Neurodivergence as dead end in thinking about mental health

What's happened with neurodivergence is the inevitable result of reducing mental illness to brain disease. People now talk about having different kinds of brains, when actually it makes no sense to do so. Of course we all have different brains because we are all different people. That's mere tautology. But to be suggesting there are particular kinds of brain that define conditions such as ADHD and autism has not been proven, however much people may hope that the hypothesis will be shown to be the case. In fact, of course, brains are only part of people. It's people that have problems diagnosed as ADHD and autism, not their brains. Such conditions are not like dementia, for example, which does reflect damage to the brain. Patterns of behaviour need to have something in common and diagnoses of ADHD and autism have become so broad that it is difficult to specify exactly what the defining feature is of people with these diagnoses. Of course rating scales are completed to make the diagnoses but their validity still needs to be established and they were only really introduced as screening, not diagnostic, tools.

What worries me in particular is the way people take from a diagnosis the implication that they have a different kind of brain causing their problems. However tempting it may be to blame the brain, why we do things and act in certain ways may not always be very easy to explain, certainly in terms of the brain. People are purposive beings, not machines. It's important to try and understand the reasons for our behaviour, however difficult that might be. But because people are not machines there is an inevitable uncertainty about such reasons. The difficulty of living with such uncertainty is what encourages the search for more concrete explanations in the brain, even though they don't really make sense.

However much neurodivergence is a developmental condition, the problem was calling it 'neurodevelopmental' rather than merely 'developmental', tending to imply a neurological abnormality. No definite biomarkers have been established in research. The results are so inconsistent and confounded that it is not possible to stipulate any underlying difference or abnormality. Speculations about the biological basis of neurodiversity are not facts, even if they may be presented as such.

Even people like Uta Frith, who encouraged a shift to neurodevelopmental theories, now question whether such diagnoses are meaningful because they have become so broad in scope (see previous post). Biological understandings were encouraged to get away from what was considered to be inappropriate blaming of families (see eg. another previous post). It is obviously wrong and naive to simply blame families for causing nuerodivergence. But it is important to understand the familial context (see yet another previous post). When I first trained child psychiatry was focused on family therapy but this aspect has been undermined by the biologisation within psychiatry spreading to children (see eg. even yet previous post). Psychosocial theories can still provide understanding even if they do not provide one-to-one causal explanations.

There needs to be a shift back to psychological and social understandings of mental health problems and neurodivergence. Reducing people to their brains has resulted in a conceptual system that is not fit for purpose and in which people are being misled about their problems and personality.

Declining use of the terms 'schizophrenia' and 'mental illness'

The Philadelphia Association (PA) (see eg. previous post) was originally founded by R.D. Laing and others in 1965 to relieve "mental illness of all descriptions, particularly schizophrenia". These days, as on its website, the PA tends to talk about challenging "established ways of thinking about and responding to distress" without mentioning 'mental illness' or 'schizophrenia'. People have become far more reluctant since 1965 to use what may be seen as stigmatising terms such as 'mental illness' and 'schizophrenia'. I want to look at what this change in everyday language means and its implications for PA objectives.

Mario Maj also comments in a World Psychiatry editorial on the declining professional use of the term 'schizophrenia' in both clinical work and academic publications. Even psychiatrists now tend to use the term 'psychosis' rather than 'schizophrenia'. A case has been made in the academic literature that there is no specific schizophrenic genetic, brain disease within the psychosis spectrum and the term should be abandoned (see eg. previous post). 

'Mental illness' now tends to be replaced with more general terms such as 'mental health problems' or even 'distress'. Some people want to relinquish the notion of 'mental illness' because they say it implies biological abnormality when it shouldn't (see eg. another previous post). As the remit of psychiatry has broadened over the years, the use of the term 'distress' opens up psychiatry to anyone with mental health problems. Psychotherapy likewise tends to make itself available to people with any psychological difficulty, although people are not always suitable for therapy, for example because of their lack of motivation or other personal factors. As one of the main activities of PA is its psychotherapy training, its use of the phrase 'responding to distress' in its current objectives could indicate that its focus is on psychotherapy. 

