E134 - Is Psychiatry Making Things Worse? (w/ Marieke Bigg)

Marieke Bigg is an author of fiction and nonfiction in the areas of women’s health, mental health, and the history of science. She holds a PhD in sociology from the University of Cambridge where her research focused on the debates on human embryo research in Britain. She is currently also training as a psychotherapist and works as a peer support coordinator and client liaison at the mental health charity Mind. Her most recent book is No Such Thing As Normal: Disorders, Diagnoses and the Limits of Psychiatry.

Interviewed by Dr. Alex Curmi. Dr. Alex is a consultant psychiatrist and a UKCP registered psychotherapist in-training.

If you would like to invite Alex to speak at your organisation please email alexcurmitherapy@gmail.com with "Speaking Enquiry" in the subject line.

Alex is not currently taking on new psychotherapy clients, if you are interested in working with Alex for focused behaviour change coaching , you can email - alexcurmitherapy@gmail.com with "Coaching" in the subject line.

Check out The Thinking Mind Blog on Substack: https://open.substack.com/pub/thinkingmindblog/p/thinking-mind-blog-big-thoughts-edition?r=1cn09u&utm_medium=ios

Give feedback here - thinkingmindpodcast@gmail.com Follow us here: Twitter @thinkingmindpod Instagram @thinkingmindpodcast

Transcript

Welcome back to The Thinking Mind, a podcast all about psychiatry, psychotherapy, self-development, and related topics. If you've listened to this show for any length of time, you know that from time to time we have conversations on the podcast about the limitations of psychiatry, the limitations of the medical model as a way of dealing with mental health problems, and to some extent how mental health systems could be improved.

These kinds of conversations emerged organically as the podcast developed. It was never really an explicit goal of the podcast to discuss how mental health systems could be improved. As such, it's certainly not my area of expertise, but I do think the conversations I've ended up having in this area have been some of the most valuable that I have had, and I've had those conversations with people like Rose Kartra.

Joanna Re, Roberto Meina, Richard Benal, and others. Today we're continuing that conversation with Marika. Big Marika is an author of fiction and nonfiction in [00:01:00] the He of Women's Health, mental Health, and the History of Science. She holds a PhD in sociology from the University of Cambridge. She's currently also training as a psychotherapist and works as a peer support coordinator at the Mental Health Charity Mind.

Her most recent book is No such thing as Normal Disorders, diagnoses, and the Limits of Psychiatry. In today's conversation, we discuss whether there is any value to this idea of normality and is normality something we should even be discussing when it comes to mental health. We talk about what we get wrong about the line between so-called sanity and madness.

Why a medical approach by itself can be very limiting for people dealing with complex mental health problems, the relevance of social, cultural problems when it comes to mental health. We discuss Marika's view on neurodiversity and the psychedelics renaissance, and much more Before we get into today's discussion.

One quick announcement. As I mentioned on the podcast last week, [00:02:00] the Thinking Mind blog is now out on Substack. This is headed up by Dr. Rosie Bloodstone, a psychiatry and psychotherapy registrar who's been working behind the scenes on the podcast for a few years. We're going to be posting a monthly newsletter on the Substack, which is a companion to the podcast.

It's will feature emerging discussion points within mental health, some news within mental health and mental health technologies, reviews of recent podcast episodes, discussions around popular books within the realm of mental health and psychology. The first edition of the newsletter is out now, and the link is in the description and in this first edition among other things.

We discussed the origin story of this podcast and how it got started back in 2019. As I said before, we'll be posting a newsletter at least monthly, and I'm hoping that myself and Anya will also be able to post ourselves on the Substack in between. We're excited about getting to share more content with you guys related to the topics you're interested in, in a new format.

This is the Thinking Mind. If you'd like [00:03:00] to support the podcast, you can check out some of the links in the descriptions with regards to the services we offer. And now here's today's conversation with Marika Big on her new book. No such thing as normal. Thanks for listening. Marika, thank you so much for joining me.

Yeah, no worries. Thanks for having me on. As a, as we were saying offline, obviously there's a huge amount in your book, one can learn about the limits of psychiatry itself and maybe how mental health. It can be done differently. I'm always interested in the underlying philosophy of, of ideas and underlying this book I'm thinking about, you know, it's in the title, no such thing as normal.

Is there any value to normality or is there any value to striving towards some sort of ideal? Do you have any strong thoughts on that? Yeah, I think normality, when I, when I think about helping people, you know, going through a difficult time, normality to me seems a little bit besides the point. [00:04:00] Um, I think, you know, I'm also a, a, a.

Trainee therapist, and when I think about working with people, what I'm trying to do is to help them. Arrive at some kind of understanding of whatever's happened to them, to empower them, to find ways of coping, ways of making sense, ways of kind of moving through that. So I don't really see why you need a concept of normality in doing that kind of work.

