Beyond Pills

All parliaments have official committees, but the UK Parliament also has interest groups, called All-Party Parliamentary Groups (APPG). These have no official standing but involve MPs from government and opposition who work together (aha, so that's why we don't have them in Australia!) to investigate and publicise different topics that would otherwise slip through the cracks. All such groups are registered and readily accessible through a website; there are about 70 groups relating to different countries or regions, and several hundred on specific topics.

Some must lead to riveting hearings: Cats and Dark Skies ("To highlight the importance of preserving our ability to see a dark sky at night...") stand out, while Beer ("To promote the wholesomeness and enjoyment of beer"), Jazz, Scotch Whiskey and Snooker might be a little more lively, especially a combined field trip. Others seem to warrant more than just a friendly chat among the like-minded. One of these is the Beyond Pills APPG whose remit is:

To move UK healthcare beyond an over-reliance on pills by combining social prescribing, lifestyle medicine, psychosocial interventions and safe deprescribing. As well as reducing unnecessary and inappropriate prescribing, this integrated approach will improve outcomes and reduce health inequalities.

It's good to see that somebody in authority has noticed, unlike the recent fandangle in the Australian Senate which was determined to get everybody on drugs for so-called ADHD.

On May 14th, the Group released a report titled: "Shifting the Balance Towards Social Interventions: A Call for an Overhaul of the Mental Health System." This covers a lot of important points and will certainly provoke outraged shrieks of "Anti-psychiatry!" from the usual chorus of psychiatrists eager to protect their privileges. It's a valuable source of carefully-considered material and, at about 35 double-spaced pages, doesn't take long to read. I intend to send it to a number of state and Federal MPs in the hope they read it.

Its starting point is the sorry but hugely expensive state of mental health in the UK which they say amounts to a crisis. After spending the stupefying sum of nearly a quarter of a trillion pounds (about AU$480billion) over the past forty years or so, there's been no measurable improvement. One by one, they list the many failings of the current approach to mental health, e.g. while about 20% of British adults take antidepressants, the suicide rate is going up (did you hear that, Dr Hickie? Up, not down); the prevalence of mental disorder is the same or worse after 40 years, yet the rate of disability from mental health diagnoses has trebled. Modern psychiatric drugs are many times more expensive than the older, "first generation" of psychotropics yet they are no better in terms of outcome and have just as many serious to dangerous side effects. Most importantly, "...the gap in life expectancy between individuals with severe mental health issues and the general population has doubled since the 1980s" (p7). The mortality rate of diagnosed patients is 3.6 times higher than the rest of the population, meaning they can look forward to a life some twenty years shorter than their undiagnosed and undrugged peers.

When you look at the reality of the "mental health" industry, the figures are damning, and the reason is ... psychiatry. In particular, the Group concluded, the failure is due to the near-universal reliance on the "biomedical model." This conceptualises mental disorder as a matter of individual pathology caused by genetic disturbances of brain function, but the report sees it as the problem, not the solution:

2. The dominant biomedical model of mental health care has led to over-reliance on psychiatric drugs and neglect of effective social, community and relational approaches. This approach fails to address the underlying social, economic and psychological determinants of mental distress and is contributing to worsening outcomes (executive summary, p5).

While the report mentions 'biomedical' and its various cognates sixteen times, it is not defined, nor do any of the 89 citations lead to it. By clear implication, psychiatry's biomedical model is closely related to, if not a direct descendant of, the dominant model in medicine itself. Again, this is not defined but we're all expected to know exactly what it says. Clearly, everybody involved in this extensive investigation takes it for granted. I have a rule that says "Never take important things for granted," so after the first few mentions of "biomedical," the alarms were flashing.

Starting on p7, "Why we need an overhaul of our mental health system," the Group lists one failing after another of the current system. In particular, they emphasise the breathtaking loss of life span for people in the mental health system, but the economic cost is also staggering: in 2022, the total cost of poor mental health in England alone was estimated at £300 billion (~AU$575billion), or about 12% of their GDP. The numbers are so big they start to lose meaning.

