It’s interview week here at Frontier Psychiatrist and I’m very excited that Dr Iain McGilchrist has agreed to be featured on this website.  Dr McGilchrist is a psychiatrist with an unusual background as, before he turned his attentions to psychiatry, his first career was in the academic study of literature.  He has recently published ‘The Master and his Emissary’ a book which posits that the division of the brain into two hemispheres is essential to human existence, making possible incompatible versions of the world, with quite different priorities and values.

If readers would like to find out more about Dr McGilchrist’s ideas then the introduction of the book is available for download from his website.  He has also published an essay in the Wall Street Journal: The Battle of the Brain: The mind’s great conflict spills over onto the world stage

You’ve had a very varied career, most notably starting off as a scholar of English literature before training as a doctor and then as a psychiatrist. What was the motivation behind your change of tack?

Much as I loved working with literature, I began to see that the explicit approach to a work of art, which the critical process demanded, was inherently unsatisfactory. It substituted something abstract, cerebral and generalised for an entity the whole purpose of which was to lead us in the opposite direction.  The encounter between the work of art – the poem or whatever – and ourselves was not like dealing with an object, more like the encounter of two people, each unique, each embodied, each an indissoluble whole that could be only mis-represented by examining its parts.  The value of the work of art depended on things that were radically altered by their context, which were implicit, and had to remain implicit, if they were not to lose their power.  The relationship between mental experience and the physical fact of our own embodied selves seemed to be central to this conundrum, and I studied what the philosophers had to say about the so-called ‘mind-body problem’.  Eventually it became clear to me that they were themselves too prone to deal with this fundamental fact of existence in an abstract, decontextualised, disembodied fashion, and I thought I ought to train in medicine and find out for myself, in a more embodied way, what it was like when things went wrong with people’s brains and bodies, and how that affected their minds.  So I wrote a book about my concerns, called Against Criticism, and went off to study medicine.  Then after a brief spell of  neurology, I went to the Maudsley to train as a psychiatrist.

How has a training in literary scholarship informed your practice as a psychiatrist?

You might expect me to say that perhaps the reading of great novels and so forth has influenced the way I think about disease and death.  Maybe it has, but if so it is at a level beneath my awareness – implicitly, one might say, rather than explicitly.  What I would say, though, is that having a training in the humanities in general makes a vast difference to how we see what it is we are looking at when we approach the human being, the human body.  Many medics, whether they are aware of it or not, accept unquestioningly the scientific model of the body as a machine.  I say ‘scientific’, but of course the paradox is that in physics a far more sophisticated understanding of what matter is has been forced on its practitioners, with the result that their universe is far less mechanical than that of biological scientists, who remain becalmed in the untroubled waters of Victorian scientific materialism. 

Medicine could be seen as a branch of psychiatry, and psychiatry as a branch of philosophy.  Philosophically speaking, many medics are quite unreflective.  I think that the Americans have got it right in making medicine a second degree.  Of course at the simplest level, it allows people time to mature, and to make sure they have made the right decision – some doctors I have encountered clearly didn’t.  But, even more important, it permits a period of intellectual exploration and questioning, before getting stuck into a medical degree, with its overwhelming demands for rote learning and the acquisition of information, largely without time to question.  As a result the fundamental questions don’t get asked by those who actually have the experience – the questions are left to philosophical outsiders.  It is no kind of piety to say that, hard as we work for it, the experience we have as physicians of the mind and body is vastly precious, a real privilege that the others, the professional philosophers, can only imagine, and we must never lose the ability to stand back and look at what it all tells us in the broadest possible context.

Can you explain what you mean by ‘medicine could be seen as a branch of psychiatry’

When I was a House Physician, I remember there were all these patients who came in on take with chest pain.  Of course we did ECGs and cardiac enzymes – but no luck.  Sometimes we sent off all manner of rarified tests.  All negative.  I remember working for the Professor of Medicine: the tests we were supposed to send for extended all down one page of A4 and half way down the next.  But no-one thought of – possibly, it occurs to me now, no-one even knew how to – sit down with them and ask about their lives: their families, their wives or husbands, their children, their jobs.  And when I was the House Surgeon it was the same, except the problem now was abdominal pain, rather than chest pain.  But the same picture – loads of tests, drips and invasive procedures: zero insight into the most common cause of abdominal pain.  The psyche.

