Insane Medicine, Chapter 2: The Scientism of Psychiatry (Part 1)


Editor’s Note: Over the next several months, Mad in America will publish a serialized version of Sami Timimi’s book, Insane Medicine. In this chapter, he begins an overview of the scientism of psychiatry. Each Monday, a new section of the book will be published, and all chapters will be archived here. 

Hardly a week goes by without another headline about mental health, the epidemic of mental health problems in society, particularly in young people, the importance of talking about mental health, and how our services are stretched and at a breaking point because of lack of resources.

Anybody listening to this would be forgiven for assuming that mental health problems are burying our populations as we buckle under the weight of stress, anxiety, depression, self-harm and worse. Mental illness is to be found in every classroom and around every corner. You’d also be forgiven for thinking that there are real treatments for these real medical conditions and that people get better with treatments delivered by professionals with special expertise.

You’d likely think that our problem with mental health is that we don’t have enough services, that the issue is woeful underfunding and long waiting lists, that the scandal is the lack of quick access and adequate availability of treatment and support for those who have been struck down by a mental disorder.

But here is the uncomfortable conundrum. Wherever you find mental health services to have expanded with more people receiving what is considered to be mental health treatments (whether these are psychological or drugs) you find a parallel increase in the numbers who have been classed as disabled due to a mental health disorder.

Of course, many people do benefit. There remains much that an enlightened mental health service could and should provide that could be helpful to many more than today. However, as things stand, the data that we do have about outcomes from real-life mental health services says this is not currently the case. One of the first problems that confront us is that when people (the media, professionals, and public alike) talk about mental health, they actually don’t know what they’re talking about—literally.

What is a mental disorder?

What do people mean when they talk about mental disorder, mental health, or mental illness? What sort of “thing” is a mental disorder? Where are its boundaries? When does a behaviour become abnormal or disordered or pathological and who decides based on what?

Issues of where to place boundaries between the ordinary and not are something that most of medicine grapples with. When it comes to mental disorders we have a whole new level of potential confusion, uncertainty, and meanings to get through before we can assert something to be out of the ordinary, abnormal, or disordered. In psychiatry, the entire phenomena require interpretation, not just the boundaries.

Take, for example, the fairly straightforward situation where there is minimal confusion about what sort of “thing” we are dealing with. Somebody has an accident and experiences extreme pain and some swelling in their leg and they can’t walk on it. At the hospital an X-ray reveals there is a fracture in the tibia (shin bone). In this scenario the medical model is working at its best.

The fracture of the tibia is what is known as a “natural kind,” so in terms of classification the diagnosis explains an abnormality in the person’s physical body which can be empirically verified and measured. As a natural kind that can be seen, it exists out there in the world beyond our subjective hypothesis. It is a verifiable fact of nature and we can develop knowledge bases that relate to this verifiable reality of a natural phenomenon.

Just as the chair I am sitting on can be weighed, measured, and analysed in all sorts of empirical ways, as it exists out there in external reality, so we can build technical knowledge about fractures of the tibia by comparing many people who have the same condition, trying out different treatment approaches and combinations, grading different types of severity, looking at the various factors (in the fracture, the body of the person, the type of accident, and so on) that might affect responses to different treatments.

Medicine is particularly good at these emergency scenarios where there is an identified abnormality and where the treatment period is relatively short. Here we can gather data on the disease, the treatment, the recovery, complications, and so on, using verifiable empirical evidence. We know what sort of a “thing” a fracture of the tibia is. Once seen on the X-ray, we have an explanation (a diagnosis) for what is causing the patient’s pain, swelling, and inability to walk.

Not all presentations to doctors follow this easy to understand idea of what sort of thing we are dealing with. Let’s take diabetes as an example. The connection between symptoms and the underlying cause may not be as immediately apparent. In diabetes a diagnosis refers to an abnormality of sugar metabolism and this can be measured mainly through blood tests but also in other ways, such as through testing your urine for something called “ketones.”

Some abnormality of blood sugar metabolism may exist for a period of time without the patient displaying any obvious symptoms. They may just have some non-specific symptoms such as generalised tiredness or loss of concentration, particularly in type II diabetes, which has an onset later in life when the body becomes resistant to insulin or when the pancreas is unable to produce enough insulin.

Type II diabetes could present just as a susceptibility to infections and so could go unnoticed for months or even years in some. Nonetheless, there is a physical parameter that can be measured, and there is a physiological process present in the physical body and that exists in the world external to the diagnoser and is verifiable with independent data.

So, in this example, whilst the connections between symptoms and disease are not as clear and indeed may involve other factors than just the sugar metabolism and may be missed in the early stages or by a poorly trained doctor, the diagnosis again is explanatory. It is pointing to an abnormality that can cause symptoms in the patient and will cause more if not treated.

But there are many disagreements in diabetes diagnosis and treatments; for example, when to consider the blood sugar has crossed a threshold justifying a diagnosis, whether to just use dietary approaches and for how long, when to use medication, how to deal with complications, the psychological impact of having a chronic disease, the social dimension of long-term care, and so on. But still, we know what sort of “thing” diabetes is.

So far so good. Now we start to get into medical conditions which can have recognisable symptoms and sometimes physical signs and some objective tests, but in which there are mysteries as to the initial cause or explanation. Many types of headaches, such as migraines, are good examples of this category. Diagnoses such as migraine are mainly based on a description of symptoms. We are now moving toward a descriptive rather than explanatory system. However, given that there are characteristic physical symptoms (in migraine, you may get blurring of vision, pain behind the eyes on one side of the face), it is likely that there is physical pathology.

