Carry on Criticising

These posts examine modern psychiatry from a critical point of view. Unfortunately, mainstream psychiatrists usually react badly to any sort of critical analysis of their activities, labelling critics as “anti-psychiatry,” whatever that is. Regardless, criticism is an integral part of any scientific field and psychiatry is no different. As it emerges, there is a lot to be critical about.

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I mentioned last week I had submitted a brief paper to the local journal on their little course of critical thinking, pointing out that it showed psychiatry is formally a pseudoscience. I expected it to be rejected, and it was, without being sent out for review, on the basis that it was “unsuitable” for their journal. One wonders just what would constitute “suitable”? Oscar Wilde knew: “An idea that is not dangerous is unworthy of being called an idea at all.”

Years ago, aged 34, a senior psychiatrist and head of department at a Veterans’ Affairs hospital, I decided to go back to university to study philosophy. Because of some work I’d published, I was pushed through to second year, including philosophy of language. The pre-reading for this course was a Penguin text simply called Logic – an introduction, by Wilfrd Hodges. “Right,” I decided, “I’ll knock this off in a couple of nights.” It all made sense, seemed pretty straightforward so I went to my first classes – with a group of rowdy 18yr old students. After the first week, I said to somebody: “I can’t do this, I’m going to have to pull out. Those kids can think better than I can.” For the next three months, we studied that book, almost page by page, learning the hard way that we normally call thinking bears only a passing relationship to thinking logically.

The problem is that medical school education is not about thinking. It’s about memorising vast loads of material, about being very organised and punctual, and keeping your mouth shut. Actual critical thinking is not quite stamped on but the message comes through loud and clear: “I’m the professor, you’re nobody, so just do as I say.” There’s a case for this in that medical education is about safety, but there are limits, and they don’t know them. Whether that’s changed now I don’t know but I don’t see any encouraging signs. What I do know is that you don’t learn critical thinking from a quick online course. Critical thinking is first of all an attitude, a disposition to question, which is later honed by having the right analytic tools. One such simple tool is recognising when a person is using a word in two different ways in the same sentence, or using two different sentences which only say the same thing. That’s very important, politicians do it all the time, some deliberately and the rest because they’re too stupid to recognise how stupid they are. The remedy is to teach logic in school. It should be a required subject in Year 10, and an obligatory unit for every university course. That’s not likely to happen in a hurry, far too threatening to the political class, including the political class in universities.

But back to the critical thinking course. Units 2 and 4 arrived this week although it isn’t clear why they came in that order. No. 2 starts with different forms of reasoning including the classic modus ponens and modus tollens (I never remember which is which), and a brief section on the difference between description and explanation. That was interesting as I often complain that vast parts of psychiatry are nothing but description masquerading as an explanation, but they skipped over it without any real examples. Another of my pet annoyances got a mention, begging the question. Almost invariably, people misuse this. They will say something like: “That begs the question as to why he was there in the first place.” That’s wrong, they mean “raises the question.” Begging the question means “assuming the truth of that which requires proof.” The Romans named it petitio principii, which shows how long it’s been known – and overlooked. This is commonly used by racists: “Coloured people don’t need education because they’re dumb, and we know they’re dumb because they can’t be educated.” Granted it’s usually buried in high-sounding talk but that’s the message they want you to get.

Item 10 in unit 2 sets a high standard: “Support a culture of respectful questioning: Foster an environment where learners and team members can explore alternative explanations without fear of disrespect.” However, item 9 had just said: “Use a biopsychosocial formulation that integrates biological vulnerability, psychological processes, and social context. Avoid reducing care to a single explanatory model.” Can we assume then that pointing out that their “biopsychosocial” model doesn’t exist wasn’t quite what they had in mind, that people who say this deserve all the disrespect they get? That’s what comes across when articles are rejected as “unsuitable” with no reasons given. Not to worry, it would be scary if they suddenly changed their spots. And so we come to the last unit in the course, No. 4, which starts with an uplifting plea: “In psychiatry, this journey begins with a willingness to challenge our own ‘blueprint.’ We must ask, with intellectual humility: What do we consider to be our ‘facts’?” I couldn’t agree more. Question everything, challenge every expert, demand that the professor come down from his throne and prove his point, word by word. They give an example:

The biopsychosocial mode: George Engel’s (1977) call for a ‘new medical model’ was a profoundly humanistic plea to recognise the person beyond their biology. Yet the question remains: have we genuinely integrated this vision into practice, or do we merely invoke it rhetorically while defaulting to the comfort of biological reductionism?

