Insane Medicine, Chapter 10: The Paradigm Shift Is Inevitable

Editor’s Note: Over the course of several months, Mad in America is publishing a serialized version of Sami Timimi’s book, Insane Medicine (available for purchase here). In this chapter, he summarizes the challenges to the current paradigm of mental health treatment. All chapters are archived here.

In 1961, an Italian psychiatrist called Franco Basaglia started refusing to bind patients to their beds in the Lunatic Asylum of Gorizia. He resisted the established methods of the time and began what is probably the single biggest revolution in modern mental health care that we have so far witnessed.

Basaglia had been revolted by what he observed as the conventional regime of institutional “care” in Italy at the time (not that different to what was common across Europe too): locked doors, only partly successful in muffling the weeping and screams of the patients, and institutional responses to human suffering that included physical restraint, straitjackets, ice packs, bed ties, isolation rooms, ECT, and insulin-coma shock therapies, whose purpose he saw as being to “quiet” the patient for institutional purposes.

From his initiative at Gorizia, he started a wide theoretical and practical debate all over Italy. The establishment railed against him and his allies, but the movement he started managed to convince politicians to change the country’s laws. In 1978, a national reform bill was passed that provided for the gradual but radical closure and dismantling of state mental hospitals in the whole country, with the aim of moving all mental health care into the community.

Law 180 is known as the “Basaglia Law” and was approved by The Parliament of Italy on May 13, 1978. It initiated the gradual dismantling of psychiatric hospitals across Italy. Full implementation of the psychiatric reform law was accomplished in 1998, which marked the end of the state psychiatric hospital system in Italy.

The movement Basaglia inspired is often referred to as “Democratic Psychiatry” and has influenced, at least to some degree, mental health laws in many countries, with community based psychiatric care becoming more of a service aim priority than institutional care.

However, Law 180 remains unique in mental health law around the world, as Italy is the only country where traditional state-run psychiatric hospitals are illegal. Instead there are psychiatric wards in general hospitals with a limited number of beds. Italy has the lowest number of psychiatric beds in Europe relative to the population. It has very stringent criteria for compulsory treatment, which doesn’t include risk as a criterion, only urgent treatment, and only for a maximum of 14 days.

Alarmist predictions about how a system like this wouldn’t work and would not only lead to diminished health for those with mental illnesses, but would also increase the risks for the public, proved to be wide of the mark. The system has had its problems and challenges, but it has also unleashed the creativity of mental health practitioners and many projects have since developed in Italy that have taken mental health work out of the clinic into being a social activity that involves connecting with patients’ families and the wider community.

I remember some years ago a colleague of mine went to visit one of these projects—the “Users and Relatives as Experts” (UFE)—in Trento, Italy. She stayed at a bed-and-breakfast that was run by patients and ex-patients. She was taken to see some of the businesses that they ran and their community mental health centre. What most amazed her was the lack of locked doors anywhere. This is a very alien experience for those of us who work in mental health systems in the UK. She recalls talking to service users over breakfast and feeling welcome, calm, and safe. She was meeting people just like others she might in any context. There was none of the “them and us” you find in most Western mental health services.

Italy is a unique example of what can be achieved, particularly if mental health is, as it should be, politicised. We have many others that I have mentioned in passing in this book. Like the Open Dialogue approach in Western Lapland, the Power Threat Meaning framework developed in the UK, the service user “survivor” movements, the Hearing Voices networks, medication free wards in Norway, and various Feedback Informed Treatment projects around the world.

These are just examples from the Western world. We hear so little about all the community focussed approaches that occur across in developing countries, because these would not even be recognised as “mental health” related initiatives, so wide is the stigma and institutionalised colonialism against the “other” of the non-Western world.

What marks out these approaches is that they have dispensed with diagnostic and symptom-based thinking, embraced an understanding of the person that connects them to their wider social and personal contexts, and allows for the importance of relationships, both with the practitioner and important people in their lives, to be acknowledged.

