No Pain, No Gain.

For a muscular philosophy.

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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John Read is professor of psychology at University of East London but is less interested in psychology’s traditional focus on “rats and stats” than on what psychiatrists are doing. In particular, he studies ECT: has it been researched properly, is it effective, how do people react to it, and so on. Recently, he and his team have published a series of papers based on a large international survey of people who have received ECT and their families. They have recently published another on the perceived positive and negative effects [1], and one of the team has published an article on MIA. This was not your usual survey which tells people what answers they’re allowed to give but simply asked:

‘Please name up to three positive effects of your ECT, if any’ and

‘Please name up to three negative effects of your ECT, if any’.

3% of the responses reported only beneficial effects, such as improved mood, or reduction in suicidal ideas or psychotic symptoms. 46% reported a mix of positive and negative effects but 51% reported only negative effects. In all, 97% reported some adverse effects of the ECT. The paper, which is free to download (link below), gives many examples of how people felt their lives were made worse. The important point here is that, as reported a few months ago, nearly half of people said that following ECT, their quality of life was “much worse” or “very much worse” [2]. This is a problem as the traditional medical oath says: Primum non nocere. First, do no harm. According to the “consumers” of ECT, it does a lot of harm such as wiping out people’s memories of their childhood or, much worse, erasing their memories of their children’s childhoods. Why is it still used? In my view, the answer to that is not a matter of science but of the sociology of psychiatry [3; this paper includes all the following figures].

ECT is widely used in Australia, for example, the state of Queensland, population 5.5million, uses more ECT than the England-Wales division of the UK NHS, population about 55million. In the UK, ECT usage has declined by 90% since 1980; in Australia, it is going up and up, including nearly doubling in West Australia in the 10 years to 2016. ECT is given for “treatment resistant depression” or as an emergency, to save life or sanity. Most of it is given in private practice, mainly to middle-aged, middle class women with private insurance. They just happen to be the group with the lowest suicide rate; the group with the highest rate, young men, hardly get any ECT. They also have the lowest rate of private health insurance. This is all justified by the RANZCP which has a very active section who think mental trouble is best managed by electricity. The college itself says ECT is:

Safe; effective; essential; irreplaceable; an established and valuable treatment that should always be available when clinically indicated; important and necessary treatment; an injustice if unavailable; doesn’t cause brain damage; no long-term ill effects; the only alternative for many patients; and much of the opposition to ECT is based on fear and irrational thinking, not science [3].

Phew. No wonder it’s used so freely in Australia and parts of the US but what about the rest of the world, groping in the darkness of prescientific thinking? The key to answering that lies in a large-scale review published in 2012 [4] which charted how ECT is used worldwide. The first and most important point is that there are places in the world where it is banned. According to the RANZCP, they’ve been overwhelmed by fear and irrational unscientific thinking but in fact, they refute everything the college claims for ECT. There are also lots of places in the world, some of them such as Norway and Italy quite civilised, where it is severely restricted or simply not available without considerable inconvenience, so people don’t bother. They muddle along somehow. In places where it is used, there are always huge differences from one region to another or even one part of a city to another. The state of Victoria, for example, uses ECT 600% more than New Zealand, which has the same climate and exactly the same demography in all respects. The only significant difference is that New Zealand has practically no private psychiatrists.

Based on the results of the survey by Read and his team, there is no doubt that if ECT were invented today and submitted to proper testing, which it never has been, it would not be approved so why is it still used? Psychiatrists can choose from only three conceivable justifications for using ECT. They may say:

1. I believe all mental disorder is physical in nature and therefore requires physical treatment, such as drugs or ECT; or

2. I have reached the limit of my skill set; I don’t know what else to do; or

3. It pays well.

Option (1), that mental disorder is all physical, is not only an unproven ideology, there are convincing reasons to believe it can’t be true, it is logically contradictory [5]. Option (2) flows from the first, in that psychiatrists with little training or experience in psychotherapy (most of the moderns) will quickly run out of ideas and will reach for the electrodes. Option (3), that the money is unbeatable, is a winner. For psychiatrists in private practice, ECT is extremely lucrative. They can pull in up to AU$250 for something that takes about 5 minutes, most of which is spent waiting while the rest requires no more intellectual effort than opening a can of beer. A dozen of those on a Monday morning gets the week off to a great start.

