In Sickness and in Health - What Jewish Law Can Say about Psychology and Psychiatry

By Rabbi Ira Bedzow, MA

Rabbi Ira Bedzow

Rabbi Ira Bedzow is a 2013 recipient of the Emory Center for Ethics Neuroethics Travel Award. He is the project director for Moral Education research project for the TAG Institute, and is currently pursuing his PhD in Religion at Emory University.



While it is obvious that the term "insanity" expresses the value judgments of a society's legal system, psychology and psychiatry also accept social mores as a guideline for determining mental illness and health, even when their practitioners deny doing so.  For example, according to the DSM-5, mental illness is diagnosed by dysfunctional behavior (though some psychiatrists are pushing for a biological categorization of mental illness) and thus assumes social or cultural norms by which to interpret behavior in order to determine whether it is dysfunctional or not.  Because insanity and mental illness are both predicated on social norms, they are by definition determined by society's ethical posture.



In Jewish law, and in the Jewish tradition more generally, there is a rich debate over the nature of mental health and mental illness, which can provide insight into the ethical influence over diagnosing and treating mental illness.  In general, the key question found in Jewish juridical sources with respect to mental illness is how to understand a person's behavior and how to habituate different, healthier behavior.  Of course, this may not apply to major mental disorders, yet given the current critique, that the DSM-5 has psychiatrized daily life, this discussion would apply to certain less serious mood and addictive disorders.



At first glance, the criteria in the Talmud to determine whether a person is mentally ill seem to be behavioral; a person is mentally ill when he or she acts in a socially dysfunctional manner.  In the pursuant Talmudic discussion regarding how many symptoms a person must possess to indicate whether he or she has a mental illness, however, it becomes clear that behavior alone is not a marker; rather, the question is whether the person is capable of rational thought which can explain the abnormal behavior.  If a person has no rational explanation for his or her behavior, he/she should be regarded as insane; rational explanation would imply sanity.  Questions arise over the extent to which one can interpret a person's actions as rational.  (The Talmud gives the following examples: If the signs that a person is mentally ill are that he that goes out alone at night, or he spends the night in a cemetery, or that he tears his garments, then if a person actually does one of these things, it may nevertheless be possible to say, "He spent the night in a cemetery in order to perform magic, or he went out alone at night because he was seized with the need to go outside, or he tore his garment because he was lost in thought."  If, however, he performs all of these actions, it becomes much more difficult to provide rational reasons for his behavior.)

Rabbi Moshe Feinstein

Because rationality, and therefore insanity, is often dependent on interpretation, Jewish law provides a scale for mental illness, whereby a person could be considered sane in some respects yet not in others.  For example, in one of his responsum, Rabbi Moshe Feinstein discusses a case where a person seems to be completely normal except for the fact that he believes himself to be the Messiah.  The person would climb trees in order to give speeches to the people below and he would walk around naked claiming to emulate the first human being.  Rabbi Feinstein distinguishes between being capable of comprehending the purpose and worldview embedded within Jewish law and being capable of conducting oneself in a greater society, whereby the person engages in trade and has social responsibilities.  Because the person who claims to be the Messiah is unable to comprehend the mores and values of Jewish law, not that he does not believe in them but rather that he cannot understand them, he is exempt from its (Jewish law's) obligations by virtue of being mentally ill.  On the other hand, with respect to living in the greater society his transactions would be effective since he can understand social norms as any other sane person.  In this sense, he is both sane and insane, depending on the standard by which his behavior is judged.

From: www.i09.com

Rationality is an important marker for mental health in the Jewish legal tradition for two reasons.  First, the tradition acknowledges that all people naturally create cognitive schemata (worldviews) in which their thoughts and actions make sense to them.  Rationality, therefore, gives the person the ability to understand accepted social norms as well as the ability to understand his or her own behavior vis-à-vis those norms.  Second, rationality allows for free choice through which a person can change his or her habits.  Changes in habits are believed to create changes in a person's temperament and thinking.



If a person is incapable of rational thought, then adherence to Jewish law has no beneficial effects. If, on the other hand, a person is rational, then even if he or she has a mood or an addictive disorder, Jewish law is meant to be the means by which to return to full mental health.  From the perspective of cognitive behavioral therapy, Jewish law attempts to create small tests which allow a person to find success easily when he or she observes the law and allows the person to avoid the "What the hell" effect when he or she does not.  It is able to do this because the legal framework provides the ability to perceive each act as independent of the next, yet the totality of one's daily behavior still gives rise to a unified sense of living according to a measurable standard.  Also, Talmudic thinking, which allows for greater hermeneutical flexibility than other forms of reasoning, can allow a person to reinterpret negative experiences and make them pivot-points towards different choices.  The benefits of this type of approach in therapy has been explored recently in acceptance and commitment therapy.  (This is not to negate the possible benefits of psychopharmacology; however, psychopharmacology is completely cosmetic.  It does not cure a person, it only deals with his or her symptoms.  Once the patient stops taking medication, the symptoms will return.)



The influence of Jewish social values on the determination of mental illness and on treatment is demonstrated by the fact that the techniques to treat a mentally ill person (such as observance of Jewish law and interpreting experience so as to promote positive goal-oriented development) are the same as those used to improve a mentally healthy person's well-being.  Because the ethical posture of Jewish law is consistent, prescriptions for mental illness and health are on the same spectrum as those for human flourishing.  If the Jewish tradition can impart one insight to contemporary discussions in psychology and psychiatry, it should be that categorizing mental illness also sets the boundaries for what is normal.  Whether those boundaries are fixed by biology or by social markers, diagnostics must also entail a good look into what kind of society we want to be and what type of people we want to become.





