Book Review: Humanizing Madness

The book i’m reviewing is ‘Humanizing Madness – Psychiatry and the Cognitive Neurosciences’ by Dr Niall McLaren. Dr Niall McLaren is described as having been the ‘world’s most isolated psychiatrist’ when he worked in the Kimberley Region in Western Australia. Dr McLaren is straight talking and so his ideas are presented clearly. This book is a presentation of his biocognitive theory which sets out to explain human experience and cognition.

In the first part of the book, Dr Mclaren moves elegantly through the different theoretical models including the biological model, behaviourism, mentalism, the biopsychosocial ‘model’ and classic dualism and discussed why he thinks they cannot provide the answers that psychiatry needs. This section shows McLaren’s profound breadth of knowledge and understanding of the issues that create the limits of psychiatry.

However, before moving on, I would like to make a point about the biopsychosocial model. The biopsychosocial approach is a practical one. When a psychiatrist sees a patient with needs in a number of areas, it is not unreasonable for the psychiatrist to refer to a colleague (e.g. a social worker with a knowledge of sociological theory) when appropriate. There are two reasons that I mention this.

(1) The first one is that it is not necessary for the psychiatrist to have a working sociological model (for instance) for practice but instead it is important to recognise when to call on someone with that expertise to take management forwards. The emphasis is on knowing where things are, rather than necessarily having a working integrated theoretical model.

(2) This leads me neatly onto the next point which is the difference between theory and practice. It would of course be nice to have an integrated biopsychosocial model. By this, I mean a model which we can follow from the genes all the way through the manifestation of behaviour in a cultural context. Indeed it seems essential to psychiatry to have such a model. Nevertheless, psychiatry is a practical as well as theoretical discipline. Whilst theoreticians debate the merits of one model over another, patients in the real world require help. There are a number of approaches that are utilised in this instance. There are approaches based on medical, psychological or social theories (e.g. the monoaminergic hypothesis of mood disorders). There is the empirical approach. Drug A works in this instance. It is not clear why it works but it does and it works effectively. There are also the unmeasured aspects of service provision (e.g. the relationship with the doctor and other members of the care team).

Therefore I would distinguish between the biopsychosocial ‘approach’ and the biopsychosocial model, unless of course it is a model of practice.

Dr McLaren then goes onto discuss his biocognitive model which is presented in a descriptive form which, I think, serves as the higher level framework in which to organise the finer details of this theory. The concept is a brilliant one and has been arrived at both through the process of acquiring clinical acumen and exploration of philosophical texts relevant to psychiatry. He also invokes the works of the brilliant 20th century genius Alan Turing, whose towering achievements have perhaps not reached an appropriate level in the cultural ‘psyche’. McLaren’s model differs from epiphenomenological explanations of inner experience by identifying such experiences as the physiological outcome of the cognitive hardwiring. He also emphasises a postclassical interpretation of mind-brain dualism through the device of symbolism – that is that the neuronal firing patterns can be described both symbolically and in terms of their physical state (e.g. potential, frequency of firing etc). It is the symbolic representation which is irreducible.

In the final part of the book, McLaren then goes onto to apply the theory to different psychiatric conditions. However he also offers clinical insights into these conditions. Within the last section, there is also one point of discussion. Perhaps there might never be a simple theory that could account for psychiatric conditions because of the very diverse and vast nature of such conditions. Therefore McLaren, in my opinion, focuses on some of the most common psychiatric conditions and again offers a framework perhaps for understanding the more common causes of these conditions although some of these suggestions are perhaps too simplistic. For instance I would support the existence and importance of dissociative conditions although adding that the concept would benefit from improvements in formulation.

