In this podcast (episode #447) and blog, I talk to child and adolescent psychiatrist, psychotherapist, professor, mental health advocate and author Sami Timimi about the dangers of pathologizing childhood, the myths surrounding ADHD, a better way to approach children’s mental health, and more. This is part 1 of a 2 part series I am doing with Dr. Timimi, so be sure to tune in again soon when part 2 is released!
Dr. Sami Timimi has been a Consultant Child and Adolescent Psychiatrist since 1997. He is also an experienced psychotherapist and he currently works and lives in the UK. He qualified as a doctor from Dundee University in 1988 and became a Member of the UK Royal College of Psychiatrists in 1992, becoming a Fellow of the college in 2012. He has been a Visiting Professor of Child Psychiatry and Mental Health Improvement at the University of Lincoln, UK, for many years. He is also an author who writes from a critical psychiatry perspective on topics relating to mental health, and he has published over 130 articles and dozens of chapters on many subjects including childhood, psychotherapy, behavioral disorders and cross-cultural psychiatry. He has authored five books, including Naughty Boys: Anti-Social Behaviour and ADHD and the Role of Culture, co-edited 4 books including, Libratory Psychiatry: Philosophy, Politics and Mental Health with Carl Cohen, and co-authored 2 others including The Myth of Autism: Medicalising Men’s and Boys’ Social and Emotional Competence with Neil Gardiner and Brian McCabe. His latest book, Insane Medicine: How the Mental Health Industry Creates Damaging Treatment Traps and How You Can Escape Them, is available in serialised form on the Mad in America website.
As Dr. Timimi points out, the current mental healthcare system is far better at creating long-term patients than alleviating mental distress. As things stand, the mental health services that have been developed have not led to a large increase in human wellbeing, particularly in countries that have access to “state of the art” resources, technology and research.
One of the central issues related to these repeated findings of poor outcomes is the disconcerting gap between increasing the uptake of mental health services and the fact that more, not less, people are developing chronic mental health conditions, which often leaves them disabled and incapable of participating fully in society. Indeed, there is alarming research highlighting the relationship between recurrent or severe mental health problems and reduced lifespan, which should concern us: what are we doing wrong, and how can we improve mental healthcare?
This is not just an issue of funding or limited resources and time. If we are simply putting more funds and resources into a system that is not working, we will make the issue worse, not better.
Unfortunately, the problems with our current approach to mental wellbeing run deeper than just the services provided. In Western countries in particular, we have now developed a culture that believes that when you experience various types of mental distress, these are the result of conditions that are identifiable in the same way that other medical conditions are identifiable (such as low insulin and diabetes), which is simply not supported by the evidence we do have. There is also a common assumption that if we do not intervene early, then it will result in further problems down the line (like with cancer), which is also not supported by existing mental health research. Many people assume that the paradigms we use in general medicine can be exported wholesale into the area of mental health, and this kind of thinking has dramatically impacted not only how we view mental health, but also how we treat people with mental distress.
Within this context, it is important to understand that a diagnosis is a form of classification. In medicine, diagnostic classification emerged based on understanding the initial/proximal cause(s) of a patient’s suffering, which helps you determine what treatments and interventions may help alleviate this suffering. Based on these empirical anchors, we can start to build a framework of knowledge based on a technical understanding of the human body. This system works best with acute presentations of suffering, such as someone who just had a car accident and has bodily injuries like swelling and a fractured bone. The diagnosis is key to understanding what someone needs in terms of treatment.
Even with some medical issues that may have non-specific symptoms like being tired and prone to infection, this system generally works, although there is always room for improvement. For example, someone with diabetes may have tiredness, but that is not how we diagnose diabetes. We use this as a starting point to explore the various symptoms the patient is experiencing. We do not, however, define diabetes by a description of symptoms or experiences like tiredness and send the patient on their way. We define diabetes by blood sugar that is considered too high, which will then determine the type of treatment that someone is given.
Although the technical framework isn’t sufficient to understand all the different aspects of a diagnosis such as diabetes (like psycho-social issues and other disparities), there are at least some empirical anchors guiding the diagnosis. As Dr. Timimi points out in his new book Insane Medicine, “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.”
Where this system really falls apart is in the field of mental healthcare. When we try to define or diagnose something like depression, unlike the diabetes example used above, we do so based ona description of symptoms. Are you sad and no longer enjoying life? You may have depression. Why? Because you are sad and no longer enjoy life. This is a tautology, not an empirical diagnosis—using the description as the cause of itself. It is a type of circular thinking, not a system based on good empirical data.