And I think it is that kind of work that, you know, we're talking about when it comes to supporting mental health. I can definitely see there's a way you can. Use, you can like enforce normality can't you? Or you can like prescribe normality in a way that I think would be counterproductive. You can say, you know, you're, you're here over here and you're doing things in some way that's wrong or, you know, abnormal and you should be coming over here to this, you know, version of [00:05:00] normality, which I'm going to prescribe for you and I'm gonna tell you what it looks like.

And that's definitely, I think. Use of no, of this idea of normality that can be counterproductive. Yeah. No, I think, I think I agree. I think that normality and, and the way I sort of approach it or discuss, you know, or cri critique that kind of, um, standard in the book is very much related to power and how power is enforced.

Um, you know, in a, in a situation where one person is generally regarded as the expert, so the psychiatrist or the therapist and, and you know, the client or, or the patient is the one who, you know. Needs help. And with that power kind of imbalance, it's very easy to enforce kind of standards and ideas of normality on someone that might not make sense to them.

Yes. And I think that's especially relevant when someone's in crisis, in a very acute situation, [00:06:00] a very distress, distressing situation. At the, at the same time I'm thinking. Maybe especially in the medium to long term, and especially in forums which are more about like psychoeducation, is there not a value about describing certain, I'm not a hundred percent sure if ideas is the right word, but let's say ideas for now to strive for.

So for example, you might talk about the value of, for example, being able to delay gratification to not be impulsive necessarily or be overly uh, reactive, uh, in any particular situation. Um, or the value of mutually beneficial relationships, forming mutually beneficial relationships with others and how that can help and various other values.

Mm. You might talk about less than a kind of strict, I'm enforcing this on nuisance. I'm more in a kind of, this is how humans have gotten along for a long time and we find in large groups of people, when we look at studies of large groups of people, this seems to be pretty good path to go down. [00:07:00] Is that a use of an ideal that might be more beneficial?

I, I think when, again, when you're supporting someone and working with them, it's generally helpful to understand what someone you know, needs or wants. We need to arrive at some kind of understanding of what they think. It's the challenge they're dealing with in their life. And if then based on that you, you can offer something in terms of, you know, this is a way of working with this or, you know, this might help this, you can offer someone that.

Definitely. But generally I think it's much more helpful to have someone discover and create and, and you know, innovate in order to find their own way through. And I think people are really great at doing that. This is really interesting. I mean, totally agree with the idea of, you know, it has to come from them.

Like what do they want? And when I'm working with someone in a [00:08:00] psychotherapy or coaching forum, I mean, no. I mean even psychiatrically, I would say super important to, I think it start, the conversation starts with them. What do they want? Um, and I think encouraging an individual's. Tendency to innovate. So maybe Carl Rogers might have called this actualizing tendency to come up with strategies and solutions to those problems.

I think that's super useful. At the same time, I'm thinking about the tension. Let, let's just think about the politically, the tension between right and left politically. So. So as far as I can tell, the political left will generally. Emphasize the value of innovation and individuals coming to their own sort of conclusions about how best to live their lives.

And then conservatives will tend to en emphasize tradition like life is like from a conservative point of view. It to be something like [00:09:00] life is really hard. We need to rely on what's worked because life is too unpredictable to be coming up with your own rules. Somehow I find when it comes to mental health, there's similarly this balance of both of yes, absolutely encouraging the individual and then also trying to figure out what works and not really in an enforcement kind of way.

But in an optionality kind of way, giving people the options of like, these are some things that have worked for other people, perhaps they might work for you as well. Yeah, and I don't see that as attention. I think that the two can very exist, very coexist very well when you operate from this basis of, you know, empowering.

The person you're working with to make their own choices and decisions. And I think from that place you can explore what, you know, this individual has experienced themselves, how they make sense of it, you know, empower [00:10:00] them to, to figure that out. And also again, offer them, you know, what's been done in the past and what's available.

And also I think, uh, attention that I did feel when writing the book was one between. You know, criticizing some of the kind of medical approaches to dealing with mental health and at the same time recognizing that within, you know, the world that we, the sort of society we're working in, the mental health care systems we're working within.

This is what's available to people. You know, getting a diagnosis can make a difference to someone's life. Getting a prescription might really help someone, especially when there's not many other options available to them. So it's, yeah. There's always this, this tension for me between working within the kind of system you have and empowering people to get some form of help based on what's been done before [00:11:00] and.

Supporting people and, and kind of reaching for a system in which we can have much more individualized care that really empowers people to make their own meaning and find their own way through. Yeah, and I, and I could see in your writing how you are wrestling with that tension and really trying to be responsible and not, you know, it's, it's easy nowadays to write something very polemic.

