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 discusses the end results of the scientism of psychiatry. Each Monday, a new section of the book will be published, and all chapters will be archived here.
Mainstream psychiatry has been afflicted by at least two types of scientism. Firstly, it parodies science as ideology, liking to talk in scientific language, using the language of Evidence Based Medicine (EBM), and carrying out research that “looks” scientific (such as brain scanning). Psychiatry wants to be seen as residing in the same scientific cosmology as the rest of medicine. Yet the cupboard of actual scientific and clinically relevant findings from all this research remains empty.
Secondly, it ignores much of the genuine science there is and instead goes on supporting and perpetuating concepts and treatments that have little scientific support. This is a more harmful and deceptive form of scientism; it means that psychiatry likes to talk in the language of science and treats this as more important than the actual science.
I have had debates with fellow psychiatrists on many aspects of the actual evidence base. Two defences have become familiar to me. The first is use of anecdote—such and such a patient got better with such and such a treatment, therefore, this treatment “works.” Anecdote is precisely what EBM was trying to get away from.
The second is an appeal for me to take a “balanced” perspective. Of course each person’s idea of what is a balanced position depends on where they are sitting. We get our ideas on what is balanced from what is culturally dominant, not from what the science is telling us. At one point, to many people, Nelson Mandala was a violent terrorist; later to many more people, he becomes the embodiment of peaceful reconciliation and forgiveness. What were considered balanced views on him were almost polar opposites, depending on where and when you were examining him from.
Furthermore, in science, facts are simply that. Our interpretations are, of course, based on our reading of these facts. Providing an interpretation consistent with the facts is more important than any one person’s notion of what a balanced position should look like.
Looking at the actual evidence provides a worrying picture for mainstream mental health services’ real world effectiveness. Although over-diagnosis and unnecessary care is recognised as a growing problem across medicine, the short- and long-term outcomes for many conditions dealt with by the rest of medicine has improved, often reflecting genuine technical advances.
This is not the case in mental health. Research from a number of countries has found that despite continuous growth in the availability of mental health services, only about 15-25% of those referred significantly improve or recover in the long term. This dismal picture is found in both child and adult mental health services. Non-attendance rates and numbers dropping out of treatment are also substantial.
There has been a steep rise in the number of youth and adults categorised as disabled mentally ill in most Western countries. In the UK, recent research found that mental disorders have become the most common reason for receiving disability benefits, with the number of claimants rising by 103% from 1995 to 2014, whereas claimants with other conditions fell by 35%.
Most people who attend standard community mental health services, it seems, experience either no lasting improvement or deteriorate. In order to “cover up” this disastrous state of affairs we have created an idea that the conditions we deal with are “chronic.” This provides a framework for accepting as unproblematic the expanding numbers of people categorised as mentally ill who don’t seem to get better or keep relapsing despite our treatments (could it be because of?), without feeling that it is, at least in part, the fault of our concepts and treatments.
Thus, I know of colleague psychiatrists in adult services with case-loads of several hundred patients. They are overwhelmed and all they can manage are 20-minute medication reviews once every six or so months for patients who never get discharged.
This picture of poor real world outcomes is exacerbated by one of the signs of “scientism” found in psychiatry—the belief that there is such a thing as a psychiatric diagnosis. As discussed earlier, it is fairly straightforward to demonstrate that the concept of psychiatric diagnosis is scientism, as from a logical/technical perspective there is no such thing as a psychiatric diagnosis.
To recap: in medicine, 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 a specific pathological process. Pseudo-diagnoses, like for example Attention Deficit Hyperactivity Disorder (ADHD), cannot explain behaviours, as there are only “symptoms” that are descriptions (not explanations) of behaviours. In psychiatry, what we are calling diagnosis (such as ADHD) will only describe, but is unable to explain.
The problem with the notion of “diagnosis” in psychiatry is not just that it lacks validity and leads to the crazy tautology where we are effectively saying an experience (like low mood) causes itself (as in your low mood is caused by depression). Because we are, as mental health preachers, teaching people that our perceived abnormal feelings can magically cause themselves to occur, we train—no, hypnotise—millions to succumb to the doctrine of being helpless to deal with intense emotional states. We undermine peoples’ natural resilience, autonomy, and capacity for adjusting, accepting, or protesting against the social conditions and power imbalances they are faced with, and thus impair their potential for more useful insights to emerge.
