Parity in Medicine Means Parity in Motives

There’s a lot of talk about parity in medicine, especially now during Mental Health Month. Brain disorders are treated differently than other illnesses, so there’s differences in policy, funding, and so forth. But when we talk about parity, we also need to keep in mind that, for carers, nurses, doctors, and other non-disordered people, we need parity in motives.

I’ve come across many people who seem to just want an ordered world–a world free of psychotic people. These people are not acting from the motive of caring and concern for someone who may be suffering. They are acting from other motives. When we think about treating brain disorders, or when we think about possibly curing or ridding the world of them, we need to search our motives, and make sure they are the same for any ill person.

Sometimes I think psychosis simply bothers some people, and they feel the need to rid the world of it. This is not the motive one wishes to move from.

On Trusting Yourself, Knowing You Are Not Trustworthy

There’s a good article here about the biases we all hold. I mean bias in the psychological sense.

I learned a lot about bias as an undergraduate, and tried to root out as many as I could over the years. I can’t say that I’m perfect (who is?), but I think I’ve gotten better.

I thought this related interestingly to my work on schizophrenia because I want to take seriously people’s narratives about what they think caused their psychosis, and what happened when they went psychotic. But I also want to take into account that we are imperfect when it comes to these things. We tend to overestimate bad things that happen to us, for example. Still, I think it’s important to take the agent seriously.

In practicing the biopsychosocial model, interviews with the client are paramount. However, other data is collected, such as interviews with other people, school records, and so forth. This, I think, is good. It takes into account the individual, and also refers to other data so we can glean a picture of what possibly caused the illness in this particular case, and what treatments we should apply for health. This is a strength for the biopsychosocial model.

After reading about bias, you should be skeptical about yourself. If you aren’t you didn’t take the data seriously. But there are ways to reduce bias, and it’s good to apply them. This could make a better place for all of us. This means you don’t have to remain skeptical of yourself. But it does mean you need to constantly work on yourself.

If you live in a constant state of skepticism about yourself, that’s probably not healthy. But a light dose of skepticism is good.

On Striving within a Culture

I was thinking about how people strive for things.

Aside from basic survival, and other basics of life, most of out strivings are within a context and a culture. For example, I wanted to be a philosopher, and, currently, most philosophers are associated with a university. So I learned the game of the university. I learned how to teach, how to conduct research, who are the important people in the field, and what the major university departments are. My goal, like anyone’s was to do well in philosophy.

But even as I thought about things that weren’t necessarily tied to my culture, these embedded rational decisions were within the context of a culture and, importantly, with the context of an institution. Institution, here, I use broadly, in the sense of being institutionalized.

Most of out strivings are embedded in this way. These are socially constructed realities within which our reason applies itself.

For example, I was just reading a bit about the prestige bias within philosophy. People from prestigious departments are more likely to get hired at prestigious departments. Many people strive to work for a prestigious department, but few do, and it seems that the bias is towards people who are already prestige-affiliated.

But for me, as an now an outsider, it seems to me that these longings and strivings are embedded within a large university-industrial-complex, which I am not a part of. I’m not saying it’s bad to strive in this way, or that that system is a bad thing. I’m just saying the things related–such as where one applies for a job, that one applies for a job, what one wears to interviews, that one goes to the APA, and so forth–are embedded within a constructed system.

I think most of our strivings are embedded in this way. Our reason is often “applied” within a context and culture. This doesn’t make it any less rational, but it does seem that we may be fooling ourselves if we think, normally, that we are applying reason to the thing-in-itself.

On Feral Children, and Being ‘Hooked In’

One may think that feral children can teach us a lot about, especially, psychology. In fact, I turned to feral children today in order to think about what happens to a person devoid of the social. I was thinking about this in order to think about the -psycho- in the biopsychosocial.

Here’s what I thought. It’s hard to glean a whole lot from studying feral children. For one, these children aren’t randomly feral. That is, they aren’t randomly assigned to being feral. We can’t do that. It’s unethical.

