Psychiatry and the Shores of Social Construction: Sami Timimi, MD

March 12, 2021
Awais Aftab, MD
Awais Aftab, MD

Are current systems of mental health care alienating children and adults from the meaning inherent in their own emotional difficulties?

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 United Kingdom’s (UK) National Health Service and a visiting professor of Child Psychiatry and Mental Health Improvement at the University of Lincoln, UK. He writes from a critical psychiatry perspective on topics relating to mental health and childhood and has published over 130 articles and dozens of chapters on many subjects, including childhood, psychotherapy, and cross-cultural psychiatry. He has authored 6 books, co-authored 2 books, and co-edited 4 books, including Liberatory Psychiatry: Philosophy, Politics and Mental Health (co-edited with Carl Cohen, MD, Cambridge University Press, 2008), Rethinking ADHD: From Brain to Culture (co-edited with Jonathan Leo, PhD, Macmillan Education UK, 2009), and The Myth of Autism (co-written with Neil Gardner and Brian McCabe, Palgrave Macmillan, 2011). His latest book is Insane Medicine: How the Mental Health Industry Creates Damaging Treatment Traps and How You Can Escape Them (Kindle Direct Publishing, 2021), available in serialized form on Mad in America as well as on Amazon in paperback/ebook formats.

Dr Timimi is among the fiercest critics of psychiatric diagnoses and the medical model in psychiatry (especially child psychiatry, his own area of specialization). 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 (see article in the British Journal of Psychiatry).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 This present interview with Dr Timimi is in the context of his new book Insane Medicine.

Awais Aftab, MD: Your critique of current psychiatric thinking and practices is so broad and touches on so many conceptual and philosophical issues that I worry that it would be too easy for us in this interview to get mired in disagreements about more abstract questions regarding the nature and goals of psychiatric classification or the medical model. Perhaps a more fruitful way to start may be to do so with a focus on clinical practice. For instance, how would you approach the assessment and management of a child who is brought to your clinic by the family with a pervasive and persistent pattern of inattention and hyperactivity?

Sami Timimi, MD: First of all, 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, so I am glad that you are hosting these dialogues. I hear the concern in your first question, but 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 2 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 to independent of subjective opinion empirical evidence).

So, 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. In the last 5 years, I have started 1 child on stimulants, and although it helped ameliorate a dire situation in the short term, I do not think it has helped much in the long term. Much more common in my practice is to inherit young individuals on stimulants, where the perceived problems keep returning, but are now viewed through a medicalized lens leading down a one-way street of requests for increasing the dose or adding another medication in. Despite that, with time and patience, nearly every patient I inherit is off all stimulants by the time I discharge them at 18 years old, with their lives much improved.

Aftab: Yes, I do not think either conceptual and 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 in your writings. 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 construct of ADHD allows clinicians to capitalize on the literature related to the use of 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 for a psychiatrist 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 least 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 need more than this interview to properly unpack; nevertheless, I will have a go. Firstly, 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 does not when the system of classification is unable to identify or even get close to identifying proximal causes. Worse than that, 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.

Despite over a century of research to establish possible causes using psychiatric diagnosis as the framing, the cupboard of positive findings remains astonishingly bare. No markers, no genes (apart from a significant portion of those with a learning disability), and no identifiable characteristic brain abnormalities (apart from dementias). Studies looking at outcome from treatment with either pharmaceutical or psychotherapeutic models matched to diagnosis have not shown outcomes improving over time. What has increased instead are the numbers of patients who get a psychiatric diagnosis, the amount of psychiatric medication prescribed, and the numbers who claim disability allowances for a psychiatric problem. If the classification system we use was on the way to becoming diagnostic then we should be seeing something very different in both the science and the outcomes.

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, 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 they ingest the same substance that we warn adults about its profound dangers.

The effect of stimulants has been known for a very long time and is no different whether you get the label of ADHD or not. Decades ago, studies found that if you take stimulants, regardless of diagnosis, it improves your ability, in the short term at least, to maintain concentration on a task. A Cochrane systematic review of stimulant treatment for ADHD4 concluded all the trials they included were considered poor quality with unblinding likely to be common (due to frequency of adverse effects), and so they could not conclude with any certainty that taking methylphenidate will improve the lives of children and adolescents with ADHD, even in the short term. The evidence is even worse for long term outcomes, where research without vested interest involvement finds that regardless of initial severity there is no evidence that long-term outcomes are any different whether or not a stimulant is prescribed, with some studies finding worse long-term outcomes (in physical, academic, or psychiatric measures) for those prescribed stimulants. 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.5

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 the 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 timely 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.). Furthermore, these products may also enhance your life.

