How to Explain Top Psychiatrists’ “Dr. Strangelove Exuberance” Unchecked by Reality

Exuberant individuals who disregard societal consensus reality are routinely diagnosed by psychiatrists with bipolar disorder; however, among psychiatrists themselves, exuberance about psychiatry regardless of the reality of psychiatry’s repeated scientific failures makes one a leading psychiatrist.

While one explanation for top psychiatrists’ exuberance unchecked by reality is their financial conflicts of interest with Big Pharma, historically, not all leading psychiatrists have been drug-company shills. So, what are other explanations for this phenomenon? Before examining these other reasons, a look at two high-profile examples of this exuberance.

In the twenty-first century, there has been no higher-level psychiatrist then Thomas Insel, director of the National Institute of Mental Health (NIMH) from 2002-2015. Insel left NIMH to lead the mental health team at Verily (formerly Google Life Sciences); then in 2017, co-founded Mindstrong Health, where he promoted digital phenotyping (which, for example, includes the monitoring of patient smartphone text messages to gauge mental illness).

Insel is a prime example of a top psychiatrist with exuberance about psychiatry regardless of his awareness of the reality of its repeated failures.

“I spent 13 years at NIMH really pushing on the neuroscience and genetics of mental disorders, and when I look back on that I realize that while I think I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs—I think $20 billion—I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness.”—Thomas Insel, quoted in 2017.

“To be clear, I have no regrets about NIMH funding for genomics and neuroscience.” —Thomas Insel, in Insel’s 2022 book Healing, xxvi.

“Whatever we’ve been doing for five decades, it ain’t working . . . . When I look at the numbers—the number of suicides, the number of disabilities, the mortality data—it’s abysmal, and it’s not getting any better.” —Thomas Insel, quoted in 2013.

“The scientific progress in our field was stunning, but while we studied the risk factors for suicide, the death rate had climbed 33 percent.” —Thomas Insel, Healing, xvii.

“. . . current treatments are as effective as some of the most widely used medications in medicine.” —Thomas Insel, Healing, xxiv.

The history of psychiatry is replete with ultimately discarded psycho-babble, bio-babble, and techno-babble. The discarding of the DSM, psychiatry’s diagnostic manual, was actually called for by Insel in 2013, and in his 2022 book Healing, he acknowledged that the chemical imbalance theory of mental illness has now been discarded. Today, he is techno-exuberant not only for digital phenotyping but for brain-circuit explanations of mental illness and for more electroconvulsive therapy (ECT), commonly called electroshock:

“The idea of mental illness as a ‘chemical imbalance’ has now given way to mental illnesses as ‘connectional’ or brain circuit disorders.” —Thomas Insel, Healing, 138.

“The approach [ECT], which induces a seizure across the full cortex in an anesthetized patient, might be akin to rebooting a computer. . . Simply zapping the cortex with electricity may seem like a Hail Mary pass, and yet it actually is effective. . . .” —Thomas Insel, Healing, 55.

Dr. Strangelove or: How I Learned to Stop Worrying and Love the Bomb, Stanley Kubrick’s 1964 satirical film, ridicules nuclear war planning and the Cold War ideology of “mutually assured destruction.” The film also mocks nuclear war expert Dr. Strangelove, who is unfazed by the horrific consequences of nuclear weapons.

Analogous to the fictional Dr. Strangelove, Insel is aware of the adverse effects of ECT, noting that “there are serious adverse effects, including headache and memory loss” (Healing, 55); however, he is unfazed by these adverse effects. Rather, Insel is upset that “only 0.25 percent of people with depression [are] treated with ECT,” telling us that the stigma of ECT has occurred because “antipsychiatry groups have demonized it” (Healing, 146-147).