By contrast, the original objectives of the PA founders seem broader than just psychotherapy. The use of the term 'schizophrenia', rather than opening up psychiatry to all, focuses psychiatry on those with more severe mental health problems. Schizophrenia has been seen as one of the most serious of mental illnesses, because it reflects a losing of touch with reality and at least potential chronicity. Kingsley Hall, the original PA household (see eg. previous post), tended to function as an alternative to psychiatric admission, and at least some residents would have been diagnosed as schizophrenic. Laing in fact admitted he felt trapped in his psychotherapy training and wanted to pursue his interests with more severely disturbed people in hospital (see my book chapter). I think the emphasis on 'schizophrenia' in the original PA objectives reflects this. 

There is an issue about whether schizophrenic or psychotic people may be eligible for psychotherapy because of their lack of insight and not even necessarily seeing themselves as ill and being motivated for therapy. Laing would have been aware that psychotherapy was not suitable for all mentally ill people. But he wanted to change the way mental health and mental illness are understood. Ironically, despite the general shift away from the use of 'schizophrenia', psychiatry could be said to have become even more dominated by a biomedical perspective on mental illness. This was what Laing wanted to challenge, hoping psychiatry rather would become more existential and social (see eg. previous post). Psychiatry still needs to move on from its outdated physical disease model of mental illness to a more relational mental health practice.

Implications of critical psychiatry for practice

Daniel Cohrs & Awais Aftab (2025) provide a useful overview of the heterogeneity and debate within critical psychiatry and adjacent movements. Although the article proposes a reorientation of psychiatric practice, I have criticised Awais before (see eg. previous post) for not going far enough in his critique. When commenting on another article about critical psychiatry by Samei Huda (see previous post), I tried to simplify this issue. Essentially, it is that people tend to understand from psychiatry that mental illness is due to brain disease. Psychiatry needs to be far more explicit that most mental illness is not due to brain disease. It wants to hold on too much to speculative hopes that a biological understanding of functional mental illness will be found.

Do I want or need an ADHD identity?

The recent Channel 4 programme ‘The great ADHD myth?’ has highlighted how the ADHD community feels under attack (see previous post). This community has been validated, for example, by the Neurodevelopmental Psychiatry Special Interest Group (NDPSIG) of the Royal College of Psychiatrists. I’m not wanting to undermine the benefits people value from being identified as ADHD, but I do worry they are being misled, including by NDPSIG.

But is the role of psychiatry to identify people to provide an explanation for years of frustration, even failure, in their life? Originally, modern psychiatry identified people with mental illness within the poor law system and provided asylum care for them (see eg. previous post). With the closure of the asylums, psychiatry has broadened its remit. Not many people wanted to be admitted to an asylum; in fact, originally they had to be compulsorily detained. Now people complain about being on a waiting list for a neurodivergent diagnosis, because they at least wonder if they have the diagnosis, and in a sense at least, maybe hope they have to explain their personal difficulties. As I said, not many people would have wanted a diagnosis of mental illness to be committed to an asylum, whereas many value a diagnosis of ADHD and other neurodiversity diagnoses.

This situation highlights how much psychiatry has changed since the closure of the asylums. As a young person, I may have agonised about my difficulty in communication and relating to people, and seen myself as having schizoid personality disorder. These days I guess I may fit within the autistic spectrum. Does it matter that our understanding of such personal difficulties may have changed? At least it shows how arbitrary such distinctions may be. Despite my personal difficulties, I’ve survived into retirement as a psychiatrist!

I still think that psychiatry’s priority should be psychotic mental illness. Such people are likely not even to see themselves as being ill. But from other people’s point of view, they may be out of touch with reality (see eg. previous post). They are deserving of an affective, caring kind of relationship with others (see eg. another previous post). I’m not saying neurodivergent people shouldn’t be treated in a similar way, although many are merely wanting their difference to be recognised, rather than wishing to be identified as ill.  

My primary concern, and this concern straddles what I am calling the change in psychiatry since the closure of the asylums, is that people understand functional mental illness and neurodiversity as a disorder of the brain. Of course the brain is implicated. It mediates our thoughts, feelings and behaviour, but people are not machines and are more than their brains. There’s always been a philosophical problem in relating mind to brain. But that difficulty should not mean that we reduce people to their brains, however much such oversimplistic apparent solutions may be attractive. The data on which NDPSIG makes its claims is at least open to interpretation. It makes bold statements about the biological and genetic basis of ADHD which mislead people (see eg. last post).

