Mind-Brain Dualism and Its Place in Mental Health Care

This chapter begins by setting out and explaining the doctrine of "substance dualism", according to which the mind and the brain are distinct and mutually independent "substances". It then examines the merits and deficiencies of dualism, in comparison with those of alternative theories, in answering questions about the nature and treatment of mental disorder. its similarities and differences from bodily illness, and the relation between mental disorder and brain dysfunctnon. The alternative theories considered are the mind-brain identity version of materialism, and Merleau-Ponty's conception of human beings as "embodied subjects".

Paper 12. Mind-Brain Dualism and Its Place in Mental Health Care by Eric Matthews


Pat D September 27, 2020 at 11:47 AM

Reason for choosing this paper

- Is it possible to bring analytical and phenomenological accounts of mental health/ psychological functioning into constructive dialogue with one another?

- I will begin by comparing Matthews and Boorse and then suggest that Lonergan offers a way to mediate their positions.


Pat D September 27, 2020 at 11:49 AM

EM’s characterization of Boorse’s position on mental disorder is inaccurate

- “Boorse draws skeptical conclusions about the idea of mental illness. The reason for doubt seems to be that mental disorders like schizophrenia or depression, while they may qualify as illnesses, in the sense of being conditions which we find undesirable, do not seem to be diseases, in the sense of being objectively determinable deviations from the nornal functioning of an organism in accordance with its design” [EM, p. 349].

- “It is quite likely that there is such a thing as mental health; yet the majority of ‘mental-health’ theorists use methodologies that offer no assurance of finding out the first thing about it. They do not set out to investigate the normal functional organization of the human mind, as they ought to do if their subject is mental health. [CB: ‘What a theory of mental health should be’ 1976, p. 68]

- According to CB, focusing on social undesirability (as per EM above) is the wrong way to work out a theory of mental health.


David H October 2, 2020 at 8:13 PM

I agree with Pat. I didn’t recognize Boorse’s theory in Matthews’s account. The Matthews quote from page 349 that from the distinction between health and disease that Boorse draws skeptical conclusions about mental illness. “The reason for doubt seems to be that mental disorders like schizophrenia or depression, while they may qualify as illnesses, in the sense we of being conditions which we find undesirable, do not seem to be ‘diseases’ in the sense of being objectively determinately deviations from the normal functioning of an organism in accordance with its design.” Surely, depression and schizophrenia easily fit his theory of disease at suboptimal contributions to survival and reproduction.

Matthews then goes to say on the next page (350) “what is bizarre in one society isn’t so perceived in another so “mental disorder is determined not by what people in any particular society generally regard as bizarre beliefs or behavior, for instance.” There is no basis in Boorse for this relativization of disease even if illness is so relativized. Doesn’t Boorse also say somewhere that he has dropped the characterization of illness that he used in his Distinction paper?


Pat D September 27, 2020 at 11:56 AM

EM’s characterization of intentionality and subjectivity [pp. 352-353] - for sake of comparison to Lonergan below

“Thoughts, emotions, desires, and other mental phenomena have certain essential properties which brain states and processes cannot have. The two properties are subjectivity and intentionality.”

- Subjectivity: “[Thoughts] are necessarily identifiable…not only by their content (e.g., ‘that dualism is false’) but also by the "subject" or person who has a thought with this content: if you and I both think that dualism is false, then there exist two thoughts with the same content.”

- Intentionality: “One cannot think without thinking of something or that something…Similarly, any emotion must be directed toward someone or something.”

“Brain dysfunctions do not involve subjectivity or intentionality and so cannot explain these essential features of mental disorder.”

- “A brain state, such as the firing of certain neurons, is identified completely by its physicochemical properties and not by which brain it occurs.”

- In contrast to a brain state, a thought cannot have “a spatial location (e.g., a thought cannot be 2 cm from another thought)” [p. 347].


Neil Feit September 28, 2020 at 4:57 PM

For what it's worth, I thought EM's discussion of subjectivity was unclear. This is supposed to be a reason why the mind is not the brain or any other material object. But EM's discussion doesn't seem to me to get at the challenge to materialism here. The idea is that I have a kind of privileged access to my mental states (only I can feel this pain, or sense this smell) but I don't have this kind of privileged access to my brain states -- in principle, the states of physical objects are equally accessible to all. I don't think this is a good reason to deny that the mind is the brain, or, that a mental state is simply a state of the brain; I just don't think EM presented the right reason.

Neil Feit September 28, 2020 at 5:03 PM

With respect to intentionality, I'm not so sure that it's the mark of the mental. It's not clear that an itch, or a pain-sensation, are directed toward anything in the relevant way (as anger might be directed at a person or at the fact that he paid so little in taxes). ;-) Moreover, it's not clear that paradigmatically physical objects cannot display intentionality. The state of a thermometer is about, or directed at, the motion of molecules in the immediate environment, etc.

