Why the foundations of diagnostic psychiatry are crumbling
I am a lucky man in many ways. I live close to nature and also near some remarkable historical sites. One of my favourite pre-Covid pastimes was to drive through the Wye Valley in Wales and visit Tintern Abbey - or rather what remains of it.
The shell of this immense Cistercian monastery makes a powerful impression as you wind down the valley road towards it, and emerge from the surrounding countryside to see it suddenly appear before you, like a Gothic apparition.
This sight never fails to enchant. I have seen the abbey shrouded in fog, illuminated by man-made lights, drenched in rain and scorched by sunshine. It truly is a sight for all seasons. How awe-inspiring it must have been in its heyday. An impregnable citadel of spiritual authority - or so it seemed.
The abbey is best observed from a vantage point high above. To reach it you have to cross the river Wye and walk slowly up a steep, strenuous, rock-strewn path that leads to a landmark overlooking the abbey. It is called the Devil’s Pulpit.
From that lofty perch the abbey seems a much less daunting sight, shorn of its awesome grandeur by a change in perspective. The abbey no longer has a roof, so there is nothing behind its proud walls except a cavernous space that was once filled by the trappings of power and doctrinal certainty. But the belief system that built the abbey and sustained it for several centuries has vanished, to be replaced by a modern form of pilgrimage: tourism. Sic transit gloria mundi.
In its glory days, the abbey would have been a hive of activity. Monastic life was an unwavering daily routine made up of worship, biblical studies, manual labour, communal meals and civic duties - such as the care of the destitute and sick. But every monastery had one overarching aim: to assert its lucrative authority over the human soul.
Abbeys were not just spiritual centres, they were also engines of commerce, specialising in the monetisation of sin. Acts of public penitence, pilgrimages to see ‘holy’ relics, the sale of indulgences and the granting of absolution all resulted in a steady stream of revenue and the strengthening of papal authority. Dirty souls were washed clean - for a fee.
But this blatant secular greed gradually undermined the spiritual authority of monasteries and strengthened the case for their dissolution. A capricious king and his wily chief minister did the rest. By 1541 the dissolution was complete and the monastic era was over. Its riches were transferred to the royal coffers. Its high priests were pensioned off. Its power dissipated.
In this secular age we do not trouble ourselves much with the health of the soul. It has been replaced in the popular imagination by another ineffable entity: the mind. This is now the contested territory over which modern priesthoods claim dominion.
The most vociferous claimant of the mind - at least in its ‘disordered’ form - is the ‘diagnose and medicate’ school of psychiatry. It has planted its flag on the surface of the mind with the fervour of a gold prospector searching for profitable new deposits - and it fights off rival claimants with ferocious condescension.
Every day it burrows deeper into the collective grey matter, in the blind certainty that it will find the buried treasure of bio-markers and errant bio-chemistry that will finally legitimise the medical dominion of mental health. No amount of futile excavations will deter it. Enticing new tunnels always await.
I came into the controversial field of mental health by accident. I had some expertise in strategy development, service design and partnership management and I was invited to apply it in the world of the managed mind.
I went on to write mental health strategies, deliver socially-informed mental health training to over a thousand NHS staff, and to design and manage many different community based mental health services - some of which received parliamentary recognition and awards.
When I tell people this they inevitably ask me, “So, are you a psychiatrist or a psychologist?” My usual answer is, “Neither, I’m a pragmatist.” It is not such a flippant response. There is a point to it.
Initially I saw my lack of education in either of the two great mental health professions as a grave disadvantage. How could I operate successfully in this field without the skills to diagnose, medicate and ameliorate mental anguish?
However, with each passing year I appreciate how my status as an outsider has helped me - for no-one sees the truth of a subject area more clearly than a stranger to it. He or she is not steeped in the language, culture or myths of their host domain. So as I have no professional interests to further, no skin in the game, I can focus on establishing the general, objective truth about ‘mental health problems’ without distraction.
From my particular vantage point - another devil’s pulpit - the truth is abundantly clear: mental health is a complex, multi-dimensional field that is part social, cognitive, emotional, biological, behavioural and spiritual.
‘Mental health problems’ are, in the main, adverse internal reactions to adverse external events - a natural process not necessarily indicative of pathology.
These painful functional impairments are most often caused by the bad things that happen to people (trauma) and the good things that don’t (deprivation, material and emotional).
Mass ‘mental health problems’ usually arise from life’s stark inequalities of opportunity, wealth, safety and social esteem. They are the inevitable product of a sickening society - and that is what we should be trying to cure.
So why do we keep treating ‘mental health problems’ like diagnosable medical conditions instead of the complex existential phenomena they obviously are? Why do we submit to the false authority and doctrinal absurdities of hubristic ‘mind doctors’, when a holistic, humane, preventative perspective is clearly required?
Diagnostic psychiatry shares more with the monastic age than it would care to admit. It too is a faith-based conceptual framework every bit as authoritarian as the monastic one devised for managing sin - though it has transposed sin for ‘disorder’ through a subtle act of palimpsest.
Diagnostic psychiatry has also borrowed and re-badged concepts such as absolution, penitence and abasement and made them core practices to be imposed by its white-robed priesthood. Guilt must be accepted by the patient/penitent, meds taken, authority deferred to - or else.
And its own ‘holy’ book, the Diagnostic and Statistical Manual (DSM), is filled with latinate obscurities that require a medical middle-man to decipher. Humble citizens are denied the sovereignty of their own minds, agency over their own lives, and the simple language with which to understand their own suffering. Mental health awaits its William Tyndale - someone who can translate pseudo-medicalise into plain English and remove the need for a paid interpreter.
It is hard to escape the conclusion that the DSM, like the Old Testament before it, was written by people who don’t like people. It is a doleful book of judgement. It presumes to police the boundary between good behaviour and bad with a ‘tut’ of disapproval and a barely concealed tendency to-wards punishment.
But though the Bible contained only seven deadly sins DSM contains hundreds of ‘disorders’. Such is the scale of its ambition that left unchecked it will form an inescapable spectrum of ‘dysfunction’ that will one day imprison us all. Then its exultant priests will utter a rapturous, “Gloria in excelsis”.
The Roman scholar Livy said that the study of history is the best medicine for a fevered mind. So when the continued dominance of diagnostic psychiatry becomes too much, we should strain our ears to detect the reassuring wisdom whispered to us from down the ages.
It tells us that belief systems, however mighty they may be, eventually fall into disrepute if they are not founded upon the bedrock of objective truth. And then their citadels of power crumble, leaving only ruins to provide amusement, bemusement or sorrow to future generations. So it will be with diagnostic psychiatry and its woeful worldview.
For as another great scholar, Sir Francis Bacon, once observed: truth is the daughter of time, not authority.
You ask, ‘So why do we keep treating ‘mental health problems’ like diagnosable medical conditions instead of the complex existential phenomena they obviously are?’ One problem, I think, is that society desperately needs to believe that there are simple answers for people who appear troubled.
If you think your friend’s troubles can be cured by a pill, well, that makes things much easier than if you have to take a long hard look at the injustices and difficulties of the world that can leave a person in such distress. If people recognised social causes for mental trauma it would mean asking difficult questions of their own lives and how these impact on others. People rarely want to do that.
So psychiatrists, I think, meet a need in society, just like monks of old. They make the vast majority who somehow manage to cope with the strange world in which we live and appear untroubled, feel good about themselves because they can dismiss the person who questions society by not reacting well to it, as merely ill just as once they may have been dismissed as possessed by the devil.