Making neurodiversity less medical

The Independent review into mental health conditions, ADHD and autism (see previous post) has produced an interim report. Its main interpretation of the evidence is that there needs to be more of an emphasis on functional need rather than diagnosis alone.

The implications for policy and service design are to be worked out before the final report. It would be better, at least as far as neurodiversity is concerned, if assessment did take more of a functional rights-based approach. The person’s level of functioning and the intervention which can maximise functioning, together with an evaluation of the usefulness of that intervention, need to be properly assessed. This is required primarily in educational and workplace settings. In effect, this should shift much of the work of assessment and treatment from health services to educational and occupational psychologists.

Changing how mental health and illness are understood

Is there anything wrong with how we understand mental health and illness? Surely we know what these terms mean. After all, our brain can be healthy, and there may be something wrong with how it functions, amounting to a pathological abnormality which we call mental illness. Isn’t that obvious?

I agree this is the way we tend to think these days. It’s our cultural understanding that there has been major progress in understanding how the brain works and what can go wrong in its functioning. We tend to believe neuroscience has made considerable advances and we expect doctors who want to be psychiatrists and other mental health professionals to learn about these matters and apply this knowledge in their care and treatment of patients.

But it's not generally brains that become unhealthy; it's us! Please don't misunderstand me. Of course I'm not saying the brain has nothing to do with our state of mental health and illness. It mediates our thoughts, feelings and behaviour. But it's not us; it's only part of us. It's us that are alive and can be mentally healthy and unhealthy. Of course our brain can contribute to that state. But we need to understand ourselves as more than our brain. 

So, what does it mean to say we, rather than our brains, can be mentally ill? We're not necessarily making a statement about our brains. And we're not necessarily saying anything about our body, as such. Illness is something we experience. It may be caused by bodily dysfunction, and we can too often assume that there must be something wrong with our body when we feel ill. We may have all sorts of speculations about what's gone wrong with our body when we experience symptoms. But, quite commonly, these ideas do not prove to be the case. Actually, often, what can be reassuring is if the doctor indicates that our concerns are unlikely to be correct from the presenting symptoms and signs.

Modern psychiatry developed by identifying insanity, which we now call psychosis. However logical their private understanding may seem to a psychotic person, it is the loss of common sense viewed by most people that is characteristic of madness/insanity (see eg. previous post). Psychiatric treatment of course covers wider conditions than psychosis and there may be questions about what counts as a psychologically morbid state. Psychiatry could be said to have extended even further in its diagnostic reach, with such modern concepts as neurodiversity, which are not necessarily even seen as abnormal. Psychiatric diagnosis is not an exact science.

Clearly, though, psychiatric diagnosis does not necessarily imply bodily dysfunction. It is a statement primarily about psychological functioning. It is usually a description of a personal, not a brain, state. The brain may cause that mental state but it does not in the majority of cases. To talk about brain health, as we now often do (see eg. previous post) may well be a misnomer. It’s about time we moved on from the misguided hope that we can understand mental health and the majority of mental illness in terms of our brain. 

We are all neurodiverse

Sami Timimi (see eg. previous post) blogs at Mad in the UK about neurodiversity (see post). As he says, “[T]he belief there is a neurological basis to these conditions … is prevalent". This is despite "[n]o unique, characteristic, and reliable findings in genetic, neuroanatomical, neurofunctional, or neurochemical investigations" having been discovered. As Sami goes on:-

Take neuro out of neurodiversity and we are left with the only reliable statement we can make about the human condition in general: that there is diversity. We are all unique. Ultimately, we are all neurodiverse, making the concept, and its sub-categories (like ADHD and autism), painfully useless at differentiating and classifying different types of people.

Any psychiatric diagnosis is not an absolute concept. Does the concept of 'neurodiversity' have any utility if it does not point to brain differences? I have suggested before (see previous post) replacing the term with 'biopsychosocial diversity'. I don't think the review into mental health conditions, ADHD and autism set up by the government (see previous post) will find any experts prepared to say that any definite biomarkers have been found for neurodiversity. There are no more than hypotheses which have not been proven.

It would be helpful if that review could make this situation clear as people are being misled. We all need to adapt to other people's differences. There's no need to propagate a myth that the biological basis of neurodiversity has been found to substantiate the need for accommodations to people's differences.

Institutional pressures in psychiatry

Lade Smith, outgoing President of the Royal College of Psychiatrists, has called on the UK government to address the “silent mental health pandemic” (see press release). The government has set up a review to examine what is driving rising demand (see previous post). The College, of course, emphasises the need for more funding, but doesn’t really talk about the need for change, apart from promoting the Community Mental Health Framework and neighbourhood hubs.

As I said in a previous post:-

The current Community Mental Health Framework for Adults and Older Adults to transform mental health services has been too non-specific in providing direction and there has been insufficient progress in its implementation. ... Community Mental Health Teams have become too large and need to be devolved so that there is one in every Primary Care Network (PCN). The PCN mental health teams also need to work alongside non-medical mental health hubs, one of which again should be in each PCN.

I’m not against increasing funding for services, but they do need to become more patient-centred. Psychiatry itself is partly responsible for the increased demand by fostering simplistic solutions to mental health problems. It misleads people about the nature of mental illness by encouraging them to see their problems in terms of brain abnormalities. There does need to be a change in the ideological position of psychiatry but Lade and the College don’t mention that in the press release. 

Conceptual understanding of psychiatric diagnosis

As I said in my last post, a paper that has been influencing the Future DSM Strategic Committee has been Hyman (2021). The abstract concludes that "scientific results demonstrate that psychiatric disorders cannot reasonably be understood as discrete categories—and certainly not as natural kinds".

Hyman reaches conclusions with strong implications for current psychiatric diagnostic systems, such as DSM. For example, he states that "The currently predominant categorical nosologies are fundamentally in error and are damaging to science". He sees psychiatric and neurological disorders as "groupings of disorders that exhibit some internal scientific and clinical coherence, but also have changing and permeable boundaries that are negotiated by interested professional groups". His argument is primarily against seeing any distinctions between disorders and non-disorders and between disorders as categorical in nature. To summarise in another quote:-

If by natural kinds we mean categories of things existing in nature that are well bounded and have stable, cohesive causal structures, as is the case for chemical elements, then the poorly bounded, etiologically and pathophysiologically complex psychiatric disorders are something else entirely. 