Robert Whitaker is an award-winning American journalist and author. Earlier in his career he was writing about the ethics of psychiatric research in developing countries and had the mainstream assumption that there were medical mental illnesses and medications that treat them. The ethics he was originally researching had led him to be concerned about drug companies doing placebo-based research on antipsychotics in developing countries because they wouldn’t be able to do that in developed ones as withholding a known effective “treatment” would be unethical. Then he came across the World Health Organisation International Pilot Study of Schizophrenia (WHO-IPSS).

WHO-IPSS began in 1966 as a large-scale cross-cultural collaborative project carried out simultaneously in nine countries that differ widely in their sociocultural and economic characteristics: Colombia, Czechoslovakia, Denmark, India, Nigeria, China, the USSR, the United Kingdom, and the United States of America.

The researchers found there was a markedly better overall outcome for schizophrenia patients in India and Nigeria at 2-year and 5-year follow-up.

A second study was launched in the early 1980s using more stringent methods and looking at those experiencing psychosis for the first time in similarly diverse sociocultural settings (Colombia, Czechoslovakia, Denmark, India, Ireland, Japan, Nigeria, Russia, the United Kingdom, and the United States). Patients and key informants were interviewed at the start and at 1-year and 2-year follow-up and a large proportion were traced and assessed again after 15 years.

Complete clinical remission was more than twice as common in developing country areas than in developed countries. Patients in developing countries experienced significantly longer periods of unimpaired functioning in the community, although only 16% of them were on continuous antipsychotic medication (compared with 61% in the developed countries).

Coming across these studies was a shock for Whitaker. It went against everything he had believed up until then. He started looking more deeply into the data around outcomes from treatment, particularly outcomes from psychiatric medication treatments. What he found shocked him even more. All sorts of outcomes, particularly levels of functioning, had been getting worse the more a society used psychiatric medication. Yet we were being told that a revolution had taken place in psychiatric care after the “discovery” of medication-based treatments. Indeed it had. Outcomes had never been worse. Whitaker started writing about his findings firstly in his 2001 book, Mad in America, and then in his seminal work Anatomy of an Epidemic, published in 2010.

Robert Whitaker became an accomplished scientist working with many others to carefully sift through the academic literature on a variety of mental health related issues. He inspired the creation of the Mad in America website (https://www.madinamerica.com) which has become a platform that brings together various critics of mainstream practice writing blogs, providing advice, reporting on the latest research, and providing in-depth academic reports and analysis on topics of interest.

I know of plenty of other projects that have got going in the UK in recent years. For example, “Drop the Disorder” has been holding one-day conferences in a tour across the country, bringing together various professionals, service users, and other interested parties including politicians and authors, to highlight the injustice and poor outcomes that are inevitable in our current mainstream mental-health services. I am also a member of several international critical organisations including the Critical Psychiatry Network, Council for Evidence Based Psychiatry, Safely held Spaces, and the International Institute of Psychiatric Drug Withdrawal, all working towards the paradigm shift in mental health services that we all need.

Critical service users have been raising their voices in protest about the treatments they receive at the hands of mainstream psychiatry. For example, Hearing Voices networks, which are composed of people who hear voices and offer support for learning to live with voices as opposed to squashing them, have sprung up in many countries worldwide. There is now even a recognised academic field known as “Mad studies.” Mad studies is a field of scholarship, theory, and activism about the lived experiences, history, cultures, and politics about people who may identify as mad, mentally ill, psychiatric survivors, consumers, service users, and patients.

Even international official bodies are recognising these shifting sands. For example, Dainius Pūras, the United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of health, has called for a “revolution” in mental health, one that would replace the bio-medical paradigm of care with a paradigm that paid more attention to social justice, human rights, and ethics, recognising that mental distress is often the product of discrimination, poverty and inequality.

These people, projects, and organisations are not about to disappear. The momentum they have created is gathering. Reason, truth, and ethics are all on the side of the critics. Italy reminds us that radical change in a system is always possible and Whitaker reminds us that sometimes it just takes one insightful and energetic person to start a movement that is waiting to happen. We don’t know when enough of a critical mass will be reached. When it does, change can happen rapidly—a revolution will take place.

What next?

