Treatment Resistance or Treater Resistance

Treatment Resistance or Treater Resistance

by Niall McLaren, MBBS, FRANZCP

I have been having another round of to and fro with psychiatrists over whether ECT is “essential, helpful, safe, effective…” and all the other stuff the mainstream claims. My case is that, using figures supplied by ECT advocates themselves, it is crystal clear that every such claim is false.1 The fact that there are parts of the world where it is banned and many other places where it is severely restricted or just not available shows that it isn’t essential. Psychiatrists use ECT because they like it, and they like it for a number of reasons:

1.      They believe that mental disorder is a biological disturbance of brain function that requires physical methods of treatment. This is an unproven ideological claim.2
2.      They have run out of options, don’t know what else to do. If so, they should get help from somebody who does know.
3.      ECT is terribly medical and helps bind psychiatry into mainstream medicine as the “science of mental disorder.” A technique does not make a science.
4.      For something that requires practically no intellectual effort, ECT pays very well, (currently $175.15 for briefly pressing something against an unconscious patient’s head).

Some less doctrinaire psychiatrists say: “I’m not keen on ECT but sometimes use it for treatment resistant depression or psychosis.” While what is now called treatment resistance is an old concept, it’s popped up again lately. It conflates three or more themes which should be seen separately.

The first sense of “treatment resistance” is also called “lack of insight.” This is the notion that a psychotic person doesn’t know that there are no voices coming from the air conditioning, or that there are no X-rays being beamed down from a geostationary satellite and so on. The person obviously believes it and has the experiences but, objectively, they’re not true. These people don’t believe they’re sick so, naturally enough, they’re resistant to the idea that they should be locked in a mental hospital and forced to take unpleasant drugs or have ECT. This is especially true for anybody who’s already experienced the boredom and infantilism of what CS Lewis likened to “hell on earth”:

Their very kindness stings with intolerable insult. To be ‘cured’ against one’s will and cured of states which we may not regard as disease is to be put on a level with those who have not yet reached the age of reason or those who never will; to be classed with infants, imbeciles, and domestic animals.

The issue here, which has never been explored properly, is whether detention with forced treatment is actually better than no treatment. Most people forget that involuntary treatment is a gross abuse of human rights. A person who commits murder has the inalienable right to a carefully managed trial with judge, jury, defence lawyers and so on, all provided per courtesy of the state. At the same time, another person who has broken no laws can be grabbed at home, wrestled to the ground, handcuffed, thrown in a police wagon, taken to a mental hospital, held down, stripped, injected and then held in solitary confinement with no right to speak to family or relatives, no phone, cigarettes, etc., just because somebody thinks “Oh, he's crazy.” Don’t say this doesn’t happen, it most certainly does.

Unsurprisingly, there are people who don’t want to be dragged off the street and slung into a nuthouse, but their anger at being treated as “infants, imbeciles, and domestic animals” is deemed “treatment resistance” by the psychiatrists. However, the peak human rights and health bodies in the world, the UN High Commissioner for Human Rights (HCHR) and World Health (WHO) have recently determined that all coercive and/or involuntary treatment is an unacceptable breach of human rights and should be phased out.3 Their carefully argued advice has run into another sort of resistance, the refusal of psychiatrists to recognise the need for progressive change, just as retired GP and historian of science, Robert Youngson, described:

The whole history of science, right up to the present, is a story of refusal to accept fundamental new ideas; of determined adherence to the status quo; of the invention of acceptable explanations, however ridiculous, for uncomfortable facts; of older people of scientific eminence dying in confirmed possession of their life-long beliefs; and of painful readjustment of younger people to new concepts.4

The second theme in “treatment resistance” comes from Sigmund Freud, the founder of psychoanalysis, who died 85 years ago. Freud’s idea of unconscious mental events was quite shocking at the time because humans (read: wealthy educated white men) liked to see themselves as fully rational and in control at all times. They didn’t like being told that a lot of what they did was driven by completely irrational impulses from the past that they couldn’t access. Psychoanalysis was directed at bringing these forbidden impulses to full consciousness but, Freud said, they were repressed by powerful ego mechanisms of defence. Therefore, the analyst had to work hard to overcome this resistance.

