Criticising Critical Thinking.

An endless task.

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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The Hungarian obstetrician, Ignaz Semmelweiss (1818-1865), died of gangrene in a mental hospital, two weeks after he was bashed by the warders. He was born in Budapest to an upper middle class family, and studied medicine in Vienna, then one of the preeminent centres in the world. In 1846, he was appointed to the First Obstetrical Clinic at Vienna General Hospital, which was run by physicians. The Second Clinic was run by midwives but he soon noticed that the death rate for women delivering in the medical clinic was 4-5 times higher than in the nurses’ wards. This was widely known in the city and women often delayed going to hospital so they could deliver at home or even in the street; at the hospital, women pleaded not to be admitted to the medical clinic.

Most of the deaths were due to puerperal fever, which means any infection of the genital tract post-delivery. Women who delivered at home or in the street had a low rate of infection, while the nurses figures were only slightly worse. Semmelweiss concluded that the problem was the doctors themselves. They conducted autopsies on their deceased patients then went straight back to the wards and examined their patients, simply wiping the blood from their hands on the way. He felt that the bits of gore and putrescent material under their fingernails carried some sort of contagion from the corpses and converted the living patients into corpses, so he instructed his staff to wash their hands in an antiseptic solution. Immediately, the death rate on his ward plummeted to about the same as the nurses, who didn’t conduct autopsies.

He began to publicise his results but soon ran into virulent opposition from the other medical staff in the city, who objected violently to the idea that they were killing their patients. They scoffed at his notion of physical contagion. For them, disease was caused by miasma, breathing bad gases, such as from swamps (mal aria, as it is now known) or from any rotting material, such as corpses. They could not understand how such a tiny amount of crud as could be found under a fingernail could kill a whole, healthy person. Given their model of illness, Semmelweiss’ claim made no sense at all, if it wasn’t frankly absurd. However, they didn’t know about germs or the concept of exponential growth of populations, of how, given the right conditions and doubling every few minutes, one tiny germ could soon cause massive infection and kill the new mother.

Semmelweiss fought the medical establishment for years but eventually started drinking and became increasingly erratic. Finally, he was lured into an asylum and forcibly detained, dying two weeks later of septicaemia, the very disease he had devoted his life to studying. The point is that, regardless of their motivation for good or for ill, the obstetricians of the day were able to see only what they had been trained to see. I’ve probably quoted Lord Lister (1827-1912), who formalised the practice of antisepsis, who said:

I remember at an early period of my own life showing to a man of high reputation as a teacher some matters which I happened to have observed. And I was very much struck and grieved to find that, while all the facts lay equally clear before him, only those that squared with his previous theories seemed to affect his organs of vision.

We see the world through the lenses we’ve been trained to wear. The model we adopt tells us what to see, it sorts the world into sense and nonsense for us. For most of human history, the primary lens was magic, the model that says there are spirits abroad who interfere in daily life through malice, mischief or (rarely) benevolence. People who believe in the supernatural see evidence of it wherever they go. Likewise, people who believe in conspiracies as the prime motivation of the world are unassailable as, without any effort, they can find vast tracts of evidence to reinforce their opinions. This is also true of psychiatry: psychiatrists see what they have been trained to see, which quickly becomes a case of seeing what they want to see. With no effort, they can find evidence to confirm their beliefs and are blind to anything that contradicts them.

That’s fairly human, politicians are worse, of course, but we’d like our shrinks to be functioning a few grades above the average pollie. So the idea that psychiatrists need a training course in something called “critical thinking” must have come as a bit of a shock to them because they’ve never believed they needed it. Far from it, the great majority of them sincerely believe they can’t be wrong, that they and they alone know all we need to know about mental disorder, that nobody else knows anything and anybody who argues is mental themselves, or malicious. We talked about the first session last week, how its definition of critical thinking actually has no meaning:

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.