The presentation tends to be characteristic, has physical symptoms, and so it is reasonable to assume that it involves a physiological processes. So we kind of know what sort of a “thing” migraine is, though we are now getting into some more fuzzy territory. With pain and the nervous system so involved, psychological aspects are becoming more prominent. But the idea of diagnosis still stands, even if it’s to conclude that whilst the migraine is a diagnosis (in that it explains the physical symptoms), it can be brought on or sometimes even mimicked by psychological factors.

Once we come to talk about mental disorders we start to get into a whole array of problems in order to support that idea that we have a “thing” that can be considered a diagnosis. The territory for what we have been calling “symptoms” of a mental disorder are now experiences and behaviours that have meanings and that may be interpreted differently by different cultures, different times, and in different settings.

This means we are shifting to an area of practice where there are not only disagreements and debates about where the boundaries are, but we also have to take into account the significance and relevance of the diverse meanings that can be attached to these symptoms, such that they are interpreted as symptoms in one setting, but not in other. We have no signs, no tests, no physical correlates, and so are entirely reliant on observations and reports of the person and/or their significant other(s).

The disputes are no longer about just the boundaries, but also the parameters; indeed, about whether they can even be considered problems in the first place and, if they are, whether they can be thought of as medical in nature. We have now strayed into a different conceptual field.

Is that patient in front of me who reports intense sadness, difficulty getting to sleep, waking up before 5am every night and not able to get back to sleep, and has a poor appetite, suffering from a “depressive disorder” or experiencing understandable heartbreak and grief after the breakup of a long-term relationship a few months back? If you argue both can be true, then sure, technically speaking, both depression and grief may be said to the patient as what they have.

One, however, cannot be a diagnosis (depression) as it explains nothing, just describes some aspects of the patient’s experiences; the other (grief) could be a diagnosis as it has explanatory pretences. Grief (unlike depression) is, in this scenario, being used as an explanation. But I have no access to the patient’s inner mental workings; none of us do.

With grief, depression, or both, I still do not know what sort of a “thing” I am dealing with. Is it a medical disease in her brain, is it the psychological process of grief, is it the loss of a social network that she had with that partner, is it her concern about how this is impacting her son, is it the fear of returning to work after a long absence, is it all of these things?

In truth I don’t know anything about what has caused her presentation. I can’t escape my subjectivity, or the patient’s for that matter. I can only guess at the “diagnosis” (proximal explanation), something that attaching the words “Major Depressive Disorder” (MDD) cannot provide.

When it comes to our emotional experiences we just have embodied experience. We then use words connected with cultural meaning making systems to attach to that experience. The meaning scaffolding we then use can itself transform our experience of the experience. “You are broken hearted” creates a different scaffold than “you are depressed,” which itself differs from “you are surviving and recovering from a painful experience.

Mental health, illness, and disorder cannot be thought of as out there in the natural world, existing somewhere within the body of the person, in a way that is identifiable as a concrete “thing.” It is not definable in a causal way in the same way as a broken leg or diabetes or even migraine.

And yet this is the way we talk about mental health and illness, as if we know what sort of “thing” this is and assume that it exists within a person, regardless of their context; that it exists as a known “thing” in objective reality and beyond the subjectivity of the person or the practitioner.

If you hear one in four of the population are possessed by or will be possessed by a mental disorder, be wary. It’s an appalling mistake to make, with appalling consequences for patients and professionals alike. One in four who have what sort of “thing”? Where is this “thing” located and how do I find it? How can I truly develop an accurate way of “measuring” it if I can’t locate it as an empirically knowable “thing”?

There is no such thing as a psychiatric diagnosis

In medicine then, diagnosis is the process of determining which disease or condition explains a person’s symptoms and signs. Diagnosis therefore points to causal processes. Making an accurate diagnosis is a technical skill that enables effective matching of treatment to address specific pathological processes.

Pseudo-diagnoses, like for example “bi-polar disorder,” cannot explain behaviours, as there are only symptoms that are descriptions (not explanations) of behaviours or experiences. Even using the word “symptom” is problematic as, in medicine, the word “symptoms” usually refers to patients’ suffering/experience as a result of an underlying disease process and is therefore associated, in our minds, with a medical procedure leading to an explanation for the symptoms.

We are meaning-seeking creatures and so have used classification systems extensively to classify all manner of things. Language is itself a system of categorisations with words that symbolise all sorts of phenomena. But different classifications serve different functions. A diagnostic classification is a classification by explanation—in other words, by cause. That’s why we say “My doctor said that the cause of my chest pain was acid reflux, not a heart attack.” We usually go to the doctor to get the “why” question answered in the hope this will then guide toward the correct treatment.

But psychiatric diagnoses do not explain symptoms. Consider the following example: If I were to ask the question “what is depression?” it’s not possible for me to answer that question by reference to a particular known pathological abnormality. I cannot say that depression is a disease that occurs due to the brain having abnormally low levels of serotonin. I cannot say that because no one has found this (despite extensive research) and so there are no tests done to confirm or refute this.

Instead, to answer the question I will have to provide a description such as “depression is the presence of the low mood and negative thinking” and so on. Contrast this with asking the question “what is diabetes?” If I were to answer this question in the same manner by just describing symptoms, such as needing to urinate excessively, thirst, and fatigue, I could be in deep trouble as a medical practitioner, as there are plenty of other conditions that may initially present with these symptoms and diabetes itself may not present with these symptoms in a recognisable way.

