TITLE PAGE:

SCIENCE AND CANADIAN PSYCHIATRY: A CRITIQUE.

AUTHOR:

N McLaren MBBS FRANZCP

Psychiatrist,
Northern Psychiatric Services

PO Box 282

Sanderson NT

Australia 0813.

Ph. +61 8 8945 5399

Fax. +61 8 89455866

Email: jockmcl@octa4.net.au

Word count of text: 2571.

Word count of abstract: 98.

Word count of references: 440.

 

 

Science and Canadian psychiatry: a critique.

Abstract:

Objective: To analyse the scientific status of Canadian psychiatry.

Method: An examination of the declared aims of the Canadian Psychiatric Association and its main publication, The Canadian Journal of Psychiatry, shows that the Associationís intellectual approach is grounded in an integrative model of mental disorder that aims to avoid the extremes of biological reductionism.

Results: The "biopsychosocial model" does not exist. Neither the Association nor its Journal base their activities in an established scientific model of mental disorder.

Conclusion: Psychiatry desperately needs a formal, scientific model of mental disorder if it wishes to survive as a discipline.

 

Among medical specialties, psychiatry shows a unique degree of theoretical plurality. It is possible for psychiatrists to practice any of a range of approaches to the question of mental disorder. Given the complexity of the field in which we work, or even its opacity, keeping the various options "in play" is generally seen as commendably cautious. That is, by declining a commitment to a particular view of mental disorder, we can avoid rushing after fads which may eventually be shown to be wrong. This peculiarity arises because the nature of the clinical phenomena in psychiatry differs profoundly from the rest of medicine. Daily practice for our colleagues in general medicine consists of eliciting signs and symptoms of diseases of the physical body, of laboratory investigations based in orthodox physical and chemical sciences leading to forms of treatment which work just as well in veterinary practice as in human. Psychiatry lacks this convenience. We deal in ephemera, in shadowy afflictions of an insubstantial realm for which the real world of physics and chemistry has no immediate answers. Psychiatry lacks the firm theoretical justification of general medicine.

Classically, there have been two solutions to dealing with the slippery mental realm, either to grasp it or to ignore it. Psychoanalysis was a well-known attempt to provide a mentalist theoretical framework for psychiatry but it has collapsed under the weight of philosophical and historical criticism [1, 2]. The alternative was simply to dismiss mental phenomena as causative entities in their own right, leaving two further possibilities. Behaviorism denied a causative role for mental events, insisting that analysis of behavioral data alone would reveal all that we need to know in order to "predict and control" human behavior [3, 4]. It was never clear whether behaviorists denied the existence of mental events, or simply their significance, but what is now clear is that there cannot be a non-mentalist account of human behavior [5, 6]. Psychology has now retreated from these brave claims and contents itself with toying with the devil of mentalism through a mild-mannered cognitivism.

Psychiatry, however, has pushed further into the realm of materialist science by insisting that the phenomena of mental disorder are not of interest in their own right but can be explained within the same reductive context as the other, successful biophysical sciences [7, 8, 9]. That is, a thorough physical knowledge of the brain will automatically provide a complete explanation of all mental disorders without exception. This is a bold claim indeed but, oddly enough, the case has never been detailed. Psychiatrists who adhere to this view simply make the claim, fully expecting the neurosciences to catch up eventually. This doctrine, known as promissory materialism, remains an ideological claim until scientists deliver the goods just because it has no empirical content in its own right. However, the statement Ďmental disease reduces to brain diseaseí is not of the form that can be answered by empirical evidence; it has to be established on first principles. Remarkably, despite the huge sums of money being spent on primary brain research in mental disorder, no psychiatrist has ever answered the question: "Is it true that mental disorder can reduce to brain disorder?" Biological psychiatry, as the unlimited application of reductive biologism to psychiatry, remains an ontological claim with no prior justification [10, 11, 12, 13].

Biological psychiatry says that, as a matter of fact, all mental disorder will eventually be shown to be a special case of brain disorder. Some psychiatrists, perhaps even the majority today, are content with this approach to the subject, surrounding themselves with PET scans, gene studies and drugs, leaving the non-scientific bits (feelings, needs, hopes and worries) to psychologists and social workers who arenít expected to understand the cold reality of scientific psychiatry. Samuel Guze, for example, claimed there cannot be a psychiatry which is "too biological" [14] (his claim has since been refuted on logical grounds, [15].

