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"Go out into the real world; work in prisons, in run-down towns with high unemployment or with refugees or in remote areas. Go overseas or into underprivileged parts of your own country. And that is how you learn about real psychiatry," says Niall McLaren, MBBS, FRANZCP, in the next installment of Conversations in Critical Psychiatry.
Conversations in Critical Psychiatry is an interview series aimed to engage prominent critics within and outside the profession who have made meaningful criticisms of psychiatry and have offered constructive alternative perspectives to the current status quo.
Dr Niall McLaren is an Australian psychiatrist with a rich clinical experience of practicing psychiatry with limited resources in some of the most remote parts of the English-speaking world. He has a lifelong interest in the philosophical and logical status of theories used in psychiatry. He is the author of a trilogy of books (Humanizing Madness, Humanizing Psychiatry, and Humanizing Psychiatrists) in which he takes on the task of developing a biocognitive model of mind and mental illness, which he sees as a replacement for the 19th century ideologies of psychoanalysis, behaviorism, and biological psychiatry. His most recent publication is Anxiety: The Inside Story.
Dr McLaren has long argued that psychiatry lacks a formal model or theory of mental disorder and that the current practice of psychiatry lacks scientific standing. He has criticized the ethos of biological reductionism, which sees mental disorders as brain disorders. While he is an acerbic critic of mainstream psychiatry, his criticisms are driven by a passionate desire to see psychiatry evolve into a philosophically and scientifically mature discipline. Largely ignored by mainstream psychiatry, his critical writings have amassed a significant worldwide readership. I may disagree with his views, but it is my fervent belief that psychiatry has much to gain by engaging with thoughtful critics like Dr McLaren.
Awais Aftab, MD: Since not all readers will be familiar with your body of writings, perhaps you could begin by summarizing your views on what ails psychiatry?
Niall McLaren, MBBS, FRANZCP: There is a great deal that ails psychiatry-over-diagnosis, over-treatment, misallocation of resources, consistent breaches of patients’ fundamental human rights, and so forth-and they all go back to the one problem: mainstream psychiatry lacks a scientific framework. It is not a science because it does not have an articulated, publicly available model of its field capable of generating testable predictions. Everybody thinks there is a model, called the biological or medical model of mental disorder, but it does not exist. It is like the phantom biopsychosocial model attributed to George Engel: He argued for the need for such a model, but he did not actually present one. Everybody thinks he did, he talked as though he did, but he didn’t.
A model needs to be set out as a series of internally consistent propositions that generate an empirical research program. Psychiatry does not have one, because we do not have a concept of the nature of mental disorder. This is not just our fault; it derives from the larger philosophical problem that there is not an accepted model of normal mind. When the psychoanalytic or psychodynamic models of mind were shown to be non-scientific, psychiatry retreated to the biological corner thinking it could save us, but nobody has ever shown that we can explain the mind in brain terms. Nor will they ever do it.1
Aftab: Earlier in your career, while you worked in the remote Kimberley Region of Western Australia for six years, you may have been the world’s most isolated psychiatrist. Did that experience have any bearing on your subsequent approach to psychiatry? It certainly fits in with your highly original ideas, and your intellectual journal appears to have been a largely isolated one as well.
McLaren: Part of the reason I left Perth to go north was because of the covert hostility of the psychiatric establishment in that very isolated city to anything that questioned what they were doing. I had enrolled in a PhD jointly with the department of philosophy, applying the philosophy of science to psychiatry. But there was no interest in psychiatry in anything that challenged their core beliefs, so I thought I would move. However, I knew it would not be any different in any other city, so I decided on a complete change rather than half a change.
I went there because I could already tolerate isolation (overwhelmingly, psychiatrists cannot). And I very quickly learned that most of what I had been taught simply was not correct, even at the most practical levels. For example, in that fiendishly hot climate with punishing levels of humidity, it is not possible to use lithium or drugs that suppress sweating. So I learned to do without them. Electroconvulsive therapy was not available, so I managed without it. More important, what was regarded as schizophrenia in Aboriginal people actually wasn’t. If they were simply watched for a while, most of them got better with very little medication. However, if they were put on depot antipsychotics, they quickly got worse, which led to more drugs, which made them worse again, and they did not recover.
Aftab: You have commented on how the current practice of psychiatry tends to ignore personality disorders, and the notion of personality dysfunction as a cause of psychiatric syndromes (former axis I) such as major depression is largely discounted. This is consistent with my clinical experience as well. For instance, psychiatry recognizes that individuals with personality disorders are more likely to have treatment resistant depression, yet the treatment algorithms for treatment resistant depression do not really take that into account. And, in practice, that leads to aggressive pharmacotherapy. Does this help explain why treatment resistance appears to be the rule rather than the exception in clinical settings?