Changing the narrative round ADHD

I was critical of Max Pemberton in a previous post for what he said in one of his Daily Mail columns. But he has fronted what I think is quite a good and helpful Channel 4 programme ‘The great ADHD myth?’ (see last post). As he said in the programme, and in a Times article, Pemberton himself was diagnosed with ADHD in an online private assessment costing £1200 (the programme also talked a little about the profit motive in ADHD assessment and treatment - see eg. another previous post). He doesn’t accept the diagnosis as he feels it unnecessarily medicalises his personal traits. As he says, “Calling that [ie. ADHD] a disability, which is what I was told during my assessment, doesn’t describe me and it borrows a word that other people need.”

Changing the narrative round ADHD is not easy, when it is sold as a disorder of people with a different kind of brain, easily defined by subjective criteria of inattention and hyperactivity and impulsivity and predominately genetically caused. There is no evidence that there is a particular ADHD brain, ADHD is not easy to define as the diagnostic criteria used are so subjective, and genetics and environment interact and are not simply additive factors. We need to be far more cautious about medicating people with stimulant medication and understand better the extent to which any apparent effects of medication may be due to placebo.

The great ADHD myth?

‘The great ADHD myth?’ will screen on channel 4 next Tuesday 18th August. This is despite a threat from ADHD UK (see mention in previous post) to report the programme to Ofcom if the programme repeats what it sees as the failures in its promotional announcement (see correspondence). The Global ADHD Advocacy Network also issued a similar response to the announcement.

The concern is that to imply ADHD may be a myth denies its reality. I don’t think anyone is saying that people cannot have problems with attention and being overactive and impulsive. Indeed, in a sense we all can do so at times (see previous post). The complainants do not want to recognise that ADHD is a social construct, but if ADHD has any meaning, it may be as an abstract rather than concrete concept. There is no clear evidence of brain dysfunction. What the complainants are objecting to is the challenge to their identity which has been created through taking on the label of ADHD. In this sense it must be a social construct, at least to some extent, because the social fact of ADHD diagnosis changes the way some people understand themselves. In fact, this is what a lot of people value about the diagnosis, because it seems to provide an explanation for what they have seen as deficiencies in their personality. An ADHD community has been created and feels it is under attack from the Channel 4 programme.

The complainants make much of the World Federation of ADHD international consensus statement (see article). I was an endorser of a critique of a previous so-called international consensus statement (see article). The literature is biased and it is reasonable for a television programme to try to correct that bias, including about the evidence for stimulant medication (see previous post). Splitting off of an unwanted part of oneself by blaming personal difficulties on an hypothesised neurodevelopmental ADHD concept, however real it may be believed to be the case, may not necessarily be the best way to understand such difficulties. Of course genes set the limits to our development but environments determine the actualities (see recent post). My concern is that people are being misled by advocates such as ADHD UK and the Global ADHD Advocacy Network about the nature of ADHD.

Loss of meaning by making the definition of autism too broad

As described by The Times (see report), Uta Frith has an article in Psychological Medicine entitled ‘Autism spectrum disorder: Has it lost its meaning and is it leading to misdiagnosis?’. Frith was also interviewed on the initial episode of the podcast called ‘Let’s talk neurosense: The psychology of neurodiversity’.

As Frith says, the criteria for diagnosis of autism have widened (see previous post on ‘The origins of concept of autism’) and there is no agreement it is a biological entity. She lists some drivers of change for increasing diagnosis, including: the desire to have a more inclusive, broader concept, such as autistic spectrum disorder; diagnosis creating a class of people which in a sense did not exist before because having the diagnosis changes their understanding of themselves, which Ian Hacking called a ‘looping effect’; spread of knowledge of the condition by social contagion, including with the increasing use of online communication; uncritical deference to the perspective of some of those with lived experience; people wanting the diagnosis to explain aspects of their personality; acceptance that the condition has been masked in females; and, negative aspects of human experience being unnecessarily pathologised. 

The concept of neurodiversity is fundamentally about recognising personal differences and the need for society to adapt to those differences (see eg. previous post). A medical diagnosis may liberate people from self-blame but wrongly blaming the brain may impair proper understanding of the reasons for personal differences (see eg. another previous post).

