The Story of a Professional Delusion: Do Psychiatrists Believe Their Own Words?
The prescription of antidepressant or antipsychotic medications is something that a psychiatrist only ever does in partnership with the patient and after due consideration of the risks and benefits (emphasis added).
As described on MIA, I lodged a lengthy complaint
with the RANZCP, alleging that, as the responsible officials, the
president and board had breached their own code of ethics at a number of
points; in particular, the claim about prescribing habits was patently
false. This has gone back and forth and, predictably, my complaints have
been dismissed. On June 29th, the incoming president of the college
wrote to me:
The (original press) statement also acknowledges… the careful consideration given when prescribing medications.
That is, he essentially repeats the false claim that drugs are “only
ever” prescribed after a friendly discussion between the caring doc and
the grateful patient. Some months ago, I published the results of a pilot study on my 176 active files, which showed that psychiatrists hardly ever
give information to patients regarding the risks of their drugs (I
would have thought that any psychiatrist who was still breathing would
know this: patients are routinely thrown to the ground and jabbed
despite their furious objections or tearful pleading. Part of his
defence was that psychiatrists have good intentions).This reminds me of another rather fractious interchange I had with the well-known psychiatrist Ronald Pies. Readers may recall that some years ago, in his role as editor of the online publication Psychiatric Times, Dr Pies penned a fulmination against the “narrative” of the “chemical imbalance” hypothesis of mental disorder:
I am not one who easily
loses his temper, but I confess to experiencing markedly increased
limbic activity whenever I hear someone proclaim, “Psychiatrists think
all mental disorders are due to a chemical imbalance!” In the past 30
years, I don’t believe I have ever heard a knowledgeable, well-trained
psychiatrist make such a preposterous claim, except perhaps to mock it.
On the other hand, the “chemical imbalance” trope has been tossed around
a great deal by opponents of psychiatry, who mendaciously attribute the
phrase to psychiatrists themselves… In truth, the “chemical imbalance”
notion was always a kind of urban legend- – never a theory seriously
propounded by well-informed psychiatrists.
In a comment (since deleted), I suggested that perhaps Dr Pies had
spent the last thirty years holed up in a cave in Patagonia because
patients tell me that all the time: “The other psychiatrists said I have
a chemical imbalance of the brain and I have to take drugs all my
life.” I don’t believe patients make that up and I don’t believe the
trope originated with them: it came straight from psychiatrists in their
latter-day role as purveyors of chemical bliss.To continue, earlier this year, I published an article1 which showed that all claims made on behalf of ECT by the RANZCP have no basis in fact. A newspaper article based on the same figures scored me a complaint, which was rather difficult to understand because all I did was collect figures from different advocates of ECT to show their claims are self-contradictory.
Similarly, in July 2017, the Australian Human Rights Commission held an enquiry into the Convention on Torture, whose full name is Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment and to which Australia is a signatory. I submitted a paper (mine is No. 3) which showed firstly, that detained psychiatric patients met the Convention’s definition of detained persons; second, what was done to them amounted to “treatment” and third, the patients themselves often said their treatment felt like torture.
Needless to say, this provoked yet another complaint that I was dragging the noble name of psychiatry in the mud, that psychiatrists are terribly nice people with good intentions who would never dream of torturing people. That may be convincing to somebody who doesn’t know psychiatry’s ghastly history,2 but anyway, the Medical Board dismissed the complaint in under 24 hours (I must say I never take complaints personally because I know it’s not me that they dislike, just what I’m saying).
Finally, an intensely personal essay3 in the influential Lancet Psychiatry extolled the virtues of psychiatry’s biopsychosocial model, originally developed by the psychiatrist George Engel. Linda Gask, a psychiatrist who does not conceal her own mental problems, concluded:
…the biopsychosocial model is, and remains, a model for the whole of medicine — not just psychiatry.
This is a little alarming. First, George Engel was not a
psychiatrist, he was a gastroenterologist. Granted, he had a dual
appointment with the department of psychiatry and had undergone
psychoanalysis, but that’s not the same. Second, he did not write for
psychiatry but for general medicine. All his case examples are medical.