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Bedzow, I. (2013). In Sickness and in Health - What Jewish Law Can Say about Psychology and Psychiatry. The Neuroethics Blog. Retrieved on
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About the Physiological Society of Japan Ethics Symposium

By Tamami Fukushi, Ph.D



Tamami Fukushi is a Senior Research Scientist at the Platform for the Realization of Regenerative Medicine at the Foundation for Biomedical Research and Innovation in Kobe, Japan and a member of the AJOB Neuroscience editorial board. Her research focuses on areas in neuroethics, neurophysiology, and the regulation and ethics of stem cell research.



At every annual meeting since 2003, the Physiological Society of Japan has scheduled a research ethics symposium, usually dealing with animal experiments and research misconduct. One purpose of the symposia has been to raise audience awareness regarding current ethical issues in neuroscience research. In addition, the symposia have sought to open their audience’s eyes to taking action regarding ethical practices in their daily research activities.



This year, the society took up ethical issues in neuroscience. The symposium was organized by Dr. Kiyoshi Kurata, the society’s Chief of Research Ethics Committee, and Dr. Atsushi Iriki, the Editor-in-Chief of Neuroscience Research, which is published as the official journal of the Japan Neuroscience Society.



The development of neuroscience research in the past several decades has brought two characteristic trends to the research community. From the experimental perspective, progress in research protocols has extended research targets in various biological scales, from molecule(s) to intact animal or human subject(s); technical innovations in imaging, recording, and stimulating tools have enabled us to observe the neural function of these subjects more precisely. However, it also puts subject(s) at risk of invasive procedures with neurosurgery and encroaches on the autonomy of human subjects. In addition, the advancement of computer software has brought us various methodologies for data illustration which may encourage the modification of unfavorable original data for unethical reasons. Several articles have reported that between 2-14% of academic journal papers may have ethical problems, which should be seriously considered in efforts to preserve just practices among peer-reviewed publications [1].



On the other hand, from the social perspective, neuroscience has been getting more popular and familiar to the general public through mass media and entertainment  devices such as TV programs, the internet, the Nintendo Brain Age game, and free online software for brain training. A popularization of neuroscience has led researchers to explain their research results with “broader” and “easier” words, as well as to consider the ethics of neuroscience research in the public sphere and in their scientific practices. The symposium organizers and speakers considered both of these trends in preparing their presentations.



The Ethical Components of Neuroscience Research



At the symposium presentation, I first outlined a history of neuroethics in Japan and Asia, and summarized the ethical components of neuroscience research using a matrix with two different X-axes. In figure1, the lower X-axis indicated the biological hierarchy of experimental targets and the upper one represented social layers in the research community [2]. The lower components in the figure were mainly related to safety and efficacy issues, which might be regulated by quantitative criteria based on the (pre-clinical) experimental data and case studies of subjects/patients. On the other hand, the upper components referred to more complicated issues in social, legal, and public contexts, and more qualitative approaches and open discussions would be needed to provide a suitable solution. The matrix was useful for categorizing current issues in neuroethics and their relationships with other presentations, in which each speaker explained further details of selected topics.



Dr. Kurata discussed the significance of information disclosure in relation to the renewal of Japanese laws pertaining to animal experiments in 2012, and recent changes in guidelines regarding conflicts of interest in the Physiological Society of Japan [3]. He also suggested a possible role for non-profit organizations (NPO), where researchers could help address legal and political issues surrounding animal experimentation.



Dr. Iriki reported on ethical problems in scientific publishing, which he has experienced as the editor-in-chief of the peer-reviewed journal Neuroscience Research. These problems have included multiple submissions, gift authorship (or the practice of awarding authorship to an individual who has not significantly contributed to the study), data fabrication, falsification, and plagiarism [4]. While certain kinds of misconduct can technically be prevented, it is important to engage with the personal morality of individual researchers to ensure transparency in peer-review process.



The last speaker, Dr. Tashiro, introduced recent developments in ethical principles geared toward clinical research. He focused on the concepts of “collaborative research partnerships” and “respect for human research participation,” and drew upon the eight ethical principles issued by the Bioethics department at National Institutes of Health Clinical Center [5, 6]. He also emphasized the importance of support from the ethics consultation system as well as the IRB system and the needs of professionals for effective consultation.

Figure 1. Ethical Components of Neuroscience Research

There were 30 audience-members who had various backgrounds in different fields of physiology, with various  roles and responsibility at their institutions/academic research communities. Through the open discussions, we recognized that appropriate actions based on the morality of individual researchers would be key to keeping competition fair in peer-reviewed science, in both the basic and clinical settings. It was also suggested that institutional/organizational monitoring systems at higher levels of the research community are needed to strengthen the community's accountability to the public. While we had less opportunity to discuss ethics of neuroscience from the perspective of the general public (or in the media), which might be the “third X-axis” on our matrix, the meeting was a successful in encouraging the researchers to refine their moral principles in both their individual and societal dimensions.



In recent years, the Japanese neuroscience community has achieved great progress in laboratory ethics by revising experimental guidelines and developing safety criteria for human brain research (see http://www.jnss.org/en/guideline/rinri/ (in English) and http://jscn.umin.ac.jp/news/index.html#121116-2 (in Japanese)). The next neuroethical issue to be faced by the Japanese research community, and which should be more extensively considered, is “how to visualize, explain, and share the experimental result(s) more ethically to others.” This kind of ethical problem must be considered by integrating media ethics, research misconduct, and public relations.



References



[1] Fanelli, Daniele. “How many scientists fabricate and falsify research? A systematic review and meta-analysis of survey data.” PLoS ONE 4, (2009) e5738.

[2] Fukushi, T. "A decade of neuroethics: Impact on neuroscience in Japan and Asia." The journal of physiological Sciences 63 supplement 1, (2013):S88.

[3] Kurata, K. "Importance of information disclosure in animal experiment ethics and conflict of interest." The journal of physiological Sciences 63 supplement 1, (2013):S88.

[4] Iriki, A. "Responsible conduct of research and ethics of scientific publishing." The journal of physiological Sciences 63 supplement 1, (2013):S88.

