If you are a religious believer, the answer is easy: The universe was created by a purposeful higher power, who had a higher purpose for the creation. Purpose came first, the universe came next, and then came living creatures including us. Our sense of purpose is therefore derived from the creator, and dependent on the universe having a purpose.

If you subscribe to the scientific worldview, then the universe is fundamentally random and purposeless[i]. And yet, our little part of the universe – planet Earth – is infused with purpose. Where did purpose come from if the universe at its inception had none?

Purpose emerged with life itself. All living creatures are purpose-driven: all biological organisms, even the simplest, are by definition goal-directed – with or without any form of conscious intentionality as an outgrowth of this basic drive. Even a bacterium or a plant is goal-directed.

In the scientific worldview , the universe came first – spontaneously and unguided. Then complex conglomerations of matter formed through self-organizing processes^[ii]. Later, at least on this planet and quite probably in many other places in the universe, complex organic assemblies of matter acquired living properties. Living creatures of astonishingly increasing complexity then evolved very slowly through fully natural processes^[iii].

Life has been evolutionarily shaped by unguided environmental natural selection, around the goal of gene propagation. Organisms have evolved a wide variety of adaptations to grow and reproduce effectively.

In more complex animals, motivation underlies goal-directedness or purposefulness. Complex animals evolved additional motivating instincts (derived from fundamental survival and reproduction instincts). For example, mammals suckle their young, so surviving and thriving necessitates a very physically intimate bonding. Therefore, beginning with the mother-infant bond, attachment is an additional powerful motivating instinct and need in mammals. Emotions of all kinds are a very potent driver of motivation in mammals.

Social mammals such as primates have evolved to depend on group cohesion for their survival, so group acceptance, social role, and reputation within the group are a matter of survival and are therefore important motivators in primates.

Humans have the same basic biological survival, reproductive, and social needs as other primates, but we have developed more multifaceted expressions of motivation and purposefulness as a result of our complex cognition and the dynamics of our social groups. Humans have also evolved remarkable capacities for innovation and adaptation to different environments.

Sophisticated purpose-driven human behaviors are, fundamentally, merely elaborations of the evolved drive to survive and reproduce as vehicles for self-propagating genes. Even the highest forms of motivation can be understood as indirectly and unconsciously serving the primary biological drives, especially reproduction (impressing and attracting mates), and the secondary drives of enhancing social role and reputation (social accomplishments and being valued by a group). The magnificent displays of human civilzation are thus the equivalent of peacock tails, extravagantly adorned by evolution. This realization needn’t demoralize us; the beauty of the peacock tail is not diminished by the fact that its purpose is merely to propagate mindless, ‘selfish’ peacock genes.

Pursuing and achieving goals is neurochemically reinforced and imbued with feelings of reward. Food and sex provide the most obvious rewards. More complex, creative, goal-directed behaviors provide more subtle rewards, such as feelings of accomplishment or self-actualization, but these are just complexly evolved elaborations of the same basic behavioral reinforcement system.

To be purpose-driven is to have an appetite for living. Our appetite for life is like our appetite for food – our love of food is not dependent on philosophical justifications, and our sophisticated appreciation of fine cuisine is not diminished by awareness that it is merely an embellishment of a biological survival instinct.

Motivation is the normal, natural state of animals, varying in intensity across individuals and partially modifiable by behavioral conditioning such as external rewards and consequences. Apathy and diminished capacity to experience feelings of reward are the abnormal, exceptional states, analogous to a loss of appetite for food. Many specific psychiatric/brain disorders cause a loss of “appetite for life” or deficits in goal-directedness. Specific psychological and social factors can do this too, triggering depression due to feeling devalued or rejected – more so in biologically predisposed individuals.

People may attribute their depression to existential, philosophical factors such as a realization that the universe has no purpose, but this is usually an after-the-fact attribution for a depression predisposed and triggered by other factors. For most people, the realization that the universe has no inherent purpose is merely a question of intellectual interest, not something that profoundly alters our personal sense of purpose[iv].

We are hard-wired to be purposeful. We have evolved to be purpose driven, and it ultimately makes little difference to our innate motivation whether the universe has a purpose or not. Remarkably, and yet fully plausibly through unmysterious processes, a random and purposeless universe produced pockets infused with purpose.

[i] Religion and science are not in the slightest way compatible on this ultimate question – they flat out contradict each other; one of them quite simply has to be mistaken.

[ii] Yes, science can explain how this is possible, and no, it does not contravene the second law of thermodynamics.

[iii] It has taken modern science to help us see through the compelling illusion of intelligent design.

[iv] With the possible exception, in my clinical experience, of people from very religious communities in which the individual has been raised to believe that their personal sense of purpose is derived from and dependent on the universe having a purpose, and for whom a loss of their faith may additionally result in alienation from their family and community.

The post How a purposeless universe became infused with purpose appeared first on Your Health Matters.

In my psychiatric practice, I’ve observed how this type of thinking can have powerful effects, both positive and negative, on motivation: it can be reassuring and comforting but can also lead to disillusionment, anguish, and feelings of abandonment, leaving some to ask, ‘Why me?’ when cruel adversity happens. I have found it difficult to predict whether religiously or spiritually inclined patients will be consoled or embittered by their faith in a purpose-driven universe when they experience tragedy and suffering.

The alternative belief, that life is random, is disquieting but can be emotionally liberating.

Our intuitions are at odds with the world according to science, which tells us that the universe is spontaneous and unguided. There isn’t a plan or purpose. Things don’t happen for intended reasons unless of course they’re caused by intentional agents—such as us.

And therein lies the reason why people think that random occurrences are planned. Humans are intentional agents who must detect and interpret the actions of other intentional agents.

Human brains are pattern-seeking[i] and agency-detecting[ii]. We evolved these tendencies as social animals, to be very adept at recognizing purposeful, intentional action on the part of other people, as well as on the part of predators or prey. These traits were likely favored by natural selection because of their survival value. We’re so adept at identifying patterns and deliberate intention that we overshoot, seeing meaningful patterns in meaningless ‘noise’ and attributing agency to inanimate objects and random natural events. This can lead people to believe that such events are controlled by supernatural agents.

