By Niall McLaren
Is it possible for a modern medical specialty to be little more than what people in the street call bullshit? As scary as that sounds, I believe it is true of psychiatry. I’ve set out my case in some detail [1] and anybody who wants to disagree can read it. For readers who prefer to think outside the box, we can define both concepts, psychiatry and bullshit, and then see how psychiatry measures up.
We can define psychiatry as the medical approach to mental disorder. Psychiatry is what psychiatrists do, which these days means interview distressed people, make a diagnosis, and then prescribe pills. It can also mean compelling the person to enter a place called a hospital but, in reality, it is actually a place of involuntary incarceration where the inmate will have fewer rights and privileges than any prisoner in this country. Once detained, he can be forced to take any drugs the psychiatrist decides, however unpleasant; he can be locked in solitary confinement and can also be physically restrained more or less indefinitely. Finally, he can be compelled to submit to electroconvulsive therapy (ECT, “shock treatment”),
Now you might think that any non-forensic process that forces a perfectly innocent citizen to lose his freedom and all his rights, even to the point where he has no sexual function (mainly because of the drugs but also because somebody is always watching), would be based in some agreed, formalised, articulated, rational, publicly-available case which shows that the benefits outweigh the disadvantages. Sadly, and as a matter of firmly-established fact, you would be wrong [2]. Orthodox psychiatry has pulled a remarkable coup. Acting entirely without the benefit of a scientific model of mental disorder, it has managed to convince governments that their approach to mental disorder is at once correct, humane and the only possible choice. I believe this is bullshit, and will explain why. For the record, I firmly believe that severe mental disturbance is real. Thomas Szasz said that all people who claim to be mentally disturbed are pretending, but I have argued that he was totally (and brutally) wrong [3].
In 1986, the Princeton philosopher, Harry Frankfurt [4], published a paper entitled “On Bullshit.” It opens with some of the most memorable lines in modern philosophy: “One of the most salient features of our culture is that there is so much bullshit. Everyone knows this….” He defined a lie as a very deliberate act of inserting a falsehood at some point in a discourse with the object of avoiding the consequences of having that point occupied by the truth. The successful liar is thus intimately concerned with the concept of truth. Bullshit, on the other hand, is the artistic production of statements that are neither true nor false, but are intended to create a particular impression in the listener. Given that definition, we can test psychiatry to see whether it passes the sniff test.
In the first place, orthodox psychiatry claims that in some vital causative sense, mental disorder is just a special case of physical malfunction of the brain. It is not psychological. Because of this, we are bombarded by material that says depression is “just” a matter of low brain serotonin, and Wonder Drug X will fix it. As a result, 10% of the Australian adult population now take antidepressants. We are routinely told these drugs are safe, effective, non-addictive, with minimal side-effects, and will be needed for life. The whole thing is bullshit. In the first place, there is nothing in the entire psychiatric literature, nor psychological, nor philosophical, nor in the vast field of neurosciences, that would permit anybody to say that mental disorder is identical to or can be reduced to brain malfunction. Psychiatrists who state, as most do, that mental disorder is “just a chemical imbalance of the brain,” are stating something that is neither true, nor false, but is designed to create a particular impression in the listener. The impression is (a) that the psychiatrist knows what he is talking about, (b) has correctly assessed the patient’s life situation, and (c) his prescription will lead to an improvement in the patient’s life which would not otherwise happen.
None of these suppositions is true. Psychiatrists do not have a formal model of mental disorder. These days, psychiatric assessments, especially in public hospitals, are a joke, very often a matter of a nurse ticking a few boxes on a couple of questionnaires of very dubious validity and reliability. Psychiatric drugs are hardly effective. In depression, a placebo (sugar pill) will lead to improvement in 55-60% of cases, whereas antidepressants are effective in only 64% of cases (my experience says that figure is much lower). Psychotropic drugs have a huge range of highly unpleasant and/or dangerous side effects (e.g. loss of sexual function, massive weight gain, suicidal and/or homicidal impulses). Psychiatric drugs produce some of the most persistent and damaging addictions of all. Finally, people who take psychiatric drugs for life can expect to die 19yrs younger than their un-drugged peers. Despite all the palaver about informed consent, psychiatrists never reveal these facts when prescribing their drugs. That’s not entirely unreasonable: if they did, nobody would take them.
Leaving drugs, we can look at electroconvulsive therapy (ECT, “shock treatment”). Many people believe this has not been used since the 1970s but it is still widely used. The Royal Australian and New Zealand College of Psychiatrists says that ECT is “…a useful and essential treatment option…” In 2013-14 in Queensland, 16,602 episodes of ECT were administered (oddly enough, the figures do not show numbers of patients). In 2014-15, this jumped to 19,365 [5]. Does the rate of depression jump 20% in one year? I doubt it. Since it’s more than were administered by the British National Health Service, I suggest something else is going on, and that something is money. A psychiatrist can easily do four per hour, at up to $150 a pop, for absolutely no intellectual effort whatsover.