The advocates of the current system will scratch their heads about what we say. They cannot speak the same language.

If their starting point in a conversation is about the availability of treatments for this and that disorder, we have already lost them, as we tell them that this or that disorder does not exist in the natural world. If they argue that the problem is lack of resources, we have already lost them, as we tell them that they can throw more and more resources at a harmful paradigm and all that will result is more people experiencing its harms.

They may argue that the problem is that we have become too reliant on medication because of the lack of therapies; we have already lost them, as therapies are squeezed into the same failed technical approach and viewed as another form of prescription, “Take one tablet of this every morning and also take 12 sessions of cognitive behaviour therapy.”

They may argue that the problem is too many General Practitioners who are too stretched and end up overprescribing antidepressants as a result; we have already lost them, for they have denied, as did the self-defined “experts,” that they are responsible for creating the idea that there is such a thing as an “antidepressant.”

In this melting away of the old paradigm, we must be careful, as many people can be harmed in the confused no-man’s land between the death of one paradigm and the emergence of a coherent other. We have to guard against a further neoliberal takeover that simply enables a different form of commercialised, McDonaldised, profit-making vehicle to emerge. We would have to guard against the political classes finding new ways to co-opt medical and allied professions into policing the population.

Humanising the paradigm should open us all to the ordinary and understandable nature of diverse behaviours and experiences, including distressing and unwanted ones. We live in a strange world where we are told that our politics are about increasing our acceptance of the diversity of populations, but in our individualised and atomised units we are simultaneously self-policing these diversities by pigeonholing people into typologies, many of which are profoundly anti-diverse.

A money-making homogenised culture then emerges where individuality is both encouraged and viewed as suspect. In compare-and-compete culture, entrepreneurial individualism is rewarded and other types are to be “normalised.” This kind of divide-and-rule keeps awareness of structural inequalities at bay.

As we ease off the value base of compare-and-compete, we allow our emotional experiences greater depth and diversity and our behavioural manifestations less need for careful inspection for signs of “abnormality.” We will then be able to reduce the panopticon self-surveillance and be less inclined to freak out at the intensity of our emotional lives. We will allow our children to grow up differently whilst enjoying their unique world views and letting them make discoveries at their own pace and in their own time.

The reformed mental-health service will also be reforming our concepts of mental health and act as a deep preventative and protective shield against the violence inflicted by psycho-therapeutic state. In fact, it may no longer be called “mental health.” The word “mental” has too many connotations and contains a slippery construct that evades capture. Perhaps we just need “emotional wellness” services.

In these emotional wellness services, we would recognise that we are not dealing with broken brains, but people who are first and foremost people. We would bracket their experiences as being ordinary and/or understandable responses, often to psychological injury. We would recognise how humans can be resilient and understand that practitioners in this area, which will include doctors, use therapeutic philosophies rather than technical knowledge to help people.

We would be political, advocating for policies that create environments that are more nurturing for us all in a society that helps provide people with meaning, a sense of community, and a sense of civic duty. There is no doubt in my mind that such societies cannot happen under the umbrella of capitalism. Reduced levels of inequality through a more socialist organisation of economy would be a starting point, but by itself would not be sufficient. Educating the public, politicians, and professionals out of the dominance of the mental health/mental illness/vulnerability/technical model would have to take place.

“We are all in this together,” is the peculiar phrase ringing out in this Covid-19 pandemic lockdown that governs our current daily routines. Our decreed isolation units seem like the perfect satirical parody of the state of woman and mankind’s atomisation in late capitalism. The mental health ideology we have bolted on is the insane-making derivative.

We are all in this together, we will have pandemics of mental health problems, we will have to have more services to diagnoses your problems and treat them. The problems belong to you and you alone. They are inside you, they have taken you, and they will eat you from within if you don’t get an expert to sort them out. You are broken, abnormal; you are the person who needs treatment. You will be made crazy by the system and then made even crazier by my telling you that you’re crazy.

This is the double violence that the system does to you. It’s time for this insane medicine to be exposed and vanquished once and for all.