Furthermore, diagnoses are poor even as a descriptive classification because of what it leads you to focus on and what it leaves out. When faced with a diagnosis of “autism” we jump to some stereotyped idea of what that child is like. We may then cease to register their family situation, parental, family, and personal histories, things they’re good at, their interests, ambitions, and so on.
Even when we do, they are now relegated to being of secondary importance, with the person’s uniqueness dissolving behind the smoke and mirrors of the “over the rainbow” fantasy that “autism” has helped us understand the young person.
Psychiatric diagnosis does violence to people, imposing a mesmerising suggestion that damages the imaginative potential we all possess to re-story our dilemmas and develop a deeper appreciation of our capacity to learn, develop, and change. It is the output of a culture that turns to scientism to be sold as commodities that are inseparable from the infantalising tendencies that neoliberalism has embedded in our culture. We can soothe our anxieties and uncertainties by buying the latest diagnostic brand and the simplistic remedies that come along with them. You can have whatever you want. God forbid that you weren’t having fun. God forbid that you had to deal with the frustration of your desires.
Of course, I am here caricaturing a tendency, not denying that pain and suffering requires help and understanding. However, I am questioning what type of help we may need—one that leans more to eliminating/suppressing or numbing suffering (the symptom reduction approach that medicalised diagnostic technology advocates), or one that encourages engagement with suffering and the accompanying potential for new discovery and the emergence of natural resilience.
I have little doubt that the scientism of psychiatric diagnosis is not reform-able or redeemable. It is a quackery that must be (and will be) abolished.
It should be easy to see that once we start interrogating the basic assumptions supporting fantasy notions like psychiatric diagnoses, then much of the literature built on such assumptions lacks validity. As ADHD is not a medical diagnosis, but a descriptive classification, we have no reliable empirical method for defining a case.
The definition of what qualifies as a case is thus arbitrary and depends on the standards employed by the diagnoser, influenced by whatever prevailing ideology concerning diagnosis they have been exposed to. As a result, we cannot eliminate wide variation in “diagnostic” practice that has more to do with the training and tastes of the individual practitioner than their capacity to identify anything real about their patients.
Psychiatry keeps faith in scientism despite these obvious flaws, because we live in a culture where technology and technological achievement are highlighted and promoted and because this connects with that broader cosmology that wants to use science to explain everything. In order to have metaphorical and literal purchase in our society we are inclined to use technological/scientific sounding language.
With this type of scientism (science as a system of faith) so prevalent, eventually what the science says is almost irrelevant as long as you can look like you are doing something that you call science and you can bullshit in a way that convinces others (who are excluded from the language and actual findings) that the knowledge you possess is based on a “truth” (because you are a scientist and you do science).
The hidden assumptions disappear and get taken for granted the more you just repeat phrases like “ADHD is a…”, “ADHD is caused by…”, “The treatment for ADHD is...” etc. As philosopher Michel Foucault and others point out, this is how institutional power builds up and gets authority to create “regimes of truth.” In this regime what you do is simply keep repeating phrases like “the evidence says...”, “studies have found…”, “evidence-based practice is…” etc. It doesn’t matter what the evidence actually is. What matters is that we trust the person saying this is what the evidence says, because they are men of the high priesthood—scientists.
The promise that psychiatric diagnoses will ultimately be shown to be like any other medical ones keeps failing to deliver. This became obvious with the publication of the American Diagnostic and Statistical Manual, fifth edition (DSM 5) in 2013, where the authors admitted that despite the DSM being originally designed to allow for research to uncover underlying causes, thus making the labels diagnostic, no causes have been identified.
Figures for the reliability of a DSM diagnosis have actually decreased for many of the diagnostic categories. The American Psychiatric Association generates much income for its organisation through publishing new DSM editions. As long as that’s the case, then perhaps the scientism that it embodies matters little to them. It should, though, matter to everyone else.
As former director of the National Institute for Mental Health (NIMH) in the USA, Thomas Insel, wrote in 2013 after he became frustrated with the inability of the psychiatric establishment to make major improvements in care or understanding of the causal basis of psychiatric problems:
“The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment. Patients with mental disorders deserve better.”
