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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A recent brief paper in the Brit J Psychiatry Bulletin by Speyer et al offered a mild and oblique criticism of what are called practice guidelines [1]. These days, every college or professional association issues advice on how each condition should be treated. For the colleges, these are a big deal, with dozens of people meeting regularly for months to churn through the literature and knock up what they agree amounts to best practice. It then has to be reviewed and revised by half a dozen committees before it is adopted. These missives are advisory only but their proud parents tend to forget that there are people, like lawyers and insurance companies and other pond life, who take them as gospel. If it’s in written form, it’s law, which works in general medicine and surgery, but not so well in psychiatry for an obvious reason. However, any psychiatrist who doesn’t follow the guidelines to the letter will be hung out to dry.
As the paper’s authors point out, there’s a world of difference between what we might call the hard sciences such as physics, chemistry and biology, and the squishy human topics including psychiatry. The standard sciences are able to use what is called linear thinking to reach their conclusions. This means they have a clear set of laws (physics, chemistry, etc) that work in one direction only and can have just one outcome: A + B = C and nothing else. Thus, given the starting conditions (of an experiment, a building collapse, a trip to the moon), only one outcome is possible. This rigidity is not an accident. The goal of the doctrine of positivism was to strip all uncertainty from science in order to build a reliable body of scientific knowledge. Everything had to be related in a stepwise manner to what had gone before. There was nothing more uncertain than human emotion, values, wishes, likes and dislikes, so all of it had to go. Science can only be concerned with what can be seen and measured: values are mental constructs; mental constructs can’t be measured; therefore mental constructs have no place in science. QED.
However, as the various sciences developed, it became clear that, very often, equations were far more complex than the simple A + B = C model. Nuclear physicists, then chemists, then biologists, found they were dealing with dozens of factors, all changing and depending on a myriad other factors. These were highly complex but still rational and well-behaved; they just needed far more computing power than even a dozen human brains could provide. Eventually, a theory of complex systems developed that could handle these using immensely powerful supercomputers.
That’s all pretty clear and uncluttered, mainstream science has made enormous progress but what about the “science of mental life”? Psychiatry and psychology are only about mental constructs, so what can we do about them? And it’s not just psychiatry, what about all the other fields where values have to be taken into account, such as social services, town planning, custodial services, budget allocations and so on? How can anybody hope to solve these very complex matters when linear thinking simply fails just because it wasn’t designed for them? As I’ve outlined, psychology tried to convert itself into a “hard science” with behaviorism [2], dispensing with the mind altogether but this failed. For its part, psychiatry has tried convincing itself that the mind is really only the brain, so biology will tell us everything we need to know.
That hasn’t worked well, as this paper points out. Trying to control daily practice by adopting rigid “guidelines” removes the human element entirely. For example, if a patient stops taking the drugs due to side effects, that’s deemed “non-compliance” and the dose is given by injection under duress. If a person wants to believe that lizard people have taken over the government, who are psychiatrists to decide that that means insanity which means brain disease which means disabling treatment for life, which will therefore be shorter? The authors didn’t say it, but the reductionist biological approach to psychiatry automatically puts psychiatrists in a paternal role at best and, at worst, as oppressors. Granted, there are plenty of psychiatrists who feel quite comfortable in that role and aren’t in any hurry to change it but the paper suggests that in opting for compulsory treatment, there are many human considerations that don’t fit in the simple world envisaged by the guidelines. Yes, the drugs may suppress hallucinations making life easier for the patient’s relatives, but if the cost to the patient is loss of sex life, whose interests and values should prevail? In order to answer these difficult questions (which, overwhelmingly, are simply ignored by psychiatrists), the paper offers a suggestion from a totally different field from fifty years ago.
Town planning is very much a hybrid field, with all sorts of complex material and legal questions that can be solved with a computer, but there’s also the human element, which can’t. It may make perfect sense to put a highway straight through a small swamp but that will inflame the swamp-lovers (of whom I’m one). NIMBY, it’s called, “not in my backyard,” and they (we) are the bane of town planners and air traffic controllers and a host of other well-meaning technicians who simply don’t understand that ducks and possums have rights, too. In a paper from 1973, Rittel and Webber, two academic town planners, suggested we should distinguish between “tame problems,” both simple and complex, and what they called “wicked problems” [3]. It’s not a good word but it emphasises that these are profoundly different in that technical issues are deeply entangled with values and judgements: human wishes as distinct from human needs. There is no single solution to a wicked problem, only a balancing of conflicting interests, the matter is resolved rather than solved. For all its braying about being a rational science of mental disorder, psychiatry slots straight into this group. Rittel and Webber saw ten features that distinguish wicked problems from tame:
1. There is no definitive formulation of a wicked problem; different people will see it from different angles.
2. Wicked problems have no stopping rule, no clear solution, so one can always try to do better.
3. Solutions to wicked problems are not true-or-false, but good-or-bad, i.e. it’s all about values so don’t try to kid yourself.
