“Critical Psychiatry” Has Failed to Reform Psychiatric Practice. Let’s Try Something More Mindful.
Our current biological model of psychiatry, favoring medications and other medical interventions to treat psychiatric conditions, emerged in the early 1980s–in the wake of the Neo-Kraepelinian revolution, as documented elsewhere on this website. This ended the dominance of talk-driven psychoanalytic treatment that had prevailed for most of the 20th century.
An early sign of this new era was the emergence of a mythical “chemical imbalance” to promote the use of psychiatric medications for depression, and sometimes other disorders as well. The pattern of speculative logic applied to the administration of antidepressants was as follows:
If a neurochemical deficiency were causing depression, you would want a drug that increases the level of that neurotransmitter in order to relieve the depression. If such an antidepressant does relieve depression, then depression must be caused by a neurochemical deficiency.
This subtly flawed logic produced a convenient myth, contrived by pharmaceutical companies to promote the use of their antidepressants. It was eagerly embraced and applied by countless gullible psychiatrists. It greatly appealed to us psychiatrists because it made us feel like “real doctors,” who actually knew what the hell we were doing–and it increased patient acceptance of our medications. Patients were eager to accept this fairy tale, since “my chemical imbalance” was a more socially acceptable explanation for one’s depression than the characterological “weakness” that was often attributed to those suffering with depression in generations past.
This marketable myth spread like wildfire throughout psychiatric practice, and even to the public at large, without a lick of scientific evidence–clearly because it sounded so plausible in its simplicity. It may seem perfectly logical to assume that depression is caused by a deficiency of one or more of these neurotransmitters, given the improvement observed with the administration of such medications. But like science, logic has strict standards—and the above assumption is the product of a common logical fallacy, called affirmation of the consequent.
Affirmation of the consequent is structurally stated as:
If X is the case, then Y would also be the case. Y is true, so X must be true as well.
This is illustrated by the obvious absurdity: “When it rains, the streets get wet. The streets are wet, so it must have rained.” This interpretation overlooks the possibility that something else may have caused the streets to be wet.
Psychiatry’s embrace of this flawed logic failed to account for at least one other possible explanation for a patient’s response to the medication: What if that antidepressant relieves depression by causing an abnormally high level of serotonin in the synapses, rather than correcting some hypothetical deficiency? This is what I actually believe is happening–and I provide evidence for this supposition both on this website, and in my book.
Resistance within psychiatry to its current biological model began in 1999 with the creation of the Critical Psychiatry Network–a collection of British psychiatrists advocating amendment of the Mental Health Act passed in 1983, in an effort to preserve the human rights and civil liberties of psychiatric patients under the care of the National Health Service. A prominent member of the CPN was Dr. Joanna Moncrieff, a personal hero of mine, who in 2008 published The Myth of the Chemical Cure. This landmark book challenged the existence of that dubious (and now debunked) “chemical imbalance.” Dr. Moncrieff eventually refuted this fraudulent sales pitch in 2022, with the publication of her exhaustive review of research studies. By that time, nearly every psychiatrist was claiming that we had never peddled this falsehood.
For over 25 years now, reform-minded psychiatrists and other advocates continue to raise the banner of critical psychiatry when they call out the bullshit and corruption that sustains our flawed model of care. Despite the success noted above, its concerted efforts have failed to make any significant dent in psychiatry’s “medical” self-image, its standing among medical peers, or the public’s embrace of our medicalized model of humanity. I attribute that failure to make our concerns heard to three distinct reasons:
1. Our target audience
I think we spend way too much time trying to convince our psychiatric peers that their practice is bogus, when they’re receiving a constant flow of checks that compensate them for their faith in our pseudoscientific liturgy. As Upton Sinclair, a heroic muckraking author in the early 20th century, noted:
It is difficult to get a man to understand something, when his salary depends on his not understanding it.
It seems to me that our efforts would be much more fruitful if we instead concentrated on informing the public at large about psychiatry’s foibles and failures. The general public has way too much unearned faith in psychiatry as a medical specialty, swallowing and regurgitating psychiatric diagnoses that aren’t at all based on hard science. The fad diagnosis of autistic spectrum disorder has caught fire among young people on social media, despite its vague definition, dubious nature, and questionable pathology.