Although he still held to a primarily biological understanding of mental health problems, Insel realised that the DSM and all other diagnostic manuals we use, did a poor job of accurately capturing any biological categories.
DSM is based on categorising by “symptoms”—and even then, its categories are wide nets that ensnared many different diagnostic fish. For instance, the long list of symptoms classed under “Major Depressive Disorder” means that any two people with the diagnosis might have very different symptoms. As discussed, even the idea of symptoms is misleading as it assumes the experiences that are being categorised are best captured using a medical lens. Insel finally understood the calamity of this situation:
“I spent 13 years at the National Institute of Mental Health really pushing on the neuroscience and genetics of mental disorders, and when I look back on that I realise 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 hospitalisations, improving recovery for the tens of millions of people who have mental illness.”
But like many in the academic field who have realised this, instead of doing the most logical thing and abandoning the idea that mental distress and difference can be captured through studying biological phenomena using the natural sciences paradigm, he doubled down and opened the door to billions more wasted money by creating a new diagnostic structure (The Research Domain Criteria [RDoC]) in the forlorn hope that this will deliver where DSM and its companions haven’t. Just as DSM failed, so will RDoC.
Medication magic and the creating patients industry
In my clinical practice it is not uncommon for me to encounter patients who have become or are on their way to becoming long term patients because (at least in part) of the way mental health services has given meaning to their suffering and dilemmas. Like the 14-year-old girl transferred to my care who has been taking psychiatric medications since she was 10, of gradually increasing amounts to help with “anxiety” and “depression.” She had been told one is an antidepressant and the other is an antianxiety drug, although this antianxiety drug is actually classified in the books as an antipsychotic.
She has had a few months stay at an inpatient unit following expressing suicidal feelings a year ago. She has also had some individual psychotherapy and there have been some family therapy sessions. She believes she may need to take medication for the rest of her life. Her parents don’t feel anyone is getting “to the bottom” of what is wrong with their daughter.
Despite all the therapy, parents feel that she “doesn’t open up” and isn’t honest with her therapist, and their frustration with the lack of progress often leads them to accuse services of “not doing anything” and of not helping.1
In the above fairly common scenario, everyone—parents, their daughter, and professionals—is trapped in a constructed nightmare that, far from uncovering what’s wrong in order to help make it better, perpetuates, solidifies, and worsens the problem. A long-term patient has been unnecessarily created. Not because the mental health professionals aren’t trying their compassionate best, not because the girl is malingering, and not because the parents don’t care or know how to properly love her. Because they are all trapped in a story about what mental health and ill health is and who has the power to influence that. It’s a story that is making millions around the world ill and disempowered.
The evidence on the relationship between treatment model and outcomes favours the “common factors” over treatment model factors. Common factors refer to things that all treatments have in common, whereas treatment model factors suggest that different treatment models (such as different types of psychotherapy) have specific techniques that work for particular diagnoses better than others (such as the idea that cognitive behavioural therapy treats depression better than psychodynamic psychotherapy).
Decades of outcome research has concluded that just about all of the things that influence outcome are accounted for by common factors and not treatment specific ones.
The most influential of those common factors are those that have nothing to do with the therapy, usually referred to as “extra-therapeutic” factors. These are all those things from the patient’s life outside of therapy that patients bring with them when they walk into a consulting room. This includes their history, childhood, level of education, cultural background, social support network, financial situation, beliefs about therapy and so on.
Once in the consulting room, the quality of the therapeutic alliance, as rated by the patient, accounts for most of the within-therapy impact on outcomes. Alliance is an interesting and multi-faceted object that goes much further than an open and non-judgmental empathic stance (important as that is) and includes agreement on goals, a sense of trust and confidence, and the ability to work through disagreements.
There has been no progress, nor any technical breakthrough, as the percentage improving from “treatment” hasn’t got higher in research done today compared to decades ago when outcome research first started being done.
What this evidence seems to be telling us is that what we wrap up in special expert-sounding language has more to do with everyday human experiences than any special knowledge that leads to accurate classifications and particular treatments that follow from that. Basically, we all have unique circumstances, histories, and interpretations of that, and we find some people more helpful (including therapists) than others.
