More on Human Minds

Science needs to catch up.

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.

If you like what you read, please click the “like” button at the bottom of the text, it helps spread the posts to new readers. If you want to comment, please use the link at the end rather than email me as they get lost and nobody sees them.

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Reader Michael K, who posts as “Meaning and Being,” commented:

You also write that “I do not have a running commentary in my head”. This is surprising to me because I do, and it is almost continuous, often as a second voice in my mind arranging what I am about to say out loud while I am still talking half a sentence back (but I find it tiring, so I prefer to write). In critical, time constrained situations, I do resort to ‘automatic’, conditioned behaviour. Our automatic, conditioned behaviour may also be influenced by conscious action, carefully evaluated and chosen. We have the capacity to condition ourselves, intentionally, animals do not.

After the last couple of posts, some people have wondered if this is getting too far from the theme of the file, “Critical Psychiatry.” My answer is we need a critical psychiatry just because psychiatry is such a mess, and the reason it’s a mess is perfectly clear. The core of any science consists of two constructs, a theory and a model derived from the theory in order to test it. At the core of psychiatry, there is a black hole. There is no theory of mind and therefore no model of mental disorder, although this failing is concealed by a blizzard of scientific-sounding stuff. Psychiatrists today are in much the same intellectual swamp as physicians were in the early 19^th Century, prior to Louis Pasteur’s “germ theory of infection.”

The Hungarian-born obstetrician, Ignaz Semmelweis (1818-1865), was a pioneer of aseptic technique. Largely by trial and error, he found that if the physicians washed their hands after doing an autopsy on a woman who had died of puerperal fever (childbed fever, meaning massive streptococcal infection), the death rate among their patients plummeted (I first heard his story at the age of twelve and it became one of my inspirations to study medicine). However, his colleagues rejected his ideas as they could not believe that a tiny amount of material hidden under their fingernails could cause the death of a patient. Due to his outspoken defence of his case, Semmelweis became isolated and estranged from the medical establishment. Eventually, on the say-so of his enemies, he was confined to a mental hospital where he was beaten by guards and died 2 weeks later of gangrene caused by the assault. Pasteur himself (1822-1895, another inspiration) was also subjected to prolonged hostility by the scientific and medical establishments, not least because he wasn’t a physician himself. Lord Lister (1827-1912) commented on the inertia of his senior colleagues:

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.

In the 1850s, before Pasteur’s major discoveries, the question “Can a tiny amount of human flesh cause death?” didn’t make any sense to physicians. They understood the concept of poisons, but they were external chemicals, not barely visible bits of human material. It took Pasteur’s breakthrough on the notion of exponential growth of microbial populations to convince a new generation of physicians (the old lot were a lost cause). That is, once in the human body, microbes are self-replicating, doubling every few minutes until they have overwhelmed the body’s defences and game over, as they say. Gangrene is a case in point. The causative organism, Clostridium perfringens (used to be welchii), is anaerobic; it is killed by oxygen. As it spreads, it causes intense swelling which blocks the arterial blood supply, causing death of the tissues, so the bug moves into the areas it has itself killed, quickly takes over and kills some more. This concept, of the self-reinforcing or self-enabling, self-amplifying agent is central to modern understanding of complex systems but a lot of people struggle with it. They were brought up on the concept of linear causation and just don’t get non-linear systems.

Similarly, psychiatrists raised in the anti-humanist atmosphere that has dominated psychiatry for the past 75 years are incapable of comprehending the notion that ideas or beliefs can cause mental disorder just because they can self-amplify exponentially. That is the entire basis of the host of anxiety states that are so troublesome to humans [1] but psychiatrists don’t get that. They want something concrete they can see under a microscope or in a scanner. They are saying: “FFS, how could something so flimsy and insubstantial as an idea bring down the immensely powerful human mind? We can’t comprehend insubstantial and unlocalised spirits causing anything so devastating as mental disorder, so it must be physical.” Two questions arise: Why is psychiatry anti-humanist, and how can we construct a model of mental disorder on the concept of self-reinforcing or self-amplifying mental states?