Something that's gonna be, uh, very sensational, but I could see you really trying to wrestle with that tension in quite a responsible way. And it really reminded me of the tension I felt training as a psychiatrist, working as a psychiatrist, often in extremely imperfect conditions where you're dealing with problems like lack of resources and just the problem.

I think when you're dealing with large numbers of people, for example, a community mental health team. That is responsible for, say, 400 people with maybe two doctors on it, and some and other staff obviously. But [00:12:00] similarly, you're, you're dealing with tension all the time. Ethical tension, like how best to work within an imperfect.

System digging into some of the core concepts of your book. So why do you think the medical approach to mental health, at least not by itself, might not be the best approach? Yeah, I mean there's, there's various reasons, but it really comes back to what we've been exploring, this idea of denying people choice and agency in figuring out their own understanding of what's happened to them and.

Figuring out a way to deal with that and respond. What the medical kind of view often does is it takes, you know, a, a human experience of suffering and problematizes that, you know, pathologizes, it treats it as, as something that needs to be cured in isolation and often misses the surrounding, you know, context of a life.[00:13:00] 

Of experience that experiences that may have led someone to feel a particular way. So I think it's, it's this denying people a real explanation that I think can be really harmful to. Just someone in their life where, you know, these experiences really take place and where they're trying to find a way to continue to live on.

I think that the medical view treats an issue in a person rather than a whole person, and I don't think that's the most helpful way of, of dealing with mental, mental suffering. And a person, I suppose, really stripped of their, their context and that's the context of their life, the context of their family culture, wider society.

Yeah, definitely. And I, and like you said, I really grapple with that tension in the book between also trying to acknowledge, you know, what we have to work with [00:14:00] that, you know, the medical tools available have helped a lot of people, but also trying to just. Draw more attention to this much bigger context that we need to look at.

Because also in, in, you know, developing a, a response as a kind of society to mental health, when we ignore the experiences that make people feel depressed or anxious, you know, the real life problems that drive people to feel distressed. When we ignore those and treat individuals instead, we're also.

Detracting from, you know, attention and resources for the kinds of services that could really make a difference. So, you know, social provision, for example, making sure people aren't stressed. Overworked, poor, struggling to find housing or community, things like that. Um, so it's just, it's such an important part of the picture that [00:15:00] I just think we need to give much more attention to in a society where we discuss the medical view a lot and the social view less.

Yeah. So, so I guess in a way you're saying if you don't get the diagnosis right, you can't get the treatment right. So. If your diagnosis of depression, if depression means you know there is something going wrong for you at an individual brain level, that your mood, your mood being low, isn't saying anything important.

There's no signal there. It's all noise and your mood being low. I'm talking about depression really, because depression is probably the most common and anxiety by far. It's not. It's not capturing anything useful about your life or your situation or your context. It's just. An aberration of your, of your brain, that what that means is all the treatments are going to be brain focused and you know, we're seeing, you know, the limitations of how helpful purely brain-based [00:16:00] interventions are.

And although they can be very useful in some individuals, you wouldn't want to have a society that doesn't have access to them. They're settling, not. Keeping up with the huge rates of depression and anxiety, they don't seem to be as efficacious as you would expect if we're dealing with a purely sort of biological um, disorder.

Whereas, you know, what you're saying is if we can understand that depression, someone being depressed is something meaningful about their life, then we have can have an entirely con different conversation about how to make people's lives better, I suppose. Yeah, exactly. And no, and I really like that way of putting it.

You know that when we, when we view this as a, as a medical problem within a person, we deny someone the meaning of their symptoms. And when we do. Interpret those symptoms in context of a life of things that have happened to someone. We see that they're actually pointing to problems that we can address [00:17:00] using the tools we already have and that we might not need, you know, extensive brain scans or studies or, you know, thousands and thousands of, of pounds that go into that kind of research to help people right now.

Yeah. One of, one of the things that's always bothered me working in mental health and. Studying it. I mean, there's a lot of mystery in mental health, and one point I often make is that mental health professionals should be much more transparent of that mystery. I'll give you an example. If you're giving someone a diagnosis, let's say, of a DHD, and I'm gonna use A DHD because often that's talked about in media with a lot of certainty, give someone a diagnosis of A DHD that's often talked about with a lot of certainty.

Like A DHD is this really biological brain-based disorder. I think that's not true. Actually. There's no. There's no tests that can like definitively say, you know, you have a DHD, no biological tests, it's all done by clinical interview. That doesn't mean, I don't think a DH ADHD is a [00:18:00] useful diagnostic construct.

