I'm a reductionist. Maybe you are too
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A common criticism of modern psychiatry is biological reductionism - going from the complexity of the human mind (with all the sociological, psychological, and inter-personal intricacies this entails) to some crude measurement of the brain.
Reductionism, these days, is a derogatory term.1 But basically all biological psychiatry rests on the premise that there is an underlying similarity within mental disorders, despite the uniqueness of each person affected. That commonality is what we’re getting at in our research, often using proxy measurements of symptoms and how they relate to brain structure or function.
In this post, I’m going to defend the status quo and, in doing so, reclaim the term reductionist. Although rarely explicitly stated, I think most of the following would apply to reductionistic researchers like me - perhaps some of these beliefs will even resonate with you.
We believe mental illness exists. This may be obvious but it needs to be stated. Categories like schizophrenia, bipolar disorder, and depression, are real things and not simply a response to society or a character flaw. Mental disorders, similar to those we see today, have been present throughout history, across societies. We recognise them as complex, with multiple causes. Often, they are less straightforward than medical illnesses, but physical conditions can have psychological and cultural dimensions too. We know current diagnostic systems are not perfect and are open to revision. There are fuzzy boundaries between categories but they mean something and have correlates in biology.
We know mental illness is treatable. We have a good range of treatments which work well (or at least as well as in other branches of medicine). Treatments might include medication, psychological therapy, and lifestyle advice. Treatment may also encompass things like ECT, DBS, or anything else - as long as it’s been shown to work - empiricism is a key part of our belief system. We have seen massive changes in how society cares for people with mental illness, going from the asylum to the community, in large part due to the discovery of antipsychotic medication.
We believe more treatments are discoverable. Despite having some effective treatments, we know that they don’t work for everyone and have bad side-effects for some. The burden associated with mental illness, for the person experiencing it, their family, and wider society is huge. We see this first-hand every day. Better treatments are possible. Some come from our knowledge of underlying biology, others are more serendipitous, but there are plenty out there waiting to be discovered.
We think studying the brain is important. Although there are lots of factors that contribute to mental illness, working out what is going on at the level of the brain is essential. Insights from genetics, neuroimaging, neuroscience, and pharmacological studies are starting to uncover the biological basis of some illnesses. If we knew more about the underpinnings of disorders like schizophrenia, it would be easier to develop new treatments. Investigating these mechanisms is therefore a big focus of our work.
We like randomised controlled trials, a lot. Did I already mention that we are empiricists? We see randomised experiments as the gold-standard for evaluating any new treatment. By randomly assigning participants to either the treatment or control (e.g. placebo), we can cut through noise and complexity. We know that researcher bias, despite best intentions, can colour results, therefore we ensure we are ‘blind’ to the group allocation.
But we recognise the limits of evidence-based medicine. Yes we are empiricists, but we know that real-life is often different from research studies. Certain patient groups may be under-represented in trials, they may have co-morbidities, or personal preferences about specific treatments. We keep this in mind, viewing patients as individuals and promoting autonomy.
We are humble in the face of complexity. We are aware that our models, theories, and classifications are subject to change. The present understanding of what goes wrong in mental illness is rudimentary - the brain is the most complex object in the universe after all! Nevertheless, we aim to make continued incremental progress in understanding these disorders and finding new treatments.
I suspect most of the above would be endorsed by the clinical-researchers I know. The critics of biological psychiatry might even agree with some of it. I think this version is a more accurate description than is often seen from ‘critical psychiatry’ sources.
My name is Tommy, and I’m a reductionist.
Not unlike the term neoliberal - see the original of my pastiche
Yes, my definition would be reducing the complexity of a person's mental disorder to their brain. I think most psychiatrists/psychologists would accept this definition of biological reductionism. And for some disorders with a more psychological/social cause (like PTSD or borderline personality disorder) reduction to the brain probably isn't the right level of understanding.
For major mental illnesses (like schizophrenia or bipolar disorder) it seems that reducing to the level of the brain is important for discovering new treatments, although each individual needs to be understood within their own psychological/social/cultural background.
I completely agree about the problems of surrogate markers. This is less of an issue in psychiatry because at the moment we don't yet have any biomarkers in clinical practice (arguably the closest might be Alzheimer's disease).
Most psychiatric services I've worked in (all NHS) do not treat patients as numbers or ICD/DSM diagnoses. It is standard for an initial assessment to last more than an hour and follow-up assessments to be 30 minutes. I can't imagine trying to see a patient in a 15 minute window - perhaps this is one of the reasons I ended up in psychiatry!
Reductionism is a great protection against going down rabbit holes of woo, and certainly better and safer than making up arbitrary models and presenting them as reality.