The public at large should be informed of our stunning ignorance of our chosen organ system…such as the fact that psychiatrists don’t know how the brain generates thought, and our concurrent inability to explain the mind’s existence. Modern academic literature rarely references these two physiological touchstones–which I attribue to our cowardice, insecurity, and corruption. I don’t blame psychiatry for its ignorance, since the human brain-mind is consensually regarded to be “the most complicated object in the known universe.” But I am fed up with my profession’s arrogance, its pretensions, its cowardice, and its corruption.
Our corruption
The public should know that the process of defining diagnoses includes the participation of psychiatrists who have a side hustle of shilling for Big Pharma, and/or investing in pharmaceutical stock. Oh, there are limits–in the last DSM-5 process, psychiatrists were excluded from participation in a task force if they had accepted more than $10,000 in the past year from pharmaceutical interests, or if they held more than $50,000 in stock in a pharmaceutical company. Professional lobbyists for the pharmaceutical interests were, of course, invited to provide pharmaceutical education. The resulting diagnoses are less scientific (based on an understanding of nature) than industrial–a technological development to direct the administration of medications and other products. If the process were actually scientific, we wouldn’t need to convene in a business meeting every decade or so to reevaluate and redefine our diagnoses.
2. Our current branding
Psychiatry at large accepts this contaminated process because it puts food on the table, and it makes us feel medical. Despite our flimsy grasp of brain science, we don’t want or need to reform psychiatric practice–but the lay public might want it, if they knew what was really going on. But appealing to the public will require the use of language that is clear, meaningful, and motivational.
The brand “critical psychiatry” apparently called for reevaluation of the nature of psychiatric practice in the United Kingdom, within a socialized system of medical care. Its aim was to direct psychiatrists to apply critical thinking to the ongoing medicalization of psychiatric treatment–but also to the excessive coercion and social control functions of psychiatry as practiced at that time in the UK.
But as a brand to carry over to the more freewheeling and capitalistic model of care practiced in the United States, critical psychiatry seems to me a cumbersome label with significant flaws. It might sound like quite an unpleasant thing to anyone who doesn’t know better–perhaps an emotionally brutal treatment model in which the psychiatrist completes their examination, and then calls out the patient on all the perceived flaws that have been found, and their need to be corrected.
I believe that this branding defect may account for much of our failure to make any dent in our corrupt and dehumanizing model of care. To appeal to the public, you need to make your virtuous goals obvious. When you consider the vulnerability of most patients when they are entering psychiatric treatment, they’re not likely to seek out a practitioner who is “critical.” For these reasons, I believe that a more positive form of branding should be used to introduce and advance much-needed reform in contemporary psychiatric practice. And as you might suspect, I have an alternative brand to consider–one that differentiates itself from our current model, offers a more complete conception of our target organ, and greatly expands our array of therapeutic interventions.
The psychiatric reforms I support fall squarely within the boundaries of contemporary critical psychiatry. But how do we recruit others to join the march with a name that implies that “from now on we’re just going to tell you what we really think, and you will like it.” It even suggests that psychiatric practice hasn’t been as confrontational as it ought to be. No wonder it’s been a loser. After 25 years of advocacy, its only solid victory has been to debunk a myth that practically all psychiatrists already knew was bullshit. Given the egregious flaws in psychiatry’s scientific underpinnings, the 2018 results of the CDC Suicide Study…the fact that we don’t even understand how thought works–we should be beating the corruption down on each and every day.
In June 2018, the CDC Suicide Study was released, documenting a 30% increase in suicide in the U.S. from 1999 to 2016. The leaders of American psychiatry offered bland responses empty of meaning, obviously aimed at being so uninteresting that nobody would care or bother to quote them. Where was the leadership of critical psychiatry on that day? If they did make a statement, it wasn’t heard. Why wasn’t it heard?
I am thoroughly convinced that meaningful reform of psychiatry will only happen if it is driven by scrutiny from the public at large–psychiatry’s consumer base. That’s why the book I’ve written isn’t aimed at my professional peers–although hopefully some will read it, and maybe a few of them will agree with me. But as I’ve said elsewhere, I want to bite the hand that feeds me. I’m not terribly concerned whether my professional peers will agree with my arguments, because they are feeding from the same hand. For the vast majority of my professional peers, modern psychiatry’s guiding principles are a matter of faith–and their bread and butter.
In writing my book, I’ve taken great effort to make it clear to the learned public that most of the guiding principles of modern psychiatry are constructed on a body of sham science. Almost none of our diagnoses have been derived from the study of nature; rather, they are developed by our trade association, with the active participation of pharmaceutical companies and other financial interests. This alleged “knowledge base” is constructed to obscure and distract from our utter ignorance of how the brain actually works–with no scientifically valid explanation for the phenomena of thought, memory, or emotions, and thus little understanding of their dysfunction. We really don’t know what we’re doing, but it’s well established by now that we can make up a fictitious body of pseudoscience to make it look and feel like we do. And by now, we obviously know what sells.
