We often assume that the opposite of flourishing is suffering – that these are binary conditions, and that suffering is best addressed through some sort of psychotherapeutic or psychopharmacological intervention.
—“That’s triggering! Is therapy-speak changing the way we talk about ourselves?” The Guardian
“If the language used on the internet is a reliable indicator, we’re more psychologically enlightened than ever. We discuss attachment styles like the weather. We joke about our coping mechanisms. We project, or are projected on to. We shun “toxic” people. We catastrophize and ruminate. We diagnose, or are diagnosed: OCD, depression, anxiety, ADHD, narcissism. We make, break or struggle to “hold” boundaries. We practise self-care. We know how to spot gaslighting. We’re tuned into our emotional labour. We’re triggered. We’re processing our trauma. We’re doing the work.”
But despite innovations in drugs and so-called ‘evidence-based therapy,’ the prevalence of pop psychology and rise of the self-help industry, and increases in societal wealth and individual liberty, mental health outcomes haven’t improved.
In fact, things are getting worse, with levels of mental illness of all types increasing in number and severity.
Why?
Because we are mischaracterizing the challenges of living, which is leading to the medicalization of everyday life, the diagnosis of any challenging behavior as mental illness, and our collective fear or obfuscation of difficult emotions.
The result is two inadequate extremes: the clinical/biomedical model favored by mental health professionals on the one hand and pseudo-profound BS on social media on the other. I want to rescue you from this unfair binary.
Why should you trust me? You shouldn’t. Explore the information in the three sections below and make up your own mind.
Diagnoses may be scientifically invalid and harmful because they pathologize understandable reactions and falsely imply that there are medical solutions.
Take, for example, the serotonin-imbalance theory of depression which led to hundreds of millions of people around the world taking antidepressants (SSRIs like Prozac). For decades, we were told this was based on sound science. A few years ago, the entire theory was wholly discredited by a landmark study. But if chemical-neurobiological theories of depression don’t fit the data, then depression must have a genetic component, right? Wrong. Surely, there must be some markers in brain scans then? Wrong again.
Through a Freedom of Information request, a leading researcher of the placebo effect examined dozens of drug company studies submitted to the FDA and found that “all antidepressants, including the well-known SSRIs… had no clinically significant benefit over a placebo.” In 2017, a study went even further, noting “Poorer Long-Term Outcomes among Persons with Major Depressive Disorder Treated with Medication.” So, not only do they not (always) work, they can also make you more sick over time.
“Despite three decades of intense neuroimaging research, we still lack a neurobiological account for any psychiatric condition.”
co-winner of the 2017 Brain Prize
“…psychiatry has become the fastest-growing medical field in history; why [are] psychiatric drugs now more widely prescribed than ever before; and why [does] psychiatry keep expanding the number of mental disorders it believes to exist. […] these issues can be explained by one startling fact: in recent decades psychiatry has become motivated by the pursuit of pharmaceutical riches.”
Assoc. Prof., PhD in social and medical anthropology, University of Oxford
So, how can we make sense of depression? We can view it not as a disease, disorder, or pathology, but rather as an imperfect “strategy” to deal with overwhelming pain—the pain of financial problems, struggling relationships, a poor support system, or, more abstractly, the state of the world. With injustice, war, and moral hypocrisy on blatant display, it is natural to feel disheartened, defeated, and overwhelmed.
“The new Diagnostic & Statistical Manual (DSM5) is soon due to be published. DSM is the modern ‘bible’ for diagnosis in psychiatry. Yet there is little or no evidence to support the idea that the categories used in DSM are either based on sound science or clinically helpful […] science that tells us that the system of psychiatric diagnostic is a bad idea. In summary, my review found that:
- Psychiatric diagnoses are neither reliable nor valid.
- Using psychiatric diagnosis does not aid treatment decisions.
- Long-term prognosis for mental health problems has got worse over the years.”
Director of Medical Education at the Lincolnshire NHS Foundation Trust
“Multiple studies have shown that in developing countries, where psychiatric care is limited, patients who are diagnosed with schizophrenia are more likely to make a full recovery than those in the West.”
“If you tell someone, as an established fact, ‘You have bipolar disorder, you have schizophrenia, you have a personality disorder,’ really, you’re telling them something untrue. And that has consequences for people’s identity, life, insurance, relationships. It’s the major crisis of our time in some ways.”
Oxford-trained clinical psychologist and lead creator of the Power Threat Meaning Framework
“We put forward a different possibility: the ‘don’t know’ bird hypothesis. Given the problems with credibility we found across many clinical trials, we contend that we currently don’t know in many cases if some therapies perform better than others. Of course, this also means we don’t know if the majority of therapies are equally effective, and, if such equality exists, we don’t know if it owes to common factors.”
