dogma 1 – ignore the fear
sychiatry is now a dismal failure. From a strictly medical viewpoint – it doesn’twork. Its insistence on a banalmechanistic approach is simplistic and grossly inappropriate. Its obstinate over-reliance on drugsresults in epidemics, not cures. Meanwhile, a thick veil of fear hangs over all. Psychiatrists themselves, are often cast in a fearsome light, partlythrough their association with insanity, which is itself frightening. But also because they repeatedly compelfearfully damaging ‘treatments’. Fear impedes rational thought – it’s the only thing thatdoes. How can you possibly assesswhether psychiatric drugs do more harm than good, if the whole topic comes toyou overburdened with forebodings? My advice would be to take the book steadily and calmly. Keep hold of a thread of reason at alltimes. Make sure you can see somesense in what I write, by relating it to what you are already familiarwith. Above all, never stoplooking for fear of what you might see – that way madness lies. For my part, I shall endeavour to keepthe thread simple, calm and straightforward, relying on the maxim that youshould first taste what I write, but swallow only when you see enough sense init to do so: but when you do, please act.
Insane people arefrightening. They areunpredictable and can be dangerous – in fact irrationality is alwaysdestructive. My first experienceof such dangers occurred in one of my training group therapies in 1963. A man sitting only six chairs away fromme, half rose out of his chair, turned and, out of the blue, punched hisneighbour hard in the face. All ofus were shocked. The man himself, let’scall him Jonathon, appeared more shocked than most. I remember him still shuddering at the thought of what hehad just done. Once we’d recoveredour breath, we asked him what had happened – but he could only mumbleincoherently about being ‘upset’ at the way families were being discussed inthe group. He had not participatedin the discussion verbally – he communicated his feelings more directly,indeed too directly for comfort.
The psychiatrist running the groupat the time had no better idea of what had happened than I. However 30 years later, the 60murderers I worked closely with in Parkhurst Prison taught me that violencecomes from fear. Generally thisfear is itself obscured, as it was with Jonathon above. But if you want to unpick an act ofviolence, look for the fear beneath. In fact, over the last 45 years it has become increasingly obvious to methat emotions play a vital role in all mental disease. And of all the emotions, the one thatmatters most is fear. In myearlier book, Emotional Health, fear is described as the Master Emotion, highlighting the impact itcan have, especially when unacknowledged – the so‑called buried or obsolete terror.
Fear is the key component in everymental illness. It manifestsitself obviously enough in phobias or panic attacks, and in anxieties of allvarieties. Paranoia by definition,is fear incarnate; and no psychosis is ever fear‑free. Despite this, fear still finds no placein established psychiatry – only dogmatic presumption can keep itout. In real contact with realsuffering humanity, it soon becomes obvious that there is a clear analogybetween infection in general medicine and fear in psychiatry – unless anduntil both are detected and controlled, health, physical or mental, is unlikelyto be robust.
This is not the first dogma toundermine medical progress – looking back 150 years, we find thatbacteria were similarly unacknowledged, and progress was similarly obstructedfor many decades. In Victoriantimes, doctors and especially male midwives actually took pride in not washingtheir hands when moving from post mortem room to operating theatre. Exposing themselves to soap and watersomehow offended their dignity. Sothey declined – vociferously. There was no evidence they could see, or would look at, which entailedthem altering their time-honoured practices – after all, the supposed‘microbes’ were entirely and invariably invisible to the naked eye. The very existence of micro-organismswas not readily conceded, and even when it was, their relevance to disease wasactively disputed well into the early years of the twentieth century. The absence of recognisable evidence,or at least evidence deemed adequate, allowed the continuation of a pattern ofbehaviour which today would rightly be regarded as appalling.
It is instructive to look moreclosely at the circumstances prevailing at the time. Doctors in those days, worked under ferociouspressures. The death rate duringoperations, especially child-birth, was horrendous, infantile mortality aconstant refrain – almost perhaps something to be accepted as aninextricable part of the human condition. So pesky suggestions that they were doing something to make mattersworse, attracted spontaneous eruptions of contempt or suppression.