Which brings me to my point: It would be a major form of abuse to create a feral child. Why would it be an abuse? Not just because they need to be “socialized” and taught “social skills.” It would be an abuse because it fundamentally alters a child for life in a way that pretty much seems unjustifiable.

Being a feral child is, automatically, being traumatized and neglected. So what we can glean from studies of feral children can’t be pulled apart from studying trauma, abuse, and neglect.

This means they don’t provide the perfect case study for looking at the human-being-minus-the-social. The social is already interacting with the child by neglecting it.

There may be some things we can learn, anyway. Scholars think that many feral children fail to learn to speak because they miss a key point for language development.

If these children lack language, they may lack concepts that make them able to strive for things in life. They may have a basic need for survival, so they eat, but they may lack ‘thick concepts’. That is, they may not be able to strive toward being a doctor because they lack language; they lack the concepts involved in being a person who wants to grow up, go to college, and be a doctor.

Now, I know that, from studying what people say about schizophrenia, that I should be careful about what I say about people who have experiences I know nothing about. But, still, I think this may actually help me develop a theory.

On the view I developed while at the store today thinking about the psychosocial, language hooks one into the social. It brings one in to the social community as a full member. In this way, concepts can lead one, make one strive for things. But, also, when reflecting one these things, we can question, develop, make new concepts, and so forth.

Breaking from Reality

Most people give credence to biomedical research over biopsychosocial research, thinking, I suppose that biomedical research shows us about reality. I don’t want to argue that it doesn’t. What I do want to do is argue for the social sciences as giving us information about the nature of reality.

For example, we know that Holocaust survivors are at-risk for developing schizophrenia. This gives us reason to think that exposure to trauma, psychological hardship, and so forth, can trigger psychotic symptoms. What we can’t do is replicate those conditions, and randomly assign people to Holocaust-like conditions.

What we can do is look at other instances where trauma may have caused a break from reality. For example, we can look to the Ghost Dance.

I invite you to watch this video, and consider whether the restrictions of liberty, trauma, and hardship, etc., caused the break from reality which was the Ghost Dance.

Neuroskeptic on Swedish Study

Everyone’s favorite neuroscientist, Neuroskeptic, comments on an interesting study which involves adoption and schizophrenia.

I’ve mentioned that schizophrenia is currently considered a bio-based illness. And I am doing research on the biopsychosocial model, which states that schizophrenia can have multiple causes. But, of course, the biopsychosocial model is not in fashion right now. The research dollars go to what’s trendy, and Engel is not trendy right now. (No matter how much social science evidence we may have.)

This study looks at children who had ill biological parents, and were adopted. It found a decreased risk in developing schizophrenia.

Do take a look at Neuroskeptics’ blog post, and consider reading his blog more often! (I have been a reader since grad school.)

Shame and Social Causation

It may seem like being a social causal realist, the way I’m shaping up to be, would be a weird thing to be. But I just found an interesting lecture on causal explanation in the social sciences, and it includes a discussion of causal realism. I don’t have a fully formed theory I want to advance, but I want us to think a minute about social shame.

Shame is something that many people with schizophrenia can relate to because schizophrenia is a stigmatized illness. But let’s look at something other than schizophrenia. Let’s take a look at The Scarlet Letter by Nathaniel Hawthorne. In this work, the main character, Hester Prynne, has to wear a scarlet ‘A’ (for adultery), and is publicly shamed by the community.

There’s a reason we don’t shame people in this way anymore. For one thing, ethically, it’s wrong. For another, and perhaps the reason it’s wrong, is because it can cause psychological damage to a person, especially a vulnerable person; a lone person with no social supports.

In this day and age, when adultery is common, it may seem like no big deal; that one could take the public shaming. But I invite you to read the work, and see whether, if you were living in the 1600’s, if you could withstand being made to be a social outcast, and publicly marked for a private affair.