McLaren’s biocognitive model and exposition is a brilliant work which sets the scene for the formulation of this model which can be tested. McLaren’s approach is similar to that of Winnicott with a similar utilisation of clinical accumen in combination with theoretical construction and an ability to identity focal points for debate. Indeed I wonder if the creation of a regulative fiction (which I interpret in McLaren’s case as the generation of a complex internal construct involving philosophical enquiry so as to reach a better understanding of the external world) is another method of creating in science and one which is ignored by the scientific establishment without the armour of numbers. If we take this a step further, perhaps Einstein’s ‘regulative fiction’ was such a success precisely because it’s end formulation was the testable E=MC2, rather than the story of how this was arrived at. Similarly for Kekule’s dream-induced structure which was reducible to a chemical formula. The only question is whether a theory of mind/brain will ever become accepted if it isn’t expressed in symbols. In any case, I look forward to the development of McLaren’s biocognitive model.

Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.

18 thoughts on “Book Review: Humanizing Madness

  1. Niall (Jock) McLaren

    A comment on the term ‘biopsychosocial’ in modern psychiatry.

    In my work, I have examined each theory used in modern psychiatry against the standard canons of the philosophy of science (and of common sense). My conclusion is that it is now beyond question that psychiatry does not have a general theory of mental disorder. The “biopsychosocial model” proffered by the late George Engel, of Rochester, NY, was not primarily an attempt to fill this gaping hole; I am not aware that he criticised any of the major theories in psychiatry. Rather, he wished to draw psychiatry out of the orbit of “biomedicine,” as he termed it, the excessively reductionist and, ultimately, dehumanising biological culture which was sweeping medicine in the 1960s. I trained in the 1960s and nobody in those brave days had the slightest doubt that reductionist biologism would soon yield every answer medicine, including psychiatry, could ever need. Engel was fighting a rearguard action against this movement but he didn’t attack his enemy at its weakest point.

    As I have shown, the weakest point of biological reductionism is that it cannot provide a complete explanation of human behaviour. For people committed to the biological model, this comes as a profound shock. However, they do not defend themselves. They simply withdraw from the debate mumbling something about plurality in science (whatever that is). I have a list of emails from some very famous names who just refused to answer the questions I put to them.

    For some reason, the term “biopsychosocial approach” is enjoying a comeback in the UK. However, it is used in a rather odd way, certainly not as Engel originally intended. In fact, it is used to licence psychiatry’s withdrawal from the field of humanism. Engel wanted physicians to see their patients in a wholistic way, to take their culture and private fears, etc., into account. He firmly believed that doctors in general and psychiatrists in particular should be more than mere technicians, ordering blood tests and scans, prescribing drugs then withdrawing. This, he argued, is an incomplete medicine, half a practice only.

    However, as Dr Marley uses the termin his review, it licences psychiatrists to busy themselves with neurotransmitters and drugs, then hand the rest of the patient to somebody else. All that it means is that psychiatrists have chosen to make a stand on a field they feel nobody can challenge, their biological tradition. This would be fine if psychiatry had a formal biological model of mental disorder, but it doesn’t. The nett effect is that psychiatrists are gradually vacating their field, handing it to people such as psychologists and social workers, who make more noise but who are, in fact, no better off when it comes to theories. What we need to reestablish psychiatry as a specialty in its own right is a genuinely integrated theory of mind and body. I have already published the rudiments of this theory, the last part of the model is just being completed. For the first time in history, we can now trace a direct causative link from thoughts to genes and back again. But it spells the end of crude biologism of the DSM-IV/ ‘chemical imbalance of the brain’ type.

    The so-called biopsychosocial model or approach might have some validity if psychiatrists actually had a model for what they call their biological input to the multidisciplinary team, but they don’t. Anybody who disagrees with this is free to answer my standard challenge: Could a psychiatrist please give the name of the theory he uses in his daily practice, teaching and research, supported by three seminal publications which outline the fundamental propositions on which the theory is based. Every time I issue that challenge, all I hear is the shuffling of feet. Until somebody is prepared to stand up and say what the model is, then the bio- part of biopsychosocial approach is just so much propaganda. And until psychiatry has a genuinely integrative model of the type I have outlined, it is at risk of disappearing as a speciality, as is already happening in this country. The one thing I can’t explain though, is why orthodox psychiatry is so bitterly antagonistic to my model. Their response is bizarre: they say they want a biopsychosocial model, I have written one, but they turn their backs on it. Bizarre and bizarrer.

