Upon the Shores of Social Construction

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CONVERSATIONS IN CRITICAL PSYCHIATRY

Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

Sami Timimi, MD, is a consultant child and adolescent psychiatrist in the National Health Service of the United Kingdom (UK) and a visiting professor of child psychiatry and mental health improvement at the University of Lincoln, UK. He has authored, coauthored, and coedited several books, including his latest, Insane Medicine. Dr Timimi is among the fiercest critics of psychiatric diagnoses and the medical model in psychiatry, especially child psychiatry. He is a prominent voice of British critical psychiatry, and over the years he and his colleagues have argued that psychiatric conditions in their very nature reach beyond the brain to involve sociocultural dimensions and cannot be adequately understood through the epistemology of biomedicine.¹ Dr Timimi’s sweeping critique of and divergence from mainstream views is also illustrated in a 2018 debate with David Foreman, MD, in the Irish Journal of Psychological Medicine on the validity of attention-deficit/hyperactivity disorder (ADHD) as a diagnostic construct.^2,3

Awais Aftab, MD: Your critique of current psychiatric thinking and practices touches on so many conceptual and philosophical issues, that I worry that it would be too easy to get mired in disagreements about abstract questions regarding the nature and goals of psychiatric classification or the medical model. Let’s begin with clinical practice: How would you approach the assessment and management of a child who with a pervasive and persistent pattern of inattention and hyperactivity?

Sami Timimi, MD: First, many thanks for inviting me to be a part of your conversation series. It is so important for us to continue a discussion on the problems with, and alternatives to, dominant models. I hear the concern in your first question, but I do not think the conceptual and philosophical issues can be separated from clinical ones. How we imagine what we are dealing with, particularly if we are imbued with cultural meaning–making power, has a massive impact on what we show interest in clinically, what questions we ask, what interventions we make, and what impression our patients are given about what is happening in their lives.

This means the question you ask already sends us crashing against the shores of social construction. What do you (or this mythical family) mean by pervasive, persistent, inattention, and hyperactivity, and why have these bits of behavior been brought to the clinical foreground? If, like me, your clinical practice understands that what we do in psychiatry is essentially provide a new story about the stories our patients, or parents, might tell, then we cannot escape the interpretive nature of how we construct our story about them. After all, we have no recourse independent of subjective opinion empirical evidence.

I would be more interested in knowing their broader narrative. What has happened in that child’s and family’s life? Like the vast majority of those who end up in my clinics, many children who present like this have had more than their fair share of adversity. What are the child’s strengths and existing skills? If there were a mythical perfect treatment, what would they like to see change: school? home? relationships? Who is it—parents, teachers, child themselves—who most wants to see what sort of change? A 1-acronym formulation, such as ADHD, has powerful consequences. It acts as a hypnotic suggestion on those around the child and influences what they might view as important. It has the potential to obscure, or at least render as secondary, the things that might bolster the child’s esteem and the parent’s sense of empowerment.

I may choose an alternative label such as the child is “intense.” They engage with the world with an emotional intensity that provokes powerful emotions in those around them. We could see this as a gift that needs understanding, guidance, and nurturing, rather than using a label that views their behaviors as symptoms that need suppressing. With the cultural pressure to diagnose and medicate, this is not always easy, but maybe easier than we realize.

Aftab: Yes, I do not think either conceptual or philosophical issues can be separated from clinical ones—something I strongly try to convey to my trainees as well as colleagues! My hope was that by looking at how our clinical approach is informed by these issues, we may be better able to appreciate your views. And your response is very helpful in this regard. As you mention, you are not a fan of psychiatric diagnoses and you have criticized them extensively. From my perspective, one of the things psychiatric classifications do is to serve a sort of pragmatic function, which allows researchers to conduct studies about causes and treatments and allows clinicians to link the individual in front of them with the existing body of knowledge related to causes and treatments. For instance, the ADHD construct allows clinicians to capitalize on the literature related to stimulant medications. The short-term efficacy of stimulant medications for individuals who meet criteria for ADHD is so robust—and universally endorsed by practice guidelines—that it would be considered below the standard of care not to discuss them as a treatment option for individuals who could benefit from them. However, it is hard for me to imagine how we can determine who could benefit from stimulant medications if we were not making diagnostic distinctions, at the very least in our head—for instance, differentiating between anxiety syndrome vs inattention-hyperactivity syndrome. This does not necessitate that we are forced to consider these diagnoses as natural kinds or as neurobiological disease entities; it only means that we recognize them, at minimum, as pragmatic constructs, more or less helpful given our goals. What is your view on how clinicians and researchers can carry out their pragmatic functions of research and treatment?