Causing Psychosis: What We Can and Can’t Know

I want to argue, using the biopsychosocial model that, for any case of psychosis, we cannot, currently, say for sure what the ultimate cause of it is.

The biopsychosocial model can be thought of as both a theory of causes, and a theory of treatment. When thought of as a theory of causes, one looks at biological, psychological, and social factors involved in the development of psychosis.

We may find that, for example, there’s excessive pruning of neurons in the brains of most people with schizophrenia. But we may not know why that happens. It could be they are born prone to developing psychosis. It could be they are neurotypical, and have experienced a lot of hardship. It could be that, psychologically, they are vulnerable to stressors.

These can all be causes, and they can all contribute to one developing psychosis. For any individual person, they may not know what caused their own psychosis.

Think of global warming. We know that the Earth is warming at alarming rates. But, at any given place, it may be warmer or cooler. Just because one area experiences warmth or cooling doesn’t mean we can assign this to global warming. Global warming is an effect that is broad, and covers the entire Earth.

In the same way, psychosis may affect individuals, but each individual has had a different upbringing, social environment, experiences, and each individual reacts to their environment in different ways.

For some people, the biomedical explanation may be sufficient. For others, however, we may need to look at social and psychological factors. Teasing apart causes in any particular case would be difficult, and that’s more the job of clinicians and case managers, who are “on the ground” and working with the client.

As for me, when I look at data, I am looking at groups of people, and making connections. I may be focusing on social causes at the moment, but that doesn’t mean I don’t think other causes may be involved in particular cases.

Thinking about the Mind

Recently, I started writing mind with an asterisk behind it, like this mind*. That’s because sometimes I want to use the word mind, but I think people equivocate on it. I’m not going to lay out every meaning I’ve found of mind, but I will lay out two:

  1. Mind: A set of cognitive faculties that enables consciousness, perception, thinking, judgement, memory, etc.
  2. Mind: The soul; an immaterial, and mystical thing we cannot only vaguely know about.

Yes, I do think people use “mind” in that latter way. When I use “mind”, I mean the former. So I will continue to use an * after “mind” in order to make sure I’m not equivocating, and to be clear about what I mean.

If you can think of another term for mind* that I should be using, please let me know.

Thinking about Social Causes

The biopsychosocial model was never developed fully theoretically. Yet, I, and many researchers, think it shows promise. In this essay, I want to think about how a brain condition can have multiple causes. In doing this, I will make analogies with broken bones and physics, and posit social causes.

The cause of a broken bone may be many things. It could be one is vulnerable to breaking bones; there is something about one’s bones that make them prone to breaking. If this is the case, a minor bump, simply standing up, or fall could cause a broken bone.

One could get a broken bone by accident, in playing a sport.

One can get a broken bone by being assaulted by another person.

We have no problem thinking about different causes of broken bones.

Yet, many people have trouble understanding how there could be different causes for brain disorders. This seems to me not an especially difficult problem when we look at non-brain pathologies.

Causes, especially social or psychological causes, may seem strange because we cannot directly perceive them. We cannot see stress or trauma. Yet we seem to have no problem talking about these things, and, in the literature, we see a body of data that strongly suggests causation between stress, trauma, and brain disorders.

Let’s look at stress, for a moment. There’s a whole body of research on how stress can cause a variety of physical problems. Most people, and most professionals, do not have a problem assigning stress as a cause to things like acne, sleep problems, weight loss, overeating, and so forth.

Yet, many people, especially those who hold firm to the biomedical model, would have a problem assigning invisible causes to physical illness, such as brain illness.

This need not be that case.

To see why, let’s turn to introductory physics.

Although the aim in physics as a science is probably to find testable hypotheses, much of physics is theoretical, and deals with both visible and non-visible things. We cannot see gravity, for example. Yet, the average person understands the basics of how gravity works in everyday life, and physicists have a good understanding of how gravity works in the universe. We posit a name for such a thing—calling it gravity—because we can, or rather Newton could, see that things must be pulled to the Earth.