McLaren: The more I go on, the more convinced I become of the maxim, “Personality is everything.” Modern psychiatry has forgotten personality disorder. Forty years ago, people who qualified for the label were offered only brief psychotherapy and crisis support, because that is all that worked. Long-term medication was not seen as an appropriate strategy. So, people with neurotic depression, which was actually reactive depression in a neurotic or vulnerable personality, were rarely offered antidepressants. This meant they did not have lots of toxic drugs lying around when the next crisis led to an impulsive overdose. Now these patients are relabeled with major depression, bipolar disorder, ADHD, or autism spectrum disorder, and then they are given lots of powerful drugs with a huge raft of disabling side effects and they don’t get better. They go in and out of hospital, and nothing changes because treatment is misdirected. In psychiatry, personality is everything. Ignore it at your patient’s peril.
Aftab: If I were to try to capture the essence of the biocognitive model in a sentence, I would say: Mental disorders are psychological disorders created by information processing feedback loops gone awry in biologically intact brains. Is this a fair characterization? How would you succinctly describe the biocognitive model?
McLaren: That is indeed a fair characterization. The essence of the model is that self-reinforcing processing disorders can arise in perfectly healthy brains and, in the overwhelming majority of cases, that is exactly what happens. A small problem starts, then gets worse, then it causes further complications, then the person tries to rectify it-often by self-destructive means such as drinking or social isolation, which results in more complications, and so it goes. This isn’t rocket science, it is essentially chaos theory with a human face.
Aftab: If your biocognitive framework for understanding mental disorders is correct, then why should psychiatry be seen as a medical specialty? If there is no underlying biological dysfunction, then why are physicians better qualified (than say, psychologists) to take primary ownership of the diagnosis and treatment of psychological disorders?
McLaren: This is a very important question. We could abolish psychiatry today but, by early next week, we would have to reinvent it because humans are minds and bodies, not mindless bodies. I tell medical students and residents that they have to take a medical history and be prepared to examine the patient because if they do not, the next person to do so may well be the pathologist. Anxiety, for example, affects every part of the body, from the scalp (piloerection) to the soles of the feet (sweating), and we have to sort through what’s what. Only an experienced medical practitioner can do that, and the more experience you have, the better.
Only yesterday morning, I had to deal with a young woman with abdominal symptoms, dismissed as psychosomatic by the hospital. In fact, she had severe colonic dysfunction and impaction due to the massive doses of drugs she was prescribed. The last patient for the day was a young man with frontal brain damage, severe anxiety, and intractable headaches who limped because of severe cellulitis of both legs. The last thing he wanted was to go to hospital because they invariably would dismiss him as mad. We are doctors, and when everybody else does not want to know the patient, we still care. Clinical neuroscientists? What grandiose, narcissistic rubbish.
Aftab: Would you consider your biocognitive model of mental disorder to be scientific in nature or philosophical? If you consider it to be scientific, what makes it scientific? The model relies heavily on philosophical ideas of David Chalmers, PhD, and Alan Turning, PhD, and I am not entirely sure if it makes any falsifiable predictions. (And if the biocognitive model is indeed primarily philosophical, then how does it help psychiatry become a more scientific specialty?)
McLaren: How much space do I have? It is a dualist model, so in that sense, it is primarily a philosophical model, staking out a particular ontological stance. However, it is not substance dualism, because that only goes into an infinite regress, so it is nonscientific. It is scientific in the sense that it starts with a set of axioms that sit firmly within the framework of current scientific thinking. I am working on a mathematical derivation of an emergent informational model of mind, the mind as an informational space. This is not easy-I am not a mathematician-so I struggle through texts such as George Boole’s Laws of Thought. 2 He showed how we could use a dual-valued or binary algebra (now known as Boolean algebra) to duplicate the processes of reasoning, out of which came the entire informational revolution of the 20th century.
OK, so reasoning is the easy part, the low-hanging fruit of a data-processing model of mind. Now we move onto what Chalmers has called the hard problem of consciousness sensory experience. Chalmers argues that the mind arises from, or supervenes upon, the brain by rational processes governed by laws of supervenience that we can determine. I am working on the case that his laws of supervenience are, in fact, no more than Boole’s Laws of Thought. This is really interesting; this is the future of psychiatry, especially when we have just been told what I had warned 27 years ago-that biological psychiatry has limits3 and it cannot tell us all we need to know about mental disorder. This is what residents and young psychiatrists should be looking at, not wondering whether a bigger genome-wide association study will give the answers. It won’t.4,5 As for refutable predictions, here’s one: Nobody will ever find anything in the brain that could conceivably account for a single mental disorder.
Aftab: You have also been a critic of the psychiatric publishing industry. One of your arguments is that psychiatric journals do not have a declared model of mental disorder. In Humanizing Psychiatry, you wrote: “Of the major, English language journals of general psychiatry still in print, not one nominates a model of mental disorder in its instructions to authors.”6 and “Currently, no psychiatric journal in the world meets minimum criteria for a journal of scientific record. Of 28 prestigious journals reviewed, not one defined the model of mental disorder that guides its publications policy.”6 I do not know if journals in other fields of medicine would stand up to this sort of scrutiny. For instance, I do not think neurology journals (like Neurology) or general medicine journals (like the Journal of the American Medical Association or New England Journal of Medicine) endorse any particular model in their instructions to authors.