Furthermore, our story-telling brains (left hemisphere language centers) have a natural proclivity for coherent stories—grand narratives with an overarching point and a satisfying end: things must happen for specific reasons, they must have a point. Our brains are not satisfied with randomness.

The normal cognitive biases and inferential errors that lead us to over-identify pattern and purpose are magnified in severe mental disorders, rendering these biases and errors all the more obvious—human nature is writ large in such disorders, in very illuminating ways. Psychiatric disorders help us understand normally subtle human traits and cognitive habits by amplifying or distorting them. Psychosis and mania, for example, magnify ad absurdum the general human tendency to over-identify patterns and to perceive deliberate intention in random events, especially in self-referential ways.

In states of psychosis, people tend to develop blatantly false, unshakable beliefs—delusions—which can range from plausible, yet mistaken, beliefs to extremely bizarre ideas. The most common types of delusions are referred to as delusions of (self-) reference. These delusions involve the belief that unrelated, coincidental, or innocuous events, actions, or objects refer to the individual in a personal way. Patients who are delusional regularly recount to me their beliefs that “everything is happening for a reason” and it’s all about them. They detect hidden messages or signs and tell me that certain events couldn’t possibly be mere coincidence. They are convinced that these refer to them—in paranoid or sometimes grandiose ways. These patients present all kinds of evidence that they consider irrefutable, in support of such assertions. The problem is that they are connecting too many dots. Arbitrary things become infused with importance and meaning when they should not be.

We all tend to notice things more when they are personally relevant. For example, a woman who is pregnant or trying to conceive may experience a sudden increase in baby product commercials on television, and references to babies, childbirth and pregnancy everywhere she turns. For most people, their automatic reality-testing ability stops them from believing that someone in the broadcasting studio deliberately placed the ads on TV for them personally—that would be delusional. Some, however, may believe that it is some sort of “omen”—a sign, for example, that a fertility treatment is about to be successful. Somehow this does not seem bizarre to many mentally healthy people.

The brain mechanism of delusions is partly understood: it probably has a lot to do with over-activity of the neurotransmitter dopamine. Dopamine is a central player in the brain’s attentional and motivational pathways. A spike in dopamine transmission marks a stimulus as important, making the stimulus more salient—noteworthy. A person with over-activity of their dopamine transmission may think that too many things are salient, mistaking irrelevant stimuli as personally relevant[iii]. For example, a psychotic individual might see the same model of car drive past twice in a few minutes and construe this as evidence of surveillance. Many street drugs can induce psychosis by surging dopamine. Antipsychotic medications are dopamine blockers.

Delusions are in many ways just extreme versions of normal human cognitive errors. In fact, thinking that events are intended, with self-referential significance, seems to be the default form of thinking. Over-riding these intuitions requires skeptical critical thinking—also known as science.

Science tells us that the universe is fundamentally random and purposeless.

Many people worry that if the universe doesn’t have a purpose, neither do we. And they’re mystified as to how all the complexity we see around us could have come into being in a purposeless way—through unguided random processes.

A random world, which according to all the scientific evidence and despite our intuitions is the actual world we live in, is too often misconstrued as nihilistic, demotivating, or devoid of morality and meaning. It needn’t be. The scientific worldview of an unguided, spontaneous universe can be awe-inspiring and foundational to building a more compassionate society. More on this in future blogs…

[i] Shermer, Michael. “Patternicity: Finding Meaningful Patterns in Meaningless Noise.” Scientific American, November 2008.

[ii] Shermer, Michael. “Agenticity. Why People Believe That Invisible Agents Control the World.” Scientific American, May 2009.

[iii] Kapur, S. “Psychosis as a State of Aberrant Salience: A Framework Linking Biology, Phenomenology, and Pharmacology in Schizophrenia.” American Journal of Psychiatry. 160, no. 1 (2003): 13–23.

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Do you think of yourself as having a brain or being a brain? Can you conceive of your mind, your personality, your self, as entirely and only the product of your physical brain? The mind seems non-physical, ethereal and spiritual. The intuitive sense that mind and brain are separate entities can be hard to shake. But, what we know from science is that the mind comes from the brain and nothing but the brain. The mind is what the brain does. Any theory that does not begin with this assumption would necessarily imply that practically all the rest of modern science is fundamentally incorrect.

The physical basis of consciousness is a guiding principle behind a great many practical and effective treatments for mental illnesses. Daily, I witness the subtle or dramatic effects of varying degrees of disturbance of brain functioning on the ‘mind’ or ‘personality.’ I also witness the beneficial cognitive, emotional, and behavioral effects of physically based medical treatments[i]. There is no aspect of the mind, the personality, the ‘self,’ or the ‘will’ that is not completely susceptible to chemical influences or physical diseases that disrupt neuronal circuitry.

If you have ever had someone close to you suffer from gradually progressive dementia, serious head injury, or a variety of other forms of brain damage or serious mental disorder, then you have witnessed the disruption or a kind of ‘disassembly’ of the mind—and of the person or personality you once knew. Such a change highlights how the mind is entirely a product of the physical brain and is dependent on intact neural circuitry.

The mystery of consciousness may eventually be solved – like the mystery of life itself

Human consciousness, like the body, is the product of biological evolution. Though science is still at an early stage of a complete and detailed understanding of the evolution of consciousness, a great deal of progress has already been made.

It was not so long ago that the question of what makes a thing alive was just as much of a mystery as consciousness is today. Living things were believed to be imbued with some sort of mysterious animating essence, some kind of vital force (‘élan vital’) that non-living things lacked. Yet, we now understand that both living and non-living things are only composed of atoms. There is no difference in the kinds of atoms—just their relative proportions.

What makes a thing alive is the organization of its atoms.

Why humans are a ‘dynamic network of information’

Whatever else accounts for consciousness, it is probably an emergent phenomenon—the product of the organization of matter[ii].

