Psychiatry’s Failure Crisis: Are You Moderately or Radically Enlightened?

Psychiatry has historically promoted dogma—not science—and dogma tends to be boring for freethinkers who can smell its odor even before they can deconstruct it.

The challenge then is this: How can psychiatry be examined in a novel way that might intrigue freethinkers and critical thinkers of science, philosophy, politics, and history who would not ordinarily read a book about psychiatry because they are turned off by dogma? A fresh approach to examining psychiatry’s crisis of failure that I thought might interest them is utilizing the philosopher Baruch de Spinoza along with historian Jonathan Israel’s distinction between moderate and radical Enlightenment thinkers.

Excommunicated Spinoza by Samuel Hirszenberg (1907)

Today, even some key members of establishment psychiatry acknowledge three areas of failure of their profession: (1) worsening treatment outcomes despite increased treatment; (2) the invalidity of its DSM diagnostic system; and (3) the invalidity of psychiatry’s chemical imbalance theory of mental illness.

Unacknowledged by establishment psychiatry but reported even in the mainstream media is Big Pharma’s corruption of psychiatric research and treatment, and how this creates widespread conflicts of interest.

Unacknowledged by both psychiatry and the mainstream media is how virtually all of psychiatry’s policies and practices —not simply its treatments, diagnoses, and illness theories—are doing more harm than good on both an individual and societal level. In A Profession Without Reason (2022), I discuss several of psychiatry’s harmful policies and practices—including its “disease like any other” anti-stigma campaign which actually increases stigma; its “caring coercion” forced treatments which result in resentment and rage; and its individual-defect theories of mental illness that serve as diversions from socio-economic-political sources of suffering.

Among psychiatrists, there are those who are completely clueless, in denial, or dishonest about psychiatry’s record of failure. They repeatedly tell us that psychiatry is a young science that has made great progress. Promulgating the myth of progress is the historic role of the leadership of the American Psychiatric Association (APA), the guild of American psychiatrists. One of many examples is psychiatrist Paul Summergrad, who during his APA presidency (2014-2015) began a talk with the following: “We have made great improvements in many areas of psychiatric care in recent years, but there is still a lot of room for improvement in our country’s mental health system,” and he then tells us that the problem is not enough access to psychiatric treatment.

Not all psychiatrists are completely clueless, in denial, or dishonest. Among those who are not completely unenlightened there are two groups: the moderately enlightened, and the far smaller radically enlightened. The moderately enlightened acknowledge some of psychiatry’s failures but, in common with the unenlightened, desperately attempt to preserve the institution of psychiatry. In contrast, the radically enlightened care only about the truth, and have no attachment to institution preservation.

The Moderately and Radically Enlightened in the Enlightenment

In Spinoza’s era, 350 years ago, ruling religious and state institutions fought against science, freedom, and other human rights, and this resulted in a rebellion that we now term the Enlightenment. What intrigued me—and I hoped would interest others—is that among Enlightenment thinkers, there was a clash between the moderately and the radically enlightened, and today this same clash exists with respect to psychiatry.

In Radical Enlightenment (2001), historian Jonathan Israel explains this distinction between moderate versus radical Enlightenment thinkers. While the term radical can be used in many ways, for both Israel and myself, radical means a complete break with past tradition, including the dissolution of control by powerful societal institutions; and moderate refers to criticism and reform but no complete break from past traditions.

While all of the original Enlightenment thinkers embraced reason and science, and strove for greater tolerance, freedom and an improved society, moderate Enlightenment thinkers aimed to accomplish this, Israel observes, “in such a way as to preserve and safeguard what were judged essential elements of the older structures.” In contrast, radical Enlightenment thinkers such as Spinoza, Israel tell us, “rejected all compromises with the past,” denying the Judeo-Christian view of God, miracles, afterlife rewards or punishments; and they scorned theologians’ God-ordained hierarchies that sanctioned monarchies.

