Psychiatry has too much to lose to change

Why does psychiatry need to change? Because it misleads people about the nature of mental illness. It tends to encourage people to think that mental illness is caused by brain abnormality. But most mental illness is not brain disease.

Why does psychiatry mislead people in this way? Because it suits its own interests rather than those of the patients it is supposed to serve. As it can convince enough people of its perspective, it gains prestige and economic prosperity. It is institutionally corrupt (see eg. previous post). 

Psychiatry is unlikely to change. It has too much financial leverage. Its funding will continue to rise because responding to mental health need is still required. It suits psychiatry to exaggerate its ability to do so. 

Does the truth about the nature of mental illness not matter? I think it does. Of course we need myths to live by but scepticism about psychiatry’s dogmatic claims and expression of that critique is important. We just need to be realistic that the vested interests of psychiatry are difficult to overcome.

Where psychiatry winning the anti-psychiatry debate has led us

I’ve said before (see eg. previous post) I don’t like the term ‘anti-psychiatry’. Still, it serves a useful purpose of referring to what was seen as a crisis within psychiatry in the 1960/70s. Critics of psychiatry, such as RD Laing and Thomas Szasz, were labelled as anti-psychiatrists by mainstream psychiatrists, such as Martin Roth (see eg. another previous post). Roth suggested anti-psychiatry was “anti-medical, anti-therapeutic, anti-institutional and anti-scientific”. Any sensible psychiatrist should have nothing to do with it!

Psychiatry since then has been polarised between pro-psychiatry and anti-psychiatry. A compromise was sought, particularly in the book Psychiatry in dissent (1976) (see eg. previous post) by Anthony Clare. What Clare argued is that psychiatry does not merely rely on a biological approach to mental illness, and this is true (see eg. another previous post). He wanted to move on from ideological conflict about psychiatry and avoided such disagreement by fudging the difference between mind and brain.

The trouble is that such evasion of conceptual issues about mental illness does not do justice to real differences between functional and organic symptoms in psychiatry. Of course the brain mediates what we think, feel and do. The functioning of the brain can also be impaired by a physical lesion or by a toxic or degenerative process. Such syndromes when acute are known as delirium or toxic confusional states. Chronic, irreversible brain lesions produce dementia. Such brain impairments are not, however, present in the majority of psychiatric presentations, however much psychiatry may encourage people to think they will eventually be discovered by research (see eg. previous post).

Psychiatry officially abolished the distinction between functional and organic conditions in DSM-IV (see eg. previous post). It tends to focus on neuroscientific perspectives (see eg. another previous post). But reducing people to their brains loses the essence of trying to understand why they are thinking, feeling and behaving in the unhealthy way they are. Brains are only part of people. Understanding the whole person may be difficult but isn't resolved necessarily by blaming their brain.

Explaining people in terms of their brain has led to the current situation with neurodivergence (see eg. previous post). Although psychiatry won the anti-psychiatry debate it has created the misleading impression that there are particular kinds of brains that determine our personality. Tending to see ourselves as no more than our brains does not do justice to the nature of human beings and life in general. 

Coping with the increase in diagnoses of ADHD and autism

The final report of the Independent Review into Prevalence and Support for Mental Health Conditions, Autism and ADHD has been published (see previous post about interim report). As I’ve mentioned before (eg. see previous post), specialist neurodiversity services (although the review does not want to use the term ‘neurodiversity’) tend to be separated from general mental health services. This was partly because general psychiatrists did not want to be, even had concerns about being (see another previous post), involved with such assessments and treatment, particularly initially when the concept of adult ADHD expanded from its origin in the 1990s. So referrals for ADHD and autism tend to be separated off into specialist services creating vast waiting lists. Both ADHD and autism were originally childhood diagnoses, which have been extended into being also adult diagnoses, usually made in retrospect. I think the review could have emphasised more how such adult diagnoses have been developed over recent years from what were originally seen as primarily childhood diagnoses. Putting ADHD and autism together in the paradigm of neurodiversity only really developed from the 2010s, at least partly within online communities.

The review proposes more integration of services for ADHD and autism with general services by developing what it calls a shared needs assessment and prioritisation framework, both for commissioning and delivery. This includes what it calls closing treatment gaps by investing in services for those with severe, complex and enduring needs. Such changes will be delivered through implementation of a new cross-governmental mental health strategy, which I have been pointing out is needed to deal with the current fragmented and dysfunctional nature of services (see eg. previous post).

It will be interesting to see how willing and able already hard-pressed general services are in taking on responsibility for also dealing with referrals for neurodiversity. At least it should mean that assessments and formulations will be more comprehensive, rather than focused on merely filling out screening questionnaires. For children and adolescents it may lead to a shift to a more familial focus, rather than just on the child.

The review fudges what I think is the fundamental issue of the neuro-turn in popular and academic culture for our understanding of neurodiversity and mental health conditions (see eg. previous post). The increasing biologisation of the self means that people diagnosed with ADHD or autism tend to see themselves as having different kinds of brains. Neurodiversity tends to mean neurological diversity in common parlance (see eg. last post). The report does little to counter such thinking, although it does recommend commissioning a national public information and education campaign to help people better understand, support and accommodate neurodevelopmental conditions and manage their mental health. However, it does not really say what the content of such a national public campaign will be. In fact, the report says that “[n]eurodevelopmental conditions describe differences in the development of the brain and nervous system” when there is no clear such evidence. Of course personal development is mediated by the brain but that does not mean it is necessarily caused by it. Conceptually it doesn’t really make sense to blame ADHD and autistic brains for our personal nature, which of course is embodied in the brain and the body more generally but is also embedded in the environment. It is important to try and understand the reasons for why we think, feel and act as we do, but they cannot be proven or demonstrated in naturalistic terms. People are more than their brains, and are being misled about the nature of ADHD and autism. 

The review concludes that continuing as we are is unsustainable. How much it will lead to any real changes, or provide recommendations for government to make real changes, remains to be seen.