'Chatting away to each other'
The function of our brain is to ‘be a model of the world in which it must survive’, begins Professor Paul Fletcher, addressing the audience at Brains and Mental Health public discussion. The problem with the brain, however, is that it has no direct access to external reality; or, in fact, to anything external at all. Everything we perceive has been filtered through the lens of our own construct of reality, a construct which is entrenched with subjectivities and inaccuracies. Everything we experience is determined by context, emotion and our history.
According to Professor Fletcher, our psychological factors fundamentally shift how we perceive everything around us. Walking past a group of people laughing when we are in a good mood may be joyful or ordinary, whereas given the same situation in a negative mood, we may feel anxiety or self-consciousness. Our perception of the world is a fluid, ever-changing process, highly dependent on our psychological state. This is the mentality that underpins understanding those who suffer from mental illness. For example, Fletcher explains, people who experience psychosis do not necessarily have a ‘dysfunctional brain’, they simply have created ‘a new reality that is not shared with others’. This comment will form the basis for the entire discussion of the evening, inviting a plethora of considered and inquisitive responses.
Individuals who don’t have a mental illness are able to disambiguate the world using their own information of reality. They also are able to play with this concept, as demonstrated by optical illusions and distorted reality games (such as VR, a tool featured frequently in various realms throughout the exhibitions). Therefore, Professor Fletcher concludes with the idea that ‘perception is controlled hallucination’. We constantly perceive things that are not there, and the only concept that differentiates those who suffer from psychosis and those who don’t is the supposed control we have. When our control is limited, or when constructs of reality are different, we call it a mental illness and treat it accordingly.
This way of thinking blurs the boundaries of mental health, and prompts us to consider the overlap between those with and without a mental illness. Indeed, they are not discrete and rigid categories, but rather on a continuum. According to Dr Annemieke Apergis-Schoute, a neuroscientist specialising in OCD, a categorical difference between those requiring treatment for an illness and those who don’t is the presence of suffering. She urges us to stop using mental health terms in reference to daily non-psychiatric problems. Comments like ‘My OCD is kicking in’ and ‘I’m feeling depressed today’ perpetuate stigma, she explains. This notion also marks a pervasive shift within both psychiatry and psychology, learning to look at mental illnesses in a holistic way that incorporates mind, brain and body.
However, with new advances come new challenges. Psychologists and psychiatrists must find a way of linking the brain and mind without losing the person underneath. The issues of authenticity were debated in depth in the panel, and the importance of understanding the psychosocial context of mental illness treatment was at the forefront of this discussion. Professor Fletcher explained that the purpose of mental health professions is to find a careful balance between maintaining the individuals’ sense of identity, and reconstructing a new (more comfortable) psychological context. Recovery from mental illness, therefore, is not – or rather, should not – be marked merely by a change in symptoms at a clinical level. Other external factors such interpersonal relationships and an individual’s sense of identity should also be considered, particularly when contemplating discharging a patient or ending therapy.
One audience member asked why schizophrenia and epilepsy are treated as explicitly a psychological or neurological disorder, respectively. Professor Peter Jones, mental health psychiatrist, spoke about the commonalities and differences between neurologists and psychiatrists. Psychiatry ‘beats to a much longer rhythm’, he explains. It was also acknowledged that psychotherapy and talking therapies are often lengthy processes, but deserve as much merit as other faster pharmacological approaches. However, that being said, the members of the panel all in turn stressed the importance of not viewing mind, brain and body as discrete, mutually exclusive entities. The interplay was a common theme in the conversations of the evening.
One particularly salient and often ignored issue within psychiatry, as one audience member outlined, is the physical side-effects of anti-psychotic and anti-depressant medications. Weight gain is a relatively common side-effect of popular psychiatric medication. A review in 2003 suggested although weight gain is indeed a probable side-effect, it is more likely to occur after six months of using a drug. The psychological and physiological implications for this are, of course, vast. Once again, as a discipline we are left to question: what constitutes the greater good? How much change should one person have to psychologically and physically endure in order to combat a mental illness? Difficult questions, with not much in the way of answers. Surely, it is up to psychologists to strike a careful balance. Dr Hisham Ziauddeen, specialist in Psychosis and Liaison Psychiatry, stressed the importance of viewing weight-gain within the context of the mental illness medication. ‘It is not about a lack of willpower’, he argued. Instead, the weight-gain derives from inherently physiological changes: deregulated appetite systems, hormonal changes, and so on.
Professor Trevor Robbins, Neuropsychopharmacologist in mental health, joined the discussion by stressing how we (both as individual clinicians and as a society) must get away from the dualism between talking therapies and biochemical approaches. According to Professor Robbins, this duality is unhelpful in terms of both diagnosis and treatment. Indeed, they both inform and allow each other to work. For example, someone may require pharmacology to intervene in order to put them in a suitable mental state to get the most out of psychotherapy, and vice versa. The ‘nature-nurture’ debate that is so ingrained into psychological conversation is now less prominent. The neuroscientists I spoke to throughout BRAINFest all appeared to be adopting a more holistic approach to both clinical practice and research. As Professor Jones puts it, the brain, mind and immune system are ‘chatting away to each other’ constantly. Indeed, the need for more in depth research in the area was highlighted, but a cultural shift into this way of thinking in mental health professionals seems a good place to start.
The real-world application of these conversations must be considered. One audience member, a HR director, was on hand to prompt this discussion. He questioned the panel about how to incorporate mental health knowledge into a corporate workplace, asking ‘what should we be doing about this?’ In response, Professor Barbara Sahakian, Clinical Neuropsychologist, flew the flag for mindfulness and stress-reduction strategies. Sir Simon Wessely, chair of the discussion and President of the Royal College of Psychiatrists, had a different take. ‘Get rid of everybody on the outside’ he urged, citing research that suggests companies do better when they source psychology services internally. Addressing the other panel members, Wessely acknowledged ‘we all sit in our ivory towers’, explaining how important it is that clinicians are aware of their position of power. So what needs to happen now? Early detection of mental health illnesses, claims Professor Sahakian. We must inform young people about mental health, in attempts of ‘catching’ illnesses early, where they are most manageable.
The mix of audience member and panellist input made for a lively and insightful discussion. It involved questions of ethics, stigma and clinical practice, all of which prompted me to consider how psychologists can listen to the issues that were raised. The key take-home message was one of an interdisciplinary nature, encouraging psychologists, doctors and psychiatrists to consider people as a whole entity, rather than focusing on their area of expertise.
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