That’s very good: has psychiatry moved from being philosophically reductionist to a humane and rights-centred discipline? Or is that just words? “Critical thinking and ethics form the foundation of medical practice, guiding clinicians to respect patient rights, promote well‑being, and uphold professional integrity.” They quote at length from a study from the US examining whether incarceration and involuntary treatment are justified by their results. The answer?

… hospitalization nearly doubles both the probability of dying by suicide or overdose and also nearly doubles the probability of being charged with a violent crime in the three months after evaluation … Our results suggest that, on the margin, the system we study is not achieving the intended effects of the policy [1].

As we could have told them. Then there’s the results of the Italian Experiment, their famous Basaglia Law from 1978, which mandated the closure of most mental hospitals, severe restrictions on ECT and restraint, and the development of community-based services. Everybody predicted disaster, where everybody means psychiatrists. And, of course, it didn’t happen. The rate of detention of the mentally-troubled plummeted, down to about 2% of the American level, and Italy has one of the lowest rates of homicide in the world. It was all based on a shift in emphasis, from protecting society against the ravages of the insane, to providing rapid, local (and cheaper) services to those in need. Psychiatry’s hostility came from its basic position on mental disorder: “They’re crazy, it’s genetic, it’s their biology, you can’t cure madness by talking nice to them.” OK, there’s possibly an element of truth in that but one thing is beyond doubt: you can easily make mental disorder worse by treating them like wild animals.

The rest of this little course wanders off topic to talk about forensic psychiatry and ethics, both important issues but they naturally come after the psychiatrist is trained to think critically, not before:

Fostering critical thinking in psychiatry requires a continuous and structured approach in which practitioners consistently interrogate underlying assumptions, rigorously evaluate the evidence base for diagnoses and treatments, and remain attentive to inherent biases and systemic influences … (We must) Question the very assumptions our profession is built upon, including the ‘modernist project’ of psychiatry itself.

Wow. I like that, although it would help if psychiatrists knew what modernism means and how that relates to the positivist influence in science itself. Modernism is the notion that we can understand the universe and ourselves by applying our innate capacity for rational thinking, freeing ourselves of past prejudice and destructive traditions in order to built a rational, progressive society. Entirely noble when it’s put that way but modernist architecture means using steel, concrete and glass to build coldly angular, functional structures stripped of all colour, ornament and frippery – brutalism, in other words. Is that what they want, a brutalist psychiatry? Actually, they’ve already got it, just ask the victims, I mean the happy consumers (see Chris Harrop’s excellent article on long-term side effects of ECT in this week’s Mad in America).

The course continues with a section on mental health review tribunals. Their job, we are told, is to protect the patient’s rights and so on but everybody knows that all they do is rubber stamp whatever the hospital wanted. Tribunals operate outside the public view, the overt reason being to protect patient privacy but they also use that to keep everything secret. They are extremely expensive to run (in Queensland, well in excess of $20million a year), they terrify patients and they don’t change anything. The money would be far better spent on proper public housing, especially as the New York study [1] found that homelessness had a lot to do with how people coped or didn’t cope after involuntary treatment (in fact, the cost of the institution of review tribunals is much higher, as it doesn’t count the cost of staff time cutting and pasting their reports or sitting silently bored in the hearings).

Finally, they come to the end. We read that the desirable virtues of psychiatrists (actually, that’s a tautology, all virtues are desirable), their virtues are:

Compassion, Humility, Fidelity, Trustworthiness, Respect for confidentiality, Veracity, Prudence, Warmth, Sensitivity, and Perseverance.

