Over the weekend, I forced myself to watch to watch the final lectures in the “ADHD Masterclass” series issued by the college of psychiatrists in October 2022. Anything I could say now would probably be actionable so I’ll think about it for a while.
Since then, and much more interesting, I watched the launch of the joint WHO and UN Human Rights Commission guidelines on human rights and mental health legislation. Yes, it’s dry and out there but… it’s so important. This is the definitive statement from the most authoritative agencies in the world on how mental health acts are to be shaped and written. Speakers, who included the Director-General of WHO and the HR Commissioner, saw three areas that needed urgent attention:
1. The world-wide reliance on detention and involuntary treatment in institutions rather than voluntary, community-based preventive care;
2. Closely associated, the dominance of the so-called “biomedical model” which debases the human experience; and
3. The failure to allow people with mental disorders be involved in decision-making.
Until these matters are rectified, nothing will change. Institutions will continue to gobble up the bulk of the mental health budget despite deteriorating mental health statistics; more and more people will become dependent on (i.e. addicted to) psychiatric drugs for life, with all their dire complications; and ever-growing legions of people around the world will be converted into shuffling queues of drug-addled, disempowered numbers. And we can be sure that any changes to the status quo will provoke a mighty shriek of outrage from psychiatrists, who will (correctly) feel they are losing their autonomy (read: power to do what they like to whom they like with no fear of recrimination; see the post on [Mad in America about] New Zealand’s shameful Lake Alice scandal, Sept. 12th.
The guidelines are over 200 pages and arrived late last night so I haven’t done more than flick through them, but I want to focus on point 2 above, the “biomedical model.” I put this in quotes because, ten years ago this month, my paper Psychiatry as Ideology, showed that no psychiatrist, psychologist, philosopher or neuroscientist had ever written anything that would amount to an explanation of mental disorder as a biological disturbance of brain function, i.e. a “biomedical” model. Despite billions of dollars spent on basic biological research in psychiatry, it is also true that nobody has written anything of interest since that could remotely fill that gap. I have challenged a number of influential psychiatrists to produce their so-called model but, after that challenge, there is a deathly silence, broken only by the sound of the lids slamming shut on their rabbit holes. There is only one conclusion to be drawn from this “omission”:
Modern psychiatry is driven, not by a scientific model of mental disorder as a biological disturbance of brain function, but by an ideology which dictates that mentally-disturbed people are less than human and can be treated as such.
How did this come about? Why does the UN even need to produce guidelines saying “The mentally-troubled have rights, too”? By coincidence, I have just submitted a paper for publication that addresses exactly that point. It follows on from the discussion on the philosophical doctrine of positivism three weeks ago (Sept. 19th). As a reminder, positivism is the foundation of western science as it exists today. While the underlying notions had been bumping around for several hundred years, the doctrine burst on the scene nearly a century ago as “the scientific conception of the world”.
Its goal was to eliminate all the airy-fairy stuff from science, to strip it down to its essentials by starting with just the evidence that could be positively confirmed – in brief, “If we can’t see it and measure it, it doesn’t exist.” Any facts used to build a science had to be in the here and now, real observations of something tangible that could be checked and confirmed, even by people who didn’t want to believe it. The new conception of science was that it had to be independent of anything we humans would like to believe about ourselves and the universe. Thus, they resolved the conflict between different religions by rejecting them all as “unprovable metaphysics.” Trouble is, metaphysics is the branch of philosophy which deals with ultimate questions, such as the nature of being, the concept of mind or of causation, and so on, so we can’t escape it. People who say “I make no metaphysical assumptions” are, in fact, making a very big one.
As it happened, when the positivist manifesto was proclaimed in 1929, medicine was already a long way down the objectivist path. Physicians were aware that the microscope and the pathology laboratory were revealing far more than the Bible or other religious texts ever would, so they didn’t need much urging to join the movement. But, and this is a very big but, if unobservables can’t form the basis of a science, and the mind is in principle unobservable, how can we talk about disturbances of the mind without lurching into “unprovable metaphysics”? For biology and general medicine, the problem was quickly solved by the psychological field known as behaviorism.
This started with a bang in 1913 when an American psychologist, John B Watson, declared that all talk of the mind was strangling psychology by leading into unprovable arguments. Therefore, he declared, we will expel the mind from the science of psychology. Instead of “metaphysical musing” (aka “armchair philosophy”), observable behaviour will become the necessary and sufficient evidence to explain human activity (‘necessary’ means we can’t explain humans without it, and ‘sufficient’ says that we need nothing more).
Without knowing very much about it, Watson proposed that the principle of conditioning, discovered by the Russian psychologist, Ivan Pavlov, would be the building block for a new scientific psychology. Equipped with the concept of the conditioned reflex, behaviorist psychologists were ready to explain everything. Ever since, generations of students have been taught about conditioning and reinforcement and so on, with just one small problem: there’s no truth in any of it.