With these ghastly figures in mind, they point to recent reports from the UN Human Rights Commission (UNHRC) [1,2] and World Health (WHO) [3] which urge dramatic reorientation of society's attempts to deal with mental disorder. Instead of labeling and drugging people, the social and psychological factors involved in mental health must be taken into account: "Greater attention should be paid to tackling the social causes of distress: inequality, poverty, abuse, discrimination, over-work and social exclusion." The UN reports also criticised the same biomedical approach that troubled the Beyond Pills Group, provoking psychiatry's ever-alert defenders to attack all the biased and mean-minded anti-psychiatrists in the UN and WHO [4, 5]. The report concludes:

We need a radical new vision of how best to frame and manage poor mental health in order to improve clinical outcomes and reduce the escalating economic, societal and human burden of rising levels of mental distress (p8).

The authors predict, however, that any attempts to implement change will run into three obstacles. The first is the "dominance of the biomedical model in mental health care." Because of this approach, most mental trouble is framed as a biological illness which prioritises physical treatments over social and psychological interventions. The second obstacle is "... the mutually beneficial financial links between psychiatry and the pharmaceutical industry, including the biased use of evidence to shore up the dominant biomedical approach." That is, biomedical psychiatry manipulates its research evidence to suit its own interests. The third obstacle is "power asymmetries in policy making, medical education, research and care relationships." Once in control of the industry, mainstream psychiatry makes sure that no critics get a look in.

The report then recommends six principles for mental health reform:

1. Mental health problems are mostly about our circumstances and relationships;

2. Mental health problems arise within our social environments;

3. Mental health problems are exacerbated by societal messages;

4. Positive narratives and language are needed for recovery;

5. Psychiatric drugs should be used with caution and over-prescribing must be reduced; and

6. Research should focus on better psychosocial provision.

These led to four areas of intervention at government level, relating to provision of services; regulation of medications (and of conflicts of interest among the psychiatrists who set the direction of mental health care); education and training of both the public and health professions; and working to change public and professional awareness of mental disorder. While the first three areas had eight recommendations between them, the last had only one: "De-medicalise mental health language in both public and professional spaces." Oh dear.

Oh dear again. Does the committee know what an enormous cat it has just thrown among the delicate pigeons of mainstream psychiatry? Is it aware of how much time and effort psychiatrists and their friends in industry have spent trying to medicalise the mental health discourse? I think not. In giving lectures at conferences and so on, I have often made the point that medicalising propaganda is everywhere these days: "I got off the plane this morning and thought I'd better nip in for a leak in case I get stuck in a taxi somewhere. So I'm standing there, innocently minding my own business when what do I see? Straight in front at eye level is a sign that says 'Feeling anxious? Feeling depressed? See your doctor'. If you see your doctor, you will get pills because that's what doctors do. These days, you can't even have a piss in peace without being sprayed by propaganda."

The propaganda exists because it works, and it works because an extremely powerful trade lobby has insinuated itself into the machinery of government, to the extent that it has essentially captured the bodies intended to oversee it. This isn't just Australia, this is everywhere, as Bob Whitaker and Lisa Cosgrove have detailed in the US [6].

Strangely enough, there is a strong parallel between the civil nuclear power industry and the psychiatric/drug company axis that has taken control of human mental distress. In a careful analysis of nuclear power in the US, Joseph Morone and Edward Woodhouse examined how we (meaning the world) ended up with such a dangerous, expensive and unsuitable program as the uranium cycle. In The Demise of Nuclear Energy? Lessons for democratic control of technology [7], they argued that the primary driver for nuclear power was the enormous military need for weapons-grade uranium and plutonium, which were best produced in gigantic reactors.

However, to sell the ridiculously expensive (and unnecessary) program to the public as "essential to national security," they decided to produce civil versions of the reactors, versions that needed to be close to population centres. It was only after that decision was made that people realised the reactors would need massive and very expensive safety modifications to reach minimal standards; essentially, they decided on purpose, size and location first, and then bolted the safety requirements on as an afterthought. If it had been done the other way around, as in: "Let's work out whether it's safe, then whether it's economical, and then whether the public will accept it," then the current civil nuclear power industry would never have happened. Perhaps they would have put the trillions of dollars into thorium or even renewables, who knows?

