Yes, that's all there is to psychiatry

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Continuing from last week, a reader in the US asked:

·         … I want to know, what a psychiatrist is thinking when they put people on drugs…

This led to a series of penetrating questions about the psychiatry that has controlled his life for decades. Last week, we ended with these: “Are psychiatrists living in a fantasy land? If they are, why are they?” The answers are Yes, many psychiatrists live in a pleasant echo chamber that starts during their training and gets more comforting as they age. They choose to do so because the alternatives are too scary. An  article in this week’s Psychiatric Times sets the tone. It opens with this little gem:  

·         In contemporary psychiatry, there has been marked progress in neurobiological research to establish the causality of many mental disorders in brain pathology. 

This sentence is a superb example of what philosopher Daniel Dennett called an “intuition pump.” This means that a first or superficial reading gives a message which serves the writer’s hidden agenda but which, on closer examination, isn’t there and can plausibly be denied (“Oh, but I didn’t actually say that”). It seems the sentence is saying that neurobiological research is the correct approach to mental disorder but it doesn’t actually say that. Remember that former director of NIMH, Thomas Insel, said “We spent $20billion on basic research and it didn’t do a damned thing.”

In fact, the sentence is only true if you count all the failed biological research as “progress,” i.e. knowing that some idea won’t work is classed as “marked progress” over believing it may. Even if the mag’s 50,000 readers had realised this point, I doubt very much they would object, just because it’s what they want to hear. It reinforces the tropes bouncing around their echo chamber: “Yessir, we’re on the verge of unravelling mental disorder. PS keep sending all that lovely research money.”

Putting that aside, even at face value, the sentence is pure fantasy. There has never been a single example of biological causation of the major mental disorders so, as the reader asked, why do they keep saying it? The answer is that it suits the purpose of the editors who are paid by the drug companies to churn out this stuff, and it suits most of their readers as it makes them feel part of the movement called “real science.” They get away with it because there are very few people in the world who (a) know that this sort of thing is crap, and (b) are prepared to say so but (c) the editors will make sure that any objections aren’t published. I wrote about the dishonesty of the psychiatric publishing industry years ago [1]; nothing has changed. So to our reader’s next question:

·         Q8: Is it the money that drives them?

A8: Medical practitioners who are only interested in money generally don’t go into psychiatry, although once in the business, a lot of them quickly realise they can cream off a lot more than the recommended fees or their government salaries. In private practice, the biggest rackets are legal reports and prescribing stimulant drugs. Psychiatrists charge what they like for legal reports, especially when the fees are paid by insurers who, of course, expect value for money. So psychiatrists quickly sort themselves into those who aren’t swayed by whoever is paying the fee, and those who are. The unswayed don’t get much work; the easily-swayed are in clover. Similarly, authorising amphetamines has become a regular little gold mine. For up to $2500 for a 45 minute appointment, the caring doctor will ask a few questions and then, with a concerned frown, sign you up for a lifetime of free amphetamines. Which you can then take yourself, or sell, as the fancy takes you. The queues of people who have just learned from YouTube that they’re ADHD snake down the street, so just ten of those a week gives a very comfortable income and leaves plenty of time for sailing.

However, that’s not the really big money. If you want to hit the big time, you have to get into academia, and then discover either a new disease for an old drug or new drug for an old disease. Then you’ll have the drug companies beating a path to your door and, as the late Joseph Biederman of Harvard showed, the sky is the limit. His Wikipedia entry has been pruned of all the dirt but briefly, he invented paediatric bipolar disorder and sold it to the drug companies without declaring it to the university. That was a sackable offence but he was bringing in far too much money for the university to boot him. When an academic gets a research grant, the university takes a large chunk of it as a “facilities fee.” That ranges from 40-70% so, when large grants total many millions, that’s pretty big money. That’s why professors spend about 40% of their time writing grant applications. Biederman pulled in so much research money, meaning so much flowed into the Harvard coffers, that they gave him a little slap on the wrist and left him to continue raking it in. He certainly wasn’t the only one.

Essentially, the drug companies have bought the profession of psychiatry. Money means nothing to them, so if splashing it around brings more sales, that’s what they do. The psychiatrists who tout the drugs loudest and with the most enthusiasm get most of the money as speaker’s fees; the rest just get a few free meals and an executive toy for their desks.

·         Q9: Is it fear of losing their license to practice or fear of looking like a quack that drives them?