The first question is easy: the right wing of psychiatry has always been anti-humanist. The idea that mental disorder is in some crucial, causative sense biological has been with us forever. Andrew Scull [2] and Anne Heatherington [3] give some of the detail, including the horrors that have been inflicted on the mentally-troubled as a result of that idea. However, they don’t discuss the role and influence of philosophy’s positivist movement in science, in medicine and in psychiatry. I mention this from time to time, because even though it’s so important, nobody seems to know anything about it. In brief, in 1929, a small group of mathematicians, philosophers and physicists in Vienna and their colleagues shoved science in a new direction. They forced a split between empirical science, based in observations and measurements, and metaphysics, essentially everything else that didn’t have a factually-verifiable basis in the real world. That’s it. Out with the mind, in with the callipers.

In 1980, with DSMIII, psychiatry formally applied to join the mainstream medical world (for an interesting account, see Patrick Hahn in MIA this week). Immediately, and without waiting for a debate or even completing the formalities of having a model of its subject matter, it leapt into the exciting world of brain research and drug company money. And here we still are, except the world is getting a bit sick of waiting for some benefits. In fact, it’s becoming increasingly clear that, with the side effects of drugs, the disadvantages of psychiatry being “mainstream medical” are rapidly catching up to any alleged advantages (and while you’re on MIA, see John Read’s excellent commentary on drug withdrawal effects). It’s now nearly a century since the positivist revolution was announced. In all that time, and despite the explosive development of neurosciences and perhaps $100billion in funding, nothing has been found that offers any chance of an explanation of mental disorder, no biomarkers, no genetic defects, no chemical imbalances, nothing. Just endless promises.

In the frenzy of being on the cusp of a breakthrough, psychiatrists have overlooked an important point about any search: people have to say at what point they will admit defeat. Unfortunately, the purveyors of biological psychiatry are incapable of admitting that their program may not work. That alone says that what they are doing is not science: as an article of faith and not of empirical science, they believe that biology will fill their intellectual black hole where there should be a theory of mind and a model of mental disorder.

Putting that aside, the comment by reader Michael shows an important point about the difficulty in dealing with minds. He said: “I have a voice inside my head announcing what I am about to say,” as though his spoken voice is simply echoing what he “hears.” I replied that the inner voice is not necessary, it has no explanatory value because all it does is shift that which requires explanation back one level, as in: What is the ultimate step that tells the inner voice what to say? OK, well whatever it is, that’s what we’re interested in. Even if there are a hundred inner voices all telling the next voice in the queue what to say, a sort of cerebral Chinese whispers, it has to start somewhere. At the very first step, it’s generated somewhere without a voice, and that’s the crucial bit. How is it generated? I say it is generated at a silent level of computation that we cannot access, any more than I can see all the 0’s and 1’s buzzing around in the computer I’m using. All we get is the answer, the outcome of the computation, the answers become us. Technically, an inner voice has no explanatory value as it starts an infinite regress, a stepwise backward progression where one answer demands a further question, and then another question…. The only way to stop an infinite regress is to avoid taking the first step.

It has long been known that inner voices are not explanatory, and this was a powerful part of the positivist motivation to write mentality out of science. Every time anybody tried to talk about the “mind” or “soul” or “spirit,” infinity beckoned mockingly: “My mind/soul/spirit tells me what to do.” The correct response is “Fine, so what tells your mind/soul/spirit what to do? Another smaller mind?” Clearly, this goes nowhere. This is why the biocognitive model of mind doesn’t take that first step. We can, if we choose, regale ourselves from inside with a constant chatter but we don’t have to just because the inner talk comes after the decision, it echoes the decision. The decision to act is all that is required, and, using a range of sensory inputs and standing instructions, this is computed just one step removed from full conscious awareness. There are no words involved at this level, the words are grafted on later. If I “say” in my head “Now where are my keys?” I’ve already realised they are missing. If I then “say” “Oh, there they are,” I already know where they are and, crucially, I’m reaching for them.

However, a lot of people don’t like this idea. They feel that if we don’t have words involved, we’re mindless, as in “automated and unthinking,” or maybe we’re functioning at the animal level known as conditioning. Not so. The word “conditioning,” probably the core concept of behaviourism, is part of what I described last week:

As history has shown, behaviourism went nowhere, albeit at huge cost, leaving a bit of technique and a lot of jargon but the original impetus for behaviourism hasn’t gone away.