McLaren: The simple answer is that mainstream medical journals do not make any claims above and beyond the established limits of reductionism, so they all meet the criterion. For them, it works because they very carefully stick to the fields for which it was designed. Reductionism works fine if you are peering down a microscope at a nephron or squirting antibiotics into an IV line. It is only when we move beyond the narrow confines of physical medicine and try to throw a reductionist net over irreducible phenomena such as language, emotions, and so on that we run into trouble. Psychiatrists did not know that 40 years ago when they launched DSM-III, but they should have. Worse still, they painted themselves into a reductionist corner without leaving themselves an escape route, and reductionism has failed.
Aftab: Does the biocognitive model offer any guidance regarding how to draw the boundary between disorder and normal? What makes a condition a “disorder”?
McLaren: There is always going to be a social element in the definition of disorder; we cannot escape it. However, we need to pull right back from the notion of imperial psychiatry unlimited, which remorselessly encroaches on normality. I think what Allen Frances, MD, said in his contribution to this series7 is absolutely correct: Life isn’t always a barrel of fun, but that’s not mental disorder. People recover from adversity; they are very resilient creatures. But when they cannot recover, when they become trapped in a self-reinforcing cycle of mental distress and social failure, then it becomes a disorder. This says that we cannot impose treatment on people just because they do strange things like hear voices-as long as they are not damaging themselves or anybody else.
Aftab: Academic work in philosophy of psychiatry has generated a lot of articles in recent years, why do you think they are not making the sort of contribution you feel psychiatry needs?
McLaren: This is true, there are such papers, but they are few and far between. Also, they are mostly published by senior figures in psychiatry who are deeply committed to the current paradigm, not young radicals who want to analyze the paradigm itself. These types of papers are tentative suggestions on how we can improve psychiatry without rocking the boat too much.
I have never worked in academia; I spend all day, every day assessing and treating unselected public patients and then write my reports and research papers at night. I have no affiliations, but I have a breadth and depth of experience in psychiatry that academic psychiatrists can never have. I also have formal training in philosophy, and I think reductionist biological psychiatry cannot be saved by a few cosmetic changes. It is doomed to fail, just because it does not have, and never can have, a heuristic model of mental disorder. I accept that, so I stand outside mainstream psychiatry with a sledgehammer saying, “Let’s get on with wrecking this mess and start again.” Time will tell who is right, but when we look at how much money and effort has been spent on trying to build a science of biological psychiatry, you wonder why anybody bothered.
Aftab: Any words of advice for younger psychiatrists?
McLaren: Yes, I have, and thank you for asking. My advice is this: Get out of the echo chamber of modern psychiatry. Get out of the huge, luxurious inner-city hospitals where academics live in a permanent intellectual bubble. Challenge everything you are told, and insist the professors answer your criticisms. Go out into the real world; work in prisons, in run-down towns with high unemployment or with refugees or in remote areas. Go overseas or into underprivileged parts of your own country. And that is how you learn about real psychiatry. Oscar Wilde said, “An idea that is not dangerous is unworthy of being called an idea at all.” I firmly believe that.
Aftab: Thank you!
Dr Aftab is a psychiatrist in Cleveland, Ohio. He completed his psychiatry residency at Case Western Reserve University/University Hospitals and trained in geriatric psychiatry at University of California San Diego. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry (AAPP) and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also on the Psychiatric Times Advisory Board. He can be reached at email@example.com.
Dr Aftab would like to thank Yash Joshi, MD, PhD, for his valuable input regarding the works of Dr McLaren and this interview.
The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of Psychiatric Times.
Dr Aftab and Dr McLaren report no financial disclosures and conflicts of interest.
Previously in Conversations in Critical Psychiatry
1. Stoljar D. Physicalism. Oxford: Routledge; 2010.
2. Boole G. The Laws of Thought. London: McMillan. New York: Dover; Reprinted 1958.
3. McLaren N. Is mental disease just brain disease? The limits to biological psychiatry. Aust N Z J Psychiatry. 1992;26:270-276.
4. Joseph J. Schizophrenia and Genetics: The End of an Illusion. New York: Routledge; 2017.
5. Border R, Johnson EC, Evans LM, et al. No support for historical candidate gene or candidate gene-by-interaction hypotheses for major depression across multiple large samples. Am J Psychiatry. 2019;176:376–387.
6. McLaren N. Humanizing Psychiatry: The Biocognitive Model. Ann Arbor, MI: Future Psychiatry Press; 2009.
7. Aftab A (2019). Conversations in Critical Psychiatry: Allen Frances, MD. Psychiatric Times. https://www.psychiatrictimes.com/couch-crisis/conversations-critical-psychiatry-allen-frances-md. Accessed October 25, 2019.