Doctors, especially when pressed,become ever more conservative, one might say dogmatic – what workedbefore is likely to be less harmful than what is now proposed. Caution becomes the watchword –and unorthodox innovations, especially those suggesting that present remediesdo more harm than good, are seen as likely to make matters seriouslyworse. Accordingly suchsuggestions are discarded or even crushed with no lack of vigour. After all, viewed through the oldorthodoxy – current practice cannot be bettered – it is all thereis, else they would have been taught differently in medical school. Sadly today’s psychiatric dogmas havelong precedents.
denial
Under conditions of fear orstress, rational thought is impaired. How this comes about is actually straightforward enough. The mind has given us our evolutionaryadvantage by providing us with a mental model of our surroundings. Likely scenarios can be explored in ourheads, allowing us to work out a way through our many impending pitfalls,before actually falling prey to them. In particular the mind enables us to construct, and keep in good repair,the social networks which are so essential for our sanity, and indeed our verysurvival as a species. But thismodelling falters if an issue or a subject becomes too painful, or too fearfulto contemplate – a flaw which once recognised, can be seen cropping upall over the place.
It is hard enough at the best oftimes, keeping an up-to-date picture of our ever-changing world in mind –old patterns are constantly being displaced by new, nothing ‘out there’ is everstatic. If stress is added to themix, life becomes even more difficult. Add overwhelming fear or terror, and rational thought ceases –terror actively induces mental paralysis. Serious discrepancies can then begin to occur between what we think is‘out there’ and what actually is. At this point the mind is no longer able to serve its properfunction. It can no longer providereliable guidance as to what to do next. Indeed its overreaction to fear can itself become the main impediment tohealthier progress. The mind isill.
Not only is it helpful to think interms of the analogy between fear and infection as far as general mental healthcare is concerned. It is alsouseful to tease out the correlation between fear and pain, which closelyresemble each other. Everyone knowsthat a painful leg leads first to limping, and can then lead to disuse of theleg entirely. It is commonknowledge that pain readily leads to physical immobility, so it is hardlysurprising to find that fear does the same for mental agility.
The function of fear is directlyparallel to that of pain – both serve to warn us that ignoring them risksfurther damage. Chest pain is aprime example – ‘working through’ chest pain is not to be recommended :likewise ignoring a healthy fear of walking across busy motorways is equallylife-threatening. Fear becomestoxic however, when the mind is too frightened, and thence too paralysed, tobring itself up to date – earlier threats are perceived as still beingoperative – unexamined life‑saving fears then becomelife-curtailing.
At its mildest, wilful disregardof present day realities is well recognised as ‘wishful thinking’ – aconscious preference for what we would like to be the case, when the evidencearound indicates otherwise. Unchecked, the next stage along this path is ‘day dreaming’. Further down the line, it becomes‘dissociation’ – where the mind finds today’s reality far too much, so itdecides to leave it behind, and move into a world of its own making. The most extreme, of course, ispsychosis, where reality is not only abandoned, but re-constructed anew –though even here elements of reality will always tend to seep back, exceptwhere drugs dull the appetite to try.
All these mental anomalies fallunder the general term ‘denial’ – in essence, the mind ‘denies’ what isobvious, and prefers something which appears more benign. So here we have a working definition, ablueprint, for mental illhealth – once the mind no longer relates to thereality around its owner, it is no longer functioning healthily, it isill. The remedy is also equallyclear – supply sufficient quantities of emotional support to allow themind to cease ‘denying’, and re-connect itself to current realities. This is the thrust of EmotionalEducation, of Emotion Support Centres – all aimed at re-gaining controlover the emotions. The analogywith a broken leg is sharp – plaster casts support the bones, but thehealing is done by the living leg – apply emotional support in anappropriate way, and all minds heal.
Denial is therefore entirelystraightforward. A fixed ideaalready implanted in the mind resists being displaced by a novelty, unlessthere is adequate reason to do so.
Everywhere in human society,incentives are constantly being proffered to encourage you to change your mind,to change your viewpoint – the advertising industry would not otherwiseexist.
Equally however, there are anumber of disincentives to changing one’s mind. The proposed change may appear vague or uncertain; you maybe feeling somewhat insecure with what you already ‘believe’; it can seem moretrouble than it’s worth to make the change. I suspect the last partly explains why psychiatry has notyet updated its views on the longer term impact of psychiatric drugs.
