Monday, 25 October 2010

The past, present and future of psychiatry - left versus right hemispheres

Last Friday, I was invited to speak at the East of England Psychiatry Higher Trainees Annual Conference on ‘The Past, Present and Future Perfect of Psychiatry’ in Cambridge. It was for me a chance to see German Berrios for the first time, lecturing on the history of psychopathology. Early on he suggested a choice between, roughly, realist and constructivist (or constructionist) views of the psychopathological categories opting for the latter himself. But I wasn’t sure whether this was a view to promote good history (in his role as historian of psychopathology) or a metaphysical commitment.

(Apparently the word ‘psychopathology’ first appeared in the 1847 translation into English of a work by Feuchtersleben in which it had appeared as ‘psycho-pathologie’ in German. “The disappearance of the hypen was very important”, said Berrios.)

But it was also a chance to hear Ian McGilchrist (pictured) summarise the main line of argument of his newish and well reviewed book The Master and his Emissary. His own site says:

Most scientists long ago abandoned the attempt to understand why nature has so carefully segregated the hemispheres, or how to make coherent the large, and expanding, body of evidence about their differences. In fact to talk about the topic is to invite dismissal. Yet no one who knows anything about the area would dispute for an instant that there are significant differences: it's just that no-one seems to know why. And we now know that every type of function - including reason, emotion, language and imagery - is subserved not by one hemisphere alone, but by both.
This book argues that the differences lie not, as has been supposed, in the 'what' - which skills each hemisphere possesses - but in the 'how', the way in which each uses them, and to what end. But, like the brain itself, the relationship between the hemispheres is not symmetrical. The left hemisphere, though unaware of its dependence, could be thought of as an 'emissary' of the right hemisphere, valuable for taking on a role that the right hemisphere - the 'Master' - cannot itself afford to undertake. However it turns out that the emissary has his own will, and secretly believes himself to be superior to the Master. And he has the means to betray him. What he doesn't realize is that in doing so he will also betray himself.
The book begins by looking at the structure and function of the brain, and at the differences between the hemispheres, not only in attention and flexibility, but in attitudes to the implicit, the unique, and the personal, as well as the body, time, depth, music, metaphor, empathy, morality, certainty and the self. It suggests that the drive to language was not principally to do with communication or thought, but manipulation, the main aim of the left hemisphere, which manipulates the right hand. It shows the hemispheres as no mere machines with functions, but underwriting whole, self-consistent, versions of the world. Through an examination of Western philosophy, art and literature, it reveals the uneasy relationship of the hemispheres being played out in the history of ideas, from ancient times until the present. It ends by suggesting that we may be about to witness the final triumph of the left hemisphere – at the expense of us all.

If I understood the presentation, one idea was that whilst the left hemisphere deals with details, specifics and practicalities, the right hemisphere deals with wholes, contexts, broader meanings and so forth. The right checks the general picture, the left focuses down without such doubts. (I want to add other distinctions such as knowledge-that versus knowledge-how but I suspect I would be free associating rather than remembering. Ah! How about that distinction!?!) And thus it is possible - as a kind of addition or consequence - to use this distinction of characteristic ways of doing things as a critical approach to contemporary culture. It seems in its emphasis on bureaucratic and algorithmic technical fixes, contemporary culture shows the over development of left hemisphere thinking over right hemisphere thinking.

It was too much to resist using this distinction (as I misunderstood it) to characterise how psychiatry should be practiced in an ideal future: the correct balance of left and right: detail and technology but also meaning and context. It was also too much to resist the idea that Iain’s over optimistic selection of slides for his talk reflected left hemisphere concentration on the details of what should be included overriding right hemisphere realism about what, in the context, might actually fit. (Who has not done that?) But I think he saw the joke.