In the same way, I want to posit social causes. A social cause is not a force acting directly upon one’s body, that we know of. It may very well be, I would need more data in order to posit a social force in that way. What we can probably say is that, whatever we make of the psychological, be it material or immaterial, the social can act upon the mind*, and affect it in both positive and negative ways.

This is easy to see, when we look at the literature, but it’s difficult to find a theory and proper understanding of it.

I do not want to imagine the mental or psychological as something mystical and beyond comprehension. I do not think many things in the universe are mystical or beyond comprehension. I may not currently understand such things, but that does not mean human beings cannot understand them.

I also do not want to posit too many things; I want my theory to be as simple as I can make it. This is just keeping with Occam.

Likewise, in keeping in the tradition of many empiricists and philosophers, I take it that the universe makes sense. It is not disordered. It may be surprising, or counterintuitive, at times, but it is not disordered. For me, what’s disordered is my mind*, when I am psychotic. But even then, there’s some sense to it. I do not magically know how to speak Arabic—which I don’t know when I’m sane—when I’m psychotic. My mind* can only scramble, order, disorder and reassemble things I know, and it can create just so long as I am, at any rate, creative, when I am psychotic.

So I want to posit social causes, which are causes just like any direct, physical cause. This is what I mean by cause.

Much has been made of making psychology, sociology, and other social science into hard sciences. Many think this is not possible.

I think, when we are dealing with the social sciences, we are dealing, in a way, with the same kinds of things as theoretical physicists are dealing with. What I mean by that is that we are dealing with many things interacting, we are dealing with complex causes, and we are dealing with forces acting upon things which are not, necessarily, directly touching. I do not have the understanding of physics that I’d like to have in order to make this comparison even more compelling, but I’m not trying to make the social sciences into hard sciences in order to make them more credible in whatever way. I’m making this analogy because I think it’s true, and, after looking at data, think there’s some merit to it. We do not have a problem, normally, thinking that the Sun affects the Earth, even thought these two objects do not touch. In a similar way, I want us to think about social causes as one social event affecting a person, even though they may not be touching.

In this way, I believe in the armchair, but I also believe in experimenting. Because there’s only so much we can directly observe. Our personal observations may lead us astray, which is why I refer to the data, which I am keen to look at.

So, social causes, I want to think are just as real and forceful as physical causes.

Calling Schizophrenia a Brain Disorder doesn’t Give Primacy to the Biomedical Model

In this essay, I want to argue that we should refer to psychotic disorders as brain disorders, but that doing this doesn’t mean giving primacy to the biomedical view versus the biopsychosocial view.

In keeping with some of my previous thoughts, let’s assume you get a broken leg. Furthermore, let’s assume that your broken leg is due to a social ill—someone assaulted you.

You go to the doctor. You get a cast, but, in addition, as you heal, you may need physical therapy in order to heal better in your leg.

Seeing a broken leg as a medical issue doesn’t mean you won’t need treatments other than having a cast, and using crutches until you heal.

In fact, this may be yet one more trauma in your life that you don’t need.

Now imagine that, years down the road, you become psychotic. Imagine further that this is because you have experienced hardship, childhood abuse, and trauma, including being assaulted by someone who broke your leg, years back.

You are taken to the hospital. The psychiatrists there see you as a brain patient. They try to treat your brain by giving you antipsychotics.

But, in addition, you are assigned a treatment team that includes social workers, case managers and counselors.

Seeing psychosis as a brain issue doesn’t mean you won’t need other treatments, like counseling. And, further, your society may need some treatments of its own, if it produces people who traumatize and torments people, and produces social injustice.

Calling psychosis a brain illness doesn’t negate other biopsychosocial causes or cures, just as thinking of a broken leg as a medical issue doesn’t negate the fact that you have been assaulted, and may need counseling, or physical therapy. In other words, calling schizophrenia a brain disorder doesn’t commit us to the biomedical model over the biopsychosocial model.