However, most of this research refers to studies that usually last a few months and more or less suggest that some therapy is, on average, better than no therapy. Longer term, the picture becomes more concerning. Not only do those with no therapy eventually catch up, but it seems that for many, the longer you are in services, particularly if medication is part of the intervention, the worse the outlook (on average) becomes. Longer term, some models are worse, rather than better, than others.
The importance of non-specific factors is also found when using psychiatric drug treatments. As Professor Joanna Moncrieff, Dr Peter Breggin, and many others have pointed out, the evidence undoubtedly supports the view that psychiatric medications are best conceptualised as inducing particular states of mind, rather than acting in a specific way on a disease to correct a chemical imbalance. This reflects clinical practice, where the few categories of psychoactive medications used in psychiatry are used in a non-diagnosis specific way.
For example, selective serotonin reuptake inhibitors (SSRIs), which are usually referred to as “antidepressants,” are claimed to be effective in many more conditions, such as borderline personality disorder, generalised anxiety disorder, obsessive compulsive disorder, bulimia, panic disorder, social phobias, and so forth. As a psychoactive substance, SSRIs would appear to do something to a person’s state of mind, but that something is not diagnosis-specific.
Like alcohol, which will produce inebriation in a person who has been diagnosed with schizophrenia, obsessive compulsive disorder, depression, or someone with no psychiatric diagnosis, SSRIs will also impact individuals in ways that are not specific to a diagnosis. Similarly, the class of drugs known as “neuroleptics” (misnamed “antipsychotics”) have also been advocated for the treatment of psychosis, depression, anxiety disorders, bipolar disorder, personality disorders, and so on—a list that contains considerable overlap with that found for SSRIs.
The therapeutics of these drugs rely on non-specific factors rather than disease-specific therapeutic effects. For example, with SSRIs, the evidence points to placebo effects being more important than any neuro-pharmacological ones. Much more. For example, having a good relationship with the prescribing doctor is a stronger predictor of a positive response to an “anti-depressant” than just taking the drug regardless of who prescribes it.
In fact, much evidence suggests that “antidepressants” are best thought of as enhanced placebos. The tiny (and not clinically significant) extra on-average improvement over placebos that SSRIs achieve in studies is most likely accounted for by “unblinding.”
What this refers to is that in studies when you compare a drug with a sugar pill placebo (a placebo is a pill that has no active chemical ingredient), you keep secret from the patients in the study and those who assess them, which patient is taking the SSRI or the placebo. Of course, patients would like to guess whether they are taking the active treatment or not, and so if you get side effects or feel different, you may realise you are on the SSRI side of the trial. When patients correctly guess they are taking the active pill and not the placebo, this is called “unblinding” (they are no longer ‘blind’ as to which arm of the study they’re in). It seems that unblinding is common in “antidepressant” studies.
This all means there is no such thing as an “antidepressant,” “antipsychotic,” “mood stabiliser,” and so on. These are dangerous concepts that, like “psychiatric diagnosis” have become established in our culture through marketing and institutional self-promotion. As far as the science is concerned, there are no chemical imbalances that these are correcting. Psychiatric medications, like alcohol or street drugs, make you feel different and then you have to interpret the significance of that for you.
There is and has been enormous investment with time and money in neuroscience with intensive searches for informative biomarkers. The yield from this research is a big fat zero. Even optimists acknowledge that there is still no clinically useful way to assess how patients will respond to the psychiatric drugs prescribed for them. At a population level it is unarguable that their widespread use has caused more harm than good.
The trouble with placebo responses is that they don’t last. We know alcohol can make some people feel better when they’re stressed or down and we have a common phrase to interpret what it’s doing: helping you “drown your sorrows.” We culturally don’t see that as a good thing in the long term if the person carries on using this as their coping mechanism. We recognise that at some point alcohol can become addictive, won’t solve the original problem, and may become a new problem as it leads to a way of life that can make it harder to function.
If we were to use a similar narrative to explain how alcohol might help them with their troubles the way we sometimes “sell” antidepressants, then the doctor might say: “You should have a regular 250ml dose of this alcohol called Wine every day, to be taken at 10pm. If it makes you feel better, well that’s the alcohol doing its job, correcting a chemical imbalance that had developed in you. It’s treating that depression, so you need to take this for perhaps one year.”
