Insane Medicine, Chapter One: The Medical Model of Mental Health Is Finished
Editor’s Note: Over the next several months, Mad in the UK will publish a serialized version of Sami Timimi’s book, Insane Medicine, along with Mad in America. In this chapter (originally posted on MIA 19/10/20) he provides an overview of how the medical model of mental health has failed.
Have a go at the questions below. Just see what think based on what you’ve heard through whatever sources or media you follow:
- Overall, which one of the following factors has the biggest impact on outcomes from treatment of common mental health problems?
- The quality of the relationship between therapist and patient
- Factors outside of therapy such as the person’s social circumstances
- Having a diagnosis-specific treatment, whether medication or psychotherapy
- The number of sessions of treatment attended
- Which of the following factors (among treatment-specific factors) has the biggest impact on outcomes?
- Having a diagnosis-specific treatment, whether medication or psychotherapy
- Professional training of the practitioner/therapist
- Years of experience of the practitioner/therapist
- The quality of the relationship between practitioner/therapist and patient
3. According to research, the following percent of people entering community mental health centres in the USA are either not responding to treatment or deteriorating whilst in care:
4. Public education programmes that promote an understanding that mental illnesses are like physical illnesses has helped decrease stigma:
5. In Western populations, the relationship between use of mental health treatments and claims for disability benefits as a result of a mental health condition is that:
- Greater use of mental health treatments is associated with falling rates of disability claims
- Greater use of mental health treatments is associated with rising rates of disability claims
- There is no consistent correlation between the two
6. In trials comparing the effectiveness of different therapies, cognitive behavioural therapy (the most widely promoted and recommended form of psychotherapy) has overall been found to be superior to other psychotherapies for treating depression:
7. Psychiatric diagnoses are biological disorders that have been established through proper medical scientific research:
8. Autism is not an established medical condition caused by abnormalities in the development of the brain and nervous system:
9. There are no reliable tests you can take to find out whether you have Attention Deficit Hyperactivity Disorder (ADHD) or not:
10. There is a reliable way of distinguishing between clinical depression and ordinary sadness:
11. According to research, published in 2015, of a UK national project to improve outcomes from treatment for those attending community Child and Adolescent Mental Health Services, the percentage who showed “clinical improvement” from treatment was:
12. According to a 2018 study that re-assessed patients who had completed treatment in one of the national UK NHS outpatient psychotherapy services, the percentage assessed as “recovered” was:
13. In a 2019 survey of 1000 young people in the UK, the following percentage believed they currently or previously had a mental disorder:
14. According to a 2019 research paper comparing outcomes from treatment of common childhood psychiatric disorders in studies from January 1960 up to May 2017, the outcomes over the nearly six decades of studies have:
- Outcomes in studies in the 1960s were the same in terms of rates of improvement all the way through to 2017
- More patients got better in the later rather than earlier studies
- Fewer patients got better in the later rather than earlier studies
- A mixed picture with no obvious patterns over time
15. In terms of rates of recovery and levels of functioning, according to the World Health Organisation International Pilot Study of Schizophrenia, the best outcomes were in:
- The USA
16. Clinical depression is caused by a low level of the chemical “serotonin” which antidepressants can correct:
17. The relationship between drugs marketed as “antipsychotics” and size of the brain is:
- A shrinkage of brain tissue is associated with taking a higher dose of antipsychotics for longer
- Increase in brain tissue is associated with taking a higher dose of antipsychotics for longer
- Reversal of brain tissue loss seen in a psychotic illness is associated with taking a higher dose of antipsychotics for longer
- There is no is association between brain tissue size and taking a higher dose of antipsychotics for longer
18. Those categorised as having a long term Severe Mental Illness, on average, live:
- 5-10 years shorter than the population average
- 10-15 years shorter than the population average
- 15-25 years shorter than the population average
- 5-10 years longer than the population average
- The same as the population average
19. Psychiatric science has not helped advance our scientific understanding of mental distress and has failed to discover any brain-based abnormalities:
20. Clinical psychiatry has helped improve outcomes from treatment of mental distress:
Read on to start finding the answers to the above questions.