Given that definition, ask anybody whether they are critical thinkers and they’ll say of course they are, same as everybody believes they’re a good driver. Anyway, after the first session comes the third, which has a bit more meat. A large part relies on the work of cognitive psychologists Daniel Kahneman and his colleague, Amos Tversky, who explored innate biases in human cognition. At the time, their work was pretty shocking as people higher up the ladder were firmly convinced they couldn’t be biased. Fortunately, this session covers twenty of the most common biases, applying them to little clinical examples to show how things can go wrong in predictable ways.

The broader theory in which their work is seated was covered by philosopher of science, Thomas Kuhn (1922-1996), who argued that what we understand of the world is determined by our perception of the universe as a whole [1]. Everything is processed through a paradigm, which dictates what we see and, crucially, what we dismiss as irrelevant. In Semmelweiss’ day, the understanding was that disease is airborne; the idea of infectious material under their fingernails simply didn’t register, whereas to us, it’s second nature. This radical concept, of theory-laden observation, is introduced to psychiatrists thus:

Theory-dependence of observation means that what we notice and how we interpret what we see is influenced or shaped by the theories, beliefs, or frameworks we already hold … In psychiatry, the lens through which clinicians view patients is shaped by their training.

Yes, they have to be told. They then give examples of what the “orientation lens” emphasises and what it misses for three schools of thought. The psychodynamic model highlights transference and unconscious conflict but is likely to miss neurological signs such as catatonia and drug side-effects. The biological school sees medication, receptor profiles and neurochemical imbalances but ignores psychological factors (e.g., trauma, social influences). CBT is strong on automatic thoughts and behaviours or cognitive distortions but doesn’t give credit to social issues such as poverty, racism and power dynamics.

Without wishing to get into a brawl (e.g. even the most devout Freudian can recognise catatonia, and they don’t use drugs anyway), these systematic failings come about because of cognitive biases, and can be corrected by various means. There are various examples of how biases creep into daily practice and how they can be corrected. Two important correctives include using structured interview techniques to reach an unbiased diagnosis or using standardised questionnaires to assess risk, and relying on “heterogenous teams” (multidisciplinary) to cover all bases. They give figures to show that diagnoses reached by such teams are more accurate, and risks better assessed by standard techniques.

All well and good but what they didn’t say about Thomas Kuhn was the work for which he is best known, his account of how science progresses. BK (before Kuhn), it was thought that science progresses in a straight line by the steady accumulation of knowledge, leading from the dark halls of ignorance directly to our enlightened state today. Not so, he said, it’s not so rational. Science is punctuated by revolutions. To begin with, we see what the paradigm teaches us to see and we work to support that vision of the world. With time, however, all sorts of contradictions and anomalies build up that the paradigm can’t answer until one day, a new person comes along who shows that it’s all wrong and we need to dump that paradigm and move to a new and better one. Kuhn used the Copernican revolution as his exemplar, when people moved from seeing our planet as the centre of the universe, to the heliocentric model, with the sun at the centre. Inevitably, he said, the new view is opposed bitterly by the scientific establishment, which is exactly what happened to Semmelweiss: they didn’t like him saying “Your dirty hands are killing your patients,” so they killed him.

Kuhn took it further, though. In the early stages of any science, there will be competing paradigms, each of which seems to give a fairly good account of some observations but none of which gives the full picture. Eventually, the contradictions build up, a new paradigm comes along and sweeps them all away. Then, of course, everybody remembers that they didn’t like the old ones but that’s not his point. In any field that wants to be seen as scientific, if there are competing models, all of which seem to answer some questions, but never the same questions and not all the questions, then that field is prescientific. If may be a protoscience, i.e. with development, it could become a science itself, or it may even be pseudoscience, as the miasma model of disease turned out to be. Whatever, competing models says it isn’t science. Does that apply to psychiatry? Most emphatically. Presumably without knowing it, the people who wrote this little training course have offered themselves as a textbook example of Kuhnian non-science. If he could see it, Thomas Kuhn would probably sit up in his grave and applaud: with three competing and, I have argued [2], incompatible schools of thought, all of which can explain some things which the others can’t, and none of which can give an over-arching view, psychiatry just is a case of protoscience.