Timimi: These are great questions, but we need more than this interview to properly unpack them; nevertheless, I will have a go. First, there is an important difference between psychiatric diagnosis and a psychiatric classification. There are many different classification systems, with diagnosis being a particular system based on classification by cause (at least proximal cause). This is why your statement that diagnosis “allows clinicians to link the person in front of them with the existing body of knowledge related to causes and treatments” works when it is shedding light on cause and therefore the development of treatment technologies that address cause, but it does not work when the system of classification is unable to identify, or get close to identifying, proximal causes. Worse, calling it diagnosis leads to (an understandable) assumption that cause and therefore evidence-based useful treatments are known/knowable. Because what we call psychiatric diagnosis is not diagnosis, in that technical sense. Thinking that it is has led to practice that is skewed and patient expectations that are unrealistic.

What about making pragmatic decisions? I do not agree that the construct of ADHD allows clinicians to capitalize on the literature for stimulants, for example. It makes them imagine they can, which is far more dangerous. Thus, we end up with vested interests shaping guidelines, which then influence public perception and media reports, and distort doctors’ practice. The result has been catastrophic mass prescribing of stimulants to children and equally catastrophic convincing of children and their caregivers that they have a hardwired condition that makes them incapable of doing certain things and requires that they ingest the same substance that we warn adults about its profound dangers.

The effect of stimulants has been known for a long time and is no different if you get the label of ADHD or not. Decades ago, studies found that if you take them, regardless of diagnosis, it improves your ability, in the short term at least, to maintain task concentration. So that is the danger of imagining these are pragmatic groupings: It embeds and reifies ideas, turning an imagined entity into an assumed concrete reality, which when done without realizing that this is what you are doing, has the potential for unhealthy consequences to individuals, the profession, and our culture more broadly.⁴

Aftab: You have talked about the “McDonaldization” of child development, where the difficulties of growing up are categorized neatly and then addressed with quick fixes. You have also talked about psychiatric diagnoses functioning as “brands” that are sold to consumers and generate lucrative markets around them. Can you tell us more about what you mean by this?

Timimi: The “McDonaldization” of child development refers to the way the challenges and uncertainties connected with growing up are placed into neat categories of things wrong with individual children, which can then be fixed with simple, one-size-fits-all interventions. A market economy and culture preys on our desire for the here-and-now satisfaction of our cravings, provided in a fast manner that requires little engagement with the product beyond its consumption. Get your products and messaging right, and you can entice your consumers when they are still young and then have them as potential customers for life. McDonaldization is just a more culturally familiar reference to the process of commodification—in other words, the process of turning something into an object of economic value. Commodification’s overriding value is making money. In this arena, you need to convince a population that all manner of experiences may lead to unpleasant and dangerous consequences if not identified and remedied with your products (a diagnosis, a book, a medication, a therapy, a course, a supplement, etc).

Aftab: You have argued that the current system of mental health care alienates individuals from the meaning inherent in their own emotional difficulties, undermines their capacities for everyday resilience, and by doing so, perpetuates those very difficulties. Can you elaborate on how you think this process of alienation unfolds?

Timimi: The labeling of our experiences with medicalized language (diagnosis, symptoms, disorder, dysfunction, dysregulation, etc) has spread far and wide. My kids and their friends talk about feeling “depressed,” a medical word. It entrenches a fear of, and alienation from, an appreciation of the ordinariness and understandability of a panoply of human emotional experiences. When we place our emotional experiences in a problematizing framework, we extract the everyday meanings these have and become worried that there is something wrong in us beyond our capacity to comprehend. Mental health education campaigns have made this dynamic worse. Far from normalizing 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 individuals suspicious that their experiences are a signal that there is something deeply wrong in them.