However, not all psychiatrists are comfortable with this approach, partly because the claim has never been proven [12] and partly because they feel reducing human distress to matters of chemicals in the brain somehow dehumanises our subjects. As a matter of principle, they say, science cannot explain all that is important in generating mental disorder just because it involves mental causes which cannot be reduced to physics and chemistry. They correctly point out that the far-reaching claims of biological psychiatrists are utterly unsupported in the literature, to the extent that, among theorists of mind, only psychiatrists still hold that reduction of mind to brain is possible. The American psychiatrist, George Engel, was one of the earliest critics of what he called unrestrained biologism in medicine [16]. He was of the view that physicians could not understand the whole patient without taking account of the individualís roles in the biological, the psychological and in the sociological realms. Humans are not just biological preparations, he believed, and if we try to see them as such, we physicians of the mind-body run a serious risk of misrepresenting the very people we are supposed to be helping. He summarised his views in a famous paper [17] in which he argued that a properly formulated "biopsychosocial" model would allow us to do justice to our cases as ailing human beings. Psychiatrists, as he did not say, are more than just vets dealing with naked apes.

For want of a better term, these psychiatrists can be termed Ďmentalists.í That is, they believe that human mental life cannot or might not be fully accounted by a total explanation of the brain physiology. Not infrequently, they are derided as "tender-hearted," even as "soft-headed." Unfortunately for them, since the demise of psychoanalysis, there has been nothing like a formal theory of mind available to guide their work and, perhaps even more importantly, to give them a means of repelling the "mindless" assault of unrestrained biologism [18]. Engelís model therefore seemed to fill an important intellectual gap by reintroducing the human side of psychiatry in a non-sentimental equation.

While American psychiatry has hurried toward the biological pole, Australasian, British and Canadian psychiatrists have held back, not wholly convinced by the headlong rush to biology. For these countries, Engelís approach has been welcomed almost with relief. The website of the Canadian Psychiatric Association (CPA) shows that the Associationís first objective is "...to uphold and develop the biopsychosocial approach to the practice of psychiatry..." Similarly, for many years in Australia and New Zealand, the biopsychosocial model was taken to define psychiatry, the point of demarcation between our field and all others, to the extent that a College president stated: "The biopsychosocial model is fundamental to our profession... (It) underpins every aspect of our training (...and) day to day thinking and action within our own practice" [19]. In Britain today, it would not be unfair to say that the idea of psychiatry as a self-contained specialty hinges on their having this model, to the extent that, without it, psychiatrists might start to lose their raison díêtre [20]. The argument is given that, since general practitioners (family physicians) are trained in biological medicine, and routinely manage chronic biological disorders such as diabetes, arthritis, asthma etc., and given that mental disorder is biologically-determined, they are therefore qualified to manage mental disorders. QED. Effectively, if psychiatry embraces a wholly biological model of mental disorder, we will do ourselves out of a job.

But, psychiatrists counter, since mental disorder has three disparate components, biological, psychological and sociological, somebody is needed to meld them, and that person is rightly the psychiatrist. Armed with their integrating biopsychosocial model, psychiatrists are ensured of a future. However, I regard the case for psychiatry as "just another biological science" as completely wrong [12] but psychiatryís response has, in any event, been completely misconstrued just because, in 1998, I showed that Engel never wrote his model [21].

The "biopsychosocial model," so beloved of moderate psychiatrists always has been and always will be a wish-fulfilling illusion. All Engel did was call for a model that would unite the biological, the psychological and the sociological, but he did not and, I have argued, never could have written it. The technology, both logical and practical, wasnít available in the early 1970s and, furthermore, he would never have been able to utilise it because he was trained as an analyst. Still, it was a very comforting illusion, so comforting, in fact, that the Royal Australian and New Zealand College of Psychiatrists subsequently adopted it as their official "position statement" on what defines a psychiatrist [22]. This leaves the CPA in a difficult position: it is committed to "upholding and developing" a non-existent model. It avails nothing to argue that the Association is merely supporting a watered-down biopsychosocial "approach" because that is even more chimerical. There is no escape: Canadian psychiatry does not have a published scientific model of mental disorder as the basis for its practice, teaching and research. How, then, can it exist as a specialty in a biologically-based medicine? This question demands an answer.

Furthermore, if the Associationís chosen model of mental disorder is a phantom, where does that leave The Canadian Journal of Psychiatry (The CJP)? According to its website, the Journal exists to publish "peer-reviewed scientific articles" including reviews, original research, debates on controversial issues and letters to the editor, all of which must contribute to scholarly debate. Any author can submit "...scientific articles related to all aspects of Canadian and international psychiatry." In addition, the editor commissions editorials, reviews and debates and publishes letters commenting on previous papers. At first glance, this is uncontentious to the point of being banal: just another psychiatric journal publishing routine scientific material contributed by established researchers, Kuhnís "normal science" in action [23].