For me, Hyman, and the Future DSM Strategic Committee in general, could go further in their conceptual understanding of psychiatric diagnosis. They still seem to be too enamoured of the possibilities for "localising the mind" in the brain. Despite the lack of evidence for biomedical markers of mental illness, psychiatry remains paradigmatically committed to the idea that mental functions must be localised in the brain in some way (see eg. previous post). Of course the brain is the vehicle for meaningful experiences, such as functional mental illness. But the brain does not create meaning; it is people as a whole that do that. 

In particular, a new DSM needs to re-create the distinction between functional and organic psychosis, which was present in DSM-I, and was abolished by DSM-IV (see previous post). I am not arguing for Cartesian dualism, splitting the mind from the brain (see eg. another previous post). Mind and body are integrated in the organism. People are animate, embodied beings. But what needs to be made clear is that naturalistic explanations of primary mental illness are inadequate because of the need to take a holistic personalistic perspective of mental health problems. The evidence for the abolition of the distinction between organic and functional mental illness does not exist and the argument for doing so by DSM-IV was flawed (see yet another previous post).

Related to this, I suspect Hyman still wants to hold on to the idea that primary mental illness will be shown to have biological aspects to its causation. Of course there's a tautological sense in which this is true, because the brain is necessary to mediate mental illness. But in the same way as we can't, or at least shouldn't, talk about our 'normal' thoughts, emotions and behaviour as being caused by the brain as such, nor should functional mental illness be described in those terms. The whole organism is the condition of its parts, and is in turn realised by them. We may be able to understand some of the reasons for functional mental illness, but these cannot be proven in a natural scientific way (see eg. previous post). We can only hope to understand formative causal influences, not efficient causes (see eg. another previous post). By contrast, brain pathology is a necessary cause of organic mental illness, such as dementia or delirium.

It's unclear to me what the next stage of the DSM review process will be, but as I've always said, proper conceptual foundations for understanding psychiatric diagnosis are needed before progress can be made.

Whither DSM?

Scientific American reports that the American Psychiatric Association (APA) is optimistic that “DSM [Diagnostic and Statistical Manual] can be retooled to become more scientific” (see article). Maybe because of the current DSM-5, people may assume that APA means ‘scientific’ in the sense of natural scientific, implying that a biological cause of primary mental illness will be found. But the press release comes across as, at least potentially, more open-minded. And ‘scientific’ can be defined more in terms of the application of rigour to analysing data (see eg. previous post) than implying a positivistic understanding of mental illness. Science doesn’t have to be reduced to physics and chemistry or mere empiricism. It can make sense to say that psychiatry should be more scientific (see eg. another previous post). There is, in fact, a need to move away from so much of the pseudoscience of biomedical psychiatry (see eg. yet another previous post). A key paper influencing the Future DSM Strategic Committee is by Steven Hyman (2021), a former National Institute of Mental Health (NIMH) director and DSM-5 Task Force member, which makes the case that psychiatric disorders are not natural kinds (see eg. previous post).

DSM-5 failed because of its misdirected aspirations (see eg. previous post). The current DSM review committee has to accommodate a range of different views. But there are some hopeful signs in its paper on the ‘Initial strategy for the Future of DSM’. One of its four subcommittees is the Socioeconomic, Cultural, and Environmental Determinants of Mental Health Subcommittee, which the paper admits 

fills a gap in DSM given that despite the influence of socioeconomic, cultural, and environmental determinants of mental health on the development, progression, and treatment of mental disorders, they are not adequately addressed in DSM or in other psychiatric nosologies.

The overall committee also wants to avoid the problem of reification of psychiatric disorders (see eg. previous post). The idea of embracing “biology and environment and their interactions as key determinants of mental disorders” is said to be under consideration. The committee wants to find a pragmatic solution to psychiatric diagnosis “without abandoning the whole effort or eschewing improving current nosology”. Let’s see how this process develops.

I may be being overoptimistic about the initial publication of the Future DSM Strategic Committee. DSM may never properly incorporate the uncertainty of psychiatry. It may find it difficult to accommodate the inevitable unreliability of psychiatric diagnosis, considering the historical motivation of DSM-III to increase reliability (see eg. previous post). Psychiatric assessment has always been about differential diagnosis and aetiology, rather than a single diagnosis, often seen as having implied biological causes. I’ve never been one for wanting to completely abandon psychiatric diagnosis but modern psychiatry does overvalue it, particularly when it takes a biomedical approach (see eg. previous post and my 2002 article).

Is critical psychiatry creating its own myths?

I’ve just watched Joanna Moncrieff being interviewed on It’s your life with James “JC” Cooley” (see video), one of several video podcasts to which she has contributed. She says that antidepressants numb people, which may initially be helpful, but cannot be a long term solution because they may prevent people being “tuned into what they need to do to feel better”. She talks as if the numbing is a physiological effect, but I think it is more likely to be the result of a placebo reaction (see eg. previous post). Any apparent benefit of antidepressants because of a placebo reaction may not last, or may diminish over time, and/or cause a nocebo effect, such as emotional numbing because people do not think their psychosocial problems have really been dealt with. 

I’ve expressed concern before about how social media can misrepresent the truth about psychiatry (see eg. previous post). Video podcasts may be helpful in promoting personal perspectives, such as Jo’s, but there are not necessarily the same checks on transmitted information as more traditional forms of communication. As far as I know, Jo cannot point to any academic reference to support SSRI antidepressants being pharmacologically emotionally numbing, In fact SSRIs were introduced partly because they tended to be less sedative than tricyclics, the previous generation of antidepressants. I’m not of course saying that patients do not complain of emotional numbing with antidepressants, particularly over the longer term; the argument is about the mechanism of this effect. There does seem to be a need for discussion on this issue in the academic medical press.