And actually the treatments for a DH ADHD are really good compared to say depression. Um, so I think there's a lot of mystery diagnostically. There isn't a huge lot of mystery, and I think you make this point in your book a lot about what makes a mentally healthy life or what is more likely to give someone mental being.

And often it's talked about like there is a lot of mystery, but I don't think there is. So could you speak to that a bit? Like, is, is it, is it that complicated to have, for someone to have a life that's gonna be maximally likely to give them some good mental wellbeing? I mean, it is, and it isn't in the sense that, I guess it's an age old human question of how we live a fulfilling, a meaningful, and, you know, life.

And, and that's a, a process and a journey everyone goes through. But in terms of when people really reach a point where certain experiences or responses to their lives, uh, you know, [00:19:00] inhibitive and just preventing them from, from doing the things that. Make someone feel good enough. Yes, it's, it's pretty, it's pretty obvious and you know, it is, it is things like I've mentioned, like just having a roof, just basic needs met, roof over your head, you know, enough to eat, not having to worry about money too much, having people around, community exercising.

Just all of the things that we all know and talk about, kind of, you know, just in our cultures, in, in various. Forms just make people feel good and when those things are missing or when someone has a really difficult experience, you know, experiences, violence or some kind of trauma that makes them feel not good and that that's something they need support with.

And it's just, it's, it's [00:20:00] all, you know, and it's not. Straightforward. It's always a process and like we, like we've been saying, it looks different for everyone, but when you are able to, like you said, diagnose the problem as a social one, as one that exists in the context of someone's life and in the world, then you can begin to respond in a way that will help to some extent.

Definitely. Whereas. You know, a, a medical diagnosis may or may not. I think I would probably diagnoses the problem as the, this, this constant interface between, between our biology, our psychology, our, I mean this, the bio-psychosocial model, the constant interface and interaction between our biology, social landscape, uh, and our psychology.

But, but on, on this point, I guess, again, one other point of tension, at least for me, is. This balancing between personal responsibility and collective [00:21:00] responsibility. They, they both seem to be very important. You know, a, a person needs to have responsibility for their lives because only they can make the best choices, you know, for their, for their lives.

You talked about agency earlier. I, a huge fan of the concept of agency and inspiring agency in our patients and clients at the same time when you we're dealing with nation states of. Hundreds of thousands to millions of people at at that point. I mean, you could argue even in a family of four, collective responsibility comes into play at some point.

Like an individual isn't just responsible for themselves, but an individual is to some degree also responsible for everyone else. And we have this shared collective responsibility. This is a super difficult question I'm not expecting you to have a straightforward answer to, but how do we start to balance those?

How, how, how, where do we draw the line between what an individual is, is responsible for versus what society at large is responsible for? Well, [00:22:00] I guess if we're talking specifically about, you know, mental health, I think it just depends on how we frame the task or the, the challenge and when we frame it in terms of our responsibility is to cure people.

That leads to a very different distribution of power to when we say our responsibility is to facilitating choice for individuals. And when you see it as, as that, that as the collective responsibility, then you can start to think about a system and how people might work in order to empower individuals rather than.

Remove, you know? Right. Their abnormalities or bring them in line. So I think that to me, that's, that's how you bring those two together. It's about, it's about thinking about what you're actually trying to, to do. Yeah. So what support does someone need to be able to make choices? They'll need shelter, as you said, don't [00:23:00] need a certain amount of wealth.

Still need opportunities, like opportunities to work and so on. Opportunities to meet people and form relationships. So you're saying what, what are the, what are the bedrock support someone will need to be able to even like, get to the point of seeing choices? Yeah. Well that and also facilitating choice in terms of the care they receive.

You know, I use examples of, for example, in, in the Netherlands where I am right now, they're trialing a, a system of care where people really, um. Design their own kind of treatment based, not just, you know, they can choose to, to take, you know, drugs like antidepressants if they want to, but might also want to access meditation, yoga, and they're supported to kind of make meaning out of their experiences and then figure out how they want to respond.

And the assumption is always that someone. In a system like that is always that someone can [00:24:00] choose rather than the opposite assumption, which often starts to take over, you know, more traditionally in mental healthcare systems based on the medical view, which is that people are, you know, not capable of making decisions that they're somehow risky to themselves or to others that they need to kind of be, um, led and.

I just think that's a very different, um, assumption that leads to a very different form of care. Just always trying to protect as much as we can, the sense of agency, the sense that someone does have a choice in how they want to be in the world and how they want to live their life. We also know that when someone doesn't feel that they have that agency or choice, when they feel powerless, it's, you know, one of the biggest causes of why people feel mentally, you know, unwell in the first place.