Frith particularly highlights the difference between those diagnosed with autism as young children and those diagnosed later in adolescence and adulthood. Originally autism had to be diagnosed in children before the age of 30 months. As Frith says, “the clinical meaning of ASD [autistic spectrum disorder] has been diluted”.  I suspect what this means when the review set up by the government into mental health conditions, autism and ADHD (see previous post) produces its final report is that the diagnoses of autism and ADHD alone will be insufficient for a successful benefit claim. 

Neurodivergent diagnoses, such as autism and ADHD, are not the only psychiatric diagnoses in which there has been expansion of the concept, potentially making the diagnosis meaningless. For example, bipolar disorder has been expanded to come to mean essentially mood instability, which is very common (see eg. previous post). Even further back, the use of the term schizophrenia, particularly in USA, became too broad, so that the definition was narrowed by DSM-III (see eg. my article).

Frith was influential in shifting understanding of autism from psychogenic to neurodevelopmental theories. Her questioning of the loss of meaning of autism, with her focus on the need to provide support for those with severe impairments, may well be influential.

Heritability of mental disorders

Heritability of mental disorder is a difficult concept to understand. For example, it is commonly said that the heritability of schizophrenia is as high as 80%. People are different. Heritability is said to measure the extent to which the variability among people is accounted for by genetics. But is it really possible to quantify the relative importance of genetic and environmental influences? Is schizophrenia, for example, really 80% heritable?

The problem is that genetics and environment interact and are not simply additive factors. Both genes and environment are necessary. As Jay Joseph (see eg. his past guest post and recent post on his ‘The gene illusion’ blog) says in his article, “[B]oth genetic and environmental factors are essential interacting influences whose contributions jointly, as opposed to additively, combine to produce the observed behavioral characteristic (phenotype)”. It makes no sense to say that schizophrenia, or any other mental disorder is 80% genetic. Genes define the boundaries of the possible but environments determine the actuality.

Psychiatry must stop objectifying people

At its worst, psychiatry treats patients as needing their brains cured. People may be considered by psychiatry to have a brain abnormality when there is no confirmed evidence this is the case. Even though psychiatric research has not established a physical basis for functional mental illness, psychiatry tends to act as though it will be established, or at least that biological factors will be shown to be involved in some way.

Patients, of course, have thoughts and feelings. They are mediated by the brain, no doubt. But that doesn’t mean those thoughts and feelings can be reduced to the brain, which is a mere object not a person, albeit part of the person. The brain does not have meaning, whereas what is important with mental illness is to try and understand the reasons for which the person may be presenting. Objectifying patients is not understanding them, however difficult it may be to be sure of what has caused their problems. 

Psychiatry does need to stop objectifying people by implying their thoughts and feelings are caused by the brain. People are not mere machines and psychiatry’s tendency to treat them in this way can be part of the problem rather than the solution to mental illness.

Obtaining the truth about psychiatric medication

Andrew A. Nierenberg in an editorial in Psychiatric Annals defends psychiatry against the Make America Healthy Again (MAHA) action plan to curb psychiatric overprescribing (see previous post). What he particularly objects to is Robert F. Kennedy, Jnr, resurrecting Robert Whitaker’s book Anatomy of an epidemic “to vilify psychiatry” and for saying that his cousin’s withdrawal from an SSRI antidepressant was worse that his own withdrawals from heroin. 

I commented on reviews of Robert’s books in a previous post. I’m not convinced Nierenberg takes Whitaker’s arguments seriously enough even if there may be some overstatement in Whitaker's views (see eg. another previous post). 

I think what Kennedy is pointing to with opiate withdrawal is that such physical experiences tend to be short-lived over a few days, whereas antidepressant withdrawal can be prolonged and even occur some time after stopping. Personally I’ve always argued that this is because antidepressants create a belief system that they have been correcting a biological abnormality, which is difficult to resolve on discontinuation (see eg. previous post).

As Nierenberg also points out, Kennedy has implicated SSRIs in mass shootings. I have always been sceptical that SSRIs can cause violence through a physiological mechanism, such as akathisia (see eg. previous post). Psychiatry itself at times has seemed to take on the projection of blame for not preventing mass shootings (see eg. another previous post). Why people run amok in American society does need to be taken seriously (see yet another previous post).

With such a polarised debate about psychiatric medication, it’s not easy for patients to negotiate the truth. I’ve complained multiple times in this blog about psychiatry marginalising critique by calling it anti-psychiatry as does Nierenberg (see eg. previous post). I agree with him that we do need to create a clearer position for patients.

