"Life is far too short to hold anything but delusional notions about yourself." So said Mr Gene Simmons (b. 1949), perhaps better known as "The Demon," bassist and co-lead singer for the rock band, Kiss. Kiss, as older readers may recall, was a truly awful bunch of musically- and cosmetically-challenged headbangers whose main appeal was they gave far-right-wing religious groups the shits ("The satanists are coming for your children!!!"). Mr Simmons' insight came to me when I checked the RANZCP website (abbreviations at end). I had intended to report on their three-hour "Masterclass in Anxiety Disorders" but they wanted to charge me $195 for the pleasure so I declined. For the 25 years I was working in the north of this country, I paid about $200 a year for "branch activities," meaning educational and other events, even though the nearest such activities were about 2,500km away and therefore unavailable. My efforts to get a rebate on this fee met with quite ferocious hostility so eventually I just paid but it would be nice if the RANZCP thought more of their members than they do of their income. However, while on the site, the advertisement for the coming annual conference caught my eye. The theme of the conference is Excellence and Empathy, Knowledge and Kindness. The blurb continues:
As the world continues to recover from the pandemic, our Congress embodies the themes of Excellence and Empathy, Knowledge and Kindness. We aim to curate a scientific program that showcases the excellence of psychiatric research, and how, as psychiatrists we engage with empathy, knowledge and kindness with those receiving mental healthcare and the community. Our program represents all the diversity of our profession and the high-quality research that underpins our practice, ranging from basic clinical sciences, psychiatric epidemiology, pharmacological and psychotherapies, through to new digital technologies and understandings from related sciences such as anthropology, psychology and sociology.
Excellence and Empathy, Knowledge and Kindness. Putting aside the schoolboy alliteration, we can consider each of these virtues which it pleases the psychiatry profession to bestow on itself.
Excellence: Years ago, I got a letter from Graylands Hospital, in Perth, where I had spent a year of my training. The motto on their new letterhead was "A centre of excellence." I remember looking at it and thinking "Is this a joke?" When I checked with a friend who was still working there, she assured me the administration had been quite serious and took umbrage when anybody sniggered at it. Over the years, this bit of idle onanism popped up in many different parts of the psychiatric world but, mercifully, it seems to have faded lately. Perhaps the various PR bods have bought a dictionary, or maybe they read a sobering essay by the late and highly-regarded Halstead R Holman, foundation chief physician of California's prestigious Stanford Medical Centre and long-time professor of medicine. In 1975, Holman pointed out that medicine in the US was in a state of crisis. Health costs were rising rapidly but measurable outcomes were going nowhere or even backwards. Over the ensuing 50 years, matters have actually got worse. Today health consumes about 17.3% of GDP (compared with about 9% in Australia). In the US, 32c of each private health care dollar is spent on administration (working out how not to pay the claimants); in Australia, it's 8c per dollar. Mean life span in the US has declined in recent years, poor people cannot afford treatment and health costs are now the single largest cause of bankruptcy in the country. Meanwhile, private health insurers amass a profit of about US$100billion a year.
In The Excellence Deception in Medicine, Holman defined excellence and argued that the term is deliberately misleading:
In the aggregate, medical institutions and practices are not excellent. The self-acclaimed excellence is, in practice, a myth ... the medical establishment is not engaged in the disinterested pursuit of knowledge and the translation of that knowledge into medical practice; rather, in significant part, it is engaged in special interest advocacy, pursuing and preserving social power. The concept of excellence is a component of the ideological justification of that role [1].
These are not trivial gripes by a moaning malcontent. First, he says, self-praise is no recommendation. A standard of "excellence" is an award given to you, it's not something you snatch and pin to your chest. People can aspire to excellence, and can even put that on their letterhead, but particularly in medicine, it will rarely be achieved as there is always something that could be done better. In psychiatry, however, a standard of "excellence" is in principle unattainable, partly because of the enormous burden of responsibility of their "social power" over involuntary patients, and partly because of the insuperable burden of dealing with something (the mind) for which science freely admits it has no tools. All these psychiatrists braying about their "scientific psychiatry" need to understand, because clearly they don't, that western science is firmly founded on the principle that it can't deal with mental matters [2]. As for "special interest advocacy," that's a huge and dismaying field in its own right (see [3]). So we can forget excellence. Mediocrity would be more appropriate. Next award:
Empathy: n. the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another (Merriam-Webster).
Again, why don't psychiatrists know their own history? Biological psychiatry is built on the notion not only that people with "mental diseases" (their word) don't have to be understood, but they can't be understood. They're crazy, that's what crazy means. For a biological psychiatrist, putting oneself in the position of understanding what is going on in a psychotic patient's head is not only impossible, it's potentially bloody dangerous, a case of "down the rabbit hole" to insanity. But the most important point is that it would be a waste of time as the significant activity in mental disorder is not at the level of "feelings," "thoughts" or "experience," because that's all fanciful. No, mental disorder is wrought at the level of neurotransmitters, genes and such like, which only we clever scientists can access via "the excellence of our psychiatric research." Well-funded and very well-paid, of course, and quite overlooking the innumerable conflicts of interest (see end note) such as payments from drug companies. No, empathy doesn't get a look-in, but venality sure does.