Finally, and damningly, in 1998 I showed that his ‘biopsychosocial
model’ wasn’t a theory, nor a model, nor anything, because Engel never
actually wrote it.4
Indeed, in 2004, I went so far as to say that any psychiatrist who
claimed there is a biopsychosocial model is committing scientific fraud,5 but Dr Gask and all Engel’s fervent disciples manage to brush that off.Let’s pause to look at these facts:
- Very senior psychiatrists repeatedly insist that psychiatric drugs are “only ever” prescribed after a friendly chat involving “due consideration of the risks and benefits…” However, everybody knows that every day in every town in the world, mentally troubled people are wrestled to the ground and injected, but if they complain, they will get more, not less, drugs.
- A very influential psychiatrist bursts his boiler over the calumny that a “knowledgeable, well-trained… well-informed psychiatrist” would ever use the expression “chemical imbalance of the brain.” Tens of thousands of psychiatrists actually do use it, as do drug companies, family doctors and just about everybody else. A Google search yields 1,180,000 citations in 0.48secs.
- Certain psychiatrists in Queensland take vigorous exception to the public being told that Australia uses ECT 600% more than New Zealand, even though on every conceivable demographic factor, the populations are the same. The only difference between the two countries is that the surge in ECT in Australia is almost entirely in private practice, and New Zealand has no private psychiatic industry. Even though the RANZCP code of ethics explicitly forbids exploiting patients, private hospitals charge what they like (the only figure I have is $620 per shock, which would be a shock in its own right). Queensland uses ECT 1000% more than the British National Health Service, and it is all but banned in Italy, where it was invented, but apparently none of that counts as evidence of exploitation.
- Psychiatrists object bitterly to the idea that anything they do could count as torture because their intentions are honorable. A considerable proportion of psychiatric patients don’t actually like being locked up, trussed up and/or stripped naked and injected with powerful, psychoactive chemicals which induce a wide range of exceedingly unpleasant, long-term and/or dangerous side effects, and/or shocked, and liken their experience to torture, which brings them under the purview of the Convention on Torture because, very foolishly, the Convention defines torture as what the recipient feels about it, not what the perpetrator intends by it.
- Large numbers of psychiatrists around the world think that a model that was never written licenses both their immense and essentially unaccountable power over people who have broken no laws, and their outrageous fees.
On the one hand, we have a bunch of ideas that Blind Freddy can see are either idiotic or completely false, and on the other, we have a very large group of highly educated, mostly intelligent, mostly sober and well-behaved people who swear by them.
Is there a tablet for cognitive dissonance? Thanks, I’ll take two.
Talking of cognitive functions, let’s try a little exercise in epistemology, the philosophy of knowledge. The goal is to assign each of the above statements to an epistemological category. We’ll go through them in reverse order, starting with No. 5. This one interests me greatly. How can anybody read Engel’s work and come away with an idea that matches the power and scope of, say, the modern synthetic theory of evolution? Or the standard model of physics? Or plate tectonics? Immunology? It’s ludicrous because it simply isn’t there, but I think the answer is that psychiatrists are too scared to look at the truth, which is that they don’t have a model of mental disorder.6 Instead, they clutch Engel’s pseudo-model to their chests like a security blanket. Standing in a group chanting “We believe, oh Engel, we believe,” is much less scary than asking: “Do I really know what I’m doing?” That is, it’s just another example of believing a comforting lie rather than confront a scary truth, which is terribly human. Human, but hardly edifying.
No. 4, torture. Oh dear, do any humans ever believe they are doing bad things? A few, but most of humanity’s more egregious crimes against itself have been committed in the pursuit of noble ideals. Hitler’s plan in his war for Lebensraum was to wipe out 30 million Slavs in the first year but that was noble because his Aryan races ranked higher in the cosmic order than mere Slavs. And in his final testament, his notorious Table Talk, he fully expected that the world would be grateful for his sideline in getting rid of the Jews. Ernst Rüdin, psychiatrist and architect of the T4 Program, which sterilised and murdered hundreds of thousands of mental patients, and prototype of the Final Solution, did not believe he was doing anything wrong: he explicitly ordered that their deaths should be easy. Even Stalin thought he was doing the proletariat a favor — well, those that survived. As Kenneth Clarke said in another context:
They suffered from that most terrible of delusions, they believed themselves to be virtuous.
