Jock McLaren – The Biopsychosocial Model is a Mirage, Time for a Biocognitive Model?

On the Mad in America podcast this week, we hear from Dr. Niall McLaren. Niall, known to many as Jock, is an Australian psychiatrist who worked for 25 years in the remote north of the country. Also an author, Jock’s latest book is entitled Natural Dualism and Mental Disorder, the Biocognitive Model in Psychiatry, and it was published in December 2021. 

Recently retired after 47 years, Jock joined me to talk about his experiences working in psychiatry and explains why the models that purport to guide psychiatric diagnosis and treatment are not what they seem.

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

James Moore: Could you tell our listeners a little bit about you and what it was that led to your career as a psychiatrist?

Jock McLaren: I’m from the rural areas of Western Australia and I studied in Perth. I’d never seen a university when I got there, I really was quite an outsider all along. Then, when I graduated, I was very interested in neurosurgery. Originally, I wanted to be a country GP [general practitioner], but then, after six months in neurosurgery, I became interested so I actually started during the surgical training. 

They put me into a term in psychiatry just to fill up three months and I realized then that was what I actually wanted. To me, psychiatry was big ideas and it was dealing with people directly as distinct from neurosurgery where they’re all unconscious. So it just went from there and I’m very happy. As you know, I’ve just retired after 47 years in psychiatry, but I don’t regret that for one second. It hasn’t been easy, but I don’t regret it.

Moore: You spent some time in the rural North of Australia, which must have presented some fairly unique challenges?

McLaren: That’s a nice way of putting it. In 1987, I left Perth and went to the Kimberley region, which is one of the most isolated parts of the English speaking world, and I was there for six years. I was married during that time, we had a baby, and the work was getting dangerous, and I thought what’s acceptable as a single bloke is not acceptable when you’ve got a family. So we moved to Darwin, which is only marginally less isolated, so I was in the North for 25 years. Then we came down South and we’ve been here in Brisbane for about 10 years.

Moore: Can you tell us a little bit about how psychiatry is practiced in Australia? Does it tend to follow a U.S./European biomedical approach?

McLaren: Yes, psychiatry here is split very much between private and public practice and university is considered public practice. I’ve never worked in a university, but of course, I’ve worked in both private and public. 

Public psychiatry is, I’m sure, exactly the same as in the U.K., a lot of the people who work in it, a lot of the psychiatrists are from the U.K. or they’ve trained there or they’ve been there. Very heavy influence from places like the Maudsley [Hospital in London] and not, I would say, a benign influence, but that’s just my opinion. 

Private practice is different. It is very much Central City Practice. There are very few private practitioners in the outlying areas and they are there essentially to make money and that’s what they do. So I was actually in private practice for the last 20 years, I think. But I was running what’s called a bulk billing practice, which means that I didn’t bill the patients directly, I’d bill the government and so I only got 85% of the fee. Whereas a full-time private practitioner can charge what he likes, some of them were charging three times the recommended fee whereas I was only getting 85% of it. 

But I was doing the sort of work I wanted to do. I was working in working class areas, with high levels of family breakdown, unemployment, drug problems, a lot of refugees, a lot of immigrants and a lot of movement. I’m sure you’ve got exactly the same in the U.K. You’ve got your private practitioners all squelched into one small area and then you’ve got this vast wasteland which is under serviced. That’s what interested me.

Moore: How are the needs of Australian First Nations people taken into account in standard practice?

McLaren: Well, I went to the Kimberley region with the express purpose of providing a service on the ground. There had never been anything like it. So I was there for six years. My job was to stop Aboriginal people from being sent down to Perth. Perth, from where I was, is further than London to Moscow and the cultural differences for Aboriginals are probably about the same. They’re completely different people, they speak different languages and there was very little understanding of them in the mental hospitals. 

Once they got into the mental hospitals, they just got the standard biological approach, the same as they would get in the hospitals in the U.K. or the U.S. And, of course, it didn’t work; they would be there stuck there for months on end.

So my job was to stop them from being sent there and in that sense, it was extremely successful. In the six years I was there, it dropped from 50 people a year being sent down to Perth to just one or two. Most of them were not admitted to hospital, they could be managed at home. If you’re on the spot, you’re moving around, making contact with the local communities, making contact with the Aboriginal people themselves and their families, you can manage things. You don’t need these big hospitals and institutions. They’re inherently inefficient and hugely expensive. So it saved the government a great deal of money, just having one psychiatrist on the spot, but it was damned hard work.