As I’ve also said several times before, although ideologically I am close to Jo, I do worry about her niggling overstatement (see eg. previous post). She makes very clear in the interview on the JC Cooley show that her motivation for change is not necessarily to stop people using antidepressants, but more to ensure they are properly informed to be able to make a decision about them. She also says she’s always had a “rebellious streak”. Misplaced authority should be challenged but the rebel within Jo may need to be tempered by accuracy and truth. It’s important critical/relational psychiatry does not merely replace the myths of biomedical psychiatry with its own myths.

Changing the way the facts of mental health and illness are seen

As I wrote in my book chapter (see extract), "From the beginning, the aim of the Philadelphia Association (PA) was to "change the way the 'facts' of 'mental health' and 'mental illness' are seen" (R. Cooper, 1994). Current activities of PA include the support of their two community houses, a low-cost psychotherapy service and a training programme in psychotherapy and other study programmes and events.

Despite PA’s intentions for change, psychiatry still clings to what is really an outdated view of mental health and illness (see eg. last post). Psychiatry has always hoped that a biological understanding of mental illness as brain abnormality is just round the corner. It does now tend to accept that the pharmacological and neuroscientific emphases of the last 50 or so years has not really progressed practice, but nonetheless refuses to acknowledge that the flaw is its own conceptual foundations.

People have been so indoctrinated into believing that they are their brains that they cannot see the conceptual fallacy in doing so. People’s brains are only part of them, like their other bodily parts. Most mental illness is not caused by faulty brains; it relates more to them as a person as a whole. By thinking of ourselves as machines, we fail to recognise the purposiveness of life.

Will psychiatry ever change?

As Diana and Nikolas Rose wrote in their 2023 Psychological Medicine article (see previous post), psychiatrists tend to see themselves as 

exponents of highly effective, neurobiological based, targeted treatment of brain disorders, like their peers in other biomedical specialities. The leaders of the psychiatric establishment are likely to resist … a reconfiguration of their profession [by giving up such a claim].

This is despite the fact that psychiatric disorders are not dependent on biological pathology, whereas physical diseases are. A purely biological account of primary mental disorder is not possible, but psychiatrists keep hoping one will be found.

It’s depressing to see how much psychiatry is prepared to cling to its outdated understanding of mental illness, which it actually promotes as a major advance, misleading people that there has been real progress (see eg. recent post). As I’ve commonly said (see eg. my editorial), the essential position of critical/relational psychiatry is that functional mental illness should not be reduced to brain disease. Although, of course, all mental disorders involve cerebral processes, despite what psychiatry says, neuroscience is not moving us towards having a biological and genetic understanding of primary mental disorders (see eg. previous post).

Will new Mental Health Act make much difference?

The Mental Health Act 2025 amending the Mental Health Act 1983 received Royal Assent on 18 December 2025 (see DHSC press release). Alex Ruck Keene has produced an unofficial update of the 1983 Act, together with a video of him which walks through the changes that will be implemented over time (see his post on his Mental Capacity Law and Policy website). 

I’m not convinced the new Act will really better protect people with severe mental illness. Although the criteria for detention have been tightened up and the civil compulsory treatment of autism and learning disability will also require the presence of psychiatric disorder, in my view an opportunity has been lost to have a truly rights-based review of the Mental Health Act (MHA) in line with WHO/OHCHR guidance to countries on mental health legislation (see eg. previous post). This would include the abolition of compulsory treatment in the community which I do not think can be justified, at least for civil patients (see eg. another previous post). I welcome the introduction of the new S56 arrangements to introduce statutory care planning, although how this will work out in practice remains to be seen (see eg. yet another previous post). I worry that the new Act will merely create more bureaucracy by increasing the number of Tribunals and providing more access to SOADs and Tribunals. I am also concerned about how the voice of carers may be lost by the introduction of the role of the Nominated Person.

As far as I am concerned, reform should have been about abolishing Community Treatment Orders (CTOs); making the Tribunal more rights-based, including being able to intervene about treatment as well as detention; improving advocacy and access to a truly independent second opinion, leading to the abolition of so-called second opinions from appointed doctors (SOADs) from the Care Quality Commission; and preventing admissions to secure facilities for civil detentions (see my submission to the Joint Committee on the Draft Mental Health Bill). 

Minds are not immaterial

I’ve criticised Ed Bullmore, Regius Professor of Psychiatry at the Institute of Psychiatry, Psychology & Neuroscience at King's College London (see previous post) before for wanting to replace dualism with reductionism (see another previous post). Psychiatry actually needs a non-reductionistic understanding of the relationship between mind and brain by seeing them as integrated in the embodied person (see eg. yet another previous post). Bullmore seems to think the only critique of dualism is reducing mind to brain.

Descartes was the first to apply a natural scientific mechanistic approach to life. Animate and inanimate matter were understood by the same mechanistic principles. Animals were, therefore, seen as machines; and human physiology also understood as mechanistic. Descartes stopped short, though, of including the human mind in this mechanistic framework. The soul was denied any influence in physiology. Descartes, thereby, avoided the materialistic implication that man himself is a machine. The split he created between mind and brain is what is referred to as Cartesianism. 

Living beings, including humans, actually have a purposiveness which cannot be derived from mere physical-chemical processes. This creates a split between organic life and the inorganic, not, as Descartes said, a separation of the mind from the body. An organismic perspective in the life and human sciences forms the basis for an emphasis on psychosomatic medicine, and a focus on clinical medicine rather than the physical sciences. Bullmore doesn’t seem to have a role for psychosomatic medicine. Minds are not immaterial, as he states. He needs to develop his understanding of people as embodied beings.

In his recent book The divided mind: A new way of thinking about mental health, Bullmore builds on his philosophical misunderstandings by describing the development of his psychiatric career to 'shoot down' the concept of functional psychosis. Instead, he still believes schizophrenia is an "organic psychosis, rooted in atypical brain network development". He remains “deeply thrilled by the current pace of change in our scientific understanding of schizophrenia ... [and] highly confident that this force and volume of scientific advances will eventually drive changes in the real world”. This is despite his admission that those real world changes have not yet happened. 