[5] Tashiro, S. "New trends in clinical research ethics: Eight ethical principles and research ethics consultation" The journal of physiological Sciences 63 supplement 1, (2013):S89.

[6] Emanuel, Ezekiel J. et al. (2008). “An ethical framework for biomedical research,” Emanuel, Ezekiel J. et al. eds., The Oxford Textbook of Clinical Research Ethics, Oxford University Press, 123-135.



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Fukushi, T. (2013). About the Physiological Society of Japan Ethics Symposium. The Neuroethics Blog. Retrieved on
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Robots: the Answer for Treating Children with Autism Spectrum Disorder?

By Guest Contributor Irina Lucaciu, Emory University  



A smile appears on Jack’s face as the robot he is playing with congratulates him for accomplishing a task. Aiden seems captivated by the moving arms of Nao, a robot that has become his new playmate. Thousands of miles away, in London, a copy of Nao sits in the middle of a circle of five boys no more than 10 years old, encouraging them to imitate his movements, touch his hands, and try to identify the feelings he is describing.

Nao

When asked how the robot makes him feel and why, one of the boys replies that he is happy because the robot feels happy too.



However, Nao and the other robots are not simply toys, and neither are Jack, Aiden, and the five British boys simply children at play. They have autism spectrum disorder, and Nao is acting as a treatment tool for improving their life experience and helping them develop socially-relevant skills. Above are described the results of robot-assisted therapy [1, 3, 9, 13].



What is autism spectrum disorder, and why would the use of robots benefit those who have it?





Social interaction is embedded within human nature. We engage in it continuously, and, when deprived, we seek it to alleviate an immediate absence that provokes pain and anxiety. Regardless of whether it manifests in the form of dialogue, gestural interchange, or touching, social interaction is crucial for maintaining emotional and psychological well-being. The prevalence of communication is mirrored by its significance in human societies, and it justifies the persistent demand for socially-adaptable individuals as members of societal structures. [10]



However, individuals with autism spectrum disorder (ASD) have significant challenges with performing social functions, which makes it harder for them to be self-sufficient, follow a traditional education, or form families. Their difficulties primarily rest on an inability to relate to other people, understand the social information conveyed by gesticulations and facial expressions, and reciprocate touch or conversation initiated by an interlocutor [6].



Researchers are focusing on different strategies to encourage the development of social functions in autistic individuals. Because early intervention has been shown to be particularly effective in helping people with ASD develop skills for living autonomous lives as adults, children are currently the age group most targeted by autism researchers [10].



At present, the main therapies targeting children with ASD are applied behavioral analysis and non-human facilitation. With applied behavioral analysis, trained specialists interact with the autistic child, encouraging reciprocation, attention, and following of directions, and discouraging anti-social behaviors. Non-human facilitation can involve partnering with a trained pet that would subsequently ease the challenge of interacting with another human, engaging with an interactive computer program, or undergoing virtual training that offers gradual exposure to common social environments, such as a classroom or a playground. [6, 10]



Both human-facilitated and non-human facilitated therapies have helped children with ASD to develop better social skills over time. However, problems remain. For example, pet-assisted therapies include a risk of being bitten or hurt during the therapy session, and some children are allergic to the pets. Furthermore, emotional attachment to a pet can lead to a traumatic experience of the death or loss of the animal [8]. In a recent study done by Dr. Sandra Y. Okita at Columbia University, the risks of pet-facilitated therapy were removed with the introduction of Paro, a robotic seal and class II medical device. Equipped with various sensors that detect touch, recognize speech, and generate behavior based on the information collected, Paro was previously recognized for its therapeutic effects in the treatment of children and elderly with mental and cognitive disorders. In Dr. Okita’s study, at interest were Paro’s qualities as a social facilitator between parents and their children. Would the robotic seal increase social interaction and modelling of parental behavior, thereby reducing the pain of the patients or helping them cope better with the treatment? The results showed that the children who interacted with Paro together with their parents had lower levels of pain than children who interacted with the robot alone. In turn, parents proved a heightened ability to empathize with their children and react in ways that comforted them [8]. In the light of many studies showing that children often model parental behavior in interpreting social stimuli and forming a reaction, Paro seems to have succeeded in improving this transfer of information.

Paro

Considering the previous work using robots to both better understand human social behavior and to improve human experience in general, it is no surprise that the recent technological advancements led to the introduction of robots in a variety of fields, including autism research and treatment. But how can robots such as Paro facilitate the therapy of children with ASD? The answer lies in the many studies using social robots– or robots meant to stimulate social behaviors and increase the perception of social cues– which proved that children with ASD tend to engage actively with social robots [7]. In the following videos, both Jack and the five boys from Britain prove the above stated.  


The results of these studies are particularly uplifting considering that autistic children seem to show the more enthusiasm and interest for interacting with a person after they have interacted with a robot. A study by Elizabeth Kim and her collaborators at Yale University showed that children with ASD who interacted with a robot spoke more with an adult partner than children who interacted with a person alone [7]. In other words, it appears that interaction with a robot facilitates social interaction with an adult, at least in the short-term.

Another study showed that when a therapy session is led by a human facilitator, children with ASD spent significantly less time watching the instructor than children without the condition. However, when the session was led by a robot, both groups spent approximately the same amount of time directing their eye gaze towards the robot [9]. What is it that social robots can offer and human facilitators cannot? Dr. Kim attributes the amplified interest shown by children with ASD towards robots to a greater curiosity in them, as well as to the design of the protocol [7]. Dr. Brian Scassellati, Henny Admoni, and Dr. Maka Matarić suggested that perhaps the simplified appearance and behavior of the robot in comparison to that of a person helps with the overstimulation problem specific to many people with ASD [4, 10, 12]. Furthermore, robots might not be perceived as judgmental, helping the children to be more open to interacting with them [12].