In order to answer the question “what is diabetes?” I have to refer to its pathology involving abnormalities of sugar metabolism, as in, “Diabetes is a disease that occurs when blood glucose, also called blood sugar, is too high.” To move from a hypothesised to a confirmed diagnosis, I would get independent (to my subjective opinion) empirical data to support my hypothesis about what may be causing the patient’s described experiences (such as testing the urine for ketones and/or blood for levels of fasting glucose).

In most of the rest of medicine, therefore, my diagnosis explains and has some causal connection with the patient’s experiences/symptoms. Thus, diagnosis sits in a “technical” explanatory classification framework.

The problem with using a classification like “depression” to explain an experience (i.e., as a diagnosis) can be illustrated by asking another set of questions. If I was asked why someone is feeling low and I answered that this is because they have depression, then a legitimate question to ask is “how do you know that this feeling low is caused by depression?

The only answer I can give to that question is that I know it is depression because they are feeling low. In other words, if we try to use a classification that can only describe in order to explain, we end up with what philosophically is known as a “tautology.” A tautology is a circular thinking trap. A description cannot explain itself. Low mood and depression are synonymous; you cannot use one to explain the other.

It’s troubling when doctors use a descriptive category like depression to explain and cannot see this problem of tautological circularity. Using depression to explain low mood is like saying the pain in my head is caused by a headache or my cough is caused by coughing disorder. In psychiatry, therefore, what we are calling diagnosis will only describe, but is unable to explain.

If the rest of medicine were practiced like psychiatry, then when you go to your General Practitioner (GP; this is the UK title for a primary care doctor) because you have a recurrent cough, the GP wouldn’t examine you at all; they would just ask you questions about your cough and then some about your relevant history. They would then pronounce that you have a “Recurrent Cough Disorder (RCD)” and give you a steroid inhaler to take once a day.

The inhaler has non-specific effects and will open the airways, so at least in the short term there would be some improvement in symptoms for many with a cough. However, if you had a chest infection, it will likely ultimately get worse, even though initially you might feel better. Furthermore, long-term steroids can have all sorts of unpleasant and dangerous side effects if taken in sufficient quantities.

If RCD was part of what GPs “diagnose,” then there will always be some patients who will have great faith in it (as their cough did improve and so they want to continue taking the steroids long-term), whereas for others the consequences would have been horrible, even potentially fatal.

But you wouldn’t expect your doctor to behave like that. At the very least you would expect them to listen to your chest with a stethoscope, to seek out signs, and perhaps arrange further tests (like a chest X-ray) if they remain uncertain as to the cause of the cough. In the rest of medicine, diagnosis really matters. It will guide the doctor towards a treatment that addresses the initial cause of the cough.

The failure of decades of basic science research to reveal any specific biological or psychological marker that identifies a psychiatric diagnosis is well recognised. Unlike the rest of medicine, which has developed diagnostic systems that build on a causal and physiological framework, psychiatric diagnostic manuals have failed to connect diagnostic categories with any causes or physical markers. Thus, there are no physical tests referred to in any mental health diagnostic manual that can be used to help establish a real diagnosis.

Despite the belief that psychiatric disorders have a significant genetic loading, molecular genetic research is failing to uncover any specific genetic profile for any psychiatric disorder. Possible genetic abnormalities appear to account for an insignificant percentage of possible associated causal factors, and whatever genetic contribution has been found crosses diagnostic categories rather than having a distinct profile for each diagnostic category.

Similarly, brain imaging studies are coming up empty handed, particularly once you control for possible learning difficulties. I will later look at some examples from my field of child psychiatry to illustrate how the rhetoric that is trumpeted to the media of “scientific breakthroughs” is at odds with what such research is really finding.

The reason why there are no genetic screens, brain scans, or indeed any other physical tests in psychiatry is that no one can find anything that can act as a physical marker. The evidence cupboard, despite the billions in funding allocated to such biological research, is empty. The most likely reason for not finding any evidence is that there are no genetic or other brain abnormalities causing what we call psychiatric diagnoses.

The development of diagnostic manuals in psychiatry has not followed accepted scientific protocol and instead, the diagnoses that have appeared in them have been literally imagined into being by a few influential (largely male and white) individuals.

Not only does the concept of psychiatric diagnosis lack validity, it is also unreliable. Reliability refers to the how likely it is that if you went to different psychiatrists and said exactly the same thing about what problem you had, they would agree on what your “diagnosis” is.

Analysis of these reliability studies finds that there is no psychiatric diagnostic category for which reliability is uniformly high. Ranges of reliability have been found to be broad, and in some cases ranged the entire spectrum from chance to perfect agreement, with the case summary studies (in which clinicians are given detailed written case histories and asked to make diagnoses—an approach that most closely approximates what happens in clinical practice) producing the lowest reliability levels.

In 2013, the Diagnostic Statistical Manual fifth edition (DSM-5) was published by the American Psychiatric Association. It is a huge money-spinner for them. In the DSM-5 field trials, measures of reliability were uniformly poor, with some common diagnoses such as Major Depressive Disorder and Generalised Anxiety Disorder having levels of inter-rater agreement so poor that diagnosis was determined more by who was doing the diagnosis than by what the problem was.

In summary, then, psychiatric diagnoses are not valid (cannot explain), have low levels of reliability, and are not even “diagnoses.”

What is the “normal” to which we are comparing our behaviour and experiences?

