When I speak or write, my brain generates neural signals that activate my lungs, vocal cords, mouth, or alternatively my fingers on a keyboard to form words and sentences. This sort of activity applies to anything “I” do. It seems natural then to propose “I am my brain.”
Citing difficulty with the notion of “I”, some neuropsychologists would prefer to say, “The mind is the brain.” The naturalist philosopher Daniel Dennett, who agrees with this position, took it further and once predicted that personal pronouns such as “I” and “you” would likely disappear from human speech in the not-too-distant future. In that happy time neuropsychologists and psychiatrists may understand much better than today how to treat brains and their disorders. Or maybe not.
We don’t have to wait a hundred years to find a group of people whose concept of “I” or self has been shattered. They already exist. They are people with severe mental illness, especially schizophrenia.
The title of this blog – I am not my brain – attempts to suggest that who I am depends as much on the relationships in which I participate as it does on the content of my brain.
Who am I? My will is the most important designator of who I am, what I do, how I respond. Yet who I am is not limited to an individual will, because a larger, more complete will distributes among my individual self and all the groups in which I participate – the middle domes of life. To paraphrase José Ortega y Gassett (see previous blog), I am I and my participations.
Medical science in the fields of psychology and psychiatry appears to maintain rigorous silence on questions of will. Yet in practical terms those questions come up again and again. Legal requirements affirm the right of patients with mental illness to make their own decisions. Doctors can commit psychotic patients for hospitalization against their will, except in cases involving threat of suicide, homicide, or bodily harm. Given the unrelenting attention that must be paid to building trust and willingness on the part of the patient to come to therapy visits and take medication, we should find ourselves amazed at the tragic inattention to the will in psychiatry in the age of modernity.
Approximately 1 in 100 people have schizophrenia. The most severe of mental disorders, it paralyzes the will, partly by disrupting the ability to set and achieve goals and partly by breaking or grossly distorting the connection between a person and people around him or her. E. Fuller Torrey, psychiatrist and author of Surviving Schizophrenia, describes its major manifestations in these terms:
- Marked impairment of the ability to filter, sort, and interpret incoming sensations.
- An inability to interpret and respond appropriately to other people. This often results in a preference to spend time alone.
- Impairment of causal and logical thinking, exemplified by minimalist interpretation of common proverbs. Speech can be fluent, but ideas may be expressed in disconnected sequence.
- Delusions and/or hallucinations.
- An altered sense of self.
- Changes in emotions, movement, and behavior.
- Lack of awareness of illness.
Torrey speculates, “It is as if their will had eroded, and indeed something like that probably does happen as part of the disease process.”
Not every person with schizophrenia lacks awareness of the illness. In Torrey’s words,
One woman, afflicted by schizophrenia for many years, wrote me that she would gladly “sacrifice my right arm to make my brain work.” Another woman who had had severe schizophrenia for seven years, when I asked her what she was asking for at Christmas, looked at me sadly, paused for a moment, and then replied: “A mind.”
The task of the psychiatrist is to rebuild, usually with the help of medication, a healthy sense of self in relation to others as well as appropriate filtration/interpretation of incoming and apparently incoming signals. Usually the psychiatrist works closely with a psychotherapist. Both medication and talk therapy typically are needed.
Too often resources important to the personhood of healthy minded people – good relationships with family, friends, mentors – are lacking for the person with schizophrenia. The illness itself disrupts those relationships. Moreover, considerations of autonomy appropriate for healthy people may be applied in legal terms to the ill person whose will has collapsed in randomness and brokenness.
Health for the person with schizophrenia may not be achieved by restoration of the individual will alone. And it seems that health might not be restored just by gaining appropriate transactional abilities. Health may require the restoration of a balanced distribution of the will among me and us – individual, family, friends, and culture. A healthy, caring family member or friend can provide vital ongoing help to the person with serious mental illness. But this can happen only if allowed by the patient, the psychiatric team, and the legal system.