However, no long-term studies on the benefits of robot-assisted therapy have been conducted yet. Despite the benefits that robots seem to bring, many questions remain about the ethical implications of introducing robots as large-scale therapy aids.

• What should the robot look like? At present, the appearance of robots used in autism varies widely [10]. Nao, for instance, looks like the stereotypical machine-like robot. Keepon has the appearance of a toy duck, and it was even introduced as merchandise at Toys ‘R’ Us in 2011 [14]. Paro, on the other hand, is clearly more complex, and its appearance resembles closely that of a real seal. Kaspar shares many features with a human child, but it is still clearly a man-made object. However, FACE looks incredibly human-like, and has complex mechanisms that allow her to express human emotions with very accurate facial expressions.

FACE, image from sciencespacerobots.com  

     

Keepon, image from clockers.co.uk

Kaspar, image from blogs.herts.ac.uk

    

         







































Considering that children with ASD are easily overstimulated [10], would it be wiser to introduce them to robots with a simplified appearance such as Keepon or Nao, rather than a robot like FACE? In that case, how are they to interpret such an interaction, and transfer what they learned from it to the interaction with a human? All these robots are programmed to reproduce the characteristics of either humans or animals. Nao, for instance, uses language. His speaking abilities, along with many other human-like behaviors he shows suggest to the child that Nao’s actions are governed by a brain very similar to that of a human. But Nao does not have a brain of its own, and despite its multiple sensors that make him able to adapt its behaviors according to the responses of a child, he does not possess the human ability to produce behavior and speech that are sensitive to context. Even robots such as Kismet, which received a social “brain” based upon the four modules identified by psychiatrist Simon Baron-Cohen as necessary for social interaction– Intentionality Detector, Eye Direction Detector, Shared Attention Mechanism, and Theory of Mind Mechanism [11]– can only simulate simplified human behaviors, such as following people with its gaze and seeking human company. The only way to increase a robot’s range of behaviors and make its reactions more particular to the emotions and responses of the child is to increase the amount of information that the robot receives from its interaction partner. In turn, that would require more physiological detectors, which could range from galvanic skin response detectors and pulse monitors to brain activity detectors. Such recording devices could become bothersome and invasive, and could have a negative effect on therapy. [10]

• Take the case of FACE. Her appearance is, indeed, very human-like. However, modern-day technology has not been able to give her the ability to express more than six basic human emotions. Facial expressions are possible on account of sensitive nervous control of multiple muscles of the face. As expected, such control is difficult to reproduce using modern-day technology [10].

• What if a malfunction occurs in the mechanisms of the robot during its interaction with the child [10]? It was discussed above that the death of a pet providing animal-assisted therapy could be traumatic for the child. However, death is at least embedded within human experience, and it is something that the child with ASD will have to face as a functional member of society. Robots cannot die, but they can be damaged, because they are currently not designed to resist bumps, spills, and falls.

• Last but not least, what role should the robot take around the child? Should it be a friend, instructor, parental figure, or simply a toy [10]? Using a robot during therapy would not be as simple as using a pet. While a pet, although trained, remains essentially an animal with the characteristics of its own species, a robot borrows many essential human features, such as language and gesticulation. In the case of Nao, for example, the robot also looks drastically different from a human. The child holds the hard and cold hand of the robot, and then the warm and soft hand of a human, and yet, both the robot and the human play games, talk, and dance. How will the child react to such conflicting features?

A robot, no matter how advanced the technology invested in its creation is, does not think similarly to a human. Despite its many sensors, it cannot integrate information with the same efficiency, simply because its motors do not possess the level of connectivity that characterizes the human brain. While there are still so many things to be understood about our brain, it seems unlikely that a robot with the ability to mimic human emotions and behaviors could be created. Until neuroscience can decipher the secrets of the brain, the introduction of robots as a means to teach children with ASD about human social behaviors should be carefully thought-out. Only long-term projects investigating both the benefits and the downfalls of using robots for treating children with autism spectrum disorder could testify either in support or in opposition to robot-assisted therapy.



References

[1] Aldebaran Robotics. "Robots teach communication to children with autism." Online video clip. YouTube. YouTube, 29 Apr. 2013. Web. 30 Apr. 2013. Retrieved from http://www.youtube.com/watch?v=lm3vE7YFsGM

[2] Associated Press. “Kaspar the Friendly Robot Helps Autistic Kids.” Online video clip. YouTube. YouTube, 8 Mar. 2011. Web. 30 Apr. 2013. Retrieved from http://www.youtube.com/watch?v=D6gTHPoO9VI

[3] Breen, Tom, and Bret Eckhardt. "How Robots Can Help Children with Autism Learn and Communicate." UConn Today. 25 Apr. 2013. Web. 30 Apr. 2013. Retrieved from http://today.uconn.edu/blog/2013/04/how-robots-can-help-children-with-autism-learn-and-communicate/

[4] Foss-Feig, Jennifer H., Duje Tadin, Kimberly B. Schauder, and Carissa J. Cascio. "The Journal of Neuroscience." A Substantial and Unexpected Enhancement of Motion Perception in Autism. Web. 5 May 2013. Retrieved from http://www.jneurosci.org/content/33/19/8243

[5] Goodrich, Michael A., Mark Colton, Martin Fujiki, Alan Atherton, Lee Robinson, Daniel Ricks, and Margaret H. Maxfield. "Incorporating a Robot into an Autism Therapy Team." Incorporating a Robot into an Autism Therapy Team. IEEE Life Sciences, n.d. Web. 29 Apr. 2013. Retrieved from http://lifesciences.ieee.org/articles/134-incorporating-a-robot-into-an-autism-therapy-team

[6] "How Is Autism Treated?" Autism Speaks. Web. 3 May 2013. Retrieved from http://www.autismspeaks.org/what-autism/treatment