Moore: No doubt it’s better for the individual to be kept in their local community and have their needs met there rather than being sent to a place that they don’t recognize.

McLaren: There is no comparison, absolutely no comparison from their point of view. They were happy to be treated at home and I got known, people would be sitting waiting when I arrived, they knew when I was coming. We would talk and get things done, it made life a lot simpler. Unfortunately, they haven’t persisted with that model. They’ve reverted to a large extent to a more mental hospital type approach and I don’t think that’s very good. I think that’s retrograde, but that’s how it is.

Moore: You’ve written a great deal about the problems of psychiatry’s reductionist biological model. So I wondered if we could talk a little bit about your view of the shortcomings of that model?

McLaren: Well, just to tell you a little bit about my background, when I was in Perth, not long after I graduated in psychiatry, I started writing what was obviously philosophical stuff. So I then started a PhD jointly in philosophy and psychiatry. And unfortunately, when I left to go to Kimberley, I couldn’t continue and I had to give it up, I never completed the PhD. But as part of that, I had to do some undergraduate units in philosophy and there are not very many psychiatrists who have done that. I’ve maintained that interest all along, that’s what I do after hours, at work I’m a psychotherapist.

So the first thing that became obvious coming into psychiatry from neurosurgery, I realized that what the professors were saying about mental disorder and chemical imbalances, all that sort of stuff, I knew it was false. It was simply wrong. That’s where things went bad because I would say to the professor, who was a very rigid Scotsman, I’d say, ‘Well, I don’t think that’s actually right’ and he would be so angry and would then just freeze me out. That was part of the reason I left Perth because my PhD was just going nowhere. I was getting no support and I was actually getting hostility from the psychiatry department. 

So it is a fact, an established fact, there is no biological reductionist model of mental disorder, it has never been written. That’s the end of that. There is no chemical imbalance theory, it doesn’t exist. That is a trope that’s thrown around, it’s beaten up by the drug companies, it’s beaten up by the Women’s Weekly [magazines]. It’s the sort of easy thing that can appeal to the masses and it’s just ladled out and they suck it up. People do come in saying, “My doctor told me that I’ve got a chemical imbalance in the brain” and I think ‘Let’s just put that aside, let’s focus on your life as it is and we’ll see where we go from there’.

In doing that you don’t have to use drugs. I’ve personally assessed and managed well over 12,000 cases in a wide variety of settings, mostly alone, I had no support in the Kimberley, none whatsoever. A lot of Aboriginal people didn’t speak much English at all, they don’t speak English at home and I had to manage without using drugs, without ECT. I’ve never used ECT and I used minimal levels of drugs. The only time I’ve ever looked at the figures, I was actually on the third percentile of the prescription rate for antidepressants for psychiatrists. And the other 2% were psychoanalysts who don’t use drugs.

So yes, you can manage but it’s different. You’ve got to practice a different sort of psychiatry, it has to be biological, and it has to be psychological, and it has to be sociological. I put a lot of emphasis on personality assessment whereas, of course, psychiatry doesn’t have a model of personality. So there’s no biological model of mental disorder. Psychiatry doesn’t have a model of personality or personality disorder. But, I can see you’re going to say, ‘what about the biopsychosocial model?’ It doesn’t exist, that’s that.

I have just had probably my 20th paper on it rejected. Most of my papers get published, but this one has been rejected repeatedly and it says that psychiatry’s use of the biopsychosocial model meets the criteria for fraud. So I have lots of quotes from psychiatrists in the U.K., Australia and around the world, saying, ‘this is the greatest thing since sliced bread, this is wonderful, we’ve got this fantastic model, and we’re really flying high.’

Then I look at the sociology of psychiatry, I go through George Engel’s 1977 paper practically line by line and show that it has no ontology. It has no statement of his opinions. It’s got nothing. So then I have quoted from the Queensland Criminal Code Section on Fraud, and it meets those criteria.

When it was rejected, the reviewer said, “This article is not written in the form of an academic work.” Despite it having 39 citations. “It is more an opinion piece, but not one that could be credibly published in an academic journal.” That, to me, is reprehensible, but it’s also emblematic of the point the paper makes. So we’ll get it published but so much for your biopsychosocial model.