An emergent phenomenon (also simply called emergence) refers to how a complex system acquires properties that differ both quantitatively and qualitatively from its simpler constituents—properties that are not inherent to its constituents and cannot be inferred or predicted from them. The whole is greater than the sum of its parts. There is no ‘magic’ involved here, just complex physical interactions. Emergence is a spontaneous, bottom-up, self-organising phenomenon of complexity, with no external cause required.

A great deal is known about the evolution of nervous systems, from simple organisms all the way up the evolutionary tree to the human brain. And much is now understood about how nervous systems give rise to sensory perception, emotion[iii], thought process[iv], and action or behaviour.

For example, the building blocks of learning and memory are molecular mechanisms that are essentially the same in humans as they are in the humble sea snail. Information is physically encoded—embodied, you could say—in structural molecular changes in the neuron. In some ways, the vastly superior power of the human brain is just the result of the complex combinations in which these simple molecular building blocks have been assembled by evolution.

Biological systems have evolved complex genetic control of local processes, but there is no blueprint for the system as a whole—no grand design for a whole organ or whole organism. Elements within the system interact with neighboring elements at a local level according to very simple ‘rules’ or patterns. Complex feedback loops spontaneously arise in the system. The cells and organs that make up a single organism function more like an ant colony than an army—there is no top-down command and control. This is more or less the case for neurons and the brain as a whole.

Science has shown us how all this amazing self-organising complexity can be sculpted by blind natural evolutionary processes, creating an illusion of design. Counterintuitively, these evolutionary processes that lack even a smidgeon of awareness, planning, foresight or caring have produced humans capable of great awareness, planning, foresight and caring.

There are gradations of conscious self-awareness in humans at different levels of early development, in people with different levels of impairment of brain function, and in animals at different levels of evolutionary complexity.[v]

We are the sum of all our complex, dynamically interconnected brain networks. We are composed of a lifetime of remembered experiences, knowledge, learned behaviors and habits. We are all of that information, physically embodied in the total network’s connections, recursively reflecting on itself in a cybernetic loop. We are organized matter. Information is physical and humans are a dynamic network of information. The sense of self is an elaborate illusion. But it’s a pretty darn awesome illusion.

[i]Conversely, brain scans reveal the physical effects of psychological therapies.

[ii]More specifically, a product of the interactions and spatiotemporal relationships between particles.

[iii] Emotions are chemically mediated.

[iv] Thought process can be physically modelled as computation and representation.

[v]Correlating with the degree of neuronal complexity and the degree of functional integrity of the nervous system.

The post The physical evolution of consciousness appeared first on Your Health Matters.

Or, have you had moments thinking, “I don’t know why I just said that”, or, “I don’t know what came over me when I did that!”

My patients with psychiatric disorders more readily admit that there are times when they definitely do not feel in control of their thoughts, emotions, speech and actions. It’s frightening and dismaying for them.

Most mental disorders can be understood as ends of a continuum of normal human traits[i], as shown in this graphic.

Parents regularly bring their misbehaving, moody or unmotivated teenager for assessment “to figure out” if the teen “has a mental disorder or just a behaviour and attitude problem.” They ask me if the problem is that they “can’t—or just won’t” behave better, stay calmer or work harder.

It’s a practical distinction, but a false dichotomy. There is no sharp dividing line between voluntary and involuntary behaviours.

Free will and the brain

If there were such a thing as pure free will—then ‘mind stuff’ and the rest of the physical stuff in the universe would have to be categorically separate. Of course, we know, it’s not that simple.

The brain is entirely the product of genes and environment interacting over the history of the life of the animal[ii]. The brain is shaped by a person’s experience. That is how learning occurs.

Every brain is primed or biased by its unique genetic predisposition to respond slightly differently to the environment, and to learn differently. That’s what temperament is. For example, people differ in their capacity for self-control. Upbringing also influences self-control, as do practice and a person’s habits. Too much self-control can be as impairing (and involuntary) as too little of it.

So now think about it: since we are entirely the product of our genes and our environment, where does free will enter the picture? Believing in true free will would entail taking the position that within each of our brains there exists some sort of independent entity unaffected by those factors, like a little executive captain piloting the brain, able to freely ‘decide’ when and how to act.

However, the brain consists of interdependent regions in a reverberating circuit[iii]. There is no absolute, separate executive. The sense of executive self is an elaborate illusion.

Complex systems like the human brain behave in complex and unpredictable ways. For this reason, trying to predict how a person will respond to a situation is difficult or even impossible—even if we had an unimaginably powerful computer that could compute all the variables.

In that sense—the uniqueness and unpredictability of each decision and action—a brain does possess something resembling free will. But, this is not true free will in pure principle.

Brains that are affected by mental illness, damage or developmental delay lose much of their flexible complexity. Thought pattern and behaviour becomes more rigid, distorted and reactive. Responses are less cognitively controlled and instead more determined by emotion, habit, or impulse.

But remember, what constitutes a mental disorder is often a matter of degree—being further along the continuum of a normal human trait. So those questions we were considering about “mental disorder or attitude” and “can’t or won’t” might need to be answered in shades of grey rather than black or white. I try to keep this in mind with those difficult teens or anyone else with mental health concerns… and in fact when evaluating all human behaviour.

So, free will is a matter of degrees of relative freedom – degrees of flexibility. But the brain’s decision-making ability is never completely untethered from its recent or distant determining factors.

Some people find this realization depressing—that our will is never truly free. But I find it awe-inspiring and humbling. It’s also empathy-inducing, especially when considering those who face mental illness.

[i]  Even clearly abnormal conditions that are not just accentuations of normal human traits such as head injuries, developmental delay, dementia, or schizophrenia have a range of severity, with the mildest versions being practically indistinguishable from normality.

[ii]  And the genes an animal inherits at conception are the product of evolution – itself shaped by gene-environment interaction over eons of time.

[iii]  Or cybernetic loop.

The post Do you have free will? appeared first on Your Health Matters.

Your hospital roommate is very ill too. She’s quite a religious Catholic, so you weren’t surprised when her family asked her nurse to arrange for a visit by the hospital chaplain. You yourself are a non-believer, so the thought of speaking to a chaplain would never have occurred to you. When the chaplain visited your roommate, you overheard bits and pieces of what sounded like a profound and lengthy conversation about her life story, and her feelings about it. The conversation didn’t seem to be focusing predominantly on religion, God or the afterlife. Actually, as far as you could tell, it sounded more like a psychotherapy session.

