E106 - Overcoming Cynicism in Mental Health (Anti-Psychiatry, Anti-depressants, Big Pharma, ADHD, Psychotherapy)

Today Alex chats with Dr. Alex Meaburn, a speciality doctor in psychiatry who has been working on the podcast behind the scenes. They discuss some of the limitations of psychiatry including problems with the biomedical model of depression, social-cultural reasons for mental health problems, crticisms of anti-depressants, dysfunctional attitudes towards suffering, the pros and cons of psychotherapy, the value of medication for ADHD and much more.

Dr. Alex Curmi 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 thinkingmindpodcast@gmail.com with "Speaking Enquiry" in the subject line.

If you would like to enquire about an online psychotherapy appointment with Dr. Alex, you can email - alexcurmitherapy@gmail.com.

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

Transcript

[00:00:00] Welcome back everyone. Today we're going to be recording a podcast all about the limitations of psychiatry and the limitations of the biomedical model and related topics. We've made a lot of podcasts around these topics in the past year with the author Rose Cartwright. with Dr. Alan Francis, who was on the chair of the DSM, most recently with Mark Horowitz, where we talked about de prescribing antidepressants and perhaps the limitations of antidepressants. 

We're going to continue that conversation today, and with me to talk about it is Dr. Alan Francis. Dr. Alex Mabern, who's on the podcast team and has been helping us organize interviews more recently. Alex, thanks so much for joining me. Thanks very much for having me. It's nice to be back. So how should we frame today's conversation? 

Well, I mean, I think, I've been thinking a lot lately about, Practicing as a psychiatrist and the, the, there are a lot of, there are a lot of difficulties in, [00:01:00] in working in mental health in, in, in the modern, modern time, which I'm sure a lot of people can relate to. And it's quite hard to, to not sort of get, or yeah, not to get bogged down by these things or, or to find yourself feeling really disheartened in your practice. 

So I wanted to maybe. talk about some of those issues today, uh, and maybe think about, I guess, firstly, what your perspective is on your experience of, of perhaps those, those common issues, but also maybe thinking together a bit about some ways in which we could, um, either tackle them, address them, reframe them, um, you know, that way we kind of, uh, sort of, yeah, I guess I said not get really bogged down and disheartened, um, in the field. 

And I think central to that to that idea. I mean one thing that's that's really stuck with me was a friend of mine Um told me, uh before I actually went into psychiatry training as a reason why [00:02:00] They had left psychiatric training albeit in a different country They told me that their experience was that bad psychiatric care was worse than no psychiatric sex. 

Yeah psychiatric care. Um, and That's something that's i'm I've been in training. I've, I've, I've come to witness for myself to be, to be true. Um, and you know, it goes against our, our, one of our first principles as a doctor, you know, first do no harm. So, Really the focus of what all the minds are trying to say is I'd like to to create a podcast that kind of helps, you know, helps myself, helps listeners, uh, you know, still find the joys in working in this field, um, for all the, you know, for its richness and how stimulating it is and not end up all becoming raging anti psychiatrists. 

Yeah. And you see a lot of that online, anti psychiatry. So it sounds like what you're worried about is becoming cynical in your profession. Is that? Absolutely. Yeah. Yeah. [00:03:00] I mean, I would say I probably, when I was in my training, I shared a lot of these concerns. I think that when you enter a profession with good intentions, you tend to have a bit of a idealistic point of view. 

You have a sense of like where you want to get to, but you haven't yet. experience the harshness of the industry or the area that you're working in. You haven't experienced a lot of like the more difficult realities. And this is, I think it's true for almost any industry, but it's particularly true for mental health. 

Myself and I remember my cohort, the people I trained with, we all had the sense that, you know, we were medically trained medical professionals. We wanted to use that knowledge and to help people with mental health difficulties. It's as simple as that, right? When you enter your training, but then what are the challenges that you find when you start the challenges of needing in some Circumstances to use the Mental Health Act where people [00:04:00] are detained in hospital against their will or given medication against their will You start to realize the limitations of diagnoses that our diagnoses Within mental health and sometimes even within physical health aren't exactly perfect, but as our treatment isn't exactly perfect I think the danger is that you go from idealism to cynicism, and I don't know about you, but I've seen professionals who I think have gotten stuck in that cynicism for a long time. 

And I think the cynicism is actually a bit of a part of the process, but if you, if you handle it carefully, I think the trajectory is. Idealism to cynicism to wisdom that you almost that cynicism going through cynicism to some degree is like a necessary part of the trials and tribulations of training in any industry, but especially mental health, but hopefully can get out [00:05:00] the other end to some kind of wisdom. 