[7] Kim, Elizabeth S., Lauren D. Berkovits, Emily P. Bernier, Dan Leyzberg, Frederick Shic, Rhea Paul, and Brian Scassellati. "Social Robots as Embedded Reinforcers of Social Behaviors in Children with Autism." National Center for Biotechnology Information. U.S. National Library of Medicine, 31 Oct. 2012. Web. 16 May 2013. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23111617

[8] Okita, Sandra Y. "Self-Other's Perspective Taking: The Use of Therapeutic Robot Companions as Social Agents for Reducing Pain and Anxiety in Pediatric Pacients." National Center for Biotechnology Information. U.S. National Library of Medicine, n.d. Web. 16 May 2013. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23505968

[9] Salisbury, David. "Humanoid Robot Helps Train Children with Autism | Research News @ Vanderbilt | Vanderbilt University." Vanderbilt Research. N.p., 23 Mar. 2013. Web. 3 May 2013. Retrieved from http://www.youtube.com/watch?v=lZSDnvOoX84

[10] Scassellati, Brian, Henny Admoni, and Maja Matarić. "Robots for Use in Autism Research." - Annual Review of Biomedical Engineering, 14(1):275. N.p., 9 May 2012. Web. 16 May 2013. Retrieved from http://www.annualreviews.org/doi/abs/10.1146/annurev-bioeng-071811-150036

[11] Smith, Jeremy Adam. "Can Robots Feel Your Pain?" Greater Good. University of California, Berkeley, Summer 2007. Web. 16 May 2013. Retrieved from http://greatergood.berkeley.edu/article/item/can_robots_feel_your_pain

[12] "Talking Robots Play Part in Therapeutic Treatment for People with Special Needs." PBS. 9 Jan. 2013. Web. 5 May 2013. Retrieved from http://www.pbs.org/newshour/bb/science/jan-june13/robots_01-09.html

[13] UConn. “A Story of Robots and Autism.” Online video clip. YouTube. YouTube, 25 Apr. 2013. Web. 30 Apr. 2013. Retrieved from http://www.youtube.com/watch?v=nwJsxLOilcc

[14] Vance, Ashley. “Toys ‘R’ Us Wants a Robot to Sell for Christmas. Bloomberg Business Week Magazine. (2011). Retrieved from http://www.businessweek.com/magazine/toys-r-us-wants-a-robot-to-sell-for-christmas-08112011.html



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Lucaciu, IM. (2103). Robots: the Answer for Treating Children with Autism Spectrum Disorder? The Neuroethics Blog. Retrieved on
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We’re All Mad Here

In the early 1970’s, eight people checked themselves into psychiatric
hospitals throughout the United States, complaining of hearing voices. They
were all admitted, and during their hospitalizations exhibited no unusual
behavior and claimed to no longer be experiencing auditory hallucinations.
After stays between 7 and 52 days in the institutions, the patients were
discharged and given diagnoses of either schizophrenia or bipolar disorder. None
of these people had any mental illnesses, and had, in fact, falsified their symptoms
as part of an experiment conducted by psychologist David Rosenhan (who was
himself one of the “pseudopatients”).




The results of the study were published in a 1973
paper in Science titled “On being sane in insane
places”. In the paper Rosenhan argues that it is difficult to distinguish
between “normality” and “abnormality” when it comes to mental health, and that,
once applied, the label of a psychiatric diagnosis can be so strong that all of
an individual’s actions are viewed in light of that label, especially in a
place like a psychiatric hospital where patients are assumed to be “insane”. The
study was seen as an eye-opening commentary on the American mental health system
and also criticized for its methodology and conclusions.^1,2

The founders of the Icarus Project believe that, just like Icarus' wings, madness can lift people to great heights or send them falling to their doom

Thirty years later, the study is still cited in debates
about the science and ethics of psychiatric diagnoses and treatments, often by those
critical of the field. One interesting and controversial voice active in this
debate is the mad pride movement.³ In my previous post, I discussed the
neurodiversity movement’s views on autism. Mad pride (which has recently
been discussed
on this blog) takes a similar approach to issues of mental health. Like neurodiversity
(and most movements and ideologies in general) mad pride encompasses a wide
variety of beliefs and causes, but the primary one is to give a voice to people
living with mental illness (although some in the movement dislike that term ⁴)
in the hopes of educating the public, creating patient-run communities and support
networks, and pushing for reform in mental health systems.



Psychiatric Survivor Pride Day (considered one of the first mad
pride events) took place in Toronto, Canada in 1993, and was organized, in part,
in response to housing discrimination against former psychiatric patients.⁵ The goal was to combat the stereotypes and stigma faced by current and former
consumers (a neutral term commonly used by mad pride activists) of mental
health services and to celebrate their contributions to culture and society.
The way in which mental illness is viewed by the public (which has been explored previously
on this blog) remains a key focus of the mad pride movement.



Another focus of the movement is to create communities (through,
for example, group meetings and online forums and blogs) where people with various
mental health issues can discuss their experiences for both educational and
therapeutic reasons. Two notable examples of such communities are The Icarus Project and the National Empowerment Center. The
creators of these communities believe that talking with others who have had
similar experiences and being able to describe their own unique situations
(which are more complex and specific than the broad diagnostic labels applied
to them) are good ways for people to improve their mental health, especially if
they feel marginalized and misunderstood in their day-to-day lives. 

Many mad pride organizations also advocate for changes in the
field of psychiatry and the mental health system. Just as they fight for a
voice in society, they fight for a voice in their treatment, arguing that, like
the Rosenhan study seemed to show, those diagnosed with mental illnesses are
often patronized and not taken seriously by doctors and therapists when, in fact, they need
to be heard both out of respect for them as people and because it is
beneficial to their treatment.