So it's, [00:25:00] it's just, to me, has to be so integral has to be, you know, central value to delivering care. Yeah, absolutely. I've made the argument quite often that we lean too hard in taking on all the responsibility as mental health professionals because we are worried about risk. Mm-hmm. And even though risk is a real issue in some extreme situations, I think that filters down to a lot of situations with clients and patients where we feel.

We have to, on some unconscious level, make choices for them. Mm-hmm. Mm-hmm. And I think the phrase, which applies in what you say when people feel like they don't have choice, is learned helplessness. People feel a sense of learned helplessness. In other words, no matter what I do, I'm gonna get the same result.

And I can't think of a psychological factor that would lead to depression more than. Land helplessness, no matter what I do, just I'm gonna get the same outcome, the same bad outcome over and over again. [00:26:00] Completely. And it makes me think a lot. I also use some examples of care systems delivered in prisons.

It makes me think a little bit about those because there, there's also attempts to, you know, they have this real. You know, imposed power discrepancy between, you know, the people in charge guards or whoever's working there and, and, um, the inmates and in kind of attempts to innovate and, and, and help and support prisoners in a different way.

There's also this idea that as long as you treat someone as you know. A prisoner as someone incapable of making decisions, that's all they will ever be. And when you start to create a supportive environment where, you know what they call pro-social behavior is modeled and people are able to form [00:27:00] relationships and try things out a little differently and, and grow in that way.

There's a possibility of someone making changes. So yeah, it's very much about, um, projecting what you, you know, what you're hoping to kind of cultivate. Yeah. And, and the long similar lines. One thing I have seen in, in mental health systems, not all the time, but I've seen it often enough, is there's this.

Illusion that there is this really bright line between really good functioning mentally and having a severe mental health condition, or what you could call the boundary between sanity and insanity, say, is, is that wrong? Is that wrong? Is that not a, is that not a bright line? What do you think people need to know about the, the, the boundary between good and bad mental health?

Yeah, I mean, I think, again, maybe these, these concepts of good and bad. Aren't so useful. I think it makes me think of, you know, peer support [00:28:00] models where I worked a lot with an organization through my work at mind who, um, go in and deliver training for mental healthcare professionals and, um, and psychiatrists as well.

Um, and really encouraged, um, them to relate to the people they're working with on a more, you know, experiential, just human level sharing experiences. Where maybe they struggled, where they had a difficult time, rather than perpetuating this idea, like you said, that one of you as well and one of you is unwell.

Yes, and I think that's really, I think that's probably really healing and I think that it gives people a lot of hope to and, and makes people feel less alone to kind of talk to someone, realize that other people go through difficulties too, and that it's not an inherent problem. Within you, but just something that all people go through in different ways to different degrees [00:29:00] and you know that we're all dealing with this hardship, it's this coming together, you know, in these, or through these experiences that we share as humans that is just missing from this kind of.

System where you have an expert and a, you know, and a patient who needs help. Yeah. If there's any advice I would give to anyone training in mental health or anyone seeing someone in a healthcare context, it's like the only thing separating you from having the same kinds of problems your patients might be having is genetics and environment.

And you can argue about which is more important, and that'll be different in different situations, but regardless of of the proportions, you don't choose your genetics. You definitely don't choose your early life environment. Maybe you can start to choose your environment later on. People who don't believe in free will would also debate that, but you certainly don't choose your genetics in early life environment, and that's the only thing [00:30:00] separating you from them In some sense, if you had certain genetic predispositions or certain stresses or traumas, social deprivations, you might be in very much the same situation.

Very important to appreciate. You could have a, you could, you could, you could have a week that's so bad that you could be in crisis yourself. And it's so important to understand that. I think you can, if you can really understand that, you then sort of mm-hmm. Bring that into the consult consultation with you and it filters down to how you speak with a patient.

And, and they, and they understand that you're not talking them from a place of separation, but actually a place of like. Let's, let's connect, see where you're coming from and let's kind of work together. Yeah, no, it's really interesting you saying that because it does make me just wonder how many of us really do see that, that, that it's, you know, that chance and [00:31:00] circumstance that separates the people who suffer from the people who don't.

And at the same time that we all suffer, of course, to, you know, to some degree and. I think just a lot of, um, the kind of discourse, the way these things are talked about nowadays. You know, things like self-care really frame mental health as a personal responsibility and so what follows is if you are struggling with your mental health, you haven't done enough.

And it's that really individualistic view, you know, that again does. Connect with the medical view, which makes this an individual problem rather than a social problem where we don't see the social structures connecting us that, you know, make this a collective human experience. And yeah, and you, and you miss that and, and it leads to feelings or ideas that about, you [00:32:00] know, that of superiority, that people who.

Are not struggling with their mental health as much, are somehow better. And you know, the, I think that's where the, the title comes in, you know, no such thing as normal that when we started with that and, and also, you know, the specter of kind of eugenics in mental health and just this idea that people who suffer.

