Finding Dignity in Disorder
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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In a recent paper on dignity in mental health care, Robert Anders from the College of Nursing, University of Texas, emphasised how fundamental the sense of dignity is to mental well-being, and how important it is for mental health professionals to take this into account [1]. He pointed out that, all too often, and despite their high language, mental health services around the world “fail to deliver dignity in practice.” This deficiency will not, he believed, be rectified in isolation but requires communities, mental health staff and legislatures to work together to the common end, namely, recognising “the fundamental humanity of those experiencing mental health challenges.”
Anders doesn’t mention it but anybody who knows anything of the history of psychiatry, or anybody who has been on the receiving end of mental health services (MHSs), knows only too well that dignity is generally the last thing on anybody’s mind. In fact, psychiatry has a long record of treating the mentally-troubled as beasts, fit only to be locked away, to be drugged or their brains cut or, in the ultimate contempt, to be euthanased [2]. Given that background, any attempt to inject a sense of dignity faces an uphill battle but the times are changing, albeit sporadically and against great resistance. The main impetus to change comes from the UN Convention on the Rights of Persons with Disabilities from 2006, which advocates individual autonomy and freedom from coercion [3]. Recent UN reports confirm that a move to a person-centred, rights-based approach is essential [4]. Quite clearly, this is not going to be implemented overnight. Worldwide, psychiatry is built on a foundation of involuntary treatment to the point that many psychiatrists, probably most, can’t conceive of a psychiatry without coercion. It does not, however, need to be that way as alternatives are available.
Taking different aspects of psychiatry in turn, Anders argued that the first and most important is the legal framework. Treatment can never be any better than the law but, almost universally, the law is repressive, punitive and inhumane. People caught in the mental health system lose most of their civil rights. The current Queensland Mental Health Act [5] is 614 pages long but it is not about mental health at all. It is an act about locking people away and forcing treatment on them. Detained patients, especially forensic patients, have fewer rights than a convicted criminal.
Once a law is in place, the next question is where it will be administered. For most psychiatrists most of the time, that means large, centrally-placed and ridiculously expensive hospitals. Almost invariably, these are difficult for families to access and are highly intolerant of even slightly deviant behaviour. The figures are clear: if you move the staff out of the hospitals, to the suburbs or the small towns or remote areas where the patients actually live, hospital admissions can be dramatically reduced, with lower rates of drugging, better relations with the patients, etc. Trouble is, staff don’t like it. They like being in their hospitals with all their friends, they enjoy their meetings and conferences and can always find reasons to have more, not less. Even professional people don’t like feeling exposed and unsupported, they need the sense of being part of the power structure. Even working alone half the time is too scary to think about, and this applies to psychiatrists as well.
If we can move the staff to a distributed and highly personalised form of service-delivery, then it’s possible to focus more on what is now called “trauma-informed and person-centred” forms of management. Since it has always been my impression that all psychiatry is centred on the patient’s experience of, and response to, events they perceived as traumatic, I had to look this up. My impression was, of course, mere wishful thinking. Mainstream psychiatry is “genes-informed and symptom-centred” because that’s what they see as significant. The patient’s life events just get in the way.
Even with a good law and proper places to administer it, many mentally-troubled people can’t present their case coherently and need somebody to do it for them. Anders took an optimistic view:
Independent oversight mechanisms—like mental health review boards—further protect dignity by monitoring psychiatric practices, investigating rights violations, and holding systems accountable. These watchdog structures help transform mental health care from control-oriented models to approaches that respect each person’s autonomy and worth. (p2)
He also proposed civil advocacy and other support services, and “Engaging policymakers in conversations centered on lived experiences…” Moving to “Addressing barriers to dignity in mental health,” he saw efforts to reduce stigma and discrimination as essential:
Widespread stigma remains one of the biggest obstacles to dignity in mental health. It discourages people from seeking help and shapes public attitudes, often leading to exclusion from jobs, education, and social connections.
