Insane Medicine: Epilogue

Sami Timimi, MD

Editor’s Note: Over the course of several months, Mad in America has published a serialized version of Sami Timimi’s book, Insane Medicine (available for purchase here). This is the final chapter. All chapters are archived here.

I’ve had the idea for this book for a number of years now. I wanted to write something for a general rather than academic or clinical audience that brings together all the bits and pieces of theory and practice that has preoccupied me into an empirically-supported polemic. Bogged down with the grind of daily private and work life, and demoralised by the stickiness of the institutional swamps I have been trying to professionally survive, I just couldn’t get any momentum going.

Ideas can lay dormant for a long time while the socio-political landscape is static. The contradictions, inconsistencies, and downright lies of what we come to believe and accept as the “correct” knowledge can move around unhindered and unchallenged for decades. Every now and then a crisis of a magnitude sufficient to throw a web of uncertainty far and wide occurs, and previously supressed ideas may find the soil more fertile for growth. Good, bad, dangerous, empowering, liberating, oppressing—the potential for new imaginings to emerge or long dead ones to be re-born (and the fight against these) start churning around us.

It wasn’t long after Covid-19 spread far and wide, and lockdowns followed in its wake, that commentators and their institutional representatives started talking about the other coming pandemic—mental ill health. There was something revealing in this public discourse. If you scratched the surface of this narrative (that the knock-on effects of lockdown will be a mental disorder pandemic) a glaring contradiction emerged.

On the one hand it makes plain that the mental health pandemic will develop out of the social consequences of the new political and cultural landscape we have to inhabit for public health reasons. The impacts upon our mental health, we were told, will be through isolation, disconnection, loss of livelihoods, loss of socialised entertainment, and so on.

Having been warned that mental ill health is a by-product of ordinary and understandable disruptions in real life experiences, we were then being informed that this will have to be dealt with, not by addressing these social causes and the adversities that arise from them, but through services that can “diagnose” and “treat” resulting individual dysfunctions.

Calling the impact of social disruption “mental disorders/illness,” coupled with the idea that services will be overwhelmed, placed the response away from this social landscape into the depoliticised space that exists between the ears. In the mental health industry, social problems need individualised solutions, delivered by experts with the technical know-how for identifying and somehow fixing the resulting “abnormalities.”

Incensed at this disorderly construction, and energised by the potential for change that crises bring, I was finally ready to put pen to paper (or more accurately finger to keyboard). The detachment of the world of mental health from the everyday human realities was now in the realm of the absurd. Mental health ideology was firmly in the grip of neoliberal/late capitalist system (or whatever you want to call our disaster of an unequal economic system and the vapid politics it promotes): individualising, dividing, and disempowering as it commodifies distress and difference into ever greater numbers of human typologies.

These colonial typologies (both in terms of imposing Western constructs on non-Western populations and imposing Western elite constructs on Western populations) impose a caste system that inadvertently deprives large swathes of the population of their citizenship rights—condemning them to being simultaneously felt sorry for and distrusted. It is a system that victimises and creates victims (usually without its practitioners intending to), but also renders you unconscious (not just through its powerful sedatives) to the consequent enslavement that comes through promises to free your psyche from invisible evils that have somehow morphed away from your social history and reality into eruptions of abnormal biology and psychology.

I didn’t want to write just another book that can be quietly tucked away in some nice academic niche adding colour to a few critics’ bookcases. Was there any way to connect this to social movements? How could this contribute in whatever tiny manner to hacking away at that enlarging crack in the institutional edifices, to let in a little more light (enlightenment) on a subject shrouded in myth and fantasy?

I therefore decided to try something new to see if I can get that wider readership. I have been impressed by the way the Mad in America (MIA) website has expanded into a digital space that brings together a diversity of international critical voices, including blogs, reporting on new research, and some of their own excellent reports and analyses. I was delighted when Robert Whitaker agreed to publish the full book in a weekly serialised form on MIA (it is also now available in paperback and eBook forms on Amazon). I also want thank Peter Simons who has been my go-to contact at MIA and helped turn this idea into reality.

All ten chapters of the book have now been published and read by thousands. I hope some of those who read the book, or parts of it, found something useful and that it energised them in some way. As well as providing further ammunition in on-going critiques, I would like to imagine it also inoculated some with a few seeds of hope that may make further room for new imaginings of a post-mental health industry world to grow.