On second glance, however, something is wrong: at no point in its Instructions for Contributors does The CJP specify an agreed model of mental disorder toward which the "scientific research" must be directed. The only suggestion is that reviews will address "a broad range of biopsychosocial topics." While this appears to commit The CJP to a model nobody has ever seen, the Journal evades this imbroglio by omitting reference to anything more substantial. Effectively, this means the CPA and its "flagship" publication, The CJP, are operating without scientific warrant. This is a bold claim, but the justification is simple: science is directed toward elucidating models and theories of the universe and all therein. If there is no model of mental disorder, the research takes place in an intellectual vacuum and there is perforce no science [24]. So the first aspect of Canadian psychiatry and, indeed, international psychiatry, that must be addressed is just this: what are we talking about? When we psychiatrists claim that we have a scientific understanding of mental disorder, what is the nature of the claim we are making? I take it that we are saying that our approach is more than merely ideology, fad or whimsy. I further take it that we are saying we should have first go at mentally-disordered people while others, such as crystal gazers, colonic irrigators, exorcists or euthanasiasts, should defer to us. However, to be taken seriously (and to be paid serious money), we need a justification, an unimpeachable claim to having a superior knowledge of the causes and treatment of mental disorder. In essence, this means that we must show we have an established model of mental disorder which is firmly based in rational, empirical science. And that is precisely what the editorial board of The Canadian Journal of Psychiatry does not show.

Some people may take this to be little more than hair-splitting on the basis that The CJP accepts only scientific papers, and everybody knows what scientific means. That argument has no merit: among many others, Freudians and Marxists once claimed that their theories were scientific, but we now accept they were mere ideologies with no empirical content. Unless the research is directed toward a specific model chosen by a transparent process, subjected to intense criticism and open to rebuttal by anybody within or without the profession, then the claim becomes self-serving. Effectively, the editorial board is saying: ĎYes, we publish only scientific material, but we alone decide what is scientific according to criteria which we do not reveal.í There is a further risk in this stance, that anybody who criticises the established view may be deemed an heretic. Designating opponents as heretics is, of course, one of the hallmarks of non-science. However, by mentioning the CPA and heresies in the same sentence, am I not taking matters too far? I donít believe so, for the following reasons.

Firstly, original research papers are accepted or rejected according to whether they meet the editorial boardís implicit understanding of what constitutes a science of mental disorder. Because we do not know what it means by "scientific psychiatry," this might mean no more than "like/dislike the paper." Worse still, because the review process is not blind, it might only mean "like/dislike the author." There is no point insisting that this would never happen because what we require of a scientific journal is that, by virtue of a transparent editorial process, it could never happen. Bias must be impossible, and the first step toward rendering it impossible is to declare the model of mental disorder the board uses as its standard.

Secondly, the board chooses the topics for its editorials, reviews and debates, and then decides who will write them. The Instructions for Contributors are very explicit on this point: "Unsolicited manuscripts are not accepted." So, armed with its private perception of what mental disorder is about, the editorial board chooses the people it feels will best address the questions it believes important, then insists readers comment only on the topics it has chosen. This might still be a valid scientific exercise, except for one critical point: the process does not allow anybody to distinguish between verifiable scientific progress, and mere question-begging (i.e. assuming the truth of that which requires proof). In scientific publishing, the burden of proof is very much on the editorial board: they have to show that what they are doing is valid beyond any conceivable doubt. In my view, there is not just room for conceptual doubt about the selection process, but it would be perfectly reasonable to ask whether the whole matter is simply a case of the establishment looking after its own interests. A necessary but not sufficient step toward establishing the editorial boardís impartiality is to name and publish the scientific model of mental disorder it uses as its standard.

Finally, letters to the editor must address published papers. There is no provision for anybody to point out that there might be reasonable grounds to suspect that the publishing policy of The CJP fails to meet the minimal requirements for a journal of scientific record.

I conclude that neither The Canadian Journal of Psychiatry nor its parent organisation are guided in their activities by a valid scientific theory of mental disorder. When we recall that criticism of the status quo is the motive force of scientific progress, it is clear that editorial policies which do not facilitate criticism are anti-scientific. I am of the view that psychiatry can make progress and can reverse its long, slow decline. My own model [11] meets the minimum criteria for a scientific model of dualist (mind-body) interaction, reinstating mind as the guiding principle of human behavior, both normal and abnormal, but that is another story.

References

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19. Wilson J. Presidentís Letter. Australasian Psychiatry 1998; 6:83-84on the college website. AP, 1998.

20. Holmes J. Fitting the biopsychosocial jigsaw together (editorial). British Journal of Psychiatry 2000; 177; 93-94.

21. McLaren N. Is mental disease just brain disease? The limits to biological psychiatry. Australian and New Zealand Journal of Psychiatry 1992. Revised version: Brain disease, mental disease, and the limits to biological psychiatry. Chapter 2 in ref. 11.

22. Royal Australian and New Zealand College of Psychiatrists, 1998. Position Statement No. 39: What is a psychiatrist, and what does a psychiatrist do? RANZCP, Melbourne.

23. Kuhn TS. The Structure of Scientific Revolutions. 2nd Edition, 1970. University Press" Chicago, Ill. (International Encyclopedia of Unified Science, Vol. 2, No. 2)

24. McLaren N. Science and the psychiatric publishing industry. Ethical Human Psychology and Psychiatry (submitted for publication).