If, after a few months you came back saying that you have noticed that you’re feeling worse again after initially feeling better, perhaps the doctor might increase the dose to say 350ml. After a year you try to stop as you’ve noticed you don’t concentrate as well and don’t function as well as you used to, and don’t seem to care too much about the fact that you’d lost your job, and so wondered if you might be better off to stop this prescription.
After a few days you feel worse, have tremors in your hands and bad headaches, as well as feeling depressed again. The doctor now explains that this is proof that you need to carry on taking your alcohol anti-depressant for longer, possibly for life. They return you to the 350ml dose of Wine-alcohol, but after a few months you return saying you feel depressed again. The doctor decides to add in a 30ml prescription of this newer alcohol antidepressant called “Vodka.” You get the picture.
Yes, alcohol is a different chemical, consumed in a different way, and with a different profile of mental and physical effects. But the basic principles are the same. The main difference between substances that affect the central nervous system that you can purchase legally or illegally and those prescribed by a doctor, is mainly just that; in other words, the main difference is that they’re prescribed by a doctor.
There is a well-known biological reason why any substance that has effects on the brain might start fading in its effects, and if you take it long enough and regularly enough may result in a withdrawal syndrome after you stop it.
Like most bodily systems the brain has various homeostatic mechanisms that try to keep biological systems functioning within a specific range. Nerve cells release chemical signals (neurotransmitters) which are picked up by receptors in the nerve cells they communicate with. Substances that act on the brain and make you feel “different” in some way act on this system by increasing or decreasing, through various mechanisms, the amount of particular neurotransmitters that get passed between nerve cells.
If there is a change in the amount of neurotransmitter that keeps happening continuously (for example if you drink alcohol, or take cocaine, or take an “antidepressant” every day), the receiving nerve cell starts to respond by turning off receptors if its homeostatic mechanisms sense that too much of this neurotransmitter is passing through, or turning on extra receptors if it senses that not enough of that particular neurotransmitter is passing into its nerve cell.
This is why those who, for example, abuse cocaine, find that after regularly using it, they need a larger amount than when they first started to get the same “high.” The brain has by then started turning off receptors for “dopamine” (the main neurotransmitter cocaine increases), hence the need to take more to get the high. This also means getting strong withdrawal symptoms if you suddenly stop.
Different substances have differences in the speed and depth of this homeostatic response, but even substances with quite mild effects like coffee can still cause headaches and irritability if you drink sufficient amounts daily and then stop suddenly.
The lack of treatment specificity is not limited to the more common presentations like anxiety and depression. Although drugs marketed as “antipsychotic” are often claimed to reverse a chemical imbalance in psychotic patients, just as with the antidepressants, no such imbalance has ever been demonstrated. That’s why you never get any physical test.
Because nobody can find these chemical imbalances, there is no blood test or brain scan or anything like that. The research findings here also support my conclusion that whilst psychiatric medication can produce short-term improvement, in the long term the picture for those who end up staying on these medications is grim.
Research carried out by the World Health Organisation over the course of 30 years, starting in the early 1970s, found that patients diagnosed with “schizophrenia” who live outside the United States and Europe have much lower relapse rates, and are significantly more likely to have made a full recovery and show lower degrees of impairment when followed up over several years, despite most having limited or no access to “antipsychotic” medication.
It seems that the regions of the world with the most resources to devote to mental illness—the best technology, medicines, and the best-financed academic and private research institutions—had the most troubled and socially marginalised patients.
Evidence has also been accumulating that, particularly in terms of functional outcomes, those who manage to wean themselves off “antipsychotics” have better long-term outcomes than those who stay on them. This is just the effectiveness data. So-called “antipsychotics” have horrible side effects on your nervous system, heart, and endocrine system, and are likely a significant contributor to the finding that those with a “severe mental illness” (SMI) die, on average, about 15-25 years earlier than the rest of the population. The comparison with alcohol seems more than apt.
The medical model is stigmatising
Because of the promotion of diagnostic thinking we have come to believe that a large proportion of the population suffers from some sort of mental disorder, that this amounts to a significant economic burden, and that there is a strong case for investing in improved mechanisms of screening, detection, and treatment for these disorders.