During Spinoza’s seventeenth century, much of society—including virtually all ecclesiastic authorities, most civil authorities, and much of the public—was unenlightened; they sought to maintain the status quo of faith in traditional authorities, and they rejected freethinking, religious tolerance, and democracy. Moderately enlightened thinkers saw value in science and tolerance, but they sought to limit the Enlightenment so as not to pose a threat to ecclesiastic and state institutions. The radical Enlightenment was an underground movement that included Spinoza and his friends—and which threatened institutions holding power.

This contrast between moderate and radical has persisted throughout history. In the 1850s in the United States, with regard to the institution of slavery, if one was moderately enlightened, one was troubled by slavery and opposed its spread to new states but did not call for the abolition of slavery. In contrast, if one was radically enlightened, one fought for the immediate abolition of slavery—this advocated by the “Radical Republicans.”

Today, we see a moderate-radical contrast with regard to psychiatry.

Psychiatry’s Moderately Enlightened

Many psychiatrists, including some key members of establishment psychiatry, are not completely clueless, in denial, or dishonest about psychiatry’s record of failure with respect to (1) worsening treatment outcomes despite increased treatment; (2) the invalidity of its DSM diagnostic system; and (3) the invalidity of psychiatry’s chemical imbalance theory of mental illness.

In A Profession Without Reason, an example of a moderately enlightened psychiatrist I offer is Thomas Insel, National Institute of Mental Health (NIMH) director from 2002-2015. Disappointingly, in his recently published book Healing (2022), Insel omits some of his previous acknowledgments of psychiatry’s failures that I had given him credit for, and he offers illogical rationalizations for other failures.

While Insel remains consistent in his acknowledgement of psychiatry’s record of “abysmal” treatment outcomes, his rationalizations for it in Healing are illogical, unscientific, and thus pre-Enlightenment thinking. As I detail in my review of Healing (“Former NIMH Director’s New Book: Why, With More Treatment, Have Suicides and Mental Distress Increased?“), while Insel continues to acknowledge that treatment outcomes are worsening despite increasing numbers of people in treatment, at the same time, he proclaims that modern psychiatric treatments are very effective.

The invalidity of psychiatry’s chemical imbalance theory of mental illness has increasingly been acknowledged by the moderately enlightened members of Establishment psychiatry—including Insel. In 2011, establishment psychiatrist Ronald Pies, Editor-in-Chief Emeritus of the Psychiatric Times, stated: “In truth, the ‘chemical imbalance’ notion was always a kind of urban legend—never a theory seriously propounded by well-informed psychiatrists.” In Healing, Insel acknowledged the jettisoning of the chemical imbalance theory, stating: “The idea of mental illness as a ‘chemical imbalance’ has now given way to mental illnesses as ‘connectional’ or brain circuit disorders.”

With respect to this “brain circuit disorder” theory, there is as little evidence for this new biological-defect theory as there was for the now discarded chemical imbalance theory. However, crucial to psychiatry’s usefulness for the ruling class—which values any explanation for emotional suffering that does not include an increasingly alienating and dehumanizing society—is some kind of “individual-defect theory of mental illness.” Thus, moderate institutional preservationists such as Insel know that if they cannot provide such an individual-defect theory—be it chemical-imbalance defects, brain-circuit defects, or some kind of genetic defects—the ruling class will turn to some other profession who will provide a diversion from the socio-economic-political causes, perhaps providing more power to clergy.

With respect to the invalidity of the DSM, Insel (unlike the APA) evidenced enlightenment when, as NIMH director in 2013, he stated that the DSMs diagnostic categories lack validity and announced that “NIMH will be re-orienting its research away from DSM categories.” In his 2022 Healing, Insel states: “The DSM had created a common language, but much of that language had not been validated by science.” In plain language, Insel is calling it bullshit.

As NIMH director, Insel pushed for replacing the DSM with something called RDoC, upsetting the APA who publishes the DSM (which is the major money maker for the APA). Even though Insel has declared the DSM to be invalid and unscientific, the DSM continues to be used by psychiatry for patient diagnosis and treatment.

Thus, even though high-ranking moderately enlightened psychiatrists know that the DSM is scientifically invalid bullshit, they wish not to offend the APA and derail the institution of psychiatry. And so, the moderately enlightened engage in what philosophers call “reconciliatory theism,” compromising between the truth and acceptable dogma, and they caution us, as psychiatrist Jim Phelps did in a recent post on Mad in America, not to “throw out the baby with the bathwater.”

