Tribes and Turf Wars

Psychiatrists aren’t immune

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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Many years ago when I arrived in the Kimberley region of West Australia as their first psychiatrist, there was no internet. Before I left Perth, I signed to join the journal circulation list for half a dozen psychiatric journals. The first bundle arrived 18 months later, along with a letter saying that due to increased costs, journals would no longer be sent around (predictably, they had been sent to the “executive suite” of MHS first for them to read during office hours; I was on the end of a long list). That meant that if I wanted a journal article, I had to wait for one of my irregular trips to Perth and then spend as much time in the medical library as possible, photocopying anything that might be of interest (I had to pay myself as the librarian didn’t think philosophy or anthropology were necessary for psychiatrists). BTW, the first fax machine was installed in the hospital the week I arrived but it was kept under lock and key by the hospital manager.

How times have changed. These days, the problem isn’t insufficient information, it’s a case of too much. A large part of the deluge is junk, especially advertising disguised as “valuable learning experiences.” What are called medical newsletters are simply marketing arms of the drug industry. They’re mostly disguised as teaching material that allow people to get their brownie points to keep the medical board happy but don’t require any intellectual effort. There are dozens of them, mostly from the US, and the psychiatric weeklies push a rigidly biological line. However, they’re all facing a common problem: they don’t have anything new to say. Psychiatric Times is based in Boston and churns out articles bursting with the sense that psychiatry is teetering on the brink of major breakthroughs, but they’re always the same old same old with occasional novelties, e.g. psychedelic drugs as the latest fad to brighten the otherwise dull landscape.

This week, in an interview, the editor of PT, a Dr John Miller, talked about something that bothers him, tribalism in psychiatry (it starts at 2.45). Tribes, he said, are very much part of the human scene, there’s always been this sense of them and us: “That dynamic,” he says, “seems to have to exist in all cultures.” He uses the example of sport, how people get fanatical about their teams: “We want to win and (want the other team) to lose, that’s tribalism in its essence.” After 40 years, he feels psychiatrists are becoming walled off from each other. At the beginning of his career, he quickly became involved in giving lectures and seminars for the drug companies which were very well integrated into academic psychiatry and organisations such as the NIMH. He thought this helped spread knowledge and improve patient care and it was all very exciting (an lucrative, he didn’t say).

Here, the interviewer interrupted to say she too had been involved with representing drug companies and it gave her the sense of being at the cutting edge of science and up to date, which made her a better clinician. She was able to tell patients something good was coming so they should hang on and gradually they got better. Dr Miller added that knowing innovation was “always there” also helped keep psychiatrists well (7.00): “When I started, we had very limited tools, you could learn psychopharmacology in a week.” He began his career as a biochemist and was intrigued to see how “innovative molecules” (i.e. new drugs) were developed and released to great benefit (there is in fact only one). These days, however, prescribers are so flooded by paperwork and administrative demands that there’s no time for self-education (9.30). Clinicians don’t know about all the advances but there’s the additional problem that they don’t want to be compromised by conflicts of interest, so they keep away from drug companies. This has led to the system becoming fragmented (12.20):

Every decade, we have these paradigm enhancers that are helping us understand circuitry and systems and the integration of neurotransmitters ... the drug companies and NIMH and prescribers, we all need to be in the same tribe, working together to move the pendulum forward ...

Despite huge numbers of prescribers, not everybody is following the same script which means the epidemic of untreated mental illness (16.50) isn’t being addressed efficiently. It would be much better if everybody in the field, academics, researchers, funding agencies, clinicians, etc. worked together. “Wow,” said the interviewer, ending the session (17.45), “these are such great points. We could do five more sessions like this. Thank you for your insights. And for the viewers, if you have something on your mind, email us and we’ll get back to you.”

Mercifully, this wasn’t one of the sessions that counts as “education,” clearly just a word from the sponsors. First, as editor-in-chief, Miller is aged 66 and started psychiatry in 1986, i.e. well after the ideological convulsion that dumped psychiatry in the biological “stream,” discarding the notion that one’s life has anything to do with mental trouble. At the time, technology was racing ahead on a dozen fronts: scanners, genetics, viral research, neurotransmitters. Everything seemed so clear and exciting, just study the brain and, with a bit of money and time, all will be revealed. As a biochemist who then studied medicine, Miller was thrilled by this febrile atmosphere but, what at first seemed a stream limpid and clear has turned dark and run into the sand.

Thirty years ago, he says, everybody was pushing the same barrow, kindly provided by the drug companies and funded by the US taxpayer. Now, people object to drug company ties but it’s what he didn’t say is most revealing. He didn’t mention how the “genomics revolution” hasn’t delivered a single benefit to psychiatry. He didn’t mention how drug companies have largely given up on psychiatry, with no new “tailor-made chemicals” in the pipeline to fiddle with people’s neurotransmitters. He certainly didn’t say a word about the destruction of research wrought by the wierdo Secretary of Health, Mr RFK Jr, or the loss of Medicare and Medicaid cover for poor people pushed by the Trumpists, meaning they can’t afford treatment, and he didn’t show any suggestion that he needed to ask WHY there is “an epidemic of untreated mental illness...” (16.50). That would seem to be fairly basic. The only thing that concerned him was that everybody involved in mental health should start to sing from the same hymn book, the one that says “Drugs, glorious drugs, don’t care what they do.” The whole talk was just boilerplate drug company propaganda. The introduction said:

Both (the interviewer) and Miller advocate for a more integrated and supportive system among all health care professionals to address the epidemic of untreated mental illness ... The psychiatric field needs to work together more cohesively, Miller emphasized, sharing that we need a unified approach among psychiatrists, psychiatric nurse practitioners, and physician assistants to address the mental health crisis effectively.

