Editor’s note: This essay was commissioned by Mad in the UK, and submitted to Mad in America for simultaneous publication as a MIA Report.
Following the publication of the review finding no evidence for the low serotonin (“chemical imbalance”) theory of depression last month, I have been increasingly aware of the strongly held and often opposing opinions on social media. There are multiple voices in this field we broadly know as “mental health,” with clinical professionals, researchers, lived experience practitioners, service users, and the mainstream media all with apparently different views.
I thought it might be useful to talk to some of the key figures in this sometimes contentious debate. From alleged associations with the far-right, to what the experiences we call “mental illness” actually are, I challenged some of the biggest voices on the broadly “critical” side of the debate to find out what they actually believe.
It turned out to be a challenging task, trying to pin down what the critics actually think—or what they even want to be called—as it became apparent is there is no fixed, universal set of positions. The movement broadly critical of psychiatry does not exist as a monolith, and, as expected from a group of thinkers opposed to labels, many of them don’t want to be referred to as critical psychologists, “antipsychiatrists” (see why that is problematic here), or even “critical” at all! So, I am going to refer to the people I spoke to simply as “critics.”
One thing I found coming up in all my conversations is the emphasis on working in partnership with and finding inspiration from survivors and people with lived experience of distress. As someone with my own history of distress, I was pleased to hear that this movement is not just about the professionals; service-users’ experience was at the heart of everything the critics spoke about, as well as the importance of relying on the most up-to-date and accurate evidence.
All sounds sensible enough to me, so why all the media debate, and why do I keep hearing about the far-right?
(In writing this post Charlotte spoke with Dr Lucy Johnstone, James Barnes, Professor Peter Kinderman, Jo Watson, Professor John Read, Dr Sami Timimi, and several others.)
Do you really believe that mental illness doesn’t exist?
This is a common and confusing statement. Everyone I spoke to emphasised that they completely accept the existence and validity of people’s suffering, despair, and distress. (How could you not?)
What they are challenging is the idea that these experiences and divergences can best be explained as medical illnesses or “disorders.” This is a quite different point, but one that is often confusing to people who have never questioned (or even been given the opportunity to question) deeply held assumptions about distress that are widely held in society.
To challenge the medical model is not at all the same thing as denying people’s experiences. This would be a nonsensical view to hold for the many critics whose views are based on extensive clinical work, and in some cases on their own personal experiences as well. What is challenged is the idea that these very real experiences and differences can be best understood as a medical illness or “disorder.”
As one critic said: “No one would work in services if they thought people were somehow inventing these experiences!”
Ok, we’re calling it distress, but not a disorder. So, are critics all about banning words and policing language?
Some of the people I spoke to have been involved in drawing up guidelines for journalists, while others have proposed non-diagnostic approaches in services. No critics want people to be told how to describe themselves and their experiences, whether they use medical terms or any other vocabulary. But ironically, as they told me, one particular view—the current medical or diagnostic explanation—is routinely imposed on people. It is opposing this imposition that unites all the critics, despite their differences in some other respects; they all said that what they were concerned with is the lack of choice of perspective and the fact that being medicalised has almost become the precondition for receiving any mental health support or care at all.
The current medical and diagnosis-based explanation of suffering and distress is deeply embedded in services, the media, and the minds of the general public. The critics are concerned that the unquestioned use of terms like “mental illness” or “disorder” leads to a certain set of views which shuts down other possibilities.
The aim of promoting more neutral terms, especially in the media, is to open up, not shut down, room for personal preferences. As it is, people who enter services are very rarely offered any choice of language, perspective, or culturally sensitive understanding. In this system it may be risky or even be punished (for example telling them they “lack insight”) to hold legitimate but alternative views.
One of the ways of promoting choice is to use language—such as “hearing voices,” “extreme distress,” “low mood”—which does not assume any particular model.
What about my diagnosis?
The critics I spoke to explained how they believe that in the long-term there are much better ways to plan care and offer benefits, accommodations, and services than is being delivered by the current system of psychiatric diagnoses. Many of them argue for reform, or better versions of what we have; others put forward a more radical vision that is based on fundamentally different principles, such as the Power Threat Meaning Framework.
But all of them recognise that in the system we now have, no matter its significant flaws, people currently need diagnoses to access essential services and benefits, and that getting support must be prioritised. “I have spent many hours filling in forms with people,” said one clinician, “The difference is, I have an honest discussion about what term is most likely to get them what they need, and is most acceptable to them. I don’t just tell them they ‘have’ X psychiatric condition.”
The critics respect the fact that some people (both service-users and professionals) find diagnoses helpful and meaningful. They are also aware that others have found diagnostic labels deeply disempowering and stigmatising, and a long-term barrier to dealing with their actual difficulties. Labels, stigma, and stereotype-threat can all be experienced as distressing or detrimental to hope and a positive self-image.