Ready access to quality care is crucial to reducing stigma, meaning timely care delivered locally with a minimum of disruption to family life. Unusually for an American author, he didn’t mention the cost of treatment which, in that country, is probably the biggest single barrier to care. Finally, he suggested there is a role for “Spirituality as a dignity-affirming resource.” Essentially, this meant using the social and psychological resources of faith-based groups as a source of reassurance that the patient is a human with the right to dignity. He concluded: “When governments, healthcare organizations, and advocacy networks collaborate, they can build mental health systems that prioritize fairness, inclusion, and dignity.” Yes, they can. The only question remaining is “Why don’t they?”
Let’s start with a definition: Dignity is “the state or quality of being worthy of honour or respect.” That tells us everything we need to know: mentally-troubled people aren’t treated with honour or respect just because people don’t honour or respect them. They are regarded as weaklings, layabouts, trouble-makers, shirkers, whiners, schemers, or out of their minds and dangerously unpredictable, or all of the above, thus not worthy of respect and are treated as such. Thomas Szasz was emphatic: There’s no such thing as mental illness. Patients and psychiatrists have this gigantic racket going where the patients pretend to be disabled and the shrinks pretend to be helping them [6]. It’s impossible to treat a racketeer with dignity. This attitude, that people who claim to be troubled are lying or cheating, leads to appalling abuses.
Ernst Rüdin, Adolf Hitler’s favourite psychiatrist, denied there is any dignity in mental disorder. He spoke for generations of psychiatrists when he said that mental patients are the bearers of defective genetic material, although he took it a little further than most by arranging for them to be exterminated (it’s worth mentioning that sterilising or murdering many hundreds of thousands of mentally-disturbed people in Germany and other countries had no impact on the incidence of mental disorder). If you believe a person is defective, you may feel they deserve respect for coping with their defect or worthy of pity but you still see them as defective. This leads to the concept of stigma.
In Latin, a stigma is a mark (from the Greek for tattoo); over centuries, it has evolved to mean some mark or feature that deserves contempt or hostility and for which the bearer of the mark should feel ashamed and guilty, and keep a low profile. Two emotions seem to underlie it, fear and disgust (some people don’t recognise disgust as a stand-alone emotion but it is, e.g. seeing maggots, an open sore on somebody’s face, depraved conduct, etc). With mental disorder, it’s compounded by not knowing what’s causing the problem and not knowing what to do about it. People don’t like not knowing what to do so they quickly flip the intense emotions into rage and drive the sufferer away. For the sufferer, life gets worse but it’s actually the angry person’s problem, not the sufferer’s, although they will never accept that.
As an attempt to reduce stigma, Anders said: “Independent oversight mechanisms—like mental health review boards—further protect dignity by monitoring psychiatric practices…” Nice in theory but, as Yogi Berra said, “In theory, there is no difference between theory and practice but, in practice, there is.” All too often, review boards degenerate into rubber stamps, authorising and justifying everything the hospital asks for. In turn, the orders the hospital requests are designed to safeguard them, to make sure that if anything goes wrong, they can’t be blamed. Thus, they impose onerous restrictions to make sure nothing goes wrong – which, from the patient’s point of view, is worse. Despite the noble sentiments at the start of each mental health act, the patient’s wishes rarely get a look in. Even the obvious move, of making it more difficult for hospitals to get detention orders, backfires as staff then spend even more of their time writing reports and less time actually talking to the patients.
My view is that, as it is presently structured, psychiatry is incapable of treating mentally-troubled people with dignity. The institution of psychiatry doesn’t want a “trauma-informed and person-centred” approach as there is no room in its doctrine for this concept. It will always treat them as second rate, as damaged adults, or worse, as children, just because this is central to their entire concept of mental disorder. For the mainstream, mental problems aren’t a predictable response to traumatic events, they’re the sign of an inner weakness. Sure, it’s genetic but (a) it’s still a weakness and (b) psychiatrists never have it. For mainstream psychiatry, mental disorder is never a case of: “There but for the grace of God go I.” It’s not the psychiatrist’s intention to deal with the patient as an equal because they’re not even thinking in terms of “trauma-informed care.” Which leads to the last point, that when it comes to expressions like “spirituality,” psychiatrists are off the planet.
