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 blog, he introduces the book. Each Monday, a new section of the book will be published, and all chapters will be archived here.
Preface: Why I Wrote This Book and What It’s About
At the end of a discussion after a teaching session, a psychiatric trainee colleague of mine made a bet with me that within 25 years there will be a physical test for schizophrenia. As I had progressed through training, the scales had been falling from my eyes. I was becoming increasingly suspicious of the promises of milk and honey for psychiatric technology being just around the corner.
It was the early 1990s, and “decade of the brain” talk was causing great excitement in our teachers. The fevered academic discourse pointing to this or that region of the brain or this and that neurotransmitter receptor existed in a different world to the psychiatric wards I worked on. Patients, all too often, were objects of fear, loathing, or paternalistic sympathy. Psychiatrists acted as glorified pharmacists usually adding medications and diagnoses to someone’s health records, while nurses struggled to deal with the emotional intensity of these deeply untherapeutic environments by trying to work out which patients had behavioural problems (and were therefore “personality disorders”) in order to lobby for their discharge and which ones were “ill” and therefore merited sympathy and more medication.
To survive as a psychiatrist, several of my senior supervisors warned me, I needed to learn how to cut off my emotions when dealing with patients. To be objective, I had to become un-empathic. I was never able to master that skill.
Those 25 years have come and gone. No test has emerged, not for schizophrenia or any other so-called psychiatric diagnosis. I became a child psychiatrist to escape the oppressive world of faux diagnosis and brain numbing sedatives, only for child psychiatry to get sucked into the pseudoscience scientism and for children to become the latest victims of the cruel, violent, and dehumanising mental health systems we created.
I have written this book as a warning to all who are contemplating engaging in mental health services, have engaged with mental health services, or continue to engage with mental health services, and to those who love and care for them.
Beware: Mental health services may be bad for your mental health.
I hope this book helps you understand why, gives you some background on the science, history, and culture of mental health technologies, and provides a few pointers to keep in mind when trying to make sense of your own journey. This book is also aimed at those who work in mental health services, politicians, the media, and the public at large: Mental health problems and treatments are not what you might think they are.
I hope this book helps you re-imagine this area of practice, and influences, in whatever small way it can, anything you might do to help move theory and practice out of the dark ages it is stuck in.
The book digs through the rotten undergrowth that sits beneath the artificially-scented man-made plastic gardens that we call mental health care—gardens that look and smell so nice on the surface, but release a stench if you poke your head in too far. As the foundations decay and crumble, the reality of the monstrous edifice we produced reveals itself. I hope there are a few gasps and shakes of the head by readers as they are exposed to the horrifying reality that mainstream mental health services have created.
But this book is more than just a critique; it is also points to the green shoots of hope gathering around us. Yes, we need to drastically reform the foundational assumptions that govern the ideologies that pervade our systems, but many now know the truth about what is happening, and transformational approaches have been sprouting up organically in the rich soils of human creativity.
This is not a book that criticises individual psychiatrists, psychologists, or therapists. I have known and worked alongside many who don’t share my opinions. Despite this, and with very few exceptions, I have found those who work in mental health services kind, thoughtful, and genuinely motivated to help people.
I think mental health work attracts people with altruistic tendencies; after all it is neither glamorous nor particularly lucrative (unless you decide to be a skivvy for the pharmaceutical industry). Like most systems, when you become a cog in its wheels it will swallow you up and you will have to adhere to its logic. Standing outside or refusing to turn in the same direction as the other cogs can cause personal suffering, criticism, and even risk your career and livelihood.
Yet, in those behind the scenes moments, the conversations I have with colleagues convince me that what I present in this book is not too far off the majority opinion of most who work in mental health (perhaps with the exception of psychiatrists who may fear they have most to lose by a change that diminishes their power). Most also understand that our mental wellbeing is heavily influenced by the political and economic systems that dictate the logics that structure our material lives. Almost universally (at least where I work in the UK), the politics that mental health workers support are, like mine, left of centre redistribution of wealth policies.
I do not see myself as an anti-psychiatrist, either. Anti-psychiatry is label used against critics as an easy way to silence them and ignore uncomfortable facts.
I understand why psychiatry gets the brunt of the criticism aimed at the mental health industry, given its relative power compared to other professions. Psychiatry has a dark history that embroiled it with some of the worst human rights atrocities, including active collusion with the eugenics movement and then the Nazis, where it was psychiatrists who first built and operated gas chambers to eliminate lives they deemed were not worth living.
We have a duty as psychiatrists not to brush over these inconvenient episodes, but to face them, understand them, and learn from them, so we never repeat those horrors. Whilst it hasn’t sunk to those terrible levels of inhumanity since, psychiatric practice remains complicit in incarcerating people and policing the population, which makes clinical endeavours impossible to disentangle from host political regimes’ approaches to regulation and authority.
However, my personal experience of the psychiatrists I meet is that there are a handful of diehard biologically minded psychiatrists; a larger group who are mostly sympathetic to (at least some of) the views expressed in this book, but who feel too exhausted and overwhelmed to know what they should do about it and how to change anything; and a smallish but growing group of “critical” psychiatrists who, like myself, ask more searching questions of the system and remain hopeful that change is not just desirable, but also possible and inevitable.
