Critical Thinking in Psychiatry

It starts with a mirror

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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“Now the essence of the scientific spirit is criticism. It tells us that whenever a doctrine claims our assent, we should reply, Take it if you can compel it.” Thomas Huxley, 1893.

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Like most professional bodies, the RANZCP has a continuing education program intended to keep people up to date with recent developments. I mentioned a recent lecture on deprescribing by Prof. David Taylor and Dr Mark Horowitz, in London, how it could only happen in psychiatry that, 70 years after they were introduced, psychiatrists are still arguing over whether antidepressants are addictive (Substack 14.10.25). But we should be grateful for progress. Even ten years ago, their talk would never have been broadcast. So, with great fanfare, a new series of educational videos has just arrived which, on the face of it, indicates an even bigger shift in policy: critical thinking. This is correct. It seems our miniscule Critical Psychiatry Network, about 1% of college membership, has been rendered obsolete. That’s good. If mainstream psychiatry adopts our policy of questioning everything within reach, then we’ve achieved our goal and can sit back to watch psychiatry renovate itself. However, as this compelling article in this week’s Mad in America shows, total demolition and rebuild would be better.

There are four videos in all, prepared by a committee of a dozen people, but only two have been released so far, the first and third (no idea), with the other two coming in a month. The videos were obviously expensive to produce, and also infuriatingly childish in presentation. The whole format, with a myriad uplifting pictures of improbably neat, earnestly-smiling young people, irritates the guts out of me but we need to focus on the content. So let’s start, as I like to start, with their definition:

Critical thinking is the disciplined process of actively and skilfully conceptualising, analysing, evaluating, and synthesising information from observation, experience, reasoning, or communication to guide belief and action.

Note that this tells us what it does, but not how it does it. The next few boxes expand the description:

Critical thinking is …. Systematic: It follows a structured process rather than relying solely on instinct or precedent: it is … Reflective: It encourages self-awareness about how conclusions are formed: Analytical: It breaks down complex problems into components for better understanding; and Ethically grounded: It considers the moral implications of decisions.

Again, it all sounds terribly impressive so we move on. Psychiatry differs from other fields of medicine as it rests on a range of often conflicting models of mind, mental disorder and recovery: “These fundamental debates go beyond academic disagreement and directly shape how mental health conditions are understood, diagnosed, and treated.” Yes, that’s correct, our models do influence how and what we see: is this mental disorder or social reaction? Is it the brain or the mind? Is it illness or misinterpretation, etc? Difficult questions but psychiatrists are aware of them as psychiatry requires “Nuanced understanding of human behaviour; Tolerance for ambiguity; and An awareness of the limits of our knowledge.” These finer points are, it seems, honed by critical thinking.

Psychiatrists who are not equipped with critical thinking tend to fall into a number of standard errors. These include diagnostic oversimplification (as in shoving everybody into one of the little DSM boxes); what are called cognitive biases (more later); ethical blindness, for example, failing to see the injustice in coercive practices or how power imbalances affect the disempowered; and “cultural insensitivity,” failing to see how what we see as abnormal can be normal in other cultures. Of course, a lot of this stems from the deep-seated Western cultural hegemony, of believing that what we believe to be true is also true for everybody else. However, with critical thinking, all these faults and blind spots are rectified. With critical thinking…

… psychiatrists are better able to: Interpret complex clinical data in a balanced, evidence-informed way; Make thoughtful, person-centred decisions even in the absence of clear-cut answers; Recognise when institutional or systemic structures may be influencing judgment; Uphold ethical standards, especially in the face of moral ambiguity; and Embrace intellectual humility, acknowledging what we don’t know and being open to revision.

Obviously, this is transformative. What the committee has in mind is known as “basic process reengineering,” i.e. starting with a blank sheet and working out what the job must do, as distinct from starting with a mishmash of historical bits and pieces and building on top of them while trying to balance budget, local government, union, social, media and other pressures. The next section gives clues on how this is to be done, by naming five types of reasoning: deductive, inductive, abductive, dialogical and analogical. Unfortunately, they don’t use standard definitions and the examples are too vague to be of much assistance. Nonetheless, by using these tools, psychiatrists an acknowledge that mental health problems are “… multifaceted, with no single, definitive explanation … mental health conditions cannot be reduced to just one aspect, such as biological dysfunctions.” By this means, psychiatrists are able to “Integrate biological, psychological, and social contributors to mental distress” (for examples of misdirected reductionist thinking, see the MIA article linked above).