How do we arrive at an understanding of “normal”? This is a crucial question. Our classification of behaviours and experiences considered disordered relies on an idea that the person’s presentation sits outside an imagined normal. How is this defined, by whom, and in what context?

We are not talking here of conditions that can be measured in the same way as the functioning of kidneys. Kidneys don’t have dreams, ambitions, fears, and existential dilemmas. Mental health involves all these subjectivities that relate to our understanding of what it means to be human.

Let’s take the idea of the “self” for example. Where does it reside? Is there such a thing as a “true self”? If so, how do we find it and what does that mean about those experiences and behaviours that we do not consider part of that true self? Do they then not belong to us, have nothing to offer us, and should be something we try to get rid of?

Philosophers, theologians, sociologists, anthropologists and many others have been grappling with these questions for millennia. These “technologies of self” have emphasised all sorts of phenomena that are thought to shape how we experience and understand our being in the world. From the invisible hands of the supernatural forces of ancestors and gods, to the structures of social power that tell the public what the normal/common sense should be, to the potential for agency and resistance individuals have to dominating beliefs. We cannot escape subjectivity in our attempts to understand subjectivity.

Because of this, the ways we think about the nature of the self are not fixed, but fluid and changeable, with different cultures and different times having different ideals through which to interpret and understand our experiences of self. For example, general tendencies that shape Western compared to more Eastern ideas about the self can be contrasted (Table 1):

Table 1: Contrasting tendencies in technologies of the self

West East
Rational/Scientific Spiritual
Control of emotions Emotions experienced
Differentiated (classified) humanity Common humanity
Vulnerable Resilient
Individualist Collectivist

These are not absolute positions (as we are at risk of stereotyping when we turn these into totalised realities), just tendencies that are more prevalent and thus likely to influence the ideas that different populations grow up with.

We can also see how cultures approach the self and personal problems by looking at the words they use to describe phenomena. I am half Iraqi (my father is from Iraq) and grew up there until I was 14 years old and so have some familiarity with Arabic—the main language spoken.

There is no direct Arabic word that means “mental,” let alone a concept of mental health. There are several words that could be used for the concept of mental; perhaps the closest is the word “nefseeyah,” which approximately means soul-self (in translation from Arabic back to English it’s also not easy to find an exact word). This word has roots in the word “tenafos,” which means “to breathe.”

Can you already see that concepts of self and mentalising draw on different roots? The common word for “madness” in Arabic is “majnoon” whose roots lie in the word “jinn,” which refers to supernatural spirits and implies a possession state; whereas the English “madness” derives from “mad,” which also means angry.

In the West we tend to think about the self in more logical, rational terms, often using the language of science, and we believe psychology to be a branch of science (because it uses the language of research and numbers) that helps us understand the human condition. Problems of the self (what we in the West call “mental health”) are then dealt with by experts who use this language of science and logic. It would be strange in Western media to turn to a priest or imam to explain a patient’s suffering in religious/spiritual terms.

Western scientific beliefs have shaped our understanding of the self, out of which psychiatry and psychology create definitions of the abnormal. What we see come out of that is a focus on the individual as an entity that is separate from her context, with the idea that what is going wrong can be located as belonging to that individual (whether psychologically or biologically).

This going wrong is thought of in material scientific terms—in other words, as something that can be understood by applying the same principles we use for the natural sciences. This way of thinking assumes we can shed light on experiences/behaviours considered “abnormal” by measurement and experimentation to understand the rules that govern our individualist biology and psychology. Thus we use words such as “psychopathology,” “dysfunctional,” “dysregulated,” “disordered,” and so on to describe and classify mental phenomena considered to be problematic.

Many consequences flow from this way of trying to understand the “normal” and “abnormal.” For example, it results in an obsession with classifying as a starting point for making sense. The process we use starts with analysing the individual for signs of “psychopathology,” “dysregulation,” etc. and then uses these to slot them into a “typology” (which we, as I have discussed, mistakenly call a diagnosis).

The methods we use also valorise logic and thinking and sees emotions as an obstacle to a rational way of living. Thus, much of psychiatric and psychological technology is suspicious of what emotions do to us and uses interventions whose raison d’être is ultimately the control of emotions.

Another consequence of this way of constructing “what it means to be human” is that we have outlined, classified, and advertised all sorts of ways that humans can go wrong mentally. In our psychiatric diagnostic manuals, the number of diagnoses that we can give expands with each new edition, as do the boundaries for diagnosing these disorders. This creates a sense of vulnerability for all of us, as disorder is felt to lurk around every corner.

The extended media coverage of a proposed mental health epidemic, quoting abstract figures like “one in four,” anti-stigma campaigns, and the special pleading Royal Colleges like mine (the Royal College of Psychiatrists) make for parity with physical health and more funding and without pointing out the definitional and outcome issues I am highlighting, all add fuel to the fire of panic and the belief in our individual mental fragility and vulnerability.

How we conceptualise the human condition and its problems cannot be separated from powerful forces that shape our subjectivity. Philosophers and sociologists refer to this as “social construction.” Our understanding of how the world works, and how we work within it, is built up by the stories we are exposed to and how they interact with our real-life experiences.

In that way of understanding, our psychology is the meeting point between our embodied experience (we are after all biological beings with hormones and instincts too) and the experience and messages we receive from our social world. We do not have access to infinite ways of making sense of this experience, but will inevitably draw on the sense-making efforts of those we grow up with and other influences we are exposed to (such as the media).

In any society at any one time there will be a variety of ways available to make sense of any dilemma, but some will be more dominant than others. Those with more power to sell their version of reality will have more influence on what that dominating story will be.