So that means that psychiatry is operating without a warrant. There isn’t a biomedical model, they talk about it. It isn’t there, who wrote it? Show me, I would love to see this thing so I could rip it to bits. I would love to see it. It doesn’t exist.

Then you have Ronald Pies in the US, editor of Psychiatric Times hammering the table saying “it’s the biopsychosocial model, this is the guide for our practice and it’s been this way for 30 years.” I’ve challenged him, show me it, produce it. He didn’t answer, they never answer. Time and time again, I challenge people to show me where it says in that paper this is my biopsychosocial model because it doesn’t say it.

So psychiatry is operating without a warrant and that is a very, very serious state of affairs.

Moore: So your view is that the biopsychosocial model is a mirage, it doesn’t really exist, maybe similarly to the chemical imbalance, it’s there to palm off difficult questions rather than something that people use in everyday practice.

McLaren: It’s a fig leaf which conceals the fact that psychiatry doesn’t have an established, articulated, publicly available model of mental disorder. It’s also a distraction, it’s hand waving. There’s that terrible sense of, ‘oh, don’t worry about the details, we’ll sort that out later.’ You hear this from academics, ‘oh that’s in the literature, you should be familiar with the literature.’ Well, actually, I am and I’m telling you, there is no model of mental disorder available to modern psychiatry, and therefore modern psychiatry fails to meet the basic criteria for a science.

Moore: Turning now to your most recent book, which you kindly shared with me, it’s entitled Natural Dualism and Mental Disorder, the Biocognitive Model in Psychiatry, and it was published very recently in December 2021.
In the book, you write: ‘The biocognitive model for psychiatry represents a total break with the past. It is highly developed, far reaching and its scope, firmly based on well-established principles from other fields of science and leads to dramatically different ways of seeing old problems. 
More to the point, it says, practically everything we are doing in psychiatry today is wrong, if not frankly, destructive. It offers a new model of treatment that shifts the focus from blind meddling with the brain’s function to seeing humans as information users with the capacity to get caught in self-sustaining mental traps. However, it also says we are dangerously irrational, which must be taken seriously. While this may be shocking, for some, we ignore it at our peril.’
I wondered if you could tell us a little bit about the biocognitive model and how it differs from the kind of thinking you were talking about in terms of diagnosis and brain chemical imbalances?

McLaren: The dominant theme in modern psychiatry is that each mental disorder is categorically unique and the job of the nosology, that’s the classification system, is to sort out these discrete entities and then ultimately they will be mapped down onto the genome. And so for each discrete mental entity, there will be a discrete error in the genome, which ultimately the goal is there will be a drug for each mental disorder. That’s what modern psychiatry is all about, that’s what it does. All of that is without warrant, that’s all there is to that. 

So the biocognitive model, and that’s just a name I tacked on to it because you’ve got to have a name, starts with the most basic fundamental principle that we are information processers as humans, but we’re very complex information processers. We’ve got these peculiar things called emotions. So that’s much more complex than something sitting on your desk that just barks at you and so we’ve got to give account for that, but we have to start with the most basic point and build up.

Psychiatry goes the other way around. They started with the clinical impressions and they’ve gone backwards. They’re going backwards all the time, and it’s not working. The biocognitive model says that there is no physical cause for mental disorder, but a psychological account is possible and it can account for all mental disorder. So mental disorder becomes a psychological phenomenon—very complicated, I don’t just say it’s simple. If it’s simple, then we’re probably wrong. Mental disorder is essentially psychological and that’s how it has to be assessed, that’s how it has to be understood, and that’s how it should be managed.

Giving people brain-destabilizing drugs, doing things like giving them ECT, implanting things into the brain, filling them with narcotic drugs, like ketamine, all that sort of stuff. The old surgery, the leucotomies, I assisted at the last leucotomy in Western Australia and at the time I was just a neurosurgery resident, I didn’t know. He said, ‘We’re doing this’, so there we are. Those things are entirely without warrant, there’s no justification, it doesn’t exist. The problem is that there are so many people who are so heavily committed to this idea that you’re fighting a rearguard action all the time.