Pat D September 29, 2020 at 9:58 AM

Neil, I agree that EM's discussion of subjectivity is unclear. That is why I introduce Lonergan as an alternative way to understand intentionality, which admittedly is a disputed notion. Where EM contrasts subjectivity and intentionality, Lonergan contrasts consciousness and intentionality as two sides of a subject's acts; if effect, two sides of the same coin. BL lists the acts to which he is referring - hearing, seeing, inquiring, etc. Each of these acts has two poles related to the act and its contents. For instance, the act of hearing presents a sound (as sensed) to the subject (as conscious). Intentionality refers to the directedness of an act toward its content; consciousness refers to the subject's awareness of hearing (for example) while in the act of hearing. Similarly, feeling an itch or pain involves the act of feeling and the content we characterize as itch or pain; what is the source of the itch or pain is another question that elicits further acts of sensing, inquiring, and verifying. The conscious-intentional acts that Lonergan lists differ in being conscious and intentional from processes ('acts') such as digestion, kidney filtration, or oxygenation.

I do agree with EM in denying that mind is a thing or separate substance and affirming that it refers to a level of activity of the whole organism, of which the brain is a necessary part.

Pat D September 29, 2020 at 10:17 AM

One more comment - a thermometer is a human artifact; it is neither conscious nor self-directed.

Pat D October 1, 2020 at 9:29 AM

EM's characterizing subjectivity and intentionality as properties of "thoughts, emotions, desires and other mental phenomena" appears to reverse the order of dependency between subjects and their acts of thinking, emoting... and the respective contents of these acts. A thought does not exist without a subject. Written documents do not speak for themselves; like the constitution, they need a reader or interpreter. In this respect, written documents are like the thermometer, which doesn't make sense of itself.

David H October 2, 2020 at 7:17 PM


I wonder if it is better to say the thermometer indicates the temperature rather than is about the temperature. It is a natural sign akin to smoke indicating there is fire or the many stars indicating tomorrow morning won't be cloudy.

David H October 2, 2020 at 9:09 PM


You quote Matthews "In contrast to a brain state, a thought cannot have “a spatial location (e.g., a thought cannot be 2 cm from another thought)” [p. 347]. If minds are not things but levels of activity of the whole organism, do they not still have a location, that of the whole organism? Is it still not odd to think of thoughts as pervading the body or is that better than being located in the brain? Maybe we shouldn't speak of states being anywhere though their subjects are. States inhere but it is perhaps a category mistake to locate them, even if they inhere in a located object.

Bob Kelly October 3, 2020 at 11:35 AM

I agree with Neil on both points about "subjectivity" and "intentionality" according to EM. More than just being unclear, I think Neil correctly points out that EM's explanation of the subjectivity of the mental is simply not the right explanation if the goal is to provide an objection to materialism. As Neil says, the objection is supposed to be about our first-person, privileged access to the mental (and maybe qualia and such), which portions of matter like brain states do not have. Instead, EM says that subjectivity amounts to a mental state being identifiable by its subject. In this way, two brain states of the same type are different than two mental states of the same type because the latter, unlike the former, are also identifiable by who has them--their subject. First, this is just not what I take the subjectivity objection to materialism to be about (again, it's about first-person access and such). Second, this is simply false. The pairs of states do not differ in this way since, quite obviously, the brain states have subjects in this sense as well. The two instances of the brain state type differ from each other in just the same way EM says the two instances of the mental state type do--one is had by one person, and the other by the other. If this is what subjectivity comes to, it does not distinguish mental states from brain states and, thus, is poses no challenge to materialism.

I think EM's intentionality suffers from the same general problem--it does not actually distinguish mental from brain states. I think the mental does have aboutness, and so disagree with Neil that my itches and pain states are not about anything (I think, minimally, they are about me). As Neil points out, though, a thermometer is about the temperature. David H suggests that it is not *about* the temperature but instead *indicates* it. I don't see a difference (that matters to the point). To be an indicator is still to be about something. One might reply that an artifact X is only indicative (about) something because of some human's (or group of humans') thinking about it in that way. Perhaps, but I don't see why this would make it false that the material object is indeed, and in virtue of how it is physically, about something. A photo of me is about me--it has *representational* qualities (or maybe *a* representational quality). It's not even clear to me that this has anything to do with anyone thinking about it in this way, and doesn't seem to even depend on being made to be about me. Both are true, but if a picture of me appeared from nothing, it would still be about me in this representational sense. In short, material objects can (and quite commonly do) have this aboutness due to their qualities--the way they are physically. Thus, this sense of "intentionality" (being about some portion of reality) cannot distinguish mental from brain states, even if (as I agree) the mental is intentional in this sense.

