value before it can even think about it.

[1] Sam York. “The pop star and the prophet” bbc.com , 17 September 2015
[2] “Why the Gap Between Worker Pay and Productivity Is So Problematic” The Atlantic

The comedian and political commentator Stephen Colbert coined the term “truthiness ”. This is a way of mocking politicians who claim to know something intuitively but fail to put forward any evidence to support their assertion. Too often in political rhetoric, truthiness presents as fact was is merely an ideological belief – not a real truth, but a truth that we want to exist. As Colbert put it “Anyone can read the news to you. I promise to feel the news at you.”

Over the last few weeks, academic economists have started the share the fun. The equivalent term that Paul Romer coined to mock his less-than-robust colleagues is “mathiness ”. This, he says, is an argument that looks like robust mathematics and sounds like robust mathematics, but actually isn’t. Sloppy economists create arguments that deploy terms that are mathematically defined elsewhere but which have subtly different meanings in the argument presented. In this way, an ideological position (e.g. if welfare is cut, the unemployed will all magically find jobs) can be presented as a robust economic argument. As Romer says “Academic politics, like any other type of politics, is better served by words that are evocative and ambiguous, but if an argument is transparently political, economists interested in science will simply ignore it.” Mathematical theories, like those created by academic economists, should only be trusted when each term is precisely defined and consistently used. Only then can the conclusions of such arguments be empirically demonstrated to be either true or false. The example that he gives is growth theory, where competing theories all appear to be clearly stated, yet show no emerging consensus.

Now that creating words to mock woolly thinking is in danger of becoming an epidemic. It occurs to me that the humanities need one of their own. As Stephen Colbert might say, “truthiness” and “mathiness” just don’t feel right in our context. I propose that we adopt the word “explaininess” because I think this is a problem that is pervasive throughout academic writing in philosophy and human sciences. Explaininess is a Ponzi scheme where one nebulous notion is needed to explain another nebulous notion, and the cumulative effect is presented as an explanation. For example, in connection with my principal current project, I recently spent a two miserable weeks reading all the recent academic theories explaining various forms of mental illness. In one paper summarising four theories of borderline personality disorder, I was left struggling to succinctly state the difference between Theory B and Theory C. These used terms like “maternal imprinting”, “suppressed memory”, “learned anxiety” and “secondary emotion”. At least an example was given for the last one: anger turns to shame. But I was left asking: is that normal? I certainly don’t think it happens that way with me, so if we are to talk about how that happens at all, we at least need a box and arrow diagram with meaningful things in the boxes and understandable causal relationships. Otherwise, the existence of secondary emotions is questionable and their causality is entirely unknown. Yet in the world of explaininess, this is a theory of a mental illness where competing theories don’t converge towards consensus because none of them are empirically verifiable.

In philosophy, explaininess is rampant. The most egregious example is Jacques Derrida’s theory of deconstruction. This is centrally based around two terms that Derrida coined “differance” and “presance”. These are two perfectly reasonable words intentionally misspelt by just one letter. Geddit? But he tells us that these terms can’t be defined; so how am I supposed to know that my understanding of them is the same as his? After a period of hair-tearing frustration, I eventually discovered that Noam Chomsky and Michel Foucault both stated that they didn’t understand it either.

Oh, that’s OK then! If you say you don’t understand it, then you are in more elite company than if you pretend that you do.

Derrida is famous for his obscurity, but explaininess exists everywhere in philosophy. There are hundreds of books on “freewill” but few of them offer a robust hypothesis as to what it is. If you are writing a book claiming that this concept is useful, then the burden falls on you to explain to your readers what it is. Too often, writers just presume that I understand the term, but actually I don’t. If freewill is a piece of brain hardware, then that is alright because eventually a neuroscientist will find it in the hypothalamus or somewhere. And if it is a piece of mental software, then eventually some mathy person will build a model of it so that we can all understand how it works; so that is all good as well. But if it is a part of your aura or something that is beamed to you through the ether, then I suggest that some academic philosophers should be seeking alternative employment. Oh, the joys of tenure!

The problem is that if we ban explaininess in philosophy, then there isn’t much left for us to talk about. But I think this points to the real objective of philosophy. Too often, people say that philosophy’s objective is to ask questions. But it ends up with us talking ad infinitum about all the questions that can’t be answered – the things that scientists can’t be bothered with. But if philosophy’s objective was to answer questions, then we would all have given up in the 3rd century BC, by which time it was already clear that no progress would be made in concrete terms. My suggestions is that the objective of philosophy should be to take unanswerable questions and try to change them into ones that can be addressed in a scientific fashion. For example, if nobody can tell us what freewill actually is, then maybe we should change the question into “what is the cause of a human action?” Already that is starting to sound like a scientific question, rather than a philosophical one. A large part of my work is to attempt to answer that question without the nebulous notions of “freewill” appearing the dialogue at all. Pull off that trick, and true progress will have been made.