For overseas readers, Australia has been shocked by an incident in a shopping centre in Sydney where a 40yo man with a long history of schizophrenia stabbed six people to death and injured another dozen before he was shot dead by police. There was apparently no warning but he had been moving around between New South Wales and Queensland, where his parents live, and had been living in his car at times, so there is a suggestion he had stopped his drugs.
There has been a huge amount of commentary since then, far more coverage than the continuing catastrophe in Gaza, and the NSW Government has announced it will give $18million toward the coronial enquiry. What will be lost in the storm are facts: that mentally-disordered people rarely commit major offences; when they do offend, it is mostly trivial; they are much more likely to be victims of crime than perpetrators; and social isolation, as in having nowhere to live, seems to increase the risk of offending.
In due course, we can expect the psychiatric research industry to put its hand out for more money to "study the problem," but nothing will come from it apart from the usual calls to spend more money on keeping more people detained in hospitals longer and on more drugs. That will be throwing good money after bad, not to mention the lives. The problem in psychiatry is not lack of money, it's where the money goes. In Australia, a large and growing chunk of the mental health budget is spent on private hospitals. My limited experience of them is that they are a total racket, allowing well-heeled psychiatrists to fleece patients, governments and insurers providing "treatment" for people who, overwhelmingly, could be managed as out-patients, if they need anything at all.
The other area where money is wasted is on the grim public wards, where patients are treated as biological specimens to be drugged and shocked until they comply. Mad in America regularly carries articles by people who have experienced the delights of public psychiatry (see this week's here) but, having seen their public wards and ours, and in other countries, I'd say they're much the same all over the world. After a cursory, box-ticking "assessment," people are simply herded into settings ranging from unpleasantly boring to terrifying, and forced to comply on the basis "You're insane, we're sane, so you do exactly as we say when we say. And arguing is proof of insanity."
Any genuine enquiry into these matters goes straight back to the question of the nature of mental disorder, which is what critical psychiatry is about. The name simply means: "Anything and everything about psychiatry must be exposed to rigorous critical scrutiny." This is, of course, standard science. There are two aspects to it. The first is what people normally think about when they hear "critical psychiatry," the process of investigating particular forms of treatment, or particular conditions, or a certain research program, etc. There are many people involved in this around the world, including Bob Whitaker, who started Mad in America, and his energetic team (I have to mention psychologist Peter Simons, it's worth subscribing to MiA for his posts alone). In Denmark, Prof. Peter Gotzsche regularly produces highly detailed reports, particularly on drugs. In the UK, Prof. John Read of East London University is slowly dismembering all the many claims made for ECT (he has an online survey here for anybody who has had ECT or knows of a friend or relative who has). In Australia, Prof. John Jureidini of Adelaide University leads the Critical Psychiatry Network of Australasia, which is still getting underway but his own publications go back years [e.g. 1].
This work is critically important. I mentioned a few weeks ago how the equal-most influential psychiatrist in this country, Prof. Ian Hickie, had claimed in a radio interview that as the rate of prescription of antidepressants goes up, so the rate of suicides goes down. That wasn't my understanding at all so I emailed him asking for evidence for this claim. I haven't been favoured with a response, perhaps because he's just seen this article, from the US Centers for Disease Control and Prevention [2]. This says that suicides in the US, which have been trending up for years, are now at the highest level since 1941. As is their rate of prescription of antidepressants. And this is what this aspect of critical psychiatry is about: do the claims made by mainstream psychiatrists reach the minimal standards of science? Far too often, they don't, as in this outrageous claim by Hickie. The trouble is, he gets away with it. He has the press knocking on his door but be assured, they are definitely not interested in anybody trying to point out where he's wrong. Which is what Peter Simons said in the article linked above: a very significant part of "research" on antidepressants is simply a marketing exercise by drug companies.
This aspect of critical psychiatry could be summarised as ensuring that the actions of psychiatrists meet minimal standards of science. Unfortunately, all too often, they don't. The other side of critical psychiatry asks: Do psychiatrists actually know what they are doing? Is it true that sadness is the sort of thing that ought to be "treated" with mind-numbing and highly addictive drugs with a vast range of unpleasant to dangerous, long-term side effects, or shocked, or whatever, or is that notion entirely wrong, as effective as head massage (but much more dangerous and expensive)? Did the tragedy in Sydney happen because the man was suffering withdrawal akathisia from drugs prescribed for a "chemical imbalance of the brain," or should his teenage problems have been managed entirely differently, so they didn't drift into permanent alienation? Critical psychiatry type II asks: What is the nature of mental disorder, because the answer to that question determines how to manage it - or whether it is the sort of thing that can ever be, or even ought to be, "managed."