Whatever else you may decide psychiatric diagnoses are or are not, in their public life they now operate as brands. As market brands, they have products like any other product in profit-driven consumer 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 will continue to need them, hopefully with regular upgrades, to stay happy. Markets then develop around these psychiatric brands. Some brands develop huge markets worth billions from pharmaceutical products to services, from so-called “experts” to particular therapies, to research institutes, to courses, to trainings, to books, to other self-help materials, and more. Get your brand to cover an area of common public concern, and money and custom will flow. Like most consumables there is some immediate satisfaction, but the products ability sustain long-term satisfaction is limited, but hopefully (for the retailer), the consumer, once started down this avenue, will keep coming back for more.

Some psychiatric brands are more niche and harder to popularize (such as personality disorder and schizophrenia), but where the market can reach the professional classes in sufficient numbers to allow the brand to take root, then it can still, 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 behavior and development of children also have enormous potential (unless they are associated with blame for the care givers, the main group of customers). Thus, strong brands like bipolar disorder, depression, ADHD, and autism demonstrate their popularity by their rapid expansion in the absence of any scientifically tangible discovery that supports the existence of these constructs in an empirically identifiable form in the bodies of those labelled, and beyond the imaginations of those who label individuals with these brands.

Aftab: I think part of what you are describing is also captured by the notion of looping effects, so-called by Ian Hacking in the philosophical literature, the complex ways in which individuals interact with classifications, how classifications change them, and how they change classifications in turn, particularly when the classifications are imbued with sociocultural significance and these feedback interactions take place within a capitalist society.6 The area where we may perhaps disagree is whether there is any reality to these brands beyond that of social construction. I am inclined to think of many psychological phenomena as being on the border of natural and social, as having characteristics of both. There are psychological patterns of behavior that are inevitably shaped by sociocultural influences, but they also have an existence that goes beyond such influences. Consider homosexuality. Many cultures in the past did not have the concept of sexual orientation that we do and did not think of individuals in terms of “heterosexuality” or “homosexuality,” so in a manner the concept is socially constructed, but the concept captures aspects of our psychological lives that are not, so to speak, made up. To the best of our knowledge, there is no gene for homosexuality or any identifiable neurobiological cause, yet being a homosexual is not like being a republican or a democrat. Setting aside the issue of disorder attribution, I think constructs such as autism have a similar sort of reality as homosexuality, in the sense that they capture patterns in our psychological lives that have a degree of stability and endurance, and which can neither be reduced to society nor biology. Both also have complex looping effects, as evident by their inclusion in current or past diagnostic manuals, and ongoing LGBTQ+ pride and neurodiversity movements. Your thoughts on this?

Timimi: How do you know there is anything beyond social construction? Of course, there is in straightforward biological terms, as physiological mechanisms are at play all the time. But once we reach into what we construct as the mind (or the psyche if you want to sound scientific, or the soul if you prefer a religious frame) we have very few givens biologically. What we make of our embodied physiology relies on what paradigm we wish to superimpose on what we observe and experience. We have no scientific window on the mind; we can only measure (environmental) inputs and (functioning) outputs. We have no idea what goes on in between. Neither psychology nor neuroscience has been able to tell us anything particularly universal about that in-between bit. Understanding the mind requires a different epistemology to that of the natural sciences. In that sense I see psychology and psychiatry as ultimately branches of philosophy. We are always involved in making sense, so that one of the few universal characteristics of the mind is meaning-making. Our meaning-making frameworks (including the professional ones we use) are cultural models that provide us with meaning-making tools with consequences. Thus, I am more interested in the consequences of the cultural meaning-making framework we use, rather than whether such a framework can be thought of as providing a truth or something that can be viewed as stable and enduring.

You use the example of sexual orientation. This is a behavioral output, and as you state we do not know what causes that, nor should we particularly care. In relation to psychiatry, homosexuality is an interesting example, as it used to be viewed as a psychiatric illness but was narrowly voted out of DSM in 1973 (after a vigorous campaign). So, framework of interpretation mattered far more for consequences than the behavior/feeling state itself.