In a modern hospital like Sunnybrook, spiritual care practitioners are trained to understand diversity in beliefs.

That’s because it was. Hospital chaplains, or spiritual care practitioners, as they are more often called today in Canadian hospitals, receive considerable psychotherapy training. They learn the art and skill of active listening, empathy, comforting, mirroring, reframing, and constructive feedback. By the very nature of who gets drawn to this profession, they tend to be compassionate, reflective, deep-thinking, philosophically minded people. They provide spiritual guidance and conduct specific religious rituals upon request, but they are also good at providing meaning-oriented counseling.

In a modern hospital like Sunnybrook, spiritual care practitioners are trained to understand diversity in beliefs. In secular societies, at least half the urban population is atheistic, agnostic or spiritually uncertain, and this proportion of the population is rapidly rising. As well, the religious proportion of the population is itself culturally highly diverse. Increasingly, spiritual care practitioners are being trained to understand and respect non-believing worldviews, as part of our society’s diversity[i].

Spiritual care practitioners’ training emphasizes regarding the individual human life as a narrative that is constantly in the process of being re-written; a “living human document” lending a person’s life story coherence and meaning. As people strive to make meaning in their lives, most find comfort by reflecting on how their life has mattered to others. Most of us need to affirm that we have had some significant positive impact, leaving some sort of legacy.

Even, or especially, in the course of a serious or terminal illness, the empathy and interest of others mitigates suffering by affirming to the patient that they matter. Very ill people are often helped by having someone to talk with as they reflect on the meaning in their lives. Relationships are often the most powerful source of meaning in our lives, and relationships with caregivers in hospital during a serious or terminal illness can sometimes be especially profound.

Hospital chaplains, or spiritual care practitioners, as they are more often called today in Canadian hospitals, receive considerable psychotherapy training.

As a psychiatrist, I try to emphasize the personal impact that the patient is having on me in the therapeutic relationship we form. I try to express gratitude to my patients for sharing their life experience with me, for teaching me profound lessons about the human condition, teaching me how to live, and how to approach the end of life. It may be comforting for them to know that their impact on me, and the lessons I am learning from them, will be transmitted through me to other patients as well as to students, having a ripple effect on more lives than they could possibly know[ii].

Spiritual care practitioners do all this too, and many of them do it very well. Our hospital’s spiritual care practitioners describe their work this way:

Chaplains/Spiritual Care Therapists provide emotional and spiritual support to patients and family members in exploring their beliefs and values and helping to discover or make meaning/purpose in living with cancer and life events; listening deeply to the person by exploring one’s lifetime contributions, choices and legacy, reconciling losses in life, examining significant relationships, as well as facilitating religious needs and rituals where desired.

So, give some thought to asking your nurse to arrange for a spiritual care practitioner to drop by, if you need this kind of help, but don’t really need to see a psychiatrist. Hopefully you’ll be able to lay to rest the outdated stereotype of a chaplain as only interested in speaking about God and religion. And as a family member or friend, knowing how hard these kinds of conversations can be, and appreciating the value of an objective therapist, consider suggesting this service to your loved one.[iii]

[i] The spiritual care practitioners at Sunnybrook are a particularly progressive group. At their invitation I have been actively involved in the process of helping them to more deeply understand the secular humanist worldview. I too have learned from them.

[ii] This kind of therapeutic relationship with a hospital caregiver may be all the more valuable for those individuals who are truly isolated, or who feel that their lives have been less satisfying, more frustrated or alienated.

[iii] For more on the topic of secular chaplaincy, as well as the subject of how personality type and worldview intersect to shape how people cope with cancer as an existential crisis, see: https://www.youtube.com/watch?v=wJgStR_znAo

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Since starting university, Lawrence had begun to think deeply about existential questions – the ‘purpose’ of the universe, of life, of his own life. He had rejected the (fairly liberal) religious worldview of his parents and had concluded that the universe and human existence are pointless. He couldn’t see the point of his own life. Why bother even studying toward a career? He had also reached dismal conclusions about human nature. He had not made any close friends at university.

It seemed clear to me that Lawrence’s depression was caused by an existential crisis. I tried to help him out of his depression by engaging in psychotherapy addressing his philosophical questions about the meaning of human existence, countering his negative assumptions. Unfortunately, although he found our discussions very interesting, and with my help was able to construct a secular humanist worldview that he said he found coherent, life-affirming and even inspiring, his depression and motivation did not improve[ii].

After several months, we decided to try antidepressant medication. I had initially been reluctant to choose this option because I believed that his moderate depression was mainly caused by his existential crisis and that it would improve as he reformulated his worldview. Within weeks of starting the antidepressant, Lawrence’s mood brightened and his motivation ramped up. He even became more social and found some friends he really liked. His view of the world and of humankind became more balanced. He remained interested in existential questions but this became more of a secondary intellectual interest rather than a subject defining his will to live and his motivation to engage in life.

I have since had a great many patients like Lawrence – patients whose depression, disengagement, and nihilistic feelings about life’s pointlessness seemed on the face of it to be the result of an existential crisis – their ‘realization’ that the universe has no inherent purpose. Lawrence had seen me early in my psychiatric career, so I was still too easily persuaded back then by people’s own intellectual attributions for their negative psychological and philosophical outlook. I hadn’t yet appreciated the full extent to which the biological state of our brain completely colours this outlook. Sense of purpose, like all other human behaviour, is fundamentally a physical, biological function. Motivational and reward circuitry in the brain is dependent on chemical transmitters. When people are clinically depressed, they lose the feeling of reward that normally reinforces motivation.

Human purpose, and the motivation that drives it, is an evolved function. Fundamentally, purpose-driven human behaviours are merely elaborations of the evolved drive to survive, attract mates and procreate, as vehicles for self-propagating genes. All biological organisms, even the simplest, are by definition goal-directed – with or without any form of conscious intentionality as an outgrowth of this basic drive. Even a bacterium or a plant is goal-directed.