Just as we socially construct what we consider to be a normal, healthy individual and, by implication, what a disordered one looks like, we also socially construct childhood, growing up, and what we consider to be good parenting. As with how we construct the self, the choice of construct we use has consequences in what we notice, how we notice, and what we then do. In Table 2 you can see some of the differing tendencies in child rearing approaches contrasting Western and some Eastern philosophies.

Table 2: Contrasting tendencies in child rearing philosophies

West East
Individualist Community
Control of behaviour Harmony
Material orientation Spiritual orientation
Consensual Conflictual
Short infancy Long infancy
Long childhood Early adulthood
Ambivalent Welcoming

Broadly speaking, differences between Eastern and Western approaches to children is that in many Eastern cultures, infancy tends to be more prolonged with little expectation that the infant will demonstrate independence and make choices, but with adult-like responsibilities (for example caring for younger siblings and running errands for the family) arriving earlier.

Thus, in Western cultures the search for evidence of independence, self-reliance, and self-control starts more or less as soon as you are born. In Eastern cultures you are more likely to encounter more immediate gratification of perceived needs and an encouragement towards emotional dependence with the child. As the child grows older in Western culture, independent thinking, verbal communication, and overt emotional expression are encouraged.

Physical labour and the acceptance of duties and responsibilities do not occur until much later in Western as opposed to many non-Western cultures, to the extent that a new phase in children’s development emerged, a phase between childhood and adulthood, which we call adolescence. In many Eastern cultures, adolescence as a clear life stage with its own culture is not as apparent, with duties and responsibilities, as well as an early introduction to spiritual life, already apparent before the onset of puberty.

Western culture focuses on behavioural control and expectation of demonstrating rational decision making much earlier than in most non-Western cultures. These are just a few of the differences you may encounter and they each have their consequences in how we understand and respond to children’s behaviours.

Psychiatry, society, and the state

Psychiatric logic has regularly reflected the social dynamics of the society it originates from. As the field of psychiatry developed at the time of colonialism and slavery it’s not surprising that racist beliefs and practices has been infused into its concepts.

By the end of the 19th century, it was an accepted belief that members of the “African” races had smaller brains, as well as a more natural instinct for physical labour, and were psychologically primitive compared to members of the “European” race. “Drapetomania” was the diagnosis used for the supposed mental disorder that caused Africans to flee from slave captivity. Civil Rights movement leaders and protesters in the 1950s and 1960s were often labelled as mentally disordered due to their supposed “pathological” reaction of emotional disharmony, hostility, and aggression.

The history of psychiatry reveals an appalling role in colluding and popularising prevailing eugenic, racist, and other social trends. German psychiatrist Emil Kraepelin (1858-1926), considered the father of biological psychiatry, whose system for categorising psychiatric presentations is still the basis for diagnostic systems used today, was an ardent eugenicist and racist. Kraepelin complained about a steady increase in psychiatric disorders in civilised people, while arguing that mental disorders remained comparably rare in “primitive” races.

He argued that the effect of large numbers of “idiots, epileptics, psychopaths, criminals, prostitutes, and tramps” who descend from alcoholic and syphilitic parents, and who transfer their inferiority to their offspring, was incalculable. Kraepelin’s pupil and successor Ernst Rüdin (1874-1952), whose influence also continued into the post-war era, also advocated eugenic theories of degeneration, alleging that bad genes entering the gene pool was the main causal factor for the alleged increasing prevalence rates of mental disorders. Kraepelin and Rüdin were both advocates of “racial hygiene,” and came to see people with mental illness primarily as a burden on society.

Rüdin was involved in the introduction of the 1933 Nazi “Law for the Prevention of Offspring with Hereditary Diseases” which allowed for the forceful sterilisation of a range of people, including those with a diagnosis of schizophrenia or manic-depression. This law paved the way for psychiatrists to eventually become involved in the most shameful episode in its history—systematically exterminating their patients.

Nazi-era psychiatrists were instrumental and often enthusiastic advocates for instituting a system of identifying, notifying, transporting, and killing tens, possibly hundreds, of thousands of mentally ill and “racially” or “cognitively” compromised individuals in settings ranging from centralised psychiatric hospitals to prisons and death camps. Their role was critical to the success of Nazi policy, plans, and principles.

Many of those involved were senior professors in academia who sat on the planning committees for developing the euthanasia processes and who provided the theoretical backing for what transpired. They developed the first gas chambers used for mass murder before the plan to annihilate the Jews, Gypsies, homosexuals, and other “undesirables” was put in place. Killing of psychiatric patients was a key mediator in the development of the eugenic logic and technology that facilitated the holocaust.

This legacy of institutionalised and institutional racism still persists today. For example, the higher rates of diagnosis of a psychotic disorder, use of mental health acts, forced treatments, and deprivations of liberty, amongst black patients in countries like the US and UK continues to this day, even though such high rates are not similarly seen in black majority countries in the Caribbean or Africa.

Not only are the concepts used in psychiatry institutionally racist, but in addition, through the process of “psychologisation,” problems that are socio-political become converted into problems that are psychological. The devastating consequences of racism and discrimination, together with the persistent and pervasive inequities in society, are turned into mental disorders needing “mental health care” rather than political action.

Over the past four decades, the mental health industrial complex has continued to oppress disenfranchised populations while benefiting from billions in revenue through individualising and psychologising their mental suffering.