Every Instagram scroll brings you some kind of pseudo-spiritual solution: “speak your truth,” “I am enough,” etc. But can we deep breathe and daily affirm our way to a state of flourishing? Probably not.
The prevailing self-help culture creates a kind of safetyism that is at odds with both modern psychology and ancient wisdom. It means that most young people treating ‘safety’ as a kind of sacred value are increasingly unwilling to make trade-offs demanded by other practical and moral concerns. If we are constantly triggered and offended by external stimuli—and constantly telling ourselves that ‘our truth’ is all we need and that we are ‘enough’—we are unlikely to introspect, hold ourselves accountable, and take responsibility for positive change.
Over the past decade, we have been programmed to centralize comfort. Unfortunately, growth cannot happen from a place of comfort. The paradox is: how do we take charge and improve while trying to feel adequate?
Moral relativism along a near-infinite spectrum has eroded any sense of the (objective) common good or of excellence itself, a key ingredient of flourishing.
“…full of misplaced clichés, silly quotes, and superstitious drivel. It’s a playbook for entitlement and self-absorption and I think that anybody who reads it and implements its advice in any serious way will likely make themselves worse off in the long run.”
three-time #1 New York Times bestselling author of The Subtle Art of Not Giving a F*ck
“It is no measure of health to be well-adjusted to a profoundly sick society.”
“A culture that allows the concept of “safety” to creep so far that it equates emotional discomfort with physical danger is a culture that encourages people to systematically protect one another from the very experiences embedded in daily life that they need in order to become strong and healthy.”
The following is an excerpt from Dr. Timimi’s blog. He is the author of Insane Medicine: How the Mental Health Industry Creates Damaging Treatment Traps and How You Can Escape Them, and Director of Medical Education at the Lincolnshire NHS Foundation Trust, UK.
Mainstream psychiatry has been afflicted by at least two types of scientism. Firstly, it parodies science as ideology, liking to talk in scientific language, using the language of EBM, and carrying out research that ‘looks’ scientific (such as brain scanning). Psychiatry wants to be seen as residing in the same scientific cosmology as the rest of medicine. Yet the cupboard of actual clinically relevant findings remains pretty empty. Secondly, it ignores much of the genuine science there is and goes on supporting and perpetuating concepts and treatments that have little scientific support. This is a more harmful and deceptive form of scientism; it means that psychiatry likes to talk in the language of science and treats this as more important than the actual science.
I have had debates with fellow psychiatrists on many aspects of the actual evidence base. Two ‘defences’ have become familiar to me. The first is use of anecdote — such and such a patient got better with such and such a treatment, therefore, this treatment ‘works.’ Anecdote is precisely what EBM was trying to get away from. The second is an appeal for me to take a ‘balanced’ perspective. Of course each person’s idea of what is a ‘balanced’ position depends on where they are sitting. We get our ideas on what is ‘balanced’ from what is culturally dominant, not from what the science is telling us. At one point, to many people, Nelson Mandala was a violent terrorist; later to many more people, he becomes the embodiment of peaceful reconciliation and forgiveness. What were considered ‘balanced’ views on him were almost polar opposites, depending on where and when you were examining him from. Furthermore, in science facts are simply that. Our interpretations are of course based on our reading of these facts. Providing an interpretation consistent with the facts is more important than any one person’s notion of what a ‘balanced’ position should look like.
Looking at the actual evidence provides a worrying picture for mainstream mental health services’ real world effectiveness. Although over-diagnosis and unnecessary care is recognized as a growing problem across medicine, the short and long term outcomes for many conditions dealt with by the rest of medicine have improved, often reflecting genuine technical advances. This is not the case in mental health. Research from a number of countries has found that despite continuous growth in the availability of mental health services, only about 15-25% of those referred significantly improve or recover. This dismal picture is found in both child and adult mental health services. Non-attendance rates and numbers of people dropping out of treatment are also substantial. There has been a steep rise in the number of youth and adults categorized as disabled mentally ill in most Western countries. In the UK, recent research found that mental disorders have become the most common reason for receiving disability benefits, with the number of claimants rising by 103% from 1995 to 2014, whereas claimants with other conditions fell by 35%. Most people who attend standard community mental health services, it seems, experience either no lasting improvement or deteriorate.