I follow a patient with chronic schizophrenia for diabetes and dyslipidemia. His brother came with him to the first visit. They stay in touch constantly. They confer on decisions he makes. He’s doing well and now comes to visits by himself. Both the patient and his brother make family part of their notion of self.
There are some signs that psychiatry is making progress toward inclusion of the “middle domes” beyond the therapist-client team alone in the therapeutic endeavor. The Clubhouse movement gives evidence. Persons with serious mental illness, for whom family and other prior connections do not suffice, find friendship and community by living with others in similar circumstances.
Marvin Swartz at Duke University, among others, has written about the use of psychiatric advance directives to bring family and friends into the decision-making process for people with severe mental illness at times of crisis.
A re-interpretation of selfhood could help in the struggle to improve the lives of people with serious mental illness. I am not my brain. More to the point, I am my brain and much more. Who I am extends beyond this skull. Who I am includes all those with whom I participate in we-sentences.
Schizophrenia is a brain disorder. But I have resources beyond my brain, because my life moves – my will distributes, participates, and emerges – in larger domes as well.
In the past 2 decades, recovery from schizophrenia has emerged as an unexpected phenomenon. Here is a report from the American Psychological Association:
All in all, says [Robert D.] Coursey at Maryland, “A very large group of consumers has achieved remarkable recovery. They are people who, in spite of ongoing symptoms, have carved out a life. They have goals, they make choices, they improve their situation with the right type of interventions.”
One of them is Ronald Bassman, PhD. Diagnosed with schizophrenia as a young man, he recovered, earned his doctorate and is now involved in patient empowerment programs in the New York State Office of Mental Health.
“It’s miraculous how people come back,” he says. “If you talk to someone who is doing better, he or she will tell you that someone–a friend, a family member, a pastor, a therapist–reached out with warmth and gentleness and kindness. This is not what is typically done in the mental health system.”
To counter that, many former patients and their families have organized themselves as formidable advocates, calling themselves consumers, ex-patients and survivors. Their demand to be recognized as individuals who deserve a voice in their treatment is captured in the slogan “Nothing about us, without us.”
Having goals, making choices, carving out a life are expressions of will. Bonding with another person generates power that gives voice to the will. An individual without a voice lacks an effective will. Providing that voice in therapeutic relationships creates our will which exceeds my will in strength. This is a key message from advocacy groups, who are building new middle domes to make decisions and push for change.
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Header image. Brain model, by sbtlneet, CC0 public domain, from Pixabay.
 Dennett made that prediction in a seminar I attended at the University of Houston in the 1980s, described in this blog. I would add a note here that traditional mind-body dualism, which postulates crudely parallel spiritual and physical worlds, does not necessarily solve the problem. Philosophies of dualism often view the brain as a privileged conduit through which the spiritual world connects with the physical. Thus in dualism anything that might be called “will” still works through the individual brain.
 Torry EF. Surviving Schizophrenia. 4th edition. Quill, New York, 2011, pp. 32-79.
 Meis L, Griffin J, Greer N, et al. Family Involved Psychosocial Treatments for Adult Mental Health Conditions: A Review of the Evidence [Internet]. Washington (DC): Department of Veterans Affairs; 2012 Feb. URL: < http://www.ncbi.nlm.nih.gov/books/NBK117209/> accessed 1/2/2016.
 Easter M.M., Swanson J.W., Robertson A.G., Moser L.L., Swartz M.S. Facilitation of psychiatric advance directives by peers and clinicians on assertive community treatment teams. Psychiatric Services 2017, Apr 3:appips201600423. doi: 10.1176/appi.ps.201600423. [Epub ahead of print]
 McGuire, P.A. New hope for people with schizophrenia. Monitor on Psychology (American Psychological Association) 2000; 31:24. Accessed online at http://www.apa.org/monitor/feb00/schizophrenia.aspx 12/25/2015.