And maybe we can talk about The cynicism and the wisdom and what, what that might look like. Do you think that just on that note, do you think the cynicism is kind of, it sounds like it serves a function then it to, to, to maybe create a bit of reflection on your work, um, to think about, you know, what am I, where am I going wrong and how can I do better? 

Is that, is that what, is that the path to wisdom? It's, whenever you're doing something that's difficult and challenging, by definition, there's going to be periods where you don't know what to do, where you're encountering a lot of mystery, where you yourself haven't like updated your personal philosophy sufficiently to grapple with the things you're dealing with. 

Like before you train as a psychiatrist, you probably, I mean some people have, but you probably haven't really grappled with what it means to deal with dysfunctional families, for instance, to deal with societal unfairness, to deal with biases [00:06:00] within the medical system or how studies are carried out, to deal with the limitations of things like medication. 

These are all things that are totally foreign to you. And then you start working and you have to start grappling with all of these things one by one. And in my opinion, what you have to do is develop a personal philosophy around all of these things, their pros, their cons, their benefits, their drawbacks. 

And then through that, figure out how you can be the best clinician that you can be. So I think cynicism is baked into the process because we're doing something very difficult. And I think that's worth noting, you know, helping people, helping, you know, a stranger essentially with their mental health problems. 

Is a very difficult thing and that's why it requires, you know, a lot of training, you know In our case something like eight years of training because it's a it's a difficult thing to do Should we start with the first cynical point then? Yeah, let's do it. Yeah. Well, um, so I think maybe top of my list [00:07:00] um In terms of or at least high up there in terms of concerns working as a psychiatrist Is this at least my perspective is over reliance on the the sort of biomedical biological model. 

Um, medical model of of psychiatry You So by that I mean viewing psychiatric illnesses, um, as, as solely based in the biological, and therefore the, the treatments are predo, predominantly medications. Um, is this a, is this something that you feel you've experienced in the field? So when you're training as a psychiatrist, they obviously talk a lot about the bio-psychosocial model. 

So the, the interplay between biological, psychological, and social. I think that's very important. And depending on the setting, I think in some settings, it's more like it's only lip service that's being played to the psychological and social part. I think that's what a lot of people encounter. [00:08:00] Especially in acute inpatient wards, where we're dealing with acute, more severe mental health problems. 

So I think it is a problem, and I also think medical students and doctors are conditioned to see things through a biological lens. And we need to be reflective and critical about that, and see actually we're a little bit more complicated than just biology. And that helps us to figure out a lot of solutions which aren't immediately obvious if you're just thinking along biomedical lines. 

But first, you kind of have to give the devil its due. So giving the devil its due, the biomedical model, we are biological creatures. A lot of our mental life is mediated, obviously, by our body, but also our brains. As we learn in medicine, a lot of the time, organs stop working or go wrong, sometimes for reasons which have no real clear meaning. 

There might, there might be an explanation, but if you read pathology [00:09:00] books, there'll be one chapter on how and why the kidney goes wrong in some inexplicable way. How and why the thyroid gland goes wrong. And I think this can happen in the brain as well. I think it's actually only really a minority of cases that that happens in. 

I think a biomedical model of psychiatry used to be used in the past a bit more appropriately for more severe chronic cases. And now for different reasons we can talk about that are more socio cultural or environmental perhaps there's a higher prevalence of mental health problems. But psychiatry is being asked to swallow up those problems, to deal with those problems. 

And I think this is more unconsciously, treat them all as if they were somehow brain disorders. Whereas, in fact, myself, most psychiatrists I know would say, for most people suffering with mental health difficulties that we see, particularly the milder, [00:10:00] more moderate, Thinking of things like anxiety and depression, which is super common nowadays. 

We're probably not dealing with a primary brain disorder as such, so I think that's why it's important not to just pay lip service to the biopsychosocial model, but actually let's really think about the psychology and the social and cultural aspects, which we can talk about in more detail if you want. 

I mean, first, I'd say, firstly, you know, I really agree with that, particularly in the case for depression. Um, you know, certainly my experience is that the majority of cases that I would, I would see are at least not solely biological for sure. Um, if not, you know, I, I often view depression as, you know, a, a relatively normal response to an extreme circumstance, sort of extreme stress or social upheaval. 

Um, And I think that for, for years, um, psychiatry and mental health, uh, tried [00:11:00] to push this sort of biological model onto, onto the public. So in particular, I think now most patients have probably come across or many patients have come across this idea of a chemical imbalance, which may have some truth to it, but I think most psychiatrists these days kind of reject that as being true. 

You know, the sole cause of, of, of, of a depressive illness. But I think our patients are lagging behind there now. I think, you know, sometimes we we've met, we've led them to believe that, okay, there's a deficiency in their brain and that they need to take these hormones to get them better, not hormones, but you know, drugs and, and. 