In order to increase rates of diagnosis and treatment, a variety of campaigns have been undertaken. For example, in the early 1990s in the UK, the Royal College of Psychiatrists and Royal College of General Practitioners launched their “Defeat Depression” campaign. Evaluations of this campaign found no evidence that it led to any significant improvements in clinical outcomes, but instead was associated with a rapid increase in antidepressant prescribing.
Similarly, research evaluating the “Beyond Blue” campaign in Australia, which aimed to increase awareness about depression and other mental disorders, demonstrated an increase in medical model beliefs about depression and an increase in rates of diagnosis of major depression between 1998 and 2008. It also noted a decrease in mental health-related quality of life over this decade, and that having “mental health literacy” (i.e. a belief that depression was a medical diagnosis requiring medical treatment) that was classified as “poor” or “fair” was a significant protective for recovery from major depression! In other words, those who rejected the idea that their mental suffering was the result of a disease were more likely to recover.
The likelihood of positive outcomes for those with mental disorders is also further hampered by the stigma associated with the idea that mental distress is the product of a medically malfunctioning brain. Nearly all studies that have looked at public attitudes towards mental illness have found that the medical model for mental illness (“mental illness is an illness like any other illness”) is associated with increased negative attitudes, greater fear of patients, and a greater likelihood of wanting to avoid interacting with them.
In contrast, the idea that mental distress, in all the variety of ways it may be expressed, is the outcome of adverse experiences is associated with empathy and a desire to help.
What about real-life mental health services? What does the evidence look like when we look at the data we have for outcomes for those attending mental health services, not just from those enrolled in research programmes?
Whilst outcomes for most conditions dealt with by the rest of medicine has improved, often reflecting genuine technical advances, no such progress has been seen for those who use mental health services. The figures on outcomes from treatment in real-world mental health settings in the developed world are nothing short of shocking.
A number of studies in the US have concluded that as few as 20-25% of patients improve in routine mental health services. In Britain, reviews of the effectiveness of the national Improving Access to Psychological Therapies (IAPT) services found that unlike their published figures, only 15% of people referred to the project were achieving “recovery” by the time they left, and one study found that less than 10% could be classified as “recovered” a short while after completing a course of treatment with IAPT.
In Australia, despite massive investment in mental health services in the past two decades, no corresponding improvement in the adult mental health of the population has been found. All these services rely on a matching treatment to diagnosis model and assume that this is the correct, evidence-based way to proceed.
A similar picture of poor outcomes in real-world child and adolescent mental health services has also been found. Researchers have reported that for traditional treatment in the community, the overall effect size of change for those attending community Child and Adolescent Mental Health Services (CAMHS), compared to those who weren’t, is pretty much zero. Some have also found that, across a variety of measures, those who continuously attended community CAMHS had higher levels of self-rated distress/problems when compared to a matched community sample with similar levels of initial distress/problems, but who did not to access CAMHS long term.
Wherever you look, standard mental health services have poor outcomes. They seem better at creating patients than curing them.
Robert Whitaker, a prize-winning journalist, has put to shame establishment academic psychiatry with his painstaking research on the enduring negative effects of the proliferation of psychiatric medications in our societies. He has documented a tripling of the number of people categorised as disabled mentally ill in the USA over the recent decades.
Similarly, the numbers of youth in America categorised as having a disability because of a mental condition leapt from around 16,000 in 1987 to 560,000 in 2007. Mental disorders have also become the most common reason for receiving benefits in the UK, with the number of claimants rising by 103% from 1995 to 2014, whilst claimants with other conditions fell by 35%.
These figures tell the opposite story to the one we regularly hear celebrating progress and discovery in mental health. We have been going backwards and our cultural responses of alarm, calling for more services, anti-stigma campaigns, and so on, have made matters worse. They all promote a dangerously wrong way of understanding and responding to distress.
We have created a system which funnels people down a route that creates layers of harm, which become harder to see the further into the quagmire they go. You may start with a real life crisis brought on by an unfortunate event that brings to the surface historical hurts. If you are lucky, a kindly general practitioner will keep things low key, notice you’re still functioning, have strengths, and an existing social network that can be mobilised and provide some light-touch support.
However, more likely, they may put you on an “antidepressant.” You feel better for a while, but after a couple of months those feelings, now called “depression,” come back. Now the antidepressant dose is increased and the doctor suggests you see someone from the NHS psychotherapy service for some therapy. These help, you feel better, and you decide to come off the antidepressant. The doctor suggests reducing the dose and stopping over a couple of weeks.