The medical model of mental health is finished
Mainstream mental health services are a disaster. The problem isn’t underfunding or the scale of the mental health challenge in society. It isn’t social media, stigma, lack of education, lack of training, lack of doctors, or lack of therapists.
The problem that must be tackled before there is any real chance of improving mental health provision is the dominant ideology. It’s the concepts of mental health, mental wellness, mental illness, and mental disorder that pervade our public debates. It’s the way we have come to talk about and think about mental health. It’s the narratives that the public are exposed to, day in day out, popularising a jaundiced, scientifically illiterate idea that we know what sort of a “thing” mental disorder is, that it is widespread, and needs diagnosing, so that effective treatments can be provided. It’s the endless expansion and commercialisation of so-called psychiatric diagnoses, so that they operate as lucrative brands rather than legitimate categories that help build knowledge and improve clinical practice. It’s the ideology that guides the frameworks that organise mental health services and the professional trainings those who work in them receive.
Tinkering with these dominant ideologies and the systems spawned from them will not help. To clear up this abominable mess we must first rid our trainings, services, and culture of the pseudo-science that has delivered the diabolical outcomes we have where services are better at creating long term patients, being slowly poisoned with neurotoxins erroneously labelled “medication,” than at alleviating understandable distress.
It’s even worse than this. Our dominant ideologies are dripped daily into our consciousness, turning us into potential patients, alienating us from ordinary and understandable emotions, convincing us we have mental disorders that need experts, and terrifying us that our experiences (or the experiences of those whom we love) are markers of a deep dark problem lurking in our broken, dysfunctional minds.
How else do you explain a recent survey of one thousand young people that found that 68% believed they had or did have at some point a mental disorder? Forget the fake 1 in 4 widely advertised, this is approaching the point where only 1 in 4 won’t have experienced a mental disorder by the time they’re a young adult. We have created with our astrological, stargazing mental health ideologies a vast sea of people who believe they are broken, who see their emotional intensity as dangerous and as a foreign body needing to be excised, rather than a human experience needing more ordinary understandings.
Mental health services have become the mouthpieces of an industry of decontextualising and individualising hurt, fear, sadness, and anger, turning so many into the embodiment of caricatures we label them with. The mental health industry creates and solidifies the mental disorders it claims to alleviate. It’s horribly sick. It misses people’s natural resilience in the face of all kinds of adversity (believing resilience is something you can teach rather than innate and waiting to be discovered) and instead carves open chasms of vulnerability alongside patronising paternalism and sympathy.
The therapies we use (perhaps with the exception of some aspects of psychoanalytic and systemic theory) are just systematised versions of Western “folk psychology”; variants with a few rules and turns of language to create an aura of cleverness, professionalism, and science. From challenging your “dysfunctional thinking” to facing your fears; from creating a space for unconditional positive regard to calming down your emotions (such as through “mindfulness”), from focusing on positives to identifying trauma; these are all, when put in simpler everyday terms, things we would recognise as common sense in everyday Western cultures.
By far the worst model is the idea that our mental disorders are rooted in our genes and expressed in alien takeovers of our brain by our biology. This is just a crude version of possession states that we would criticise other cultures for their stupid superstition; only in this Western enlightened version something invisible erupts out of your biology and takes over your body and mind. Our modernist voodoo theory is arguably more sinister, as at least the idea that an external spirit takes over your mind and body creates potential room for recovering an autonomous self.
But this problem will not last. The current dominant “diagnosis followed by specific treatment model” we use is finished. Whether it takes 5, 10, or 50 years there is no rescuing these models. Challenges and alternatives are emerging from all directions and whilst there is still huge money to be made from the commercialisation of diagnostic “brands” and therefore powerful vested interests involved, the deception cannot last forever.
In the same way that neoliberal economies write their own epitaph through the contradictions created by the inequality they breed, so psychiatry and the mental health industry’s dirty secrets are being exposed and the emperors’ pseudo-scientific nonsense is becoming visible. No tests, no markers, horrible outcomes, drugs that cause early death, more people becoming disabled after accessing mental health treatments, a culture confused as to what a mental disorder is and what mental health is. Such a record cannot sustain its institutions unreconstructed forever. And it won’t.
