THE AGE OF FRAUD (Part 2)

Can psychiatrists justify what they do?

THE AGE OF FRAUD (Part 2)

Despite impressions, science is conducted according to rules. Some are procedural, on how to go about the business of research; some are ethical, on what is permissible and what is not; there are plenty of financial rules, of course, and then there are the epistemological rules, meaning rules relating to what you can know and believe. Last week, I introduced the epistemological structure of science, of what you can believe and the order of beliefs.

All of this sounds a bit far out but it is actually of critical importance: science is not just a matter of "anything goes." Lives depend on it, our way of life depends on it. In medicine, which is actually an applied science or technology, the rules are strict, and rightly so. You want to know that the drugs you are prescribed do what they are supposed to do and nothing else; if your child needs an operation, you need to know that the surgeon and nurses are fully qualified, the tests are accurate, the anaesthetist's drugs are safe and reliable, and so on.

When it comes to psychiatry, my belief is that the rules apply even more strongly, that there should be less wriggle room, not more, because people have little or no choice. A person can decide not to have an operation or chemotherapy, or to decline vaccination, but people detained under mental health acts don't have that choice. Instead, they are stripped off practically the whole of their human rights. In practice, they are totally at the mercy of the psychiatrist, which leads to another topic but we'll cover it in a few weeks. Today, I want to look at the question of whether psychiatrists actually know what they are claiming to know.

Briefly, we saw that our scientific beliefs and procedures fit into a structure, with the broadest and most general belief, one's ontology, at the top of the pyramid; underneath sits the paradigm, then the theory and finally the model. In psychiatry, the paradigm is materialist, which says that everything in the universe can be studied reductively, i.e. that mental disorder will reduce to a matter of brain chemistry, with no questions left unanswered. This is what psychiatrists believe, this is where the research money goes and this, of course, governs treatment. So if you're depressed, it's because you've got a genetic defect of brain function which can only be treated by some form of physical treatment such as drugs, ECT and lately, magnetic stimulation (TCMS), with brain surgery and implants eager to join the party. For a mainstream psychiatrist, there is nothing to be gained from talking to patients about their problems because everything that counts is determined by genes, and genes aren't affected by talking (this is actually wrong, but we'll leave it aside for now). Our concern is: How much truth is there in this set of beliefs?

Last week, I said: "Biological psychiatry is a paradigm dangling from a skyhook, an ideology of mental disorder which has never been justified." There is no formal, or even an informal, theory of mental disorder that leads to a model of treatment. There is no theory of personality that tells us the difference between mental disorder and personality disorder. And there is no model of mental disorder that justifies physical treatment exclusively. The whole thing is a belief system only, aka ideology. But, of course, it is a belief system that generates vast sales for the drug companies so it has a lot of momentum. And a lot of that money is showered on psychiatrists who are happy doing the sort of research that drug companies like.

However, that's not all psychiatrists. There are plenty who still feel there's more to people than chemicals whizzing around the darkness inside their heads. Most of these will say they rely on a particular model developed for psychiatry that incorporates biological, psychological and social elements, one that allows them to see the patient as a whole. What is known as the biopsychosocial model (BPSM) was published in 1977 by a psychiatrist from Rochester, NY, called George Engel, and is now widely followed by all but rigid biological psychiatrists. It is taught in medical schools, there is an extensive literature for those who want to know more, and there is enthusiastic support for it, as the following quotes show.

In October 1998, the Royal Australian and New Zealand College of Psychiatrists (RANZCP) adopted it as their guiding principle:

By virtue of their specialist training, (psychiatrists) bring a comprehensive and integrated biopsychosocial approach to the diagnosis, assessment, treatment and prevention of psychiatric disorder and mental health problems… An integrated understanding of the biological, psychological and social aspects of mental health problems enables psychiatrists to recognise and treat both the physical and emotional effects of psychiatric disorder (RANZCP, 2002).

For years, the website of the Canadian Journal of Psychiatry said its goal was to publish material on the BPSM. Writing in the journal Philosophy, Psychology and Psychiatry in 2008, New York psychiatrist Bradley Lewis said:

... Engel’s (BPSM) has achieved worldwide recognition as one of the most influential developments psychiatry and medicine. Unveiled in 1977 as a comprehensive and integrative alternative to the dominant but highly restrictive biomedical model, the (BPSM) has become a beacon for a balanced and humanistic approach to clinical encounters. Indeed, it has become a beacon for the soul of medicine and psychiatry in the twenty-first century.

In his book published in 2009, Nassir Ghaemi from Tufts University in Boston said:

The biopsychosocial model is the conceptual status quo of contemporary psychiatry.... The mainstream ideology of contemporary psychiatry is the biopsychosocial model.…

In 2014, Allan Frances, chairman of the DSMIV committee, of Duke University was clear:

...(Engel's) biopsychosocial model of mental illness and mental health care created a conceptual underpinning that unified psychiatric practice...

Linda Gask in the UK, 2018, saw a more general role:

...the biopsychosocial model is, and remains, a model for the whole of medicine—not just psychiatry.