Morone and Woodward concluded it is "...obvious that humans are responsible for whether and how technologies are used (yet) technologies somehow have a tendency to elude intelligent control" (p ix-x). The problem lay partly in the government making a decision to base its military strength in nuclear weapons, and then letting an unrestrained and entirely self-interested industry loose with practically no restrictions. Moreover, the nuclear industry managed to convince everybody in power that there was only one conceivable model of the nuclear program to consider, which just happened to be theirs. The rest of the problem was that governments forgot to ask for details (or stupidly believed what they were told, or were too lazy, or making too much money, or all of the above), to ask for silly details like "So what are your plans if one of these babies blows up?"

As Morone and Woodward point out, there is a problem of "technological inertia" which takes over once too much money has been spent (and more to be made) and too many careers have been built on the technology, even if it's a dog's dinner. Governments forgot, if they ever knew, or if they cared, that their primary responsibility was, is and always will be, to the citizens who have no say in what is being done to them. But this is the problem with vast and complex technologies: neither governments nor citizens understand them, so when vested interests move in and shape the technology to suit themselves, nobody realises what they're doing or knows enough to tell them to stop.

I doubt many people would look to the nuclear power industry for lessons for what has happened to mental health but common to both is the institutional pressures that allow a dud technology to take over and maintain itself against the public interest. As mentioned last week, the idea that mental disorder is brain disorder goes back forever, but it has never before taken control of government and the public discourse as it has done today. Partly, this is because governments don't want to know about mental disorder, they all know they can't win votes by being nice to crazies but they will surely lose votes by not being tough enough. The pressures are ratcheted up, they are never ratcheted down. The rest is because psychiatrists and their friends in the drug industry moved in, telling governments: "We've got the magic bullet, our wonderful biomedical model and the amazing drugs it has developed. Trust us, we'll eliminate the problem of mental disorder so you don't have to worry about it again. Just keep pouring money into our coffers and you won't hear a squeak from them. PS. If you do, it means they need more drugs."

Let's see what's happened. The entirely self-interested axis of psychiatry and drug companies “... managed to convince everybody in power that there was only one conceivable model of mental disorder, which just happened to be theirs. The rest of the problem was that governments forgot to ask for details (or stupidly believed what they were told, or were too lazy, or making too much money, or all of the above), to ask for silly details like 'So what are your plans if your psychosurgery destroys brains or your drugs shorten people's lives?' There is a problem of 'technological inertia' which takes over once too much money has been spent (and more to be made) and too many careers have been built on the technology, even if it's a dog's dinner. Governments forgot, if they ever knew, or if they cared, that their primary responsibility was, is and always will be, to the citizens who have no say in what is being done to them. But this is the problem with vast and complex technologies (nothing we know is more complex than the human mind): neither governments nor citizens understand them, so when vested interests move in and shape the technology to suit themselves, nobody knows what they're doing or knows enough to tell them to stop."

The technology that worked in physical medicine, namely the reductionist positivist model (which reduces physical structures to their elements) was transposed holus-bolus to psychiatry and renamed the "biomedical model." Somewhere, they forgot to check whether mental matters are of the nature that can reduce to physical structures (they're not). All the excited people who hoped they could advance their careers and get lots of money and power managed to fool governments into believing that they had the technology to rid society of the "scourge of mental disorder." That was a message governments wanted and will always want to hear; the last thing an MP wants is some disturbed person creating havoc in the waiting room (or these days on social media). When governments asked: "Do you have the technology?" the excited people jumped up and down: "Yes yes, we sure have, we've got the biomedical model. Would you like some details? Let's start with serotonin levels in the amygdala, that's a little gold mine, sorry, a fascinating story." And, decade after decade, lazy, stupid or indifferent governments waved a dismissive hand: "Boring boring. OK, it's all yours, take what you want from the Treasury. If it works, we get the credit but if it fails, you'd better make sure it doesn't leak out."