Advocating for giving patients a greater voice also extends
to supporting self-determination and choice when it comes to psychiatric
treatment. Mad pride and patient advocacy groups, like the Law Project for Psychiatric Rights and MindFreedom International, campaign
against involuntary treatment and involuntary institutionalization, seeing these
actions as human rights violations. Some take this argument further, casting
suspicion on mainstream psychiatry and arguing that the medical model of mental
health is not the only legitimate approach. To them, conditions labeled as psychiatric
disorders (particularly mood disorders like depression and bipolar disorder) might in fact be extreme forms of the non-pathological emotions and mental states we all
experience and which, while they can be unpleasant and even dangerous, can be
controlled and managed in ways other than medication or traditional psychotherapy.
While they do not oppose the use of psychiatric drugs by those who choose to do
so, their rejection of what they see as a healthy/sick duality leads them to also
support the freedom to reject treatment or to explore alternative therapies.⁶ 

A MindFreedom protest against the American Psychiatric Association

These critiques of psychiatric treatment (both
compulsory and otherwise) and the support for non-traditional therapies are
where the controversy lies. I am personally very uneasy with the concept of
involuntary institutionalization; ideally all medical treatments should be
purely consensual. But when a person’s thoughts are possibly compromised, the
concepts of self-determination and autonomy obviously get murkier, especially
when the debilitating nature of some of these disorders and the risk of suicide
is taken into account.




Many of the outspoken critics of psychiatry in the mad pride
movement are current or former psychiatric patients whose opinions were formed
through their own experiences with involuntary treatment and abuses in the
system. But many of them were patients in the 1960s and 70s (or earlier)⁷ when
the state of the field was much different than it is now. Involuntary
commitments were more common and harmful and painful procedures were
performed (like insulin
shock therapy and electroconvulsive
therapy done without anesthesia) that are no longer used.⁸ I know that these
activists are aware of such changes in psychiatry and most likely are more
familiar with the current state of the mental health system than most people,
but in making their arguments they sometimes seem to present it as it was
decades ago.




The rejection of the medical model among some mad pride
advocates enters into anti-psychiatry
(a different, but related movement that opposes the foundations and activities
of the medical field of psychiatry), blurring the lines between the two
movements. The opponents of psychiatry claim that there is not enough evidence
to support purely biological models of mental illness and the use of
psychiatric drugs.⁶ While the effectiveness of such drugs and the accuracy
of such models are being questioned in the medical and scientific communities^9,10 (including the controversy surrounding the newly released DSM-5¹¹),
anti-psychiatry takes those criticisms further and is (not surprisingly) denounced by psychiatrists.¹² And those who are skeptical of psychiatric medication don’t apply the
same standards to their own claims since there is even less evidence to support
the alternative therapies they advocate. Though the alternatives usually
include diet, exercise, meditation and social support, which are supported by
medical professionals, just not as replacements for psychiatric help.  

Is the serotonin hypothesis of depression correct?

In addition, the rejection of the medical model of mental illness
might actually put some mad pride activists at odds with other mental health
activists. Mad pride advocates dislike portraying psychiatric conditions as
illnesses or diseases because they think that it increases the stigma around
them, making people see those diagnosed with such conditions as diseased and
abnormal. But some mental health professionals and patients encourage the
medical view of mental health, hoping that it will reduce stigma because such
disorders will seen as medical conditions (just like physical illnesses) rather
than character flaws or moral failings on the part of the patient (for example,
seeing a depressed person as being lazy) or their families (believing that all
mental health problems are the result of an abusive household).^13,14



Still, the most visible and active elements of the mad pride
movement are working for the rights of those diagnosed with mental illnesses
both in society and in the psychiatric systems. Reducing stigma and giving
patients a greater voice in their treatment will only improve the current state
of psychiatry, and should be accepted by everyone, no matter where they stand
in this debate. Whether you see those with psychiatric conditions as people who
are sick and need help or as people whose emotions and mental states are more extreme
than usual, they are still people who deserve the same rights and respect as everyone
else.




References


1. Spitzer, Robert L. On
pseudoscience in science, logic in remission, and psychiatric diagnosis: A
critique of Rosenhan's "On being sane in insane places". Journal of
Abnormal Psychology, 1975, 84(5): 442-452.


2.  “Rosenhan
Experiment,” the Psychology Wiki.

3. Gabrielle
Glaser. ‘Mad Pride’ Fights a Stigma. The New York Times, 2008.

4. David
Oaks. Let’s stop saying ‘Mental Illness”! MindFreedom International.

5. Consumer/Survivor Information
Resource Centre of Toronto. July 15, 2008 bulletin.

6.  David
Davis. Losing the Mind. Los Angeles Times, 2003.

7. MindFreedom International:
Personal Stories.

8. Eisenberg,
L. and Guttmacher, L. B. Were we all asleep at the switch? A personal
reminiscence of psychiatry from 1940 to 2010. Acta Psychiatrica Scandinavica, 2010,
122: 89–102.

9. Lacasse
JR, Leo J.  Serotonin and Depression: A
Disconnect between the Advertisements and the Scientific Literature. PLoS Med, 2005,
2(12): e392.

10. Moncrieff
J, Cohen D. Do Antidepressants Cure or Create Abnormal Brain States? PLoS Med, 2006,
3(7): e240.

11. Thomas
Insel. Director’s Blog: Transforming Diagnosis.

12. Nasrallah,
Henry. The antipsychiatry movement: Who and Why. Current Psychiatry, 2011,
10(12).

13. “Overcoming The Stigma
of Depression.” Healing From Depression.

14. Jennifer
Welsh. Blood Test may Reduce Stigma of Depression. Live Science, 2012.





Want to cite this post?


Queen, J. (2013). We’re All Mad Here. The Neuroethics Blog. Retrieved on

, from http://www.theneuroethicsblog.com/2013/07/were-all-mad-here.html.

A Creative Balance

When it comes to creativity, one might most readily think of children. The young, innocent imagination is a great conduit for idea generation. Or perhaps the term calls to mind an image of a prolific artist who could be well described by the term "eccentric." Generally speaking though, the thought of creativity may not be immediately associated with mental illness.



