A short epistle today, I'm worn out by enquiries and reports and all that stuff. Also by the endlessly proliferating wars around the world.

There's a rule in senior levels of public services around the world: Never hold an enquiry unless you're sure you can get the answers you want. The show must go on, but make sure it doesn't blow up in your face. The report of the Senate enquiry into ADHD, released a week or two ago, is a neat example of the genre: Ask a series of loaded questions, then invite a gaggle of people whose minds are made up to answer them. As theatre, it's a winner, and that's all this enquiry was, a diversion, a distraction and a total waste of public time and money. However, a lot of people around the country are feeling very satisfied, believing they're going to get what they want. Well, beware of what you wish for. I've had my fill of ADHD this month, we'll come back to it another day, but one small point on p137, almost a throw-away, caught my eye.

Item 5.30: The RANZCP (college of psychiatists) also advocated for psychiatrists to remain in a position of clinical leadership within a multidisciplinary team, advising that they have a 'unique and comprehensive understanding of the bio-psycho-social assessment and treatment of ADHD' and other, potentially coexisting conditions (RANZCP submission, No. 21, p3).

(While you're looking at the enquiry submissions, mine is No. 634 on p32, which is a bit strange as it went in early but it's fairly long and I'm sure they were terribly busy. Also they would have to think). This claim comes from the RANZCP website, which says:

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 (RANZCP Position Statement No. 80, 2013).

Here we go again, psychiatrists eagerly shoving themselves to the front of the queue, waving their hands and calling out "Over here, we've got the exact model that says we should be in charge." Fortunately, it's not the old "biopsychosocial model" that has been shown to be seriously deceptive, if not frankly fraudulent [1], it's the modern version, a "bio-psycho-social model." That's lucky, it would be a terrible thing if the RANZCP went to the Senate enquiry and gave false evidence. I have written to the president of the college, apologising for my ignorance and asking for information on their model:

As the College's choice of its ‘bio-psycho-social’ model is so central to teaching and practice in this country, I imagine there must be many academic papers on the topic, and perhaps even a text book or two. I wonder if you would be good enough to send me specific references where the concept is set out in the form of a scientific model. In particular, I would like the name of the primary author and three or four seminal references where other authors have developed and tested the idea against reality.

I don't expect to have to wait long for a response, I'm sure they'll have this information at their fingertips and will be only too keen to spread the word. Or should I say The Word. But why does it matter? Because the model tells you what's important and what isn't. The whole point of the Senate enquiry was to establish as gospel one fact alone: that the clusters of symptoms known as ADHD are exclusively caused by a brain disease, for which expensive, highly-addictive drugs with many side effects are essential. The role of the psychiatrists and the drug companies who are backing them was to get official approval of a project that is so secret that they don't actually know about it. Well, not in so many words. It's this:

The goal of psychiatry for the last twenty-five years has been an exponential expansion of the numbers of people taking psychiatric drugs. This goal has been implemented by the large-scale process of reclassifying people with personality disorders, for which psychiatry has no treatment, as people with mental disorders, who need drugs for life.

This is so simple but before anybody starts screeching "Conspiracy theory!" and reaching for the insect spray, remember this: It's only a conspiracy when the conspirators know what they're doing. When it comes to distinguishing between normality, eccentricity, mental disorder and personality disorder, my case is that, despite all their high-falutin' talk about "holistic biopsychosocial models" and so on, psychiatrists don't actually know what they're doing. This is because they don't have a model of their subject matter.

Psychiatrists deal in mind but they do not have a theory of mind. Most, indeed, don't even know what the expression "theory of mind" means. They don't know how to categorise mental events, to sort the normal from the abnormal, or have any understanding of how normal minds work. And because they don't have that starting point, they then can't move to the next step, which is to develop a model of mental disorder (note a theory or normality precedes the model of abnormality). They say "Mental disorder is brain disorder," but that is an ideological claim, not a scientific statement. It actually says nothing because if you have one answer that explains everything, then you're not explaining anything.

Moving on, a well-developed theory of mind leads to a theory of personality. We all know what personality is but it's notoriously difficult to pin down. That means that, even though we can recognise it (in somebody else), the idea of personality disorder is difficult to pin down but it's not out of reach. Trouble is, personality disorder is not mental disorder, therefore it's not a brain disorder, and therefore there are no drugs for personality disorder, so psychiatrists can't get any money out of the 20% or so of the population with more or less disordered personalities. Damn.

But all is not lost. People with mental disorders tend to be fairly quiet and pliable whereas personality disorders are loud and in your face and want the attention. And they also don't like being told "You're responsible for yourself, so sort out your mess before you end up in real trouble." So if somebody comes along and says "Actually, you're not just a naughty or selfish or lazy person who needs a kick in the pants, you're a mentally-disordered person who needs lots of sympathy and extra attention," who are they going to listen to? Right first time. So because psychiatrists have so much power (another story) and stand up in public and say...

We psychiatrists understand the impact of ‘biological’, ‘psychological’ and ‘social’ factors on mental health and the causation of mental illness. Our ‘bio-psycho-social’ model is a holistic approach....

... people listen, because they assume that, as "doctors of the mind," psychiatrists actually know what they're talking about when, as a matter of epistemological fact, they don't. If you don't have models of mental disorder and personality disorder, you can say what you like, you can keep shifting the goal posts but everybody has to keep quiet and not ask rude questions, like "Do you people actually know what you're doing?" Nobody at the Senate enquiry contacted the president of the RANZCP and asked her to provide a copy of her fancy "bio-psycho-social model," they just assumed she was acting with due integrity and it would be offensive to challenge her, so they let it pass (I'm challenging her).

This ADHD business is just a repeat of the bipolar business, when anybody who had anything like a period of mild agitation or excitement followed by a bit of a slump (that's most of us at some stage) was labelled "manic depressive" and was put on drugs for life. Which didn't work because, in fact, the person just had one or two screws loose, the result of early life experiences, which could have been fixed with proper psychotherapy, but when the patient doesn't get better, whose fault is that? Gosh, you know this story, don't you. It's not the doctor's fault, it's the patient's fault, because the doctor is never wrong. Only patients are wrong, and if they're not happy with their treatment and try to stop it, well, that just proves how insightless they are and they need more tablets, not less. And more. And if you get too stroppy and try to leave, we'll just detain you and you can have the big needles and the shock treatment. We know how to deal with the likes of you.

With the ADHD epidemic, anybody with any sort of difficulty is being relabelled as mentally ill and put on drugs. It happens because it can. The labels are so loose you could diagnose a ham sandwich with inattentive-type ADHD, so diagnosing what is rightly a personality problem as a mental disorder is a breeze. And it all comes about due to psychiatry's lack of a model of mental disorder and its calm conviction that, as a discipline, it can do no wrong.

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There is one more hill to climb before we can close the book on ADHD this year, the "victory lap" broadcast by Sen. Jordan Steele-John, who organised the whole shebang. This will be tomorrow evening and promises to be riveting but I will "steel" myself and watch it. With my microphone on mute in case I say something impulsive and they realise I'm neurodivergent.

Reference:

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

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This material is copyright but can be quoted and republished as long as the author is acknowledged.

Niall McLaren on Critical Psychiatry

Last mention of ADHD for the year.