The model isn’t meant to be simple, but the concept of self-sustaining anxiety is pretty simple. We get caught in self-reinforcing, self-sustaining traps of anxiety, but we do that in other things, too. We get caught in self-sustaining traps of aggression, and you can see one going on in Ukraine right now.

So, we get caught in self-sustaining loops, the big one is anxiety, aggression is another and depression can become a self-sustaining loop. That’s where it becomes terribly important to understand the person as a person. Why is this person in this position in life right now? And that’s the therapist’s job, is to sort that out.

Moore: Again, in the book, you point out that many of history’s great thinkers would probably today receive a host of diagnoses. So it made me wonder if that’s part of the issue, that we can’t tolerate difference anymore. Difference of behavior, difference of thought or difference of culture?

McLaren: There is this tendency to homogenize ourselves, I have this with my kids all the time. Why are you listening to that crappy music? Why do you wear your cap backwards? Things like that. Why do you homogenize yourselves? Where’s the individuality? Yeah, so that’s true.

A lot of great people were very difficult, people like Santiago Ramón y Cajal in Spain was one of my heroes because he was such a difficult person, and yet he achieved at this high level. His father took him out of school because he was such a little ratbag. They had to take him out of school and then in these days, he’d be put on drugs. That’d be the end of it.

This is why it’s very interesting. Descartes is another writer whom I admire very much, he would have been labeled as autistic. I don’t know what’s happened to us, we fear individuality.

Moore: I think it’s fair to say that you take the view that more psychiatric treatment has led to worse outcomes overall. So, I wonder, is there evidence that we can draw on that this is commonly the case?

McLaren: Well, if you want that, just look at Thomas Insel, the former Director of the National Institute of Mental Health. He was there for 13 years and in 2015, he gave an interview after he had left that job and he said, ‘we haven’t budged the needle at all. I’ve spent $20 billion on research, we got lots of cool papers published by cool scientists and we haven’t budged the needle for the mentally disordered one iota’. I mean, what else do you want? That’s a good enough authority, isn’t it?

Moore: He’s confirmed that again in his recent book, hasn’t he? His book doesn’t really talk very much about long term outcomes for people, and surely that should be the measure of our success at helping people with mental health struggles. Do they go on to live long, meaningful lives? And that isn’t really discussed.

McLaren: There’s always a problem in that we actually haven’t got very much to compare it with. This is why research like David Healy’s work, looking at figures from the mental hospitals 130 or 140 years ago, is so valuable. Things were a lot different then. I can remember that people did not come in and out, in and out like they do now. You did not see people on six, eight or 10 different psychiatric drugs. There were nowhere near as many people going into hospital with the same regularity, it didn’t happen.

This thing called rapid cycling manic depressive psychosis or bipolar disorder, that didn’t exist in 1976. I can tell you now, it did not exist, but it does now, why does it now? What’s changed? The only thing that’s changed is the drugs. That’s the only thing.

Moore: You quote Richard Buckminster Fuller in your book, and he said, “You never change something by fighting the existing reality, to change something, build a new model that makes the current model obsolete.” 
How do we go about making the current model obsolete when so much power shapes and controls it?

McLaren: That’s true, and that’s why I wrote the article recently, entitled, “Why Do We Lock People Up?” There’s no justification, it’s just the way it’s always been done. Why do psychiatrists have this immense civil power to lock people up, to deprive them of practically the whole of their human rights on hearsay evidence? Where does this power come from? Why is it there? What’s the justification? There is no justification, there is no model of mental disorder. This is a fabrication and it’s necessary to expose it. I’ve been knocking politely on the door for decades, you get absolutely nowhere.

That’s why I think it’s important to say, look, here’s this biopsychosocial model, here’s the law on fraud. Why is this not fraud? Why are you people not conducting a fraudulent enterprise? You must justify it.

Moore: If you had the power to make change in the way that we react and respond to people suffering all kinds of mental distress, what’s the biggest change that we could make that would dramatically reduce the number of people exposed to harm?

McLaren: The first thing is for psychiatry to accept that it does not have a model of mental disorder. Stop touting this chemical imbalance in the brain. Stop spouting things like a medical model or a biomedical model. Stop saying that basic brain research will tell us all we need to know about mental disorder. Stop saying there’s something called a biopsychosocial model, and accept that there is no model and psychiatry really needs to go back to square one.