Pat, I have no idea why it would matter (to the point about intentionality as EM defines it distinguishing mental from brain states) that the thermometer, or photo, or book, or road sign, or whatever it is, is an artifact. You add that artifacts like this are neither conscious nor self-directed. Of course not, but they don't need to be conscious or self-directed to make the point. Intentionality, for EM, simply comes to aboutness (not self-aboutness or conscious aboutness). Maybe the latter would have been better attempts to distinguish the mental from the non-mental (and Neil's comment about subjectivity suggests he should have meant something like conscious rather than belonging to a subject). But this just isn't what he said.


Pat D October 3, 2020 at 8:25 PM

Thanks, David and Bob, for your comments.

In terms of generating dialogue between analytic and phenomenological understanding of mental illness, I'd say we are at the stage of mutual incomprehension, which is not a bad place to start, but is not the place I hope we land without at least a little movement of each of us toward understanding our differences. Lonergan, I believe, offers a clue about how to proceed methodically in that direction - that is, to begin with the operations that we perform in knowing and doing. So, rather than start with the intelligibility of objects that we know, like stars and clouds or thermometers and temperature readings, he starts with the intelligent operations by which we come to know about such objects. We don't perform these operations - seeing, hearing, touching, smelling, tasting, inquiring, imagining, understanding, conceiving, formulating, reflecting, marshalling and weighing the evidence, judging, deliberating, evaluating, deciding, speaking, writing - while we are in dreamless sleep. In that sense, these operations are performed consciously. Consciousness is a quality of these everyday acts; it is not a distinct operation by which we gain privileged access to our minds. These acts are intentional in that they go beyond the subject; they are transitive - psychologically, as well as grammatically - rather than intransitive and self-enclosed. The analytic focus on intentionality as aboutness cuts off subjects and objects from the get-go. The scholastic notion of intentionality on which Brentano drew focused on the existential difference between objects of thought and objects that exist independent of thought. This is not just a matter of intentional 'in-existence' of objects like unicorns, but also of the intentional 'in-existence' of the fire and smoke in our minds or our discourse.


David H October 3, 2020 at 9:30 PM


The air temperature causes the mercury of the thermometer to move which indicates the temperature to us. The thermometer is not representing the temperature for itself. It must be interpreted by a being capable of representing the world. Causation isn't enough for intentionality. Nor is similarity. The photo is not about you any more than the abstract drawing of a circle and three dots is about your face. They must be interpreted. Everything is similar to everything else in some way but that similarity won't make either object about the other.

Subjects play a role in individuating their thoughts that brains don't play in individuating brain states. How many thoughts there are is determined by the number of relationships between the thinkers and contents. If there are two beings sharing a brain, say a person and organism, there are two thoughts of say "I am essentially a person" - one true and one false. But there is only one brain state. The two thinkers have one and the same brain state just as my body, arm and elbow have one and the same bruise. The brain state of my brain is the same state as that of the cerebrum. There aren't two brain states, one of the whole brain and one of the cerebrum. I think that is his point when he oddly describes the brain state occurring without the brain in a lab dish with neurons firing

David H October 5, 2020 at 10:03 AM


What is your response to Searle's Chinese Room thought experiments? Does the instructional book have intentionality, the guy using it, or is it the entire system that has intentionality? I wonder if you are not committed to all three being intentional

Bob Kelly October 5, 2020 at 2:52 PM

I don't think I was as clear as I would have liked in my reply, since it seems I was interpreted as defending identity theory, or some such view that would have brain states doing all the work we could care about for the mental. This was certainly not my intention. I thought it would be quite uncontroversial to say that material objects can represent. I did suggest that this may not depend on thinkers (like someone creating the object so that it represents or needing someone to interpret the representation). But set this aside. Material objects (like photographs, road signs, paperback books, a circle and three dots drawn on a chalkboard, and so many other things) represent portions of reality (people, places, winding curves, icy bridges, the Battle of the Bulge, states of happiness, etc.). I'm missing what the objection is supposed to be to this by pointing out that material objects represent because humans may have made them to do so. In the same way a book can concretize information (and so be about something), so can a photograph or a road sign possess qualities which make them about something. My dissertation is about addiction whether anyone ever reads it or not. The same goes for a road sign. Sure, this requires some creative purpose or function by a maker, but I don't see why this means the material objects do not represent. I find it a utterly counterintuitive claim that material objects do not represent, and I am having trouble understanding the responses as saying something other than this.

The upshot comes from the fact that EM tried to say mental states are inherently different from brain states because only the former have intentionality (where by this he meant that they are about something). Unless Neil and I are completely misunderstanding him, the fact that material objects can represent is a problem for this claim of his (as is, for Neil, the purported fact that mental states need not represent).

Again, none of this is supposed to mean that there is no such thing as the mental, that mental states are identical to brain states, that the Chinese Room thought experiment is successful (or not), or what have you. Objects can represent. This seems obvious. What is less obvious is why this is supposed to entail that nothing is left for the mental to do, or that brain states fully explain consciousness or knowing. I fail to see the connection.