Next cab off the rank: Knowledge. Oh dear, this is so tiring. There is no such knowledge. There is a huge jumble of facts and figures, assembled over decades through vast expenditure of public money, but no fundamental theory to hang them on. Psychiatry talks about the mind. It has no theory of mind. It talks about mental disorder. It has no model of mental disorder. It has an ideology of mental disorder as a biological phenomenon [4] and it also has an unwritten "biopsychosocial model" that is waved around to keep critics at bay [5]. It talks about personality but has no theory of personality, and definitely no model of personality disorder, although that doesn't matter much as mainstream psychiatry is busy rediagnosing people with personality disorders as "mentally-ill" so they can be put on psychiatric drugs for life [6], thereby pleasing Big Pharma and guaranteeing the flow of "research and education funds" far into the future.
More recently, psychiatry has found a new fig leaf called "evidence-based psychiatry," meaning "everything we do is backed by practical facts." All good and interesting, except that argument has been used for millennia to justify whatever it is the good doctors are doing, such as bleeding and purging, burning amputation stumps, chaining people to walls in dungeons, brain surgery, and so on. There is so much "evidence" in the world, so many practical facts, that the incoming information has to be filtered, and we necessarily filter it according to our belief systems. If you believe all mental disorder is physical in nature, then you will attach significance to the fact that the patient's bowels are sluggish. You won't pay attention to the fact that she's not eating because she can never decide what to cook. That is, in the absence of a governing theory, evidence is collected according to prejudice. What I see as significant in a patient's life (her mother was terribly critical) is dismissed as irrelevant by the mainstream psychiatrist. Without a governing theory which tells us what is important, there is no knowledge; we collect only facts that justify our pre-existing beliefs. The astrophysicist, Carl Sagan (of nuclear winter fame) put his finger on it:
...at the heart of science is an essential balance between two seemingly contradictory attitudes – an openness to new ideas, no matter how bizarre or counterintuitive, and the most ruthlessly sceptical scrutiny of all ideas, old and new. This is how deep truths are winnowed from deep nonsense [7].
Modern psychiatry is not a science but an ideology of mental disorder, a mishmash of carefully filtered "deep nonsense." Which brings us to ... Kindness. Sometimes, words seem to turn to ash in your mouth. The UNHRC and WHO have recently said psychiatry needs to phase out involuntary detention and enforced treatment. Psychiatry's kindly response could be summarised as "Get stuffed" [8]. When I attempted to defend the moderate position, I was roundly abused [9] - which the editor defended as "robust scientific debate." When the UN Committee for the Prevention of Torture tried to inspect Queensland's locked psychiatric wards, they were told there was no legislative provision for it. This was false. The chief psychiatrist could have appointed the committee as inspectors and, short of a new Mental Health Act rushed through overnight, nobody could have stopped that move (that has actually happened, when it was found that a lawyer on the tribunal wasn't qualified so the government had to act quickly to prevent a flood of lawsuits alleging illegal detention and medical assault). Two years ago, the members of the Queensland Mental Health Tribunal were treated to a lecture on ECT. I am not permitted to see what was in it, but we all know: it said ECT is the safest, most wonderful, amazing treatment for depression and patients are all so grateful after it that it should never be denied, even to the unenlightened who don't want it. We all know what wasn't said: there are plenty of places in the world where it is either unavailable or banned, and they get along just fine without it, and the primary motivation for the excessive use of ECT in Australia is the huge financial returns it generates [10]. However, that's surmise because even though everything in the lecture must have come from the scientific literature, nobody is allowed to see it.
I have heaps of texts and emails from patients complaining of what they said was torture after they were detained and treated against their will, including ECT, but can't use them because they were "detained persons" at the time. It's a great system where people who feel they're being tortured cannot be heard, but that's what happens when people who believe they are acting "kindly" and with scientific backing are given power of life and living death over people who have broken no laws. This quote by Clive Staples Lewis is rather long but nobody could put it better:
Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. It may be better to live under robber barons than under omnipotent moral busybodies. The robber baron’s cruelty may sometimes sleep, his cupidity may at some point be satiated; but those who torment us for our own good will torment us without end for they do so with the approval of their own conscience. They may be more likely to go to Heaven yet at the same time likelier to make a Hell of earth. Their very kindness stings with intolerable insult. To be ‘cured’ against one’s will and cured of states which we may not regard as disease is to be put on a level with those who have not yet reached the age of reason or those who never will; to be classed with infants, imbeciles, and domestic animals.
It's not kindness, it's brutality.
Excellence and Empathy, Knowledge and Kindness. Or mediocrity and venality, ideology and brutality. It's not a good idea to believe your own propaganda or hold "delusional notions about yourself." The inestimable Carl Sagan again:
One of the saddest lessons of history is this: if we've been bamboozled long enough, we tend to reject any evidence of the bamboozle. We're no longer interested in finding out the truth. The bamboozle has captured us. It's simply too painful to acknowledge, even to ourselves, that we've been taken. Once you give a charlatan power over you, you almost never get it back. So the old bamboozles tend to persist as the new ones rise.