In contrast, for Spinoza and contemporary radically enlightened thinkers, if reason and science make clear that any conceptualization is invalid—or what Spinoza called an inadequate idea that results in models and paradigms based on confused and false concepts—radically enlightened thinkers would not compromise their position for the sake of maintaining an institution.

Perhaps Insel’s most disappointing deterioration is his omission from Healing of his previous assertion as NIMH director about the treatment of individuals whom psychiatrists label with “serious mental illness” (SMI). Absent from Insel’s 2022 Healing is any reference to his 2013 NIMH commentary “Antipsychotics: Taking the Long View” (that has recently been removed from the NIMH website but remains republished on other sites), in which Insel surprised establishment psychiatry by agreeing, in large measure, with psychiatry critics such as journalist Robert Whitaker that standard psychiatric medication treatments for some individuals diagnosed with SMI are counterproductive.

Insel actually acknowledged in 2013: “It appears that what we currently call ‘schizophrenia’ [which Insel puts within quotation marks] may comprise disorders with quite different trajectories. For some people, re­maining on medication long-term might impede a full return to wellness. For others, discontinuing medication can be disastrous.”

This assertion was part of why I had considered Insel to be an example of a moderately enlightened psychiatrist. However, sadly, nowhere in his new book (which extensively discusses this so-called SMI population) does Insel repeat it and reference the Harrow-Jobe and Wunderink research—which Whitaker had brought attention to—that Insel had referenced in 2013 to back up his assertion: “For some people, re­maining on medication long-term might impede a full return to wellness.”

While in A Profession Without Reason I gave Insel credit for being moderately enlightened, with his recent omissions and rationalizations in Healing, I can understand why some might now diagnose him with diminishing enlightenment, a milder form of the unenlightenment that routinely characterizes APA presidents.

The Radically Enlightened

While the moderately enlightened acknowledge some of psychiatry’s failures, they—no different than those APA leaders who are completely unenlightened—do everything possible to preserve the institution of psychiatry.

In contrast, the radically enlightened care only about scientific truths, not institutional preservation.

The radically enlightened look at the evidence for the “medical model of mental illness,” and seeing no justification for it, they advocate discarding it, unbothered by the consequences for psychiatry as an institution within medicine. Similarly, seeing no evidence that professional credentials are associated with superior outcomes, the radically enlightened proclaim this reality, unbothered by the fact that this costs prestige, power, and money to psychiatrists and other mental health professionals.

While the moderately enlightened are critical of psychiatry’s poor performance, the DSM, and psychiatry’s chemical imbalance theory of mental illness, and they may even believe in moderate reforms—for example, seeing value in peer-to-peer support as long as this doesn’t reduce professional authority—they do not challenge the legitimacy of psychiatry as a societal institution, and they do not challenge the current mental illness industry hierarchy with psychiatrists at the top of it.

In contrast, if science and reason dictate so, the radically enlightened are open to a complete break with past tradition and its institutions. With respect to psychiatry, this includes: eliminating the power that the APA has over civil society through its mental illness declarations; abolishing institutional hierarchies in which individuals with extensive experience in recovery but lacking professional degrees have little or no power; and prioritizing societal variables and social policies that affect emotional well-being.

For those who think radical means something “too extreme” and “bad,” it is important to keep in mind that as radical a thinker as Spinoza was in his day, there is nothing in what he said that is today considered by progressive thinkers to be too politically radical; and in fact, modern progressive thinkers actually view Spinoza as not progressive enough in some matters. Similarly, in the 1850s, as radical as the Radical Republicans were in their views of African Americans and the abolition of slavery, there is nothing about their views that today would be considered too radical by most Americans; and in fact many progressives would today view the Radical Republicans as not progressive enough.

This should provoke psychiatry’s critics to consider the possibility that as radical as their views about contemporary psychiatry are considered today, in the future, these views may well be seen as not progressive enough.

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

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