These medicalized frames also undermine our natural resilience, sensitize us to an idea of our vulnerability, and encourage us to transfer our agency to practitioners who are assumed to have some special knowledge about our experiences that we cannot possess.

Medical colonialism—of language and the concepts that flow from this—means that we do not have any other strong culturally available model for emotions beyond banal mechanical ones. As a result, we fear, and are fascinated by, displays of emotions, and we easily slide into an idea that individuals need help to learn how to control and manage how they feel. To me, one of the worst phrases to emerge in modernist mental health practice is the oxymoronic “emotionally dysregulated.” The aspired to neoliberal entrepreneurial individual has to learn how to nourish their ego and use their thoughts to control their emotions. There are too few resources in medicalized Western cultures for learning how to sit with, experience, withstand, and understand emotions as important forces for action and connection. We have imbued our emotional life with a destructive power more than a liberatory one.

Aftab: Given that mental health is a multidisciplinary area, a professional space shared by psychiatrists, primary care physicians/general practitioners, psychologists, and social workers, among others, what are your thoughts on the relationship between these disciplines? How would you like this professional space to be reorganized? In what areas should psychiatry be at the forefront and in what areas should it take a backseat and let other professions take the lead?

Timimi: It is sad that psychiatrists have been pushed into being primarily viewed as the prescribers in mental health services. Our representative institutions and academics have been complicit in this. The flimsy appeal that our models and practices are biopsychosocial—apart from not really knowing what this looks like in practice—is a smokescreen to what much of practice as a psychiatrist has become.

I consider myself a traditional child psychiatrist. My first placement in child psychiatry in the early 1990s was in a children’s hospital in London. The lead consultant worked in collaboration with the other professionals and the team used primarily systemic models. We had access to 2 beds for in-patients and, as well as outpatient work, we carried out consultation on cases requested by the pediatricians. In those 9 months, I prescribed medication to only 1 individual, and beyond broad formulations, the idea of a diagnosis was nowhere. It all made sense to me and persuaded me that this was the career for me. I felt that child psychiatry’s gift to medicine was understanding that there was a context to individuals’ suffering—they existed in systems of support and meaning—and to the idea of development—that life is dynamic and changes.

As I undertook the 4-year training to become a consultant, I saw, with concern, the tide of medicalization sweep across the Atlantic from the United States. It gradually colonized our curriculums.

Potentially, psychiatrists are the only mental health practitioners who can do it all, from prescribing to therapy. We also ought to be
able to identify organic conditions that may cause psychological problems as well as the organic complications that arise from psychological challenges, such as eating issues. If we live up to our promise, we should be leaders in mental health services, helping bring other professions along, as well as not being afraid of becoming embroiled in the politics and politicization of services. If we do not seriously reform and reconnect with our wider roots as a profession (most psychotherapies were originally developed by doctors), which, for example, had historically strong relationships with disciplines such as anthropology, then there are plenty who would come and rightfully take our place. This would be a great loss to the task of humanizing medicine.

The opinions expressed are those of the participants and do not necessarily reflect the opinions of Psychiatric Times™.

Dr Aftab is a psychiatrist in Ohio, and clinical assistant professor of psychiatry at Case Western Reserve University. He is a member of the executive council of the Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the Psychiatric Times™ Editorial Board. He can be reached at awaisaftab@gmail.com or on Twitter @awaisaftab.

References

1. Bracken P, Thomas P, Timimi S, et al. Psychiatry beyond the current paradigm. Br J Psychiatry. 2012;201(6):430-434.

2. Foreman DM, Timimi S. Attention-deficit hyperactivity disorder (ADHD): progress and controversy in diagnosis and treatment. Ir J Psychol Med. 2018;35(3):251-257.

3. Timimi S. Rebuttal to Foreman’s article ‘Attention-deficit hyperactivity disorder (ADHD): progress and controversy in diagnosis and treatment.’ Ir J Psychol Med. 2018;35(3):262-265.

4. Timimi S. Insane Medicine: How the Mental Health Industry Creates Damaging Treatment Traps and How You Can Escape Them. Kindle Direct Publishing; 2020. ❒