I mean that that causes lots of different problems. Um, it becomes difficult for a psychiatrist in the room to to not sort of reflexively reach for the the prescription pad and sort of Prescribed medications, especially if that's what the patients are expecting and that's what they've kind of there on their understanding of mental illness has [00:12:00] been But it feels so wrong to do so many times I mean, you know I'm sure you you agree with us that when when when someone comes into your into your clinic and they say that they're depressed Usually there's a good few reasons you can identify in the clinic for them to feel that way. 

Absolutely. And It just feels inherently wrong to then say well You know You know, rather than addressing those things, let's just give you some medications and probably just dampen down your experience. Yeah, I mean, getting back to the point you mentioned about chemical imbalance theory, I am not so sure it was psychiatry pushing that onto the public so much as some sort of strange, and I am, I must say, I am speculating a bit, but how much if it was more of a strange collusion between psychiatry, the pharma industry and the general public, That we've come to this sort of shared narrative of what [00:13:00] causes depression that makes everyone feel a little bit better, Creates a little bit more certainty, creates a clear defined solution, and then importantly it is the more psychological aspect Prevents us from looking at any deeper, more complicated issues. 

I don't actually think it's a mystery. We'll talk about this later. I don't think it's a mystery what causes depression, uh, but it is complicated and, and, and tackling those deeper aspects is a lot of work, whereas having this shared understanding of, okay, you have a deficit of serotonin in your brain, you take this antidepressant which boosts that, and then you feel better, I think everyone in the short term benefits a little bit. 

from that narrative. Uh, obviously some people have financial interests in pushing that narrative. Personally, I am one of the more antidepressant, skeptical psychiatrists you would meet. By skeptical, I don't mean they don't have their uses or there aren't situations where I would [00:14:00] prescribe them. And in fact, we talked to Mark Horowitz recently. 

I might be a little bit more pro antidepressant medication than he is in certain situations. Thanks for watching! But as you say, when I see someone with depression or anxiety, it's very rare that I think that the right thing to do probably is to prescribe an antidepressant because I see so many potential contributors to their low mood or their anxiety, and this may be the way my mind works when I see those contributors, I see solutions, maybe difficult solutions, maybe complicated ones, maybe ones that That would take time, I grant you, but opportunities nonetheless. 

So, if you're really talking to someone about their depression and maybe at first it seems inexplicable But then they say, well, actually, I don't really like my job. I don't get very much meaning from my job. Um, I'm having a bit of a weird relationship with my, my wife at the [00:15:00] moment. Maybe it's lacking in emotional intimacy. 

I haven't exercised in two years. Those are all contributors. Those are also opportunities and how perhaps the depression can be addressed or ameliorated. Granted, maybe not all at once, but you could easily see how delineating a few contributors, you can start to figure out a plan slowly with slow, consistent action that a person can start to improve. 

Again, some people are cynical about that and they say, you know, people have really tough lives and how dare you suggest that they try and like improve their lives. I have gotten that pushback funnily enough from different people at times, but I would take the view that Even starting to take control of your life, even if you're, even if you don't drastically change your circumstances, particularly at first, because it can be a slow process, even the act of getting more in the driver's seat of your life and starting to [00:16:00] take control and viewing things within your control is, it's in itself therapeutic for things like anxiety and depression because so much of it is about helplessness and fear and a feeling that life is happening to you, so even starting to change someone's mindset that actually you can be at the cause of your life rather than the effect, I think can be therapeutic, but that would just be the beginning of how you can start to work with someone to deal with problems, so quite rare for me personally as a prescriber that I would use an antidepressant. 

I might use it in more like moderate to severe situations. Maybe situations where people are in hospital as a result of their depression. But then perhaps some things I might do that another person might not is, I would prescribe in a more time limited manner. And I would say, you know, we need to look at this at least in three months, six months. 

See, is it benefiting you? What are the drawbacks? What are the side effects? [00:17:00] If it's not benefiting you, and I don't know about you, but I've seen many people who have taken antidepressants for years and no one's even asked them if it's of any benefit to them, or not, which is a huge problem. Um, and if on reviewing, you know, things are actually better, then that might be a good argument for withdrawing and stopping the antidepressant. 

And if it's not having any benefit, then that's a really good argument for stopping the antidepressant. So I do think, even if I, when, when they are prescribed, I think it's useful to do it more in a time limited factor. And then when you come to anxiety, I think anxiety is even more amenable to psychological intervention because anxiety is one that we know anxiety responds so well to sort of planned intentional exposure. 