Pat D October 5, 2020 at 4:14 PM

I would say that the intelligibility of some objects (or what they are about or represent, as you say) arises from acts of human intelligence (for example, symbolizing or tool making) and the intelligibility of other objects about which we inquire do not. The intelligibility of the Rosetta stone or a thermometer differs in this respect from the intelligibility of a geological formation and a fallen tree branch. I may understand what these objects represent, but I do not subscribe to the idea that these objects do the representing independent of acts of animal or human or possibly extra-terrestrial intelligence (present, past, or future). This gets into epistemological questions concerning the difference between knowing by confrontation (knowing as taking a good look) and knowing by identification (per Aristotle, the sensible in act is the same as sense in act; the intelligible in act is the same as intelligence in act). So, in my estimation, consciousness and intentionality pertain to the acts of sentient and intelligent subjects, and not to the objects that they sense and understand.



Pat D September 27, 2020 at 12:01 PM

Is a mind the kind of thing that can literally be healthy or unhealthy? [CB: Concepts of health 1987, p. 462]

CB: “Our analysis implies that the concept of mental health makes sense on one condition: that human psychology be divisible into part-processes with biological functions. Mental health and mental disorders exist if and only if there are counterparts to anatomy and physiology for the mind. This does not mean that psychology, to support a concept of mental health, must be physiology. Contrary to much usage in mental health literature, "biological" does not mean "physicochemical”; biology is not the same as chemistry and physics. Biology is the study of inherited functional structures of organisms produced by evolution” [Concepts of health 1987, p.376].

- “Mental disturbance refers to feelings, beliefs, and experience,” while neurologic disturbances like dyslexia, aphasia, and retardation do not. [What a theory of mental health should be” 1976, p.67]. Note similarity to EM’s list of ‘mental’ functions below.

- “The main function of perceptual and intellectual processes is to give us knowledge of the world…if my cognitive functions are disrupted to a highly unusual degree by my wishes, it seems safe to call my condition an unnatural dysfunction, i.e. a disease” [ibid., p.77].

- “If some of the neurotic’s strongest desires remain locked in combat without freely releasing their motivational force in behaviour, it is not an implausible hypothesis that the conflict-resolution mechanism is functioning incorrectly” [ibid].

- Not clear if these part-functions – perception, cognition, conflict-resolution – constitute a thing called mind or whether these are functions of the whole organism.

EM: “Starting with the notion of human beings as embodied subjects offers the possibility of a totally different way of thinking about mind-brain relationships and their relevance to the treatment of both mental and physical disorders, from that implicit in either Cartesian dualism or Cartesian materialism. In this understanding, thinking, feeling, desiring, wishing, intending, hoping, remembering, and the behavior, which is explained by them, are activities of neither "minds" nor "brains" but of human beings.” [pp. 356].

- The whole organism – that is, the human being – is a thing, not the mind or, for that matter, the brain. The latter are functional or anatomical parts of an organism.


Bob Kelly October 3, 2020 at 11:48 AM

It seems to me that X's being a part of Y necessarily makes X an entity. It may, but need not, be a dependent entity. Yet it would still be an entity. In your last couple lines, then, you seem to give the game away for the point EM was trying to make. If he is making the point as you are, leaving it open that the mind is a part of the human, then it would still be a "thing" (an entity which stands in a parthood relation to some other entity). I suspect that he has something more radical in mind (no pun intended) when he says the mind is embodied. That is, when he says that the common properties thought to inhere in minds actually inhere in the "whole organism", he is suggesting that there really is no such thing as a mind. The way in which we typically identify the mind (and the mental) is by appeal to certain properties and activities. EM seems to be offering something like an error theory--these ascriptions (if they are aimed at some mind or mental thing--are false. These are actually properties and activities of a human being. This seems to be an identity-like reductionist view of the mental. If this is incorrect, and he wants to keep the mental (e.g. as a part, like you suggest), then I see no reason to think that calling it a part means that it is no thing at all. This is an odd and, I think, invalid inference.

Pat D October 3, 2020 at 8:30 PM

Carrying forward with a focus on operations, knowing and doing are parts of human living in the same way that surviving and reproducing are. None of these activities is a thing itself, but rather the operations or functions of a thing.

Bob Kelly October 5, 2020 at 3:07 PM

I don't think I understand the upshot of your reply. You say, "...knowing and doing are parts of human living in the same way that surviving and reproducing are." Agreed. They are each processes which can be a part of a human life (which is itself made up of a collection of processes that the human participates in). Then you say, "None of these activities is a thing itself, but rather the operations or functions of a thing." I agree that these processes depend on something participating in them (there is no process of knowing without a knower), and so they are dependent in this sense. But your use of "of a thing" is a bit unclear. Of course they are process "of" the thing(s) participating in them, if by this you just mean that they are indeed processes which the thing in question participated in. But they are not *parts* of the person (another sense of "of a thing"), unless you are a four dimensioanlist (which I didn't take you to be defending). So I guess I am still confused as to what the upshot of the reply is.