A9: You’re not a quack unless society says you are. Since society has been totally brainwashed into believing that regardless of the question, drugs are the answer, it is highly unlikely that anybody would accuse psychiatrists of quackery for overprescribing. The risk is under-prescribing: if a patient is given a low dose of a drug and something goes wrong, the psychiatrist is exposed to complaints. The real trouble lies in who makes the decisions on complaints: it’s the same group around the world, rock-solid conservative and utterly conventional old psychiatrists who can be trusted to make the decisions the mainstream would like to hear. The small fact that they don’t have a model of mental disorder between them is overlooked but if you dare to question them, look out.

You will have heard the expression “In the land of the blind, the one-eyed man is king.” In 1904, HG Wells wrote a short story called The Country of the Blind in which having the gift of sight in the land of the blind became a curse. In general, psychiatrists are very conventional and very conservative. They stick with the crowd as there’s safety in numbers. An eager young shrink who shouts “Can’t you see that? You lot must be blind,” will be chopped into little bits and fed to the birds. Just remember that no psychiatrist was ever prosecuted for cutting a patient’s brain during the “lobotomy” craze in the 1940s and 50s. Likewise, when the Lake Alice scandal in New Zealand was first exposed, the perpetrator was protected by other psychiatrists; the children who complained were punished for daring to speak against the kind-hearted doctor.

·         Q10: Is it their schooling?

A10: Yes. We went over this last week. Medical people are trained to memorise vast quantities of material, not to question the greats. Critical thinking is not part of the curriculum; questioning the professors is the quickest way to get the boot from the course. When I was 34, a senior consultant and head of department in a Veterans’ Hospital, I decided to go back to university to study philosophy. Because of stuff I’d published, I was able to start at second year (sophomore) level, and was put in a class of rowdy 18 year olds who had just finished their first year. After a week, I was ready to give up as it was clear these kids could think better than I could. It was very embarrassing but I pressed on, and a strange thing happened. With time, I learned the language of critical analysis but, as I picked up how to talk philosophy, I found I was becoming alienated from my psychiatric colleagues. You can take it from somebody who’s been ejected from lots of meetings: psychiatrists do not like probing questions or alternative points of view, and the more senior they are, the more phobic they become of anybody daring to question them.

·         Q11: Does it have anything to do with the key opinion leaders or the journals or the studies?

A11: Yes, it has everything to do with the KOLs and the journals and the approved courses. Psychiatry as it exists today is a dogma, not a science. If you want to stay in the training program, you have to play the game. Don’t argue with the professor, even when he’s patently wrong. Definitely don’t laugh when he says something stupid. If you want to work in public psychiatry, you have to be conventional since unconventional people are driven nuts by the public service. If you want to get ahead in academia, you won’t get a foot on the ladder unless you’re recommended by a lot of people higher up the ladder, and they’re not going to approve somebody who seems likely to shake the ladder or even push a few of them off. Similarly, as I said above, if you want to get ahead in private practice, it’s much, much more profitable to write reports that insurers like, or prescribe drugs that different groups like, or just prescribe lots of drugs so the patients get addicted and have to keep coming back for more.

·         Q12: Are there potential lawsuits that they are afraid of?

A12: In general, no. Psychiatrists with a totally conventional practice, using heaps of drugs and ECT, have very little to fear. Worst comes to worst, they know their mates on the medical board will look after them. A government psychiatrist would have to do something truly outrageous before a complaint would stick: look at the infamous Dr Selwyn Leeks of Lake Alice (for more background, see Mad in America by Phillip Hickey; also here and here). Leeks was using an old-fashioned ECT machine to give electric shocks to children and teenagers for punishment, including clamping it on teenage boys’ balls. Complaints were “investigated” by his friends, who brushed them off saying it was “rather unconventional but within the bounds of practice” or some such drivel. Even after his conduct was exposed and he fled New Zealand for Victoria, the RANZCP did nothing on the basis they had “no powers of investigation” but that was a lie.