First point to note: for all his academic appointments and so on, Miller doesn’t know what tribes are. If he did, he wouldn’t use it because “tribes” are always in some sense ideological and never rational (as scientific) or even anti-rational. Most tribes are self-appointed (political parties, religions and their myriad sects, sporting teams, languages and so on). Even when the tribe is race-based, it’s still a matter of ideology, as in “We’re superior to them.” Miller is right to say that tribalism is a fundamental part of human nature (it’s actually higher primate nature) but it’s a bad part, based in our innate xenophobia: without fear of The Other, there would be no urge to cluster among familiar faces. Whereas in the good old days, he says, everybody involved in mental health was happily riding together on the biological train, these days, they want to sit in separate carriages. For example, nobody wants to be seen sitting in the same compartment with the drug companies. He simply doesn’t get how people could object to them, they’re so helpful in producing all these amazing chemicals for prescribers to spread around, what’s wrong with drug companies, after all? Heavens to Betsy, they gave him lots of speaker’s fees and free airline tickets to travel around and spread the word, why are people today so anti drug companies? Why has the field of mental health split into tribes that don’t talk to each other? Part of it, as he pointed out, is the flood of paperwork and the pressure to push patients through to meet “productivity measures” but for the rest? No idea.

Compounding his error, he thinks the solution to tribalism is for everybody to join his tribe, then there’d be no arguing. That’s true, and there are heaps of historical examples of how different political or religious groups settled the arguments with their neighbours by forced conversion. But they can do that because their differences are ideological, not rational. Miller simply doesn’t grasp the concept of science as a process of rational enquiry, where differences are brought into the open, discussed and resolved. Certainly, the question of mainstream psychiatry’s relationship with drug companies has to be examined closely but that’s a matter of scientific ethics, i.e. metaphysics, and not one of empirical or evidence-based science. In fact, all the evidence says that psychiatrists, even at the highest levels, are easily seduced by the rivers of money flowing from drug companies, as the sleazy Joseph Biederman showed. The only way to resolve that is to keep drug companies well and truly locked in a separate carriage.

Miller is correct in saying there are separate tribes in psychiatry, but they’re not what he thinks they are. There are two major tribes, labelled according to their ideological positions on the question of the causation of mental disorder. The dominant tribe today is the biological tribe, whose card Miller carries and treasures. They say “Mental disorder is brain disorder; a full understanding of the brain will tell us everything we need to know about mental disorder.” From this unproven and openly ideological stance flows the belief that physical treatments (drugs, ECT and so on) are both necessary and sufficient, i.e. physical treatment is necessary for recovery, and physical treatment alone will guarantee recovery. That, however, is wholly a matter of opinion, not of science. You either believe it or you don’t but don’t waste your time looking for their justification because they haven’t got around to it yet.

Opposing them is the tribe that says mental disorder is a primary psychological phenomenon, that there is nothing wrong with the brain and that drugs are only going to conceal the true nature of the problem and create further physical problems of their own. That’s much more difficult to prove as psychiatry doesn’t have a theory of mind on which to base their opinion. The biocognitive model for psychiatry is intended to fill this gap but is meeting a bit of buyer resistance. Turns out psychiatrists would rather stick to their three-word non-models than try a new one, especially as it fills an entire book.

The major point is that the mere existence of ideologically-based tribes announces to the world that psychiatry is in a pre-scientific position. That’s the charitable conclusion; I say modern psychiatry is a pseudoscience, meaning it has the trappings of science (journals, professors, conferences, expensive studies and so on) but it lacks the substance (an agreed ontological position that entails a research program and treatment modalities) and that, at some level, the institution is aware of this but keeps it quiet. The reason psychiatry is splitting into tribes, and the tribes into subtribes is crystal clear: there’s nothing to stop them. There is nothing to hold them together, no central theory or doctrine or dogma that says “This is what you must believe and everything else is verboten.” Even their so-called bible, the DSM, is revised regularly as the various warring parties force their latest hair-splitting diagnoses on the mainstream. Of course psychiatrists will split into bickering tribes, all humans have an urge to get to the top by forcing everybody else to accept their views, and everybody else has an urge to resist. That’s what humans do, and psychiatrists are no different. Would it help if they all had to undergo psychotherapy? It didn’t stop the Freudians from tearing themselves to bits.

The interview with the eminent Dr Miller is a good example of how the pseudoscience of psychiatry is perpetuated. A senior member of the fraternity delivers a talk which, superficially, is full of interesting points and good sense, but closer inspection shows it’s essentially cliche-riddled drivel. The interviewer closed with the usual fawning stuff, adding: “And for the viewers, if you have something on your mind, email us and we’ll get back to you.” I’ll email them but I know they only like complimentary emails. Their attitude is that critics should shut up and learn the correct script that will let them join the dominant tribe. Their script, of course. In politics or religion, this sort of thing is called brainwashing.

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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.