"the answer is to be as conservative as you possibly can"

Sense and nonsense about mental health

James Orr is not a household name - yet. Nevertheless he is the leader of the UK outpost of the National Conservatism movement and an adviser to the Vice-President of the USA. So his opinions matter to people other than his students at Cambridge.

He has particularly strong opinions on mental health - some of which have some validity, others that strike me as wishful thinking and many of which that are actively harmful. I first encountered these on a podcast with Australian Christian College. I noted them but they were only briefly touched on. Then yesterday I came across a much longer discussion called The Myth of Mental Illness: A Conversation With Dr. James Orr on the Psychobabble podcast. This Substack podcast is run by Hannah Spier - a medic turned tradwife whose podcasting output seems to be mostly about the ills of feminism.

Lets see how we go.

“This whole kind of constellation of disciplines, psychology, psychiatry, different schools of psychology, and so on and so forth, show all the signs of a kind of fake avenue of human inquiry that has begun from fundamentally mistaken assumptions and therefore can't get anything right except by accident”

It’s true psychology has some issues. Some people think it isn’t a real science. It has problems with its theories but as argued here: “the problem is not (just) that psychological scientists do not put enough effort into developing theories or do not know how to build theories but that there are great obstacles to building good psychological theories because of the nature of the subject matter.”

There are two responses to these difficulties. One is to try harder - which is obviously what most psychologists are doing. The replication crisis of the early 2010s shook out a lot of dubious research and reinforced a seriousness in the discipline. Canadian psychologist Michael Inzlicht provides an entertaining and informative account of his own journey of intellectual love and loss on ego depletion (seriously, this is a must read). There are so many gaps in our knowledge of the brain, the mind, and human behaviour but this is such an important area of research that I think we have to try.

The other is to abandon it entirely, which seems to the choice that Orr takes. BTW I don’t think we can wait for philosophers to resolve the mind-body problem - in part because I don’t think they will. Philosophers tend to sit and ponder things rather than engaging in empirical inquiry and empirical inquiry is needed. Nor do I think we can rely on religion. The Bible says many things but it doesn’t tell us much about the relationship between the amydala and emotion. We’re going to have to do some hard work.

Moving on specifically to Orr’s claims about mental health.

“Well, they were and they weren't. I mean, you've got to remember that for most of the last few centuries, at least up until the 18th century, certainly, psychological suffering is... Severe psychological suffering would probably be interpreted spiritually as a spiritual kind of illness, whether coming through... human fragility and human sin, or simply the finitude and brokenness of the world, or possibly through non-natural activity, demonic activity, whatever it might be. What they didn't do was assume that a sick mind was the same as a sick body. That to be anxious about something was... a problem of the same kind as a broken arm or a cut on your finger.”

It’s not clear to me that Orr even thinks mental illness is a “thing”. He’s much more comfortable with pre-modern views of the human condition - “sins not syndromes”. Now, cards on the table, I have a mental illness that crops up now and again (it’s probably bipolar 2) and I have a close relative with schizophrenia. These are not Dr Google diagnoses, psychiatric professionals were involved. Now I hope Orr is not being so crude as to say this is divine punishment or demonic activity but it’s hard to be sure.

The practitioners that I have met view mental illness as it is - a complex mix of genetics, physical environment and mental experiences. Treatment is a mix of the physical (medications), some therapy, and behavioural changes (getting up and moving around is good). Simplistic approaches are still out there (e.g. handing out pills willy nilly) but I think we have come a long way in my lifetime. And that’s a good thing. I can’t help but feel that Orr’s perspective takes us back 50 years.

I think part of the issue is that Orr has no personal experience of mental illness. Having experienced clinical depression, it is not simply feeling sad about the world. It is a horrible deadness. It is hard to put into words. And if you haven’t been through it then you should probably be more humble in your judgments of it. Otherwise you come across as not knowing what you are talking about.

“But the point is it is a kind of passive posture. This is another problem about medicalizing and pathologizing ordinary feelings of human disquiet or unease. As soon as you pathologize it, as soon as you have a condition that's in the DSM-5, you are effectively turning yourself into a patient in the sense of you are removing your agency.”