Compared with simpler animals, human purposive behaviour has evolved to become extravagantly and wondrously embellished, elaborated by conscious intention, but it is fundamentally driven by the same basic instinctive goals of all living things: survival and reproduction. This simple biological fact needn’t diminish the meaning of our spectacular purpose-driven accomplishments any more than does the realization that the beauty of peacock tails is blindly driven by sexually selected peacock genes getting themselves copied into the next generation. Complex goal-directed human behaviours have produced the magnificent spectacle of human civilization.

We are purpose-driven simply because we are wired to be goal-directed, driven by our brain’s highly evolved motivation and reward circuits. Pursuing and achieving goals is neurochemically reinforced and infused with feelings of reward. This rewarding feeling is most obviously and dramatically experienced for food and sex. For more complex, creative, goal-directed behaviours, we experience feelings of reward in subtle ways, such as by feelings of ‘accomplishment’ or ‘self-actualization’. These are complexly evolved embellishments of the same basic behavioural reinforcement system. Lawrence had temporarily lost the feeling of reward that normally drives motivation.

Motivation is the normal, natural state of animals (varying in intensity as a trait across individuals and modifiable by external rewards and consequences). Complete indifference, and diminished capacity to experience feelings of reward, is the abnormal, exceptional state. Many psychiatric or brain disorders cause loss of our normal ‘appetite’ for life. Lawrence’s depression was one such case. Depression is often triggered by psychological or social factors in biologically predisposed individuals.

Lawrence remained very interested in the big questions of human existence, but they no longer affected his mood and motivation once his depression was treated. They became the subject of late night dorm room philosophical conversations – merely intellectually interesting to ponder and debate.

The universe may not be purposeful, but humans are. Our sense of purpose is neither derived from nor dependent on the universe having inherent purpose. Rather, it is the other way round: we perceive purpose in the universe because we ourselves are intentional agents and because we are exquisitely adept at perceiving intention in others. We infer intention so readily that we have a habit of over-attributing agency or purpose to inanimate objects and random natural occurrences. Our innate purpose-driven nature leads us to believe that the universe itself has a purpose – perceiving it as the product of a deliberate, creative designing agent – an agent just like us, only immensely more powerful. Just as we struggle to intuitively feel that the sun’s rising and setting is caused by the earth spinning rapidly with us on it, it’s hard for us to intuit that the universe came first and purpose came later.

Science tells us that purpose is an emergent, evolved property in a random purposeless universe. If we want to reach a different conclusion, we must be prepared to reject a sizeable proportion of the entire body of scientific knowledge and evidence, and start over (this is the same knowledge and evidence-base that makes your cell phone work). Impressively and counter-intuitively, twenty-first century science is able to show us how the universe and all the complexity that has arisen within it, including the eventual development of purpose-driven self-aware creatures like us, could plausibly have emerged and evolved spontaneously through entirely unguided processes.

A random world, which according to all the scientific evidence and despite our intuitions is the actual world we live in, is too often misconstrued as nihilistic, demotivating, or devoid of morality and meaning. It needn’t be so. The scientific worldview of an unguided, spontaneous universe can be awe-inspiring and foundational to building a more compassionate society.

Once Lawrence’s depression had resolved biologically, he grasped the difference between skepticism and cynicism[iii].

The post Our sense of purpose is not dependent on the universe having a purpose appeared first on Your Health Matters.

In his early elementary school years Andrew’s performance had been okay, though never stellar. In retrospect, he probably cruised because he was smart, the demands were low and the structure and supervision were high. In higher grades, teachers expected him to be more self-directed. Testing in Grade 3 had found him to be in the gifted range of intellectual functioning. This only made the problem feel worse in later years – he was underachieving terribly relative to his potential, just coasting along aimlessly, a sad waste of natural talent in his parents’ eyes.

It’s not that he had no intellectual interests at all. He would briefly become excited about a topic beyond the school curriculum – like the time he had watched a Steven Hawking documentary on the Discovery Channel, or when his family went on a tour of WWI battlefields in France. He would start to read up on science or history, but he would quickly lose interest. He seemed perpetually bored, lazy and lacking persistence, focus or self-discipline. He could not apply himself to long-term goals involving delayed rewards. He had recently become a fairly regular marijuana user, but probably not heavy enough to really account for his lack of motivation, and the lack of motivation had long predated this habit.

In my assessment of Andrew, he did not have enough specific and persisting depressive symptoms to meet criteria for a Major Depressive Disorder. Besides, there was no clear onset or change from his usual baseline. Rather, he seemed to have just slowly drifted into a state of increasing aimlessness and low motivation over a period of years. He did not feel a sense of hopelessness or profound pointlessness about his life and the future, but neither could he see any clear purpose for himself in life. He lacked any career goals, let alone ambition.

One thing stood out in my questioning of Andrew and his parents: he had a short attention span – especially for tasks requiring sustained effortful focus. He had a longstanding frequent tendency to zone out in class and to be more easily distracted compared with most of his peers.  He would quickly become bored and restless. His parents had been aware of this, but they had always assumed that his lack of focus was the result of his lack of interest and motivation, rather than the other way round. He also lacked organizational systems for his work, despite his parents’ attempts to help him set these up. And his time management was atrocious.

Andrew had many of the typical characteristics of Attention Deficit Disorder. ADD is a diagnosis applied to children or adults with very short attention spans. It also involves relative deficits of what is referred to as executive functioning, or cognitive control (simply put: the ability to control one’s thoughts and actions – the basis of ‘will power’; these higher mental functions are closely related to, and to some degree dependent on, the ability to focus). Attention and motivation are integrally linked and mutually dependent, but it is often the case that attention is the more primary and fundamental function, influencing motivation.

Needless to say, there are very many possible explanations for lack of motivation. ADD is just one of them, albeit a fairly common one. Unfortunately and obviously, psychiatric assessment and treatment is not the answer for all unmotivated teens.