The scientific reality of ECT? As is the case historically with every psychiatric treatment, including bloodletting, there are positive anecdotal testimonials for ECT, however, ECT has not met the scientific criteria for effectiveness. A 2019 review of the research on ECT effectiveness for depression reported that there have been no randomized placebo-controlled studies since 1985, and those studies that were done prior to 1985 are of such poor quality that conclusions about efficacy are not possible. Moreover, it has been consistently shown that ECT results in serious adverse effects such as “persistent or permanent gaps in life memories, including of weddings and birthdays, somewhere between 12 and 55 per cent,” as reported by psychologist John Read in 2021, who also reported that “one in 50 patients experience ‘major adverse cardiac events.’”

When I think of Insel’s exuberance for psychiatry undaunted by abysmal outcomes and horrific adverse effects, I think of Major Kong (Slim Pickens) riding the bomb in Dr. Strangelove.

High-profile psychiatrists’ exuberance over psychiatric treatments regardless of scientific realities is not new.

In the late-eighteenth and early-nineteenth century, the most well-known American physician who treated the “mad” was Benjamin Rush, a signer of the Declaration of Independence. Rush is often referred to as “the father of American psychiatry,” and his image long adorned the seal of the American Psychiatric Association (APA), the guild of American psychiatrists. Rush proclaimed himself a slave abolitionist though he had owned a slave, and his views on race included the idea that blackness in skin color was caused by leprosy, and so he advocated “curing” skin color.

Based on an earlier bio-babble theory that irregular convulsive action of the blood vessels was the cause of madness (and other diseases), Rush was an enthusiastic proponent of what was called “depletion therapy,” which included aggressive bloodletting, notes Gerry Greenstone in “The History of Bloodletting” (BC Medical Journal, 2010). Greenstone tells us: “Dr. Benjamin Rush (1745–1813) was one of the most controversial phy­sicians in his time. He was arrogant and paternalistic . . . and devoted much time to the problem of mental illness.” Greenstone reports that Rush removed “extraordinary amounts of blood and often bled patients several times,” and he maintained his exuberance about bloodletting even when other physicians were beginning to doubt its wisdom. “Some doctors,” Greenstone notes, “referred to his practices as ‘murderous.’”

How to Explain Top Psychiatrists’ Exuberance Unchecked by Reality

In “What Can Physicians Learn from Benjamin Rush, Blood, and the Red Cross?” (Hektoen International: A Journal of Medical Humanities, 2020), Ryan Hill notes, “Despite the adamant opposition he encountered from many of his contemporaries, Dr. Benjamin Rush was undeterred.” Hill points out, “During Rush’s day . . . many began to look at the practice with great skepticism, if not rejecting it outright . . . . It was obvious to many of Rush’s contemporaries, who took a much more objective view of bloodletting, that the practice was doing more harm than good.”

Hill then asks and attempts to answer two questions that are highly relevant to contemporary psychiatry:

“So, given this shift in thinking, why did Dr. Rush, one of the most brilliant and educated men of his day, hold on to this near-obsolete practice so unswervingly, even in the face of opposing evidence? Taking the question a bit further, is there anything physicians can learn from his apparent intransigence today?”

One answer, Hill tells us, is provided by Thomas Kuhn’s The Structure of Scientific Revolutions (1962), which explains why many scientists do not abandon their current paradigm even in the face of data showing the paradigm is incorrect. Hill concludes, “Perhaps Rush was stubborn, and maybe even self-righteous, but it was likely his inability to comprehend the shifting paradigm, rather than sheer stubbornness that tethered him so closely to the age-old belief in depletion therapy.”

Another explanation offered by Hill is that overconfidence is a “common human bias” against questioning outdated techniques. In the history of psychiatry, from Rush to Insel, psychiatrists who can project extreme confidence are more likely to move into leadership roles. This phenomenon exists in other areas of life, including the military leaders and political advisors satirized in Dr. Strangelove, and it also exists in business, as described by Susan Cain in Quiet (2012). Cain reports how the Harvard Business School information session on how to be a good class participant instructs: “Speak with conviction. Even if you believe something only fifty-five percent, say it as if you believe it a hundred percent.” Projecting confidence that is unjustified by reality can make one a leader in many areas of US society.