I’m not anti-psychiatry; I am anti-bad-psychiatry and believe it’s my responsibility to call it out wherever I see it.
The history of psychiatry is not just a history of abuse and human rights violations. Doctors (psychiatrists are trained as doctors first before specialising in psychiatry) have often led the way in trying to shed light on the lives of the alienated and marginalised. Most of the major schools of psychotherapy were developed with the influence, observations, and thoughtful reflections of doctors.
Whilst in recent decades the commercialised, narrow biomedical model has taken centre stage, the profession also has a long history of collaborating with fields of study as diverse as philosophy, anthropology, sociology, and cultural studies, as well as the natural sciences. Critical thinking has always been a vital and energetic part of accepted theory and practice. Out of all the fields of medicine, psychiatry, perhaps along with public health, has the greatest potential for bringing together the diverse influences that shapes wellbeing in our lives.
For me, a reformed mental health system will have reformed psychiatric practice at its heart, not only because this will improve the care of those with mental distress, but because it will also improve care across health and social care services.
The American philosopher of science Thomas Kuhn understood that science and knowledge is constructed by humans and so vulnerable to being shaped by the emotional attachments those who have the power to tell us the scientific “truth” have to their favourite theories. He noted that the existing theoretical framework (which we often refer to as a “paradigm”) a group of scientists work within sometimes throws up anomalies, results that do not fit with what the framework expects. These are usually ignored or explained away.
However, a point is reached where the accumulation of these anomalies poses difficult questions for the current paradigm. They start to eat away at the viability and explanatory capacity of that framework. This eventually results in a crisis of confidence, and ultimately to revolution, where the until-then-dominant paradigm is discarded because it was unable to support the new findings.
But for a revolution to be successful it must replace, overthrow, or radically reform existing institutions that support and have a vested interest in maintaining the failed paradigm. This implies a period of uncertainty in which there is no clear authority and groups become divided into various camps, some defending the old institutions, others advocating for new ones or significant reforms of the old ones. It is at the point at which such polarisation occurs that either revolution occurs or the opposition is repressed (at least for a while), because there is no common language through which a debate can take place.
This happens because the proponents of different paradigms are unable to understand each other’s points of view, as the shifts of meaning between old and new theoretical frameworks are so profound that the concepts employed by a new paradigm are simply inexpressible in the terms used by a pre-revolutionary one.
Did you follow that line of thinking? Kuhn’s observations of how accepted scientific truth changes led him to draw a comparison with how social change occurs. Science, it seems, is not immune to the social dynamics that afflict any organised group of people. His use of the word “revolution” to describe how one dominant theoretical framework gets replaced by another tells you that such changes do not occur because of what the science is telling you. A more human process is involved with power, hierarchy, and, in today’s world, money, all playing their part. Failed paradigms can stay dominant for long periods before a revolution is eventually successful.
The tension and conflict such a revolution produces is unavoidable. Mental health systems are now shaking with rumblings from its critics. Services and individuals who have rejected the current dominant paradigm are already operating in many places. Sections of service users and survivors of the system have organised and found voice raising objections that cannot be easily dismissed.
These pockets of resistance will at some point create an unmovable critical mass. Change is coming. An earthquake is forming. We should be ready to embrace and help shape it in humane and enlightened directions, putting people’s real-life contexts and relationships (including with services) at the centre of what we do. We can then become excited by how the next generation of critics will see the holes and problems in the new forms of practice we create.
Most of the first half of this book explains why the current dominant paradigm we use in mental health practice is broken, empirically unsustainable, and so wrong that it’s dangerous to our mental health. It explains why scientifically and ethically it’s a failed paradigm. In the middle of the book I examine the role of politics and culture in shaping our ideas about mental health problems and treatments. In the final chapters I share some thoughts on what might be helpful for some people and for parents who are looking for understandings that don’t come from the dominant diagnostic models’ services use.
Chapter one introduces the reader to the landscape of the rest of the book, proposing that far from a picture of enlightened progress, the mental health industry and awareness campaigns have set us on a path toward a deep alienation from our emotional lives and a lack of curiosity about suffering.
Chapter two interrogates the assumptions implicit in how mental health is presented to the public: from mental health awareness campaigns to warnings of mental health pandemics, lack of services, and the importance of early treatment. This chapter excavates the language and ideology hidden in Western mental health promotion, which pretends that mental disorders/illnesses are concrete objects like other medical “things” such as a broken leg or diabetes. I explain why there is, in a technical sense, no such thing as a psychiatric diagnosis.
I contrast some Eastern and Western philosophical positions on the self and childhood, and explore the consequences that flow from the different ways we construct our expectations of ourselves and our children. I also introduce the reader to the empirical literature showing how little progress we have made scientifically or clinically in improving our understanding or treatment of those we label as mentally dysfunctional.