4. There is no immediate and no ultimate test of a solution to a wicked problem, especially as solutions have unintended consquences.
5. Every solution to a wicked problem is a “one-shot operation”; because there is no opportunity to learn by trial-and-error, every attempt counts significantly.
6. Wicked problems do not have fixed set of potential solutions, nor is there a well-described set of permissible operations that may be incorporated into the plan.
7. Every wicked problem is essentially unique.
8. Every wicked problem can be considered to be a symptom of another problem (i.e. causes are undefined due to lack of a model).
9. The existence of a discrepancy representing a wicked problem can be explained in numerous ways. The choice of explanation determines the nature of the problem’s resolution ... There is no rule or procedure to determine the “correct” explanation or combination of them.
10. The planner has no right to be wrong but will be punished by one group or another who disagree with the outcome.
The last one is important, as they point out: “... the aim is not to find the truth, but to improve some characteristics of the world where people live. Planners are liable for the consequences of the actions they generate; the effects can matter a great deal to those people that are touched by those actions” [3, p167]. How true this is of psychiatry. For all their efforts to reduce psychiatry to the status of a biological science (psychiatrists as “clinical neuroscientists,” in the words of Thomas Insel), to convert its “wicked problems” of emotions and values into “tame” ones of neurotransmitters, the fundamental question of how to incorporate a sufferer’s values refuses to go away. With its DSM tick-a-box approach, psychiatry tries to reduce depression, for example, to a “chemical imbalance of the brain.” This has been widely deplored as “imperial psychiatry,” converting normal emotions into “diseases,” as Horwitz and Wakefield pointed out 20 years ago in their important but widely ignored study, The Loss of Sadness [4]. More to the daily point, it fails. 15% of the adult population take antidepressants and the suicide rate just keeps climbing, as the ever-polite British psychiatrist, Joanna Moncreiff, points out:
Although the discovery of a specific antidepressant agent in the future cannot be ruled out, it is possible that we misunderstand the nature of depression, and that regarding it as a discrete and universal disorder may have raised false hopes about the chance of a generally applicable ‘cure’ or treatment. The alternative view of depression as part of the spectrum of meaningful human responses to the world suggests that drugs will only dull the experience. In the end, the situation that provoked the negative emotion needs to be addressed. Depression is a signal that change is needed in some aspect of life [5].
In fact, depression is a signal that some important aspect of life has been lost, it is the universal reaction to a loss. Awareness that “change is needed in some aspect of life” causes the universal reaction to a threat, known as the “flight of fight reaction,” aka anxiety. Early in their paper, Speyer and partners [1] opine that clinical guidelines have been very helpful but aren’t perfect:
Although this format works well and has greatly improved quality of care in some situations (p1) ... guidelines developed solely within professional and academic communities embed a particular epistemic standpoint as the authoritative standard ... Addressing complex wickedness therefore requires that service users, carers, clinicians and researchers participate as genuine co-producers. Finally, meaningful deliberation presupposes equal access to knowledge ... a matter of epistemic justice, a prerequisite for ensuring that all stakeholders can engage as informed participants in the decisions that govern their care (p3).
Stripped of the jargon, what psychiatry likes to portray as its professionalism turns out to be dressed-up amateurism. And it’s everywhere. Take the first sentence in that quote: “Although this format works well and has greatly improved quality of care in some situations...” This is false. Clinical guidelines have not “greatly improved care.” Nothing has changed but the statement is a classic motte and bailey defence, which needs a bit of explanation. In feudal times, the local lords and princelings spent their days raiding each other, which the peasants and villagers found somewhat irksome. Farmland, known as the motte, isn’t easy to defend so they often built a fort on a hilltop, the keep or bailey (hence Old Bailey in London) to which they could retreat while the raiders stole their cows and chickens. When the raiding party had gone, the peasants came out and started cleaning up again.
In philosophy, it applies to a person who makes extravagant claims about something but when questioned, retreats to a much smaller, defensible position. Politicians do this all the time, esp. one DJ Trump, who uses the extreme version. Today, he spouts some bit of nonsense but when questioned by reporters tomorrow, he says “I didn’t say that, that’s fake noos.” Has psychiatric care “greatly improved”? If having more people on more drugs for longer is an improvement, possibly, but not if the side effects are taken into account.
