In comments on last week’s post, a reader asked a series of questions that go to the core of the notion of critical psychiatry. First, however, we need to be clear on the answer to the crucial question: What is psychiatry? We can then ask: Does it work, and if not, why not?
Question: What is modern psychiatry?
Answer: Psychiatry is a medical specialty concerned with abnormal mental states (from Greek, psyche + iatros, the physician). Traditional societies (i.e. without western medical services) all recognised mental disturbance, starting with children who are born mentally slow and who never catch up. Intellectually handicapped people mostly stayed with their families and were kept busy with small jobs. At the other end of life, people understood that when granny went gaga, the end wasn’t far off. They recognised that head injuries or epilepsy (both common in traditional societies) can result in permanent changes to the mind. They understood that some people have bouts of sadness while others are fearful and insecure. They recognised “bad character” and, finally, they were familiar with the madness that came on during teenage years, and often didn’t get better. What we know as schizophrenia, formerly called dementia praecox, the dementia of adolescence, was well-known. As far as we know, these categories of mental disorder were more or less universal. It was certainly true in the remote southern region of Thailand where I worked in 1981, and also among the Aboriginal people in Western Australia’s even more remote Kimberley Region, where I worked starting in 1987.
As far as explanations go, there weren’t many choices. Most traditional societies had the concept that the supernatural could interfere with daily life, either by demonic possession, or by magic spells cast by a bad person. Head injuries were certainly understood, not least among survivors of the endless wars that plagued life – and still do. This also extended to the idea that there is some food or chemical that can be given to the sufferer, or excluded from the diet, that would relieve the symptoms, as well as physical treatments like bowel washouts, bleeding, heating or chilling the patient, and so on. Finally, there was the idea that mental disorder is a mental thing, caused either by some moral failing or by severe emotional shocks.
Starting early in the 17th Century, and gradually winning over the intelligentsia, if not the common herd, the rational program of the Enlightenment forced the hobgoblins and witches into unwilling retirement. Where once the Church had insisted that everybody had to believe in witchcraft, the matter was quietly dropped, even though the Bible refers to magicians and sorcery. By the 19th Century, mental disorder was seen as a natural phenomenon, mostly as some sort of hereditary degeneration, so “treatment” was largely physical in nature, i.e. brutal. Benjamin Rush, one of the signatories of the US Declaration of Independence and so-called “father of American psychiatry,” believed passionately that organised brutality coupled with copious blood-letting was the key to recovery. Patients had to be terrified out of their mental disorders, he insisted, and he made sure they were [1].
Throughout the century, the idea of putting people in a safe place or asylum gained strength but, in short order, these turned from places of refuge to places of torture. Across Europe, North America and in many European colonies, small, quiet homes for the mentally troubled morphed into gigantic “loonie bins” holding thousands of unwilling patients in ghastly conditions. The idea that mentally-troubled people have to be locked up, even for life, is still part of Western culture, although nobody has ever shown that it is both necessary and beneficial.
So we arrive at the beginning of the modern era, late 19th – early 20th Century, when the concept of science was redefined to get rid of all unobservable elements. Driven by stern logicians and physicists, all emotion and sentiment was stripped from science, leaving only bare facts. Science was to be based on what could be seen by any observer; if it wasn’t measurable, it couldn’t be used. It was only a small step from there to “If it can’t be seen, it doesn’t exist.” That was fine for physics and geology and even biology, but it left psychiatry in a bind: psychiatry deals with minds but minds are, in principle, unobservable; therefore, psychiatrists who want to be rational can’t talk meaningfully about “troubled minds.”
Leaving psychoanalysis for another day, psychiatry’s resolution was to adopt the hardest of hard lines: All mental disorder is brain disorder. That kept psychiatry within the field of science, as in: “It may sound as though we’re talking about the mind, but we’re really talking about the brain.” By stripping all emotion from patients’ statements about their minds, psychiatrists believed they could use the bare statements as reliable pointers to the underlying biology. They could then talk about the unobservable mind in detached terms, confident that they weren’t being led astray by emotion, sentiment or any of that wishy-washy stuff. Thus, a statement like “I’m so depressed” was seen as a code that only psychiatrists understood. This was not an accident, it was a deliberate move to gain scientific status – at the expense of the patient’s sense of humanity. And that is how it is today.