Bullmore believes “we are now well informed about what schizophrenia looks like in the brain” in terms of “changes in connectivity at the micro scale of the synaptic connections between nerve cells and at the macro scale of the hubs of the brain’s myelinated wiring diagram”. He sees some children at increased risk from “interactions between genetic and environmental protagonists” creating a  “trajectory of brain and mind development [which] is atypical from an early age”. This is despite not being able to point to any specific physical causes for schizophrenia. I think he just needs to admit that his life’s work to overturn the concept of functional psychosis has failed. Functional does not mean non-organic, in the sense that mental illness is not mediated by the brain. It’s mere tautology, not a major scientific advance, to say that schizophrenia is mediated by the brain.

Is my brain working differently?

Is it me that is different or is it my brain? Everyone is different, aren’t they? But is it because of my brain?

Many people find the diagnosis of neurodiversity helpful. It seems to explain why they are different from others. Society does need to adapt to the individual differences of people. But to be blaming our brains may not be the best way to look at the issue (see eg. previous post). 

Of course our behaviour, emotions and thoughts are mediated by the brain. But that doesn’t mean they are caused by them. People are more than their brains which are only part of them. The brain is of course socially constructed. It’s not just born ready made. But that doesn’t mean it makes sense to reduce people to their brains, which are only part of them. Descartes looked for the seat of the person in the pineal gland, an endocrine gland deep in the brain. But the brain isn’t the seat of the person. We are all damaged in some way which is what makes us human. We’ve become so obsessed by the neurosciences that we can’t see that it’s us that are alive not our brains. 

Acknowledging the limits of psychiatry

The UK government has set up an independent review into mental health conditions, ADHD and autism (see press release). The aim is to examine what is driving rising demand for services and recommend practical, evidence-based approaches to prevention and early intervention.

Psychiatry itself may have ironically at least contributed to the rising demand for services (see eg. previous post). The limitations of treatment do need to be acknowledged by psychiatry as well as by patients. I’m not being nihilistic about the value of treatment, but social interventions, not just from psychiatric services, may well be as effective at least in dealing with people’s psychosocial problems than either medication or psychological therapy. Believing there are simple solutions to mental health difficulties may be counterproductive (see eg. another previous post).

People are also being misled about the nature of mental illness by psychiatry encouraging them to see their problems as caused by the brain (see eg. previous post). Common mental health problems are not generally caused by the brain. Of course they are mediated by the brain but they have psychosocial not physical causes. Neurodiversity is, at least implicitly, being misunderstood as a brain problem (see eg. another previous post). Mental health assessment tends to focus too much on a single-word diagnosis rather than understanding the reasons for people’s difficulties (see eg. yet another previous post).

When I first trained, mental health services concentrated on what was called severe mental illness. More minor, common problems tended to be managed in primary care. Over the years, NHS secondary mental health services have been opened up to all, particularly with the introduction of Improving Access to Psychological Therapies (IAPT) (see eg. previous post). Despite IAPT being particularly aimed at treating common mental health problems and the proportion of people with common mental health problems reporting receipt of treatment steadily increasing, the number of people actually being identified with a common mental disorder in the community has increased (see previous post). The vast increase in treatment may have been expected to reduce prevalence of common mental disorder but in fact it is associated with the reverse trend.

Until the introduction of IAPT, psychological therapy tended not to be readily available in the NHS. Even within IAPT what tends to be on offer is only short-term therapy or guided self-help. I’m not undermining the value of such treatments as long as people recognise their limitations. It’s important they are not left with frustrations that actually increase demand for services.

How much the review set up by the government will address these issues  remains to be seen. Non-medical services, often provided within the so-called third sector of voluntary organisations, need to be developed to allow more medical services to concentrate on severe mental illness (see previous post). Recovery Colleges are an underestimated valuable means of providing support for some people. Neurodiversity should also be provided for within non-medical services. The time-scale for the review is short, so I doubt it will encroach too much on the conceptual issues I have raised, but it could give a steer towards more patient-centred, therapeutic services for the future. 

The power of psychiatry to shape our sense of self

The belief that mental illness will be shown to be caused by the brain dominates psychiatric thinking. Of course brain abnormalities can cause organic mental illness, such as dementia and delirium. But most mental illness has not been shown to be caused by brain abnormalities. Research has failed to identify such definite biomarkers of functional mental illness. Biomedical psychiatry is more like a faith that people are expected to believe than a proven scientific practice.

Having such a basis for practice does not seem to matter, as biomedical approaches dominate mental health services. Although psychosocial interventions are used, medication plays a key role in treatment. People are encouraged to believe that medication is correcting a brain abnormality that has caused their mental health problems.

The biomedical hypothesis has obvious attractions, even if it seems to oversimplify. Understanding the reasons for mental health problems are generally complex and in a sense unprovable. Being able to latch onto a physical, more mechanical, explanation may seem to offer more certainty. But such mechanistic thinking fails to provide a complete characterisation of human beings and life in general. Organisms are self-organising and self-reproducing systems unlike inanimate objects. The brain is only part of a person, who needs to be understood as a whole.

Believing in the hope that mental illness can be fixed in the brain may, therefore, alter our understanding of ourselves. If we are no more than the operation of our brains, then our subjective sense of meaning is reduced. People deserve more from psychiatry than to be treated as objects.

Sealing over emotional problems with medication

I’ve never been convinced that any apparent response to antidepressants is more than placebo. Although short-term clinical trials may show a small advantage for active treatment over placebo, it is possible that this difference could be a artefact because of methodological problems with the trials and bias in the literature (see eg. previous post).

Placebos have effects because of patients’ belief in their treatment. These positive hopes about the effectiveness of antidepressants may be reinforced by the serotonin myth or other hypothesised brain mechanisms of antidepressant action. Patients are encouraged to take their medication by doctors telling them that their depression is due to a brain problem that is corrected by medication. However, by believing the myth that depression is caused by brain abnormalities, the real reasons for emotional problems may not be recognised and corrected. In other words, although emotional difficulties may be sealed over by taking medication because of the placebo effect, patients haven’t necessarily improved their understanding of the reasons for their problems. They do not necessarily incorporate their experience in a properly integrative way.