Let’s take an example from this morning’s Economist newsletter (July 1st, possibly a paywall) which states: “Australia is trying to buttress its defences to deter Chinese military aggression …” All the terribly sensible and realistic people in Canberra who take it in turns to decide which country is to be this week’s enemy would be deeply offended by being asked: “What aggression?” They believe that the world’s biggest economy and our major trading partner is such a grievous threat to this country that they have to spend hundreds of billions of dollars on weapons such as F-35s and nuclear submarines and mesh ourselves ever-deeper into the world’s biggest and most destructive military machine. Yet when asked for examples of Chinese aggression toward this country, they can’t provide any, just because there aren’t any. No Chinese troops or ships have served south of the equator since Admiral Zheng He’s expeditions in the thirties. To be clear, that’s the 1430s.

Any evidence that says China is not a threat is batted away without so much as the blink of an eyelid: it simply doesn’t penetrate what passes as their collective consciousness. Every attempt to get them to see that fact is resisted aggressively, which is precisely as Freud described it a hundred years ago. The ego mechanism of defence called “projection” sees to that. Projection means “attributing an impulse or emotion to another person when it is actually our own.” It’s usually negative, such as saying other people are aggressive when it’s really us who want to attack them, but it can be positive as in assuming everybody agrees with our likes or dislikes. Freud said the analyst must work hard to overcome treatment resistance, but that made it impossible to tell when the patient was telling the truth or was showing unconscious resistance. In practice, it was always the latter as the psychoanalyst was never wrong.  

The last types of resistance come from general medicine. When antibiotics were first discovered early last century, it wasn’t long before physicians became aware that the drugs quickly lost their effect on some bugs. It’s due to rapid genetic mutations which allow the bacteria to break the antibiotic down, rather than the other way round. Another physiological form of resistance is seen in diabetes, where cells become resistant to the effects of the glucose-lowering hormone, insulin. This is seen in obesity, in sedentary lifestyles, with certain sorts of medication, with a high fat-low fibre diet, or with various other medical conditions. Insulin resistance is real and is becoming more important. The best treatment is to exercise, lose weight and lay off the junk food, which is a hard sell to teenagers.

These forms of “medical resistance” are based in physiology and can readily be demonstrated in the laboratory. Antibiotic resistance is a very real problem as there’s evidence to show that resistance genes can spread from one species of bug to another. There are even breeds of insulin-resistant rats to keep researchers busy. But this is most definitely not in the same class of events as a person saying: “Stick your treatment, I’d rather look after myself.”

Mainstream medicine is built around the idea of safe treatment, as in “First, do no harm.” Medical treatments are very conventional for the simple reason that they work. Hundreds of thousands of cases establish what is the most effective therapy. If the standard treatment doesn’t work, the physician starts again: probe the history again, talk to the relatives, re-examine the patient, review the test results, get some more tests, revise the treatment and watch what happens. But, when treatment fails, unless there are compelling reasons, don’t blame the patient. This is where it differs from the idea of “treatment resistant mental disorder,” because not one of the people throwing this buzz phrase around has the slightest idea of the physiology of depression, or even whether it is the sort of thing that has a physiology. They may believe it, but they certainly can’t prove it, and it leads to conversations like this:

You’ve got MDD, major depression, which is a chemical imbalance of the brain. We’ll give you this antidepressant to fix it and you’ll get better” … “Oh, it hasn’t worked? Try this one” … “Two drugs haven’t worked? Right, that means you’ve got TRD, treatment resistant depression, we’ll book you for ECT.

