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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An article on the next DSM in this week’s Psychiatric Times asks what seems to be a startling question for psychiatrists: What makes us human? I’d say the general public would be surprised to hear that, they’d assume psychiatrists have a fairly good grip on the subject. We all know that surgeons have little interest in it (“The operation was a success but the patient died”), and psychologists are strong on “rats and stats,” but isn’t psychiatry about human feelings and all that stuff? No, not since 1980 and the release of DSM-III, emotion and values have been anathema. Psychiatry is about brain science; Thomas Insel, the former head of NIMH, even wanted psychiatrists to be seen as “clinical neuroscientists.” The ordinary technology of laboratory science, he confidently claimed, would tell us everything we need to know about mental disorder with no interesting questions unanswered: “… the biological model (of mental disorder) is sufficiently entrenched to ignore criticism and commit psychiatry to a new reductionist program ...” [1].
The three authors of this article are big names in American psychiatry – one was even president of the APA – so how come, nearly fifty years after DSM-III, they’ve just discovered there may be something to humans that scanners can’t show? Perhaps they’re taking their cue from Insel, who, after he left NIMH, said:
I spent 13yrs at NIMH really pushing on the neuroscience and genetics of mental disorders, and when I look back on that, I realise that while I think I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs - I think $20billion - I don’t think we moved the needle in reducing suicide, reducing hospitalisations, improving recovery for the tens of millions of people who have mental illness (the original article on Wired has been taken down).
It seems that after 40 years of neurobiology, Insel had given up on the search for “biomarkers” of mental disorder, i.e. blood tests, scans, DNA studies and so on. He went off to Silicon Valley to make his fortune in “digital phenotypes” (sic), leaving these authors to make the unexpected admission: “The era of ‘one neurotransmitter, one gene, one drug, one disorder’ has passed.” I’ll quote their article at some length as it’s imporant and some readers may not be able to access the original. They continue:
Psychiatric trajectories emerge from interactions among genes, brain circuits, development, lifestyle, trauma, social determinants, loneliness, climate change, technology, aging, brain health, and resilience. Our diagnostic system must begin to reflect that complexity.
This is more than a bit radical. It’s not that long since a Dr Paul Appelbaum, another former pres of APA, said: “Our brains are biological organs by their very nature. Any [mental] disorder is in its essence a biological process.” Samuel Guze (1923-2000), one of the main architects of the entire biological thrust in American psychiatry, said: “There is no such thing as a psychiatry that is too biological,” yet this article says the exact opposite of Guze’s brave claim:
Psychiatry occupies a unique position in medicine. We cannot confine ourselves to an organ or laboratory value. Psychiatry inevitably enters the territories of meaning, identity, suffering, relationships, morality, freedom, and consciousness.
Are they saying that studying the brain through a microscope will not tell us what we need to know about meaning, identity, suffering and so on? Amazing. The DSM system prioritised reliability over all other considerations: as long as two psychiatrists looking at the same patient could agree on the diagnosis, all the fluffy stuff like meaning and identity could be ignored. The way they managed this was by eliminating all matters that could not seen and objectively measured. As the article says: “The DSM historically prioritized reliability over philosophy ...” That’s exactly right, and there’s a reason for it, which they don’t appear to know. 45 years ago, when DSM-III was issued, there were plenty of people who said that the entire DSM system was indeed “too biological,” and issued dire warnings about the risks of dehumanising humans. Now, it seems, those warnings are coming to pass. Modern psychiatry has lost human contact with human suffering, as the authors admit:
But something was also lost. Diagnosis increasingly became a taxonomy of observable symptoms separated from the lived context of the person experiencing them ... Clinicians can complete required checklists while missing the narrative architecture of a human life.
To put it bluntly, psychiatry has been dumbed down to the point where it requires next to no intellectual effort and certainly no emotional involvement with suffering people. This, I suggest, is the real point of their complaint: they’re not so much concerned with a dehumanised psychiatry, because we’ve had that for decades, if not centuries. However, if psychiatry is reduced to merely ticking boxes on proformas, then AI can do that much quicker, much better and, crucially, very much cheaper than psychiatrists. Panic! (I like the line from Toy Story where the toys are lost. Buzz Lightyear says sternly “This is no time to panic,” but Woody replies: “Are you kidding? We’re lost, this is a great time to panic”). If a psychiatric diagnosis becomes “primarily pattern recognition from a checklist,” something AI programs are designed to do, then the institution of psychiatry is staring into the abyss: “What,” they ask nervously, “can a human psychiatrist offer that an algorithm cannot?” Excellent question, and clearly a wonderful time for psychiatrists to wake in panic from their biological torpor to pay attention to the really difficult questions they’ve long sneered at, such as what makes us human.