Broken Bones and Psychosis: Psychosocial Causes and Testability

Imagine that you get assaulted. You are kicked in the leg and it is broken. You go to the hospital. Your leg is x-rayed, and casted. You are given crutches, and asked if you want to press charges.

That’s the way it normally goes, I assume, when you are assaulted and get a broken leg.

No one says you aren’t really hurt, even though your broken leg was caused by a social ill—a bad person assaulting you.

Now imagine you have a psychotic break. Your symptoms cause your family to call the police so you can be taken to a hospital. At the hospital, your blood is taken, you are given a CAT scan, and are, after a while, diagnosed with schizophrenia.

The tests in involved—taking blood, and CAT scan—don’t reveal anything. They are done in order to rule out other things. You are given an antipsychotic, and released from the hospital after seven days, when the doctors see that your medication seems to be working.

At home, you peruse the literature, and find that some people think your illness is not real the way a broken leg is real—because your illness, they think, has psychosocial causes. Perhaps you experienced a lot of adversity, or trauma as a child. These are things correlated with experiencing psychosis.

Not everyone who gets kicked in the leg will get a broken leg. That depends on a lot of things—where you were kicked, how hard you were kicked, if you were kicked repeatedly, and if your bones were prone to breaking.

Not everyone who experiences adversity or trauma will experience psychosis, either.

Both of these things can be caused by social illness, and social ills in combination with your makeup. If you have especially brittle bones, and some bad guy kicks you, you are probably more likely to get a broken leg. Likewise, if you “are prone to” (we don’t know what that means, but let’s not assume it means you are less “hardy”) psychosis and experience trauma, you are more likely to develop schizophrenia.

But no one says you aren’t *really* hurt when you get a broken leg this way.

Unfortunately, they do say this when you become psychotic.

There is no test, they say, for schizophrenia.

True, the biomedical markers for schizophrenia are not testable in most hospitals. They can’t, for every patient, check for chemical imbalances. Instead, they rule things out, try a medication, and see if that medication (in my case, regulating dopamine) works to restore health.

Not long ago, before the x-ray, they couldn’t *see* a broken bone, either. They had to do similar things in order to diagnose and treat a broken bone. The patient would, I assume, report symptoms and people could observe symptoms. That doesn’t mean broken legs weren’t real problems before the x-ray, just like it doesn’t mean psychosis isn’t real just because not everyone has access to MRIs.

Just because something may have a psychosocial cause, or can’t currently be directly apprehended in the hospital doesn’t make it less real.

Psychosocial Causes, and ‘The Real’

The tendency has always been strong to believe that whatever has a name must be an entity or being, having an independent existence of its own. And if no entity answering to the name could be found, men did not for that reason suppose that none existed, but imagined that it was something peculiarly abstruse and mysterious. –JS Mill

I just read a psychosocial report on psychosis. While I agree with looking at psychosocial causes of psychosis, the report states that psychosis is not real the way a broken bone is real. That there are no medical tests, like an x-ray, that can help us diagnose psychosis.

I think, when thinking about the ‘mental’ or ‘psychological’, people get mystified by it. That’s one reason why I decided to refer to schizophrenia as a brain disorder. The fact is, in many people who experience psychosis, there *are* biological differences. There is, according to many studies, excessive pruning of neurons in the brain. There is, moreover, often chemical differences, which is why regulating dopamine in my brain is helpful to me.

However, that doesn’t mean psychosocial causes aren’t important. I’m a believer that they can be causes just like, if someone kicks you in the leg, you may get a broken leg. Not everyone who gets kicked in the leg will experience a broken leg, but some will. There are a lot of factors at play, such as how hard they kicked you, if you were kicked more than once, and how vulnerable your leg is to being broken. And when we look at data, we will find that people who got kicked in the leg will show up more to the hospital with a broken leg, just like we find that people who, eg, experience childhood trauma will more often later show up with psychosis.

So we think of a broken leg as a medical problem with the leg, and I (at least) think of psychosis as a disorder of the brain. This, even though abuse may be the cause of both of them.