Psychiatry must be clear that most mental illness is not due to brain abnormality

I reviewed Samei Huda’s book The medical model in mental health: An explanation and evaluation (2019) when it first came out (see review). Jo Moncrieff and I also responded to his Asylum article entitled ‘Critical psychiatry: Dead ends and avenues of opportunity’ (see both articles).

Samei has taken forward his commentary on critical psychiatry in a recent BJPsych Bulletin article ‘Critical psychiatry in the UK: Potentially useful but in need of regeneration’. As he recognises, critical psychiatry aims to improve practice. This acknowledgement may indicate that critical psychiatry has at least moved on from anti-psychiatry, which Martin Roth (1973) condemned as  “anti-medical, anti-therapeutic, anti-institutional and anti-scientific” (see eg. previous post).

Samei accuses critical psychiatry of not fully taking on board the evidence against some of its views. His critique is not dissimilar to Anthony Clare's critique of anti-psychiatry (see eg. previous post) or Awais Aftab's promotion of integrative and critical pluralism as a variant of critical psychiatry (see eg. another previous post). The claim being made by Clare, Aftab and Huda is that mainstream psychiatry is not really as damned as critical psychiatry makes out.

As I've often said, critical psychiatry seeks to move on from the reductionism and positivism of much of modern psychiatry. Similarly, I've often said psychiatry needs to move on from a system based on a ‘disease’ model of primary mental illness. Despite Samei, I do think mainstream psychiatry is as damned as critical psychiatry makes out. Quite simply, most mental illness is not due to brain abnormality. This is not what most people hear from psychiatry and has consequences for their understanding and treatment of their mental health problems (see eg. recent post).

Will the Nottingham inquiry help improve mental health services?

The Nottingham Inquiry has heard 57 days of evidence with the aim of obtaining a clear understanding of the events, acts and omissions that led to Valdo Calocane, who had a diagnosis of paranoid schizophrenia, killing three people and seriously injuring three others (see previous post). Closing submissions will be held in September. 

There are substantial rates of mental disorder in people convicted of homicide. But most perpetrators of homicide do not have severe mental illness or a history of contact with mental health services. There is therefore a danger in identifying the mentally ill in general as at risk of homicide. 

The campaigning by the families of the victims of the Nottingham attack to improve mental health services, as well as police services, is welcome. It is worth watching the beginning of the Channel 4 News podcast to understand their perspective. 

It does seem to me that services did not manage the initial presentation of Calocane well when he was a student at Nottingham University. He seems to have received a rather fragmented and dysfunctional input from mental health services leading to him eventually being discharged. This blog has highlighted this rather fragmented and dysfunctional nature of services for some time (see eg. previous post). The government has recently announced another call for evidence for a new mental health strategy to transform mental health care (see press release). 

The Nottingham Inquiry legal team has produced a review of mental health homicides from all publicly available independent reviews of mental health homicides since the conclusion of the Ritchie Report in 1994, together with information from an  a Inquiry questionnaire inviting friends and family to share their experience of mental health homicides. Data, therefore, depends on a case being subject to a publicly available report and/or being volunteered through the Inquiry questionnaire. 96% of cases were not subject to a Community Treatment Order (CTO) at the time of the homicide and 92% had never been subject to a CTO. 

I don't think the issue is really about CTOs. They were mistakenly seen as a way to reduce homicide and suicide by patients in mental health services. In many ways, mental health services are still facing the same issues about homicide by psychiatric patients as before CTOs were first introduced (see previous post). The focus needs to be on improving services for people. Making them more defensive may well make them worse.

Has critical psychiatry failed?

The Critical Psychiatry Network (CPN) was formed in 1999 (see eg. my editorial). The Royal College of Psychiatrists has rejected its application three times to be a special interest group of the college. CPN argues that the wish to find a physicalist basis for primary mental illness is damaging psychiatry (see eg. my article). That’s not always a message most psychiatrists want to hear. They tend to think neuroscience has made major advances which are helping the understanding of mental illness, even though most mental illnesses do not have a neurological cause. There is of course a reason why psychiatry is a separate speciality from neurology. Despite the best efforts of CPN, mainstream psychiatry unfortunately still tends to rely too much on unfounded speculations about the nature of mental illness. It needs to move on from the wish to create a physical disease model of mental illness.