A good place to start would be asking how this came about in the first place. Blind Freddy can see that humans are concerned with “... meaning, identity, suffering, relationships, morality, freedom, and consciousness,” so why did educated people such as Guze and Insel make their outlandish claims that biology will tell us everything? There’s a history here, and we can be fairly sure neither they nor the illustrious authors of the Psych Times article know it. The first part goes back a hundred years to a proclamation by a group of mathematicians, physicists and logicians at the University of Vienna, known to history as the Vienna Circle [2]. Science, they said, is empirical, meaning it can only be based in observation and direct deductions from those observations. Science cannot allow itself to be contaminated by ideas that have no basis in firm fact. It must expel all metaphysical elements, where metaphysics means more or less “everything else.” If we can’t see it and measure it, it’s not the province of science. All that stuff about values and meaning and destiny can be left to priests and poets because it just goes in circles: for every opinion in metaphysics, there’s an opposite and equally unarguable opinion, just as convincing to somebody else as yours is to you (which is what the 23yo Descartes said, 400 years ago).
This was the birth of what is called positivist science, covering essentially all scientific activity since that day in 1929. It led to the mindlessness of behaviorist psychology, to a nuclear physics divorced from morality, to the brutality of neoliberal economics, and directly to the anti-mentalist revolution of biological psychiatry, marked by the publication of DSMl-III in 1980: out with the mind, in with biology. Part of the positivist influence related to how we think about the world, summarised in their quote “one neurotransmitter, one gene, one drug, one disorder.” That is, it dictated what is called linear thinking: Event A leads to Event B which combines with Fact C to produce outcome D. Excessive force to the arm causes a fracture; reducing and immobilising it leads to healing. Infection with a bacterium produces a disease; an antibiotic cures the disease; the patient is happy. The patient cries; the patient is depressed; prescribe an antidepressant and another grateful patient rolls off the production line. So simple, so clear, humans reduced to the level of molecules bumping in the dark. Trouble is, very little in biology, and next to nothing in human affairs, is so simple. Complex fields almost always show non-linear causation, where an outcome feeds back or forward to influence subsequent steps. After decades of biological reductionism, this is now unavoidable.
The second bit of important history arrived almost fifty years ago in the form of a paper published in the prestigious journal, Science [3]. George Engel, a physician of Rochester, NY, complained that medicine had become too biological. What he termed ‘biomedicine’ paid no attention to the humanity of patients, to what makes them tick as humans and not just as biological preparations lying inertly on the examination couch or the operating table, waiting for the semi-magical physicians to do their jobs. This process, he believed, had gone too far:
(Biomedicine) assumes disease to be fully accounted for by deviations from the norm of measurable biological (somatic) variables. It leaves no room within its framework for the social, psychological and behavioral dimensions of illness (p130).
Engel’s argument against biomedicine was long on passion but rather short on facts. He bemoaned the emphasis medicine, including psychiatry, placed on laboratory diagnostic procedures at the expense of taking a broad history of where the patient’s life had reached. There was nothing distinctively human about medical treatment, it worked equally well in veterinary practice. It’s important to note that in his brief historical account of biomedicine, he did not mention the Vienna Circle’s positivist revolution some 50 years before he was writing. This omission is so common as to be absolutely normal; very few psychologists or psychiatrists know why their disciplines have taken their modern, anti-mentalist form. Engel proposed that medicine needed to replace its “biomedical model” with a “biopsychosocial model” that could give account to psychological and social factors. He suggested that the principles behind Ludwig von Bertalanffy’s “general theory of systems” would be a good starting point for his proposed integrative model.
