Current mental health services across the world are a disaster. The problem isn’t underfunding or the scale of the mental health challenge in society. It isn’t social media, stigma, lack of education, lack of training, lack of doctors or lack of therapists. The problem that must be tackled before there is any real chance of improving mental health provision is the dominant ideology. It is the concepts of mental health, mental wellness, mental illness and mental disorder that pervade our public discourse. It is the way we have come to talk about and think about mental health. It is the narratives that the public are exposed to, day in day out, popularizing a jaundiced, scientifically illiterate, idea that we know what sort of a ‘thing’ mental disorder is, that it is widespread and needs diagnosing so that effective treatments can be provided. It is the endless expansion and commercialization of so-called psychiatric diagnoses, so that they operate as lucrative brands rather than legitimate categories that help build knowledge and improve clinical practice. It is the ideology that guides the frameworks that organize our mental health services and the professional trainings those who work in them receive. Tinkering with the current ideologies and the systems organized around them will not help. To clear up this abominable mess we must first rid our trainings, services and discourse of the pseudo-science that has delivered the diabolical outcomes we have where services are better at creating long-term patients, being slowly poisoned with neurotoxins erroneously labeled “medication,” than alleviating understandable distress.
It is vital to understand some of the basic flaws. The current taxonomy used in psychiatry is not diagnostic. In medicine, diagnosis is the process of determining which disease or condition explains (at least in proximal terms) a person’s symptoms and signs. When making a diagnosis of “asthma,” for example, we are determining that the cough the patient complains about is caused by spasm in the bronchi of the lungs, as opposed to other causes of cough (at least in proximal terms; we may not fully know more distal causes). Hence, asthma is defined by this pathological process: asthma is attacks caused by spasms in the bronchi of the lungs. Classifications in psychiatry cannot explain behaviors or experiences, and there are no signs, only descriptions (not explanations) of behaviors or experiences. Thus, one does not classify psychiatric conditions by reference to a particular known pathological abnormality (i.e., an explanation). Instead, it is a descriptive taxonomy. Calling descriptive categories “diagnostic” doesn’t pass a basic understanding of the scientific principles that support such a taxonomy. Calling our descriptive classifications diagnostic leads to circular reasoning and thus reification.
Saying, for example, that someone’s poor attention is caused by Attention Deficit Disorder is like saying that the pain in my head is caused by a headache. A descriptive taxonomy cannot, by definition, be diagnostic. That’s not a matter of my opinion — it is basic principles. Further, we must recognize that our current taxonomy is not just descriptive but subjective. In the rest of medicine, we have, like in psychiatry, debates about the boundaries for particular conditions, but unlike psychiatry, there are no debates about the parameters we use to define the conditions. Height, weight, blood sugar, peak flow, blood pressure, etc., exist as objective parameters that can be measured and are independent, as parameters, of doctors’ subjective opinions. This is not the case in psychiatry. The relevance of what we decide is pathological low mood, for example, is subjective in terms of both assessment of its boundaries and the meanings we construct for it. It doesn’t exist as a value neutral objective entity out there in the physical world that can be measured independent of subjective interpretation. For many cultures and religions, low mood/mental suffering may be a source of personal growth and wisdom, not a sign of an “ill” mind. We cannot escape that psychiatric taxonomy is not the same as the rest of medicine. It is descriptive, not diagnostic, and it uses subjective and therefore culturally bound/constructed parameters.
The result of this basic error is that medical scientific knowledge in the area of mental health is at a standstill. No chemical imbalances, consistent neurological differences, genetic abnormalities or markers found. None. Billions of dollars of wasted money on wasted biological research that leads nowhere. Studies of outcomes from mainstream services shows not only that have we not advanced technically (if anything, outcome studies 50 years ago showed better outcomes than now), but at a population level we have more people than ever taking psychotropic medication (many long term), higher levels of reported stress and anxiety, higher numbers of people disabled due to a mental health condition and rates of significant improvement from those attending mainstream services hovering at around a quarter to a third of those they see. These are not the outcomes you would expect to see from an effective model of clinical care.
I, therefore, welcome the open letter regarding the reform and revision of diagnostic systems from the Task Force on Diagnostic Alternatives of the Society for Humanistic Psychology. The failings of the current system must be called out. As the letter points out, we have much data showing that adversity in its many forms is the most strongly associated with mental distress. We have a variety of non-diagnostic- and non-medication-centered models that can be further developed for administrative, clinical practice, and service design and that can be used in place of the current diagnostic paradigm. I applaud the Society for Humanistic Psychology for writing this letter but am not optimistic that they will receive a sympathetic response that takes seriously the points they raise. There are too many guild interests and hierarchical influence and power to protect. This should not dissuade anyone from the importance of continued resistance to this societal tyranny.
There is every reason to continue this struggle as biomedical-driven models that we use are ultimately finished. Whether it takes five, ten or 50 years, there is no rescuing these models. Challenges and alternatives are emerging from all directions, and whilst there is still huge money to be made — and therefore powerful vested interests involved in maintaining this broken status quo — the deception cannot last forever. Psychiatry’s dirty secrets are being exposed and the emperors’ modernist pretensions are becoming ever more obvious.
Sami Timimi, MD is consultant child and adolescent psychiatrist and visiting professor of child psychiatry and mental health improvement, University of Lincoln, UK.