Ivan Pavlov was not a psychologist, he was a physiologist and he didn’t think much of psychologists. In the second last paper published in his long life time, he described them as little more than a bunch of amateurs. Second, he didn’t describe a process of conditioning, he described a technique for studying physiological actions, such as salivation in the dog. As a process, conditioning doesn’t exist; the whole thing is a myth but it sounded very impressive so people were able to string it out for the next 75 years. Finally, it doesn’t explain anything. To say that somebody has been “conditioned” to do something says no more than “That person does just that.” Pavlov himself knew all this: “I reject point blank and have a strong dislike for any theory which claims a complete inclusion of all that makes up our subjective world”. That is, he did not believe the doctrine of behaviorism could explain human mental life. But he died soon after and his prescient paper was completely ignored by the very people who were so keen to talk about “Pavlovian conditioning.”
Meantime, on a planet far far away, psychiatrists were happily messing with people’s brains and minds. Messing with brains, as in shocking them with various chemicals and electricity, or cutting them as in “leucotomy/lobotomy” (see PBS American Experience: The Lobotomist); messing with minds as in “You’ve got a bad case of penis envy, my good woman.” Now if psychiatry wanted to join the happy scientific throng (read: get all the benefits), it had to abandon any notion that it could meaningfully talk about the mind, so out it went. Human mentality joined religion in the waste paper bin out the back. In the new psychiatry, when a person says “I feel so sad and hopeless, I may as well be dead,” he’s actually talking in metaphor. It’s the same as saying “The sun’s going down.” No, the sun isn’t going anywhere, that’s just an impression that our science shows to be false.
Same with emotions: when a person says “I’m anxious,” all she’s doing is indicating in her quaint human way that her neurotransmitters are playing up. As a good positivist, the psychiatrist recognises this and, without letting his emotions or her prejudices get in the way, prescribes treatment to fix those pesky imbalanced chemicals. What the patient says is not to be taken at face value, it doesn’t invite an emotional response as it is simply an indicator of the true state of affairs beneath the surface. Which the patient, of course, can’t possibly know about but the keen-eyed and sharp-witted psychiatrist does: “Yes dear, of course you’re sad, that’s the nature of your illness, so here’s your tablets, come back in a month next please.” To put it differently, psychiatry removed any and all spiritual element from mental disorder. And that will provoke another howl of outrage, so we’ll pause to consider it.
The concept of humans as spiritual creatures goes back forever: recent findings in South Africa indicate that a small hominin called Homo naledi, which was separate from our lineage, was ritually burying its dead 300,000 years ago. Maybe the little creatures had some religious sense, maybe they didn’t, but humans do, centred around the notion of a spirit or soul, something above and beyond the “mere meat” of the body and brain. Now this is where it gets a bit murky because practically every human who has ever lived thinks of spirits or souls as having magical properties, such as immortality, or being able to act on the world without being part of it. Science can’t deal with magical properties so this is precisely what positivism is designed to eradicate. For naive positivists, such as the Vienna Circle in 1929 or psychiatrists in 2023, mental = spiritual = magical = nonsense.
From that flows the idea that mentally-troubled people don’t need to be taken at face value. For example, if they talk about their feelings, they’re talking nonsense, especially when they’re saying “I feel you people aren’t listening. I don’t want to be in your stinking hospital, I don’t want your drugs and shock treatment. I want my clothes back and I want somebody who knows how to listen. I want to be treated with respect.” And this is exactly what the UN is saying: the field of mental disorder has been coopted for purposes that suit the state and the psychiatric industry, not for purposes that suit the sufferers. Therefore this needs to be rectified. Now, not in the nebulous future. And, with their guidelines, they show just how it is to be done, except psychiatry isn’t listening.
The institution of psychiatry is continuing along its old path of medicalising normality, of reducing psychosocial factors to tokens, of paying lip-service to the concepts of the Universal Declaration of Human Rights and the Convention on the Rights of People with Disabilities, and so on. We see this in the three lectures sponsored by the Royal Australian and New Zealand College of Psychiatrists which aim to put 5% of children on dangerous and addictive drugs without any understanding of what has happened to those children. 80% of people started on ADHD drugs as teenagers and young adults choose to stop them within five years. Doesn’t that say something? Psychiatry claims to be “evidence-based.” Isn’t that evidence of something? Yes, it is evidence of selectively filtering the evidence to get rid of all the material that doesn’t confirm your position. Similarly, where is the evidence that locking innocent people up in the very long term and drugging them insensible is better than other forms of management, or even no management at all? There is no evidence, that’s why the UN says it’s time to stop and reconsider.
My paper argues that we can write a science of mental disorder which gives full credit to the idea of humans as mentally-capable beings (I use the word spirituality but with no supernatural connotations). It is not meaningless to claim that mental symptoms can and do arise purely as the result of psychological and social pressures in a perfectly healthy brain. We need to reintegrate the concept of humans as mental/spiritual beings into psychiatry, as the first step to implementing a human-centred, rights-based approach to mental disorder.
While psychiatrists can wave the positivist manifesto (which none of them have read) at their critics, then we’re in for a long, hard slog to change things. We may as well start now.