So far, so revelatory. All this leads to clinical decisions that are “not only effective but compassionate and ethical,” a lesson that is reinforced by a brief glance at the good, the bad and the ugly in psychiatry’s history. A large part of this was three lectures but everybody would be much better off reading the history books [e.g. 1, 2]. Psychiatry got some things right, e.g. discarding the firmly-held belief that homosexuality was a mental illness in its own right. This was a combined effort of activists and of critical thinking in psychiatry, as a result of which psychiatrists are now equipped to view the scene with “cultural humility and sensitivity.” The shift from institutions to community care is discussed, including (remarkably) a tribute to Ronald Laing, former enfant terrible of the antipsychiatry movement. However, some bad hangovers from the past include the rigid system of classification introduced by Emil Kraepelin in the 19^th Century and the restrictive concept of mental disorder and capacity from the famed M’Naghten case in 1843. Closer to home, we have the terrible examples of Soviet psychiatry’s abuse of dissidents, and psychiatry’s key role in Nazi eugenics, by murdering and sterilising hundreds of thousands of people with mental trouble, which led to the mass murder of racial groups, including Jews, Romany and Slavs.

We press on, via the notion of a future psychiatry which is caring, humble, compassionate and considerate of alternative points of view. In particular, indigenous populations require a unique approach, which more or less says that what works in the West doesn’t work elsewhere. It has to be remembered that there are subcultures within the mainstream population, e.g. teenagers, who don’t always fit the standard model. Essential elements to a new psychiatry include cultural humility and safety; ethical reasoning; systems thinking as distinct from the idea of linear causation; self-reflection (called ‘metacognition’) and how to respond to the inherent uncertainty in dealing with mental matters without lapsing into “authoritarian certainty.” This lecture then ends with some examples of enlightened thinking in psychiatry, such as how, in the 1970s, insulin coma treatment, developed in the 1930s, was shown to be ineffective and was discarded. The “antipsychiatry” movement from the 1960s and 70s helped the move against coercive treatment in institutions. Psychiatry’s move from rigid diagnostic categories of biological illness is seen in the biopsychosocial model which, of course, contributes to the new ethos of scientific and cultural humility. The third session is more of the same but with a talk by the execrable Steven Pinker on the wonders of Bayesian probability, although this short video is far better. We’ll cover it another day.

Well, I’m sure everybody feels so much better knowing that psychiatry is about to leap from what are suddenly acknowledged as the dark ages, so brutally described in MIA, to a new era of humility and sensitivity etc. There’s a few problems, however, starting with the very obvious point that the whole thing is a castle built on no foundation. What, exactly, is “critical thinking”? Well, we don’t know. We know what it’s supposed to do, change repressive old churls into kindly guides, but we don’t know how. What do people get or learn or perhaps take, that changes their approach from shoving people into pigeonholes and spraying them with drugs, to listening carefully to the patient’s complaints and arriving at an agreed path? We don’t know, there’s no mention of the actual process.

There is one method of course, it’s been around for a few years, actually a few thousand years, but psychiatrists don’t study it. Instead, they are brought up with the notion that, as good scientists, they are objective and unswayed by sentiment or emotion, and therefore can’t be wrong. This is part of the legacy of the positivist movement but, of course, they’ve got it wrong. It’s good to avoid bias and misplaced sentiment but, since we’re all humans, you need tools to do it. The best available are the techniques collectively known as logic, the study of valid inference, which goes back a long way. So you can’t just say, as these lectures appear to say, that since we’ve now got Critical Thinking, we’re free of faults so you can’t argue with us. We all like to think we’re sharp thinkers but the first thing you learn in a logic course is that you don’t know how to think.