Chapter three is the first of three case example chapters, with each one following a similar structure: The mainstream view, history of the development of the concept, a discussion of the cultural and political drivers of the concept, an examination of the scientific evidence, and a conclusion on what this review tells us about the concept. Chapter three thus explores the assumptions, evidence, and consequences of the concept of Attention Deficit Hyperactivity Disorder (ADHD) and chapter four does the same with the concept of Autistic Spectrum Disorders (ASD).
In the third and last of the case example chapters, chapter five moves away from our cultural pre-occupation with children’s behaviour to engage with our cultural attitudes to suffering and the migration of the medicalisation of mood and mental distress into childhood. I examine our changing attitudes in the last century to growing up and the gradual (what I call) “McDonaldisation” of child development, where the challenges and uncertainties connected with growing up can be placed into neat categories of things “wrong” with individual children, which can then be fixed with simple, one size fits all, easy to consume, short-term satisfiers.
I examine the empirical evidence on the use and effectiveness of antidepressants in young people, showing how their use in children and adolescents expanded in tandem with the rise of the narrative that childhood depression is like adult depression, widespread, and amenable to treatment with medication. Having examined the empirical and cultural basis for the twists and turns in the creation of the childhood depression narrative, I conclude that we should resist this McDonaldisation of growing up.
Chapter six looks at neoliberal politics and the spur it gave to creating a “compare and compete” society. It moves the discussion onto the political context out of which mental health ideology developed and is perpetuated. Starting with a description of the origins and basis of neoliberal politics and economy, I explore what sort of concept of human being such a system assumes and promotes.
Neoliberalism sees Darwinian-like competition as the defining characteristic of human relations. It redefines citizens as consumers, whose democratic choices are best exercised by buying and selling. A creeping alienation from each other develops as our instinct to socially connect is reshaped as a vehicle to gain personal advantage. Competition is a key economic driver in neoliberal economies and so becomes a prominent social and cultural value. Many are then subject to the ongoing fear of falling behind and becoming defined (and/or self-defined) as being a member of a class of “losers.” Defining people as “vulnerable” or “ill” allows marketisation and exploitation of the mental pain such a culture produces.
In chapter seven I explain how most psychotherapy used by, and promoted in, services simply packages and then markets Western folk psychology. There is an inherent bias in what we refer to as “psychology” as it is really the psychology of Western societies and largely Western educated society. Mainstream psychology is really a branch of philosophy expounding a particular Western-centric view of the mind.
I examine the evidence for the effectiveness of different models of psychotherapy that use ideas drawn from mainstream psychology. The proliferation of psychotherapy models has not resulted in improving outcomes. I also discuss the turn toward “industrialised” (large numbers funnelled into standardised “care pathways”) forms of psychotherapy and the shockingly poor outcomes they produce.
These banal outcomes are to be expected as the theoretical basis of the dominant models of therapies we use are just extensions of Western “common sense.” I suggest that mental health practitioners are best thought of as philosophical guides who adopt interpretive frameworks (paradigms) that they use to construct a particular narrative for describing the nature of a problem and the process of change.
Chapter eight is drawn mainly out of my decades of clinical experience. I outline some insights that have helped me develop a particular philosophy that I use to guide my practice. The central aspects of this framework are:
- Deconstructing diagnosis,
- Understanding the relevance of psychological injury,
- Working on the therapeutic relationship,
- An awareness of culture and context, and
- How a problem once established perpetuates itself in a process I call “the problem becomes the problem.”
This last insight requires the therapeutic focus to shift away from trying to solve, get rid of, or even change the problem (however this is defined), toward helping the person, and those around them, change their relationship to and/or feeling about the problem. The process of “the problem becomes the problem” potentially explains why both mental health diagnoses and treatments (whether medication or therapy) risk embedding the problem, alienating people from their legitimate emotional experiences, undermining their resilience, and creating long-term patients out of them.
Instead, I try to adopt a paradigm that allows people to experience growth and meaning through their adverse experiences and distress, empowering them to deal with altered and distressing states of mind. I also discuss medication and make suggestions for a model of working with medication that doesn’t lead to the person receiving medication becoming disempowered and alienated from their natural resilience.
In Chapter nine I outline a “toolbox” of ideas for parents worried about, or frustrated by, their child’s behaviour. I describe some concepts and frameworks that can be used in a flexible manner to suit different circumstances. Many of the ideas are drawn from an approach that I have used successfully for many years called the “Relational Awareness Programme” (RAP).
RAP focuses on prioritising improving the relational aspects over the behavioural manifestations of a child a parent is concerned about. It uses a system of analogies to help parents better understand the “emotional flow” that occurs in their relationship with their child. The chapter then guides parents through a series of deceptively simple narratives that can help them structure more useful ways of understanding and intervening in family life when that has become loaded with stress and strife.
The concluding tenth chapter proposes that a paradigm shift for mental health care is inevitable. I include examples from people, projects, and organisations that have created change in how mental health is understood and how services are delivered. The momentum they have created is gathering.
Reason, truth, and ethics are all on the side of critics. We don’t know when enough of a critical mass will be reached. When it does, change can happen rapidly and a revolution will take place. We must be ready for it.
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.