To Fool or Not to Fool.

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.

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You can fool too many of the people too much of the time (James Thurber: “The owl who was god,” in A Thurber Carnival, 1945).

In a comment on last week’s post, a reader referred to psychiatry as “an abusive western cult” with a “toxic pill” for any and all deviations from some undefined social norm. Perhaps the reader has cause to be dismayed, I don’t know, but the point can’t be dismissed as there is absolute proof that psychiatry has at least one major feature of cults: psychiatry is never wrong. As an institution, psychiatry puts forward one particular point of view, that all mental disorder is due to physical disorders of the brain, and the whole of society has to accept this without question. There is no evidence for this, only an airy wave in the direction of something called the “biomedical model.” Since nobody has ever seen it, it is accepted as an article of faith. Similarly, if a psychiatrist says the patient must take a particular form of treatment but the patient declines, then the psychiatrist simply signs an order certifying the patient as insightless, and s/he gets it, regardless. Once the diagnosis and treatment decisions are made, anything the patient says or does is taken as confirmation.

The parallels with the era of witchcraft are chilling [1]. Based on a single reference in the Bible ((Exodus 22:18. Thou shalt not suffer a witch to live), in 1484, Pope Innocent VIII ordered everybody to believe in witches. Witches were seen as the cause of all sorts of woes and ailments but anybody who scoffed was punished as an agent of witchcraft or satanism. Once the accusation was made, anything the victim said or did confirmed the charge. There was only one possible outcome: a bonfire. This was because witches were diabolically clever and nothing they said could be trusted. It was safer to burn a wrongly-suspected witch than to leave a genuine one at large, as God would sort them out. Psychiatry is similar: failing to diagnose and treat a case of mental disorder is a much worse offence than treating a normal person as mentally-ill (for the record, Thomas Szasz was of the view that psychiatry is the same social phenomenon as witchcraft; in my view, he got it completely back to front [2, Chaps for extensive references]).

How does psychiatry get away with it? Very simple: keep the whole practice of psychiatry at the level of opinion. Never provide a formal model of mental disorder that “unbelievers” can read and analyse, and never provide an objective test that can over-ride opinion. This way, the opinions of psychiatrists always carry more weight than the opinions of non-psychiatrists. For most of human history, majority opinion has been that all mental disorder is a brain disorder. In the West, there was a period of perhaps fifty years last century when people broadly accepted the Sigmund Freud’s psychoanalytic model, which says that mental disorder is mental in origin. However, even that had practically no impact on the great bulk of mentally-troubled people as the heyday of psychoanalysis coincided with peak use of ECT, insulin coma treatment and of psychosurgery. The last traces of Freudian influence on mainstream psychiatry disappeared in 1980 when the dramatically-revised DSMIII was launched. Since then, it’s been biology, biology, all the way (for a brief account of the level of psychiatry’s intellectual development, see [3, Chap. 2]).

At present, practically all professors and other “key opinion leaders” have been raised in a pervasive biological ethos that they accept as both factually correct and complete. According to Thomas Insel, former long-time director of NIMH, there’s no point questioning it: “… the biological model (of mental disorder) is sufficiently entrenched to ignore criticism and commit psychiatry to a new reductionist program ...” [4]. Apart from a few loose ends to sort out, they’re satisfied that psychiatry is finally and definitely on the home run. For example, the omnipresent Prof. Ian Hickie told an interviewer last year that we don’t become mentally-disordered because of adverse life events, it’s the other way around. A person’s genetic make-up causes them to have a mental disorder which, in turn, causes the bad life events. He is very comfortable with this surprising notion. It’s a bit unexpected then that we’re now starting to see a few doubts creep in. Small doubts, of course, but still doubts.

The first is psychiatry’s sudden lurch down the well-trodden path of using psychotomimetic (hallucinogenic) drugs as an aid to psychotherapy. Reprising the 1970s (but unfortunately without the brilliant music), psychiatrists are inviting all comers to try their remarkable recycled drugs, MDMA (a methamphetamine, BTW), psilocybin (mushrooms) and ketamine (an anaesthetic agent). There is some evidence that they can help people adjust to traumatic memories but this comes after decades of psychiatry pouring scorn on the idea of talking cures: “Talking? How can talking change your genetic make-up? Ridiculous.”