That’s pretty shocking but it shouldn’t be: we all have to learn how to drive a car, how to look after a baby, play a piano or take out an appendix, and disciplined thinking is no different. It’s something you learn, a skill to be mastered as part of the educational process, and it starts with a long look in a mirror: “What do I actually believe? What mistakes am I making in reaching this conclusion?” It’s not comfortable but it’s essential, especially for people who have influence over other people’s lives, such as psychiatrists – and politicians and teachers and lots of others. We can confidently conclude that if anybody in the dozen people involved in writing this little spiel has actually studied logic and therefore may qualify as a “critical thinker,” they didn’t have much say in the final product. A couple of examples will show this.

First, get your facts right. Insulin coma treatment for schizophrenia was shown to be both expensive and useless in 1953, by Harold Bourne, then a junior MO in a London teaching hospital [3], not in the 1970s. His was an early example of how objective statistics are more value than “clinical experience” but it didn’t do him any good. Many of the big names in British psychiatry had built their careers on insulin treatment and were enraged by his revelation, so they blacklisted him and he had to go to New Zealand to get work. It wasn’t that the institution of psychiatry looked at itself and decided to update its methods, it fought all the way until a new generation took over (see Max Planck: “A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it” 1936). Similarly, the fact that the debate over whether being gay is a mental illness or not was bitter says it all. Psychiatry had to be dragged kicking and screaming to the party [4]. The same is true of those pushing the “antipsychiatry” movement 50 or more years ago; at the time, they were vilified. As somebody who was interested in it and read a fair bit of their work, I was told in the clearest of terms that if I wanted a future in psychiatry, I’d better find something else to read. What we see in these examples is the very antithesis of critical thinking, an Orwellian process of rewriting history to give a narrative favouring the people holding all the power.

History’s important. Every person involved in mental health, and lots more, should read the two books mentioned earlier [1,2] because they show that there was a lot more to the Nazi euthanasia program than is described in this lecture. In the first place, eugenics was the default position of the educated, the privileged and the wealthy. They disliked the working classes and foreigners intensely, especially after the Bolsheviks took power in the USSR. The models for the Nuremberg race laws came from Kentucky and Tennessee; they established the principle of sterilising unworthy humans (mental patients, drug and alcohol addicts, recidivist criminals, prostitutes etc) which the Germans then codified and put into large-scale practice. Some of the most important figures in British psychiatry were heavily influenced by eugenics and German “race science.” The founder of the Institute of Psychiatry at London’s Maudsley Hospital, now part of KCL, was an Australian, Prof. Aubrey Lewis, from Adelaide. In 1934, he contributed a chapter on the inheritance of mental disorders to an influential book published by the British Eugenics Society [5]. Similarly, the former editor of the British Journal of Psychiatry, Eliot Slater, studied population genetics and epidemiology in Germany under Ernst Rüdin, the architect of the T4 program which morphed into the Final Solution of the Holocaust. There’s a lot more to this but it says that modern psychiatry’s entire program to find a genetic basis for mental disorder started in the very offices which led to Auschwitz. How come the people who are talking about critical thinking haven’t taken this sort of thing into account?

They also mentioned how, late in its career, the USSR started putting dissidents in mental hospitals with a diagnosis of “sluggish schizophrenia” and giving them antipsychotic drugs such as fluphenazine as a form of punishment. However, they stopped when attention was drawn to it but it’s worth noting that if the drug tortured dissidents, it probably also tortures patients. Meantime, in the US, the incorrigible Dr Robert Heath was experimenting with brain implants to “cure” homosexuality. Talk of brain stimulation in psychiatry never goes away. All that it needs is a theory of mind and a model of mental disorder to convert it into a science, which the critical thinkers seem to have overelooked.

Talking of models, there are several mentions in the lecture of the biopsychosocial model, how this allows the humble and sensitive psychiatrist to integrate biological facts, psychological factors and social input into a holistic model of mental disorder and to then join with the patient, the relatives and other MHS staff to devise a plan of recovery. The reference for this model is a paper from 1977, by the late George Engel, a gastroenterologist from Syracuse, NY [6]. The same model is used as the basis of psychiatric training and practice in Australia and New Zealand, and is influential in the UK and other countries. For example, Position Statement No. 80 of the RANZCP, currently in force, states:

Medical expertise: Psychiatrists apply their medical knowledge, specialist clinical skills and acumen in the provision of person-centred care. They understand the impact of ‘biological’, ‘psychological’ and ‘social’ factors on mental health and the causation of mental illness. This ‘bio-psycho-social’ model is a holistic approach that recognises the impact of social adversity and physical health on mental well-being [7].