And for some of the critics, there is a bigger issue regarding the scientific validity of diagnosis, which poses the question as to whether we should be moving towards a different way of explaining distress. Critics all believe that we need better alternatives, which would lead to services that operate on a more humane model. At the very least, people—both professionals and service users—need to be made aware that there are non-medical ways of understanding their experiences. They also have a right to be offered these alternatives. However, we are a long way from that more democratic position, despite open acknowledgement that DSM categories are not scientifically valid.
What about my medication? Are you against the use of psychiatric drugs?
First of all, if you are taking psychiatric drugs, we would urge you not to come off them abruptly and to seek the advice of your prescriber (apart from anything else, these are powerful drugs which can have severe withdrawal effects).1
Everyone I spoke to agreed that drugs have a role and can be helpful or even experienced as lifesaving by some. As one of them said, “I have personally never met someone who wanted to ban use of psychiatric drugs, or describes them as evil, or shames people for taking them. These allegations contribute to an unhelpful polarisation of views, which prevent us from having a constructive dialogue about how to use drugs with most benefit and least harm.”
However, they were all very concerned (as are many senior professionals in mainstream services) about the overuse and misuse of psychiatric drugs—the overstating of benefits, underplaying of risks, and lack of proper informed consent. The critics suggested that these factors are related to the huge increases in psychiatric drug prescribing and use. They all were adamant that proper, accurate information is key so that people can make their own informed decisions.
They also deplored misinformation—the recent debunking of the widely held “chemical imbalance” myth is an example, but critics pointed out that the same myth is promoted about so-called “antipsychotics.” The evidence for the effectiveness of many psychiatric drugs is less impressive than it appears. Some critics have been extensively involved in campaigning for awareness of potential damage, including in the form of severe withdrawal effects, and the need for tapering advice and support.
In fact, some felt these names (“antipsychotics” and “antidepressants”) were very misleading in themselves; as one person told me, “They used to be called major tranquillisers, which actually described them much better. There is no specific effect on psychosis, in the same way that there is no specific effect on depression.” Critics all knew people from the “prescribed harm” community who have undoubtedly been more damaged than helped. They want much greater honesty about what drugs can and cannot do, and thus, much better, and safer choices for service users, both when starting and when coming off their drugs.
So, where does biology come into all this?
The way this was explained to me is that all human experience has biological aspects—whether we are talking about emotional distress, happiness, or any other state of mind. There is nothing unique about emotional suffering or acute distress in that sense.
The fact itself that biology is involved does not justify calling something an “illness” or “disorder,” where the assumption is that the main cause is something that is malfunctioning in the brain or body, rather than something that has gone wrong in a person’s life or wider environment.
This is the basis of the slogan “Instead of asking what’s wrong with me, ask what’s happened to me—socially, relationally, culturally, politically etc.” In other words, critics argue—and say there is a lot of evidence to support them—that many forms of emotional distress become entirely comprehensible when read carefully in the full context of a person’s social, cultural and relational life. Obviously, this has major implications for the best ways forward.
I read online that critics are allied with the far-right?
This allegation has come to the fore recently, and critics were united in seeing it as ridiculous. In fact, they believe it can only be understood as a desperate attempt to smear their views.
What I instead found was that people critical of traditional psychiatric care tend to be politically left-wing, emphasising social justice and the need for better, and better funded, services for people in distress. One critic explained how they believe we are entitled to better and more equitable social services, financial support, and vital accommodations for people in difficult circumstances or with particular needs. In their view we should offer social and financial benefits based not on the presence or absence of disputed “disorders” but on a person’s needs (now that’s what I call socialism).
Recently, right-wing politicians and commentators have tried to co-opt language, views, and research from the “critical” perspective for their own agenda. One critic pointed to narrow forms of CBT being turned into the “back-to-work” IAPT project, as an example. They are strongly opposed to these ways of co-opting ideas. However, they were keen to point out that it is actually medical ideas (that some people have defective genes or are inherently flawed) that have been most frequently misused in this way—for example, in support of eugenics or, more recently, in conservative pro-gun policies (that blame gun shootings on “mental illnesses” rather than on lax gun laws).
Overall, everyone I spoke to seemed confident that no one actually takes this accusation seriously. However, they did see these accusations, no matter how strange, as almost inevitable. “You don’t get fundamental change without a backlash,” said one of them.
I heard that critics are anti-vaxx, anti-science, and involved in Scientology?
This is another point that critics strongly dispute. Several of them are prominent academic and scientific researchers, working in universities, and all I spoke to were also confident that their views are supported by the best evidence; evidence which, if enacted, would lead to mental health policies and practices that are more just, humane, effective, and compassionate. The critics all stated that they support evidence-based care and that includes vaccination.