Our ideologies’ foundations are built upon the idea that there is such a thing as a “psychiatric diagnosis.” Apart from the dementias (where there are also problematic issues, but I will not be covering them in this book), there is, technically speaking, no such thing as a psychiatric diagnosis. It exists in our daily discourse as a fact of culture, shaping how we imagine what “normal,” “ordinary,” or “understandable” functioning and experience is. It does not exist in the same way as, say, a broken leg or pneumonia exist as facts of nature.
As you read on, you’ll understand why I am stating this as fact, rather than an opinion. Such a dreadful basic mistake has had huge consequences, determining our dichotomised notions of healthy and unhealthy, normal and abnormal, expected and disordered.
There is no more argument or debate to be had. Whatever metric you use, you can see the ideology has failed. More than failed—it makes things worse. It’s time to move on and start imagining the post-medical/technical model mental health paradigm.
We have brands, not diagnoses
Psychiatric diagnoses are not diagnoses; they are brands. They work as brands that have products like any other product in our profit-driven consumer exploitative markets. They appeal to customers with the promise that if you purchase (literally and metaphorically) and identify with this or that brand, your life troubles will make sense and be improved in some way.
Like most market consumables, they are objects of fantasy and desire; must-haves with a limited shelf life. For markets to keep growing you must convince your customers they need your wares, and continue to need to need them, hopefully with regular upgrades, to stay happy. Markets then develop around psychiatric brands; some brands develop huge markets worth billions from pharmaceutical products, to services from “experts,” to particular therapies, to research institutes, to courses, to trainings, to books, other self-help materials, and more. Get your brand to cover an area of common public concern and money and custom will flow.
In this McDonaldised culture there is some immediate satisfaction, but most have the correct suspicion that using these products to satisfy is problematic in the long term.
Some psychiatric brands are more niche and harder to popularise (such as personality disorders and schizophrenia), but where the market can reach the professional classes in sufficient numbers to allow the brand to take root, then it can, to some degree, influence public discourse too. However, brands that target mood, stress, and insecurities about the self in adults have enormous potential. Similarly brands that target the behaviour and development of children also have enormous potential (unless they are associated with blame for the caregivers).
Thus, strong brands like Bipolar Disorder, Depression, Attention Deficit Hyperactivity Disorder, and Autism demonstrate their popularity by their rapid expansion in the absence of ANY scientifically tangible discovery.
It’s the social and cultural lacunae of meaning, denial of the ubiquity of human struggle, fantasy of Hollywood “you can have whatever you dream of,” in a performance-driven economy, and therefore value system, that breathes life and vigour into these otherwise failed mental health ideologies. They tap into our universal human experiences of distress and suffering, from the mundane to the catastrophic, and supercharge it with our no-less-human desire for pleasure and the absence of the suffering.
Yes, you do not need ever suffer. The world of our emotions, intentions, thoughts and beliefs are just neurotransmitters that can be changed, dysregulated emotions that can be regulated, dysfunctional thoughts that can be corrected. Behaviours are the manifestations of these internal processes and so are amenable to expert manipulation. Mental suffering and behavioural “deviance” can be cured and eliminated. The multiple meanings that can be attached to more intense and troubling human experiences can be reduced to simple categories for which there are “special” snake-oil remedies. How could that not appeal?
Whilst I have reduced to a caricature modern mental health discourse and practice, this is actually what it has been in the process of trying to morph into for the last century; a technical, scientific, system of categorisation, based on cause (i.e. diagnosis) that provides an explanation for the person’s mental suffering or aberrant behaviour and therefore a rational basis for treatment that has a specificity that remedies the particular abnormality it has discovered through application of the correct treatment for a diagnosis.
There is no doubt that many of the people who work in services and who have contributed over the years to developing the concepts, the research, and the practices it spawned, have genuine deep and heartfelt desire to improve people’s lives. But as the famous saying goes, “The road to hell is paved with good intentions.”