ADD is common. If we include slightly milder cases, about 5–10 per cent of the population have these characteristics. Think of ADD as one end of a normal continuum rather than a true disorder in a category distinct from normality. It’s just the way some people are—it’s part of who they are, not a ‘thing’ that they have or an illness they are afflicted by. As with most psychiatric disorders, the line separating a disorder from normality is determined (imprecisely) by the particular trait/s causing significant impairment of functioning in relation to the demands of the individual’s environment. There are evolutionary reasons for this diversity of traits in a population. Our modern environment tends to favour people who are focused, so these otherwise normal traits can be a liability in many settings.

The brains of people with ADD traits can in a sense be thought of as less internally stimulated than average brains – their brains require higher levels of external stimulation to engage them. So these people find unstimulating activities that require patient mental effort to be completely unengaging and intolerably boring. They need activities that are more stimulating, exciting, rewarding, novel or varying (video games are designed to meet these criteria). These relatively ‘under-stimulated’ brains are thought to have lower activity levels of the neurotransmitter dopamine. Dopamine plays a central role in attention and reinforcement of behaviour. When dopamine is activated in our brains by a particular stimulus or action, it is nature’s way of ‘telling’ us that something is important or good for us—it marks a stimulus as salient (noteworthy) and it reinforces an action so that it is more likely to be repeated. Dopamine activation thereby directs our attention and motivates us to persist in a behaviour. Medications that improve attention are called stimulants (caffeine is in this category). They increase dopamine activation, among other chemical effects.

I spoke with Andrew and his parents about strategies for reducing distraction, optimizing focus, improving organization, and leveraging incentives to increase his motivation. We discussed medication as an additional option, with a careful discussion of the pros and cons (side effects, risks). I was careful to emphasize that medications don’t work for everyone. Some people understandably have reservations about medications for ADD, but Andrew’s parents, being doctors, were quite interested in considering the medication options, and Andrew was willing to give it a try.

I started him on an attention stimulant medication, which he could take on days when he needed to be focused and motivated. Fortunately, he had an excellent response to the drug, and no side effects. He found school much more interesting and engaging when he was on the medication, and was much more persistent and productive on those days. He said he felt on those days like his attention “locked onto” the task at hand, and he felt a strong urge to keep doing whatever he was busy with. He even felt annoyed if he was interrupted from his task. He didn’t take the medication on days when he didn’t need to concentrate as much, because he didn’t want to feel so intense all the time.

Andrew’s marks improved impressively over the next few months. This greatly boosted his morale and his motivation more generally. There was some spill-over effect of his motivation in that he tried harder to apply himself to his work even on days when he was not on the medication, but his focus was consistently better on the days when he was on it.

I have followed Andrew for several years now. He still loves playing video games, and he still gets to bed too late at night (smoking a joint – just one, he assures me – “to settle my mind and help me sleep”). But he is close to completing a tough degree in engineering, and he is now well on the way toward achieving the clear, attainable long term career goals that he has set for himself.

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For my patient, whom I will refer to as Jane,ⁱⁱ it was different. Jane had requested and been granted Medical Assistance in Dying (MAID). At a time of her choosing, with a select group of family and friends gathered around the bedside to say goodbye and support her, and with her favourite music playing in the background, a physician infused a powerful sedative into the intravenous line in Jane’s arm. Within seconds, she fell asleep. A series of further infusions followed, inducing deep anaesthesia. The last of the infusions stopped her breathing and her heart. The colour slowly drained from Jane’s face. The whole process took just a few minutes. Her family and friends tearfully hugged each other and then spent some private time in the room with her lifeless body.

I had met Jane three years earlier at age 71, soon after she was first diagnosed with an incurable brain cancer. As a psychiatrist, I was helping her deal with the stresses and losses of her declining physical abilities and the knowledge that this particular kind of cancer could only be temporarily controlled and would ultimately be a terminal illness. Jane had made it clear to me early in her illness that she supported in principle the idea of medical assistance in dying. The issue was still being debated in Canada and was being considered at that time by the Supreme Court. The idea of being able to “die with dignity,” as Jane put it, fit with the strongly independent way she had lived her life. It was important to her to feel that she have as much control over her life as reasonably possible. Quality of life was most important to her, and she was adamant that under certain conditions of severely limited physical ability, she would no longer consider her life worth livingⁱⁱⁱ. “I really don’t see the point of suffering pain, indignity and loss of my autonomy, with only a few more weeks or months to live anyway.”

It was shortly after Parliament had passed legislation legalizing MAID in Canada in June 2016 that Jane was told by her oncologists that her illness had entered its terminal phase. Nothing more could be done to slow its course. According to her oncologists’ estimates, she had a few months left at most. It was then that Jane asked me how she could proceed to apply for MAID. We discussed the process in detail, in particular, the legal requirement that the patient be fully mentally competent up to the last moment in order to be deemed eligible to request MAID (NOTE: This requirement has since been removed in specific circumstances).

We also discussed the alternative options available to her, which included palliative care and palliative sedation^iv. Palliative care can include a wide range of measures designed to maximize comfort and minimize pain or distress, all the way to the end of life. Palliative care is frequently very effective, but of course cannot be guaranteed of achieving its goals.

Jane had been suffering some depression as well as mild cognitive deficits since her initial diagnosis as a result of the brain tumour, but she had consistently displayed excellent insight and appropriate judgement. After Jane formally submitted a written application for MAID, I conducted a formal assessment of her eligibility and of her mental competence^v.

One of the tricky things in assessing competence to choose MAID is trying to determine if or to what degree the person’s decision is distorted by depression. It is not abnormal to feel depressed and a sense of futility in the face of great suffering and a hopeless prognosis. But I have also known people who continue to find purpose and meaning in their dying days, sometimes profoundly. They might have the opportunity to say deeply meaningful things to loved ones – things that they might never otherwise have said, and to feel valued by others caring for them (the carers often feel valued too, in their important role).

Ultimately the patient has the right to choose, and a right to autonomy, as long as they retain mental competence. Depression does bias a person’s outlook, but bias is not the same as mental incompetence. Doctors have to balance the need to protect patients from exercising poor judgement in vulnerable mental states against the need to respect the patient’s autonomy.