Faced with these sorts of questions, psychiatry is silent. In order to answer the question, we need an understanding of the nature of mind, because that's the logical starting point. That's my interest, partly because I see it as essential and largely overlooked, but also because the first sort of critical psychiatry needs a lot of staff, money and resources, which I don't have. Which brings us to the forthcoming volume, due in July. We are trying to find a philosopher whose work could fill the intellectual vacuum in psychiatry. Specifically, we need a theory of mind that generates a model of mental disorder.
As an aside, the terms 'theory' and 'model' are not interchangeable. A theory is a higher-order concept intended to explain certain observations whose occurrence would otherwise not make sense. It is an idea suggesting an unseen and potentially explanatory mechanism (consistent with the laws of physics, etc) that could exist one dimension removed from the observations. Now if that suggestion is correct, then it should be possible to predict certain novel events or unexpected further observations. In order to test those predictions to see whether they are correct, the theory is used to build a model. While a theory is an idea, a model is a real thing, technically an instantiation of the theory. A model can be a physical thing, like a model aircraft built to test the theory of heavier-than-air flight; or it could be two laboratory rats, one with a particular disease which the researcher hopes to prove is infective by transmitting it to the second rat; or, these days, it could be a digital program such as a computer model of the theory of climate which uses today's weather observations to makes predictions for the next few days, also known as the weather forecast.
The important point is that a model is real, it exists and is used, not to make its own predictions but to test the predictions made by the theory. The theory comes first, the model is developed later; conversely, there can be no model without a theory. Psychiatry doesn't understand this elementary point and cheerfully mixes terms like theory, model, approach, spectrum, paradigm, idea, concept, hunch and so on, as though they were all the same. They're not. Strangely enough, when this is pointed out to psychiatrists, they become quite enraged and stamp off.
Part II of Theories in Psychiatry: Building a Post-Positivist Psychiatry, asks whether any of the most prominent theories of mind offered by different philosophers can be used to develop a model of mental disorder. Very few philosophers mention mental disorder and those who do are usually concerned with ethics, not so much with what mental disorder is but how we should deal with the mentally-troubled. To me, that's putting the cart before the horse because until we know what it actually is, we can't decide how to deal with it. Is mental disorder the sort of thing that will respond to having parts of the brain cut or burned? Is it the sort of thing that responds best to prayers and exorcism rituals; should the mentally-troubled by flogged until they come to their senses; or maybe they should be left to talk to their demons or jump off bridges if they choose? These are not trivial questions, not least because how we deal with mental disorder says a lot about what sort of society we are (and yes, the evening news tells us exactly what we are but that's another issue). But back to the philosophers.
As mentioned last week, philosophers Noam Chomsky and Daniel Dennett in Boston, MA, treat each other with frosty disdain but there is more to the world than their small state. Far away in California, John Searle (b. 1932) has held forth at UCal, Berkley, for well over sixty years. His position is absolutely clear: he accepts the mentality of mind as a real thing that we can work with, but is sure it's biological in nature, such that standard laboratory science will tell us all we need to know about it. For somebody who has had no training at all in science, he is making what nervous peoplethey call a bold claim. The trouble is, he doesn't justify it. He simply repeats the claim, over and over again, in different ways in different works, and leaves it dangling. This is what is called "promissory materialism," meaning "I promise that materialism will deliver the goods." There are a lot of people who agree with him and have managed to convince governments around the world to pour vast sums of money into their pockets, with nothing to show for it. Those of us who say it's wrong are generally unheard over the stampede of people trying to get their noses into the trough.
I say Searle is completely wrong, and the reason is quite clear: he is trying to explain the mentality of mind in non-mental terms, i.e. he is an antidualist, which is what you'd expect from somebody who got all his degrees from Oxford University (as did Dennett, but see Chap 13, on Gilbert Ryle, still to come). There is no prospect that the work of John Searle will throw any light on mental disorder.
Moving on, we come to a peripatetic Australian philosopher, David Chalmers, again a graduate of Oxford but he started his career in Adelaide as a mathematician with an enduring fascination for computers and science fiction. Chalmers goes against the antidualist tide that has swept the world for a hundred years, arguing that the concept of the mind as a non-material entity is not just common sense but we can derive a rational account of it, called natural dualism. According to Chalmers, it is not, as Dennett sneers, nonsensical to say mind and body are of different orders of nature and can interact. However, since Chalmers gives no details of how mind arises from the body or their mode of interaction, he can't say anything about how the mind could go wrong. Still, his case that the mind is real, natural and causally effective is plausible. That's more than can be said for his latest project.