Maybe it would help to restate my original point. It sounded like you were saying that (i) EM says the mind is no thing at all (instead, we just use "mind" to refer to collections of certain processes performed by humans), and (ii) the mind in this "no thing" sense is a part of the human. I think I agree with (i), that EM is denying the mind is any sort of thing. My post was a response to (ii), and just says that if X is a part of Y, then X is a thing (an entity that exists). So, I was trying to point out the tension between (i) and (ii)--EM (or PD) cannot say that the mind is no thing at all but that it is also a part of the human.

Pat D October 5, 2020 at 4:31 PM

I agree with (i), also. Re (ii), it depends on what you mean by 'the human.' I would say that walking and sitting and thinking are part of human living, but I wouldn't say that they are part of the human organism, as such. This relates to the difference between form and act, in Aristotelian terms.


Pat D September 27, 2020 at 12:05 PM

Mediating Matthews and Boorse

In line with Boorse’s agenda for a methodical investigation of the “normal functional organization of the human mind,” Bernard Lonergan develops an empirically grounded account of the structured operations of cognition and deliberation.

- The structure is dynamic and includes 4 levels of operation: experiencing, understanding, judging, and deciding.

- These operations are intrinsically normative: be attentive at the level of experience, be intelligent at the level of understanding; be reasonable at the level of judging; be responsible at the level of deciding.

- Moral norms kick in with deliberating and choosing at the level of deciding.

- This structure provides an objective basis for identifying delusion as a cognitive dysfunction and psychopathy as a deliberative dysfunction as distinct from physiological dysfunctions, such as stroke or heart attack.

In line with Matthews’ phenomenological agenda, Lonergan’s account begins with attention to the reciprocal relation between operations (functions) and their contents (see extract of his account below).

- It is the subject’s operations that are both conscious and intentional, not the contents of these operations.

- For example, presentations (phenomena) are not themselves conscious and intentional, but the subject’s acts of presenting data are

- Brain states occur here and now. Thoughts are not spatio-temporally determinate. You and I can have the same thought – the Celtics are a great team – at different times and places.

- Intentionality can be directed at an unknown – for instance, in asking a question. It is not necessarily about any existing thing or relation. It is an indication of being part of something bigger than one’s own ego.


David H October 2, 2020 at 9:17 PM


I don't see why the operations and the content are not conscious. I am engaged in a conscious operation and consciously aware of what are the contents of my thought. I am conscious of what I am writing. This would be contrasted with unconscious cognitive processes and their contents. There were some processes that I was unaware of that led to these ideas being conscious, just as I have certain dispositional beliefs that will become conscious when you ask me about something is now dispositional belief

Pat D October 3, 2020 at 5:58 PM


In calling beliefs to mind, beliefs do not become conscious; rather, the subject consciously attends to what these are.

Regarding self-awareness, although conscious and consciousness are used in the sense of the act of being aware of something, I do not understand consciousness this way. Lonergan refers to this way of understanding consciousness as consciousness-as-perception. The alternative that he advances is the notion of consciousness-as-experience. Just as we can be more or less awake, we can heighten our consciousness of what we are doing as we do it - as an athlete or skilled musician or teacher does in actual performance. This heightening of consciousness is not a separate operation, but rather a perfecting of the performance of an operation.


Pat D September 27, 2020 at 12:06 PM

Bernard Lonergan: A preliminary notion of method [Method in Theology, 1972, pp. 6-8]

Our preliminary notion conceives method not as a set of rules but as a prior, normative pattern of operations from which the rules may be derived…

Operations in the pattern are seeing, hearing, touching, smelling, tasting, inquiring, imagining, understanding, conceiving, formulating, reflecting, marshalling and weighing the evidence, judging, deliberating, evaluating, deciding, speaking, writing.

It will be assumed that everyone is familiar with some at least of these operations and that he has some notion of what the other terms mean…The reader will have to evoke the relevant operations in his own consciousness. He will have to discover in his own experience the dynamic relationships leading from one operation to the next. Otherwise he will find not merely this chapter but the whole book about as illuminating as a blind man finds a lecture on color.

First, then, the operations in the list are transitive. They have objects. They are transitive not merely in the grammatical sense that they are denoted by transitive verbs but also in the psychological sense that by the operation one becomes aware of the object. This psychological sense is what is meant by the verb, intend, the adjective, intentional; the noun, intentionality. To say that the operations intend objects is to refer to such facts as that by seeing there becomes present what is seen, by hearing there becomes present what is heard, by imagining there becomes present what is imagined, and so on, where in each case the presence in question is a psychological event.

