Psychiatric diagnosis does violence to people, imposing a mesmerising suggestion that damages the imaginative potential we all possess to re-story our dilemmas and develop a deeper appreciation of our capacity to learn, develop, and change. It is the output of a culture that turns to scientism to be sold as commodities that are inseparable from the infantalising tendencies that neoliberalism has embedded in our culture. We can soothe our anxieties and uncertainties by buying the latest diagnostic brand and the simplistic remedies that come along with them. You can have whatever you want. God forbid that you weren’t having fun. God forbid that you had to deal with the frustration of your desires.
Of course, I am here caricaturing a tendency, not denying that pain and suffering requires help and understanding. However, I am questioning what type of help we may need—one that leans more to eliminating/suppressing or numbing suffering (the symptom reduction approach that medicalised diagnostic technology advocates), or one that encourages engagement with suffering and the accompanying potential for new discovery and the emergence of natural resilience.
I have little doubt that the scientism of psychiatric diagnosis is not reform-able or redeemable. It is a quackery that must be (and will be) abolished.
It should be easy to see that once we start interrogating the basic assumptions supporting fantasy notions like psychiatric diagnoses, then much of the literature built on such assumptions lacks validity. As ADHD is not a medical diagnosis, but a descriptive classification, we have no reliable empirical method for defining a case.
The definition of what qualifies as a case is thus arbitrary and depends on the standards employed by the diagnoser, influenced by whatever prevailing ideology concerning diagnosis they have been exposed to. As a result, we cannot eliminate wide variation in “diagnostic” practice that has more to do with the training and tastes of the individual practitioner than their capacity to identify anything real about their patients.
Psychiatry keeps faith in scientism despite these obvious flaws, because we live in a culture where technology and technological achievement are highlighted and promoted and because this connects with that broader cosmology that wants to use science to explain everything. In order to have metaphorical and literal purchase in our society we are inclined to use technological/scientific sounding language.
With this type of scientism (science as a system of faith) so prevalent, eventually what the science says is almost irrelevant as long as you can look like you are doing something that you call science and you can bullshit in a way that convinces others (who are excluded from the language and actual findings) that the knowledge you possess is based on a “truth” (because you are a scientist and you do science).
The hidden assumptions disappear and get taken for granted the more you just repeat phrases like “ADHD is a…”, “ADHD is caused by…”, “The treatment for ADHD is...” etc. As philosopher Michel Foucault and others point out, this is how institutional power builds up and gets authority to create “regimes of truth.” In this regime what you do is simply keep repeating phrases like “the evidence says...”, “studies have found…”, “evidence-based practice is…” etc. It doesn’t matter what the evidence actually is. What matters is that we trust the person saying this is what the evidence says, because they are men of the high priesthood—scientists.
The promise that psychiatric diagnoses will ultimately be shown to be like any other medical ones keeps failing to deliver. This became obvious with the publication of the American Diagnostic and Statistical Manual, fifth edition (DSM 5) in 2013, where the authors admitted that despite the DSM being originally designed to allow for research to uncover underlying causes, thus making the labels diagnostic, no causes have been identified.
Figures for the reliability of a DSM diagnosis have actually decreased for many of the diagnostic categories. The American Psychiatric Association generates much income for its organisation through publishing new DSM editions. As long as that’s the case, then perhaps the scientism that it embodies matters little to them. It should, though, matter to everyone else.
As former director of the National Institute for Mental Health (NIMH) in the USA, Thomas Insel, wrote in 2013 after he became frustrated with the inability of the psychiatric establishment to make major improvements in care or understanding of the causal basis of psychiatric problems:
“The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment. Patients with mental disorders deserve better.”
Although he still held to a primarily biological understanding of mental health problems, Insel realised that the DSM and all other diagnostic manuals we use, did a poor job of accurately capturing any biological categories.
DSM is based on categorising by “symptoms”—and even then, its categories are wide nets that ensnared many different diagnostic fish. For instance, the long list of symptoms classed under “Major Depressive Disorder” means that any two people with the diagnosis might have very different symptoms. As discussed, even the idea of symptoms is misleading as it assumes the experiences that are being categorised are best captured using a medical lens. Insel finally understood the calamity of this situation:
“I spent 13 years at the National Institute of Mental Health really pushing on the neuroscience and genetics of mental disorders, and when I look back on that I realise that while I think I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs—I think $20 billion—I don’t think we moved the needle in reducing suicide, reducing hospitalisations, improving recovery for the tens of millions of people who have mental illness.”
But like many in the academic field who have realised this, instead of doing the most logical thing and abandoning the idea that mental distress and difference can be captured through studying biological phenomena using the natural sciences paradigm, he doubled down and opened the door to billions more wasted money by creating a new diagnostic structure (The Research Domain Criteria [RDoC]) in the forlorn hope that this will deliver where DSM and its companions haven’t. Just as DSM failed, so will RDoC.
Medication magic and the creating patients industry
In my clinical practice it is not uncommon for me to encounter patients who have become or are on their way to becoming long term patients because (at least in part) of the way mental health services has given meaning to their suffering and dilemmas. Like the 14-year-old girl transferred to my care who has been taking psychiatric medications since she was 10, of gradually increasing amounts to help with “anxiety” and “depression.” She had been told one is an antidepressant and the other is an antianxiety drug, although this antianxiety drug is actually classified in the books as an antipsychotic.
She has had a few months stay at an inpatient unit following expressing suicidal feelings a year ago. She has also had some individual psychotherapy and there have been some family therapy sessions. She believes she may need to take medication for the rest of her life. Her parents don’t feel anyone is getting “to the bottom” of what is wrong with their daughter.