Psychiatry’s “institution” of ECT relies on nobody doing the proper studies to justify it. Why haven’t they been done? Because only a “true believer” will want to go to all the trouble of applying for a grant and setting up a large-scale, multi-centre, long term (20 years) survey to decide whether we need ECT or not. However, true believers shape the studies to deliver the results they want. To make it worse, all the people sitting on the grants committees and the ethics committees and so on are true believers. They’re like the people who get themselves on mental health tribunals: they’re all committed to the idea that “mental people” have to be treated firmly for their own good, even where it means locking them up long term and holding them down for their “treatment.” The fact that, as Read’s group showed, for a sizeable proportion of people, this is seriously traumatising, not to mention degrading and humiliating, doesn’t get a mention: if they don’t want treatment, that just proves how deranged they are. If they complain, they obviously need more, as a Sydney anaesthetist reported:

The consequences (of ECT) were dire. Retrograde memory loss was profound. I was devastated and searched for answers where my treating doctors could give none.... I was left then to claw back a life only half remembered [6].

According to the RANZCP, the good doctor’s complaints are due to fearful, irrational and unscientific thinking and should be ignored.

There is no other field in medicine, or indeed in science as a whole, that can get away with this sort of thing, which leads to the crucial point: how do they do it? How can they say it doesn’t cause brain damage and has no long-term ill-effects when 49% of people say it made their lives “much worse or very much worse”? This is unbelievable but it takes us out of the field of ordinary science into questions of what psychiatrists are thinking, i.e. the sociology of psychiatry and its philosophical underpinnings. Thus it was with considerable interest last week, that I tuned into a seminar on philosophy and psychiatry run by the college’s section on philosophy. It featured two speakers from the UK, a professor of philosophy and psychiatry and a researcher, as well as one psychiatrist from NZ and one from WA on the topic “Philosophy - and why philosophy now for psychiatrists.” It consisted of a half hour ramble from the professor, with the other speakers adding bits here and there, on how interesting philosophy is and how psychiatry is leading the field in introducing something called “values-based practice.” He illustrated what this meant by a long story about a lady who was booked for a knee replacement but didn’t end up getting it because she wanted her mobility restored whereas the operation is good for pain relief but not mobility, so she decided she would rather put up with the pain which was then successfully treated with physio and tablets.

This says that what patients believe and want for their lives should be taken into account, a partner, as it were, to what is called “evidence-based practice.” The evidence base is the scientific stuff, i.e. what works and doesn’t work, and why. This has to be integrated with what could be called people’s “irrational fears and unscientific thinking” about mental disorder. There is a lengthy and highly biased editorial from nearly 20yrs ago announcing the birth of this hybrid which concludes:

Psychiatry, therefore, in being first in the field with policy, training, and research developments in values-based practice as an essential partner to evidence-based practice, is leading the way towards a medicine for the 21st century that is both firmly science-based and also genuinely patient-centered [7].

Great. Perhaps this is a step along the path leading away from coercive, custodial treatment toward what the UN Commission for Human Rights calls “rights-based practice.” That it, we have to get rid of all coercion in psychiatry and base our practice on people’s human rights [8]. Except psychiatrists don’t want it [9]. In fact, they get very angry when people talk about closing the nuthouses and banning ECT [10] and allowing patients to choose what treatment they want and who they see. Choose who they see? What next?

I sat through 75 minutes of this “seminar” but all we were told is how exciting and stimulating philosophy is and how it leads to lots of joyous discussions with colleagues on the delights of exploring ideas such as integrating what is called “lived experience” into mainstream psychiatry (i.e. listening to people who have been on the receiving end). There was none of what we might call “philosophising,” i.e asking sticky questions and demanding answers. My experience of trying this is that you will get kicked out of the meetings. After clicking off the seminar, I was reminded of a cartoon in Punch many years ago, where a man, obviously a common council worker, was standing at a counter while a very glamorous young thing stared imperiously at him around a sumptuous drape. “How dare you come into this boutique and shout ‘Shop’?” she demanded. Now I understand how psychiatrists who claim to be interested in philosophy are actually hostile to sticky questions, as in “How dare you come into our charming civilised meeting and shout ‘Bullshit’?” They like the idea of listening to patients complain about their treatment, they just don’t like patients who complain. They like the idea of integrating patients’ values into their treatment, as long as the patient’s values are the same as the psychiatrist’s. They like the idea of a “rational, evidence-based scientific psychiatry” as long as they get to define what evidence is scientific and what is the product of fearful and irrational antipsychiatry propaganda. That’s not philosophy as I was taught it. Moreover, the idea that philosophy is joyous and exciting and stimulating is pure crap. People who say that sort of thing don’t know what they’re talking about. It’s as Orwell said of writing:

All writers are vain, selfish, and lazy, and at the very bottom of their motives there lies a mystery. Writing a book is a horrible, exhausting struggle, like a long bout of some painful illness. One would never undertake such a thing if one were not driven on by some demon whom one can neither resist nor understand (From Why I Write, in Decline of the English Murder).