In about 2016, I was interviewed by a local reporter for an article for Mental Health Week. He asked about ECT; I replied that the main motivation for the excessive use of ECT in Australia is the huge financial returns it generated. I never saw his article but he must have used that line. Subsequently, a complaint was lodged with the RANZCP who set up a committee to investigate my “crime” of bad-mouthing their toy. I was required to provide a response and although they didn’t say I was wrong, I was deemed to have been naughty and a black mark would be entered on my file. If I wanted the matter reviewed, it would cost $1000; an appeal would cost $4000. As though I cared. At the time, Dr Selwyn Leeks was still a member of the RANZCP and was not expelled until after he died. That is, the RANZCP did nothing about the criminal Dr Leeks but I was penalised for telling the truth. That’s how it is in Australia; I am certain that this sort of manipulation and deceit is just as common overseas, if not worse. For an insight into how the American Psychiatric Association runs its affairs, see Whitaker and Cosgrove [2]. For the facts on ECT, see [3, 4]; there has not been a squeak out of the RANZCP since these papers were published. The message is: while your trade body is protecting you, there is very little risk of lawsuits.  

·         Q13: Other than (pharmaceutical industry inducements), the problem can look very complex and mysterious …

A13: It’s actually quite simple. Throughout the world, psychiatrists enjoy enormous power, wealth and influence, as well as the prestige of being medical specialists. The statutory powers of a psychiatrist probably exceed those of any other civilian in the country. What is the basis of that power, the authority that stands behind it and justifies it? It’s not moral or religious, as with priests and imams. It’s not military, but most armies only have power outside their country’s borders. It’s not the power handed to courts and police officers to enforce the criminal code and other laws, because they are constrained by very strict rules of investigation and evidence, as are other enforcement officers like taxation inspectors, child welfare officers, dog catchers, etc.

Psychiatry’s power is none of these things but it’s very real. By a process of exclusion, we see the power of psychiatry is the power of science. Mental disorder is seen as a considerable bother to polite society; voters don’t like locking up people and throwing away the key, not least because it’s too expensive; so when a group of people announce: “We hold the science of mental disorder in our hands; give us your problem children and, for a suitable fee, we’ll keep them out of your hair,” then society jumps at the chance. It’s a neat story; there’s only one thing wrong with it: psychiatry doesn’t have a science of mental disorder. That bit is carefully-cultivated make believe, smoke and mirrors designed to fool politicians – and the voting public - into handing over the requisite power (and cash).

Perhaps the most important part of the deal is not asking any sticky questions or looking too closely into what’s going on behind the façade of science with which the institution of psychiatry surrounds itself. That’s why we have this thing called critical psychiatry. Of course, if psychiatry were a science, there wouldn’t be such a beast as critical psychiatry as the unwavering duty of all scientists is to criticise, not just what their competitors are doing but, more importantly, what they are doing themselves.

I hope these points answer the reader’s insightful questions, an insight gained only from experiencing psychiatry from the rough end rather than believing the press releases. Nobel Laureate physicist Richard Feynman put his finger on it:

·         The first principle is that you must not fool yourself—and you are the easiest person to fool. … After that, you just have to be honest in a conventional way. . . I would like to add something that’s not essential to the science, but something I believe, which is that you should not fool the layman when you’re talking as a scientist. . . I’m talking about a specific, extra type of integrity that is more than just not lying, but bending over backwards to show how you may be wrong, an integrity that you ought to have when acting as a scientist (from Cargo Cult Science).

More than just not lying. The mere fact that critical psychiatry groups are slowly emerging around the world says that this principle of intellectual integrity has been ignored, if not actively suppressed. Hence, when I said ECT is a racket, the thought police of the RANZCP were enraged and lashed out: they don’t want anybody peeking behind their artfully-constructed stage scenery. Psychiatry cut its teeth on abuse of the defenceless [5], so mere sadistic abuse of children they can handle; but threatening their incomes and power and status by questioning the “science”? Oh no, that’s a step too far; such sedition must be crushed before it catches on.

References:

1. 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.

2. Whitaker R, Cosgrove L (2015). Psychiatry Under the Influence: Institutional Corruption, Social Injury, and Prescriptions for Reform. New York: Palgrave MacMillan.

3. Read, J, and Arnold, C (2017). Is Electroconvulsive Therapy for Depression More Effective Than Placebo? A Systematic Review of Studies Since 2009. Ethical Human Psychology and Psychiatry 19: 5-23.

4. McLaren N (2017). Electroconvulsive Therapy: A Critical Perspective. Ethical Human Psychology and Psychiatry 19: 91-104. DOI: 10.1891/1559-4343.19.2.91

5. Scull A (2022) Desperate Remedies: Psychiatry and the mysteries of mental illness. London: Penguin.

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