I actually think that institutional psychiatry does not really want to change (see eg. previous post and another). It is more focused on obtaining more money for services than changing its way of thinking about how to do psychiatry (see another previous post). In this sense, critical psychiatry could be said to have failed, as in many respects psychiatry has only become even more biomedical over recent years. Just take child and adolescent psychiatry as an example, where when I first trained medication was hardly used (see eg. yet another previous post). 

Mainstream psychiatry likes to make out that CPN’s criticisms are not quite as damaging as it suggests because it is broader than just taking a biomedical perspective. It will often suggest that its approach is biopsychosocial rather than biomedical. But seeing biological, psychological and social as all more or less equally relevant in all cases and at all times is an ill-defined basis for practice. What matters more is trying to understand the reasons for mental health problems rather than blaming underlying brain processes (see eg. previous post). The message patients tend to hear from psychiatry is that a psychiatric diagnosis means there is something wrong with their brain. Psychiatry needs to change to be explicit that for the vast majority of psychiatric presentations that is simply not the case.

Primary mental illness should not be looked for in the brain

People often understand that something has gone wrong in their brain when they receive a psychiatric diagnosis. For example, people have been told that ADHD is a neurodevelopmental condition affecting the prefrontal cortex of the brain (see previous post). Neurodiversity in general is commonly seen as having a neurological basis (see another previous post). Similarly, schizophrenia has been said to originate from disruption of brain development, despite the need for caution about drawing any conclusions from the evidence about biological abnormalities in schizophrenia (see yet another previous post). We continue to believe that brain functions must be localised in the brain in some way.

Phrenology was the first doctrine to suggest that cortical functions could be localised in the brain (see previous post). Features of the skull, the bumps of which could be felt on the scalp, were said to be indicators of specific faculties of mind in the underlying brain. This was eventually recognised as nonsense. Nonetheless, people continue to believe that brain functions must be localised in the brain. 

But subjective experience cannot be naturalised as physical processes. It doesn’t make sense to do so. Mental states have a meaning which the brain as an object lacks (see previous post). As far as mental disorder is concerned, not all of it is due to brain disease (see another previous post). It is people that are conscious, not their brains (see yet another previous post). Mental illness shows through the brain, but not necessarily in it. Reduction of functional mental mental illness to brain disease is just not possible in principle. The brain isn’t alive; it is people that are. The mystery of the nature of the relationship of consciousness to physical events in the brain has not been solved and never will be. This is what psychiatry, and people in general, find difficult to accept.

Psychiatry must stop misleading people about the nature of mental illness

As I've said many times (see eg. last post), psychiatry must stop misleading people about the nature of mental illness. It wants to hold on to the possibility that primary mental illness is caused by the brain but the reality is that the vast majority of presentations to mental health services are not caused by the brain. 

Psychiatry likes to make out that it takes psychosocial as well as biological factors in mental illness into account. It is true that the degree to which individual practitioners do varies. But too often, the message heard by patients is that there is something wrong with their brain. After all, why are psychiatrists so keen to prescribe medication if they don't think that mental health problems are caused by brain dysfunction which needs correcting by the medication?

Of course brain dysfunction can lead to organic mental illness, such as dementia and delirium. These conditions can generally be separated in clinical assessment from the bulk of functional psychiatric presentations because of symptoms of cognitive impairment, such as disorientation in time and place. But misleading people that their functional mental health problems are due to brain dysfunction can have consequences for people's understanding of themselves. Taking psychiatric medication can be identity altering, for example making people feel different or damaged and reliant on medical expertise. Psychiatry must be clear with people with primary mental health problems that they are not biologically flawed.

Movement against overpsychiatrisation

The Mental Health and Overmedicalization Summit organised by the Make America Healthy Again (MAHA) Institute was livestreamed (see youtube video) and led to the launch of the MAHA Action Plan to Curb Psychiatric Overprescribing (see press release). The Summit was supported by Inner Compass, founded by Laura Delano, author of the book Unshrunk: How the mental health industry took over my life - and my fight to get it back. Look at least at the first part of the livestream for the personal testimonies of several young people, like Laura, who feel they were 'psychiatrised' as children. 