Ah yes, DSM-5: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. There are many problems with DSM-5. The conditions it lists are less distinct illnesses than symptom clusters. There are very probably multiple different kinds of depression or bipolar but we don’t really know for sure. The diagnostic tools are generally checklists and questionnaires that depend on the subjective judgment of the patient and the clinician. You can take a RAT or PCR test and get an objective assessment of whether you have COVID-19 or not. There is no RAT for depression. DSM-5 is almost certainly wrong about a broad range of things and in 100 years we will hopefully look at it in the same way that we look at humorism (which is not the same as a humorist although bits of it are pretty funny). However right now, DSM-5 is the least worst diagnostic and statistical manual of mental disorders that we have.

The comment about the risks of medicalizing everyday life is a valid one. Are we overprescribing anti-depressants? Are we overdiagnosing ADHD? I think these are valid questions to ask regardless of the answers that we come to. But I would say these are actively being discussed by researchers, practitioners, and patient groups. And the only way that we are going to come to answers is by some good old empirical inquiry. I do not think the answer is to ban anti-depressants and pretend that ADHD doesn’t exist.

It is often hard for people to get high quality psychiatric care. Yes GPs can dole out pills and there are plenty of people offering “therapies” (which may have no evidentiary basis whatsoever). But competent psychiatrists and psychologists can be unavailable or expensive and it seems that this situation is getting worse. If anything, we are undertreated.

As for being a patient meaning you have removed agency, that might be the case for some people but my experience has been that medics expect some agency from their patients and patients often dish it out. I have had some robust discussions with my psychiatrist about treatment - but I am the kind of pain in the ass who will read 50 bipolar medication RCT papers just to win an argument. The passive patient is (for better or worse) more a relic of the past than a reality of the present.

“these spikes in rates of depression is our deep social economic legal forces that are not that are then as it were turned into psychological ones as if it's the fault of an individual person that they're feeling depressed that they would like to have three children but they've only been able to have one because they wanted”

This section made me laugh because it reminded me a lot of Mark Fisher’s “capitalism causes mental illness” argument. Fisher was a lefty whereas Orr is seriously conservative*. Although for Orr the culprit is less capitalism (although he’s probably with the post-liberals in not liking capitalism as much as some of his fellow-travellers) than people not having all the kids they want. As I stated in relation to Fisher’s work, the economic and social contexts in which people live will have an impact on their mental health. But I don’t believe that mental illnesses magically appeared at the start of the modern period. Depression, mania, addiction, schizophrenic delusions - all these can be found in the historical record (just as infections and cancers can).

So what does Orr think we need to do?

“And recognizing that a problem in your life, maybe from something you've done wrong or something you've admitted to do right, is not in fact something that is a syndrome that you're going to live with for the rest of your life and that you've got to kind of medicate yourself to cope with. But it's something you can be free from. You can confess it either to a priest in a formal context or in the privacy of your own room to God. And you can be promised and assured freedom. You're free from it now. It's gone.”

I’m sorry James, but I don’t think this is going to cut it. I don’t think confessing my sins will cure my condition. BTW I grew up in a Baptist church. There was a lot of spiritual healing that went on (mostly people with back problems that were caused by them having one leg longer than the other - or so the pastors said). One senior guy got cancer. He claimed God had healed him. Then a few months later he died. Of cancer. The Lord giveth and the Lord taketh away.

In short, this is terrible advice.

I also think it is unfair to religious functionaries. Expecting a vicar to treat someone in the middle of psychotic episode is completely unreasonable. Many priests and rabbis have minimal training in counseling. As Jeremiah Peck states here: “I did not feel thoroughly equipped to minister to people in the context of the mental, emotional, and relational struggles which they were bringing to me.” So he very sensibly goes off and gets some training. I am often critical of organized religion but it is true that many people are more likely to go to their pastor than a psychiatrist (if only because it is so much cheaper) and pastors like Peck show a great deal of wisdom is seeking to be the best pastor they can. The problem is not, as Dr Spier claims, that “clergy aren’t giving people what they need because they are pandering to the woke ideology”. It’s that many of them don’t know what they are doing.

All of this might just be two random people talking on a podcast. However given Dr Orr’s influence within a conservative movement that has just gained power in the world’s most powerful nation, I am concerned that his advice on mental illness will be taken up by those with the authority to implement it. These ideas provide a handy rationale for cutting research into psychology and the provision of psychiatric services and redirecting the money to religious organizations. Which can only end well.

*The horseshoe theory of mental illness.