Of course as we have seen, thereis a whole spectrum of denial, ranging from wishful thinking through day dreamsto dissociation even psychosis – and each is accompanied by a similarrange in intensity of the disincentive involved. Thus at the milder end, one would expect mild discomfort– “Oh I wish I hadn’t missed the bus”. More severe would be “I’ll wait until all my problems aresolved by winning the lottery”. Yet more sinister are those pressures we carry over with us fromchildhood – these can be highly potent, but worse, they are the moreactively ‘denied’ because of that. Childhood traumas can impose the deepest denials. Life support systems in dysfunctionalfamilies are not conducive to encouraging the change from infantiledependencies to adult mutual inter‑dependencies. These areoften the most difficult to remedy. However human beings are nothing if not resilient – given theright support and the appropriate ‘education’ – change and indeed curecan be expected for all.
dogma 2 – ignore the mind
I want now to try and describequite what it is like when a medical student is first confronted with mentaldisease. (Just to be clear, bothpsychiatrists and psychologists deal with the mind, but only the former, beingfully medically qualified, prescribe drugs – so far.) Medical training itself represents theimposition of a whole new way of looking at life, at human beings, indeed athuman bodies. This wrench from thenorm is accompanied by an entirely foreign vocabulary of some 3000 words whichare conspicuously different from everyday usage.
I well remember being confrontedwith my first abdominal examination. Here in front of me was a torso, the shape and external appearance ofwhich was entirely familiar to me. But such familiarity counted for nothing. Hiding behind the leathery surface were dim, and shiftingoutlines of vague organs I was called upon to describe immediately in confidentdetail. Fumbling about with spadeshaped hands, I struggled to feel ‘the edge of the liver’, I delved inexpertlyto touch the ‘pole of the kidney’. The spleen of course, utterly escaped me. It seemed quite impossible that anyone could make sense ofthe slightest twinge, the smallest resistance to the probing fingers in a waythat would satisfy the critical questions being demanded. And for the neophyte it was impossible– only long careful training could make sense of the entirely unobviousdifferences that these oh-so-soft organs made to the enquiring hands. Later of course, I became more skilled– my especial expertise being in palpating colons, but that’s anotherstory.
If such difficulties attend theexamination of something as tangible as the abdomen and its vital contents,imagine the problems that arise with the mind. First of all you have no fingers to poke this intangibleorgan. Second, your own mind mayhave blind spots, resulting from unexamined ‘denials’ on your part, whichrender accurate examination difficult if not impossible. Thirdly, the sense of awe which allnaïve medical students feel for their superiors – such people can evenhear a fourth heart sound – this sense of being in the presence ofsuperior knowledge and skill can seriously distort your precepts.
Though the mind is the mostimportant organ in the body, the ‘socialising’ organ, it is entirely intangible. There are no external lumps or bumpsyou can feel to distinguish a healthy organ from its sick counterpart. Despite these problems, which have beenknown throughout history, it is still curious to observe that establishedpsychiatry ‘solves’ them by ignoring the mind altogether – giving usdogma 2. The problem is –what you are first taught in medical school, forms the foundation stones foryour understanding in later life. If the foundation stones are sound, then so will be your subsequent understanding;if they are faulty, because your first teachers had only a dim view of theirtopic, your later view is liable to be similarly hampered.
The remedy, as for all itemstaught in medical school, is to have these basic teachings tried and tested inclinical practice. This entailsbeing open and confident enough to accept clinical axioms that continue to makesense, and to ditch those which fail to improve your patients. It’s not always easy. Remember that medical schools holdexams every few months – in these you are required to recite theconventional wisdom of the day. You may disagree, but others have already decided what the correctanswers are, since they set the questions in the first place. And they are the ones who fail you, notthe other way around. A certainamount of regimentation is inevitable in any medical training – onlyconfident exposure to a wide variety of clinical conditions can rescue this,and indeed save more lives as a result.
By resolutely ignoring the mind,psychiatry today has no alternative but to make psychiatry as inflexible asconcrete. This is not so hard toaccomplish as it might seem. Indeed it falls in nicely with a profound, persistent, and almostirresistible psychiatric ambition to put the whole troublesome topic on a parwith physical medicine – a kind of fallacious psychiatric holy grail,driven by a desperate yearning to make the wonderfully intangible and creativemental organ as concrete as say the liver or the brain.
Humans are forever trying toconcretise this most wonderful of all attributes, to regulate it, to make itpredictable. There is an entirelyregrettable tendency to find, or if need be invent, a clear anatomy of the mind– something comparable to the anatomy of the brain. This leads to enormous difficulties andto much illhealth, as Freud himself exemplifies.
Sigmund Freud was perhaps thesharpest clinical observer of his day. Unhappily he was an indifferent philosopher (though vastly superior inthis regard when compared to those currently commanding our psychiatricheights, as the next chapter explores). He started out life as a neurologist, where the superficial anatomy ofthe brain was there for all to see. Then he embarked on an ambitious quest to secure ‘The Science of the Mind’. He had no difficulty in dividing thehuman mind into various parts – he had the greatest difficulty in makingthem stick. For what is obvious toone mind, is obscure to another; what sounds like an instinct, a complex, anego to one, is mere tittle-tattle to another – and there is no solid,reliable, objective way of deciding the issue between them. Nor ever will be.