At first, his paper had very little impact but after a few years, psychiatrists discovered it, especially those who weren’t thrilled with the reductive biologism (and imperialism) of DSM-III when it arrived in 1980. Essentially, this meant “anywhere but America.” It was avidly adopted by psychiatrists in the UK, in Canada, Australia and New Zealand, although less so in Europe. In those countries, it was essentially taken as defining psychiatrists. There was only one problem with his “biopsychosocial model”: Engel never wrote it [4]. He specified a role for an integrative model of mind and body, he gave it a name, he suggested a possible basis for it but neither he nor any author since has offered any clue of what it actually says. After fifty years, it remains a model in name only, which brings us back to the paper on the new DSM and “What makes us human?” These authors propose that a mechanistic, reductionist psychiatry ignores critically important information in the patient’s lives but this can be taken into account in a broader definition of “biological”:
Nor should psychiatry perpetuate a false division between biology and meaning ... Human experience is biological precisely because humans are biological organisms continually interacting with their environments ... mental illness is neither only brain disease nor merely social construction. A more sophisticated formulation would integrate symptom phenomenology with neurobiology, development and neurodiversity, trauma, functional impairment, culture, relationships, social and environmental context, resilience, strengths, brain health, aging, and existential meaning ... psychiatry must distinguish psychopathology from normal suffering, existential crisis, socially produced distress, and adaptive emotional responses. A broader psychiatry should not become an excuse to medicalize the human condition.
Jolly good, totally agree with the sentiment but at the risk of being a party-pooper, Engel said exactly the same fifty years ago and nothing came of it. Damn you, history, why do you keep repeating yourself? Engel’s phantom “biopsychosocial model” was intended to fill the very same hole they identified, although they’ve gone a bit further by proposing that all psychological matters are in fact biological. Sadly for them, that’s also a dead-end; while we’ll give them an E for Effort, it’s still an F [5, Chap. 2]. So why was this article published? If I’d submitted it, it would have gone straight in the bin. Look at who wrote it and where it was published. Three Eminent Worthies, one of them a deputy editor at Psych Times, got together to pen what seems like outright lèse-majesté, challenging the underlying orthodoxy of DSM and, indeed, of all modern American psychiatry.
Human beings are meaning-making creatures embedded in relationships, cultures, histories, bodies, aspirations, and moral worlds. Suffering emerges not only from disturbed biology but also from fractured belonging, loss of purpose, humiliation, loneliness, trauma, and existential despair ... Lived experience is the needed context for the clinical decision making, not just “noise” in patient’s history.
To my cynical mind, that is a monumental admission of failure of the entire biological enterprise. It says that, oh so slowly, awareness is growing that all is not well in the halls of psychiatry, that the vast promise bestowed on biological psychiatry by highly paid luminaries such as Guze and Insel has proven to be empty. Now psychiatrists have to find a way to wriggle out of their self-made mess without losing too much face or income (and without facing a flood of lawsuits). Why was this article published? It’s what they call a feeler, a probe to see how people will react. If the reaction is bad, they’ll keep quiet but if it doesn’t provoke too much apoplexy, they’ll slowly press ahead, gently uncovering the wound they’ve caused without the patient squealing too much.
However, they’re a bit late. An integrative model of mind and body, which starts from first principles and generates models of personality, of mental disorder and of personality disorder, has already been published [6]. The biocognitive model for psychiatry does everything they need in order to supersede the dehumanising reductionism of biological psychiatry and its boring, mechanical and mostly wrong DSM system. Why then does history repeat? Because as their little essay shows, people don’t read history. They’re all so busy trying to divert attention from the mess they’ve made of psychiatry that they create another one.
References:
1. Insel TR, Cuthbert BN, Garvey M, et al (2010). Research Domain Criteria (RDoC): toward a new classification framework for research on mental disorders. Commentary. American Journal of Psychiatry, 167: 748-751.
2. Hahn H, Neurath O, Carnap R (1929). The Scientific Conception of the World: The Vienna Circle. Ernst Mach Society, University of Vienna. ). Reprinted in: Robert Scharf and Val Dusek (Eds.) Philosophy of Technology: The Technological Condition: An Anthology, Second Edition. (New York: J Wiley, 2014):101-110. http://rreece.github.io/philosophy-reading-list/docs/the-scientific-conception-of-the-world-the-vienna-circle.pdf
3. Engel GL (1977). The need for a new medical model: a challenge for biomedicine. Science; 196:129-136.
4. McLaren N (1998). A critical review of the biopsychosocial model. Australian and New Zealand Journal of Psychiatry. 32; 86-92. See also: McLaren N (2023). The Biopsychosocial Model and Scientific Deception. Ethical Human Psychology and Psychiatry, 25: 106-118.doi:10.1891/EHPP-2023-0008.
5. McLaren N (2024). Theories in Psychiatry: building a post-positivist psychiatry.
6. McLaren N (2021): Natural Dualism and Mental Disorder: The biocognitive model for psychiatry.
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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.