It still seems to me a scandal, in view of the fact that over 60% of GP consultations are ultimately psychiatric in nature, that you can’t become a GP unless you have done attachments in obs & gynae, and paediatrics, but you don’t have to know the first thing about psychiatry.

That is in a way trivial answer, but I hope a vivid one. 

A more serious one is that we need to see every complaint, physical or mental, in the context of the whole person.  Typically physical medicine looks only at this ‘machine’, the body.   I want us to look at the person as whole, by far the most important and complex part of which is the psyche.   Every physical illness affects the mind; every mental illness affects the mind.  Every symptom reported comes via the patient’s mind.  That is why medicine is a branch of psychiatry.  It is just the report of the person of physical as well as mental symptoms.  To understand mental symptoms you need to understand psychiatry.  To understand physical symptoms you need to understand – psychiatry.

Also it’s not clear to me why you write that physicists are less mechanical in their thought than biological scientists.  Surely if mechanistic thought has a place it is within the realm of physics?

You may not have kept up with contemporary physics!  If you look at Bohr, Bohm, Dirac, Planck, Heisenberg, Davies, Polkinghorne,  you will see that all the mechanistic assumptions of Newtonian physics have had to be abandoned, in the face of evidence that reality is not determinate, precise, atomistic, explicit, but indeterminate, probabilistic, interconnected and implicit. A vast topic, and one that has been very widely explored, but one that is of ultimate philosophical importance, and sets the ‘hard’ sciences against the current intellectually lazy mindset of biology.

Having started off working for the NHS you now work exclusively in private practice. What motivated your switch?

I never foresaw that I would end up working privately – I was completely committed to the ideal of the NHS; and to this day I do not have health insurance myself.  But I could not ignore what was happening.  I felt I was deskilled working as a psychiatrist in the NHS.  A largely politically motivated, and in my view deeply mistaken, drive to marginalise the role of the psychiatrist, and with it the skills of diagnosis and appropriate treatment, has been disastrous.  And the range of conditions with which, in practice, one gets to deal in the NHS is too limited, the therapeutic resources at one’s disposal are too meagre, and too much time is taken up with paperwork, ticking boxes, and keeping various bureaucrats happy – far too little in patient contact. 

On top of that, I wanted freedom to be in control of my time and the way in which I worked.  I knew I wanted to write the book that became The Master and his Emissary, and I knew that there was no way I could do that unless I could choose to work as I do now, fitting a normal week’s work into three very long days (during which, incidentally, I get as much clinical contact as I would have done in weeks in the NHS). This gives me a fighting chance of spending the intercalated days in the library and on research.  I also felt, rightly or wrongly, that the sausage machine that academic psychiatry has become was no place for someone like myself, who wanted to do something unconventional – despite the fact that many people probably see me as a natural academic.  The constant pressure to publish papers would not have given me time to develop a long piece of work, and would have prematurely foreclosed the direction of my thinking.  And you can no longer get funding unless the work you do is fairly similar to what other people have already demonstrated to be ‘fruitful’, produces ‘positive’ findings in a limited period, and brings in money and prestige for the research group to which you belong. I fear that this is likely to have a stifling effect on originality, and can only encourage us to go ever more down the path we are already treading.

What are the main differences between NHS and private psychiatry?

First of all, I think the difference between private medicine in general and private psychiatry is enormous.  In private medicine (or surgery) all you get by going privately is a chance to jump the queue and, when you get into hospital, to have a glass of wine in your hand.  The range of conditions covered, and the standard of treatments, is largely the same.  But private psychiatry is different.  There are whole swathes of suffering humanity who get little or no help under the NHS.  Unless you are psychotic, and about to kill yourself or someone else, you don’t stand much of a chance.  However there are enormous numbers of people, who, to my eternal shame, when I was in the NHS I learnt to think of as ‘the worried well’, who suffer at least as much as the psychotic, and in some cases more, from a range of anxiety and depressive disorders, often quite subtly interlaced with personality factors, and sometimes addictive behaviours, that are simply given short shrift in the NHS – because they are too complex and time-consuming to treat – but are treated, along with the psychotic, by private psychiatrists almost alone.   I am glad to say that I see many psychotic patients, in whose treatment medication plays a central part, but I am also able to help people who need much more than a drug can give.  And having control of one’s time is not only personally liberating, but makes it easier to be kind to people and to listen to them carefully.