I would particularly like to thank all, and I mean all, who took the time to write comments, whether this was on MIA or through personal emails or social media. I do try and read them all. I’m sorry that I never participate with any replies. I took a decision many years ago, after dipping my toe in social media and other online discussions/debates, to steer clear of this. I came to the conclusion that it can often consume a lot of mental and physical time without really going anywhere productive. I hope you can understand and respect my reasoning, but I am very grateful for all the comments made that help me, and hopefully others, reflect on what I’ve written, whether that’s in critique or support of it.

I understand some of the comments that the subject I wrote about has been covered by more personally affected writers already and, as someone who has spent their working life in the system, that my perspective will not have the same authenticity as those who have been at the receiving end of the disempowerment, cruelty, and oppression that mainstream services are capable of delivering.  I hope that a critique from an “insider” that pulls no punches nonetheless has some merit. The more critical voices there are, the bigger the critical literature is, the better. I think that critical accounts from a diversity of perspectives, backgrounds, and positions each contribute in a small way to the growth of a social movement for change.

I wanted in this book to interrogate the assumptions that pervade theory, research, and practice in mental health. When stripped right back to the essential building blocks, you can see the emptiness of the empirical and philosophical paradigms in circulation. You cannot measure the mind using the same methodology for measuring urine flow. You cannot discover meanings and intentions by looking at colourful images of the brain.

Of course biology is involved, just as there are active biological networks making it possible for me to type these sentences. But we cannot see, feel, weigh, calibrate, and calculate standard deviations for how I came up with those sentences. We cannot escape subjectivity in understanding subjectivity. We cannot discover the “truth” about why I typed a particular sentence; we can only create a framework to explain that from a limited number of available systems of knowledge that we have been exposed to. Our choice of explanatory framework has profound consequences.

When we analyse my urine for various substances, my urine is not subsequently affected by that analysis. It will not change in response to my conclusions. Urine doesn’t get delighted, anxious, offended, decide to stick with me, or desert me. Not so for the explanations we use for mental phenomena. If you tell me that what drove me to write the above sentences was a mental “disorder” leading me to a dangerous and paranoid state of mind, the effects on my emotions, thoughts, and behaviours may be very different to if you told me that these sentences are a “breath of fresh air.” The effects will be more marked the more power the person has (or I perceive them to have) over me.

When we lose touch with this basic idea—that all we have are meaning making frameworks rather than neutral truths—we become dangerous without realising we’ve become dangerous, particularly if we find ourselves in positions of potential power and influence. Dominant mental health ideologies have created a reality where they have replaced the soul with psych. Imagining you know and can explain what’s wrong traps the practitioner and the patient in a cult-like religious paradigm, without recognising that this is what is happening.

With diagnosis, you create abstract objects circulating in the minds of the practitioner and patient, like daemons that are imagined to erupt out of your biology or psychology, which the modern priests (psychiatrists) will expunge with their magical potions and confessional rooms. Unlike a religious absolution however, these daemons are here to stay, periodically emerging, because they are not external, but genetic, hard-wired, somewhere in the brain, to be supressed/controlled.

The Royal College of Psychiatrists in the UK should be renamed The Royal College of Psychianity. In this, the religion of Psychianity, the notion of the psych emerges out of faith, not science. The psych is conceived as a real concrete object, which will reveal its “truths” through trusted ways of measuring and evaluating it. The psych can be understood objectively as a mind without meanings. Spirituality has been sucked out, leaving a churning soup of dangerous neurotransmitters to be studied using the scriptures of The Holy DSM and other quasi-religious manuals.

Questioning assumptions takes my arguments well beyond the stale psychotherapy versus psychopharmacology conflict. What matters more is the framework the practice is formulated in. Psychotherapy is just as liable as psychopharmacology to embed the story of diseases/dysfunction/disorder. Therapy, including occasional judicious use of psychotropics, can also employ more empowering models through maintaining a critical stance and being able to understand our models cannot reflect “truths,” but instead are tools with consequences.

The more important debate is not what we have more or less of in our mental health services, but what ideology they rely on. We may even have to do away with the concept of mental health (which creates inevitable polarisation with illness/ill health). I have questioned the idea of “mental” and the framing of “health.” Maybe we will just eventually have wellbeing services—whatever it is, it should imply something that doesn’t foment the us/them, well/ill, normal/abnormal divisions.