Psychiatrists firmly believe that leaving a mental disorder untreated
is a very much worse sin than locking a person up and pumping him full
of drugs that they know will shorten his life. Why do they believe this?
You’d have to ask them, but I expect they would say something like,
“Have you no humanity? Think of the poor schizophrenic huddled in a
doorway in winter.” Indeed, but there are plenty of poor people huddled
in doorways and nobody bothers much about them. I think we could class
this as an example of psychiatrists not taking the effort to sort out
what’s good for them (lots of busy hospitals stuffed full of patients,
lots of conferences in nice resorts, research grants and so on) and
what’s good for the man on the receiving end of the needle. But who
cares about him anyway, we all know he’s nuts.As an aside, Rüdin’s very successful efforts to sterilise and murder pre-war Germany’s population of people diagnosed with schizophrenia had no effect on the post-war incidence of the condition, which is a problem if you want to believe it’s all genetic.
No. 3, about ECT, is easy:
It’s difficult to get a man to understand something when his salary depends on his not understanding it. (Upton Sinclair)
If you can earn up to $250 for about two minutes of “work” by
believing ECT is the greatest, only a fool or a churl wouldn’t believe
it. That is, psychiatry’s fascination with ECT is a simple case of
Skinnerian positive reinforcement (if you’re rewarded for doing
something, you’re more likely to do it again). It means that if we
stopped paying people for giving ECT, it would soon die out.No. 2. Ah, the good Dr Pies. I detect a touch of professional jealousy here. He doesn’t like the naive reductionist biological approach favored by the likes of Thomas Insel7 8 as he believes he’s more sophisticated than that, but even he can see that when the NIMH disburses its $1.5 billion a year, the lion’s share goes to basic biological research and his side hardly gets a look it. So he stamps around the place, banging lecterns with his shoe and growling to whoever will listen, but guess who keeps his newspaper afloat? That’s right: drug companies.
And so we arrive at Number 1: Why would a sensible person thrice deny the empirically-established fact that psychiatrists hardly ever give any information about their drugs, and the little they do give is sugar-coated and highly misleading?
Option No. 1A: They’re idiots.
Let’s assume they don’t have the brains to analyse a complex question and arrive at the right answer. They’d get lost crossing the street. No, we can dismiss this because they passed medical school. How, we don’t need to know.
Option No. 1B: They’re sheep.
If in order to get your ticket in psychiatry, and get a job, and keep it, and be able to go to conventions and have people talk to you, and have people sit through your lectures without walking out, and get your papers published, you have to believe that black is white, what do you do? That’s right, you go with the flow. Listen to the words of the esteemed Brother Chomsky:
Still, in the universities or in any
other institution, you can often find some dissidents hanging around in
the woodwork—and they can survive in one fashion or another,
particularly if they get community support. But if they become too
disruptive or too obstreperous—or, you know, too effective—they’re
likely to be kicked out. The standard thing, though, is that they won’t
make it within the institutions in the first place, particularly if they
were that way when they were young—they’ll simply be weeded out
somewhere along the line. So in most cases, the people who make it
through the institutions and are able to remain in them have already
internalized the right kinds of beliefs: it’s not a problem for them to
be obedient, they already are obedient, that’s how they got there. And
that’s pretty much how the ideological control system perpetuates itself
in the schools.9
I’d say it’s a case of the echo chamber effect, where a group of
people sit in a circle and a man says to the woman on his right: “The
woman on my left just said that everybody she’s spoken to agrees the
emperor is wearing wonderful new clothes, so I’ll agree. Pass it on.”
Nobody has the courage to stand up and state the obvious.Option No. 1C: They’re deluded.