Despite all the therapy, parents feel that she “doesn’t open up” and isn’t honest with her therapist, and their frustration with the lack of progress often leads them to accuse services of “not doing anything” and of not helping.1
In the above fairly common scenario, everyone—parents, their daughter, and professionals—is trapped in a constructed nightmare that, far from uncovering what’s wrong in order to help make it better, perpetuates, solidifies, and worsens the problem. A long-term patient has been unnecessarily created. Not because the mental health professionals aren’t trying their compassionate best, not because the girl is malingering, and not because the parents don’t care or know how to properly love her. Because they are all trapped in a story about what mental health and ill health is and who has the power to influence that. It’s a story that is making millions around the world ill and disempowered.
The evidence on the relationship between treatment model and outcomes favours the “common factors” over treatment model factors. Common factors refer to things that all treatments have in common, whereas treatment model factors suggest that different treatment models (such as different types of psychotherapy) have specific techniques that work for particular diagnoses better than others (such as the idea that cognitive behavioural therapy treats depression better than psychodynamic psychotherapy).
Decades of outcome research has concluded that just about all of the things that influence outcome are accounted for by common factors and not treatment specific ones.
The most influential of those common factors are those that have nothing to do with the therapy, usually referred to as “extra-therapeutic” factors. These are all those things from the patient’s life outside of therapy that patients bring with them when they walk into a consulting room. This includes their history, childhood, level of education, cultural background, social support network, financial situation, beliefs about therapy and so on.
Once in the consulting room, the quality of the therapeutic alliance, as rated by the patient, accounts for most of the within-therapy impact on outcomes. Alliance is an interesting and multi-faceted object that goes much further than an open and non-judgmental empathic stance (important as that is) and includes agreement on goals, a sense of trust and confidence, and the ability to work through disagreements.
There has been no progress, nor any technical breakthrough, as the percentage improving from “treatment” hasn’t got higher in research done today compared to decades ago when outcome research first started being done.
What this evidence seems to be telling us is that what we wrap up in special expert-sounding language has more to do with everyday human experiences than any special knowledge that leads to accurate classifications and particular treatments that follow from that. Basically, we all have unique circumstances, histories, and interpretations of that, and we find some people more helpful (including therapists) than others.
However, most of this research refers to studies that usually last a few months and more or less suggest that some therapy is, on average, better than no therapy. Longer term, the picture becomes more concerning. Not only do those with no therapy eventually catch up, but it seems that for many, the longer you are in services, particularly if medication is part of the intervention, the worse the outlook (on average) becomes. Longer term, some models are worse, rather than better, than others.
The importance of non-specific factors is also found when using psychiatric drug treatments. As Professor Joanna Moncrieff, Dr Peter Breggin, and many others have pointed out, the evidence undoubtedly supports the view that psychiatric medications are best conceptualised as inducing particular states of mind, rather than acting in a specific way on a disease to correct a chemical imbalance. This reflects clinical practice, where the few categories of psychoactive medications used in psychiatry are used in a non-diagnosis specific way.
For example, selective serotonin reuptake inhibitors (SSRIs), which are usually referred to as “antidepressants,” are claimed to be effective in many more conditions, such as borderline personality disorder, generalised anxiety disorder, obsessive compulsive disorder, bulimia, panic disorder, social phobias, and so forth. As a psychoactive substance, SSRIs would appear to do something to a person’s state of mind, but that something is not diagnosis-specific.
Like alcohol, which will produce inebriation in a person who has been diagnosed with schizophrenia, obsessive compulsive disorder, depression, or someone with no psychiatric diagnosis, SSRIs will also impact individuals in ways that are not specific to a diagnosis. Similarly, the class of drugs known as “neuroleptics” (misnamed “antipsychotics”) have also been advocated for the treatment of psychosis, depression, anxiety disorders, bipolar disorder, personality disorders, and so on—a list that contains considerable overlap with that found for SSRIs.
The therapeutics of these drugs rely on non-specific factors rather than disease-specific therapeutic effects. For example, with SSRIs, the evidence points to placebo effects being more important than any neuro-pharmacological ones. Much more. For example, having a good relationship with the prescribing doctor is a stronger predictor of a positive response to an “anti-depressant” than just taking the drug regardless of who prescribes it.
In fact, much evidence suggests that “antidepressants” are best thought of as enhanced placebos. The tiny (and not clinically significant) extra on-average improvement over placebos that SSRIs achieve in studies is most likely accounted for by “unblinding.”
What this refers to is that in studies when you compare a drug with a sugar pill placebo (a placebo is a pill that has no active chemical ingredient), you keep secret from the patients in the study and those who assess them, which patient is taking the SSRI or the placebo. Of course, patients would like to guess whether they are taking the active treatment or not, and so if you get side effects or feel different, you may realise you are on the SSRI side of the trial. When patients correctly guess they are taking the active pill and not the placebo, this is called “unblinding” (they are no longer ‘blind’ as to which arm of the study they’re in). It seems that unblinding is common in “antidepressant” studies.
This all means there is no such thing as an “antidepressant,” “antipsychotic,” “mood stabiliser,” and so on. These are dangerous concepts that, like “psychiatric diagnosis” have become established in our culture through marketing and institutional self-promotion. As far as the science is concerned, there are no chemical imbalances that these are correcting. Psychiatric medications, like alcohol or street drugs, make you feel different and then you have to interpret the significance of that for you.
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