It is an ironic twist that the etymology of the word psychiatry is “treatment of the psyche”–referring to the mind, thought, and spirit of man. The guiding literature of psychiatric study may occasionally refer to “thought” as pressured, disorganized, or otherwise disordered in our diagnostic assessments–but it doesn’t seem to be at all inhibited by the fact that we don’t know how it is created. The mind is completely absent in the bulk of contemporary psychiatric literature, most likely because it is something that we cannot at all scientifically explain. It seems at this time to be deemed completely irrelevant in contemporary psychiatric practice. And the spirit? Don’t even get me started….
3. A more positive and inviting brand
It’s commonly accepted nowadays that any attempt to engage the general public in a movement requires clear and positive branding–the identification of ideas or products in a way that is self-explanatory, and preferably appealing. The banner of “critical psychiatry” qualifies as “inside-baseball” terminology, understandable by those who already know–but with no value at all in engaging the general public. To the uninformed, “critical psychiatry” sounds like a treatment model, and one that isn’t very pleasant–in which the patient sits quietly, and listens to a psychiatric provider call them out for their particular deficiencies.
My book How Psychiatry Lost Its Mind…and Where It Might Be Found provides a multipronged takedown of modern psychiatry and its deficits, in a manner that strives to be constructive and thought-provoking–most notably in the chapter in which I present a neurodigital hypothesis to explain the phenomenon of thought. (This hypothesis was previously peer-reviewed and published on the front page of the May 2022 issue of Psychiatry Times.) In this model, I propose that the brain might be utilizing nucleic acids (DNA and/or RNA) to execute digital processing–and that the mind could thus be the “software” component of the brain–an ephemeral entity composed of digital information, and yet just as real as our own computer’s software. In my book, I suggest that wisdom could be incorporated into psychiatric practice, applying it as we would a “software patch” in our computers. I go on to note that this is already being implemented in the psychiatric care of some of our most difficult psychiatric patients–the application of dialectic behavioral therapy (DBT) to treat patients with post-traumatic stress disorder and borderline personality disorder.
It’s my contention that wisdom-oriented treatment could substantially minimize the contemporary practice of prescribing multiple psychiatric medications to many of our patients, which exploits the chronic dependence of patients on such medication regimens, to the profit of both psychiatrists and pharmaceutical interests. Wisdom-oriented treatment would spend at least some time exploring the nature of the patient’s feelings, the factors in their past and present lives that might contribute to their mood or mood instability—and thus broaden the array of interventions available to address them. It would require more time, because personal growth demands it. But it wouldn’t require a medical degree. And I believe that it would reduce the chronic dependence on medications that prevails today.
The current biological model of psychiatric treatment evidently isn’t saving lives, but most certainly is making money. I propose that a good portion of this money would be better spent pursuing treatment that engages the mind, in an effort to more permanently ameliorate these problems–rather than consigning patients to a lifelong dependence on medications.
Mindful psychiatry is a brand that could offer some reassurance to our patients that they are not necessarily bound to psychopharmacological treatment for the rest of their lives. It could also improve the patient’s self-image, with a perception of themselves as troubled with much to learn, rather than sick and dependent on medication for the rest of their lives. And if that ever happened, these patients might be less inclined to kill themselves.
But perhaps the most rewarding aspect of mindful psychiatry is that it is grounded in truth. Just treating depression with a simple-minded recipe of chemicals isn’t curing anything–it’s just suppressing undesirable symptoms. Patients with schizophrenia, bipolar I disorder, and other severe disorders will certainly require medication management–those disorders were discovered in natural observation, not concocted by our trade association. But nowadays a substantial amount of psychiatric medication is prescribed for mild to moderate depression and anxiety disorders, with no consideration that the mind could be engaged in the patient’s recovery. I’m not suggesting that these medications be disposed of altogether. I just believe that many of our cases could be more durably treated with more mindful interventions.
I perceive modern psychiatry’s willful dismissal of the mind and its capacities as ignorant, arrogant, lazy, and corrupt. And quite possibly lethal, if one simply dares to embrace the CDC’s suicide statistics. It’s high time for psychiatry to rediscover the mind–and to exercise our own wisdom enough to incorporate it into our clinical practice.
