Too much brain and not enough thought?

I sometimes have difficulty getting to sleep- but if you put me in a warm room, turn down the lights and start showing me pictures of brain scans I can guarantee that I will be snoring in five minutes- particularly if its after lunch.

You have probably guessed that I didn’t become a psychiatrist because I was fascinated by how the brain actually works. I was one of those medical students who wanted to spend time trying to understand what people I met were experiencing, and to find the right words or images to describe them. People with mental health problems are just like you and me (and I have them too), but with different ways of making sense of life, which can be sometimes be (for them and those around them) distressing, engrossing, terrifying, or engaging- to name but a few of the infinite possibilities. As a doctor I tried in turn to draw a person into a conversation, and then provide help and care.

What I am not, could not, and would never choose to have been was some kind of clinical neuroscientist. As you might expect from my problem in lectures, I’ve never found the intricacies of neuroimaging, neuropharmacology or neurophysiology, to name but a few of the specialties with that prefix, very exciting. Perhaps it’s because those subjects were so poorly taught to me. I get lost very quickly when I listen to someone who is talking with enormous enthusiasm, for example, about the genetics of mental illness, because sooner or later they go into minutiae that seem so far away from the ‘person’ that my brain moves to its economy setting then switches off completely.

However, young doctors who are beginning their training now in psychiatry are going to get a much better education than I got in neuroscience, and hopefully will be able to appreciate- and understand it-better than I did. This is indeed considered to be a golden time for neuroscience with many important breakthroughs. One of the recent winners of the Brain prize was a British psychiatrist. Perhaps its time has finally come and we will begin to see real benefits for patients in terms of more effective treatments.

Perhaps this will all happen, but possibly not as fast as some might believe.

When I started training in 1980, world psychiatry was moving out of what Leon Eisenberg called its ‘Brainless’ phase, dominated particularly in the USA by psychoanalytic theory, into the ‘Mindless’ era, where biological explanations took over to the point that the ‘medical’ for many became synonymous with the biomedical approach- although many of us remain firmly ‘bio-psychosocial’. Sometimes it feels as though the mental health world itself is split into those (especially psychiatrists) who are determined to show their psychosocial credentials and others who feel the need to defend against the onslaught of biomedicine. One of their favourite battlegrounds is on twitter, where blows are regularly exchanged.

I have certainly met some psychiatric colleagues who are remarkably single track in their biological view of mental illness. One or two of them were eminent neuroscientists whom I would dearly not wish to consult as a patient as it was clear they were yearning to get back to the lab where they could have a closer relationship with a sliced up brain than a living one. But I have come across many others over the years that were keenly determined to try and find new ways of helping people and demonstrated considerable empathy for their patients – even if they were highly skeptical about the role of psychotherapeutic interventions in achieving recovery.

However one of the major problems I have with neuroscience is that despite the amount of money that has been poured into researching the brain there is still so little to show that is relevant to patients. I started training more than 35 years ago, and we have been repeatedly told that the day when this investment will result in real clinical improvement is somewhere just over the horizon.

Psychiatrists cannot simply become ‘clinical neuroscientists’ or even- as some have suggested, neurologists for several reasons. Clinical neuroscience is not yet ready for clinical use. There is still a great deal to do before that point will be reached and the brain is an infinitely complex organ. Furthermore we mustn’t forget that the person who inhabits that brain is very complex too, and lives in an increasingly complex world. I have spent my life trying to help others achieve change, facilitate health care systems to change, and grow and change in my self. None of these were straightforward and I often failed.

Recently a group of eminent American psychiatrists concluded in the British Journal of Psychiatry:

‘our mental health research funding neglects immediate public health needs to focus on future discoveries, reflecting the drive for technological solutions for disorders that are unequally distributed and partly socially determined. Time frames for such payoffs have previously been consistently under- estimated’

Neuroscience may ultimately provide us with some of the answers, but I often feel when I’m in one of those lectures that I would really like to hear more how we can link up a little more across the multidisciplinary divide – and try to understand the interactions between the person, their environment and their brain. Because any real solution is always going to involve some thought about the first two of these. Instead there is so much research (and treatment) still going on in (sometimes idealogical ) silos.

Perhaps the new emphasis on neuroscience will attract more students into psychiatry, as it provides some tangible ‘medical’ credentials of a very high order (close as it is to neurology). But there is always the risk that too much of this will deter those, like me, who were fascinated by what people said, and wanted to be a doctor who listened, thought carefully about the options, discussed them, and then tried to help using every avenue available.

So I think we still have plenty to think about.

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