Was this ever worked out properly? Did a group of psychiatrists ever explore the consequences of what it meant to say “All mental disorder is brain disorder”? Did they publish a theory of mind that allowed them to say this? Did they have a model of mental disorder as a subgroup of all possible brain disorders? No, none of it [2]. The lurch to a biological psychiatry was nothing more than a blind hope that, as Daniel Dennett put it, “Somehow, the brain must be the mind” [3, p41]. However, at the time, the conceptually simple reduction of mind to brain sounded impressive even though nobody has ever shown how it could be possible [4]. The whole of modern biological psychiatry is based in a 100 year old ideological commitment to a form of science that developed before we had any concept of information as a real but “unobservable” thing. While science in general has raced ahead, psychiatry is locked into a reductionist model of science that made sense a hundred years ago and is now nearly 90 years out of date.
The real problem in psychiatry today is the absolute refusal of the movers and shakers in the world of mental disorder to consider they may be wrong. If you want to work in a field of science, that’s entirely the wrong attitude but it starts at the top and works its way down. Take an example I’ve mentioned several times: the widespread belief that on a population level, antidepressants are effective in reducing suicide rates. So says Prof. Ian Hickie, a high octane mover and shaker in this country. However, a recent report from the US says exactly the opposite: currently, suicide rates in that country, as in Australia, are trending UP, not down. At the same time, rates of prescription of antidepressants and all other psychoactive drugs are reaching levels that once would have been thought impossible, if not ridiculous. So why did he say that? What drove him to make a public statement that was patently false? Ideology, that’s what. People believe facts only if they are consistent with their broader, ontological position, otherwise they discard them. That’s what ideology does to people, it turns their brains to mush and makes them churn out nonsense in the service of the ideology. (I talk about this more in the forthcoming book on theories in psychiatry).
OK, back to the question: What is modern psychiatry? Psychiatry today is the attempt to recast mental disorder as a biological phenomenon within the positivist, reductionist framework. As a result, it is automatically dehumanising. This is not an accident, this is deliberate. It is also hopelessly wrong, just because the great bulk of mental disorder can be understood entirely within a psychological model. I have set out the case for anxiety as a purely psychological reaction in my book called … (drumroll) … Anxiety [5].
In the old days, physicians used to tell their students: “If you know syphilis, you will know medicine.” I say: “If you understand anxiety, you will understand psychiatry.” To illustrate, we can look at a point the reader made in his post:
When I was younger my mother would tell me that I had autism … I was in a private religious school. At lunch time the kids would converse. It continually would puzzle me how each kid would know when to speak so that there would be a group conversation going on. I would sit at lunch time day after day, hardly eating, just focusing on how to solve this enigma. After a while I just gave up. As a kid I was a loner.
Notice how this is a description of behaviour, including mental activity, but there is no emotion. The emotion has been stripped out, leaving only bare facts, a picture of the human as a mechanical thing. We saw the same thing in the post on autism on June 4th:
Have you always felt different from your peers? Do you feel you're an outsider, that you don't really belong, even in a group? … Do you have trouble expressing what you really mean, especially under stress? Are there some common types of communication that you find extremely difficult or uncomfortable?
The psychiatrist’s goal here is to describe the behaviour without mentioning the mental state that drives it, that makes the behaviour into what it is. This produces a wooden, detached caricature of a sentient human being, because that’s what psychiatry wants. Partly, it spares the shrink the trouble of having to deal with messy human emotions, for which they have no training and little intuitive grasp, but mainly because it fits the narrative that psychiatry is a science. However, as Comrade Hickie shows, the narrative is only sustained by judicious excision of uncomfortable facts. Here, the uncomfortable fact is that everything this child experienced was better explained by anxiety.
