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2001 Third Web Report
What Valenstein argues is that we have come to a point where we accept all mental illness as purely biological in origin, and have discarded older ideas about social and psychological effects, rather then attempting to see how these two different types of explanations fit together. While some may argue that this shift has helped to significantly de-stigmatize mental illness, it also has caused a neglect of important factors which must play a role in these disorders. In 1999, in a report by the Surgeon General, it was stated that research into the biology of the brain is "a potent antidote to stigma," but it was also emphasized that psychotherapy not be forgotten as it sometimes plays a large role in recovery.
Finding middle ground:
Although we do not know all there is to know about disorders of the nervous system, I believe that it is very plausible that mental illness is mostly the result of disturbances in the nervous system. Although in extreme situtions, some claim things like, "it reduces a complex human activity to a slice of damaged brain tissue" (4). I wouldn't go this far to assume that this is all there is to it, although I also don't believe that all mental illnesses can fit into the same box. While social and psychological factors may have an effect in many disorders such as depression, eating disorders and addiction, it seems unlikely that bipolar disorder or schizophrenia may be strongly influenced by social factors. Valenstein does seek a middle ground in stating that mental disorders may be a result of a biological predisposition, coupled with an outside environmental or social factor which triggers the problem. In the case of schizophrenia, new research has shown that maternal malnutrition, stress, or sickness during the third trimester of pregnancy correlates with a higher percentage of offspring who later develop the disorder - a case for environmental factors (5).
This idea of a biological predisposition along with an outside stresser leading to a possible psychiatric illness is one which I find difficult to dispute. There is a lot of room for interpretation and at this point in research, it does serve to explain the evidence which we have. The problem is that the amount of knowledge that we have concerning mental illness is often exaggerated, so that most of the general public believes that scientists and doctors do have all, or at least most, of the answers. Freud wrote, "It is a mistake to believe that science consists in nothing but conclusively proved propositions, and it is unjust to demand that it should." This thought can speak to the field of neuroscience; with the biological revolution, the development of psychotherapeutic drugs, and deinstitutionalization, it may be hard to understand that neuroscience does not have as many answers as it may seem. Drugs have been developed to treat disorders, yet the mechanisms of their action are not even known. The dopamine hypothesis of schizophrenia has been so altered from what it used to be; we once believed that schizophrenics suffered from an excess of dopamine. Then we believed that upregulation of receptors was to blame. We move from one idea to the next based on previous failures and successes in research and treatment.
"We could examine brains all day and by whatever sophisticated means we want, but we would never label someone a drug addict unless he acted like one" (4).
As quoted here, one cannot be deemed mentally ill from their biology alone. It is the nature of mental illnesses to manifest themselves in behavior, and this is of course the basis of diagnosis. It also can be stated that we can't begin to explain the brain by talking straight chemistry. There is no way around this fact. The brain allows us to see, touch, taste, hear, in order that we can experience things other than our own selves. Our own selves, which begin as virtually blank slates, are constantly shaped and changed by these outside experiences. The etiology of mental disorders cannot be excluded from this interplay between science and environment. The question does not seem to be nature vs. nuture as much as nature plus nurture, in explaining ordered behavior as well as disordered.
Reading Valenstein's book, I was reminded of a book by Peter Duesberg, called Inventing the AIDS Virus. In this book, Duesberg challenged the idea that AIDS has a viral etiology, and implicated drug use instead as a possible cause. He wrote that once (unsatisfactory) evidence was found for a virus causing AIDS, the scientific community (and the general community at large) took off with research in retrovirology and never looked back to question the original assumption underlying their work. Couldn't this be a reason why we have yet to come up with a cure or adequate treatment, he asked? Although I disagree with Duesberg's ideas, in essence he is making a similar statement to Valenstein. Both are challenging commonly and strongly held beliefs that are the foundation for all research and therapeutics in their respective fields. They are also challenging ideas held by non-scientists. This has implications for both the way that illness, mental or otherwise, is perceived and the way it is treated.
Valenstein's facts and figures are accurate and he does bring together a wealth of evidence supporting his ideas. The question which came to me after spending some time with the claims that he presents was not whether he was correct, but whether it mattered if he was correct or not. Does it matter if we believe that schizophrenia is like diabetes? Or that depression is caused by a chemical imbalance that can be fixed by drugs? Even if the research behind these beliefs has not held up in every experiment performed, what harm is there in accepting them as the best answers we have at this point? We don't know the exact mechanism of many of our FDA-approved psychotherapeutic drugs, but we do know that they work most of the time. They give people living with mental illness the opportunity to live "normal" lives, and they provide reassurance to everyone affected that these disorders can be controlled.
However, on the other hand, it should matter whether we are right in our theories of mental disorders. It is one thing to perpetuate the fact that we don't really know what is going on, but the evidence presented is the best we have right now. It is another thing to tell people that psychiatric illnesses are kind of like diabetes - we can keep them in check with drugs, and everything will be normal. With this line of thinking, other forms of treatment are neglected, such as psychotherapy. This has been seen to be just as useful as drug treatment for depressed patients in many cases, yet most health insurers will not cover the cost of psychotherapy treatment as willingly as they will cover drugs (3).
Current thinking implicates the brain as the main culprit in mental illness, and downplays the role that environmental and social factors may play. This type of thinking is problematic in that it perpetuates an inaccurate perception of psychiatric illness, and this leads to trends in treatment and management which may not be the most beneficial for the people living with the disorders. The extent to which pharmacotherapy for mental illness is effective treatment has been exaggerated to the extent that we put all of our faith in a drug which may fail to work, and will certainly not cure. The field of neuroscience has grown and made great progress, however this does not mean that our understanding of the mechanisms for mental illness and disorders in the brain is anywhere near being adequate. Some of the treatments commonly used to treat schizophrenia, depression, and other disorders, have mechanisms which are not completely understood.
The study of neuroscience depends on this assimilation of biological, chemical, psychological and environmental ideas together to explain phenomena. Without collaboration of all of these disciplines, the field of neuroscience would not have exploded to what it is today. Although, unlike Valenstein, I do not believe that "for reasons having little to do with science, the [biochemical] theory is being pursued relenlessly on a path filled with many dangers," the role he is playing by making his ideas known is more important then whether he is right or wrong. It may be safe to say that without continued collaboration and multi-disciplinary dialogue such as this, progress in neuroscience and mental health might just lose its momentum.
2) Mental Health - A Report of the Surgeon General, 1999
3) Psychiatry at a Crossroads
4)The fallacies of no-fault addiction
6) Scientists Call for End to Neurology-Psychiatry `Divide'
Valenstein, Eliot. (1998). Blaming the Brain. New York: The Free Press
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