Somehow innately inferior. And I just think we need to do everything we can to make sure we never, you know, go there again. Yeah. Because e even if you could make the argument, like e even if you could say, let's say the, the path to not having any kind of mental health problem is to be really hardworking and and conscientious.

And I don't believe that's true, but let's just say for a second it was true. That is also a personality trait that is influenced by genetics and environment, which you also did not [00:33:00] choose. Like heavily influenced by, I mean, entirely influenced by those two things. So even when people say, uh, it's about hard work and industriousness and responsibility that is subject to the same.

Influences. So then for me, the question becomes, 'cause I think, you know, these personality traits are actually really useful and important. The question becomes, how do we again, create an environment that makes people as conscientious about their own lives as possible in a way that's helpful? Hmm. Yeah. I think make people feel safe.

Make sure that basic needs are met. You know, it's, I think it's, it's simple people. Mm. I mean it's very, you know, person centered sort of, um, ideas about, just, like you were saying, kind of just human actualization, but just give people a relatively, you know, safe environment. And I think those kinds of [00:34:00] behaviors that are supportive, that are helpful.

Do start to flourish, but it can't happen without a supportive environment. In a, a couple of chapters, towards the end of your book, you start to explore a couple of newer frontiers in mental health. The first one being psychedelics. What do you see? How, how, how are you seeing the psychedelics movement? Is it, uh, do you think it helps to.

Initiate the paradigm shifts that you'd like within mental health? Do you worry that through the psychedelics we could go fall into the same traps that we've fallen into before in mental health? Yeah, both. I think, um, that I, I see a lot of the, the sort of attitudes and, and ideas, um, from the kind of psychedelic.

Kind of movement or the use of psychedelics that I think can be really supportive of just, um, the idea that [00:35:00] individuals, you know, are just vastly different. That there's a certain element of kind of exploration and risk. Involved in any form of transformation. That again, is just a highly individual process.

There's also the kind of nod to, um, other kinds of cultures and traditions and other ways of making sense of our mental experiences that, you know, aren't necessarily pathological, but might actually show us something. And yeah, and I think that when these substances are used, you know, in. Some kind of form of support with a therapist or some other context.

They can definitely show people something new or offer a new kind of reference point or kind of experience that might weave into their. Process in some way. But I also see [00:36:00] how, you know, in a kind of hyper just commercialized context, there is this risk of psychedelics being sold as miracle substances much in the way that antidepressants were in the 1990s, and that they will be, you know, offered as this one stop cookie cutter kind of cure for supposed.

You know, uniform experiences, um, and, and you can see them being discussed in that way as these kind of breakthrough yeah. Solutions that anyone can benefit from. And that loses everything that I think, um, the, the origins of psychedelics, but also just the possibilities they offer would, you know, would really help to facilitate.

So. Yeah. It, it just depends so much on how we use them, how we frame that, their use and, and just how, yeah, they're introduced. And I, [00:37:00] I'm not overly optimistic that it will be in a, in a, you know, in that sort of, um, empowering kind of paradigm that, you know, that they could be, um, because money usually wins.

Yeah, the, the cool thing about psychedelics is that they, you know, we have an opportunity to use a biological agent that gives someone like a window of opportunity for psychological change where they don't need to be dosed continually, like a once a day dosing. They might have, you know, let's say two or three doses and a treatment, and maybe that's it forever, and that's, that's an amazing opportunity.

I worry, I think largely about the same things you worry about. Like for example, I worked in a place once, which had a ketamine clinic and ketamine has been studied and shown to be useful for depression, but I was just surprised there was no psychotherapy around the ketamine. It's almost, ketamine seems to be occupying a weird place where it's kind of seen as sort of a psychedelic, [00:38:00] but not really a psychedelic.

I don't really know why necessarily. I don't necessarily think the reasoning is super solid there, but I think then for that reason. It's, it was given in this context, it often is given without therapy, and I think that's probably a mistake. Um, and so I worry about the same things as you, that these, uh, medicines would be distributed, sort of stripped of any sort of psychological cultural context.

And it's just like, you know, take your psychedelic and you don't have to think about your life or anything like that. And everything will get better on its own. I, in, in, in terms of like. Capitalism as the engine for, for developing these medicines and therapies. I'm kind of torn. Capitalism is, in some ways great for innovation and distributing things to large numbers of people At the same time, capitalism has a history, not always, but often of stripping things of their [00:39:00] context.

You know, maximizing profit, you know, you see it all the time just to check a really trivial example of like a really great restaurant chain. Like three or four great restaurants that gets bought by a private equity company and then they scale it and they end up like making a really terrible version of that originally great restaurant.