So especially when anxiety is really localized to a particular stimulus, like someone has a phobia of a spider, we know from the literature, you can really If you have a plan and you intentionally expose that some [00:18:00] expose someone to that stimulus in increasingly scary forms over time, starting very small. 

Like, show them a picture of a spider and then increase from there. You can really reliably reduce someone's anxiety. And I think you can apply that to all sorts of things, like public speaking, or socializing. To anxiety, I'm even less inclined to use a medication. That's where I stand personally, and I'm curious. 

Psychiatrists who listen, write to me and tell me what you think. Well, I mean, actually, perhaps on that note, I mean, I imagine there are a lot of people who at least have the same views as you, that, you know, for the mild, milder to moderate conditions that they would like to avoid prescribing, or prescribe in a very time limited fashion. 

But, the reality is that in the clinic, in a short space of time, with lack of resources, they feel, they don't feel empowered to do anything else. How might, how do you manage that in, in, in sort of your clinical practice? How do you kind of [00:19:00] begin to address some of those wider issues without reaching for the prescription pad? 

Well, I think, I think it's a, it's a, it's a complicated problem. It depends where you work, particularly if you're in training where you can't choose where you work, it can be quite restrictive. Uh, when I was in training, I took it upon myself to educate myself as much as possible on The psychological and social aspects of mental health problems, particularly anxiety and depression that equipped me with a particular toolkit to help people with, with those conditions without using medication as much as possible. 

Uh, although I did prescribe it at sometimes I'm not. totally anti antidepressants. Um, and I was lucky, I was lucky that in the context in which I was training, I had time to work with patients. So to some degree, it depends on the context. I think as I've gone, as I've developed [00:20:00] more in my career, I've obviously developed my career in the direction of being more psychologically and socially focused. 

That's why I trained as a psychotherapist. So I think one of the themes that's worth touching on in this podcast, how not to be cynical as a mental health professional is. Figure out, like, where, what your talents are and where you can be of the most use and then build your career on that. So if you're really interested in doing more holistic type treatments, see if you can build your career to give you the time to actually learn about them and use them. 

So maybe an acute inpatient ward isn't the right place for you if you want to apply those kinds of treatments. Maybe it's more of an outpatient setting. Maybe studying psychotherapy or training in psychotherapy is right for you. If you are, um, stuck in a setting where you have a very limited amount of time, uh, I would say, even choosing to emphasize, uh, to your patients that there are things [00:21:00] beyond medications that they can try. 

Getting together a bunch of resources, and that's one of the reasons I make the podcast, is to have easily available resources. That you can give to patients. So even if you're not going over everything in detail in the clinic, you can at least give them some really detailed resources they can access online. 

And nowadays there's a really lot, there's a lot of good resources that people can use. I think the way a doctor emphasizes. The management plan and like recovery to patients is really important. So for example, I work a lot with ADHD. I can imagine some psychiatrists working with ADHD can be like, Okay, you have ADHD. 

You need a medication. Here's some medication. Here you go. And also you can do some other things, some lifestyle things to manage it. But here's the medication. The patient's obviously going to walk away with the impression that medication is primary. Okay. And everything else is secondary. [00:22:00] Me, personally, when working with ADHD, and I think medication can be a really useful tool for ADHD, arguably better results than antidepressants, but I frame it to the patient as, here's a bunch of non medication strategies, they're foundational, they're really important, they may have more longevity than the medication. 

And like that, You know, the doctor has told them, you know, this is really important. So at least in their minds, um, they have the appropriate emphasis. I think as doctors, so often we just deemphasize a lot of stuff unconsciously without realizing highlighting to the patient, Hey, this is also really important, maybe more important than medication in some cases, you can at least give them the green light to do more of their own research, to find different ways of managing their problems. 

And you can signpost them to the resources as well. So I do think there is quite a lot you can do in that, in that respect. Yeah. So, I mean, it's really, you know, good psychoeducation, having resources [00:23:00] at your, at your fingertips. I think just to emphasize as well, you don't have to be a psychotherapist or a psychologist to provide psychological tools to help people. 

You, as you said, if you're, if you have an interest and you want to work holistically, you can learn some, some things that you can kind of. teach the patient in a session, can't you? I mean, psychiatry and psychotherapy, like psychiatrists all used to be trained in psychotherapy. And I think that was wonderful. 

Like Freud was a neurologist, psychiatrist, Carl Jung was a psychiatrist, Eric Ben who founded transaction analysis was a psychiatrist, Fritz Perls who founded Gestalt was a psychiatrist. But around the fifties and sixties when psychopharmacology really took off, particularly with the invention of antipsychotics. 