Quiz answers

Here are the correct answers from the quiz at the start of Chapter 1:

1. Overall, which one of the following factors has the biggest impact on outcomes from treatment of common mental health problems?

• • A. The quality of the relationship between therapist and patient
  • B. Factors outside of therapy such as the person’s social circumstances or beliefs about therapy
  • C. Having a diagnosis specific treatment, whether medication or psychotherapy
  • D. The number of sessions of treatment attended

The answer is: B. Factors outside of therapy such as the person’s social circumstances or beliefs about therapy.

2. Which of the following factors (among treatment-specific factors) has the biggest impact on outcomes?

• • A. Having a diagnosis specific treatment, whether medication or psychotherapy
  • B. Professional training of the practitioner/therapist
  • C. Years of experience of the practitioner/therapist
  • D. The quality of the relationship between practitioner/therapist and patient

The answer is: D. The quality of the relationship between practitioner/therapist and patient.

3. According to research, the following percent of people entering community mental health centres in the USA are either not responding to treatment or are deteriorating whilst in care:

• • A. 20-30%
  • B. 30-40%
  • C. 60-70%
  • D. 70-80%

The answer is:  D. 70-80%.

4. Public education programmes that promote an understanding that mental illnesses are like physical illnesses has helped decrease stigma:

• • A. True
  • B. False

The answer is:  B. False.

5. In Western populations, the relationship between use of mental health treatments and claims for disability benefits as a result of a mental health condition is that:

1. • A. Greater use of mental health treatments is associated with falling rates of disability claims
   • B. Greater use of mental health treatments is associated with rising rates of disability claims
   • C. There is no consistent correlation between the two

The answer is:  B. Greater use of mental health treatments is associated with rising rates of disability claims.

6. In trials comparing the effectiveness of different therapies, cognitive behaviour therapy (the most widely promoted and recommended form of psychotherapy) has overall been found to be superior to other psychotherapies for treating depression

• • A. True
  • B. False

The answer is:  B. False.

7. Psychiatric diagnoses are biological disorders that have been established through proper medical scientific research:

• • A. True
  • B. False

The answer is:  B. False.

8. Autism is not an established medical condition caused by abnormalities in the development of the brain and nervous system:

• • A. True
  • B. False

The answer is:  A. True.

9. There are no reliable tests you can take to find out whether you have Attention Deficit Hyperactivity Disorder (ADHD) or not:

• • A. True
  • B. False

The answer is:  A. True.

10. There is a reliable way of distinguishing between clinical depression and ordinary sadness:

• • A. True
  • B. False

The answer is:  B. False.

11. According to research, published in 2015, of a UK national project to improve outcomes from treatment for those attending community Child and Adolescent Mental Health Services, the percentage who showed “Clinical Improvement” from treatment was:

• • A. 16-43%
  • B. 26-53%
  • C. 6-36%
  • D. 36-63%

The answer is:  C. 6-36%.

12. According to a 2018 study that re-assessed patients who had completed treatment in one of the national UK NHS outpatient psychotherapy services, the percentage assessed as “recovered” was:

• • A. 33%
  • B. 9%
  • C. 6%
  • D. 53%

The answer is:  B. 9%.

13. In a 2019 survey of 1000 young people in the UK, the following percentage believed they currently or previously had a mental disorder:

• • A. 38%
  • B. 68%
  • C. 58%
  • D. 48%

The answer is:  B. 68%.

14. According to a 2019 research paper comparing outcomes from treatment of common childhood psychiatric disorders in studies from January 1960 up to May 2017, the outcomes over the nearly six decades of studies have:

• • A. Outcomes in studies in the 1960s were the same in terms of rates of improvement all the way through to 2017.
  • B. More patients got better in later rather than earlier studies
  • C. Fewer patients got better in the later rather than earlier studies
  • D. A mixed picture with no obvious patterns over time

The answer is:  C. Fewer patients got better in the later rather than earlier studies.

15. In terms of rates of recovery and levels of functioning, according to the World Health Organisation International Pilot Study of Schizophrenia, best outcomes were in:

• • A. USA
  • B. India
  • C. Denmark
  • D. France

The answer is:  B. India.