In recent years I began to understand how the concreteness of the models we use across mental health services helps embed the very problems we are employed to alleviate. The short-term, McDonaldised quick relief/immediate satisfaction consumer focus means we provide a menu of goods (diagnoses and their assumed remedies) that we sell with promises that mental pain and suffering can be wiped away with no after-effects.

This then starts to write an important new chapter in the lives of people who have struggled, mostly with what I term ordinary and understandable experiences (even if they or we can’t initially see how that may be). They are now possessed by forces beyond their conscious or unconscious influence. They become alienated from their emotional lives, seeing in it dangers and never ending chasms. The new chapter written for them by Psychianity’s priests shapes how they and their loved ones interpret the significance of how they feel, behave, and think. I had to write something about this vicious trap.

It might sound like what I write is against psychiatrists, but it isn’t. Yes, I am one, and yes, that will influence my bias. Psychiatry, like any other socially constructed body, is made of individuals with various degrees of power and influence. They have been trained by the curricula and then cultured by the professional systems they have to work in. What I regularly hear from my psychiatry colleagues is how difficult it is to deal with patient demand and demand from other concerned people who understandably expect the psychiatrist to provide an explanation (diagnosis) and then a treatment plan, often with the hope that it includes medication.

Most would love to do more psychotherapy and many try to incorporate that into their practice. To disavow what is perceived by the public, other doctors, and other professionals as your role (being diagnoser and prescriber), is almost impossible. It is what I have tried to do for many years, but that really is swimming against the external tide of demand, not just the internal currents of established ideology.

This is why we need public education; an opportunity to change the discourse. Many doctors would support this as they experience the tide of medicalisation lapping at their clinic doors. Psychiatry should be the profession that can help the rest of medicine with the issue of medicalisation. Instead, a mafia-like collaboration between the pharmaceutical industry and much of academic psychiatry has rocket-fuelled my profession into the worst offenders of medicalisation—unhealthy, inappropriate, and dangerous to personal and public health.

Of course, this then necessitated that I also write about politics. McDonaldisation can only emerge in a political economy that encourages it. Therefore an appreciation of the broader political milieu, which influences who controls knowledge production, in whose interests they act, what model of “human” this promotes, and what the public then come to understand as the “common sense”position, all needed exploring.

This finally brings me to globalisation. Globalisation has accelerated in recent decades, particularly with the growth of digital technologies. This has amplified existing risks of neo-colonialism in both the concrete (such as trade and military power) and the abstract (the export and imposition of ideas). But it also creates new opportunities. International collaborations, communications, and activism are much more capable of crossing disciplines, interest groups, and borders.

I write this on a computer in my house in Lincoln in the UK, and it’s published on an American website, then affiliate websites (such as Mad in Brazil), then it’s shared on social media, where people from virtually any country may be able to read, comment, and debate it. In this new internationalism there is recognition that in our battle against a broken and corrupted ideology and its products, we share both the problems and the potential solutions or ways forward with many, many others far and wide across the globe.

Who knows when the critical mass will be sufficient for systemic change? Who knows how, where, and when it will emerge and happen? I just know we must keep believing; because we are on the side of the science, the ethics, and the future. As British politician, ex-Member of Parliament, writer, and socialist activist Tony Benn once said:

“There is no final victory, as there is no final defeat. There is just the same battle to be fought over and over again. So toughen up, bloody toughen up.”


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.


  1. Thanks. I enjoyed each chapter – actually waited for the new chapters to come out. Your epilogue ties it all together. I particularly liked the section on the coming Covid mental health pandemic. Social media, especially MIA, is a good way to get these ideas out to the public. Thanks again.

  2. I’ve waited a very long time to read a book-written by a psychiatrist-such as Insane Medicine; thank you Dr. Timimi for writing just that book. May your intellectual integrity and moral vigor catch fire in your profession, as well as with all “practicing” mental health professionals.

  3. I thank you too Sami. We hear a lot about the problems with psychiatry-as-she-is-spoke but rarely do we hear such incisive analysis of how those problems are rooted in our political and economic systems.

    I think your portmanteau could be improved with an extra character though.