But it is leaking out. I don't think a parliamentary group in such an influential country would have written this report ten years ago. It's balanced, considerate and sensible, and psychiatrists hate it already. Good. But ... (there's always a but) but buried in it is a landmine waiting to explode because, in the 1950s, when scientists told governments "Yes, we can build reactors, how big do you want them?" they already had a theory of nuclear power and working models of reactors. But when psychiatrists told the Beyond Pills Group, "Yes, we've got the biomedical model," there was a problem. They don't have it. It doesn't exist [8]. They are operating entirely without a scientific warrant. The whole thing is bullshit [9], which brings us to last week's post on the Two Sides of Critical Psychiatry.

If we go back to the ghastly experiment called "psychosurgery" in the 1940s and 50s, we can investigate it from two points of view. The first is to look at all the patients who have had their brains cut, asking whether they actually had the correct diagnosis, whether the operation was standard, any complications, and how they've done compared with their former selves and with a control group with the same symptoms but no operation. That's the post hoc approach, commendable and gets lots of support from academics who like that sort of thing. Then there is the curmudgeon's approach (mine) which is to ask: "Do you people actually know what you're doing? Where is your model that says mental disorder is rightly managed by cutting lumps out of people's brains? I want to see your theory of mind and I want the exact references to your model of mental disorder." And, of course, they didn't have it. It didn't exist. The whole thing was murderous delusion and money-grubbing bullshit from beginning to end (see Andrew Scull's account in Desperate Remedies, or Anne Harrington's Mind Fixers).

And here we are again: there is no such thing as a biomedical model of mental disorder. It is an established fact that no psychiatrist, or psychologist, or neuroscientist, or philosopher, or prophet, has ever written anything that would count as a reductionist, biological model of mental disorder [8]. Nor will there ever be [10]. Insofar as the committee was told there is such a model, then the committee has been led up the garden path. If they weren't specifically told, they just took it for granted, then they should take lessons on critical thinking.

We can't predict the future direction of mental health policy but one thing is certain: institutional psychiatry will fight bitterly to preserve its privileges. While the APPG argues for major, even revolutionary, change, there will be no change as long as the psychiatric profession can get away with the pretence that it has an articulated, scientific model of mental disorder as a biological disturbance of brain function that justifies its unparalleled powers.

The good news is that the tide is actually turning. The report exists, now it's up to us to do something for "the citizens who have no say in what is being done to them." If we don't speak up, nothing will change. And the angrier mainstream psychiatry gets, the more they screech "Anti-psychiatry," the better. Remember: Every accusation is a confession.

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References:

1. UN Human Rights Council (2017, 2019) Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.

(2017) UNHRC Document A/HRC/35/21 , available at:

http://ap.ohchr.org/documents/dpage_e.aspx?si=A/HRC/35/21

2. (2019) UNHRC Document A/HRC/41/34 , at:

https://documents-dds-ny.un.org/doc/UNDOC/GEN/G19/105/97/PDF/G1910597.pdf?OpenElement.

3. UNHRC/WHO (2023): Mental health, human rights and legislation: guidance and practice. Geneva: WHO/UNHCR. https://www.who.int/publications/i/item/9789240080737

4. Dharmawardene V and Menkes DB (2018) Responding to the UN Special Rapporteur’s anti-psychiatry bias. Australian and New Zealand Journal of Psychiatry. 53, 4: pp. 282-283. https://doi.org/10.1177/0004867418818359

5. Menkes, D, Dharmawardene, V, (2019). Anti-psychiatry in 2019, and why it matters. Australian and New Zealand Journal of Psychiatry 53: 921-922. https://doi.org/10.1177/0004867419868791

6. Whitaker R, Cosgrove L (2015). Psychiatry Under the Influence: Institutional Corruption, Social Injury, and Prescriptions for Reform. New York: Palgrave MacMillan.

7. Morone JG, Woodhouse EJ (1989) The Demise of Nuclear Energy: lessons for democratic control of technology. Yale University Press: New Haven.

8. McLaren N (2013). Psychiatry as Ideology. Ethical Human Psychology and Psychiatry 15: 7-18..

9. McLaren N (2016). Psychiatry as Bullshit. Ethical Human Psychology and Psychiatry 18: 48-57.

10. McLaren N (2021): Natural Dualism and Mental Disorder: The biocognitive model for psychiatry. London, Routledge.

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