A delusion is a fixed, false belief, out of context with the healthy subject’s cultural, social, educational and intellectual background.
Alert readers will be aware that this immediately leads to the conclusion that reality is simply a shared delusion; conversely, it’s not a delusion if enough powerful people say it isn’t. Enough powerful people are saying that psychiatrists only ever prescribe drugs after due blah blah, so it’s true and it isn’t a delusion and anyway, who’s objecting? You are, young woman? Listen to me, girly, you’d better think carefully before you say too much more, just think about your career and your kids ending up on the street. So what’s the truth about the emperor’s new clothes? That’s better. Don’t forget it.
That’s not really a delusion, more like a cult where a few charismatic people dominate a much larger number and control their thinking and everybody’s too insecure to challenge them. Psychiatry as a cult? I think somebody has already suggested that.
Option No. 1D: They’re talking shit.
Tucked between truth and falsity there is a further epistemological category, defined as bullshit. The person who talks shit has no regard for truth; it is an instrument for him, to be wielded and abandoned as the moment suits him. His utterances are neither true nor false but are designed to sway the audience on an emotional level. Mr Donald Trump is a master bullshitter. He says any bit of shit that comes into his head. If the crowd roars, he laughs and repeats it but if they don’t react, he immediately forgets it and moves to something else. He remembers the bits that got a cheer and the rest didn’t exist; if you say it did, that’s fake news (lies).
I have argued that psychiatry is stuffed full of bullshit10 and, at first glance, the “only ever” statement appears to qualify. However, the essence of a bullshit statement is that it is neither true nor false, it is a non-propositional form to which those logical categories don’t apply: “Make America Great Again.” “My country, right or wrong.” “Would I be here if I didn’t love you?” “Our wonderful sportsmen.” It doesn’t actually say anything that can be pinned down, which is the entire point. But this statement, that psychiatrists only ever prescribe blah blah most certainly can be pinned down. It’s been pinned down, and it’s been proven false. It may have started as bullshit but it ended up as crap.
Option 1E: They’re lying.
Telling a lie is an act with a sharp focus. It is designed to insert a particular falsehood at a specific point in a set or system of beliefs, in order to avoid the consequences of having that point occupied by the truth.11
I believe this is what happened. The people responsible for this travesty looked at the truth (that psychiatrists hardly ever tell the truth about their drugs) and realised they didn’t like what would flow from that fact getting loose. So they removed it and substituted a falsehood (only ever) whose consequences they could live with. On July 6th, I sent a letter to the newly-installed president of the RANZCP, reiterating my allegation that the claim was false, and that everybody involved knew it was false:
For myself, I am forced to conclude that
senior officials of the college lied, lied again, and are now trying to
conceal their lies. I believe that the broader membership of the RANZCP
would agree with me, as would any reasonable member of the general
public. I believe that any person found guilty of such behaviour would
not be a fit person to hold office in the RANZCP, and I am sure most
members would agree with me.
In view of the repeated failure of
officials of the RANZCP to follow its approved procedures, I see no
cause to believe that they have acted in good faith in this matter, nor
that they have any intention of doing so. Accordingly, I shall refer the
matter to the Australian Charities and Not-for-Profits Commission,
under which the RANZCP is registered.
By the time you read this, that complaint will have been lodged.
Meantime, let’s go back to the question posed in the title: Do
psychiatrists believe their own words? I think they do because, crammed
in their little intellectual echo chamber, the overwhelming majority
don’t have the courage to question anything in case it brings the wrath
of the profession down on their heads — or in case it affects their
incomes. For a mainstream psychiatrist, there’s only one thing worse
than realising you’ve been in an echo chamber all your career, and
that’s being kicked out of it.The last word goes to the inestimable Richard Feynman, in his 1974 lecture Cargo Cult Science:
The first principle is that
you must not fool yourself—and you are the easiest person to fool… 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. And this is our responsibility as scientists… (emphasis added)
Show 11 footnotesThank You Dr McLaren and MIA.