You are right to point out the powerful effects, at both a cultural and individual level, of looping effects. When we understand that all we really have are meaning-making tools with consequences, we can evaluate both the power of the interpretive frameworks we use and hopefully appreciate that, unlike kidney problems, what we say has an effect on the individual we say it to. Kidneys do not get delighted, anxious, offended, decide to stick with me, or desert me, if I read out the results of kidney function tests. However, if you tell me that a dangerous and paranoid state of mind caused me to write the above sentences, then the effects on my emotions, thoughts, and behaviors may be very different than if you told me that these sentences are a “breath of fresh air.” The effects will be more marked the more power the individual has (or I perceive them to have) over me.

As far as autism and the associated neurodiversity movement is concerned, where is the stable pattern? If there was, how did we go from having no idea of autism a century ago, to a prevalence of around 0.04% in the early epidemiological studies in the mid-1960s (nearly all of whom also had moderate to severe learning difficulties), to an estimated 1.6% now and growing (most of whom no longer have significant learning difficulties), without any scientific evidence at any point showing that this represents some universally recognizable pattern (no genes, brain differences, and massive heterogeneity of so-called symptoms)?5 How can a construct that at one end includes Einstein and many other geniuses (just google famous individuals with autism spectrum disorder [ASD]) and speechless residents of care facilities at the other be considered a recognizable typology? What are the potential unintended consequences of using a framework that imagines that when you label someone with an ASD, you are discovering something characteristically different or an abnormality in the way their nervous system works? The idea we can be divided into neurodiverse and neurotypical is oxymoronic. How can we not all be neurodiverse?

Aftab: Capitalism seems to have an endless capacity to commodify even resistance to the system (perhaps all human social systems do). In the mental health arena, even frameworks such as Open Dialogue and Power Threat Meaning Framework are being actively commodified, becoming brands, and developing markets around them. Perhaps a similar thing happened to dialectical behavior therapy (DBT). Marsha Linehan, PhD’s ideas were radical in many ways, but DBT was rapidly co-opted by the system, such that any revolutionary potential seems to have been lost. I wonder to what extent this dynamic is a consequence of the fact any revolutionary idea in its implementation will need to negotiate with other elements of the system (governments, insurance companies, law, etc.). I am reminded of the delightful phrase “all the élan of revolution with none of the drudge of responsible administration” (used by James Carney, PhD7). How confident do you feel your revolutionary proposals about health care will be able to survive “the drudge of responsible administration” if and when their time comes?

Timimi: Very insightful question. Mark Fisher wrote about the merciless commodification of everything in his book Capitalist Realism8 and since our economic, political, and therefore much of our cultural value subsystem, is dominated by this neoliberal logic, the dominant way for ideas to gain purchase (quite literally) is for them to become branded. Still, some ideas are better than others and have greater potential to improve how mental health is understood and how services are then structured.

Is there any way to allow new models to develop without falling prey to a McDonaldized branding process that rips out a deeper more sustainable core by becoming a process-driven bureaucracy? Possibly not. Perhaps some of the worst commodification effects can at least be partly ameliorated by a commitment to the local: an understanding that a service needs to have a sense of ownership for the models it uses, an openness to ongoing evaluation of a range of outcomes, which are then used to adjust or change aspects of the service, and a commitment to broader politicization of mental health that sees the issues we deal with intertwined with local and national material realities and discourses. My hope would then be that a new generation of critics will come along and see holes and inconsistencies in these new systems that have developed and have some creative thoughts about how best to remedy them.

Aftab: You have argued 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 labelling of our experiences with medicalized language (diagnosis, symptoms, disorder, dysfunction, dysregulation, etc.) which 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 (and our meaningful others’) 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. A survey of 1000 young individuals in the UK in 2019 found that 68% thought they have had or have a mental health problem, and of those 62% thought “destigmatization” campaigns helped them identify it.9 It troubles me that by early adulthood nearly three-quarters of the population have fallen for the propaganda that leads them to suspect they have experienced a mental disorder, as opposed to ordinary/understandable human reactions. Identifying with an idea that your emotions emerge from a disorder within you invites you to a potential lifelong struggle to suppress/control this part of you.

Medical colonialism (of language and the concepts that flow from this) means 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 easily slide into an idea that individuals need help to learn how to control and manage how they feel. One of the, to me, 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 little time or respect for the ordinariness and extra-ordinariness of our emotions. We have imbued our emotional life with a destructive power more than a liberatory one.