Conditioning is part of that old jargon; in Chap. 4 of Theories in Psychiatry [4], I put the case that it doesn’t exist, it’s an artefact. The word is a bit like a tombstone far out on the edge of the desert where somebody tried to build a town and failed; like Ozymandias, only the marker remains. Given the limited technology and even more limited conceptual tools a hundred years ago, what is called “conditioning” looked like a valid attempt to build a non-question-begging account of human behaviour. However, their fatal mistake was to give up on the attempt to explain mind and, instead, to try to explain it away. The mind, they said, isn’t what it seems to be, it’s all an illusion, just a simple matter of reflex responses to the environment.

At the time, they didn’t have anything like our concept of information, so they had to do without it. Since then, the concepts have been elaborated and developed and we now have a pretty good idea of what information is and what it can do. The good news is that it no longer seems magical, we now have no fear of the concept of ultra-high speed computation producing more or less instantaneous decisions. The bad news is that it still feels ghostly, while the inescapable conclusion, that our minds are nothing but information, can be quite shocking. However, from the scientific point of view, the idea that the mind/soul/spirit is “just information” is very good news as it allows us to take it as seriously as we take all other informational states. One important outcome is to clarify the difference between fully conscious, directed behaviour and what reader Michael termed “automated, conditioned behaviour”:

Our automatic, conditioned behaviour may also be influenced by conscious action, carefully evaluated and chosen. We have the capacity to condition ourselves, intentionally, animals do not.

“Conscious action,” as in intentional, does not imply “verbal.” I am fully conscious of and fully responsible for my actions at all times just because I choose to do them but I don’t need words to do that. The fact that those decisions are near-instantaneous and non-verbal doesn’t mean I didn’t intend them. I just glanced at the job and, even while talking about something else, I reached for the tool and got to work. What Michael calls “conditioning ourselves” is just a matter of making a decision without using words. Animals make decisions all the time but they do it (we presume) without words. That doesn’t mean they’re mindless. This is critical for a non-biological psychiatry because, with very few exceptions, mental disorders start at this high-speed, apparently automated level. The problem is that people often don’t know all the bits of information they use to make a decision. The words get in the way. Consider this very common conversation with a new patient:

Q: “Is there anything in life you’re frankly scared of, like heights, confined spaces, wide open spaces, thunder and…?”

A (interrupts): “Oh yes, frogs. I know it sounds silly but I’m absolutely terrified of frogs, always have been. I know they can’t hurt me, I know they’re harmless but if one jumps on me, I go to bits.”

On the face of it, you can see why biological psychiatry says this is a brain disease: it doesn’t make sense. How can a sensible person say in one breath that frogs are harmless and that they’re terrifying? It clearly has nothing to do with evolution and yet, since we are rational beings, how can we explain it mentally? That only leaves biology: it must be biological. Except nobody has ever found anything remotely convincing that biology is involved.

If, however, we look at the mind as an informational state with the capacity to get trapped in self-reinforcing states, the solution thrusts itself at us: the unhappy patient isn’t scared of frogs at all. He’s scared of how he will feel if he goes near a frog (and yes, it’s common in men). From experience, he knows that if he goes near a frog, he will feel terrible and probably make a fool of himself; feeling terrible and (especially) looking stupid are very frightening; feeling frightened feels terrible. The terrible feeling he fears is fear itself, and thus the vicious circle closes over him. All phobias and panic states follow the same mechanism. Now that’s totally different from trying to invoke biology but, like the angry obstetricians who howled down Semmelweis and drove him to his death, mainstream psychiatrists just don’t get how anything so simple as an idea can reduce a fit, strong man to a quivering, despairing wreck.

That raises the question of how his phobia started. Who knows and, quite frankly, who cares? All we need to know is that over the years, the fear has been amplified by bad experiences until now it is self-fulfilling. He only has to think of a frog or see some damp place and he starts to sweat and tremble. That is not conditioning as Pavlov defined it. As soon as that happens, he starts to terrify himself, not intentionally because nobody does that, but simply by thinking too fast and anticipating trouble. If this has been going on for years and he’s keeps losing jobs because of it and is too embarrassed to ask a girl out in case she finds out and laughs or, worse still, tells everybody, he’s likely to start thinking there’s no hope for him, he may as well be dead. Call that depression but the cause is a mental event, a fear of frogs which starts small and feeds on itself until it controls his life.