So it's not like being in business at all is bad. Business can be useful, but is it gonna go the same way where the actual product is diluted purely for profit? I suppose that would, that would be the concern. Yeah, and also the, the question of accessibility. Who gets access to this in a way that, you know it needs to be accessed?

We're talking about the importance of a supportive, you know, some kind of supportive context, whether that's a therapist or, or some other kind of situation, that the substance in and of itself won't necessarily help someone if those conditions aren't there. [00:40:00] And. Just the way these things tend to go is that, you know, the, the more kind of careful, supportive, elaborate care won't be accessible to people who can't afford it.

And, you know, that would just be a real shame. Mm-hmm. I, I'm moving on to the subject of neurodiversity. I think what's interesting about neurodiversity from my perspective as a clinician is, you know, in the past. I, I think that, I mean, there's a whole conversation to be had about mental health diagnosis and how to do that well or not so well, how, you know, reliable our diagnostic constructs are.

But just from my perspective, I've given, given a lot of people a mental health diagnosis, uh, often that's meant that that's met with. Uh, either some sadness or some difficulty, but sometimes some gratitude, and thank you for explaining that this occurs in other people and what it [00:41:00] means and what these symptoms mean.

But it's a kind of, sort of slightly subdued reaction that you kind of expect with any kind of medical diagnosis. You know, if there's someone they have diabetes or high blood pressure, a kind of subdued, sometimes gratitude, sometimes upset. Um, when it comes to neurodiversity, the change that I've seen is that people are very, very excited and enthusiastic about their diagnosis, and that's something, I'm not sure how I feel about that yet.

On the one hand, there is people getting a diagnosis of, let's say, autism or A DHD after struggling for a long time, 40 years, 50 years, and never having a good explanation. And I, I understand the enthusiasm in that context. On the other hand, I worry about people making their whole personality about one particular diagnosis.

Oh, my A DHD explains pretty much everything about me or my autism. Often they often patients might arrive at an [00:42:00] assessment already having the con, having reached a conclusion that they have a particular diagnosis, and then feeling that that's gonna be helpful to explain everything about them. So I worry about these two sides.

Is that something that you saw in your research for the book? Yeah, I mean, it's a really interesting question and it makes, you know, me also just, and I can see, I can see why people would be excited at receiving a neurodiversity diagnosis just because of the way it's kind of framed culturally today as, yeah, as a, as a very positive kind of.

Sometimes almost kind of necessary aspect to your personality, like just the way it's discussed today is it's almost more of a, what kind of n neurodiversity do you have? Not, do you, do you identify or do you have a diagnosis of some kind of neurodiversity? [00:43:00] But I guess it just makes me wonder what people.

Think getting that diagnosis actually means do they think it, it means, you know, I can understand that just understanding yourself better or having a language to explain your experience to others can be very helpful and I can see how it might also bring a, a kind of relief, but I guess I worry nowadays about.

Neurodiversity, which, you know, started has, it has its origins in a kind of social model of disability. So this recognition that it's not the actual impairment, say, you know, in a physical, in physical terms, maybe the, um, lack of a limb or some kind of function or a mechanism of the body that that's not the issue itself, but that the world disables.[00:44:00] 

People twice over by failing to support, you know, different. And that that was really the origin, you know, of, of this kind of thinking. It was actually subversive of the kind of biological view that says, you know, this is the problem. And challenged institutions and medicine and you know, care providers to respond to people's needs as they saw them and to.

Offer reasonable adjustments nowadays, I feel like it's often discussed once again as an individual, um, you know, diagnosis that then needs attention and treatment and. Care and the focus has shifted very much away from, you know, social provision again, onto individuals and you know, what, you know, drugs or, um, other forms of treatment they might be.

And with that, it's also been kind of re pathologized as. Often a problem or some, yeah. [00:45:00] Something to be cured. Whereas, you know, there's been so many activists and movements and efforts to move away from that kind of, um, deficit thinking, you know, in cases like autism away from a view that autism is a disease and towards understanding that people with autism just experience the world differently in many ways that are, you know, enriching to them.

Sometimes not, sometimes there's difficulties too, but that this is a very multifaceted experience that can't just be, you know, erased or that the aim should never be to, to get rid of it, but to support people just where they are and how they are. So, yeah, that's, I guess that's my concern around, um, around just the uptake of these labels and the way they're kind of talked about today.

Yeah, and I, and I think we very much need to appreciate how much both of both of [00:46:00] these conditions we've mentioned so far. Autism and A DHD are very much a spectrum and things are very different at one end of the spectrum than another. Mild A DHD and I, I see a lot of people in A DH ADHD clinics. Mild A DH, ADHD looks very different to severe A DHD, and in my view, needs kind of a different approach.