Homosexuality was a disorder right up until the 1973, when it was narrowly voted out of the American Diagnostic Statistical Manual (DSM). Out of the 17,910 eligible people to vote in that decision, the vote was 32% in favour of removal from DSM, 21% against, and 47% not voting.

Prevalence of psychiatric disorders also shows an inverse relationship with social class. In addition, the greater the level of inequality in any society, the higher the prevalence of mental disorders. I haven’t even started on gender.

We cannot escape the socially constructed nature of the territory that adult and child mental health ideologies have carved out for themselves. The theories and practices that developed in the dominating professions of psychiatry and psychology have not arisen out of a scientific endeavour that has shed new light on the workings of the brain and/or the mind. They are an encapsulated, jargonish version of the Western folk psychology of the time with immense power, as socially respected professions, to shape the way we understand both the normal and the problematic, with all the consequences that arise from their preferred social constructions.

I no longer use the misleading language of these fake pseudo-sciences. “Normal” and “disordered” are subjective and problematic terms. In practice we create rather than discover a disorder by the way we choose to talk about and classify what patients bring to us. Instead I use the two terms, “ordinary” and/or “understandable,” as my preferred constructs. Just about everything I have seen over my thirty odd years of working as a psychiatrist can easily be captured by those two starting point words.

Next week, we continue this discussion with Part 2 of Chapter 2.


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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  1. After reading this article, the only confidence I can put it into anyone with an M.D. beside his or her name and associated health care professionals is if I would happen to have a broken leg. It actually comes back to one of my father’s favorite jokes, “The operation was a success, but the patient died.” Actually, the psychiatric propaganda and even other medical related propaganda has been a success; but the patients, etc. are still suffering from the tragic after-effects, etc. Thank you.

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    • There are a few other situations I’d see a doctor for. A really bad infection that won’t go away for example.

      But your comment reminds me that setting a broken leg (or other bone) is the one thing the Christian Science cult allows its members to get help for.

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  2. “The referrer, in this case, a mental health clinician who has undergone training as an Authorised Mental Health Practitioner (AMHP), has only to ‘suspect’ on grounds they believe to be reasonable that the person requires an examination by a psychiatrist. The reasons listed on the Form 1 are considered to be reasonable grounds at the time of referral including the potential for damage to reputation and meaningful relationships. lt is noted Boans provides justifiable explanations for what was listed. The presence of potential individual explanations regarding certain behaviours does not diminish the capacity of an AMHP to consider the broader clinical picture which may give grounds to suspect mental illness. Of importance is the observed behaviours of the patient which can represent a risk to the person or other however justifiable the reasons for behaviours may be.”

    (1) note the change of the burden of proof? No longer is the AMHP required to “suspect on reasonable grounds” that the ‘referred person’ (NOT “patient”) requires to be an “involuntary patient”. They need only ‘suspect’. The Mental Health Act s. 29 states;

    “an authorised mental health practitioner who suspects on reasonable grounds that a person should be made an involuntary patient may refer the person for examination by a psychiatrist.”

    So the Chief Psychiatrist removes the protection of the law of “reasonable grounds” and enables “suss laws” with forced drugging’s as consequences. No longer does the AMHP need to believe that the person needs to meet the Criteria set out in s. 26 of the MHA, they only need to believe the person needs a chat with a psychiatrist. And when did the Chief Psychiatrist get to rewrite the laws to remove human rights protections?

    (2) The reasons listed on the Form 1 are what is called the corrupt practice of “verballing”, and even a cursory examination of what is claimed to have been “observed” could not possibly have occurred. I had been “spiked” with benzodiazepines and the AMHP wrote in his notes that I was collapsed in my bed, how then could he possibly have “observed” me “not sleeping” for the past two days? My “thoughts of harming others” observed? He would have had to have travelled back in time three weeks to have “observed” that, and well changing my right to defend my home should I be attacked as had been suggested by my wifes nephew, into a “threat to kill” was quite an “observation” to make. I’m sure muggers consider victims who try to defend themselves to be mentally disturbed killers too.

    So these important “observed behaviours” that could not possibly have been “observed” become the basis for incarceration and forced drugging?

    And consider the words “potential individual explanations regarding certain behaviours”. I mean lets be honest, it seems a little unfair that he was aware of the fact I had been ‘spiked’ with benzos, he then asks me about drug use for police who are standing either side of me, and when I refuse to self incriminate and ask to be allowed to speak to a lawyer before answering his quesion, he writes as an “observed behaviour” “refused to answer re substance abuse”. I’d have to know what substances I was being abused with before I could answer that question surely?

    This Form 1 statutory declaration is to meet a standard of ;
    Non-compliance with form or procedure, effect of
    (1) The validity of an oath, affirmation or statutory declaration is not affected by the fact that the person taking or making it does not use the exact words required as long as the words actually used do not materially affect the substance of the exact words and are not likely to mislead.

    Not only has this Form been prepared using the corrupt practice of “verballing”, it has been proven to breach the standard as it is not only “likely to mislead” it actually MISLED the Chief Psychiatrist into making the above false statement. The grounds were not “reasonable” and the only way these offences can be overlooked is to remove “reasonable grounds” from the Act and make anything the AMHP wants to be “reasonable”. So that is precisely what the Chief Psychiatrist does in the above statement, he removes any ‘reasonableness’ from the Law.