Aftab: You have written, “Psychiatry’s strength comes from the fact that it is different from the rest of medicine and involves an engagement with the nature of the human condition, suffering, and its wide roots in social, political, and cultural meanings and realities. This is what the rest of medicine needs help with and why psychiatry’s difference to the rest of medicine should be seen as valuable quality, not an embarrassment.”10 I am curious to hear more about your views on psychiatry’s medical identity and what medicine can learn from psychiatry. Setting aside the issues about medical model for now, I do not think it is particularly controversial to say that psychiatry is a branch of medicine in the sense that individuals who practice psychiatry are physicians by training and this training includes, among other things, expertise in the use of psychotropic medications in the treatment of psychiatric conditions. This means that in addition to the differences from medicine, there is also a certain continuity. You are a physician yourself. How do you understand your own medical identity?

Timimi: Medical practice originates in a care ethic devoted to eliminating suffering. In the distant past, the person of the doctor was more important in healing than any rudimentary technical knowhow. As great strides have been made in understanding our physiology and the accompanying ability to identify when and how this goes wrong, we developed a system of classification (which we refer to as diagnosis) largely based on etiology. This technical success sometimes leads us to forget that health care is a human social activity involving attending to individuals who are in distress. Yes, I would rather see a doctor with a lousy bedside manner but who knows how to treat my ruptured appendix, than a doctor with great empathy but lousy technical skills, but forgetting these social roots comes with costs, particularly at the system level.

We have had many scandals in our hospitals in the UK (as I am sure is common in many countries) where patients have been harmed and died due to staff neglecting the basics of looking after individuals, not just patients. Mesmerized by the miracles of science, medicine still has to find ways to deal with presentations that go well beyond the limits the science side of our profession can offer. Medicine is a craft informed by scientific principles performed by practitioners with some social power to shape how individuals understand their experiences. Medicalization is an issue that cuts across specialties leading to iatrogenic harms, as does commodification with profit-hungry pharmaceutical and medical device manufacturers. Chronic conditions and medically unexplained symptoms are widespread and require doctors to muddy their minds with meanings, adaptations, existential anxieties (involving loss and death), and the psychosocial milieu of their patients, without being overwhelmed or retreating to dehumanizing defenses. They have to encounter the patient, not just their diagnoses. My general practitioner friends regularly tell me that most of the work involves these psychosocial aspects. This surely is the territory where a more rigorous psychiatry, engaged with both the physical sciences and the humanities, would take the lead in collaborations that would help the rest of medicine wrestle with these pressing issues.

Instead, unnecessary identity insecurity coupled with (for some) the more profitable pretense that we are as technically advanced as other branches, has led psychiatry astray. On the lack of technical advances, we will be found out, but medicine would be a poorer profession if that also meant ejecting its need to engage with these deeper psychological, social, and political dimensions.

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 only prescribed medication to 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 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 sweeps across the Atlantic from the United States. It gradually colonized our curriculums.

Potentially, psychiatrists are the only mental health practitioners that 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. Yet, it pains me to say that if I had a child, or other loved one that I was deeply concerned about, I would not take them to see a psychiatrist. They are more likely to be harmed in the long term than helped, because of the prevalence of the justifiable assumption that what a psychiatrist does is prescribe. 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.

Aftab: Thank you!

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of Psychiatric TimesTM.

Dr Aftab is a psychiatrist in Cleveland, Ohio, and clinical assistant professor of Psychiatry at Case Western Reserve University. He is a member of the executive council of 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 TimesTM Advisory Board. He can be reached at awaisaftab@gmail.com or on twitter @awaisaftab.

Dr Aftab and Dr Timimi have no relevant financial disclosures or conflicts of interest.

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. Storebø OJ, Ramstad E, Krogh HB, et al. Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD). Cochrane Database Syst Rev. 2015;(11):CD009885.

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

6. Hacking I. The looping effects of human kinds. In: Sperber D, Premack D, and Premack AJ, eds. Symposia of the Fyssen Foundation. Causal Cognition: A Multidisciplinary Debate. Oxford University Press; 1995: 351–394.

7. Carney J. Thinking avant la lettre: A Review of 4E Cognition. Evol Stud Imaginative Cult. 2020;4(1):77-90.

8. Fisher M. Capitalist Realism: Is There No Alternative? Zero Books; 2009.

9. Wright B. Documentary reports mental health crisis amongst young people. Happiful. July 29, 2019. Accessed March 8, 2021. https://happiful.com/documentary-reports-mental-health-crisis-amongst-young-people

10. Timimi S. The medical model in mental health: an explanation and evaluation. Psychosis. 2020;12(3):299-300.