Moving on, “... guidelines developed solely within professional and academic communities embed a particular epistemic standpoint as the authoritative standard.” True. You can’t argue with a psychiatrist. While psychiatric committees and tribunals generally have a “consumer representative” these days, they don’t have critics who will poke holes in their “authority” or ask embarrassing questions. My experience is that the lay people who get appointed to these committees and so on are almost always relatives of somebody who died by suicide, and they’re convinced that if there had been more treatment and more incarceration, not less, then Johnny would still be alive. Nobody asks Johnny but he would only give personal opinions anyway, whereas we’re scientists and aren’t moved by personal values (they forget that that statement is itself a personal value, and are deeply offended when this is pointed out). We see this in the concept of “risk management.” It used to mean the relative risk to the patient of treatment vs. no treatment, but now it is only ever taken to mean “risk to the hospital and psychiatrist,” as in: “If we don’t follow the guidelines strictly, can we get into trouble? OK, lock him up and jab him.”
“Addressing complex wickedness therefore requires that service users, carers, clinicians and researchers participate as genuine co-producers.” Forget that. Do you seriously imagine that one of those powerful professors on the guidelines committee is going to listen while some nervous soul stutters that psychiatric drugs have lots of side effects, like massive weight gain and so on? Professors don’t listen to crazy people (even when the patient is a physician, as in this case in MIA), they should just control themselves and stop eating so much.
“Finally, meaningful deliberation presupposes equal access to knowledge...” The whole edifice of modern psychiatry is built on people not knowing the truth behind psychiatry’s extravagant claims. For example, the biopsychosocial model. For 12 years from 2013, the RANZCP had on their website Position Statement No. 80 which stated:
Medical expertise: Psychiatrists apply their medical knowledge, specialist clinical skills and acumen in the provision of person-centred care. They understand the impact of ‘biological’, ‘psychological’ and ‘social’ factors on mental health and the causation of mental illness. This ‘bio-psycho-social’ model is a holistic approach that recognises the impact of social adversity and physical health on mental well-being [6].
This was completely false and after yet another scratchy argument, was quietly removed and not replaced. Psychiatrists are now physicians trained in psychiatry who use their expertise in psychiatry to treat mental disorders. Very enlightening but we’ll keep going.
“... a matter of epistemic justice, a prerequisite for ensuring that all stakeholders can engage as informed participants in the decisions that govern their care.” That sounds impressive but it never happens. Philosopher Amanda Fricker defined epistemic injustice in her 1998 book Epistemic Injustice: Power & the Ethics of Knowing. What happens is that some socially privileged groups are deemed authorities by what they know whereas others are deemed incompetent in comparison, and the powerful group takes control of the process. The inferior group suffer an injustice when what they know is dismissed because of who they are, not what they have to say. A person taking half a dozen psychiatric drugs who complains of being unable to sit or lie still is not regarded as an expert on his or her own body and is simply ordered to take more tablets, even though the drugs are causing the problem (akathisia).
The conflict of interests arises just because psychiatry prides itself on discarding all personal values in order to reduce the cosmic complexity of the human mind to something that can be seen in a scanner. They forgot, or more likely refused to know, that in order to do that, you actually must have a theory of the topic (in this case, the mind) and a model of what you want to study (mental disorder). They don’t have either of those things so rather than admit their failure, they keep issuing “clinical guidelines” that pretend the “wicked” or highly complex, value-laden problems of humanity can be reduced to “tame” problems of biology, suitable for solving with linear thinking (depression + antidepressants = cure). This approach is incapable of dealing with what are called recursive or self-reinforcing problems in life, of which the classic example is anxiety states. A person becomes anxious about an appointment tomorrow. This makes the heart race, which makes them think a heart attack is on its way, so they become more anxious and start to sweat and tremble, which convinces them they need to cancel the appointment, which makes them feel like a failure.
It makes perfect sense but linear thinking can’t deal with this sort of problem. Clinical guidelines only make the problem worse by convincing people that psychiatry’s a pushover, just keep adding drugs until the patient stops complaining. From that point of view, yes, it is easy but somehow, we need to make sure the patient’s voice is heard, even or especially when the psychiatrist doesn’t want to hear it.
References:
1. Speyer H et al (2026) Clinical guidelines addressing complex and ‘wicked’ problems. BJPsych Bulletin doi:10.1192/bjb.2026.10271
2. McLaren N (2024). Behaviorism: Not Sleeping, Just Dead. Chapter 4 in Theories in Psychiatry: building a post-positivist psychiatry. Ann Arbor, MI: Future Psychiatry Press.
3. Rittel HWJ, Webber MM. Dilemmas in a general theory of planning. Policy Sci 1973; 4: 155–69.
4. Horwitz AV, Wakefield JC (2007). The Loss of Sadness: how psychiatry transformed normal sorrow into Depressive Disorder. New York: Oxford University Press.
5. Moncrieff J (2018) Against the stream: Antidepressants are not antidepressants – an alternative approach to drug action and implications for the use of antidepressants. BJPsych Bulletin 42, 42–44, doi:10.1192/bjb.2017.11
6. RANZCP (2013). Position Statement No. 80: The role of the psychiatrist in Australia and New Zealand. RANZCP Website. Accessed Nov 3rd 2023, deleted April 2025.
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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.