I deemed Jane mentally competent to make this decision.

It was relevant to note as well that Jane’s request for MAID was consistent with her long-held values.

While the final decision was Jane’s to make, it was also extremely important that her immediate family should be comfortable with her decision, and supportive of her right to make this choice, which they were.

A second assessment was conducted by another physician, as is required by the MAID legislation. The two assessments were in agreement.

Jane chose the date she would like to have MAID administered, a date that must follow a ten-day waiting period. A few days before the designated date, she organized a small “farewell party,” with the assistance of friends. It was held in the palliative care unit where she was being cared for at that stage. I dropped into the party for a while, at Jane’s invitation, where I witnessed her “holding court,” joking and reminiscing over food and wine.

I was present at Jane’s MAID procedure, at her request. While we waited for the nurse to set up the room and connect the intravenous line, we spoke about Jane’s favourite topic – politics, for the sake of distraction. She said she regretted that she would not be around to see how the present U.S. presidential term turned out.

Family and friends gathered round to say their goodbyes. Jane’s classical music choices started to play. There were hugs, kisses, loving words and mutual praise. Then the final goodbyes. When Jane said she was ready, the attending physician began the first infusion (the sleep-inducing sedative). Jane, still retaining her trademark wicked sense of humour said “I don’t feel anything. I think you’re going to need more than that to kill me!” The next moment she was asleep.

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Karin, being a here-and-now, one-step-at-a-time kind of person, coped more calmly than me. Desperate to regain a feeling of control, I coped with my shock and distress by springing into hyper-focused, goal-directed action. I focused my efforts on trying to connect us to expert services. My take-charge manner was very necessary at that stage, but my high need for control could have become a problem beyond that point.

During our first appointment with the oncologist, he astutely recognized my personality type and assertively told me to step back and let him take over. He cautioned me to not try to research and interpret medical information or make treatment decisions: he was in charge. At that moment, I felt like I had been standing outside my burning house with a garden hose after calling 911. Several fire trucks with lights flashing and sirens blaring had pulled up. I felt I had been politely but urgently pushed aside, told by the fire chief “You can step back now sir!” I was anxious relinquishing control, but at the same time immensely relieved.

From that time on, we just showed up for treatment and hoped for the best – we simply put our energies into engaging fully in daily life. We focused on the priority of taking care of our children, our relationship, spending time with extended family and friends, and doing meaningful work.

Many people urged us to be more ‘proactive’ about ensuring Karin’s health. We received a lot of unsolicited advice from many different quarters regarding treatments, alternative therapies, and healthy lifestyle measures which were said to be assured to beat the cancer and prevent recurrence. Most of the advice, while well-intended, involved measures lacking any reliable evidence.

Karin and I were painfully aware of the prognostic uncertainties of her cancer. We had a strong sense that there was nothing we could do to alter the not very reassuring statistics of the best available medical treatments. This realization was deeply unsettling, and the urge to deny it and believe otherwise was very strong.

When you’re diagnosed with cancer, it’s natural to wonder “What did I do to cause this?” and “What can I personally do to re-take control and improve the outcome?” But this need to identify causes and solutions in order to feel in control is a double-edged sword, fraught with potential for guilt and self-blame. The reality is that most of the factors causing cancer are either random or so biologically complex that for practical purposes, we can regard them as random, and beyond our control.

Most people don’t like the idea that randomness rules our lives. Studiesⁱ show that when we feel insecure and lacking control, we are even more likely than usual to perceive illusory patterns of causation. Patients commonly over-estimate the role of their own actions or lifestyle in causing their cancer and in determining the future course of their illness. Too often, people become excessively obsessed with things like diet, when what they really need to do is focus on the things in their life that give them meaning, and matter most to them.

Furthermore, many people cope with adversity by believing that life events happen for a cosmically intended reason. This belief too is a double-edged sword: while it can comfort some people, others, whose adversity seems to have no redeeming features, feel anguished or alienated by the inevitable question ‘Why me?’ In my psychiatric practice I have counseled many such people, whose experiences with illness or catastrophic life events have left them struggling to come to terms with the randomness of life.

Twelve years later, Karin remains in remission (though she did have a recurrence five years ago, which fortunately turned out to be minor, after several frightening weeks of uncertainty). One is never really out of the woods with cancer.

Despite all the anxiety and uncertainty, or maybe because of it, Karin’s and my experience of her cancer heightened our sense that our lives are suffused with meaning. I don’t want to romanticize the experience with the selective memory of hindsight, but some of our most moving and meaningful interactions with people occurred in our time of crisis. We were the grateful beneficiaries of very much kindness and caring. We had a great sense of clarity of priority and purpose. Relationships mattered most to us. For quite a while we didn’t ‘sweat the small stuff.’ We have tried to keep these lessons in mind, even though human nature relapses much more surely than does cancer, and we find ourselves ‘sweating the small stuff’ all too often now.

To be clear, all this meaning was made by us and by our support system and by other caring people; everyone was doing their utmost to make the best of a really bad situation. I don’t believe that the meaning of such a life circumstance is predetermined – none of the good that came from it was ‘meant to be’. (How can anyone in good conscience judge their own circumstances as having ‘happened for a reason’ when thinking about their own positive outcome, knowing that others have unmitigated tragic outcomes?) Nor am I endorsing the ‘cult of positivity’ surrounding cancer – I would never suggest that ‘cancer was a blessing’. It could have turned out very badly. We fully recognize that our positive outcome was heavily determined by dumb luck.

Coming to terms with randomness is frightening, but it does liberate us from the tendency to blame ourselves for illnesses we didn’t cause. It also ought to stop us from judging others for their misfortune. And an understanding of randomness should make us think twice about pressuring people with unhelpful advice of unproven therapies that are based on mistaken attributions of causality.