Moving onto your book: the relationship between the right and left sides of the brain is not something that concerns most psychiatrists.  How did you come to be interested in it?

I think it again relates to my philosophical background.  That the two hemispheres interpret and create the world differently, with different modes of attention, different priorities and different values, emerged from Bogen and Sperry’s work in the 1960s and ’70s.  That should have been of the highest interest, since the world we inhabit is brought into being for us by our brains.  And at the time it did give rise to a lot of speculation.  But we were looking for different ‘functions’ for the two halves of the brain to do, as if it were a machine with a lot of little specialised modules –language here, maths there, or reason here, emotion there – again in a ridiculously naïve way.  Over time, we discovered that each so-called ‘function’ was carried out in both hemispheres, not one, and people gave up looking for a real difference.  This is despite the fact that there are obvious, undisputed objective differences in the shape, size, neuronal architecture, neurochemistry and neuropsychology of the two hemispheres.  It seems obvious to ask: what does all that signify?  What I began to see – and it was John Cutting’s work on the right hemisphere that set me thinking – was that the difference lay not in what they do, but how they do it.  In particular, the right hemisphere was capable of appreciating ambiguity, the implicit and the metaphorical, where the left hemisphere tended to require certainty, the explicit and the literal; the right hemisphere saw the broad context and the world as a seamless whole, interconnected within itself, where the left hemisphere focussed on detail and produced a lot of separate fragments; the right hemisphere was far more capable of understanding new information, while the left hemisphere dealt with the already known; the right hemisphere saw individuals where the left hemisphere saw categories; the right hemisphere realised the importance of what is intuitive and embodied, where the left hemisphere prioritised abstraction and rationality (here I distinguish mere ‘rationality’ from the all-important, and far more complex, ‘reason’, to which both hemispheres need to contribute).  This illuminated problems in the nature of human thought and experience that I had struggled with all my life, and which had been brought into focus by my study of literature.

Can you briefly tell us about the thesis of The Master and his Emissary?

Well, some of it I have already referred to.  I posit that evolution has kept two types of attention apart, because they tend to interfere with one another; it has separated them by the hemispheric divide.  There is now an enormous and expanding body of literature that suggests that in birds and animals the left hemisphere provides focussed attention on something that we have already decided is of significance, while the right hemisphere keeps an open attention for whatever may be, without preconception.  This enables them to feed (focussed grasp of what needs to be manipulated) while staying alive (the broadest possible open attention for conspecifics or predators).  For example, chicks use their left hemisphere (right eye) to pick out the seed from the gravel on which it lies, while their right hemisphere (left eye) remains vigilant for predators.  Equally mates and kin are best identified with the right hemisphere (left eye) in most species. 

Humans have large frontal lobes, which enable them to stand back from experience: this puts the hemisphere division to new use.  For purposes of manipulation, the brain needs a relatively simple map of the world which enables it to be efficient in getting hold of things: denotative language and the ability to grasp with the hand are its tools in this representation and manipulation of the world, and they are controlled, as one might expect, from the left hemisphere.  All the rest, the ability to pick up the complexity of experience and take the broadest view, goes on in the right – which also means that it sees us, not as atomistic, distinct entities in competition with one another, as the left hemisphere must, but as interconnected, interdependent entities. Empathy, social understanding, humour, metaphor, more subtle emotional understanding, the appreciation of individuals, the reading of faces, and much else goes on in the right hemisphere.  Fascinatingly there is clear evidence that the left hemisphere alone codes for machines and tools – even in left-handers, who would be using their right hemisphere to use tools and build machines in daily life. 