The “key opinion leaders” whose life’s work has tried to accomplish this cannot face the reality of the monster they helped create. Their cobbled-together Frankenstein, born out of a desire to help, but that now marauds around the world sowing destruction wherever he turns up (and it is a “he”) is hard to face up to. So we don’t. It’s no longer excusable to avoid looking at what havoc this has wreaked, but worse to carry on defending such a destructive force, arguing that it should be further expanded.
When it comes to imagining what the good life looks like we only have ideology. Whilst ideologies may liberate us, they can also enslave us. In this book, I will set out how our current dominant mental health ideologies have enslaved us in the systems we work in, from the professionals who deliver the services to the patients who are at the receiving end. This is not because the people working with patients had or have ill intentions or wish to do anything other than help, but because the ideological assumptions that organise our responses to peoples’ dilemmas, struggles, and confusions, far from allowing the flourishing of human diversity, hypnotise individuals into viewing their mental life through a prism of suspicion, mistrust, and alienation.
Oblivious to the evidence
There are two main headings that illustrate my argument that our current systems have failed and failed spectacularly. The first is the lack of progress in science/knowledge and the second is the lack of progress in clinical practice outcomes. In this book I tap into the empirical evidence to show how and why we have failed, in both science and clinical practice, to demonstrate that the current systems have either a sound scientific basis or effective clinical utility.
I will show by contrasting with other areas of medicine, how a diagnostic system, which by definition is meant to be based on an explanation of the patient’s presentation, has failed in psychiatry. While there remain deep and important controversies in all of medicine to do with our glorification of the technical and the push toward medicalisation across disciplines, psychiatry and mental health have a unique case to answer.
Other branches of medicine have made progress, and continue to make progress, in understanding the physiological mechanisms that contribute to patient symptoms, and therefore there is an array of medical tests and procedures that can be performed to gain insight into how these physiological processes are potentially manifesting in any given body. These are empirical tools that provide some sort of measurement or insight into biological happenings that are independent of the subjective opinion of the doctor.
Of course, such investigations require interpretation and for the doctor to bring their subjective reasoning into play, but the tests themselves provide a factual finding of the objective world out there. Doctors in a variety of branches of medicine can order X-rays, different types of scans, take blood tests looking for a variety of markers, look at biopsies, culture sputum, test urine for various substances, and so on.
This doesn’t mean the rest of medicine isn’t itself without profound problems. Many diagnoses used in daily medical practice are not supported by empirical evidence; there are many problems around management of chronic conditions, problems of over-treatment for certain populations and under-treatment for others, quandaries about boundaries, conflicts of interest that have led to many dubious interventions with poor evidence on long-term outcomes and overall safety, together with little training for doctors on how to withdraw medications or rationalise them.
Nonetheless, at least there is a basis in diagnosis in the rest of medicine that makes it possible to understand proximal causes, study a disease, and evaluate the specificity of particular treatments.
Psychiatric science has hoped, and spent most of its research funds on the idea, that what we are classifying as psychiatric diagnoses are the products of abnormal functioning of the brain. This has relied on predominately two types of research attempting to establish a similar causal framework as the rest of medicine by pointing to bodily processes. The first type of research is genetics and the second is various types of brain imaging studies.
Such endeavours create an image of science and help popularise the belief that what we do in psychiatric diagnostic practice has a solid basis in science. The utter and total failure of these lines of enquiry to produce anything useful for the science of psychiatry will be further discussed with examples in this book.
The tell-tale signs of this failure are the absence of concrete molecular genetic findings that can explain hereditary factors for any psychiatric condition (despite samples of tens of thousands of patients) and that we have no brain scan technology that identifies particular brain abnormalities or differences associated with any particular psychiatric condition (aside from the dementias, evidence for which may be seen with certain types of brain imaging technology).
In fact, it is the one area of medical practice where we have no physiological or other test available, independent of the practitioner’s opinion. The practice of psychiatry and mental health is therefore entirely subjective. It rests on clinical judgement and nothing else. This means that unlike the rest of medicine, not only are there debates about the boundaries of a condition, but that in addition, in psychiatry the parameters for defining a condition require subjective interpretation too.