However there are mental illnesses that lend towards greater creativity, and some have believed that there are medicines which reduce creativity. Does our chemical attempt to monitor distraction and promote productive behavior tamper who we are at an essential level? Do the aspiring artsy-fartsy need to have some form of ADHD, bipolar disorder, psychosis, frontotemporal dementia, temporal lobe epilepsy, or depression in order to succeed? Are these types of illnesses part of our personhood makeup and consequently deserve to be embraced instead of adjusted? Perhaps a fine line can be drawn outlining what types of actions should be taken regarding mental health, creativity, and the value we place on humans in general.

Creativity does not exclusively apply to the modern day Da Vincis, Picassos, and Dalis. Creativity is a tool used and needed by each human being in everyday life. It is an approach to problem solving and idea generation, providing flexibility and availability to think in more than a single uniform way. Dr. Alice W. Flaherty has her Ph. D. in neuroscience from M.I.T. and is known for her work studying creativity. She also has bipolar disorder from which she experiences hypergraphia, the intensive urge to write. It is through her depressions that she is able to empathize with patients. She explores the relationship between creativity and mental illness in her paper Brain Illness and Creativity: Mechanisms and Treatment Risks. She concludes: "Creativity requires brains with adequate capacity for goal oriented motivation, novelty seeking, flexible associative networks, and lower inhibition. Creativity's link to illness stems from the fact that most novel ideas are bad ones and, in dangerous environments, unhealthy ones. Creative solutions usually require many failed experiments first. The novelty-seeking and unusual behaviours that confer vulnerability to environmental stressors may underlie inventiveness in tolerant surroundings. One way to separate illness from creativity, then, is to place patients in more enriched or supportive environments. Although that is often not possible, we should not ignore the situations where it is" (Flaherty, p. 140). It is unclear to me whether or not it is indeed the case that most novel ideas are bad ideas. While the qualitative status of novel ideas may be unclear, I do agree that the solutions require trial and error, and that when and if possible, we should place individuals in environments that support, encourage, and promote well-being.

The nature of the brain illness (psychiatric or neurological), the location within the brain, and the type of medicine used each has its own influence on creativity. According to Flaherty's review, though she does not intimate the guidelines she employs, the following illnesses are generally considered to be psychiatric:



(1) Hypomania: It is the moderate form of self-confidence and hyperassociativeness accompanying hypomania that generates more "focused goal-directed activity."

(2) History of depressed episodes: The rebounding energy after a depressed episode boosts creativity, by the [approach] motivational drive the positive energy provides. The increase in creativity that “activating moods” produce is explored by De Dreu CK, Baas M, and Nijstad BA.

(3) Psychosis: Flaherty notes that traits associated with psychosis, manic psychosis rather than schizophrenic, are better indicators of creativity. This is most likely annotated by reduced latent inhibition (LI), discovered by Carson SH, Peterson JB, and Higgins DM.

(4) Belief in favor of substance abuse: "Substance abuse is common in creative artists. However, it may not cause creativity; it may instead be the case that many artists have illnesses that increase addictions" (Flaherty, p. 134). Contrary to (especially American because of the amount of alcoholic American writers in the 20th century) popular opinion, consuming alcohol does not increase creativity - in fact, as Flaherty points out from Gustafson’s study on “Effect of alcohol on quantity of creative production using the Purdue tests”, even a moderate amount lowers levels of creativity.

(5) ADHD: Here she notes that with ADHD there is an increase in general activity level, but not selectively for creative activity. Creative activity, I would imagine, is any activity that assents to Flaherty’s definition of creativity: “a brain state that generates actions that are novel and useful to a community” (p. 133). This is a sticky definition of creativity for I would argue that an idea or action’s usefulness, (as deemed by society) is neither necessary nor sufficient in order for it to be creative. Although Flaherty thinks her 3-factor definition encompasses the cultural context creativity is examined within. She further explains that research does not support the claims that ADHD increases creativity, nor that the medicine for it diminishes creativity.



The following illnesses Flaherty lists as generally considered neurological:

(6) Temporal Lobe Epilepsy: One-tenth of those with temporal lobe epilepsy exhibit hypergraphia, a pressured drive to write that occurs between seizures and is not weakened by anticonvulsants.

(7) Frontotemporal Dementia: (FTD) can cause patients to become "suddenly and intensely motivated to paint or draw." FTD is more likely to motivate artistic production if the degeneration is worse in the temporal rather than the frontal lobes (p. 134).

(8) Amyotrophic or Primary Lateral Sclerosis is the neurodegeneration of temporal lobes and motor areas. Patients with this illness, similarly to those with FTD, will "occasionally manifest new artistic creativity as other parts of the brain fail" (p. 134).

(9) Parkinson Disease Medication: While the disease is associated with apathy and depression, the dopamine agonist medicine will spark highly focused goal-directed behavior. "In some patients with Parkinson disease, the chief compulsive behaviour is a de novo passionate artistic drive to write, compose music, or paint."

(10) Autistic Savant Syndrome: This syndrome exhibits an increased skill level of detail-oriented processing, usually concentrated within calculation, math, or musical performance. This skill often arises due to the savant's single-minded pursuit of practicing their talent (Flaherty, p. 134).