In his most recent book, Reality+: Virtual worlds and the problems of philosophy, Chalmers dumps his intellectual ballast and floats off into the wild blue yonder. His reviewers were ecstatic over it. One of them said: "Fasten your seatbelt and put your helmet on, Chalmers is going to take you on an amazing trip. Reality+ is wild, profound and playful..." Yeah. Right. I say: Reality+ is the book Chalmers would have loved to have read at age 14, when he was up to his ears in computer games, science fiction and fantasy and all that. In it, he gives a New Age gloss to creation myths that will appeal to bright but irritating 14 year olds. Essentially, it is a creation myth à la mode, and it fails for much the same reason that all creation myths fail: they're Just So stories. If you enjoy swinging playfully from a skyhook, you can join the queue of people showering praise on Clever Mr Chalmers but it goes nowhere. Otherwise, you can sit with me and all the other curmudgeons bemoaning the fact that, like all creation myths, nothing Chalmers has written gives us any point of entry to the very large and unplayful question of mental disorder. Like why people stab strangers in a shopping centre. Grimly, or maybe glumly, we soldier on.
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References.
1. Le Noury J et al (2015) Restoring Study 329: efficacy and harms of paroxetine and imipramine in treatment of major depression in adolescence. BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4320 (Published 16 September 2015). At: https://www.bmj.com/content/351/bmj.h4320
2. Curtin SC, Garnett MF, Ahmad FB (2023). Provisional Estimates of Suicide by Demographic Characteristics: United States, 2022. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System; November 2023. https://www.cdc.gov/nchs/data/vsrr/vsrr034.pdf
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This comes from a semi-retired psychiatrist with half a century of experience at the rough end of psychiatry:
McLaren:
‘ …but nothing will come from it apart from the usual calls to spend more money on keeping more people detained in hospitals longer and on more drugs. … My limited experience of them is that they are a total racket, allowing well-heeled psychiatrists to fleece patients, governments and insurers providing "treatment" for people who, overwhelmingly, could be managed as out-patients, if they need anything at all.’
Stampfer:
I have long been banging the table to say that at least 80% of inpatients at any time could have been treated as outpatients, only to see nothing change. However, I don’t think the persistence of the trend can be attributed solely, of even mainly, to psychiatrist self-interest. It is very much a two-sided arrangement/collusion between psychiatrist and patient, both in the public and private sector. Things have changed a lot since the time we started out training. Back then patients wanted to sue shrinks for detaining them, today they want to sue them for discharging them!
Discharging patients has become a stressful and problematical matter. Patients will openly say, ‘you discharge me, and I will commit suicide and name you in my suicide note’. Fear of adverse outcomes, whether deliberate or by misadventure, has made psychiatrists not infrequently seek a second opinion about discharging someone and I have been asked to provide such an opinion on several occasions. Some patients have had to be literally evicted from the ward with the help of security guards.
Family members are often worse than patients when it comes to discharge. Parents and other family members have not infrequently lodged formal complaints about someone in the family being discharged too soon. Too many parents want their wayward children hospitalized for at least one year … to stop them taking drugs! Parents recently reported me to ahpra for discharging their drug-taking son too soon, even though there was no justification for detaining him. Thankfully nothing came of it but I’m sure you would understand how the paperwork involved in having to justify my decision, caused me to suffer an emotionally driven bowel movement.
Not only do patients want to remain in hospital far longer than can ever be justified (and for obvious reasons) but far too many insist in being maintained on their largely useless medications – because taking them helps to define the severity of their illness and need to remain in hospital! I have on many occasions persuaded patients to come off their useless medications when they were inpatients, only to discover they were back on the very same medications and often a few more, when they returned to outpatient follow-up.
My bottom line is that it’s not just greedy, self-serving shrinks - patients and their relatives contribute at least equally in perpetuating unnecessary inpatient treatment and persistence with ineffective medication that only achieves side effects.
Andrew Amos is bravely writing some interesting stuff about psychiatry in Aus in relation to the transition of children and prescribing puberty blockers and hormones. It great to see someone in the profession finally speaking up about this. Have you read the Cass review? Would be interested to hear your https://open.substack.com/pub/freudsrazor/p/madness-and-gender-medicine-boundaries?r=16o8fg&utm_campaign=post&utm_medium=web&showWelcomeOnShare=true