This focus on empirical evidence was reiterated to me several times, with other critics arguing that many current practices in biomedical mental health care seem in opposition to the best, most up-to-date evidence—for example ECT (see below) and recent publicity about the chemical imbalance theory. Indeed, it is precisely this emphasis on the scientific approach that critics use as an argument to reform traditional psychiatry—because so much of the dominant, bio-medical, mental health care runs counter to science and is not, in fact, supported by the evidence.
“Science, as well as strongly supporting vaccination and other public health responses to viral pandemics, also tells us that many of the claims of traditional psychiatry are untrue,” said one person.
No one I spoke to was anti-vaxx, nor did they want to spend time debating what they saw as an irrelevant attempt to discredit them. Similarly, they were clear that they have absolutely no links with Scientology.
Critics are anti-ECT and want it banned
This was one of the issues where people had different opinions; some feel, and have said for years, that there is no place for ECT, while others believe it might still be appropriate in clearly defined situations if the evidence supported it. All agree that the only way to resolve the issue is to have a thorough review of ECT. That means re-visiting research about its effectiveness and taking a close look at the evidence for the claims that it is a miraculous, life-saving treatment. It means looking at how ECT is used—which in many cases is not in accordance with NICE guidelines. And it also means investigating the possibility of harm—including brain damage—caused by ECT and ensuring that people are giving fully informed consent. Campaigners strongly believe that it is unacceptable for accreditation of ECT clinics to be optional and are surprised that this idea is denied or resisted. As one of them said to me, “Surely it is in everyone’s interest for interventions to be carried out safely, and regulated properly?”
The key issue here seemed to be whether people are being honestly given the information they need to give informed consent. So, yes, people critical of traditional psychiatric care are concerned that the evidence supporting the use of ECT is simply not there, but the focus of their current campaign is a review of the practice, not a simple “ban.”
Everything is caused by trauma
No one I spoke to believed that all distress is caused by traumatic events; in fact, they thought the idea was self-evidently ridiculous. Some of them had criticisms of the rapid spreading of the term “trauma” to the extent that it risks losing its meaning. What they do say is that mental health systems typically ignore, deny, and fail to address traumatic experiences when they actually are present.
Another critic stressed the distinction between “PTSD”-type acute event trauma and ongoing relational/complex trauma. “Relational/complex traumas,” said this critic, “are subtle and insidious types of trauma that are much more common, and which do often play a role in distress, but this is very different to saying that people must have horrific events in their background.” Detractors often purposefully collapse this distinction, to make it appear as if critics are saying something clearly untrue.
Many service users have testified about how the label of “borderline personality disorder” has been used to silence and blame people who have survived exceedingly difficult events. This is not acceptable. We also need ways of understanding how distress can arise even without obvious “traumas.” The Power Threat Meaning Framework was cited to me as showing how wider contexts—such as poverty, discrimination, and living in competitive, fragmented, and unequal societies—can put all of us at risk, something we are likely to see more of as the cost of living and fuel-crises worsen.
It’s a power game; it’s all about psychologists attacking psychiatrists in order to take over from them
Critics strongly disputed this common accusation. They pointed out that a number of people in their loose group are psychiatrists and people who want their own profession to reform, and that many psychologists use diagnostic approaches. As above, some of them saw this as a way of deflecting from the real issues. Most of them have extensive clinical experience and emphasised the importance of working constructively alongside colleagues of all backgrounds. As one of them said, “The only people who accuse me of attacking psychiatrists are those who have never actually met or worked with me.”
Returning to the main issues, critics do all agree that psychiatry has serious conceptual failings, with often damaging impacts in practice. They emphasised that this doesn’t mean people are universally let down by the mental health system, but it does mean, in their view, that far too many are not helped, or even damaged and re-traumatised, and that clinical outcomes have been uniformly poor during the period of the medical model’s dominance.
I started by saying that this is not a homogenous group, nor do they have a precise or shared agenda about moving forward. Rather, they tend to point to a whole range of ongoing projects and initiatives, many of which come from the service user/survivor movement, such as the Hearing Voices Network. One of them said, “None of us has the answer, and we cannot see how the field is going to develop. But I hope that one day critical perspectives will be seen as simple, humane common sense.”
From my conversations with certain critics, I was struck by how passionately they talk about equality, wanting the best for service-users and the importance of grounding their beliefs in empirical research. Despite what their detractors suggest, they are a loose collective of clinicians, academics, writers, scientists, and journalists, some of whom have personal experience of distress and use of services, who just want to reform the existing models based on evidence and what’s best for the people affected. Everyone I spoke to had suffered difficult career consequences because of their views, including suspension, loss of jobs, and obstacles to promotion. However, this had not diminished their confidence, determination, and commitment to advancing and advocating for humane and effective mental health reform.
Of course, these people operate in a highly controversial arena. But I failed to find the rigidity, polarisation, and silencing that you might expect if you simply gathered your information from social media like Twitter. Whether or not you agree with such critical voices—and, as I found, they don’t always agree among themselves—many see their voices as a very necessary part of the fight for better services, better experiences, and better outcomes for people in distress.