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End note: That paper takes the cake. How many of the 26 authors in the pious chorus have since been accused of conflicts of interest?
References:
1. Holman HR (1976). The 'Excellence' Deception in Medicine. Hospital Practice 11: 11. (April, 1976).
2. McLaren N (2023) Diagnosing psychiatry's failure: The need for a post-positivist psychiatry.
Chapter 4 in Practical Alternatives to the Psychiatric Model of Mental Illness: Beyond DSM and ICD Diagnosing. London: Ethics International Press: Critical Psychology and Critical Psychiatry Series, Vol III.
3. Whitaker R, Cosgrove L (2015). Psychiatry Under the Influence: Institutional Corruption, Social Injury, and Prescriptions for Reform. New York: Palgrave MacMillan.
4. McLaren N (2013). Psychiatry as Ideology. Ethical Human Psychology and Psychiatry 15: 7-18.
5. McLaren N (2023). The Biopsychosocial Model and Scientific Deception. Ethical Human 15: 7-18 Psychology and Psychiatry, 25: 106-118.doi:10.1891/EHPP-2023-0008.
6. McLaren N (2012). Chapters 14-16 in The Mind-Body Problem Explained: The Biocognitive Model for Psychiatry. Ann Arbor, MI: Future Psychiatry Press. ISBN 978-1-61599-171-6
7. Sagan C (1997) The Demon-Haunted World: Science as a Candle in the Dark. London: Hodder/Headline.
8. Dharmawardene, V, Menkes, DB (2019) Responding to the UN Special Rapporteur’s anti-psychiatry bias. Australian and New Zealand Journal of Psychiatry 53: 282–283.
https://doi.org/10.1177/0004867418818359
9. Menkes, D, Dharmawardene, V, (2019). Anti-psychiatry in 2019, and why it matters. Australian and New Zealand Journal of Psychiatry 53: 921-922. https://doi.org/10.1177/0004867419868791
10. 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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I ran out of space last week so didn't mention the forthcoming volume, Theories in Psychiatry: Building a Post-Positivist Psychiatry, which may see light in July. Chapters 2 (biological psychiatry) and 3 (psychodynamic) end on a gloomy note, so perhaps we can do better. Chapter 4 looks at the huge excursion made by academic psychology through the wilderness of anti-mentalism. As described in Chapter 1, western science committed itself to the idea that it could not deal with the mind, so psychologists tried to oblige with a theory of mind that didn't mention it. This led to "black box" psychology, better known as behaviorism, which said that psychologists can only deal with what they see, the environmental input or stimulus, and the behavioral output or response. Anything that happened between stimulus and response was in principle unobservable, and therefore had to be excluded. That is, they tried to build a psychology that missed out all the interesting bits that take place in the mind. Tried, and failed. In fact, it was one of the more spectacular failures in the history of science but that didn't deter anybody, mainstream psychology simply took back the mind, renamed it the "cognitive realm," and got on with business as "cognitive behavioral scientists." Don't worry that "cognitive" and "behavioral" are contradictory, like "generous skinflint" or "Australian gentleman," professors are never sacked because their bets turned sour.
Talking of sour bets, Chapter 5 looks at what the current president of the RANZCP says is "...the predominant theoretical framework underpinning contemporary psychiatry ... a relevant and useful component of training and practice ..." (Moore, E. correspondence, Nov. 20th 2023). She refers, of course, to the wondrous "biopsychosocial model" that licenses psychiatrists to speak as experts upon "... basic clinical sciences, psychiatric epidemiology, pharmacological and psychotherapies, through to new digital technologies and understandings from related sciences such as anthropology, psychology and sociology." None of this is true, of course, what they don't understand is that their "little precious" is a truism. All it says is: "Mind and body interact." That's all. Descartes said as much 400 years ago. There is no training module in "biopsychosocial psychiatry," no lectures or practical classes, no reading list and certainly no journals, conferences or any of the other trappings of science that we would expect from "contemporary psychiatry's theoretical underpinnings." In my view, this amounts to a scientific fraud but readers will have to look at my case and make their own decisions.
However, the complaint that modern psychiatry is built on a fraud is not new. The late Thomas Szasz built his reputation on the claim that there is no such thing as "mental illness," and that both psychiatrists and their patients are engaged in an elaborate fraud. My view is that his conclusion was right in some respects but his case was wrong, he used the wrong argument: Mental disorder is real, but it isn't biological. Thus, he accidently intensified mainstream psychiatry's hostility to criticism.
That concludes Part I: of the various options to explain mental disorder used by mainstream psychiatry, not one survives even a cursory critical glance. Part II looks at a range of philosophers to see whether their work can form the basis for a rational psychiatry. Stay tuned.
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This material is copyright but can be copied or quoted on condition the author is acknowledged.
Abbreviations:
RANZCP: Royal Australian and New Zealand College of Psychiatrists.
ECT: Electroconvulsive treatment.