Unfortunately, negative stigma is often attached to mental illness. However, there are advocates, such as those with Mad Pride, who provide support, encouragement, generate discussion on mental illnesses, and argue for a "pro-choice" attitude towards medicine. The Stanford Encyclopedia of Philosophy’s entry on identity politics cites Sonia Kruk in explaining the focus of different groups gaining recognition: “The demand is not for inclusion within the fold of ‘universal humankind’ on the basis of shared human attributes; nor is it for respect ‘in spite of’ one’s differences. Rather, what is demanded is respect for oneself as different.” Certainly this raises an important issue: do patients with brain illnesses reserve the right to voluntarily consent to take medicine? In Gabrielle Glaser's article on Mad Pride for the New York Times, she outlines the weary concerns psychiatrists have about this pro-choice attitude. Dr. E. Fuller Torrey raises the question of whether we should allow someone with a brain illness such as Alzheimer's "who wants to walk outside in the snow without their shoes and socks" to decide to take medicine that manages the disease. It seems that there is a gradient amongst brain illnesses in how they affect our decisions for our overall well-being. Most would agree that the patient with Alzheimer's walking barefoot in the snow needs medicine or some intervention to maintain their ultimate well-being. But what if we compare some of the brain illnesses mentioned above? Do the diseases, at any stage, demand involuntary treatment?

I like the terms "manage" and "maintain" when referencing treatment for the illnesses. These terms, I think, uphold the respect of the persons with the disease, and the focus is on managing disruptive symptoms and maintaining some level of consistency. Does managing treatment diminish creativity in cases of related brain illnesses? If this is the case, are we affecting the value we place on ourselves as well as others? If we were to treat these mental illnesses entwined with creativity, would we tamper the way in which we value Van Gogh? Would we tamper the way in which Van Gogh values himself? It is also important to note that not all individuals respond to treatments in the same way. While some may be able to manage symptoms with their own coping strategies others may in fact need psychiatric medication for management.

Alfred Lord Tennyson, Fyodor Dostoevsky, Charles Dickens, and Lewis Carroll are some of history's prolific writers who suffered from epilepsy. Would we have the stories of Alice in Wonderland and Through the Looking Glass without Lewis Carroll’s epileptic experience? “The very sensation initiating Alice’s adventures – that of falling down a hole – is a familiar one to many people with seizures. Alice often feels that her own body (or the objects around her) is shrinking or growing before her eyes, another seizure symptom.”



Madigan Shive, a musician and Mad Pride member, asks a similar question: “I think often that if Da Vinci were alive during our time, would we just dope him up? What would we do?” She embraces her mental illness, viewing her bipolar disorder as a part of who she is and not a psychiatric label. She pleads, “please don’t change this thing inside in me that creates this music and keeps me alive…I need my madness.”



The nature of these occurrences in the brain figure into the equation of our personhood and therefore require a careful approach to avoid altering creativity while mitigating suffering related to mental illness. Although the term person or personhood is a controversial term, especially in philosophy, I will reconcile with Cressida Heyes’ simply put explanation: “one’s sense of self and its persistence.”  This sense of self and its persistence is what demands such careful consideration when approaching mental illness. This is to say that our status as persons demands respect: a certain threshold of moral obligation in the way we treat each other. We should respect everyone’s sense of self and its persistence while also considering their overall well-being, finding the balance. This respect for selves merits our worth as human beings. Of course, overall these questions are difficult to tackle. The definitions of mental illness, creativity, and worth have become increasingly controversial.  In Michelle Roberts’ article for BBC News Creativity ‘closely entwined with mental illness’, Dr. Simon Kyaga explicates: “If one takes the view that certain phenomena associated with the patient’s illness are beneficial, it opens the way for a new approach to treatment. In that case, the doctor and patient must come to an agreement on what is to be treated, and at what cost.” This is an excellent point to take note of when faced with the challenges of mental illness and personal integrity. Dr. Alice W. Flaherty has realized herself the empathic ability that her bipolar disorder has provided. An article in the New York Times  focuses on the bipolar empathic doctor. “‘What made me empathic was my depressions,’ she said recently. ‘People’s emotions were pounding me in the face. The mania is like wasps under the skin, like my head’s going to explode with ideas. But the depressions help the doctor aspect of me.’”

While some components of a disease may be beneficial, especially in a creative way, other effects may be detrimental in other avenues of life. A precarious balance is established taking into account a person’s worth, the demands of one’s daily life, and the effects of one’s illness. On one side we want to uphold and respect a person’s worth when managing symptoms, while on the other side also wanting to preserve the creativity of each human being and our present day Dalis and Carrolls. This is not to say that we should keep someone suffering from epilepsy because they write great stories – but that we should develop and advocate a system of treatment that will manage symptoms of the illness while maintaining the person’s sense of self, in turn preserving attributes that make them who they are, including creativity.



References



Ely, Elissa. (2009). From Bipolar Darkness, the Empathy to be a Doctor. The New York Times.Retrieved from

http://www.nytimes.com/2009/03/17/science/17prof.html?pagewanted=all&_r=0



Flaherty, A.W. (2011). Brain Illness and Creativity: Mechanisms and Treatment Risks. Canadian Journal of Psychiatry, 56(3), 132-143. Retrieved from

http://connection.ebscohost.com/c/articles/60818694/brain-illness-creativity-mechanisms-treatment-risks



Glaser, Gabrielle. (2008). ‘Mad Pride’ Fights a Stigma. The New York Times.Retrieved from

http://www.nytimes.com/2008/05/11/fashion/11madpride.html?pagewanted=all&_r=2&



Roberts, Michelle. (2010). Creative minds ‘mimic schizophrenia’. BBC News Health. Retrieved from

http://www.bbc.co.uk/news/10154775



Roberts, Michelle. (2012). Creativity ‘closely entwined with mental illness’. BBC News Health. Retrieved from

http://www.bbc.co.uk/news/health-19959565



Robinson, IA, & Rodrigues, Astrid. (2009). ‘Mad Pride’ Activists Say They’re Unique, Not Sick. ABC News. Retrieved from

http://abcnews.go.com/Health/Story?id=8382903&page=1#.UdGfKthQiCd

Want to cite this post?


McCoyd, C. (2013). A Creative Balance. The Neuroethics Blog. Retrieved on

, from http://www.theneuroethicsblog.com/2013/07/a-creative-balance.html.