We see the picture of the scrawny kid sitting in a group looking from one noisy, cheerful and assertive kid to the next as the conversation whips around the circle. Our kid would like to talk but isn’t sure that what he says will be right, or people will listen, or maybe he’ll sound odd and out of place and they’ll either ignore him, or laugh at him, or push him away. That just is the picture of social anxiety. The child was anxious he wouldn’t fit in, or kids would ignore him, etc. He feared this outcome to the extent that, even though he wanted to speak, he was paralysed. His fear of rejection was so strong, he simply sat and looked dopey. It’s been said (and I like it): “It’s better to remain silent and appear a fool than to open your mouth and remove all doubt.” That’s true for adults, but not for kids. Kids need to talk, to babble and feel part of the group so they can grow up feeling wanted and valued.
The other children in his group didn’t care what they said, they were sitting there bursting to say their piece and butted in whenever anybody took a breath. They had no anxiety about knowing when to speak or what to say, they just opened their mouths and let fly. As kids do, as well as plenty of adults who never grew out of it. * If it sounded funny, they all laughed, and forgot it in an instant because, as every parent knows, that’s what kids do. Only the little anxious kid was left sitting there, desperately lonely and wanting to be accepted, but the fear of rejection was so strong he was frozen inside. That way, he ended up looking like a misfit and was rejected. As he said: “The times that I could best socialize was with other kids who didn’t seem to have any friends.” He could talk with them because he was less anxious as he knew they wouldn’t mock or reject him. As Karl Marx didn’t quite say: “Misfits of the world unite, you have nothing to lose but your solitude” (we will come back to just this point when I finish dredging through the Cass Report from the UK).
What psychiatry calls “autism,” the notion of the hollow, detached automaton, is nothing but anxiety minus the fear. It is just the shell of a human being, it’s what’s left after the human bit has been stripped out. That’s why it’s untreatable (Yogi Berra: It's amazing what you don't see when you don't look).
The essential feature of the psychological formulation is the self-reinforcing mental loop of expectation of a scary event (e.g. rejection for sounding dopey) producing the inner symptoms (fear, paralysis of thought) that result in acting dopey and thence rejection. Since psychiatry can’t take mental matters like this into account, it misses the central point of the anxiety state: Anxiety is the response to the expectation of a threat. If the threat just is anxiety itself, the person is trapped in a vicious circle. Expectation of the symptoms of anxiety is very scary and thus produces the symptoms of anxiety themselves. If it’s important not to shake, or sweat, or stammer, etc. and I feel people are watching and I have a history of shaking or sweating or stammering, etc, then guess what? That’s exactly what will happen. Fear is a self-fulfilling prophecy. It never fails.
Conclusion? A psychiatry without the psyche is a parody of a human science.
* Yer Honner, I plead guilty with extenuating circumstances.
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1. Scull A (2022) Desperate Remedies: Psychiatry and the mysteries of mental illness. London: Penguin.
2. McLaren N (2013). Psychiatry as Ideology. Ethical Human Psychology and Psychiatry 15: 7-18. 10.1891/1559-4343.15.1.7
3. Dennett DC. Consciousness Explained. London: Penguin Books, 1993.
4. Stoljar D (2021) Physicalism. Stanford Encyclopedia of Philosophy. At:
https://plato.stanford.edu/entries/physicalism/
5. McLaren N (2018). Anxiety: The Inside Story. Ann Arbor, MI: Future Psychiatry Press.
https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/rise-and-fall-of-the-biopsychosocial-model/A31DAA3BED6569F6080A1DF2C1D15A64
I thought this was interesting. You might like it as well. I found it in the comments of one of your MIA articles.
If one could describe psychiatry in a way that did not tip off the average medical PhD that what was described was psychiatry, the PhD would quickly realize that what was being described was utter quackery. Unfortunately, because the marriage of psychiatry and Big Pharma is a multi billion dollar quackery, it just happens to be the best thing since sliced bread.