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).