In a letter, the president of RANZCP stated: “... the BPS model (is) ...the predominant theoretical framework underpinning contemporary psychiatry ... a relevant and useful component of training and practice ...” (Moore, E. correspondence, Nov. 20th 2023). She did not respond to repeated requests to provide specific details of this model and related material from the training course. Following a further request for this material earlier this year, the current president of RANZCP stated she had nothing to add to her predecessor’s position on the matter, i.e. nothing to add to nothing.

Because the new “critical thinkers” taking over the profession are so sensitive to psychosocial factors, they are totally reliant on an integrative model of body and mind, and are pleased to be able to point to Engel’s 1977 paper as justification. Trouble is, as everybody on that committee and in the RANZCP HQ knows perfectly well, Engel never wrote it. It does not exist [8,9]. So it would seem their critical thinking doesn’t quite extend to criticising their own position but that’s to be expected.

So far, so discouraging. I have no idea how they expect the membership to leap from being hidebound positivist fossils to enlightened, humble, culturally sensitive, tender-hearted, forgiving and generally aware human beings without something to convince them they need to change, and some techniques for doing so. We can be sure that regardless of what the patients think (see above), no psychiatrists believe they are brutally repressive and dismissive martinets. They’re not going to change voluntarily, they’re not going to throw open the doors of their locked wards, as required by the CRPD, nor give up their ECT machines or throw out their lucrative hallucinogenic drugs. Instead, they’ll do their little course and simply add it to their CVs and nothing will change. Its real purpose is to stop people criticising them, as in: “You can’t say that about us, we’re certified Critical Thinkers.”

We are guided by Huxley, one of the truly great scientists. Critical thinking starts with the attitude that says “Nothing is true until it’s proven true.” However, that attitude has to be brought under control, a process known as education. Without certain analytic techniques from logic and cognitive psychology, it’s just a pain in the neck for everybody else. You believe mental disorder is just a special case of brain disorder? OK, prove it. Well, they haven’t and, more to the point, they can’t [10, Chap. 2]. Biological psychiatry is an ideology of mental disorder, not a science. Psychiatrists want to integrate biology, psychology and sociology in a seamless whole? OK, you need a theory of mind as an emergent phenomenon for that but there’s only one available and you don’t like it because it’s too critical [11]. And that’s the crucial point about critical thinking, it actually starts with a look in the mirror. It’s not a case of “What are they doing wrong?” because that’s easy; it starts with “What am I doing wrong?” which is a lot more difficult.

References:

1. Scull A (2022) Desperate Remedies: Psychiatry and the mysteries of mental illness. London: Penguin.

2. Harrington A (2020). Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness. New York: Norton.

3. Bourne, H. (1953). The insulin myth. Lancet. ii. (Nov 7 ) 265 (6798): 964–8.

4. Drescher J (2015). Out of DSM: Depathologizing Homosexuality. Behav. Sci. 5:565-575. doi:10.3390/bs5040565

5. Lewis AJ (1934). Chap IV in Blacker CP (1934). The Chances of Morbid Inheritance. London: HK Lewis/Eugenics Society.

6. Engel GL (1977). The need for a new medical model: a challenge for biomedicine. Science; 196:129-136.

7. RANZCP. Position Statement No. 80: The role of the psychiatrist in Australia and New Zealand. 2013. RANZCP Website. Accessed July 30^th 2024.

8. McLaren N (1998). A critical review of the biopsychosocial model. Austr NZ J Psychiat. 32; 86-92.

9. McLaren N (2023). The Biopsychosocial Model and Scientific Deception. Ethical Human Psychology and Psychiatry, 25: 106-118.doi:10.1891/EHPP-2023-0008

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

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

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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.