In an amazing about-face, private psychiatry has discovered there has always been a very large gap in the treatment they offer, and hallucinogens fill it neatly. Very neatly if you look at all the money they’re pulling in, anywhere up to AU$25,000 for the typical punter, or a lot more depending. Sure, the psychiatrist has to provide a nurse to assist and lovely surroundings for the trippers to loll about it, and don’t forget the psychologist. Psychologists? How do they get a look in? Well, who do you think is going to provide the psychotherapy? With very few exceptions, the great bulk of psychiatrists have little or no training, experience or, above all, interest in psychotherapy. The few who have maintained an interest or practice over the past half century have been marginalised and disdained. After 50 years or more of touting their so-called ‘biomedical model’ (the one they can’t find), psychiatrists have suddenly changed horses and are heading in the opposite direction, and they expect nobody to notice.

For those who aren’t keen on hallucinogenic drugs, there’s always conventional psychotherapy which, after years of neglect, is being dragged out and dusted off. Most of the time, the clever people at Psychiatric Times get excited about drugs and ECT and TCMS, and if that doesn’t work, more drugs. However, they have recently published a couple of articles on the value of psychotherapy and why psychiatrists should “brush up their skills” in this field (here, here, here). Even though their editors and committees have no official standing in US psychiatry, they’re still very close to all the “heavy hitters” and are in touch with the latest trends. If they’re saying “Hey, what about we resurrect psychotherapy?” then, far down in the murky underworld of psychiatry, something is happening. That something, I suggest, is a slowly growing awareness that all is not well in the world of biological psychiatry.

Rather abruptly, the general public are no longer demanding a pill for all ills, in fact, they’re starting to whisper that maybe the ill lies in the pills. More and more, they’re asking how they can safely get off the drugs; others are complaining that the side-effects are often worse than the original problem. Then there’s the cost of drugs and all the rest as well as the not inconsiderable point that they don’t actually work. Despite decades of hype, they don’t cure anything (see Peter Gotzsche in this week’s MIA for a masterly unpacking of the propaganda). All in all, where once the masses queued eagerly for the latest drugs, there are mutterings of discontent. To top it off, the new Secretary of Health in the US actually thinks people could be better off with fewer drugs. Add to this the occasional muted admissions by drug companies that they don’t actually have any new “blockbusters” in the pipeline to replace the current lot when their patents expire. Some, indeed, have given up on psychotropic drugs just because neurobiology isn’t indicating any new directions.

Compounding the mess, after years of being told everybody needs more pills, it seems psychiatrists can’t keep up with the demand they inflated, so general practitioners are being enlisted to dish them out. We all know where that ends: a brief chat with an AI bot, tick a few boxes and out pops your script. In simple terms, if all psychiatrists do is dish out pills, who needs psychiatrists? As Thurber said, you can fool a lot of people for a long time, except that one day, it stops working. The magic of psychiatry always being “on the cusp” of great breakthroughs wears off, the stirring music stops, the fluorescent lights come on and people wake up to the grim fact that they’ve been taken for a ride by experts. At vast savings in time, money and inconvenience, psychiatrists can be cut out of the loop entirely. Everything suggests they won’t be missed.

Don’t, however, expect a formal statement from the big beasts of the psychiatric jungle that everything you were told in the past is wrong, that all the old fossils have been retired and that the new management apologises for any inconvenience or unnecessary suicides. There will no revolution, that’s not how it works in academia in general or in psychiatry in particular. No professors will lose their jobs for being wrong, there will be no heads on pikes by the university gate. Instead, there will be a smooth, almost imperceptible change of direction, a change of beat but the same old musicians will keep playing much the same tune to the same television cameras. A few words in the chorus may change but the power structure won’t.

Above all, just as there was no apology for the horrors of insulin coma treatment or psychosurgery, there will be no apology for misleading the public. Today’s professors who have been pushing their biological barrow for decades will still be grinning to the cameras, delivering the same core message: “Trust us, we’ve got mental disorder by the ear. Psychiatry has made enormous progress in understanding and treating mental disorder and our latest breakthrough in …… (fill in as required) means millions of sufferers can look forward to a life free of symptoms.” Anybody who is so tasteless as to remind them “But you said that last year about X and now you’re telling us X isn’t true,” will get the suave, indulgent smile: “Yes, that’s because science progresses, we’ve progressed and you have to keep up as well.” But no apology.