But there is something more ominous in the use of ECT. Under various state mental health acts, ECT can be given against a person’s wishes if he “unreasonably refuses it.” Since I have practiced psychiatry for 40 years, in a wide variety of pretty tough settings, without using it, I would say that any refusal is reasonable. However, it is for the individual clinician to decide whether the detained person gets it, so you might expect that psychiatrists can define “unreasonable” refusal. They can’t.
If they decide the patient will get it, that’s it. A voluntary patient who refuses ECT will very quickly find himself detained. If he appeals to the mental health tribunal, the appeal will fail. The psychiatrist sitting on the tribunal will have long used ECT and will see it as “a useful and essential treatment” which cannot reasonably be refused. Moreover, all junior psychiatrists who apply to join a mental health service are required to be proficient in giving ECT, but they are not required to to be able to practice psychiatry without using ECT. This asymmetry is not seen as requiring explanation.
A psychiatrist who uses ECT is only saying that he can’t get the patient better any other way, i.e. he has reached the limit of his skill set. The claim that ECT is “essential” is factually wrong, and all talk of “reasonable” use of ECT is simply a cover for incompetence. The whole thing is pure bullshit.
Let’s look again at detention. Some years ago, I advised the Chief Psychiatrist of Qld that many people detained in security facilities, at a cost of about $1500 per day, were not being actively treated and would not be detained in other states. I gave him several examples where perfectly harmless people had been detained for years, at costs ranging up to $4.5million each, yet showed no signs of aggression. Some were even allowed to come and go as they pleased. Nothing came of this; I presume the respective ministers were told (actually by the psychiatrists who authorised the detentions) that I didn’t know what I was talking about.
However, we now have the situation where detention is under intense scrutiny. The publicity surrounding Don Dale Youth Detention Centre in Darwin, and of Australia’s concentration camps on Nauru and Manus Island, has attracted psychiatric comment. Entirely trustworthy psychiatrists have argued that detention in itself is highly undesirable. They are free to argue as citizens that it is abhorrent and we should no more practice it than corporal punishment but, as psychiatrists, they go further. They argue that it is damaging to the person’s mental health, especially where the person has broken no laws. If that is so, then they need to explain why the profession of psychiatry is far and away the major player in involuntary detention of people who have broken no laws. People are detained for decades and submitted to the repeated indignity of being held down and jabbed with very unpleasant and/or dangerous drugs, yet this is done in the name of “treatment.” Evil is as evil does: somehow, good intentions in mental hospitals seem to negate the adverse effects of detention in other settings. In philosophy, that is called Having your cake and eating it too.
Psychiatrists will often say that their treatment is sanctioned by something called the biopsychosocial model. A search of PubMed shows nearly 1600 publications on the topic since 2002, an impressive tally. However, there is a slight problem: it doesn’t exist. Nearly twenty years ago, I showed that it had never been written, that the whole thing is a charade, an illusion [6], but this doesn’t deter anybody. Psychiatrists routinely invoke the biopsychosocial model to justify their actions. Are they simply dishonest, carefully inserting a falsehood in a discourse to avoid the consequences of having that point occupied by the truth, or are they lazily allowing themselves to be taken in by their own inventions? Anybody who states the biopsychosocial model is a reality is not stating a truth, but I believe most of its supporters haven’t bothered to check the truth, they are just trying to create an impression. That is, they are bullshitting their audience.
My views are not popular with my psychiatric colleagues. I am seen as taking an extreme position but somebody has to occupy the extreme otherwise there would be no progress. Somebody has to criticise the institution of psychiatry because, rest assured, there is no institutional self-criticism. The profession has surrounded itself with walls of bullshit within which criticism is suppressed in the pursuit of an unproven concept of mental disorder. As Daniel Kahneman noted: “We know that people can maintain an unshakable faith in any proposition, however absurd, when they are sustained by a community of like-minded believers” [7]. To the great detriment of the community, that is exactly the position in which modern psychiatry finds itself.
References:
1. McLaren N (2016). Psychiatry as Bullshit. Ethical Human Psychology and Psychiatry 18: 48-57.
2. McLaren N 2013 Psychiatry as Ideology. Ethical Human Psychology and Psychiatry 15: 7-18.
3. Critique of Thomas Szasz. Chaps 12-13 in McLaren N 2012. The Mind-Body Problem Explained: The Biocognitive Model for Psychiatry. Ann Arbor, MI: Future Psychiatry Press.
4. Frankfurt H (1986). On Bullshit. Raritan Quarterly Review 6, No. 2 (Fall 1986).
5. Qld Dept of Health RTI #3273, ECT Procedures in Qld Hospitals (September 12, 2016).
6. McLaren N. A critical review of the biopsychosocial model. Australian and New Zealand Journal of Psychiatry 1998: 32; 86-92.
7. Kahneman D (2011). Thinking fast and slow. New York: Allan Lane
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