Hill also offers the explanation of confirmation bias for why Rush would not let go of bloodletting. Hill defines confirmation bias as: “when people form a hypothesis and then gather information to support it, rather than looking at data objectively before forming a conclusion.” Specifically, Rush was animated by those patients who survived and somehow improved after bloodletting, stating, “Never before did I experience such a sublime joy as I now felt in contemplating the success of my remedies.” Owing to confirmation bias, Hill notes, “Despite the fact that he had seen countless deaths, he claimed that he had never lost a patient he had bled. . . . His confirmation bias, a natural human tendency, clouded his views, creating an affirming interpretation of the evidence.” Confirmation bias is a major explanation for why contemporary psychiatrists won’t let go of their treatments despite evidence of ineffectiveness and troubling adverse effects.

Why Psychiatrists Not in Denial Stay Quiet

Why don’t more psychiatrists who are aware of scientific realities call out those exuberant top psychiatrists who continue to be unchecked by reality?

One explanation is the culture of psychiatry. This is evidenced by the 2010 article “Bloodletting 1854,” published by the American Journal of Psychiatry (AJP), the official journal of the APA. Authored by psychiatrist Marshall Garrick, this article provides a window to the cultural values of psychiatry, and how self-serving rationalizations are considered artful diplomacy.

Specifically, Garrick tells us, “I came across an April 1854 article in the American Journal of Insanity (forerunner of AJP) that made me feel much pride as a psychiatrist.” This 1854 article, “Bloodletting in Mental Disorders” was authored by Pliny Earle, one of the founders of the group that would become the APA. In 2010, Garrick explains why this article provided him with pride as a psychiatrist:

“It is striking how delicate and diplomatic Dr. Earle was in showing respect for the memory of Benjamin Rush while expressing disagreement with Dr. Rush’s advocacy of bloodletting. Dr. Earle artfully allowed that maybe the causes of some mental disorders were different during Dr. Rush’s era, compared with the mid-19th century, and that that had led to different treatment practices. Dr. Earle, I believe, demonstrated skill as a leader trying to improve the treatment of mental health disorders while avoiding unnecessarily tarnishing the memory of Benjamin Rush, a founding father of the country and an esteemed physician who published the first textbook on mental illness in the United States.”

This begs the following question: Was Pliny Earle’s excuse for Rush—“the causes of some mental disorders were different during Dr. Rush’s era, compared with the mid-19th century”—admirably “delicate and diplomatic,” or was it self-serving bullshit? In other words, Pliny Earle, Marshall Garrick, and all politically astute psychiatrists are concerned about tarnishing the memory of the father of American psychiatry because that tarnishes their profession of psychiatry.

Finally, how much progress has psychiatry made since Rush’s era? Rush actually invented two mechanical devices to treat madness: a “tranquilizing chair” to slow down the fluid movement of agitated patients, and a “gyrator” in which patients were strapped down, immobilized, and spun to stimulate blood circulation. While Rush’s exuberant attachment to bloodletting resulted in the unnecessary deaths of many patients, Rush’s own inventions to treat mental illness, though barbaric, likely resulted in less long-term physical damage than psychiatry’s treatments, not only in the late twentieth century but today.

Specifically, while no doubt Rush’s devices were physically unpleasant and psychologically traumatizing for many patients, these treatments likely resulted in far less irreversible physical damage than the twentieth century treatments of insulin coma therapy and lobotomy. Furthermore, in contrast to twenty-first century ECT and selective serotonin reuptake inhibitors (SSRIs), it is likely that after patients were freed from Rush’s tranquilizing chair and gyrator, they could still, unlike many ECT patients, remember their birthday, and unlike many former SSRI patients, they did not suffer from iatrogenic permanent sexual dysfunction, today called post-SSRI sexual dysfunction (PSSD).

Leading psychiatrists appear to be unfazed that their mental illness theories and treatments are repeatedly proven to be scientifically invalid and discarded. However, politically astute psychiatrists will forever be concerned that the general public will finally catch on that their claim that “psychiatry is a young science making great progress” is nothing more than exuberance unchecked by reality.