Freud for all his flaws, and theywere considerable, had two great contributions to make to our understanding ofthe human mind. Firstly he took astand against dogma 2 – he asserted that the mind existed, he asserted‘psychic reality’, he proceeded on the basis that there was something calledthe mind, that it was of crucial importance, and that the primary way to accessit was to talk to it. This may count as small beer to non‑psychiatrists– but I recently read through 10 years of the British Journal ofPsychiatry, and found only two mentions of ‘mind’: one was decidedlyshame-faced and tentative, and the other was by that professional amateur, thePrince of Wales. So Freud is to beapplauded for saying we each have a mind that demands respect and fullydeserves to be talked to.
The second asset he provided wasto insist that part of the mind was not immediately accessible. He made a series of painful, costlyblunders as to what to do about that, but the notion that the individual infront of you is not disclosing the key emotional fact in his or her case iscrucial to any successful progress in psychiatry. This falls under the heading ‘denial’ as described above,though that is not quite how Freud himself would have expressed it. And it arises from fear, which Freudignored as heartily as any modern psychiatrist, and for much the same reasons(see Emotional Health).
The impact of this last point, ofdenial, is unusually profound. Elsewhere in general medicine, the clinical process relies on theindividual patient describing the symptoms, relating them to past circumstances,and generally telling the truth about their disease. Indeed the most valuable clinical aphorism I took with mefrom medical school was Sir William Osler’s – “Listen to the patient s/heis telling you the diagnosis”. Since the key pathology in psychiatry is denial, then this is no longerthe case. Indeed the patient isdeterminedly keeping from you, and from themselves, the key emotional factwithout which progress is impossible. It is simply too painful for them – all they can do is ‘deny’it. While this certainlyadds to the apparent complexity of psychiatry – once mastered, it istremendously exciting and fruitful to watch human minds blossom out of theirfrozen pasts.
Sadly psychiatry reacted adverselyto Freud – his flaws were too extensive, his ‘anatomy’ too rigid and toosingular, and even his method of treatment too inflexible and longwinded. Accordingly Freud proved a falsegod. The rigidity, precision andreproducibility that this branch of the medical profession so craves, whichFreud appeared initially to offer, has never materialised, and there are soundphilosophical even logical grounds to indicate it never will. The human mind is the most creative,delightful, fluid and inventive entity in the entire cosmos – it does nottake kindly to regimentation, dissection, anatomisation or any of the otherfalse structures which a beleaguered profession might wish to inflict uponit. The psychiatric holy grail forwhich so many yearn must in reality, be exorcised. There are alternative strategies which being more realisticare also more successful – but they can never see the light of day, whilethis addiction to concretism, this dogma 2, holds sway.
What psychiatry has failed to findin reality, it has decided to invent and impose. The problem is that any structure you invent is the categoricopposite of what the mind actually is. Rigidities, inflexibilities, lack of creativity or consent may make fora fine wish list – but as these characteristics grow, their relevance tothe entity they are trying to represent, shrinks.
Given the collapse of Freud, giventhe intense desire, nay need, to be as physical and organic as general medicine– the outcome has been despair. A deep psychiatric nihilism has descended on the profession I love. A whole catalogue of daffy diagnoseshas been compiled as a bulwark against a protean, amorphous and constantlychanging psychic scene – I review it later. The mind delights in picking holes in arguments, in creatingexceptions to rules and regimentations – sadly the current psychiatricinsistence that mental disease is essentially chemical, genetic or biologicalis not only counter-intuitive to the non-psychiatrist, it turns out to bedoubly flawed. It is wrong on twocounts. Firstly there is solidevidence that this approach is failing globally – Robert Whitaker, whowill be mentioned frequently anon, counts the number of mentally disabled asgrowing by 400 a day – a number that should be shrinking, if the currentpsychiatric foundations were realistic. And secondly, the drugs which are currently thrust into the widening gapbetween agonising mental symptoms, and out‑of‑touch psychiatrists’rigidities, have themselves proved pathogenic – thus the crutch built ofmind-altering chemicals has not only buckled under the weight of reliance thatpsychiatry feels increasingly obliged to place upon it, but has provedcorrosive in the process.