This is exactly what happens in cults. There is a widespread notion that cults are about swivel-eyed gurus locking their gullible followers into loopy ideas but that’s not quite right. The ideas are only the leader’s tools in trade, that’s what he uses to get the punters in. The real purpose behind any cult is for the leader to get absolute control over his devoted followers. Granted, he believes his ridiculous ideas but they’re subject to change without notice. One day, he announces he has had a further revelation and points his devotees in a different direction or after a different enemy. Most important of all, they must do as he tells them without arguing. At base, a cult is just another vehicle for power. And, of course, piles of money and private jets and lots of illicit sex and drugs but they’re fringe benefits, and even shooting people gets a bit dull after a while. The real driver for a cult leader is the exquisite delight of having total domination and control over people’s minds, of being able to order them: “Fall down on your knees and worship ME,” and, weeping in delight, they do it. That’s the real reward, there’s nothing quite like it. Psychiatry shows a lot of these features.

Psychiatrists have immense power in modern society. Part of that is the essentially unlimited civil powers granted them by mental health acts. What the psychiatrist says goes while the rest of the paraphernalia, the tribunals and review courts and so on, are just rubber stamps The other part is society’s fear of mental disorder and its distaste/loathing for the mentally-disordered, which is the reason the civil powers were granted in the first place. The system is set up such that ordinary citizens cannot argue with a psychiatrist, they will always lose. In fact, the more they argue, the worse it gets because it shows Lack of Insight. If you hate the psychiatrist and his paralysing drugs and mind-numbing ECT and the callous staff and the horrible food and don’t think you should be locked up, then you have no insight. This is now labelled as anosognosia which, as everybody knows, is a brain disease, so you have to stay in hospital until you’re cured of your brain disease. How long? As long as it takes. Insight is shown by gratitude and taking your injections without a fight. However, that ignores the innate human need to resist being treated as inferior, even crushed underfoot. The very nature of the rigidly hierarchical mental health system is that it encourages the underdogs to push back against the self-satisfied overdogs.

All this is done in the name of science and of humanity but there’s precious little of each. As far as science goes, the most fundamental requirement for any field of science is a model of its field of study. Psychiatrists rabbit on about their biomedical and biopsychosocial models, even though they can’t produce copies of either of them and don’t like being told they’re illusions. This means that, until we see them, psychiatry is properly classed as pseudoscience. As for humanity, the recent WHO publication on guidelines for mental health legislation [5] recommended implementation of the Convention on Rights of People with Disability, such as phasing out detention and involuntary treatment in favour of rights-based, community-based, person-centred practice. How has mainstream psychiatry reacted? They start crapping on about their science but underneath they’re angry, as in “How dare you try to reduce our power?” This, in turn, conceals a deep-seated fear that perhaps society can actually get by without them.

So is psychiatry an abusive cult? It has many of the essential features: a faith-based belief system; which is not open to criticism; which is used to justify what is otherwise serious abuse of individuals; combined with a remarkable ability to change its shape while holding its enemies at bay; and an inability to acknowledge error. Just don’t expect change to come from within psychiatry. Like cultists, they have too much to lose.

References:

1. Trevor-Roper H (1969) The European Witch-Craze of the Sixteenth and Seventeenth Centuries.

2. McLaren N (2024). Thomas Szasz and Antipsychiatry: the myth of the myth. Chapter 6 in Theories in Psychiatry: building a post-positivist psychiatry. Ann Arbor, MI: Future Psychiatry Press. Amazon.

3. McLaren N (2024). Biological Psychiatry: Reductio ad Absurdum. Chapter 2 in Theories in Psychiatry: building a post-positivist psychiatry. Ann Arbor, MI: Future Psychiatry Press. Amazon.

4. Insel TR, Cuthbert BN, Garvey M, et al (2010). Research Domain Criteria (RDoC): toward a new classification framework for research on mental disorders. Commentary. American Journal of Psychiatry, 167: 748-751.

5. WHO/OHCHR (2023). Mental health, human rights and legislation: guidance and practice. HR/PUB/23/3 (OHCHR). Available at: WHO/OHCHR.

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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.