He could have been talking of philosophy: it’s horrible, drives you mad, forces you to stay up late searching through ancient books or reading the latest bit of drivel from some pretty face who makes squillions on the lecture circuit spouting uplifting tosh that appeals to the insecure and self-indulgent, just so you can show where he’s completely wrong, if not a charlatan. Like Deepak Chopra, who has just been defenestrated in the Epstein fallout (I love it, always thought he was a crook). Philosophy is as they say in the gym: No pain, no gain.

A philosophy seminar is like a boxing match: you either come out feeling bruised and battered with a fleeting sense of victory, or you come out bruised and battered and defeated, plotting vengeance. There’s no in between, no shades of grey. For example, in the college’s warm little bubble of mutual back-scratching, was there any discussion of how human values are to be reconciled with psychiatry’s positivist base, which says that values are metaphysical rubbish and can be ignored? Nope. If a patient doesn’t want ECT, how is that reconciled with his or mostly her right to refuse it? No mention but we know she’ll get it anyway. Any thought as to how Australian psychiatry is driven by something called the biopsychosocial model, the one that doesn’t actually exist? Crickets. And the biomedical model, what about that? Oh, we’ve just run out of time, have we? We always do.

I could go on but it gets boring. The whole point of what the chair called an interesting and informative and stimulating seminar is not to cause anybody your actual discomfort but to reassure each other that yes, we’re so civilised and so aware, we can tell our shiraz from our merlot while talking vaguely of human rights. That’s not critical analysis. Terms like “excellent work” and “fascinating and informative” are code for anodyne, non-threatening bilge that gives everybody the warm fuzzies and replaces the bedtime mug of Milo. Non-threatening is the operative term. Psychiatrists do not like threatening philosophy. Socrates’ gruesome end we know about; Spinoza was declared dead by his community and nearly ended up that way; Descartes fled to escape the Pope’s guardians of virtue; Voltaire was chucked in the slammer half a dozen times for insulting royalty with his questions … It reminds me of another cartoon, this one from Playboy long ago, the “Grandma” series. Grandma is lying déshabillé on a chaise while a rather angry young man looks down at her. “So whaddayer want, sonny?” she asks coquettishly. “Good taste or good grandma?” That’s what these people have to answer: “So whaddayer want, mate? Good taste or good philosophy? Take yer pick coz yer won’t get both in the same sentence.” We know what they’ll say: Let’s talk the talk but (shudder) don’t make us walk the walk. We love to talk about human rights and values in abstract but you’ll still get the ECT you don’t want.

References:

1. Read J et al (2026). The self-reported positive and negative effects of electroconvulsive therapy: an international survey. Journal of Affective Disorders Reports. 24:i0i008. At https://doi.org/10.1016/j.jadr.2025.101008

2. Read J, Arnold C (2017). Is Electroconvulsive Therapy for Depression More Effective Than Placebo? A Systematic Review of Studies Since 2009. Eth. Hum. Psychol. Psychiat. 19: 5-23.

3. McLaren N (2017). Electroconvulsive Therapy: A Critical Perspective. Ethical Human Psychology and Psychiatry 19: 91-104. DOI: 10.1891/1559-4343.19.2.91.

4. Leiknes, K.A., Jarosh-von Schweder, L., Hoie, B. (2012). Contemporary use and practice of electroconvulsive therapy worldwide. Brain and Behavior. 2(3): 283–344. doi: 10.1002/brb3.37

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

6. McPhee, I. (2009). When doctors get sick. Radius (Sydney University), Autumn 2009: 10-13. At: http://sydney.edu.au/medicine/news/pubs/radiuscontents/2009/March/22_1_coverstory.pdf

7. Fulford KWM (2008). Editorial: Values-Based Practice: A New Partner to Evidence-Based Practice and A First for Psychiatry? Mens Sana Monogr. 2008 Jan-Dec;6(1):10–21. https://pmc.ncbi.nlm.nih.gov/articles/PMC3190543/

8. UN OHCHR/WHO (2023): Mental health, human rights and legislation: guidance and practice. Geneva: WHO/UNHCR. https://www.who.int/publications/i/item/9789240080737

9. Hickie, I, (2019). Building the social, economic, legal, and health-care foundations for “Contributing Lives and Thriving Communities”. The Lancet Psychiatry. https://doi.org/10.1016/S2215-0366(19)30378-5

10. Abrams, R. (2000). Letter: Use of ECT in Italy. American Journal of Psychiatry. 157: 840.

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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.