A few weeks later you go back to the doctor saying you feel worse than ever. Instead of them recognising withdrawal symptoms, they tell you it’s your “depression” coming back and it looks like you need to stay on your pills, possibly for the rest of your life. Things get worse in the next few months. A referral to see a psychiatrist follows. They diagnose you with bipolar disorder and add an “antipsychotic” into the mix. You develop side effects and they add an “anticholinergic” for side effects.
Ten more years pass. You have now been tried on several different antipsychotics, antidepressants, sleeping tablets, anticholinergics, and lithium, chasing a mythical perfect combination that seems to arrive, only for it to stop working a few months or years later.
Your promising career has gone, relationships are volatile, living conditions poor, and your life is now unrecognisable when compared to how you were before all this started. This is what our mental health system is perfectly set up to achieve. It undermines people’s natural resilience and potential for self-discovery and sets them on a path of subservience to experts who don’t really have a clue how to do anything much more than embed the idea that the person is really, really sick.
Beyond psychiatric scientism
I often wonder what might happen if we became more curious about differences in practice and outcome. For example, in the UK, as a community child and adolescent psychiatrist, I have a particular geographical patch, which has much deprivation, for which I am the responsible consultant. I hold a caseload of around 50, see young people and families for one-hour sessions and for some that can be once a week at times.
Most (but not all) of the people I see improve and are discharged, and so I am free to do therapeutic work with more, as well as having time to receive and provide supervision and support to and from the team I work alongside. Very few are on medication, and with those who are, it is often because I inherited them from another clinician who had initiated that medication. I am more involved in helping people wean off medications than starting them on any.
I am aware from chatting with many child psychiatry colleagues that the picture described above is not one that most of my consultant colleagues in UK community child and adolescent psychiatry (who will also have a similar sized geographical patch) would recognise these days, although this is how it was with many of the consultants who trained me back in the early and mid-1990s.
Like their colleagues in adult psychiatry, child psychiatrists today also often end up accumulating cases, most of whom will end up being prescribed medication, as sadly this has increasingly come to be viewed as the role of the psychiatrist. Caught in a system that sets you up in that way, I think it’s very hard for change to come from within the profession. I suspect that psychiatry ultimately will be forced to change by pressures from outside, particularly if the focus is shifted to the poor record of outcomes at the cost of high levels of harm that comes from the emphasis on “medical” interventions.
The problem for critics like me and critical organisations (like the Critical Psychiatry Network a UK based group I am part of) is at least twofold. First, we cannot match the power and influence that comes from resource-rich bodies like the pharmaceutical industry; hence we are only able to make marginal differences.
Secondly, as individuals, those of us who go against what are considered as the standard institutional expectations of psychiatrists may become at risk from employers persecuting them for their practice. I have previously had to robustly defend myself from accusations of incompetence by colleagues with more power than me and I know of other critically minded consultants who have experienced the same.
Nonetheless, as the old saying goes, “you can fool some of the people all the time and all the people some of the time, but you can’t fool all the people all the time.” Resistance movements have often been going for decades before a significant moment comes when enough of a “critical mass” is available to tip the balance in favour of change.
We don’t know when or how that moment will arrive, but we need to be ready for its inevitability, as this particular house of cards will eventually have to come tumbling down. We must also be ready for the house to come tumbling down for the wrong reasons and with potentially harmful outcomes. If it becomes about mainly saving money, vital supports for patients could be withdrawn. If patients are suddenly taken off medications without having an understanding of the biological and psychosocial consequences for them of doing this, harms will result.
Paying attention to the science tells us that we need to look beyond formal services. People are people whether or not they experience states of mind we associate with mental illness. People need connection and meaning as well as basics such as safety, housing, and work. In services, the evidence tells us relationship is Queen. Services will have to dispense with diagnosis and focus on prioritising and operationalising collaborative models.
The science has already pointed to what is likely to be most helpful to people who suffer distress. The challenge is to make the transformation that is needed for that to happen. This may not be as difficult as it sounds.
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- Case material is based on real life clinical practice, but not on actual real cases in order to preserve confidentiality. ↩
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