The futile quest for certainty in treating mental illness

Last week at my church we started a five-week course on Mental Health and Pastoral Care. It is being facilitated by a team with different experiences and expertise, including medical, psychological, pastoral, theological, and personal. I like this as mental health is complex and multi-faceted. My role is someone who has struggled with mental health for most of my adult life and has consequently read and thought widely and interacted with a diverse range of sufferers and carers. Previously, I wrote a post giving a theological perspective on mental health and gave a sermon on the Wisdom of Weakness.

A central idea in the course is that of the four-dimensional character of mental health, and the importance of an integrated perspective. 

This is captured in the figure below from Sanctuary Mental Health Ministries.

A specific case of mental illness provokes two practical questions. 

What are the causes of this specific case of mental illness? 

What will be the most effective treatment plan that will lead to healing? 

These are natural and important questions. The problem is that in most cases the answers are not clear.

In contrast, consider most physical medical problems or when technological device fails. An expert can determine the cause of the specific problem: an infection in the left ear, a broken bone in the right arm, an electrical fuse has blown, or the spark plugs in the car engine are not working. Furthermore, the expert can propose and implement a treatment plan that will solve the problem. Given the advanced state of our knowledge, we can be almost certain that the diagnosis is correct, the treatment plan is appropriate, and that the problem will be solved. This certainty reflects the wonders and blessings of science and technology.

The problem is that the success of the sciences in some domains has led to hopes, expectations, and a myth that similar certainty and success are possible in other domains of life. However, the problem is that human brains are much more complex than ears, bones, cars, and electrical circuits. The relationship between consciousness, brain, and body remains a mystery, and people are embedded in networks of human relationships (from family to global cyberspace) and have long and complex personal histories.

This quest for certainty is driven by healthcare professionals, big pharma, governments, and patients. On the positive side, this quest reflects our humanity in our desire to alleviate human suffering. On the negative side, there are significant benefits: financial, professional, social status, and political to be gained by offering certainty, even when it is not justified. In the case of psychiatry as a science,is the issue of its professional hubris are discussed in this book review.

This quest for certainty is also driven by human desires for quick fixes to problems.

One problem with the diagram above representing the four-dimensional model is that some people, both patients and professionals, will want to locate a specific case of mental illness as being at a specific point on the diagram. For almost all cases that is simply not possible. 

Origins of the modern quest for certainty: part 3

We live in an uncertain world. Some things we can be certain of: death, taxes, gravity, the sun rising,... Furthermore, science has been successful at establishing "laws" that describe many aspects of the natural world. Yet, certainty is elusive on so many areas of life, including in our understanding of some aspects of the natural world. Certainty is an idol that is crafted and worshipped by a cast of characters, in politics, science, technology, business, church,...

The yearning for certainty may be a characteristic of humanity. But where did the idea that we could have such certainty come from?

In a previous post I quote extensively from Miroslav Volf's engagement with 

Cosmopolis: The Hidden Agenda of Modernity by the philosopher Stephen Toulmin. He traces the quest and all its unhelpful consequences back to Rene Descartes. Here is another author from a completely different field engaging with Toulmin. Malcolm Miles, in his book Paradoxical Urbanism: Anti-Urban Currents in Modern Urbanism (pages 50-51).

the Discourse was written [by Descartes] and published during the Thirty Years’ War (1618–1648), a conflict between Catholic and Protestant dynasties and ideologies in which Descartes was a gentleman observer at the Emperor’s court. That is why he travelled in Germany and found himself in a stove-heated room.  ...Stephen Toulmin writes of this period that, 

‘rival militias and military forces consisting largely of mercenaries fought to and fro, again and again, over the same disputed territories … in the name of theological doctrines that no one could give any conclusive reasons for accepting.' [Toulmin, p.55] 

 Around a third of the population of the land which now constitutes Germany and the Czech Republic were killed, either directly in fighting or through famines resulting from the destruction of crops, or in the displacement following the burning of villages and towns. Both sides committed atrocities. Toulmin asks, ‘In this blood-drenched situation, what could good intellectuals do?' They could maintain Renaissance humanism, or

withdraw. Or, 

Might not philosophers discover … a new and more rational basis for establishing a framework of concepts and beliefs capable of achieving the agreed certainty that the skeptics had said was impossible? If uncertainty, ambiguity, and the acceptance of pluralism led, in practice, only to an intensification of the religious war, the time had come to discover some rational method for demonstrating the essential correctness or incorrectness of philosophical, scientific, or theological doctrines. [Toulmin, p.55]

This is the reason for the Discourse. But Toulmin identifies another

response in the idea of Cosmopolis, a fusion of two systems: that of cosmos, the natural world and natural sciences, with polis, political and social organisation. Cosmopolis unites these ideas in a single ideal as a means to resolve the separation of the natural from the social and political world. 

Toulmin argues that Cosmopolis figures in the rise of nation-states in the seventeenth and eighteenth centuries, replacing dynastic feudalism; and in the rise of natural science in the same period. Both seek stability, and the nation-state constructs it in the relations of states to each other while also constructing a hierarchy in their internal social structures, making modern political institutions on a seemingly non-contingent basis: 

It was important to believe that the principles of stability and hierarchy were found in all of the Divine plan, down from the astronomical cosmos to the individual family. Behind the inertness of matter, they saw in Nature, as in Society, that the actions of lower things depended on, and were subordinate to oversight and command by higher creatures … The more confident one was about subordination and authority in Nature, the less anxious one need accordingly be about social inequalities. ...

The comprehensive system of ideas about nature and humanity that formed the scaffolding of Modernity was thus a social and political, as well as a scientific, device: it was seen as conferring Divine legitimacy on the political order of the sovereign nation-state. In this respect, the world view of modern science … won public support around 1700 for the legitimacy it apparently gave to the political system of nation-states as much as for its power to explain the motions of planets, or the rise and fall of tides. 

[Toulmin, p. 128]

One could be certain about the motion of planets. They followed laws, ordained by God. Similarly one could be certain about social and political structures. 

As I argued before, there are significant problems with Descartes' ideas about universal truth and method. Humans are not cannonballs falling to earth or planets orbiting the sun. We are much more complex. The methods and certainties associated with mechanical motion do not necessarily translate to other systems: human, social, economic, and political.,