Beliefs about medication can therefore be powerful and the disadvantages of relying on medication need to be recognised. Believing treatment has been effective because of its antidepressant action, when the apparent benefit has really been due to placebo, can leave people feeling that their emotional problems have not really been solved. This may well be true because the social situation that caused the depression has not changed. Patients do not necessarily feel they have made a proper recovery or returned to their true self. Masking the real problem can create a sense of inauthenticity with the experience of flattening and numbing of emotional responses.

Avoidance of stress by taking medication is not necessarily an irrational coping strategy. Many people when they are depressed are in a desperate situation. It may well be understandable that they latch on to whatever is offered to them to make a recovery. Taking medication may seem like the only possible option available. But if there is an improvement, leading patients to have faith in the medication, it can mean that they continue on the medication becoming psychologically dependent on it over time. They become fearful about upsetting the mental equilibrium acquired through taking medication. No wonder they may have discontinuation problems.

Sealing over emotional problems with antidepressant medication can therefore cause withdrawal problems and emotional numbing as nocebo effects (see eg. previous post). Using medication as a coping strategy may not necessarily produce the better outcome obtained through incorporating emotional problems into patients’ life narratives. However difficult it may be, recovery from a depressive episode can be transformative.

The origins of the concept of autism

The concept of childhood autism originated independently in the work of Leo Kanner and Hans Asperger. The original paper by Kanner (1943) ‘Autistic disturbances of affective content’ has been re-examined by Sausalito & Kocha (2025) in History of Psychiatry. Kanner described 11 cases in children with what he called "extreme autistic aloneness". Eugene Bleuler (1911) had identified the symptom of an active turning away from external reality to a preponderance of inner life as ‘autism’ and saw it as fundamental to ‘schizophrenia’, a term which he originated (see eg. previous post). Kanner emphasised that his cases were unlike schizophrenia because such aloneness had always been present rather than being a withdrawal from participation in the outside world. As Sausalito & Kocha point out, this relationship between Kanner’s autism and childhood schizophrenia tends to be overlooked today. 

Michael Rutter (1978) clarified the definition of autism based on Kanner's paper by identifying the key symptoms of general failure to develop social relationships; language retardation with impaired comprehension, echolalia and pronominal reversal; and ritualistic or compulsive phenomena. He also emphasised that autism and learning disability frequently coexist, although differentiating autism from learning disability on the basis of particular cognitive deficits that involve language and central coding processes. When I trained Rutter's perspective tended to influence the diagnosis of autism, which was rare, certainly in adults without a childhood diagnosis, and, if made, tended to be related to learning disability.

Another paper in History of Psychiatry focused on the history of Asperger's autism (see previous post). Lorna Wing (1981) resurrected Asperger’s original 1944 German paper and popularised the term Asperger’s syndrome, introducing the autistic triad of difficulties in social interaction, communication and imagination. She saw autistic spectrum disorder (ASD) as a group of disorders of development with life-long effects, having this triad of impairments in common. The spectrum included but was wider than the original syndromes of Kanner and Asperger. Rise in the incidence and prevalence of autistic diagnoses followed the change of criteria and the introduction of the spectrum. ASD over recent years is seen as part of neurodiversity, reframing various conditions such as ADHD, dyslexia and autism as differences rather than deficits (see eg. previous post). These historical perspectives on autism help to make sense of the epidemic increase in neurodevelopmental diagnoses and highlight the subjective aspect of psychiatric diagnosis. 

Psychiatric diagnosis is merely a hypothetical construct. We too easily assume such concepts are entities of some kind. They are justified by their clinical utility, but the ever expansion of the notion of neurodiversity questions its value. Diagnoses are relative rather than absolute concepts with inevitable fuzzy boundaries between syndromes. More fundamentally, speculative notions about the causal biological basis of psychiatric diagnoses, like autism, mean that people tend to be reduced to their brains when they are given a psychiatric diagnosis. People are more than their brains and the reasons for their mental health difficulties, such as autism, may not be explained by brain abnormalities at all (see eg. last post). The kind of person they are, for example, may be more to do with their family origins and personal development than their brain. 

When I trained, schizoid personality disorder (SCD) was a diagnosis that overlapped with what is now seen as autism. It was originally a non-psychotic diagnosis of people that shared the feature of social aversiveness in schizophrenia. The key symptoms of SCD are social isolation and emotional detachment. It tends to be a diagnosis made in adults whereas autism was a diagnosis originally made in children. SCD in adults has now been replaced, at least to some extent, by higher functioning autistic spectrum in people without an original diagnosis in childhood, although signs of autistic traits in childhood are recognised retrospectively. Correspondingly, ASD diagnosis in children has also increased. 

The subjective aspects of psychiatric diagnoses are to be expected because diagnoses are merely idealised descriptions. There will be inevitable unreliability in their application. Of more concern is whether the diagnostic construct is valid. What worries me is when concepts like autism are seen as natural kinds, in the sense of being seen as reflecting the objective structure of the world. People are inevitably different and how well they relate to others and express themselves will of course vary. Blaming the brain for such difficulties may be more to do with wishful thinking than reality (see eg. previous post). Autism, like ADHD (see eg. previous post), is not a neurological condition as such. Of course it is mediated by the brain, but it’s not necessarily caused by it.

The mind-body problem for psychiatry

Mental health practitioners need to know that there is a mind-body problem. Not that they need to be philosophers, but the mind-body problem affects mental health practice.

Psychiatry tends to believe that brain abnormalities will be established for mental illness. It will often admit that such abnormalities have not yet been established but many patients are led to believe by psychiatrists that their mental health problems are due to brain abnormalities when they are not. What they are told may even seem to make sense to them because it apparently gives them an explanation for their problems.