People with different personalities differ in how intensely they need and expect to be in control of their livesⁱⁱ, and in their level of anxiety when experiencing a lack of control. As a naturally high-control person myself, relinquishing it when circumstances required doing so did not come easily to me. My work now often involves trying to help patients with high-control personalities like mine who are experiencing random adversity to recognize the limits of their control. People like us need help letting go, tolerating uncertainty, and focusing on living life to the full, as meaningfully as possible. Here and now. Each day is precious and uncertain. In this way, cancer is just like life in general, only more so.

i. Whitson, J. A., and A. D. Galinsky. “Lacking Control Increases Illusory Pattern Perception.” Science 322, no. 5898 (Oct 03 2008): 115-7. 

ii. The personality trait we are talking about is also referred to as conscientiousness, which is considered one of the ‘Big Five’ personality traits:  https://en.wikipedia.org/wiki/Big_Five_personality_traits

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“For some of our most important beliefs we have no evidence at all, except that people we love and trust hold these beliefs. Considering how little we know, the confidence we have in our beliefs is preposterous—and it is also essential.”
2002 Nobel Laureate Daniel Kahnemanⁱⁱ

An astute philosopher suggests making a daily habit of looking in the mirror and asking ourselves to consider whether everything we believe with complete certainty might be wrong.

Beliefs are our brain’s way of making sense of and navigating our complex world. Our brains rely on these energy-saving shortcuts to organize and evaluate the overwhelming amount of information we must process, and to form predictions about what might happen next. This enables efficient learning, and is often essential for survival. More often than not, the beliefs we form are fairly reliable representations of reality. But the trade-off for this efficient way of making sense of the world is that not infrequently our beliefs are mistaken. Adding to their fallibility, many of our beliefs are formed emotionally and unconsciously – our rationalizations for them are formed after the fact, in our attempt to explain and justify them to ourselves. And many of our beliefs are simply intuitive gut feelings: they just “feel” right.

Beliefs are often concerned with understanding the causes of things, and are based on pattern recognition: If ‘b’ closely followed ‘a’, then ‘a’ might be assumed to have been the cause of ‘b’. Our brains connect the dots. While this is often a good approximation of reality (e.g. we got sick after eating spoiled food), our brains have a habit of over-identifying patterns where they do not exist (e.g. our child first showed signs of autism around the same age as he received his first MMR vaccination – we fail to recognize that this happens to be exactly the age when the most obvious signs of autism first become evident; the MMR is irrelevant).

We are not just pattern-seeking, we are also intentional agents – we are wired to behave in motivated, purposeful ways in almost everything we do. And as social animals, we have evolved to be very adept at recognizing purposeful, intentional action on the part of other people, as well as on the part of predators or preyⁱⁱⁱ.

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The problem is that we are so primed to connect the dots, and to perceive intention, that we are inclined to over-identify pattern, and to over-attribute agency or purpose to inanimate objects and random natural occurrences. This is the evolutionary basis of animism (the belief that plants, inanimate objects, and natural phenomena have souls) and of spirituality in general. Most of us no longer believe that storms, earthquakes or volcanoes are the work of angry, vengeful agents. But many of us still wonder if illnesses strike us because of some moral failing, or maybe in order to teach us a valuable life lesson.

We have a particular propensity to think that coincidences are meaningful (everything happens for a reason). The familiar example is when someone we were just thinking about phones us. In actuality, for such a coincidence to truly be remarkable, we should have made a prediction ahead of time that this particular event would occur at this particular time (tip: write down your prediction every time you make one, and meticulously record both the hits and the misses). Otherwise we cannot conclude anything about the probability of this specific coincidence. We have merely observed the probability of any subjectively resonant coincidence occurring at any time (maybe our wedding theme song will play on the radio just after thinking about it, on any arbitrary day). We are unjustifiably impressed, judging the seeming improbability of an event after it has occurred, and assigning it significance through our egocentric, self-referential lens. In fact, the more eerie and spine-chilling a coincidence feels, the more skeptical we ought to be about our habit of thinking that the universe is intentionally designed for us.

This general human tendency to think that “everything happens for a reason” (… and it’s all about me) can be magnified to an extreme in mental illnesses. In states of psychosis and mania, people tend to develop blatantly false unshakable beliefs – delusions – which can range from plausible yet mistaken beliefs to extremely bizarre ideas. The most common types of delusions involve the false belief that unrelated, coincidental, or innocuous events, actions, or objects refer to the individual in a personal way. My patients suffering from delusions perceive deliberate intention in random events. They detect hidden messages or signs and tell me that certain events couldn’t possibly be mere coincidence, and they are convinced that these refer to them – usually in paranoid ways, sometimes in grandiose ways. They present all kinds of evidence that they consider irrefutable in support of such assertions. The problem is that they are connecting too many dots.

The fallibility of normal human subjectivity, with all the cognitive biases that regularly escape our notice, is the reason we must rely on the scientific method to probe reality more objectively. The scientific method relies on rigorous critical thinking, a healthy amount of skepticism, scrupulous attention to detail and methodology, and harshly critical peer review. It’s very much harder than most people realize to demonstrate with a high level of confidence that ‘a’ is the cause of ‘b’. Ten anecdotes are no more reliable than one anecdote, and one hundred are no more reliable than ten^iv.

A lack of critical thinking might seem harmless when it influences people’s behaviours for relatively minor decisions, like buying homeopathic remedies or engaging in superstitious rituals. Disenthralling people by debunking their cherished beliefs may seem unnecessary or even unkind. But an inability to critically appraise whether ‘a’ causes ‘b’ tends to inevitably influence more consequential choices and behaviours. As the great science popularizer and astronomer Carl Sagan put it, “Gullibility kills.”^v

For example, credulous beliefs regularly have tragic consequences for suggestible, vulnerable and desperate patients with potentially treatable cancers. Far too many people choose alternative therapies, whose practitioners tell them what they want to hear, while rejecting scary but evidence-based chemotherapy. They are frightened by their oncologist’s inability to give them the certainties they seek.

The good news is that critical thinking, while not natural or intuitive, can be learned, and scientific literacy is becoming much more widespread in modern societies. We’ve come a very long way from making human sacrifices to appease the gods, burning witches who lived next door for causing our household’s bad luck, and exorcising demons from people suffering from psychosis. Science is a candle in the dark^vi.

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