When treatment fails, as it often does in psychiatry, the first consideration should be that the diagnosis is wrong, and the second that the treatment is wrong. This leads to a much bigger question: perhaps the entire approach is wrong. Perhaps what is called the “mental illness of depression” is not an illness in the sense that tonsillitis or diabetes are illnesses. Perhaps this medicalisation of emotions has gone too far, an idea explored in detail in The Loss of Sadness by sociologists Allan Horwitz and Jerome Wakefield,5 which explains why the drugs don’t work. If depression is a normal reaction to life events, and not an illness in any useful sense of the word, then there’s no reason to believe it will respond to drugs. “But,” mainstream psychiatry protests, “depression does respond to drugs, so that proves it’s an illness.” Maybe, but it also responds to the passage of time, to placebo (sugar pills), to support and consideration and, damn it, to exercise:

Following extensive research, exercise has emerged as an effective treatment for major depressive disorder, and it is now a recognised therapy alongside other interventions.6

My view is that depression is indeed a reaction to life events, specifically the class of events called ‘losses.’ The job of the psychiatrist (and psychologist, and social worker and nurse etc.) is to find out just which life events are causing the trouble. Sometimes the life events are in the recent past (bereavement, divorce, loss of job or health etc.); sometimes they are in the distant past; sometimes they are real and sometimes imaginary, but the most common cause of a recurrent or persistent depressive state is in the here and now: an unrecognised anxiety state. Anxiety wrecks lives, and if it’s bad enough, eventually the anxious person will reach the stage of saying “This is never going to get better, I give up.”

Trouble is, psychiatrists don’t think anxiety is serious. To them, it’s an also-ran, a “comorbid” diagnosis rather than a seriously disabling mental state in its own right that causes the sufferer to give up on life. We see the same thing with chronic pain: a young person with, say, a major back injury has to adjust to a dramatically downgraded life, and that directly causes a massive sense of loss. That misery is grief, not an independent “disease” called depression, and unless that sense of loss is resolved, leading to a new lifestyle, the misery won’t go away. However, modern psychiatry can’t take mental factors into account, so it invents a new “disease” called TRD. As the party line goes, new diseases must have a different genetic basis, meaning lots of research grants, papers, conferences and maybe even a promotion…

In reality, of course, the idea of treatment resistance is just another ruse for evading the critical point that psychiatry’s long-term project of hammering mental problems into the procrustean bed of their phantom “biomedical” model is going nowhere. Instead of admitting that they don’t have a model of mental disorder, and no theory of personality so they can’t take personality factors into account, and no theory of mind so they can’t integrate social factors, and no concept of mind-body integration so no idea of how pain or drugs might affect mental function … instead of admitting their personal and collective failure, they simply flip it upside down and blame the patient: “It’s him, he’s got treatment-resistant depression.” Rather, they should be saying: “Did I get it wrong? Do I really understand how this person got to be in this position today? I’d better start again.”

As the history of psychiatry shows in frightening detail,7 the psychiatrist is always in error but is never wrong. “Treatment resistance” is just another cloak thrown over lack of understanding. And lack of empathy.

1 McLaren N (2017). Electroconvulsive Therapy: A Critical Perspective. Ethical Human Psychology and Psychiatry 19: 91-104.
2 McLaren N (2013). Psychiatry as Ideology. Ethical Human Psychology and Psychiatry 15: 7-18.
3 UNHRC/WHO (2023): Mental health, human rights and legislation: guidance and practice. Geneva: WHO/UNHCR.
4 Youngson, R (1988). Scientific blunders: a brief history of how wrong scientists can sometimes be. London: Robinson. p. 293.
5 Horwitz AV, Wakefield JC (2007). The Loss of Sadness: how psychiatry transformed normal sorrow into Depressive Disorder. New York: Oxford University Press.
6 Malhi G, Byrow Y (2016). Exercising control over bipolar disorder. Evidence-Based Mental Health, 19:103-105
7 Scull A (2022) Desperate Remedies: Psychiatry and the mysteries of mental illness. London: Penguin.

Niall (Jock) McLaren is an Australian psychiatrist who recently retired after 50 years of practice. He has extensive experience in military, forensic and remote area psychiatry, all at the rough and unglamorous end of psychiatry. As a specialist, he went back to university to study philosophy and has published a number of monographs on the application of the philosophy of science to mental disorder, most recently brought together as the biocognitive model for psychiatry. This is based in the concept of natural dualism, and provides a working model for mental disorder as a primary psychological matter, with no reason to suspect brain pathology. He lives in the rural outskirts of Brisbane with his family and keeps busy growing trees.


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