So the first part of the book looks at the evidence in considerable detail, and then explores the significance of this for the nature of the world which each hemisphere ‘sees’ – the take, if  you like, that it has on the world.  Overall it seems that the right hemisphere sees and knows far more than the left hemisphere, but does not have the left hemisphere’s  tools for asserting its point of view: denotative language and serial analysis.  Applying them achieves something very important, certainly, but it is also incompatible with seeing the whole.  Hence the need for separation of the two realms of thought and experience (the principle function of the corpus callosum is to inhibit).  But the relationship between them is asymmetrical, as is the brain itself.   The first appreciation of anything comes to us via the right hemisphere, and the ultimate understanding of it in context does so also. Some very subtle research by David McNeill, amongst others, confirms that thought originates in the right hemisphere, is processed for expression in speech by the left hemisphere, and the meaning integrated again by the right (which alone understands the overall meaning of a complex utterance, taking everything into account).  More generally I would see the left hemisphere as having an intermediate role: it ‘unpacks’ what the right hemisphere knows, but then must hand it back to the right hemisphere for integration into the body of our knowledge and experience.

The trouble is that the left hemisphere’s far simpler world is self-consistent, because all the complexity has been sheared off – and this makes the left hemisphere prone to believe it knows everything, when it absolutely does not: it remains ignorant of all that is most important.  The second part of the book explores the history of the Western World, looking at our changing way of thinking about ourselves in terms of what we know about hemisphere differences.  My overall conclusion is that what starts off well balanced in Ancient Greece, and again at the Renaissance, with both hemispheres working in tandem – the optimal, indeed necessary, state of affairs –  turns into unstable swings of the pendulum, with a relentless movement ever further into the world of the left hemisphere alone.

In your book you take us through, in light of your thesis, the movements which have shaped Western Civilization over the past 2,500 years.  However anthropologists hold that behavioural modernity emerged 50,000 years ago, so presumably the conflict of which you write started long before then.  Can you reflect on this? 

Yes, it’s an interesting question.  I do deal with that in Chapter 3 of the book, where I ask what kind of a thing language is, and why we have it.  The answers are, I believe, not at all what we might think. 

In any case, the Middle/Upper Palaeolithic transition 50,000 years ago which you refer to, also known as the Upper Palaeolithic revolution, reveals a massive and sudden expansion in artefacts, symbolic tokens and images which is thought to indicate the origins of language.  However language only became written much later, about 3,300 BC in Sumer.  In brief, the evolution of writing resulted in a complex tool which enables us to deal with what is no longer in front of us, to stand back from things in time and space and consider them at leisure and in detail.  Whether it was something to do with this or not, there was certainly what looks like an expansion in frontal lobe function evident in Greek civilisation: an ability to stand back from the world and from one another.  This enables us to be better at manipulating one another, to be sure, as we tirelessly hear, but also – and this seems to have been completely overlooked – to empathise more with one another, seeing others as individuals just like ourselves for the first time.  Hence Greek civilisation is marked by a need for an expansion in both what the right hemisphere does, and what the left hemisphere does.  One of these, the right, led to pre-Socratic philosophy, the sense of individual justice, of moral virtue, mythology, mathematics, empirical science, the evolution of drama, music, and poetry rich in narrative, metaphor and humour; the other to the development of Plato’s analytical philosophy, the codification of laws, military efficiency, the expansion of commerce, science in which theory came to predominate over empirical exploration, and in general the systematisation of knowledge.  There is an accentuation at this time in what each hemisphere can achieve – each becomes more individuated, in a way ‘more itself’, more distinguished from its counterpart.  Which means that they become more separate.  This is where the trouble starts.  At first they hold together like a pair of horses pulling a chariot at speed –later they pull apart and the wheels come off the chariot.  This may sound rather fanciful, since I haven’t got the space here to elaborate a very complex argument and to adduce the necessary evidence.  But I would just say to readers – please take a look for yourselves at what I have to say.

Your conclusions refer to Western Civilization.  Why do you not think that left/right conflict is more universal?