As I've said several times (see eg. previous post), when I first started in psychiatry, medication was rarely used in children and adolescents (see also my Lancet Neurology book review). Historically, child and family studies tended to take a more holistic approach to personal and social problems (see eg. my article), but have become increasingly biologised over recent years (see eg. another previous post). Calls to review the use of medication for behavioural problems in children have gone unheeded (see eg. yet another previous post). This has meant that there are now young people who have grown up feeling that their identities have been taken over by being prescribed psychiatric medication from a young age.

Daniel Bergner, author of The mind and the moon: My brother's story, the science of our brains, and the search for our psyches, has an article about the Summit in The New York Times Magazine entitled 'The strange alliance trying to remake American psychiatry'. By this he means that although Inner Compass may not seem like a natural Trump ally, it is supportive of Robert F Kennedy Jnr, as Secretary of the Department of Health and Human Services, in his attempt to curb psychiatric prescribing (see podcast interview of Laura Delano by Kennedy). As I said in a previous post, "Maybe only the politicians can effectively counter ... [the] institutional bias [of psychiatry]".

Psychiatry needs to stop misleading people. including children, about the nature of mental illness. The vast majority of presentations to psychiatric services, certainly child and adolescent services, are not due to a brain disorder. This is not what people always hear because psychiatry wants to fudge the issue, even remains hopeful that an underlying physical cause may be found. It's merely tautologous to say that the brain mediates our thoughts, feelings and behaviour. That doesn't mean they are caused by the brain and psychiatry needs to be explicit about this for a new generation.

Psychiatrists are not very good at recognising how psychologically dependent they have made people on medication

As I've said before (see eg. previous post), psychiatrists have made too many people dependent on psychiatric medication. Relying on the placebo effect can have consequences (see eg. another previous post). We might like to think that psychiatric medications can solve our personal problems. We may be suspicious initially of such claims, but if psychiatrists believe them, maybe they need to be taken seriously. After all, psychiatrists have set themselves up as experts in solving such personal problems.

As I’ve also said in yet another previous post, psychiatrists rarely think about the impact of medication on other than brain chemicals. Any initial reluctance to take medication may be overcome by feeling so desperately ill that taking medication seems a viable option, maybe thinking there is no alternative, or that it’s worth seeing if it works, especially if there do not seem to be very good alternatives. Once people have given medication a trial, they may even think it has caused an improvement, when that apparent improvement is really more due to chance or the passage of time or merely to the belief and hope of improvement. 

Over time, people may come to some sort of mental equilibrium taking medication. There may be uncertainty about how much that equilibrium is being maintained by the medication, but rather than upset any apparent balance, it may be easier just to continue taking it. Trouble is that taking medication may also leave a sense that personal problems have not really been solved, maybe because the focus has seemed to have been on treating them as a brain problem.

The problem I want to highlight is that the dynamic of taking medication may create a dependency. People can come to rely on psychiatric medication because of the fear, at least, of not being able to manage without it. Withdrawal symptoms are very common and, if experienced, may well be interpreted as physical dependence caused by the medication. Such withdrawal symptoms may even occur some time after stopping. In fact, people may initially seem to feel better after discontinuing medication, maybe relieved that they can manage without it. But over time such benefits may be lost with the need to restart medication. People can be left in a vicious cycle of wanting to discontinue medication but feeling compelled to continue (see eg. previous post). 

Psychiatric medication may therefore be started because it seemed to be the only option available; can easily become associated with the sense of being biologically flawed, if only because of such myths as chemical imbalance; leave people feeling they haven’t really returned to their true self and that their real problems have been masked; and compelled to take medication when they no longer want to (see eg. another previous post). Such dynamics of taking psychotropic medication do need to be taken seriously and into account by doctors.

Paying for neurodiversity diagnoses

Mail on Sunday article highlights the cost and profitability of private ADHD clinics. As I said in a previous post, neurodiversity has become an industry, often more motivated by profit than patient interest. Packaging our everyday problems as neurodiverse conditions that can be diagnosed and treated may well be creating more problems than it is worth (see eg. another previous post). Discouraging self-responsibility may not really be helping to resolve underlying difficulties (see eg. yet another previous post). 

As the government independent review into mental health conditions, ADHD and autism has found (see last post), diagnosis alone is insufficient for assessing the need for personal adaptations in educational and workplace settings. Exposing how ADHD diagnostic services may be organised more for their own interests than those of patients reinforces the need to challenge widespread misleading myths about neurodiversity used to bolster profitability (see eg. another previous post). 

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).