16. Clinical depression is caused by a low level of the chemical “serotonin” which antidepressants can correct:

• • A. True
  • B. False

The answer is:  B. False.

17. The relationship between drugs marketed as “antipsychotics” and size of the brain is:

• • A. A shrinkage of brain tissue is associated with taking a higher dose of antipsychotics for longer
  • B. Increase in brain tissue is associated with taking a higher dose of antipsychotics for longer
  • C. Reversal of brain tissue loss seen in a psychotic illness is associated with taking a higher dose of antipsychotics for longer
  • D. There is no is association between brain tissue size and taking a higher dose of antipsychotics for longer

The answer is:  A. A shrinkage of brain tissue is associated with taking a higher dose of antipsychotics for longer.

18. Those categorised as having a long term Severe Mental Illness, on average, live:

• • A. 5-10 years shorter than the population average
  • B. 10-15 years shorter than the population average
  • C. 15-25 years shorter than the population average
  • D. 5-10 years longer than the population average
  • E. The same as the population average

The answer is:  C. 15-25 years shorter than the population average.

19. Psychiatric science has not helped advance our scientific understanding of mental distress and has failed to discover any brain-based abnormalities:

• • A. True
  • B. False

The answer is:  A. True.

20. Clinical psychiatry has helped improve outcomes from treatment of mental distress

• • A. True
  • B. False

The answer is:  B. False.

 

Reference sources

Foot, J. (2015) The Man Who Closed the Asylums: Franco Basaglia and the Revolution in Mental Health Care. Verso.

Hopper, K., Harrison, G., Janka, A., Sartorius, N. (eds.) (2007) Recovery from Schizophrenia: An International Perspective. Oxford University Press.

Jablensky, A. (1992) Schizophrenia: Manifestations, incidence and course in different cultures. Psychological Medicine, 20(suppl.), 1-95.

Quiz answers

Questions 1 and 2

Cooper, M. (2008) Essential Research Findings in Counselling and Psychotherapy: The Facts are Friendly. Sage.

Duncan, B.L., Miller, S., Wampold, B., Hubble, M. (eds.) (2010) The Heart and Soul of Change: Delivering What Works in Therapy: Second Edition. American Psychological Association.

Wampold, B.E. (2001) The Great Psychotherapy Debate: Models, Methods, and Findings. Erlbaum.

Wampold, B.E., Imel, Z. (2015) The Great Psychotherapy Debate: Second Edition. Routledge.

Question 3

Drury, N. (2014) Mental health is an abominable mess: Mind and nature is a necessary unity. New Zealand Journal of Psychology, 43, 5-17.

Lambert, M.J. (2010) Prevention of Treatment Failure: The use of Measuring, Monitoring, and Feedback in Clinical Practice. APA.

Lambert, M.J., Ogles, B.M. (2004). The efficacy and effectiveness of psychotherapy. In, M.J. Lambert (ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 5th Edition. Wiley.

Lilienfeld, S.O. (2007) Psychological treatments that cause harm. Perspectives on Psychological Science, 2, 53-70.

Hansen, N.B., Lambert, M.J., Forman, E.M. (2002) The psychotherapy dose- response effect and its implications for treatment delivery services. Clinical Psychology: Science and Practice, 9, 329-343.

Question 4

Angermeyer, M.C., Matschinger, H. (2005) Causal beliefs and attitudes to people with schizophrenia. Trend analysis based on data from two population surveys in Germany. British Journal of Psychiatry, 186, 331-334.

Read, J., Haslam, N., Sayce, L., Davies, E. (2006) Prejudice and schizophrenia: A review of the ‘Mental illness is an Illness like any other’ approach. Acta Psychiatrica Scandinavica, 114, 303-318.

Question 5

Viola, S., Moncrieff, J. (2016) Claims for sickness and disability benefits owing to mental disorders in the UK: Trends from 1995 to 2014. British Journal of Psychiatry Open, 2, 18-24.

Question 6

Duncan, B.L., Miller, S., Wampold, B., Hubble, M. (eds.) (2010) The Heart and Soul of Change: Delivering What Works in Therapy: Second Edition. American Psychological Association.