And there was this sense of, oh, these conditions which are really hard to treat before all of a sudden we can empty the asylums. I think that gave psychiatry an [00:24:00] emphasis on medications that was probably a little bit inappropriate. And it, I think, legitimized psychiatry as a medical specialty, which on one hand is a good thing, on the other hand, made us feel like we could divorce ourselves from a lot of the wisdom that had been accumulated in psychotherapy. 

And so, when I was training as a psychiatrist, and I was really into psychotherapy, I was kind of an exception. And people were like, oh, you're into psychotherapy? Isn't that kind of archaic? And, and outdated, and is it even useful, why aren't you, why aren't you on what some people told me was like the cutting edge, which apparently is SSRIs. 

But actually I found, even learning a bit of psychotherapy, even on my own, before I started formally training, I had an edge in clinic, because I could talk to people about behavioural exposure, or I could talk to them about family dynamics, or I could talk to them about attachment. All of these things which have huge [00:25:00] roles in, say, depression or anxiety. 

And I felt it give me, it gave me a I was like a superpower and I am so sad that so many for so many psychiatrists, the psychological psychotherapeutic aspects are like a tick box. You have to get off the list. I have to do my two psychotherapy cases and then I'm signed off. And that's incredibly sad to me because I think it's just like, there's just so much wisdom packed away there that at any moment you could access. 

I wonder, should we be making a distinction between, um, serious mental illnesses and, and sort of the perhaps the mild and moderate in the sense that, um, When I think of something like schizophrenia, I think of that as more almost necessary to use biological, to use medications. Do you think that's, you know, is that your understanding as well? 

You know, does schizophrenia get, get, get [00:26:00] better on its own or, or, uh, with purely psychological interventions? Yeah, I mean, I think it's usual, it's useful to make certain distinctions. All of this exists on a continuum. Obviously we like, as human beings, we like to put things in categories. But I think in reality, most things occur on a continuum. 

You've got mild to moderate depression, um, that, that largely manifests psychologically, the more severe that something like depression gets, the more it has a more biological flavor, it gets. People who can't get out of bed, they have what's called psychomotor retardation, they move and speak very slowly, they might have trouble concentrating, they might not eat and drink, it's really severe. 

And then you have conditions which tend to be as a whole more severe. and have a more biological flavor. And for me those are things like schizophrenia, bipolar, schizoaffective disorder, which is like a hybrid of schizophrenia and [00:27:00] bipolar, ADHD, autism, and it's really interesting that you can see uh, for a lot, but not all of these conditions, they tend to respond better to medications more often. 

There's less of a placebo effect in the trials and there's also more of a genetic influence. So, you take something like schizophrenia, so that's, we've talked about it before on the podcast, but, someone has schizophrenia, they tend to have discrete episodes, where, they might hallucinate, typically they might have auditory hallucinations, they might hear voices, they might become paranoid, um, they might have what's called delusions, sort of bizarre thoughts, like someone's monitoring me, or someone's out to harm me in some way. 

Compared to depression, more of a genetic influence, so it's like 50 percent heritable. That means like, 50 percent of the variance is explained by a difference of genetics, but rather than a difference of environment. You have [00:28:00] twins, which you separate at birth. Uh, if one twin has schizophrenia, the other twin is 50 percent has a 50 percent likelihood to develop something like schizophrenia, high genetic, higher genetic influence as opposed to anxiety and depression, where it's more like, let's say 20 to 40 percent and there's more of a range schizophrenia response to medication. 

More often responds really well around a third of the time response pretty well, another third of the time. And then one third of the time doesn't respond well. So around two thirds of the time, you're going to get quite a good, you're going to at least quite a good response, um, to medication. So schizophrenia, something like 50 percent heritability. 

responds better to medication. Similar story with bipolar and something like ADHD, 80 percent heritability and also responds really well to medication. Although there might be a bit of a timeframe issue with that where our best research is that ADHD medication, our [00:29:00] best research on ADHD medication is within around two year time window of starting it. 

And beyond that, we don't actually have a lot of good research. Autism, of course, we don't use medication to treat, but we think very likely has strong biological underpinnings and has a heritability of like 80%. So you see a pattern where conditions which tend to be more severe, tend to be more heritable, tend to respond better to medication, and tend to have a lower placebo effect, you can see that pattern. 

So I think it is worth making those distinctions, but even in those conditions, the psychology and the social aspects are really, really important. Um, so I think there is increasing evidence that you're more likely if you have something like schizophrenia or bipolar, you're more likely than the average person to have trauma. 

Uh, so now we're getting into more of a nature nurture thing. You might have the genetic predisposition. [00:30:00] Uh, but perhaps if you don't have certain life stresses, uh, the condition might never manifest itself. And this is actually something I discussed in a lot of detail with Richard Bentel, Professor Bentel, who we haven't released that episode yet. 