Psychiatric phenomena cannot be measured by tapping into verifiable evidence that is independent of practitioners’ interpretation. Kidneys don’t have ambitions, dreams, doubts, and beliefs around the nature of suffering. But you cannot escape these subjective realities in attempting to delineate whether there is a psychiatric condition or not. There is no part of psychiatric practice that uses testing to provide empirical evidence on a quantity that is independent to the practitioner’s opinion.
The phenomena we use to classify symptoms in psychiatry are as subjective as the boundaries we make for them. Mood, impulsive behaviour, shyness, obsessional behaviour; can these be “medical” symptoms? Can persistent low mood be an ordinary part of the human experience? Indeed, for many cultures, personal growth and insight cannot happen without suffering. Could low mood therefore, in some contexts be seen as desirable, rather than pathological at any level of severity?
Mental health practice can only be socially constructed. The assumption that the phenomena that the practitioner encounters are the result of a brain dysfunction is as scientific as the Greek doctors who assumed that the phenomena that they faced were due to imbalances of the four bodily humours—blood, yellow bile, black bile, and phlegm.
There is a deeper problem
The outcomes, at a population level, from treatment in mental health services in Western societies are disturbing. Wherever we look, there is a distressing picture of worse outcomes appearing to be associated with more developed mental health services and/or more developed market economy systems.
I will outline, from a number of sources, how figures for those who are considered disabled due to a mental health condition have been rising. I will also look at the figures we have for what happens in real life mental health services in terms of outcomes, and some of the evidence that we have for the classes of medication that we use. Unlike other branches of medicine, where research and growing knowledge often lead to improved patient outcomes, the outcome research in mental health has not shown such improvement. In fact, some research suggests that outcomes were actually better following treatment in the past than they are today. Like the failure for any scientific breakthrough, the reliance on a medical/technical paradigm to shape mental health services has also been a profound failure.
My awareness of the scientific and clinical outcome literature, together with my experience, over many years, as a consultant child and adolescent psychiatrist, has awoken my consciousness to a deeper problem. Our language has been trapping us into a fear of, and alienation from, the richness and intensity of our emotional lives. Our way of talking about mental health as if it’s a “thing” that we know, or at least that doctors know, encourages people to believe that our emotional experiences, especially when they become intense, are signs of an abnormality, of something going wrong, of symptoms, of weakness, of some sort of dysregulation, dysfunction, and disorder.
We have come to believe that such experiences are dangerous and devoid of meaning, that they should be got rid of, expunged, ignored, distracted from, faced up to even, but particularly that they are something that needs to be “treated”; that they are beyond the ordinary. We have got so far from the ordinariness of suffering, unhappiness, and struggle that we have created a culture of fun morality where there is a problem if you are not having fun, if you are not happy in some kind of superficial Hollywood-like version of happiness.
And we think everyone else but us is. That we alone are suffering in this awful way that cannot be admitted. Even the cultural instruction to talk about your feelings has a mechanistic superficiality—talk about them, but don’t show them.
The labelling of our experiences with pseudo-diagnostic labels entrenches this fear of, and alienation from, our emotional experiences. It extracts the possibility of meaning and creates an antagonistic relationship towards aspects of the self. Our mental health education campaigns have made this worse.
Far from normalising the diversity of our emotional experiences and helping create an awareness of the variety of reactions to all the things that happen in our life being ordinary and/or understandable, even in those more extreme states, we have instead made more people suspicious that their experiences are a signal that there is something deeply wrong with them. That they need healthcare professionals to understand what is wrong and provide the right intervention. Do modern doctors make better healers than priests?
The concepts we use have undermined our natural resilience, sensitised us to an idea of our vulnerability, and encouraged us to transfer our agency to practitioners who use a system as if it has scientific validity and is clinically useful. It seems unarguable to me that we have created a whole system and language that is proficient at creating more long-term patients rather than helping people make creative sense of distress. This is a catastrophe that must be fought and reversed.