All phobias and panic states are the same, and the most common cause of a recurrent or resistant depressive state (and all its complications, including drugs and alcohol, violence and so on) is an unsuspected anxiety state. Almost invariably, these are unsuspected because nobody asks about them but, if perchance they do or the patient reveals it (definitely not common, they’re too embarrassed or misled by advertising), then the anxiety state is dismissed as “comorbid,” which is another meaningless term. So the patient will be put on antidepressants, he will get fat and lethargic and his sex life, never very good, will squeak and disappear, perhaps for life, and things will get worse. Or the antidepressants will tip him into a state of intense mental and physical agitation and he will be diagnosed as “bipolar,” where the drugs “uncovered” his genetic bipolar tendency but did not cause it as a drug effect [5, pp 124, 133], and life will get worse, especially if he’s picked up by the cops doing something dangerous, like speeding on his motorbike with no helmet, and is taken to the mental hospital and put on heavy duty drugs against his will. Then he can kiss his life goodbye. Statistically, of course, it's worse for women because nobody believes them anyway. Unfortunately, all too often, not even women psychiatrists believe them. They’re determined to show they’re as tough-minded as any of the men who dominate psychiatry, but that’s a side issue.

One thing leads to the other, everything has a cause but, if you don’t take a history, you won’t know about it. Worse, if you believe that mental disorder must be biological, then even if the patient explains all of that in great detail, you won’t believe it just because you have no idea of the power of ideas.

So let’s pull this rambling diatribe together. Orthodox science couldn’t deal with the idea of “inner voices” as they couldn’t be measured; same goes for wants, likes, regrets, fears and the rest of the mental contents, so they dumped the lot in favour of biology. In the process, psychiatrists convinced themselves they had to be objective and above all this soppy stuff so, all to often, they became heartless. The search for a biological cause for mental disorder has cost a very large fortune and has gone nowhere, as well as doing vast damage to the patients. No biological psychiatrist is capable of admitting theirs may be a search for the holy grail and should be abandoned. However, like Semmelweis’s colleagues, they are overlooking the obvious but it takes a revolution in conceptual thinking to understand it. Unfortunately, as Thomas Kuhn pointed out, the revolution won’t come from the mainstream because they will fight to retain their status and prestige. Robert Youngson, historian of science and general practitioner, concluded:

The whole history of science, right up to the present, is a story of refusal to accept fundamental new ideas; of determined adherence to the status quo; of the invention of acceptable explanations, however ridiculous, for uncomfortable facts; of older people of scientific eminence dying in confirmed possession of their life-long beliefs; and of painful readjustment of younger people to new concepts. [6, p293].

For psychiatry, the revolution is to put mental life back in control but it is a level below the very obvious words that knock around in our heads. It’s unconscious, you could say, but still us. What? Freud thought of it first? Damn his eyes.

References:

1. McLaren N (2018). Anxiety: The Inside Story. Ann Arbor, MI: Future Psychiatry Press. Amazon.

2. Scull A (2022) Desperate Remedies: Psychiatry and the mysteries of mental illness. London: Penguin.

3. Harrington A (2020). Mind Fixers: Psychiatry's Troubled Search for the Biology of Mental Illness. New York: Norton.

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

5. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders Fifth Edition. Washington DC: APA Publishing.

6. Youngson, R (1988). Scientific blunders: a brief history of how wrong scientists can sometimes be. London: Robinson.

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My critical works are best approached in this order:

The case against mainstream psychiatry:

1. 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:

2. McLaren N (2021): Natural Dualism and Mental Disorder: The biocognitive model for psychiatry. London, Routledge. At Amazon.

Clinical application of the biocognitive model:

3. McLaren N (2018). Anxiety: The Inside Story. Ann Arbor, MI: Future Psychiatry Press. At Amazon.

Testing the biocognitive model in an unrelated field:

4. 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.