That is not to say that people’s mental struggles are not real. Many people suffer on a daily basis, and their stories deserved to be heard and treated with compassion. Mental distress is incredibly real for the person who is experiencing it, and they deserve our compassion, help and understanding.
However, we should not be imposing a way of thinking onto someone’s experiences. When we do this, we do not work to discover how and why they feel the way they do, potentially setting this person up for a lifelong struggle with the belief that there is part of themselves that is broken, abnormal, lacking, or not quite right, and the belief that they will need external interventions to reduce or take away these feelings of distress. It can make this person feel that as long as they are alive, they will need to fight or get rid of these uncomfortable feelings, which can be incredibly distressing and damaging, and impair the process of growing up (especially if someone starts getting treatment when young) and being human.
The question we urgently need to ask ourselves is: how do we best help the person who is struggling? Is our current system of mental healthcare actually treating people with compassion and alleviating suffering? Based on the data we do have, it seems the answer is no.
As Dr. Timimi notes in Insane Medicine, the dominant approach to mental health’s foundations are built upon the idea that there is such a thing as a ‘psychiatric diagnosis.’ “Apart from the dementias, there is, technically speaking, no such thing as a psychiatric diagnosis,” he writes. “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.” There is little empirical evidence that we are doing a lot of good, and a lot of empirical evidence that things are going very badly for a lot of people.
Indeed, despite the millions of dollars spent on seeking our technical and biological explanations for issues like depression and anxiety, we have little to show for these efforts. “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).” What we call diagnosis in psychiatry is not truly diagnosis.
As Dr. Timimi points out, mental healthcare “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.” And it is not making mental health outcomes better.
We know little about the mind and mental health, and how much our experiences shape how we feel and how much we shape our experiences. This is a very new area of research and incredibly hard to study. Yes, we have models we use to try understand these relationships, and these have consequences.
The technical model of mental health that dominates our current system of healthcare is not without repercussions. It tends to locate the source of the issue in the individual’s biology, divorcing that person from the complicated context of their life, and losing large parts of the narrative. It leads to what Dr. Timimi calls the “commodification of emotions” — turning human feelings into potential avenues to make money through services.
This is seen in all areas of mental healthcare, including the treatment of ADHD. Much of the existing research surrounding ADHD started with the assumption that certain behaviors are indicative of some sort of medical condition. This was eventually called a near-developmental disorder, and became a diagnosis that was made independent of someone’s history and context through asking questions (mainly of people who care for that person and not the person themselves) and, occasionally, some observation. It is incredibly subjective diagnosis, as it is totally dependent on a description that generally starts with the word “often” and is followed by a subjective observation of behavior like fidgeting.
This is why Dr. Timimi calls ADHD a “manufactured” diagnosis in his book Insane Medicine. As he notes, “there was an assumption that ADHD exists as a ‘thing’ and that this thing had a concrete reality that meant you could make authoritative statements about its features, implications, causes, prevalence, treatment, and so on.”
According to Dr. Timini, the reality is different. “There has been a failure to find any specific and/or characteristic biological abnormality such as characteristic neuroanatomical, genetic, or neurotransmitter abnormalities [related to ADHD]. Unlike the myths that have been spread to spur an ADHD industry on, the scientific reality is that we have a cupboard empty of confirming evidence and full instead of ‘junk’ scientism.” This is a system of knowledge that is built on faulty assumptions and that relies almost entirely on the subjectivity of the person doing the diagnosing and the systems we have created, which are far from the scientific method and evidence-based medicine (which we will discuss more in part 2 of this podcast series). As Dr. Timimi points out, the systems we have created are so full of unfounded assumptions that once you start looking at these systems, everything falls apart.
For more on mental health, ADHD and the failure of our current mental healthcare system, listen to my podcast with Dr. Sami Timimi (episode #447) and check out his incredible work. If you enjoy listening to my podcast, please consider leaving a 5-star review and subscribing. And keep sharing episodes with friends and family and on social media. (Don’t forget to tag me so I can see your posts!).
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2:00 Sami’s amazing work
3:10 The failures of the current mental healthcare system
6:11, 24:00 Why we urgently need to redefine mental health culture
12:18 The reality behind mental health diagnoses
20:00 The circular thinking that defines current mental healthcare
26:10 How little we actually know about mental health
28:50 The commodification of human emotion
32:30 Pathologizing mental health from youth & its consequences
37:16, 50:55 The myths surrounding ADHD
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