A humble, warm and sensitive professor? That’ll shock the poor old things, we can expect a bit of pushback over that one. And the private psychiatrists charging $3000 for an hour or so to give somebody a diagnosis of ADHD, prudent and trustworthy? Come on, they’re not going to take that lying down, think of their new Lambo and the jools for their paramours. Virtues are nice but the whole goal of positivism, which has shaped psychiatry this past hundred years, was to get rid of that sort of sentimental folderol. Don’t worry, critical thinking rides to the rescue:

Through rigorous critical thinking, the trainee must learn to navigate the complex, often contradictory, interplay of ethics and jurisprudence with both integrity and fortitude. This process involves not only mastering the biomedical model…

That settles it. Everybody can go back to sleep, there’s not going to be a revolution. No hearts on sleeves, no hugs or tears of sympathy when hearing of ghastly childhoods and all that soppy stuff, it’s all window dressing from beginning to end. How do we know this? Because of that last sentence: “Mastering the biomedical model.” That’s the same model that doesn’t exist because nobody has ever written it and nobody ever can [2]. If they were genuinely thinking critically, that wouldn’t be there. So when they say “… with a willingness to challenge our own ‘blueprint.’ We (psychiatrists) must ask, with intellectual humility: What do we consider to be our ‘facts’?” they don’t mean “challenge the blueprint we hand you, question our facts.” They mean:

Just keep on doing what you’ve always done and believe what you’re told to believe. Hang this little certificate on your wall, keep making money and paying your fees and we’ll look after the public side of things by telling all those nasty antipsychiatry people that we practice rigorous critical thinking with integrity and fortitude so there.

I had an example of that earlier this year when a professor at a prestigious university got his nose out of joint after I said his treasured “biomedical model” doesn’t exist.

It’s ridiculous to say there is no biomedical model. You may think they are wrong, but there are many biomedical models of psychiatric phenomena … anyone who has heard a theory that argues depression is caused by a chemical imbalance can say with certainty at least one biomedical model of mental disorder exists. It may not be true, but it exists.

OK, mea culpa maxima, but that’s how psychiatrists “think.” I should have said “no valid biomedical model” because by his, er, reasoning, possession states and magic spells are models of mental disorder. What he needed was a critical frame of mind equipped with the logical tools to cut through the mountains of bullshit in psychiatry. The eminent astrophysicist, Carl Sagan (1934-1996) put it precisely:

It seems to me what is called for is an exquisite balance between two conflicting needs: the most sceptical scrutiny of all the hypotheses that are served up to us and, at the same time, a great openness to new ideas. If you are only sceptical, then no new ideas make it through to you. You never learn anything new. You become a crotchety old person convinced that nonsense is ruling the world (there is, of course, much data to support you). On the other hand, if you are open to the point of gullibility and have not an ounce of sceptical sense in you, then you cannot distinguish useful ideas from worthless ones. If all ideas have equal validity, then you are lost; because then it seems to me, no ideas have any validity at all [3].

The various colleges of psychiatry can have their little CPD courses and award each other lots of brownie points for diligence, but if this course on critical thinking is what’s on offer, we can be sure of one thing: nothing will change.

References:

1. Emanuel N, Welle P, Bolotnyy V (2025). A Danger to Self and Others: Health and Criminal Consequences of Involuntary Hospitalization. Federal Reserve Bank of New York Staff Reports, no. 1158. https://doi.org/10.59576/sr.1158

2. McLaren N (2024). Theories in Psychiatry: building a post-positivist psychiatry. Ann Arbor, MI: Future Psychiatry Press. Amazon.

3. Sagan C (1987). The Burden of Skepticism. Skeptical Inquirer, 12 (1)

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My critical works are best approached in this order:

The case against mainstream psychiatry:

McLaren N (2024). Theories in Psychiatry: building a post-positivist psychiatry. Ann Arbor, MI: Future Psychiatry Press. Amazon (this also covers a range of modern philosophers, showing that their work cannot be extended to account for mental disorder).

Development and justification of the biocognitive model:

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

Clinical application of the biocognitive model:

McLaren N (2018). Anxiety: The Inside Story. Ann Arbor, MI: Future Psychiatry Press. At Amazon.

Testing the biocognitive model in an unrelated field:

McLaren N (2023): Narcisso-Fascism: The psychopathology of right wing extremism. Ann Arbor, MI: Future Psychiatry Press. At Amazon.

The whole of this work is copyright but may be copied or retransmitted provided the author is acknowledged.