Secondly, the operations in the list are operations of an operator, and the operator is named the subject. The operator is subject not merely in the grammatical sense that he is denoted by a noun that is subject of the verbs that in the active voice refer to the operations. He also is subject in the psychological sense that he operates consciously. In fact, none of the operations in the list is to be performed in dreamless sleep or in a coma. Again, whenever any of the operations are performed, the subject is aware of himself operating, present to himself operating, experiencing himself operating. Moreover, as will appear presently, the quality of consciousness changes as the subject performs different operations. The operations then not only intend objects. There is to them a further psychological dimension. They occur consciously and by them the operating subject is conscious. Just as operations by their intentionality make objects present to the subject, so also by consciousness they make the operating subject present to himself

I have used the adjective, present, both of the object and of the subject. But I have used it ambiguously, for the presence of the object is quite different from the presence of the subject. The object is present as what is gazed upon, attended to, intended. But the presence of the subject resides in the gazing, the attending, the intending. For this reason the subject can be conscious, as attending, and yet give his whole attention to the object as attended to.

Again, I spoke of the subject experiencing himself operating. But do not suppose that this experiencing is another operation to be added to the list, for this experiencing is not intending but being conscious. It is not another operation over and above the operation that is experienced. It is that very operation which, besides being intrinsically intentional, also is intrinsically conscious.


Jack Freer September 28, 2020 at 7:42 AM

First of all, I have little to argue with in Pat's application of Lonergan's analysis which strikes me as clear and reasonable.

I will instead focus on Matthews' treatment of biological psychiatry.

I believe the coherence of biological, or "medicalized" psychiatry is enhanced by a focus on the behavioral aspects of psychiatric illness. The label "mental illness" leads to a focus on the subjective life of the patient: anxious thoughts, delusional ideas, depressed mood. These mental states certainly exist, but the focus of biological psychiatry is on the manifestation of these states. Indeed, there is a growing trend to label the discipline "behavioral health." A clinician diagnoses the condition based upon the history that the patient provides, and the observable manifestations noted on examination of the patient. Psychiatric illness, on this account, is similar to other illnesses. The symptoms may be different, but the difference is grounded in the target organ and it's function. The brain is the locus of behaviors and manifests illness through altered behaviors. Undeniably, there are subjective mental symptoms associated with such illnesses, but that is not the basis for the medical management.

Arguably, there is greater potential for patients to lie about their feelings or to intentionally confound the examination, than for example, an abdominal mass. One can imagine an individual who, although severely depressed, manages to convey an image of cheerful normality. Such a person, conceivably, could answer every question by the clinician in a perfectly normal manner. In real life, however, this rarely, if ever happens. The very nature of the illness prevents such normalcy, and tips off the astute clinician to the underlying pathology. Certainly there exist people who, as Szasz might say, are simply having difficulty navigating life and dealing with its stressors, but this is not the only problem with those suffering from major depression, bipolar disease or schizophrenia.

I don't see this analysis resolving the dualism question Matthews raises. Mind is a construct we create to explain human behavior AND our own subjective experience. It is an unavoidable topic of discussion when describing manifestations of psychiatric illness, but remains a philosophical issue with little relevance to the practice of psychiatry.


Pat D September 28, 2020 at 10:05 AM

Jack, thanks for these comments. I have a couple questions.

1. How do you account for the 'cognitive' element of cognitive-behavioral therapy?

2. It seems that this relates to questions of meaning. For that matter, so does the clinician's interpretation of the significance of signs and symptoms (physical, behavioral, or mental). How do you account for meaning in terms of biological psychiatry?

3. Boorse, writing from a naturalistic perspective, says:

"‘Mental illness’ is not just a shorthand for ‘obscure brain disease’, since various conditions with obscure neural bases - dyslexia, aphasia, retardation - are not usually called mental illnesses. Rather, a mental disturbance gets classed as ‘mental illness’ when some accepted explanation of it refers not to the patient’s physiology but to his feelings, beliefs, and experiences" [WTMH 1976, p.67].

Do you agree with his distinction? If so, how do you account for the difference?

Best regards,


Pat D September 28, 2020 at 10:12 AM


4. What do you make of physician burnout?

Jack Freer September 29, 2020 at 7:18 AM


1. I'm not entirely clear on what you mean by "account for." My understanding of CBT is that it is a guided self-assessment of the patient's current thinking and resulting behaviors. I have assumed the cognitive element was the explicit analytic process employed by the patient (under the guidance of the therapist). That process involves exploring the thoughts (private mental experiences of the patient), but in a directed fashion--not simply exposing them, but analyzing how they impact the patient's behaviors.