However, it gets worse. The authors propose that, armed with something called the biopsychosocial model, psychiatrists can integrate the different observations mentioned above and come up with the correct approach. Trouble is, their so-called biopsychosocial model doesn’t exist [3]. It’s a phantom, a bit of smoke and mirrors that makes them feel superior but that’s all. By invoking this non-model, they meet one of Hansson’s definitions of pseudoscience, pseudo-theory promotion [4] but let’s not dwell on that. Instead, we can look at how they plan to rectify this tendency of psychiatrists to see what they want to see. First is their multidisciplinary teams, including a “cultural consultant,” because two heads are better than one. Even junior members of the team can have something valuable to contribute, and the outcomes of group decisions are known to be more accurate. That clearly implies psychiatrists routinely get it wrong, but it overlooks the fact that huge numbers of psychiatrists work alone in private practice with no supporting teams at all. Moreover, in their private hospitals they can do what they like with minimal supervision. Patients who complain don’t get very far, and the psychiatrists don’t complain about each other, that’s for sure (see the ghastly history of Sydney’s Chelmsford Hospital disaster for confirmation of these impolite views).

Second technique to reduce error is to rely on standardised questionnaires because they aren’t biased. What isn’t said is that if you take a proper history, you don’t need these dopey questionnaires. I mentioned last week that this “educational module” is presented in a format that might appeal to young teenagers, stuffed full of pictures of lovely smiling young people in meetings or tapping on laptops. Time and time again, the pictures show something that explains why psychiatrists need to rely on other people’s brains and on questionnaires: you cannot take a proper psychiatric history sitting in an armchair and ticking boxes on proformas on a clipboard. The reason they need all the extra staff and tick-a-box questionnaires is just because they don’t know how to take a history. The process of getting the history has to be completely standard for all patients: each person gets the same questions in the same order delivered with, as far as possible, the same tone of voice. And it has to cover everything. For schooling, these are the minimum questions:

Where did you go to school; how old were you when you left; what final grade did you pass; how many schools in all; what were your marks like; what were your main interests; how did you get on with the teachers; and with the other kids; did you play sport; what was your home life like; what were your hobbies?

That’s the bare minimum as each answer can lead to further questions. If it’s done this way, there is none of the usual nonsense of people being biased by the patient’s clothes or manner or previous history or the psychiatrist’s grumps and dislikes and prejudices and all that. The diagnosis announces itself, and treatment flows directly from that. If this is done properly, the rate of prescription of, say, antidepressants drops to about 3% of all cases; antipsychotics to about 5%, mood stabilisers approaches zero, ECT reaches zero [5] and so on. However, as Kuhn predicted and Semmelweiss experienced, mainstream psychiatrists react very angrily to those sorts of figures. Perhaps these days they don’t kill anybody who tries to broadcast them but they certainly try to have them locked in mental hospitals.

Anyway, today’s little exercise in critical thinking confirms what most of us already know: that psychiatrists are seriously biased at the personal level and by their training to the extent that they need correcting; that their “science of mental disorder” is actually pseudoscience; that the biggest problem is psychiatric groupthink, believing that they know everything and can’t be corrected; and that cosmetic changes aren’t going to fix any of this. As they conclude:

… rigid hierarchical structures can sometimes lead to authority bias—where junior clinicians hesitate to question senior decisions, even when concerns are valid. Encouraging respectful challenge, regardless of seniority, is essential … (psychiatry needs) a culture where questioning and clarification are welcomed rather than dismissed…

That’ll be the day.

References:

1. Kuhn TS (1962/1970). The Structure of Scientific Revolutions. 2^nd Edition, 1970. Chicago, Ill: University Press (International Encyclopedia of Unified Science, Vol. 2, No. 2).

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

3. McLaren N (2024), The Biopsychosocial Model: the Claytons model for psychiatry. Chap. 5 in [2].

4. Hansson SO (2025). Science and Pseudo-Science. Stanford Encyclopedia of Philosophy. At: https://plato.stanford.edu/entries/pseudo-science/

5. McLaren N (2017). Electroconvulsive Therapy: A Critical Perspective. Ethical Human Psychology and Psychiatry 19: 91-104. DOI: 10.1891/1559-4343.19.2.91

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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.