The philosopher David Chalmers makes a big thing about zombies [e.g. 7]. To him, a zombie is a creature with the body of a human, which does all the things humans do such as talk and show emotions and plan and so on, but which has no inner or mental life of any sort. It’s not even black inside a zombie’s head, it’s nothing. This leads Chalmers to some fairly unexpected conclusions, all of which I think are completely wrong [8, Chap. 10], but the point is that probably 99.99% of humans who have ever lived think there is something going on in their heads, that it’s not nothing. Moreover, 99.90% of them would use the terms “spiritual" or “mental” or something like it to describe the private three ring circus in their heads. By that, they mean “really strange, not a physical thing but clearly able to pick up a rock and throw it.”
By using the word spiritual, a lot of people also mean “immortal, will survive the death of my body,” but that’s optional as they all agree there’s no proof beyond hoping that it’s true. They also mean “This spiritual thing is very significant, it’s not nothing or irrelevant or made up.” By that, they mean “It counts toward making me who I am. If I’m depressed, there are things in my mind that make me depressed and I need to deal with them.” Psychiatry doesn’t believe that. It says: “If you’re depressed, it’s because your brain chemicals are playing up. That’s what your genes dictate so our drugs will correct the chemical imbalance.” They carefuly overlook the fact that they don’t have any concept or theory of mind, or model of mental disorder that explains this opinion. Their belief in their “biomedical model” (the same one nobody has ever seen) is unshakeable. It doesn’t matter what dreadful things have happened to the patient in the past, the words bounce off our armour-plated psychiatrist who rates that sort of mental/spiritual thing along with fairies at the bottom of the garden.
While dignity is based in equality, psychiatry is based in a sense of superiority, of knowing with near-religious certainty that the patient is wrong AND the psychiatrist can’t be. The very structure of psychiatry is a power play, a system developed to reinforce their status at the expense of the patients. In their world, even the very concept of “dignity” is a bit of irrelevant fluff. The first step toward a “trauma-informed and person-centred” will be for psychiatrists to acknowledge their current perception of mental disorder is wrong. I have no confidence that this will change in a hurry. The physicist Max Planck was even more pessimistic:
A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die.
A wag interpreted this as “Science progresses, one funeral at a time.” Fine, bring on the funerals because psychiatry will not change until it gets a formal theory of mind that leads to a testable model of mental disorder. Their current “biomedical” model, which exists as a name only, just is dominance enshrined, and that tells us why change won’t come easily. The biocognitive theory of mind says humans like to dominate each other, that treating other people with respect is not natural for humans. Advancing the self comes naturally, which applies with a vengeance to psychiatrists. As humans, reducing our status in another person’s eyes does not come naturally. Just ask Donald Trump.
References:
1. Anders R (2025) Dignity in mental health care: human rights challenges and pathways. Academia Mental Health and Well-Being. https://www.academia.edu/2997-9196/2/2/10.20935/MHealthWellB7729
2. Scull A (2022) Desperate Remedies: Psychiatry and the mysteries of mental illness. London: Penguin.
3. UN OHCHR (2006) Convention on the Rights of Persons with Disabilities. https://www.ohchr.org/en/instruments-mechanisms/instruments/convention-rights-persons-disabilities
4. UN Human Rights Council (2017) Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. available at: http://ap.ohchr.org/documents/dpage_e.aspx?si=A/HRC/35/21
5. Queensland Mental Health Act (2016). At: https://www.legislation.qld.gov.au/view/html/inforce/current/act-2016-005
6. McLaren N (2012). Critique of Thomas Szasz. Chaps. 12-13 in The Mind-Body Problem Explained: The Biocognitive Model for Psychiatry. Ann Arbor, MI: Future Psychiatry Press.
7. Chalmers DJ (2022). Reality+: Virtual worlds and the problems of philosophy. London: Allen Lane.
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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.
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