The well-known American psychiatrist and editor, Ronald Pies, also of Tufts, has never been in any doubt:

...academic psychiatry—for at least the past 30 years—has advocated a “bio-psycho-social” model of mental illness, as originally proposed by Dr George Engel... This position has been quite consistent.... (Affective) disorders are best understood using a bio-psycho-sociocultural model, which has been the mainstay of academic psychiatry for over 30 years (Pies 2019).

I could go on but you get the drift: the BPSM is uniquely psychiatric and confers on psychiatrists the same level of theoretical legitimacy, not to mention sophistication, as mainstream medicine. If you go to a psychiatric conference, you will hear this term repeatedly; if you attend a mental health review tribunal hearing, you will probably hear the psychiatrist use it in explaining why the hospital's treatment is justified; in medical schools and in training programs for psychiatrists, it is invoked freely. Such a pity, then, that there isn't a word of truth in it.

Engel's original paper, The need for a new medical model: a challenge for biomedicine, was published in the prestigious journal, Science, in 1977. Engel was a gastroenterologist, not a psychiatrist. He had spent several years in psychoanalysis, which influenced his thinking, but he didn't think much of psychiatrists. His paper was directed at general medicine, not at psychiatry, and he rarely spoke about mental disorder. All he said was: "Mainstream biomedicine treats people like lumps of meat so we need a need a new medical model that can incorporate psychological and social factors." That's it. He named it, but he most certainly didn't write it. The whole of his paper is conducted in the future conditional tense, as in "If we had a BPSM, then we could..." or "If such a model becomes available, it will change practice..."

So all the joyous praise quoted above has been directed at a phantom, an illusion, a mirage. Does mainstream psychiatry know this? Yes, they most certainly do. They have known since April 1998, meaning six whole months before the RANZCP adopted the BPSM as their guiding light, as my paper published in the main RANZCP journal explained all this [1]. A dozen times since then, papers have been published arguing the same thing but they are ignored. In various papers and at conferences, I have challenged many psychiatrists, including some of the people quoted above, to produce something that Engel wrote that amounts to a model. Not one has responded, not even to say "You have misunderstood me" (they're usually quick to say that, not so quick when their errors are pointed out). But still mainstream psychiatry trumpets that it has this wondrous model that nobody else has (and nobody else understands) because.... because why? Because they haven't got anything else, that's why. Their intellectual cupboard is bare.

Specifically, what they are claiming is that they have a formal, fully-articulated model, publically available and open to criticism, that explains mind-body interaction, and how their model of mind leads to a testable model of mental disorder and a research program, and hence justifies their treatment. When it's put like that, it's clear they don't. As a group, psychiatrists know next to nothing about the normal mind. They're not taught it, they don't read philosophy (of mind, or of science), normal psychology is a closed book to most of them, they don't keep up to date with neurobiology, and very few know any sociology beyond a few names to drop in conversation. Above all, they don't have a model of mind-body interaction because nobody does (not quite true, there is one but they don't know about it).

So what's the game? Why do they keep saying something exists when Blind Freddy can see that it doesn't? Can't they read? Well, be careful with that. Psychiatrists normally only read stuff that agrees with their views, and psychiatric journals rarely publish criticism. My paper from 1998 was held up for two years while the editors argued over it, then they got two reviews which panned it, but they never let me see them beforehand (both authors were wrong) and refused me the right of reply. OK Houston, we have a problem.

At the top of this post, I said science is governed by ethical rules, and these certainly apply to scientific publishing. Editors should not publish a paper to say the BPSM exists when there are numerous papers in the scientific record saying it doesn't. At the very least, the question has to be sorted out. Professors should not teach medical students there is a BPSM when they know, or ought to know, that they have never seen anything like such a model. Psychiatrists should not say in tribunal hearings that they are giving ECT to an involuntary patient in accordance with the BPSM when they can't produce it. So are psychiatrists just stupid? Most of them aren't, they can read perfectly well although they certainly don't like to read critical stuff. This raises a serious question: is there something else going on? How come intelligent, well-educated people consistently and persistently insist that something is true when none of them has ever seen it or can produce it. In the third and final part of this series, we will look outside psychiatry for an explanation.

My original paper was:

McLaren N (1998). A critical review of the biopsychosocial model. Australian and New Zealand Journal of Psychiatry. 32; 86-92.

Revised version: McLaren N (2010). A life of its own: the strange case of the biopsychosocial model. Chapter 7 in Humanizing Psychiatrists: Toward a Humane Psychiatry. Ann Arbor, Mi.: Future Psychiatry Press.

Most of the citations I've mentioned above are in:

McLaren N (2020). The Biopsychosocial Model: the end of a reign of error. Ethical Human Psychology and Psychiatry. 22:71-82.

I will be posting a list of my publications before long. The early books are now out of date so they're being revised and shortened, then they'll go out of print.

From time to time, I'll post a link to a book or journal article worth reading, as well as some links that provide helpful information or background.

I am not able to give any individual psychiatric advice beyond this: Psychiatric drugs meet every known definition of addiction. If you are taking psychiatric drugs, do not under any circumstances stop them abruptly as you are likely to go into a severe and potentially dangerous withdrawal state.