There's actually an interview you organized and we, we go into this subject in depth. So even though there might be more of a biological, these conditions might be more biologically mediated. I think the psychology, the psychology and the social aspects. are still really important. I mean, even if you take an example like alcoholism, alcoholism has some degree of heritability. 

There's a genetic, you can have a genetic vulnerability to being, uh, addicted to alcohol. But whatever the heritability is, if you put someone on an island where there's no alcohol, they're not going to develop the condition. So even if a condition has high heritability, it's not a, It's, it's not a hundred percent determination that they're going to get [00:31:00] those conditions, that condition. 

And I think the environment is still really important. I find it's, it's interesting that you, you spoke about ADHD in the same sort of category, and I understand why you did that, because as you said, it's highly heritable and it responds well to medication, but at the same time, ADHD, perhaps. It makes me think of the other side of things, the side of the coin where, so you know, conditions like ADHD are referred to as often, not necessarily illnesses, but kind of neurodivergence, um, and you know, you'll, you'll know more than this cause you, you, you know, you work in, in ADHD. 

So perhaps you can, you can correct me, but. Sort of my understanding is that, you know, or at least my feeling is for the majority of people with ADHD, perhaps there'll be exceptions for people who've got really, really severe ADHD, but for the majority of people with ADHD, Ultimately, the reason why they need treatment is because their condition isn't sort of, you know, they're not optimized to work in what's very much [00:32:00] modern day life. 

So by that I mean, you know, sit in a classroom for eight hours or sit in front of a computer screen and concentrate for eight hours at a time. That's quite a specific circumstance that society has created for people nowadays, modern humans to live in. And because these people struggle in particular with these things, they have to take medication to get around it. 

Do you think that's, that's, that's fair? I can see you pulling a face. I wonder what your thoughts are. So this is the argument that the modern landscape is this really artificial thing which requires levels of attention, which are kind of absurd. And so people with ADHD need to take a medication in order to fit into this very Yeah. 

And I guess just to build on this point, and it may be a separate thing for ADHD, but my worry sometimes is in, in, in psychiatry is that we are trying to [00:33:00] medicate or treat societal problems. And I, I, you know, I fear that we kind of create this idea, this, this kind of illness model, which focuses on the paper being something wrong with the person, the patient, um, and we take away therefore any responsibility or onus on the people who are responsible for shaping. 

Society and introducing policy and how our school systems are structured those kind of things we take away that onus We put it on the patients. They know you're ill the problems with you. You need to take something to fit in That's yeah, that's my fear and I'd like to talk about the socio cultural and even governmental Aspects of this but sticking to ADHD for a moment My experience in assessing people for ADHD is that largely they themselves would agree that they have a problem and it's not with trying to fit into a overly demanding system. 

Actually, if it was [00:34:00] just that, probably they would find workarounds themselves. Uh, it might be what kind of job they choose or where they fit into society. But largely the problems I see are people who have trouble executing on their own desires and passions and what they actually want to do in this world. 

For example, people with ADHD will often tell me, I have trouble keeping up with my friends and maintaining my relationships because I find texting them back difficult. I have trouble learning the guitar because I have, I love to learn the guitar, but paying attention long enough for me to practice. I would love to be able to get to sleep, but the restlessness and the hyperactivity, particularly in my body and mind, prevent me from getting to sleep. 

I enjoy my job, and I'm not trying to concentrate for 8 hour stretches, but even doing an hour without getting distracted is really difficult. So, I'm sure this, I'm sure what he said applies to some people, [00:35:00] and I would be particularly more concerned with kids. Particularly perhaps boys who are predispositioned to be a bit more aggressive. 

I would worry about that in the adult population. I think people are pretty good at sussing out. You know what they want and what tools they might need to get there. I also think when someone gets diagnosed with adult ADHD, I think medication should be presented as one tool in a menu of options and that's again personally how I practice. 

I'm pretty sure many psychiatrists don't practice it in that way, but I think medication with its pros and cons, which we can talk about if you'd like, It should be presented as one, as a menu of options, and it has to be said, many people find it very useful for the time that they take it, and medication for ADHD can be a really useful window of opportunity to put into place a lot of non medication. 

techniques and structures in their life, such that even if they don't take it forever, they're [00:36:00] still better off from when they started because they've had the opportunity to put a number of things into place. So that's been my personal experience is that it's actually ADHD gets in the way of people getting what they really want. 

Out of life rather than trying to fit a square peg and into a round hole, although I do acknowledge that I'm sure that can happen as well. I don't want to kind of Sort of move on from medication and kind of the biological model Without sort of just talking about perhaps the elephant in the room a little bit. 