Of course brain abnormalities can cause organic mental illness, such as delirium or dementia, which is caused by a primary brain disease or may be secondary to a systemic illness. It can also result from an exogenous toxic agent, or may be due to withdrawal of a physically addictive substance.  But the vast majority of psychiatric presentations are due to functional mental illness, which is not caused by brain disease. Organic and functional mental illness can usually be differentiated clinically. The typical symptoms of brain disease, particularly cognitive dysfunction, such as disorientation, are not present in functional mental illness. The reasons for functional mental illness are psychosocial in origin and there is no brain disease as such.

Mind and brain are integrated in the person. Functional mental illness is mediated by the brain but not caused by it, whereas organic mental illness is caused by the brain. Being able to visualise the structure and functioning of the brain by scanning over recent years has wrongly encouraged the abolition of the distinction between functional and organic mental illness. 

We need to restore this differentiation. It is wrong for psychiatry to reduce people to their brains. It is treating patients as objects rather than people. This is a fundamental complaint about psychiatry by patients and means psychiatry needs to change. Patients shouldn’t be taken in by psychiatry defending its own interests.

Psychiatric barbarism

Stephan Oliveira, a Brazilian psychiatrist, provides a rich phenomenological account for psychiatry in his book Barbarism and the human: Phenomenology, meaning of life and psychiatric practice, based especially on the work of Michel Henry and Jean-Luc Marion. These new French phenomenologists question the primacy of Husserlian intentionality and see the origin of human phenomena as more based on affectivity than their appearance in consciousness.

As I wrote in my article:-

The phenomenology of subjectivity and existence has implications for the nature of consciousness. The study of a person’s lived experience in the world shows that subjective experience and con­sciousness cannot be naturalised as physical pro­cesses. Our primary experience actually puts us in the world as embodied beings. It is what creates the foundation for scientific knowledge. An integrated personalistic concept of human beings is fundamental to any scientific understanding of the brain.

I’m not sure whether it matters how radical the phenomenological reduction is in its implications for psychiatric epistemology. I have emphasised in this blog the anti-cognitivist phenomenology of Thomas Fuchs (see eg. previous post) and the enactive psychiatry of Sanneke de Haan (see eg. another previous post). Both critique psychiatry from anti-positivist and anti-reductionist positions, as does Stephan, using the new French phenomenology. The experiential, subjective dimension of psychopathology needs to be recognised and accepted. Psychiatry should be understood as relational medicine.

What I like about Stephan's perspective is how he exploits the idea of 'barbarism' from Michel Henry. Doing so may create a more direct challenge to biomedical psychiatry than merely saying psychiatry needs to move to a more relational practice. The tendency to disregard subjectivity/affectivity by focusing on brain pathology can lead to patients feeling their experiences are being ignored. Treating people as objects is symbolic violence, and actual psychiatric practice, both in its history and currently, has shown its barbarity by its defiance of life.

The brain mythology of psychiatry

I’ve commonly mentioned Theodor Meynert (1833-92), a psychiatrist who thought he had delineated various ‘fibre-systems’ in the brain from his anatomical dissections; also deducing functions for these pathways (see eg. my editorial and previous post). The problem is that his findings were mere wishful thinking and they were eventually attacked and labelled as ‘brain mythology’.

Appreciating that primary mental illness is not localised in particular parts of the brain, by accepting that trying to do so is brain mythology, led to the distinction between organic and functional mental illness. Functional does not mean non-organic, in the sense that mental illness is not mediated by the brain. What it implies is that the brain functions more as a whole in such primary mental illness. People should not be reduced to their brain which is only part of them.

The distinction between functional and organic mental illness was wrongly abolished by DSM-IV (see eg. previous post). Psychiatry continues with its wishful thinking that abnormalities will be found in primary mental illness with its acclaimed findings from brain scans. However, these inconsistent results fail to be replicated, so that no biological markers have been found, which even mainstream psychiatry admits. It continues though with its brain mythology that more research will eventually find underlying biological abnormalities. It’s about time such wishful brain mythology is acknowledged in the modern age.

Psychological factors in antidepressant withdrawal should not be ignored

As a veteran of the antidepressant withdrawal debate (see eg. previous post), my views are often marginalised on Twitter (eg. see recent tweet by Adele Framer, founder of the Surviving Antidepressants forum). My Antidepressant Discontinuation Reactions webpage still exists. My entry into the field was a 1997 BMJ letter. I elaborated my views in a book chapter. 

A recent special report in Psychiatric News provides information for psychiatrists about antidepressant withdrawal. It emphasises that low doses of Serotonin Specific Reuptake Inhibitor (SSRI) antidepressants still have high levels of Serotonin Transporter (SERT) occupancy, and essentially seems to relate withdrawal symptoms to SERT occupancy, without too much evidence. It also acknowledges the lack of research and knowledge about antidepressant withdrawal in general. 

As I have always said, it’s common sense to believe that discontinuing a drug which is said to treat depression will be difficult. Taking antidepressants affects our experience, so that it can be difficult to know whether what I experience is because of illness, the medication or ‘just me’ (see article by Sanneke de Haan). Making sense of our experience is important but may well not be easy, including when experiencing antidepressant withdrawal.

Throughout this blog I’ve emphasised the fallacy of blaming our brains for our psychological difficulties despite the attractions and temptations (see eg. previous post). Because antidepressants can affect our experience, if only because of the placebo effect (see eg. another previous post), then any apparent stability acquired on antidepressants may be attributed to the medication, even though it may be more to do with factors like the passage of time or change of circumstances. In fact, the social situation which caused the depression in the first place may not have really changed at all, or have been dealt with, leaving us with a sense that we are not really back to our true self (see eg. yet another previous post). It worries me that both mainstream psychiatry and critics that argue for brain effects of antidepressants causing withdrawal do not place enough emphasis on these psychological factors.

Evidence about antidepressant withdrawal

Moncrieff et al (2025) reappraise the systematic review of antidepressant withdrawal by Henssler et al (2024). As I said in a previous post, Henssler et al minimise the significance of antidepressant withdrawal, and Moncrieff at al confirm that the Henssler review does not provide good grounds for making reliable judgements about the incidence and severity of antidepressant withdrawal. The same can be said about the even more recent review by Kalfas et al (2025) (see another previous post).