I suppose that I would have to say that I do not know enough about other civilisations to talk about them with any authority.  It may be that something similar can be found elsewhere.  But at the end of the book I do adduce evidence that has been gradually amassing over the last decade or two that Far Eastern peoples, the Chinese, Japanese and Koreans, use strategies of either hemisphere equally, in a very balanced way, in approaching the world and solving problems, whereas Westerners are very heavily skewed towards using only the strategies of the left hemisphere.  The Scientific Revolution which has, as Stephen Gaukroger, the great historian of science, puts it, led in the West to the ‘gradual assimilation of all cognitive values to scientific ones’, is ‘exceptional and anomalous’: in oriental cultures, where there were very sophisticated advances in empirical science long before we began to make them, science is seen as ‘just one of a number of activities in the culture, and attention devoted to it changes in the same way attention devoted to the other features may change, with the result that there is competition for intellectual resources within an overall balance of interests in the culture.’

My reading of your writings is that pervasive societal norms form a feedback loop with the relevant part of the brain reinforcing particular characteristics and it is this that has led to what you postulate as the current dominance of the left brain.  Do you think that that brain has evolved in the past 2,000 or so years?

Well, I believe that the world of experience obviously modifies the brain, and the brain in turn, modifies our experience.  There is a reciprocal influence.  What we experience, how we think, and what we do with our brains modifies the brain, by affecting synaptic growth and threshold, amongst other things: that modifies the likelihood of our brains responding to what they experience in a certain way.  Equally we tend to mould our environment according to how we think of the world: the cities and the great projects that we conceive and build express our values and our beliefs.  That means that we are constantly exposed to numerous positive feedback loops.  First, the more we think x now, the more we are likely to think x in the future.  Second, the more we think x, the more we will build a world that expresses x, and the more we will experience x, and so the more we will think x, etc.  

That looks like an argument for change being impossible.  But we know that it is not.  That is largely because we have in the past been open to new ideas, without preconception, in a flexible way, thanks to our right hemispheres, which are better adapted than the left to see, understand and take up new ‘information’, new habits of mind, and have a far greater repertoire of ways of thinking than the left hemisphere.  But the left hemisphere displays an unreasonable certainty that its own mechanistic construction of the world is the only one that has any validity.  The more entrenched its way of thinking becomes, the more it undermines the basis on which we might have been able to transcend its narrow way of thinking.  Remember that it deals with what it already (thinks it) knows.  Thus it ‘deconstructs’ everything that doesn’t fit its model – the power of nature, the importance of the implicit, of inherited cultural wisdom, of the meaning and value of religion and the arts – all of which the right hemisphere alone can really hope to understand.  So now we have a further positive feedback loop – the one that stops us evading the first two.

Amongst your conclusions is that Western society has become more decontextualised with prominent loneliness and materialism as a result of left brain dominance.  Are there not other ways of explaining this same outcome without invoking brain structure?  Increasingly complex societies with market triumphalism at their core for instance?

Of course you are right.  There are a very large number of levels at which one can account for any human phenomenon.  If I ask you why you robbed an old lady, you could give a number of different answers: economic – ‘I needed the cash’; psychosocial – ‘I was under irresistible peer pressure’; culturohistorical – ‘in Mrs Thatcher’s Britain it was considered normal to rob old ladies’; neurochemical – ‘I was on speed’; genetic – ‘my father was a psychopath’, etc.  Which is the right answer?  My book is about how the brain constrains the possible views of the world we can take.  As I have said above, I do not say that the brain is not in dialogue with its world.  But to speak of market triumphalism, or societal complexity, is to beg the question why we have market triumphalism and a society that is in this sense ‘complex’, or as I would say more bluntly, deracinated and fragmented.  I would say that these are direct consequences of capitalism, and the mechanistic way of thinking that characterises the Enlightenment, out of which it arose: a new way of thinking about ourselves and our relationship – or rather lack of it –  with the world.  This way of thinking happens to reflect remarkably closely the sort of world that the left hemisphere creates.  The point of my book was to draw attention to that fact, amongst others.  But I agree one could prioritise economic history, as Marx does, and try to account for everything in terms of that.  I’m just not convinced that that gets to the bottom of it at all, and I think it often leads to worse misconceptions.