2. I have limited knowledge of the nuts n' bolts of CBT, but suspect "meaning" is less a part of it than in traditional psychotherapy. Meaning for the patient will presumably come out in the discussion, but I didn't think that was the focus (although it clearly is a factor in shaping the patient's behaviors). My conception of biological psychiatry is that behaviors (and therefore, thoughts) are the result of a multifactorial mix of genetic, environmental, and neurochemical factors. Mental "health" is achieved by modifying the environment and the chemical milieu (genetic factors being fixed at this point). The wild card is the degree of intentionality and volitional capacity one believes the person possesses. Meaning seems to be one of the tools the patient utilizes to modify their thoughts and behaviors (and is therefore instrumental, rather than an end in its own right).

3. It strikes me that the Boorse quote you cite is based on the dualist framework that "mental illness" is qualitatively different than all other illness because it involves the totally different realm of "feelings, beliefs, and experiences." I think the best way to view feelings, beliefs, and experiences in this context, is as the output of brain activity (just as filtration of the blood and production of urine is the output of the kidney). These elements are not simply different from all other (physical) factors--rather, they are the unique products of the brain as an organ.

4. My take: physician burnout is a broad term that includes a variety of physician stressors that range from "paperwork" demands (insurance, regulatory and prescription wormholes), to the feelings of helplessness against death and suffering.

Thanks for your probing questions and analysis, Jack

Pat D September 29, 2020 at 2:18 PM

Jack, thanks for your thoughtful answers. I have two follow-up questions.

1. Boorse says that psychological functions are biological in an evolutionary sense; at the same time, they are not necessarily the same as physiological functions. Does that make him a dualist in your book?

2. With regard to meaning, not in the sense of personal significance and not specifically in reference to mental health, but for instance just in regard to making a diagnosis - does the different meaning of diagnosing multiple myeloma and Addison's disease come down to a difference in neurochemistry? It seems to me that thinking involves abstraction from neurologically mediated data. Otherwise, a diagnosis of multiple myeloma might differ going from English to Chinese.

Jack Freer September 30, 2020 at 7:05 AM


1. I guess I'd need more context to know whether Boorse believes that psychological and physiological functions are fundamentally different because they represent manifestations of different substances (or are non-identical in a more superficial way).

2. It is difficult to imagine a process of diagnosis that ignores meaning from the clinician's perspective (since prognosis and subsequent intervention are dependent on that meaning). Ideally, that meaning is sensitively and understandably shared with the patient (providing corresponding meaning for him/her). In any case, that meaning is almost always normative (since precise diagnoses--even "normal" convey a sense of health or illness).


David H October 2, 2020 at 7:46 PM

Interpretations of Descartes:

Matthews writes that Descartes held that "A human being...was a composite of two quite independent substances, mental and material, or "mind" and "body". This is the doctrine known as substance dualism, the conception of the world, including ourselves, to be made up of two types of stuff - mental and material." I think most dualists and most interpreters of Descartes considered him to be a Pure Dualism rather than a Compound Dualist. The former believes we are our soul and the body is not literally a part of us, the latter believes we have a body literally as a part, along with a soul. believe we are identical to a composite of soul and body. Compound dualism is attractive as it makes us literally embodied, but it is ultimately untenable as it renders the body a contingent part that we can discard at death. Try to make sense of surviving posthumously with only a single part, your soul. That means there are two immaterial beings in a part/whole relationship – immaterial you and your immaterial soul. Olson describes the view as “suffering from ontological double vision.”


David H October 2, 2020 at 7:57 PM

Giving Dualism its Due:

I don’t think a dualist should worry about anything Matthew said about dualism. If you are already a dualist, he has given you no reasons not to be. He just trots out old canards that have no merit like the neurological dependence of thought shows that dualism is false. There are few or no dualists today who think the mind is not dependent upon the brain. But dependency doesn’t give us any reason to think mental states are brain states or states of something other than the soul any more than walking and digestion’s dependence upon the brain makes walking and digesting into brain states (Plantinga).

Matthews seems to think the interaction problem plaguing the dualist of the “unintelligible influence of one substance on another” becomes with the materialist identical of the brain and mind the very unproblematic “influence of one part of a substance on another part of the same substance.” But the dualist interaction problem seems not to be a problem on many accounts of causation like Humean regularity, counterfactual dependence, preestablished harmony, occasionalism etc. None of these require causation to involve parts of one extended causal substance to come into contact in the same place with the other that it produces its effects. If materialists accept different kinds of material things can cause each other and if there can be causation at a distance, it isn’t clear why the soul couldn’t cause effects in the brain and vice versa. Anyway, if body/soul interaction is impossible, then one has a quick argument for atheism as God will not be able to create a world and place any souls in relation to bodies. Soul theorists tend to be theists who believe God created, continuously sustains the world, and intervenes in other ways at times, so his role in their mental causation pairing their nonextended souls and extended bodies will not bother them.