Mainstream psychiatry seems motivated to rely on unsatisfactory data to undermine the significance of antidepressant withdrawal. This is because it finds it difficult to accept that antidepressants are not effective and, therefore, wants to minimise any potential problems caused by the vast amount of antidepressant prescribing that takes place. It is very difficult for psychiatry to accept that it has made so many people dependent on antidepressants.

Personally I'm not convinced the evidence of antidepressant dependence indicates physical dependence, even brain damage, in the sense that the body, rather than the person, has been made dependent on antidepressants. There is evidence that neuroleptic medication can cause brain damage, as with tardive dyskinesia, but, although the brain of course needs to readapt after antidepressant discontinuation, I know of no evidence there is permanent brain damage from antidepressants. Of course withdrawal symptoms can be prolonged but the mechanism requires further elucidation. I have always emphasised the role of psychological factors. It concerns me that people who make the case for physical dependence tend not to give enough priority to psychological factors, which cannot be denied. It’s not surprising that a drug that is thought to improve mood can be habit forming, considering especially that it may have been started when people are feeling desperate. Undoing what can be an identity altering experience of taking antidepressants may well not be easy.

ADHD is not a neurological condition

ADHD is commonly said to be a neurological developmental disorder. The difficulty I have with this statement is that it implies ADHD is a brain disorder. I have no problem with people seeking environmental adjustments, for example at work or in education, because of the kind of person they are. But to justify these adjustments because of a brain disorder is misleading.

Development is neither predestined by our genes nor completely malleable to shaping by the environment. To suggest that ADHD and other neurodevelopmental conditions cannot be “cured” may underestimate the extent to which people can change. It’s all very well to encourage training and education about ADHD, but people do need to be taught facts rather than speculation.

Psychiatry commonly justifies its speculation that ADHD and other functional mental disorders have a biological cause by suggesting it takes a biopsychosocial position, properly taking into account psychosocial as well as biological factors. But it fails to allow for the extent to which the brain is socially constructed by our experiences. Genes set the boundaries of the possible but environments define the actuality of what happens. It doesn’t make sense to reduce mental conditions such as ADHD to a brain disorder. Brain connections in ADHD may be no different from our ‘normal’ experiences. Certainly they have not been proven to be different and even academic reviews of the biological basis of ADHD will caution that no biological markers for ADHD have been found.

Doctors irresponsibly minimising antidepressant withdrawal

Doctors have always minimised the significance of antidepressant discontinuation problems (see eg. previous post). It doesn’t seem to concern them that they have made so many people dependent on antidepressants (see eg. another previous post).

In a systematic review and meta-analysis, Kalfas et el (2025) conclude that the mean number of discontinuation symptoms at week 1 after stopping antidepressants was below the threshold for clinically significant discontinuation syndrome. The article is motivated to show that antidepressant withdrawal may be less common than is thought to be the case (see New Scientist article). The difficulty in obtaining estimates of incidence is made worse by the lack of methodologically rigorous, randomised placebo-controlled trials in real world settings, certainly over the longer-term rather than just after one week. In fact, initially on stopping antidepressants, people can be hopeful that they no longer need antidepressants. 

The data including in the meta-analysis was from 11 trials with short duration of use of antidepressant: 6 for 8 weeks; 4 for 12 weeks; and one for 26 weeks. People can stay on antidepressants for considerable periods of time and the risk of withdrawal symptoms increases with duration of use (see eg. Horowitz et al, 2025). This data obtained after one week discontinuation may well not be generalisable to the bulk of long-term users, particularly if followed up for more than a week.

The Telegraph reports that the research team have suggested guidelines need to be re-written to reassure people that they are unlikely to experience severe side effects when coming off antidepressants, which is clearly unjustified (see eg. article by Mark Horowitz & Joanna Moncrieff on The Conversation). Such advice is contrary to current guidance that people should be informed of the risk of withdrawal symptoms on first starting antidepressants (see eg. previous post). Doctors should be encouraged to follow this guidance, rather than the proposal by Kalfas et al. At least the researchers have subsequently admitted that most studies they reviewed had only followed up patients for two weeks and that antidepressant treatments they studied were shorter than those commonly prescribed in the real world, although this isn’t as explicit in the paper as it should be.

Common mental health conditions have worsened despite Improving Access to Psychological Therapies

Part 1 of the Adult Psychiatric Morbidty Survey (APMS) for 2023/4 has been published (see website). The last time this survey was sampled was in 2014 (see previous post). 

Despite the proportion of 16 to 74 year olds with common mental health condition symptoms reporting receipt of treatment increasing from 24.4% in 2007 to 39.4% in 2014 to 47.7% in 2023/4, the proportion of 16 to 64 year olds identified with a common mental disorder has also increased from 17.6% in 2007 to 18.9% in 2014 to 22.6% in 2023/4. Services are struggling to cope with a vast increase in demand but  mental health need nonetheless apparently continues to increase. The increased service activity, if effective, should be expected to reduce prevalence of mental disorder, not increase it.

Improving Access to Psychological Therapies (IAPT) was rolled out from 2008 (see eg. previous post). Despite reported rates of improvement over the short-term, longer-term outcome may not be so beneficial (see eg. another previous post). The reality is that hoping for easy answers to mental health problems means that providing increasing resources for services can never meet the perceived need of the population (see eg. previous post). Psychiatry can’t magic away the pain and suffering of being human (see eg. another previous post). It shouldn’t mislead people that a course of medication or a brief psychological therapy will necessarily solve all mental health difficulties. I’m not being nihilistic about psychiatric treatment but the limits to psychiatry do need to be acknowledged. Throwing money at the problem isn’t the whole solution at least.

What counts as psychopathology?

Sami Timimi in his recent book, Searching for normal, describes how the diagnoses of autism and ADHD have changed over the years. They have gone from uncommon conditions to being widespread. As Sami says:-

From rare diagnoses given to kids with significant learning difficulties or active and mischievous boys, autism and ADHD follow an impressive developmental trajectory out of the confines of child guidance clinics and into the belly of mass culture.