Is your right/left brain conflict best viewed as a metaphor or something more ‘real’?

Well, first of all, I don’t think that metaphors are an alternative to reality: I believe they are intrinsic to all forms of understanding whatever, including scientific understanding.  They are just so deeply buried in scientific discourse that we hardly see them, and are not encouraged to question them.  But there is little doubt in my mind, having spent so long gathering evidence about the difference between the hemispheres, that they do yield different experiential worlds in the most literal sense available to us – ie, if you have damage to one or other hemisphere, predictable things happen to your world.  And the differences are not a rag bag of odd findings, either, but lead to two (in their own terms) completely coherent, but philosophically distinct, worlds.  The differences I record are all backed up by scientific evidence, whether from lesion studies, imaging or EEG studies, Wada tests, commissurotomy, ECT or TMS studies, or tachistoscope or dichotic-listening experiments, and in most cases I have drawn evidence from more than one source, and always from repeated findings. 

However knowledge is never certain, always provisional. At the end of the book I say that it would surprise me if there turned out to be no correlation between the two ways, not just of thinking, but of ‘being in the world’ that I describe, and the two cerebral hemispheres, but I would not be unhappy.   I say that, not as one reviewer seemed to assume, because I don’t believe my own thesis, but because having drawn attention to these two coherent ‘takes’ on the world is itself an important step forward.  Many people will not care whether these ‘takes’ are actually to do with differences in their hemispheres or some other part of the brain or even the spinal cord – so for them it would still have meaning, I hope.  But while, like all models, it is provisional and just a basis for further thought by others, I would be amazed if it were ever shown to have no validity at all.  There is just far too much evidence.

In his review Grayling said that neuroscientific knowledge isn’t advanced enough to allow you to reach the conclusions you’ve drawn.  Would you care to comment on this?

Of course I disagree profoundly.  But he said a lot of very generous things, as well, so I don’t want to make too much of it. 

If, as is clearly the case, an emphasis on right or left hemisphere function in an individual results in certain things happening to the way that individual conceives the world, it cannot help being the case that such an emphasis in a group of individuals who share values, concepts, habits of thought – in other words a culture – will result in the same sort of things happening to the way that culture conceives the world. 

Grayling sees himself as ‘quite considerably a left-hemispheric creature’.  That may be part of the problem.  So are the majority of scientists these days – though not in the past, and with some very great exceptions among the most distinguished scientists of all.  For the left-hemisphere crowd, there will never be enough neuroscientific knowledge to relate the brain to culture.  For them not only is everything valid only within its own compartment of knowledge, but each little fragment of knowledge within that compartment, each little research paper, is just that – another tiny piece of information.  The bigger picture is lost, and even professionally frowned on.  At what point, according to Grayling, would one have enough information to be able to make sense of it at the phenomenological level – in the world where we live?  And one might ask gently, how would he know?  The information grows at an absolutely staggering rate every day.  Indeed my worry is that soon there will be so much of it that, unless someone like myself is foolish enough to try to make sense of it now, we will never be able to see what is going on at all.  More information does not necessarily lead to philosophical insight.  And it’s that, not information, that we lack.  And it’s that, not information (though there is a lot of it in my book), that I hope I have offered.

How would you like your book to influence the thinking of psychiatrists like me, and the way we conceptualize mental illness?

I would like it to humanise psychiatry, and help us to see that we need to relate what we know about the body and the brain to the history of humanity.

***

There are reviews of Dr McGilchrist’s book available on the internet:

Bryan Appleyard – Sunday Times November 29 2009 – Divide and rule: man is the new machine
The Economist November 26 2009 – The human brain: right and left
Mary Midgley – The Guardian 2 January 2010 – The Master and His Emissary: The Divided Brain and the Making of the Western World by Iain McGilchrist
A C Grayling – Literary review – In two minds

And here an appearance of Dr McGilchrist on the Today Programme 14 November 2009

The Master and his Emissary Wikipedia page has some further links