Anyway, many contemporary emergent dualists believe the soul emerges from the brain and is an extended though partless, located in space


David H October 2, 2020 at 8:07 PM

Dualist Harmful Dysfunction Account of Disorder:

Matthews believes dualism is not compatible with Wakefield’s HDA because the soul doesn’t evolve. Well, there are emergent dualists who believe that the soul emerges from the brain’s acquiring a certain complexity so maybe that means brains of different complexity produce different kinds of souls. (Unger on the other hand, is dualist who maintains that all souls are the same and the mental differences between dogs and humans is due solely to differences in their brains - he says that "one got a grand piano and the other a kazoo.") Wakefield, of course, believes the best conception of dysfunction is in terms of natural selection, but he recognizes that historically many people recognized dysfunctions without knowing anything about evolution. So the notion of dysfunction doesn’t entail failure to perform a selected effect. So the dualist has two ways to accommodate a harmful dysfunction account of disorder. One is to believe soul is a divine artifact that he designed to perform certain functions and they can fail or succeed to do so. When the mind is dysfunctional, if there is enough harm, then there is disorder as well. Alternatively, the dependence of the soul upon the brain can make it sensitive to the evolved functions of the brain. To put it crudely, imagine that the dependency of the soul’s operations upon the brain mean that here are parallel operations so when the brain is in certain states (c fibers firing), soul has certain experiences, those of pain. The soul’s dependence upon the brain could mean that the brain has evolved to product desires and thoughts in the soul that favor survival and reproduction. So a soul that didn’t evolve could be sensitive to evolved functions as it is dependent upon the brain’s operations for its own conscious operations. When the brain’s parts don’t operate as they were designed to, the mind won’t as well. Incidentally, this dependency of the soul on the brain is also compatible with Wakefield’s examples of mental diseases without brain disease as in the case of the gosling that imprints on the fox that looks like its mother that he discussed in his keynote here a few years ago and in his two part response to Lewis on addiction and disease.

If one thinks an evolved brain makes the soul superfluous, the soul theorist’s response will be to explain what the soul does that the brain cannot. For example, the soul provides one unified subject of thought capable of qualia that the brain cannot. The soul theorist will claim that the simple soul is required to give experience its unity which a complex physical entity cannot. The soul theorist may claim that there is only thinker of your thoughts despite there being two cerebral hemispheres capable of producing thought in the materialist picture, not to mention countless distinct overlapping aggregates of atoms that differ from each other just by an atom. All of those pluralities of atoms are all perfectly good candidates for composing the brain and producing thought even if they just overlap the brain. If one of those aggregates can think, so can all of the others. How do non-experiencing cells of gray matter together produce a thinking chunk of gray matter? The explanatory gap is avoided by posting a soul. One can go on adding other jobs that only the soul performs – abstract thought, free will, intentionality, etc.


David H October 2, 2020 at 9:25 PM

JW calls his account Black Box Essentialism. He borrows from Putnam account of natural kinds that there are stereotypical qualities of water or Gold but there is an underlying previously unknown essence that explains the presence of those stereotypical properties

The role of H20 and atomic number 79 is filled in the case of disorder with the mechanisms of evolution, in particular natural selection.

“It is a momentous scientific discovery, not a matter of definition, that disorders are failures of naturally selected mechanisms to perform their functions. Harmful dysfunction is the meaning of disorder, and evolution is the most incisive theory of the nature of functions and dysfunctions.” JW in Biological Function and Dysfunction p. 895


David H October 2, 2020 at 8:09 PM

Avoiding the reification of mind:

So minds are not objects on Matthew’s preferred account – neither immaterial substances (Cartesian egos) nor material brains (material Cartesianism). But many of the puzzles remain when we speak of mental properties being instantiated in material things even if these are not brains but embodied beings that act on the world from a place in the world. Is intentionality less puzzling when it something the human animal does rather than the brain? Is the generation of qualia less puzzling when human beings do it instead of brains? Is the brain or the human being less puzzling as the subject or owner of thought?

David H October 2, 2020 at 8:10 PM

Conception of Health Care:

Matthews’s claim that “health care is concerned with maintaining and restoring human well-being…” can’t be true as well-being maintenance and restoration goes far beyond health but involves other aspects of one’s life going badly or well. Even if well-being is limited to medical well-being, health care is concerned not just with maintaining and restoring but raising what had never been high or lost in the case of congenital illnesses that lead one to be born in bad shape. So the charitable read must be “well-being” is being understood as a proper level regardless of whether it has ever been obtained and so can maintained or has been lost and needs to be restored.


Pat D October 4, 2020 at 11:02 PM

Although we have seemed worlds apart in many of these exchanges, I hope that we have the opportunity to elucidate some of the differences that have surfaced in this blog in future dialogue. I happened to read an article by Marjorie Greene called "To have a mind" (JMP 1976) today. She referred to Wittgenstein's argument against private languages and contrasted this with the notion of a privileged access to our minds. Speaking in first, second, or third person is part of a common linguistic heritage