As it happens, I have a model, I’ve put it there, you can have a look at that. You may not agree, but at least let’s start talking seriously. Instead of all sitting around saying ‘yes, we’ve got a model, haven’t we? Yes, yes, we most certainly do’. There is no model, it doesn’t exist. It’s a fraud. It’s as simple as that.

Moore: Does psychology or psychotherapy need a model to adhere to, do you think?

McLaren: Yes, you have to have a model that tells you what you’re allowed to do and what you’re not allowed to do. Otherwise, we end up with this ritual, satanic abuse, alien abduction, multiple personality, blah, blah, blah. You must have a demarcation criterion, separating valid science from fanciful nonsense, that’s terribly important.

The history of psychiatry really is a history of fanciful nonsense. I don’t know why I do this to myself, but I’m reading Andrew Scull’s book [Desperate Remedies] at the moment. Then there’s Anne Harrington’s book, Mind Fixers. I mean the information is all there, all we’ve got to do is convince people to read it, but psychiatrists won’t read the critics. They only talk to each other, they don’t talk to anybody else, and they exclude critics.

I think a lot of that goes back to Thomas Szasz, who really went too far, in my view, to say that there’s no such thing as mental disorder. He’s quoted in one of his books, he says, “soldiers who complain of mental symptoms are just trying to evade their duty.” That is such a brutal thing to say about a person with a posttraumatic state. Thomas Szasz fed mainstream psychiatry the reason to avoid critics and they’ve been doing it ever since. Psychiatrists have got to get out of their echo chamber and start accepting criticism.

Moore: Do you think there’s much chance of that actually happening? Because academic psychiatry feels quite remote and entrenched. So, will they change, do you think?

McLaren: I think it will collapse. When people like Thomas Insel say, ‘we promised you that basic research would answer all questions about mental disorder, with no questions unanswered’. That was essentially what they promised in the 1980s and 1990s.

‘These drugs’, they said, ‘are safe, they are effective. They have minimal side effects, you are silly not to take them.’ It now turns out that that is all false, and eventually, it will collapse. That’s all there is to it. I would like to be alive to see it. That’s all.

One thing that troubles me and that is what is being done to medical students and trainees in psychiatry. Essentially, they are being brainwashed. They’re being fed a line which has no justification, and I’ve asked medical students this quite a number of times. On your first lecture in psychiatry, when the professor walked in and said, ‘Welcome to psychiatry’, what was the model of mental disorder that he gave you? And they have always said ‘he didn’t, he just started talking about genomes and neurotransmitters and drugs and ECT.’

That is not science, that’s not how science is conducted, that is called brainwashing, and this is a tragedy. The majority of medical students, they’re just not interested in psychiatry and they just turn away from it. So we’re ending up with essentially second rate people, or people who’ve got ulterior motives. Somebody very bright might go into psychiatry, but he’s got his eye on an academic career, that’s what he’s got mapped out. Others go into psychiatry because they recognize that this is an easy way to make heaps of money. These are very bad justifications.

I think the way medical students are indoctrinated is reprehensible. When you go in, they should say to the students, ‘today, we’re going to talk about mental disorder.’ Question number one, is there such a thing? You’d start at that point. Unfortunately, Thomas Szasz muddied those waters rather badly, but mental disorder is a real thing, ask anybody who suffers. Soldiers and civilians who are caught in tragedies, bushfires or floods as we’ve had here in Australia. They suffer, and they suffer in the long term. That’s real.

Moore: I’m guessing that part of that indoctrination can be blamed on the pharmaceutical manufacturers. We’ve heard from previous interviews that they influence the way that textbooks are written, they influence the way that medical students are taught, so it’s kind of a self-perpetuating thing, isn’t it?

McLaren: Yes, what the soldiers call a self-licking ice cream. So the psychiatrist wants the drug money, and the drug companies want the psychiatrist to endorse their product and so this just becomes a very cozy little echo chamber and there is nothing original allowed. Nothing is allowed to threaten the status quo. That’s why Mad in America is very important because it is presenting alternative views, critical views, to a public which is being deprived of those views.

Moore: Thank you, Jock, it’s because of people like you Mad in America can air those kinds of discussions.

McLaren: Thank you very much.

 

 

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MIA Reports are supported, in part, by a grant from the Open Society Foundations

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