    Logic tells me that my “potential for damage to reputation and meaningful relationships” (observed behaviour, how do you observe a potential?) requires me to be dragged off by police in front of my mother and father in law and to inform them that no I have not committed any crime, but an being taken to a locked ward of a mental institution for some ‘dribble therapy’. I’m sure they would agree as i had said I was going to leave their daughter, and that is of course surely a mental illness, or at least grounds to ‘suspect’, and thus meets the standard set out by the Chief Psychiatrist above. “need only ‘suspect'” before making referral (shame it is allowing all of these human rights abuses while he is asleep at the wheel, maybe he is being ‘spiked’ with date rape drugs too?)

    Still, he went on to have a great career torturing and kidnapping people with police, and all the people that have been harmed in the 14 months it took the Chief Psychiatrist to respond to my complaint (“sorry for the delay in responding the manager was away over the Christmas break”) in a manner which demonstrates an understanding of the Law that could be expected of a high school student, when he provides “expert legal advice to the Minister”. Citizens being ‘spiked’ and snatched from their beds on police referrals because “tomato” perfectly “reasonable” according to the person who is charged under the Act with protecting “consumers, carers and the community”?

    You write Mr Timmimi that;

    “It’s troubling when doctors use a descriptive category like depression to explain and cannot see this problem of tautological circularity. ”

    It is even more troubling when that type of reasoning is being used to conceal what ARE criminal acts. Care to take a look at this letter from our Chief Psychiatrist and see if you can unravel the ‘poison pen letter’ sent to a victim of State sanctioned torture and kidnapping? How a “referred person” under the Mental Health Act who has maintained their right to consent becomes a “patient” before the AMHP even leaves the hospital? One telephone call and your now a “patient”, it’s just a matter of having police hand you over, despite this being a crime under our Criminal Code of “procuring”. Such a shame the “expert legal” knowledge claimed by our Chief Psychiatrist doesn’t extend to AMHP lying to police and telling them they need help with a “patient”.

    And the things you can do to people once they have had their status changed. My complaint about these matters resulting in me being told I would be “fuking destroyed”, and sure enough that’s exactly what they have done to me and my family. I would have thought the Chief Psychiatrist would be interested in such matters but ……..”accepted practice” apparently. No worries ‘spiking’ “patients” and having police rough em up ready for interrogations by doctors (with police at arms length and providing the questions).

    Still, I guess my “observed behaviours” mean what I am saying could not be the truth right? My question being what does my “behaviour” have to do with the issue of these people engaging in acts of torture and kidnapping citizens? The two seem mutually exclusive to me, but by slandering me after removing the proof of the ‘spiking’ I can now be ignored and discriminated against to conceal these human rights abuses.

    Why on earth would the State wish to remove the ability to “fuking destroy” citizens who complain about public sector misconduct and human rights abuses including acts of torture, kidnapping and to use a euphemism preferred by the C.P. “unintended negative outcomes”?

    And not a soul prepared to look, and when they have they run away afraid for their families.

    “Of importance is the observed behaviours of the patient which can represent a risk to the person or other however justifiable the reasons for behaviours may be.” A bit like police and their standing on peoples necks being resisting arrest while they thrash around trying to breathe, and then when they expire they are ‘passively resisting arrest’.

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  3. The main problem with Timimi’s articles is not the explanations and analyses of what’s wrong with psychiatry. It’s the subtext, e.g.

    — The arguments made here against psychiatry have been made for scores of years by scores of experts, many of whom have themselves been victims of psychiatric assault and “gaslighting.” They do not require Dr. Timimi’s “professional” stamp of approval to be seen as credible.

    — By presenting what survivors have known for years as new revelations brought to us by the good folks at “critical psychiatry,” MIA encourages disempowerment among survivors, who are quite capable of coming to our own anti-psychiatry conclusions without “official” (i.e. shrink) concurrence or approval.

    — Once again, in what has become a hallmark of MIA’s editorial policy, Timimi presents boundless reasons to conclude that psychiatry is inherently and irrevocably rotten to the core and irredeemable — yet rather than acknowledge the indisputable, he hems, haws and backs away when challenged by people here to declare himself in league with the anti-psychiatry movement.

    — Finally, while I have no evidence that Timimi is not a “nice guy,” I still don’t quite get why psychiatrists who finally see the error of their ways near the end of their long “careers” are rewarded with publishing contracts.

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  4. Sami,
    I’m not sure what you are doing on a justice level.
    I mean, IF the paradigm is false and harm has come to people,
    and the “good psychiatrists” continue in this harm, should
    each psychiatrist not be reported for the harm they dole out?
    Why are you not all approaching the government about the
    crimes that are happening?

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    • To explain further, I am not impressed with calling out the obvious which
      you guys have been at forever.
      The debunking was done way before CP came to make their own niche.
      You actually have power, in a position to stop the crazy abuse, but each and every one
      of you are afraid to be axed out of a job. If you speak too loudly, you will be fired.
      Sorry, but each and every one of you are employed BY an abusive dehumanizing
      practice. You cannot protect me, no matter how many articles you write.

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  5. I don’t like the term “insane medicine” in a title. For one, “insane” is derived from the Latin for “unhealthy”. “Sick medicine” is an oxymoron. It’s much like the term “mental illness”, something of an abstraction.

    Scientism though certainly deserves criticism, and the “mental disease” industry itself is definitely a result of scientism. By scientism I mean the religion of science. Science begins with skepticism, and it ends where that skepticism is discarded. Belief in science? Science isn’t a belief, it’s a method for getting at the truth. Indifferent truth that doesn’t rely on belief.