In order to ‘cover up’ this disastrous state of affairs we have created an idea that the conditions we deal with are ‘chronic.’ This provides a framework for accepting as unproblematic the expanding numbers of people categorized as mentally ill, who don’t seem to get better or keep relapsing despite our treatments, without feeling that it is, at least in part, the fault of our concepts and treatments. Thus, I know of colleague psychiatrists in adult services with case loads of several hundred patients. They are overwhelmed and all they can manage are 20-minute medication reviews once every six or so months for patients who never get discharged.
This picture of poor real world outcomes may be exacerbated by one of the signs of ‘scientism’ found in psychiatry — the belief that there is such a thing as a psychiatric diagnosis. It is fairly straightforward to demonstrate that the concept of psychiatric diagnosis is scientism, as from a logical/technical perspective, there is no such thing as a psychiatric diagnosis (apart from some forms of dementia and a few other known organically based conditions that sometimes are encountered by psychiatrists). In medicine, diagnosis is the process of determining which disease or condition explains a person’s symptoms and signs. Diagnosis therefore points to causal processes. Making an accurate diagnosis is a technical skill that enables effective matching of treatment to address a specific pathological process. Pseudo diagnoses, like for example ADHD, cannot explain behaviours as there are only ‘symptoms’ that are descriptions (not explanations) of behaviours. Even using the word ‘symptom’ may be problematic, as in medicine ‘symptoms’ usually refers to patients’ suffering/experience as a result of an underlying disease process and is therefore associated in our minds with a medical procedure leading to an explanation for the ‘symptom.’ But psychiatric diagnoses do not explain symptoms.
Consider the following example: If I were to ask the question “what is ADHD?” it is not possible for me to answer that question by reference to a particular known pathological abnormality. Instead I will have to provide a description, such as ADHD is the presence of the behaviours of hyperactivity, impulsivity, and poor attention (plus a few extra qualifiers such as age of onset). Contrast this with asking the question “what is diabetes?” If I were to answer this question in the same manner by just describing symptoms such as needing to urinate excessively, thirst and fatigue, I could be in deep trouble as a medical practitioner as there are plenty of other conditions that may initially present with these symptoms and diabetes itself may not present with these symptoms in a recognizable way. In order to answer the question “what is diabetes?” I have to refer to its pathology involving abnormalities of sugar metabolism. I would get independent (to my subjective opinion) empirical data to support my hypothesis about what may be causing the patient’s described experiences (such as testing the urine and/or blood for levels of glucose). In the rest of medicine, therefore, my diagnosis explains and has some causal connection with the behaviours/symptoms that are described. Diagnosis in that context sits in a ‘technical’ explanatory framework. In psychiatry, what we are calling diagnosis (such as ADHD) will only describe but is unable to explain.
The problem of using a classification like ADHD to explain an observed set of behaviours (i.e., as a diagnosis) can be illustrated by asking another set of questions. If I was to ask “why” a particular child cannot concentrate, is hyperactive and shows impulsivity and I were to answer that these behaviours are caused by ADHD, then a legitimate question to ask is “how do you know that they are caused by ADHD?” The only answer I can give to that question is that I know it’s ADHD because the child is presenting with hyperactivity, impulsivity and poor attention. In other words, if we try to use a classification that can only describe in order to explain, we end up with what philosophically is known as a ‘tautology.’
It is troubling when doctors use a descriptive category like ADHD to explain and cannot see this problem of tautological circularity. Using ADHD to explain the behaviours of ADHD is like saying the pain in my head is caused by a headache. If we don’t communicate to patients the difference between a descriptive and diagnostic classification, the effects can be profound, affecting the patient’s identity and how those around her view her. Furthermore, the idea that a diagnosis like ADHD explains behaviour risks undermining our ability to attend to a whole host of other real-life factors that may have an important role to play in the development of a problem, or to find positive ways forward beyond the focus on reducing what are considered ‘symptoms’ that is typical of many medical-style interventions.
It is troubling when doctors use a descriptive category like ADHD to explain and cannot see this problem of tautological circularity. Using ADHD to explain the behaviours of ADHD is like saying the pain in my head is caused by a headache. If we don’t communicate to patients the difference between a descriptive and diagnostic classification, the effects can be profound, affecting the patient’s identity and how those around her view her. Furthermore, the idea that a diagnosis like ADHD explains behaviour risks undermining our ability to attend to a whole host of other real-life factors that may have an important role to play in the development of a problem, or to find positive ways forward beyond the focus on reducing what are considered ‘symptoms’ that is typical of many medical-style interventions.
It should be easy to see that once we start interrogating basic assumptions, such as the validity of 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 ‘caseness.’ 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.
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 language and the 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 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.