    Jock McLaren

  2. Dr Justin Marley Post author

    Dear Jock,

    Thank you for taking the time and trouble to write such a detailed and eloquent response to my review of your book ‘Humanizing Madness’. I must apologise for my delay in responding but I have been looking for a response which will do justice to the questions that you pose. On reflection however, I realise that there is no ideal response.

    I am interested in models. Indeed it seems that having a model should be the starting point in science for all activities. Thus your biocognitive model which addresses the difficult issues we face in psychiatry in the various domains of our practice is appealing.

    In your response, you have interpreted my writing to mean that I advocate a restricted biological approach. This is not my practice. In the standard psychiatric assessment we examine biological, psychological and social factors in informing management. In my response, I had meant that within the team there are professionals with different domains of expertise who in various situations would be better placed to take forward parts of the management – the psychologist for instance could create a detailed psychological formulation which would incorporate the results of psychometric tests, the occupational therapist could undertake a functional assessment at the person’s home and the social worker could assess for instance a person’s placement. Each of these assessments by allied health professionals informs them in their management and when taken together, the teams management covers biological, psychological and social factors and the care is integrated through established processes.

    The issue of the role of the medical model in psychiatry has also been discussed recently in the British Journal of Psychiatry (an abstract of the article is to be found at http://bjp.rcpsych.org/cgi/content/abstract/193/1/6 where the online responses can be viewed) and it is interesting to see that it has provoked a lot of debate.

    Nevertheless all of this relates to the practice of psychiatry.

    There is also the separate issue of the theoretical basis for psychiatry. In answer to your question about a biological model that can be brought into discussion, there are two that I have reviewed recently on this blog.

    The first is by Professor Tim Crow, who has been developing his model of schizophrenia and it’s relation to language. The link to that article is here (http://theamazingworldofpsychiatry.wordpress.com/category/psychologypsychotherapy-article-review/page/2/) . The article which was reviewed on the above post contains numerous references to support the various facets of the model (more than the three that you stipulate) which explains sex differences in schizophrenia as well as developmental and neuroanatomical findings.

    The second is a paper that I recently reviewed by Philip Cowen – my review is to be found here (http://theamazingworldofpsychiatry.wordpress.com/category/medical-article-review/). Cowen proposes a model which I have sketched out in the article which moves from the genetics through to the phenomenology. Cowen references a number of pieces of research to support his model (again more than the three that you have stipulated).

    However, I was unable to find reference to the deeper question of reconciling mind and brain issues in these articles. These of course are the issues that you have successfully addressed.

    I will now suggest that your model is high-level or top-down in nature. There is of course another approach which is to move from the bottom-up. This is just the kind of model that Henry Markram has developed and which is reviewed here (http://theamazingworldofpsychiatry.wordpress.com/page/3/?s=blue+brain). Markram has suggested that such detail produces not a model – but a series of constraints. In other words, a person must describe the ‘model’ in terms of what limitations are imposed upon it – it seems to be a novel way of thinking about the problem – a new type of empiricism or perhaps even one step away from it.

    This leads me onto the next point. It is my belief that the human brain is incapable of fully understanding itself. By this, I mean that if a person’s brain has a certain number of neurons, then that person will be incapable of knowing how all of those neurons interact with each other. Such a detailed understanding will perhaps never be understood as it relates to the problems inherent in measurement. However, at some point, I think that artificial intelligence solutions will gain a better understanding of the human brain and that the ‘models’, if you can call them that, will be more literal or closer to ‘nature’.

    If this holds, then the next question is this – what are we creating models for, if we will never truly understand our own nature. I argue that we create models to give us the best understanding that we are capable of and which also has some degree of validity in making predictions. There is also a second very important benefit, which I think is to create a language for use in practice. This language with special terminology helps to bridge the gap between theory and practice and I think this where the problem lies. There is no consistent language – we have to move between ‘sets’ of specialised terminology – biological, psychological and social.

    Thus your biocognitive model as well as other models can be utilised in developing an appropriate language which should further facilitate the movement of information from theory to practice and vice versa.

    Again, I look forward to developments in your model

    Kind regards

    Justin Marley

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