Elkin, I., Shea, M.T., Watkins, J.T., et al. (1989) National Institute of Mental Health Treatment of Depression Collaborative Research Program. General effectiveness of treatments. Archives of General Psychiatry, 46, 971-982.

Wampold, B.E. (2001) The Great Psychotherapy Debate: Models, Methods, and Findings. Erlbaum.

Wampold, B.E., Imel, Z. (2015) The Great Psychotherapy Debate: Second Edition. Routledge.

Question 7

Kingdon, D. (2020) Why hasn’t neuroscience delivered for psychiatry? Psychiatric Bulletin, 44, 107-109.

Timimi, S. (2014) No More Psychiatric Labels: Why formal psychiatric diagnostic systems should be abolished. International Journal of Clinical and Health Psychology, 14, 208-215.

Question 8

Runswick-Cole, K., Mallet, R., Timimi, S. (eds.) (2016) Re-thinking Autism: Diagnosis, Identity, and Equality. Jessica-Kingsley.

Timimi, S., McCabe, B., Gardner, N. (2010) The Myth of Autism: Medicalising Boys’ and Men’s Social and Emotional Competence. Palgrave MacMillan.

Question 9

Timimi, S. (2005) Naughty Boys: Anti-Social Behaviour, ADHD and the Role of Culture. Palgrave MacMillan.

Timimi, S. (2018) A critique of the concept of Attention Deficit Hyperactivity Disorder (ADHD). Irish Journal of Psychological Medicine, 35, 251-257.

Timimi, S. (2018) Rebuttal to Dr Foreman’s article on ‘ADHD: Progress and Controversy in Diagnosis and Treatment’. Irish Journal of Psychological Medicine, 35, 251-257.

Timimi, S., Leo, J. (eds.) (2009) Rethinking ADHD: From Brain to Culture. Palgrave MacMillan.

Question 10

Davies, J. (ed.) (2016) The Sedated Society: Confronting our psychiatric Prescribing Epidemic. Palgrave MacMillan.

Horwitz, V.A., Wakefield, J. (2007) The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. Oxford University Press.

van Os, J., Guloksuz, S., Willem Vijn, T., Hafkenscheid, A., Delespaul, P. (2019) The evidence-based group-level symptom-reduction model as the organizing principle for mental health care: time for change? World Psychiatry, 18, 88-96.

Question 11

Edbrooke-Childs, J., Calderon, A., Wolpert, M., Fonagy, P. (2015) Children and Young People’s Improving Access to Psychological Therapies: Rapid Internal Audit, National Report. Evidence-Based Practice Unit, the Anna Freud Centre.

Question 12

Scott, M. (2018) Improving Access to Psychological Therapies (IAPT) – The need for radical reform. Journal of Health Psychology, 23, 1136-1147.

Question 13

Wright, B. (2019). Documentary reports mental health crisis amongst young people. Retrieved from https://happiful.com/documentary-reports-mental-health-crisis-amongst-young-people/ accessed 16.06.2020.

Question 14

Weisz, J.R., Kuppens, S., Ng, M.Y., et al. (2017) What five decades of research tells us about the effects of youth psychological therapy: A multilevel meta-analysis and implications for science and practice. American Psychologist, 72, 79-117.

Question 15

Hopper, K., Harrison, G., Janka, A., Sartorius, N. (eds.) (2007) Recovery from Schizophrenia: An International Perspective. Oxford University Press.

Jablensky, A. (1992) Schizophrenia: Manifestations, incidence and course in different cultures. Psychological Medicine, 20(suppl.), 1-95.

Question 16

Moncrieff, J. (2009) The Myth of the Chemical Cure. Palgrave MacMillan.

Question 17

Moncrieff, J. (2013) The Bitterest Pills: The Troubling Story of Antipsychotic Drugs. Palgrave Macmillan.

Question 18

Parks, J., Svendsen, D., Singer, P., Foti, M.E. (eds.) (2006) Morbidity and Mortality in People with Serious Mental Illness. National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council.

Questions 19 and 20

Read the book.