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  6. We need a revolution in medicine, not only in psychiatry. Most doctors behave as owners of esoteric knowledge. There must be a cooperation between an informed patient and doctor(s).
    People must be encouraged to learn themselves about medicine, not to go with blind trust to doctors. Internet offers nowadays almost all necessary information in this field and not only.
    Charlatans can prosper only in a world of people who don’t think.

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    • Yes Andrei.
      Medicine went to psych. They heavily believe in depression not as reactions that are normal under circumstance, but as a disease.
      And they know very little about disease, or it’s treatments, so it’s easy to take the route of the mental aspect.
      This has resulted in medicine really not making themselves more credible. It has made a mess of it and cheapens real science and halts progression.
      Psych halts progression and moving forward on all fronts. It is because of the draconian patriarchal ideas.

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      • Mainstream psychiatry is cancer. A blight on the medical field.
        The perfect excuse to ignore–not just the patient’s legitimate grief or trauma–but real physical ailments that could be treated or cured but the doctor is too busy to bother with.

        The question is not whether psychiatry can be reformed, but whether Western medicine can be reformed. Doctors are so authoritarian now I hate seeing one.

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    • “Charlatans can prosper only in a world of people who don’t think.”

      People have been aware that the three card monte is a con for many years now, and yet they still enter the ‘game’ thinking they can win.

      In my situation I was forced to ‘play’ (at the point of a weapon, my right to liberty and bodily integrity the bet) despite me being fully aware of the con, and knowing that I would lose. You can’t put words into someones mouth if they don’t open it. My refusal to talk to these people resulted in me being ‘spiked’ with benzos and being roughed up by police to force me to talk. And when I refused, that refusal used as justification for further acts of torture by the State. Complaints result in you being “fucking destroyed” (to quote the person who investigated the human rights abuses and found them to be correct, and then engaged in criminal acts for the State to ensure these human rights abuses were concealed, with fraud and an attempt to kill in an Emergency Dept (see my article How to ‘hotshot’ in the E.D.; and have the Coroner sign it off). How dare I question their authority to drug me without my knowledge, have police snatch me from my bed and deliver me to a hospital for treatment for an illness they were about to make up with the twisting of words and a lie that I was their “patient”?

      Charlatans can prosper in a world where they can use force to make the victims appear to have entered the ‘game’ with full consent, and then use whatever means necessary to ‘cool out the mark’ (to use Erving Goffmans term. “the street hustler uses poise, the white collar criminal position”). Threaten their families, commit acts of fraud, slander them, and if necessary ‘unintentionally negatively outcome’ them. And to think that they are paying for it is the biggest joke of all among those ‘in the know’.

      Charlatans can prosper where they can put a gun to your head and make you sign, and then deny the use of unnecessary force to have you consent. Especially where this ‘noble corruption’ is being enabled by the State authorities. (anyone care to see the letter yet?)

      In fact, I have prepared a proposal for my government to show them how to torture citizens into confessions using the provisions of Mental Health Act, and then using the Proceeds of Crime legislation to empty their bank accounts. And there isn’t a damn thing the victims could do about it, given that they would need to complain to the same people doing it. Credit to the National Socialists in Germany for the idea, and many thanks to the State government here for making it all possible. Thinking or not isn’t going to help.

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    • Charlatans can prosper only in a world of people who don’t think.

      Oh, if only it were that easy. There is so much confusing information out there. So many different opinions (by different doctors, people with lived experience, spiritualists, etc) on the best treatments. Even people with lived experience don’t have the answers for serious mental illness – or if you do, please tell me how to help loved ones. i lost my amazing son who was diagnosed with schizophrenia. i did so much research and was open to trying anything, even if it was considered “woo woo”. i recognized early on the psychiatric community itself did not have the answers, but no one else did either. we were scared, confused, and didn’t know where to turn for help. All we knew was that we loved matt fiercely and we tried everything we could to help him fight what no one seemed to know how to help. sadly matt died by suicide shortly after being diagnosed. i continue to research, speak out, and try to find solutions as a few people have turned to me for help with their own loved ones. i’ve started a resources page posting the research that i had so far and hope it will be a living resource with others contributing what has helped them. i know that every person is different and what works for one person won’t necessarily help another, but it might. so if you can add anything to my resources page, i’d be grateful for any new information.
      as for this article, i found it very good. for those of you directly involved in the mental health community on either side, you may be well aware of all this, but there are still so many people who have no idea how little the scientific community can actually help. the majority of people think mental illness is related to a chemical imbalance and given a drug it will fix it. this is a wonderful article and much-needed info to get out to the masses. this is also the work of MIA and it’s much appreciated. thank you.
      – if you can add anything to my living resources page, here’s the link:

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      • I am sorry to hear about the loss of your son. It’s cruel and happens, often after psychiatry becomes involved.
        Suicide happens before the passage of time. Before integration and often happens as we are busy trying to fix something.
        There is truly something called time, and luck of the Irish, which is pumping into magical people, a redirection, an integration, and community of one success after another. We cannot adopt a false paradigm simply because we have no answers.

        The “answers” exist, but they look nothing like our desperations or want of control.

        And for a parent, this is the hardest fact to deal with. The real issue we have to look at is. Is the destruction of a brain that can no longer think, a good answer for their life? When they can’t work, experience community or joy? Is that truly life?

        So I know that some people want to hold onto a life, even if it is not actually living in the mind, but just stumbling and dying cells.
        But we can’t do this on any moral level, since it is not only harm, but a destroying of everything that “life” is really about.

        Psychiatry is not at ALL interested in preserving and enhancing.

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