But um for me, that's the the sort of potential for the pharmaceutical industry to have its hand in, you know, in our pockets or, or, you know, its influence on us, not necessarily its hand in our pockets. Cause, uh, you know, we're not in the U S and we're not sort of privately funded or anything like that. 

But I do wonder, I mean, do you have, apart from me just being a bit cynical or pessimistic and thinking that of course, the the companies that [00:37:00] that market the drugs are the ones that also are responsible for running the majority of the trials to prove that they're Effective and choosing what they want to present. 

I can't help but feel that our situation is going to be incredibly biased Um, even if it's supposed to be, you know all done within the scientific method. Do you have any thoughts on this? Yeah, I mean, I think that I think I agree with you and it's a huge danger. Um, to be honest It's a problem I've become aware of much more recently. 

So the extent to which pharmaceutical companies have an influence on the research itself is something I've come to understand from talking to colleagues who are more in research. I should say I'm not in the research world. Um, it's not something I have a lot of experience with, but I have friends who are. 

And I'm starting to realize just how much certain aspects of research can be influenced. Um, to make a particular medication, perhaps look, perhaps look better than it does. And there's something that Mark Horowitz talked about as [00:38:00] well. I would be an advocate of very much us as a specialty, particularly in the UK where we have a bit more of a detachment from the pharmaceutical industry to really re review a lot of the studies that we've done, um, to kind of conduct new studies, studies that might measure things that other studies haven't. 

or study things across longer timelines. I think that's a big criticism that a lot of our studies are on just short enough timelines, let's say with an antidepressant, show efficacy, and then if you continue the study, perhaps that efficacy would wane. So I think it would be a good thing if it became more the norm to do studies without any, you know, pharmaceutical company influence whatsoever. 

I think that would be a really good thing. Maybe. We can, I'd like to talk at some point about AI and maybe some technological revolutions. Maybe some technological advances could help us do research more easily, um, [00:39:00] with a bit more agility and perhaps without needing the backing of enormous financial institutions, like pharmaceutical companies. 

I think that could be good. But I think more and more it is important to be a little bit more skeptical of what could be the, the, the implicit or subversive influence of, of a pharma company on a lot of these studies and also. This is something Mark Horowitz talks about, this is something Mark Horowitz talks about, look at anecdotal evidence, and like really talk to your patients, and if they say they're having adverse reactions to medications, But they're not adverse reactions that you're familiar with from the literature. 

Still take them seriously. Like the big one for me is like emotional blunting with antidepressants, where people feel like their range of emotions is really narrowed following taking an antidepressant. I hear about that all the time. I was never taught it. It's never in our guidelines. It's not on the British natural formulary around antidepressants. 

So have [00:40:00] an ear open to what your patients are saying. Go on forums like Reddit. I know it's not scientific, it's usually valuable just to see, you know, people will be honest on the internet and just see what people are saying about the medication, if it's a medication that you commonly use or you commonly see prescribed, just to get a flavor of what maybe the studies are missing. 

I think could be good. I'm so skeptical about whether I should say this or not, but I think it's interesting because, um, you know, I, I kind of suspect that, or at least my, my kind of impression is that the main mechanism of action for antidepressants is that biological, is that, is that emotional blunting? 

Um, I do kind of find, I think that it's, it's very commonly reported, um, and, um, It, you know, it kind of makes sense to me why, you know, antidepressants might be really helpful in times when you're feeling extreme emotions. Yeah. Having that blunting, taking the edge of things, allowing people to then kind of, you know, [00:41:00] psychologically repair. 

And that's why prescribing them in a time limited manner can be useful. Because if someone's emotionally blunted for three to six months, they get through a difficult period. That's one thing. But if they're emotionally blunted for 10 years. That's another thing, and I think one of the things that I'm an advocate of is getting to know your emotional systems. 

Getting to know your emotions and use them, because in modern rationalist society we see emotions as these annoying things which get in the way, at least the negative ones. Maybe sometimes even the positive ones, like when kids say catch flights, not feels, you know, even positive emotions we're not allowed to feel or they're seen as somehow in the way and And I think so emotions are an incredibly important toolkit that if you use them your life is just better We can talk about that if you want. 

Well, yeah, I mean, I think that comes on that brings us on nicely to thinking a little bit about [00:42:00] Pathologizing normal emotions and sort of normal our tendency towards kind of labeling things as As illnesses or overdiagnosing, um, And I think, you know, we have to acknowledge that suffering is a good part of the human experience and, and experiencing emotions in its full range is not only normal, it's, it's, it's important for a fulfilling life. 

I mean, one thing that. Really stands out to me at the moment and again, here's my sort of cynicism shining through but I've noticed quite a lot of adverts, um, for something, uh, you know, not to sort of name in shame but sort of, uh, therapy apps, yeah, um, one in particular that comes up and it sort of says, the advert always strikes me because it's sort of saying, It's someone saying, Oh, I'm going for a breakup. 