In short, psychiatry todayprescribes damaging drugs because it despairs of anything better. Unhappily the ever increasing evidencethat these drugs inflict damage coincides with a parallel increase in thepressures under which psychiatry currently finds itself, leaving ever less roomfor rational evaluation of the growing scientifically proven evidence thatthese drugs do far more harm than good.
This book is intended to awakenwider interest in and understanding of this dilemma, so that more humane, moresecure and more successful psychiatric approaches can prevail. Any drug that alters the mind isgrasped with both hands – why bother with a chemical that is psychicallyinert. However, given thatchemically altered minds think and talk less well, and given that talking isthe main gateway to the mind – all mind altering drugs must inevitably beunsafe at any dose.
drunk
It is of the greatest importancethat a clear understandable thread runs through this book, one that is obviousto all. Without relating what Iwrite to what makes sense to you, then not only am I breaching the maximoffered in the first paragraph of the book, but I will soon be writing fordwindling numbers. So we need tobe a little canny when approaching the question of what current psychiatricdrugs actually do.
Let’s make one thing clear –no one knows exactly what psychiatric drugs do. There are countless models, theories and chemical interactionswhich are put forward, and frequently clung to for want of somethingbetter. But precise knowledge ofhow drugs impact on brain tissue, is puny. Enormous moment is attached to increasingly detailed scansof the brain – PET scans, MRI scans, fMRI and many others – andindeed much more data is now available than ever before. But what it all shows is that there isvastly more to know. Scratchingthe surface is not really an appropriate description – tinkering with thegravel in the drive‑way is rather more like it. Parts of the brain are more concerned with some things than with others,why should this surprise us? Forexample, when emotions are discussed, you are likely to hear “Ah yes, it’s thelimbic system”. This is about asmuch practical use as saying – “Tsunamis. Ah yes, it’s the salt water”.
Though it is certainly true thatno one knows exactly what psychiatric drugs actually do, indeed how theyactually work – one thing all agree on is that they impact on the mind,else why use them in the first place. Further if the mind heals itself on being given appropriate support,just as a leg bone will – then any chemical which impinges on it, runsthe serious risk of deferring or indeed defeating such healing – a pointconsistently confirmed by objective, repeatable scientific evidence over thelast 50 years.
The holy grail for which allconcrete psychiatry yearns is a fixed anatomy as just described – aliasdogma 2. This illusion is keptalive by regurgitating gobbets of data every so often, which link ever smallerparts of the brain with ever more complex and ever less well defined humanbehaviour patterns. The grail ismade to appear just that bit less out of reach by the supposition that there isa gene, a location, a micro-neurological niche which mirrors the oh-so-slipperypsychiatric symptom in question.
What is overlooked is the infinitecomplexity of the mind. The brainmay appear complicated – but what it supports in the way of mentalactivity is infinitely more so. And infinity, on the school boy’s definition is the biggest number youcan think of, plus one – and having now thought of this new number, youhave to add one more, and so on, endlessly. This is exactly what our delving into micro‑neurology repeats, ad infinitum. Each new datum pulls further mysteries out of the cerebralporridge, like an unbreakable string of unknowable sausages, which serve onlyto reveal ever greater ignorances. But however complicated neural processes are found to be, it is as wellto recall that those of the mind are invariably more so – indeed there isample reason to suppose we will never fully comprehend the human mind –but then we don’t need to. All weneed to know is how to heal it, an outcome contemporary psychiatry seems tobecome ever less familiar with.
And all the time, this pursuit ofmicroscopic brain function, this headlong advance is in the wrong direction– therefore it must inevitably and increasingly ignore the best channelinto the human mind, which as Freud averred, is to talk to it. The point is readily shown by askingthe simple question as to whether the individual under the scan is thinking inEnglish or in Chinese. It mattersa great deal to them and to us, and is immediately decided upon opening ourmouths – a conclusion no amount of scanning can ever reach.
The brain on which these drugshave impact is infinitely complex. Not only is it infinitely complex, but it will invariably and for everremain so. So to imagine thatthere is a simple explanation for what a given drug actually does, is, well,imaginary. The substrate, or pointof impact of the drug, is already rather more complex than we can everconceive, so we have no need here, to strain comprehension by attempting todescribe it. I have no objectionto learning more about which enzyme system in the brain is altered by whichdrug – I have a powerful objection to the suggestion that this is all weneed to know, or that it is somehow relevant to pressing irrationalities,anxieties, denials or depressions. The implication is that drugs are more important than talk, that drugshold out remedies for the multitude of mental afflictions from which so manysuffer. Now that I object to asstrenuously as possible – in my view, it’s myopic tosh.
Despite this inherent complexity,in