When Sami and I trained, mental health problems in children were mainly separated into conduct disorders and emotional disorders. There was little attempt to categorise children’s behaviour and emotions into psychiatric diagnoses, as in adult psychiatry. The focus was on family therapy with attempts made to formulate hypotheses about the functioning of the child in the context of the family and community.

Sami describes how the diagnostic ideology of adult psychiatry has invaded child psychiatry, introducing a “culture of pathologising, labelling and medicating”. As he says, “There has never been a generation of young people so colonised at such a young age by mental health propaganda”. In fact, child psychiatry has been an exporter of diagnoses to adult psychiatry leading to a ballooning of ADHD and autism in adults.  People can identify with these diagnoses, which then seem to provide explanations for their personal difficulties. 

Of course it’s important to try to understand the reasons for personal difficulties. But the reasons can’t be proven as such, which is why it’s tempting to latch onto a psychiatric diagnosis that may seem to provide an external explanation. But such states may be better appreciated as understandable responses to the situation in which the person finds themself. It’s not always easy to maintain a positive sense of self. A psychiatric diagnosis may not necessarily provide a valid explanation for any negative views of oneself and situation, particularly if that diagnosis is supported by unproven speculations about brain pathology. We all need myths to live by and whatever relief a diagnosis may appear to provide, it does need to have sound foundations. We do seem to be inflating the value of pathologising everyday difficulties, certainly in terms of the brain (see eg. previous post). 

Transforming mental health services

Pullman et al (2025) consider how social work could contribute to the transformation in mental health services from a predominately medical approach to a balanced, evidenced-based biopsychosocial approach to care, as recommended by the World Health Organisation (WHO) (see eg, its 2022 World Mental Health Report). Services need to provide person-centred, human rights-based and recovery-orientated care.

As Pullman et al say

Critical Psychiatry stands as a minority movement within contemporary psychiatry, providing a critical analysis of the Medical Model. Its primary focus lies in addressing the inclination of a reductionistic Medical Model to dehumanize care …. In contrast, Critical Psychiatry advocates for a relational, recovery-oriented, and multi-cultural treatment approach, operating within the framework of a comprehensive biopsychosocial paradigm 

Pullman et al conclude by advocating several practical strategies to support the transformation agenda:-

(1) Consistent advocacy for the biopsychosocial model within mental health policy and educational curricula. 

(2) A renewed emphasis on teaching, training and supervising biopsychosocial approaches within professional education. The Biopsychosocial model has a long history but has struggled to gain a consistently prominent position within mental health work often in the face of bio-medical hegemony within psychiatry.

(3) To prioritize the voices and experiences of those with lived experience of mental ill health and mental distress, either directly or as part of families and social groups. Too often, mentally ill people have experienced inadequate treatment and, at times, abuse and oppression. This situation has not improved adequately, despite the inception of modern psychiatric practice.

Stuck on antidepressants

A Sunday Times investigation found that a quarter of women in their fifties and sixties take antidepressants, and 15% of women over 50 have been on them for longer than five years (see article). As the article also says, some people on antidepressants also experience emotional blunting and difficult withdrawal symptoms.

James Davies, who I have mentioned before (see eg. previous post), is quoted as saying, “[T]he evidence base [for antidepressants] suggests they’re no more effective than placebos. But unlike placebos, they have side-effects”. I pointed out to him in a tweet that placebos do have side effects, which are called nocebo effects. 

Antidepressants are inadvertent placebos. They are not usually intentionally prescribed for their placebo effects. Instead doctors tend to believe in antidepressants and that their efficacy has been proven, whereas this is at least open to question (see eg. previous post). Patients have also been encouraged to take them by the myth that the serotonin imbalance theory has also been proven, which is not the case (see eg. another previous post). 

Patients may therefore acquire attachments to their medication more because of what they mean to them than what they do. Many patients often stay on psychotropic medications, maybe several at once, even though their actual benefit is questionable. Any change threatens an equilibrium related to a complex set of meanings that their medications have acquired. No wonder they may have withdrawal symptoms. They have been made dependent on antidepressants and may well be frightened to try to manage without them. It’s easier to stay on antidepressants rather than upset any apparent equilibrium their medications have seemed to create.

Such nocebo effects also apply to emotional blunting. Antidepressants can tend to leave people feeling that there is a sense in which their psychosocial problems, which caused the depression, have not really been solved (see eg. previous post).  However much they may feel that antidepressants may have helped stabilise their mood, they may, therefore, also feel emotionally flat and not back to their real self. 

I am, of course, not saying that antidepressants do not block reuptake of catecholamines, such as serotonin, in the synaptic cleft between neurones. But how much the side effects of withdrawal symptoms and emotional blunting may well be due to nocebo effects remains to be determined.

Universal remedies for mental health problems

I’ve mentioned the problems with mental health services in Greater Manchester before (eg. see previous post). Mental health workers in Manchester have recently called off their strike having obtained more funding for services (see Big Issue article). As I’ve said before (see eg. previous post), the problem isn’t just about more funding. 

The fundamental problem is the management of demand for mental health services. The trouble is that services themselves have exaggerated that demand by selling panaceas for mental health problems, both medication and psychological therapies (see eg. previous post). 

As the Big Issue article points out, the problem with coping with demand is not just in Greater Manchester Mental Health NHS Foundation Trust. I used to work at Norfolk and Suffolk NHS Foundation Trust (NSFT), and as I have said on my personal blog (see eg. previous post), it also has had its institutional difficulties over the last 10 years. It has managed to correct problems in its Trust Board over recent years but services on the ground are still struggling to cope with demand. As far as beds are concerned, this is reflected in the endemic problem across the whole country of out of area placements. NSFT board recognises there is more to do to improve services but there also is a need for national direction. We are waiting to see how specific the new NHS 10-year Health Plan, postponed from June to July 2025, will be as far as mental health policy is concerned.