Similarly with autism, at one end of the spectrum, you have. Uh, individuals who might have quite a severe learning disability might be nonverbal in some cases, in which case it does fit that medical paradigm better. But then at the moderate or milder end of the spectrum, then you can make arguments that these can, these, uh, ways of thinking and processing information can be quite adaptive.

And I've actually had some interesting conversations about this from an evolutionary point of view that it might make, you know, obviously it can make sense to have. People around in your community who see things and process things in a different way. So I think it's a complicated issue that's still really, uh, we're [00:47:00] still kind of at the beginning of, and still very much starting to understand.

Again, any clinicians listening? I think one thing I might emphasize is just be open. Like do the best research you can and be open with your patients and clients that it's, there's still a lot of mystery. We're still trying to figure out, there are some things we know, there's a lot of stuff we don't know yet.

When it comes to neurodiversity especially. Mm-hmm. Yeah. And I think, you know, this mystery that you, you've been talking about, I think is also just so useful in, in kind of undercutting this, this power discrepancy between, you know, someone who supposedly has all the answers and someone who doesn't. Just an openness like you say about what we didn't know and what we don't know, and offering people options.

Mm-hmm. We've talked a little bit about what. Direction, what directions a mental health system might move and you know, helping support people to address social problems, to inspire people towards agency. Are there any good [00:48:00] examples? Of services within the UK who seem to make be making good progress in this direction?

Yeah, I mean, I think there's so many actually and, you know, having worked in a kind of smaller service within, um, mind in Hackney, I've seen the amazing work that specialized services and, and local services can really do that, have really specialist knowledge of a particular community and a particular.

Type of experience. I also, you know, there's other services within mind, um, that I think are just so, you know, groundbreaking, although they shouldn't be. Um, like the Hearing Voices Network, for example, that, um, works with people who, um, hear, yeah, hear voices. And rather than pathologizing the problem or, or trying to kind of.

Eliminate the voices, works with people to form a relationship with them and sometimes [00:49:00] even, you know, come to like them, appreciate them. Um, you know, there's peer support services, there's, there's all sorts out there. I think the problem is generally just how fragmented the kind of landscape is and how people get often bounced back between services and their gps and kind of caught between the cracks.

There's a real need for kind of bringing them together, better resourcing them, coordinating them. But there's, there's so many, you know, depending on the kind of help and support you want, um, I would always really advise people to kind of look locally and go to, you know, charities and, and just see what a range and, you know, diversity of approaches there are out there as well.

Beyond. You know, going to your doctor. There's also, you know, all types of community support. Of course, we have social prescribing now as well in the uk. Um, so yeah, I think there's actually a lot out there. It just, it really [00:50:00] needs more funding. Yeah. I, and I think really good services, especially in mental health, often start locally.

Small organizations know the community really well. Mm-hmm. But then there's the scaling problem. As things get larger, and you see this in the NHS as things get large and you're dealing with large amounts of people, there's a scaling problem where it's hard to deliver that same like high quality, very personalized service to large numbers of people.

And I feel like this is maybe a. One of the core problems we need to grapple with as a society, how do we get a really good local service and scale it up? I saw this in the NHS all the time where you'd have one particular team, one department that just works really well, and the thing you had to do was leave them alone as much as possible.

And, and their job, the leaders of those departments, their job was to try and hide from managerial oversight as much as possible to just like keep doing what they were doing. 'cause they had a good team and a good culture. So this, this is one of the biggest problems I see in the NHS is how do you [00:51:00] scale a, a service that's already demonstrated to work really well?

You know, I've talked about the, about Chester and Italy quite a lot. They've done a really good job and they've done a really good job in Chester. But then how do you scale it across Italy, for example? It seems to be a very complicated issue. Yeah. I mean, it is, and you know, it would be, you know, huge, just huge reforms.

But like I said, I, I was looking into the, the Dutch kind of example and how they're trialing currently, you know, in specific areas, but working towards a national. Coordinated system where they're really, you know, based on kind of a modular approach where there's lots of different local services, but there's one kind of coordinator helping someone through and, and coordinating the care they receive through different local services.

And yeah, so I think just with, with the right investment and, and, and thinking it, it can really, it's possible. Yeah. Yeah. No, definitely. [00:52:00] Even though a problem's comp complicated. We shouldn't pretend like it's not possible. Yeah. 'cause that's obviously simply not true. Yeah. Agreed. We're out of time, but Marika, thank you so much for spending some time with me today.

Your book no such thing as Normal Disorders, diagnoses, and the Limits of Psychiatry. I'll put a link in the description so our listeners can check it out if they're interested in learning more about these topics. Thank you very much for joining me. Yeah, no worries. Thanks for having me once again.