So I need therapy or therapy will help me go through this very [00:43:00] breakup. And I'm sure, I'm sure there's circumstances when breakups can be particularly traumatic or they can, you know, you've tried on your own and you're not doing very well, and maybe you sort of tend to have tend towards not being able to manage these very well. 

And you could do with some, some foundation of some skills to manage, but. I think for the majority of us, going through a breakup is a normal experience and it's something that, I don't know, I don't think we should, I think by sort of saying you need therapy for it, it suggests that there's something inherently wrong with the feeling hurt and the senses of rejection and all the things that normally come with a breakup. 

I think I somewhat disagree with you, so I'm not as Maybe against the commercialization of therapy. Obviously, here's my bias. I work as a psychotherapist in the private sector. So that's my bias disclosed. I'm not, one of the things capitalism is really good for is [00:44:00] showing where value is. So the market decides actually where something is really useful. 

And when something's undeniably really useful, it accrues a lot of value. Uh, I think there's a real gap in the market for psychological awareness and psychological skills. And if you have a therapy service, if you're a therapist or a group of therapists, and you're good at providing value to your clients, which in this case would be helping them become more self aware, giving them a better psychological toolkit, helping them deal with the ups and downs of their life in a more sophisticated way that overall improves the quality of their life, and there's an exchange of money for that, I think that's a good thing. 

In terms of what you said. You know, this idea of you have a breakup, therefore you need therapy. Yeah, I think that's not a, that's kind of a dysfunctional way to dysfunctional path to go down. We shouldn't be pathologizing [00:45:00] suffering. Suffering is a part of life, will always be a part of life. Uh, and I think a lot of what you'd learn in psychotherapy is actually how to deal with suffering in a better way. 

But I think something like a breakup might be a really good opportunity to learn about relationships, right? So, like, if you have a breakup, um, you can learn about yourself, you can learn about your partner, you can learn about your relationship patterns. So, if you had therapy after a breakup, you might be able to figure out, you might be able to improve your chances, I really believe this, of getting into a more satisfying relationship. 

in the future. Do I think, oh, you've had a breakup, therefore you need therapy? No. But that's also positioning therapy as like the medicine to a disease. The breakup is the disease and therapy is the medicine. But I don't think that either. I think that breakups are part of like the suffering of everyday life. 

[00:46:00] Therapy is a really useful tool, you can learn to navigate that suffering, learn from it, get more value from it. Um, and then hopefully that can help you navigate life in a better way in the future. So, the shorter answer to your question is, insofar as therapy or its commercialization is trying to like, buffer us from suffering, then that's a bad thing, I agree with you. 

But I would also argue that's bad therapy. The therapy that says, oh, you had a breakup, you feel sad. And that's bad. Um, how can we make you feel neutral? That's like the antidepressants of being a therapist. I definitely wouldn't recommend that. But therapy that can help you understand the difficult experience and learn from it, then I think that's, that's a good thing. 

And I think, like I said, there's a huge gap in the culture in terms of psychological. So I could, I think it could be really helpful. And you raised, you touched on something there that, [00:47:00] um, perhaps I didn't give it, um, to credit, but I mean, correct me if I'm wrong, but I think it sounds like you're sort of also saying that, you know, the sole use of therapy is not just in, in illness and in, in, in poor health. 

It's also, it's also for just normal everyday skills and, and, and how to navigate and build on that. It's kind of a, you know, a self development tool as well. Yeah, so I definitely take, definitely take that position if you go to something like therapy where everything's going well in your life, roughly speaking, then probably at that point, you're using it more as a preventative tool. 

But I think that's really good. And I think more of us, not necessarily just through therapy, because I should also say therapy is just, again, one of a many of options you can use to maintain your mental health. But Prevention is better than cure. And I think this works across the wider society as well. 

If you're feeling [00:48:00] okay and you think maybe therapy might be right for you to improve your self awareness, to increase your psychological toolkit, it might help your well being now, but importantly, it might help you in 5 or 10 years. where something actually really bad does happen and help you to navigate that. 

If you're going through a hard time now, therapy can help you, um, navigate that as well. But as I said, there's, that's one of many options of things you could do to improve your mental health. And I think my understanding is that in some cultures, it's more normal to, to be in therapy or to go to therapy more regularly. 

Um, whereas I think perhaps in the UK where certainly it hasn't been that in the past and maybe we're, we're getting there now. Yeah. I mean, it seems like it. But I mean, also, one of the things that we're really not focused enough on, I think, is community and the value of relationships, and the value of high quality relationships. 

If there is a danger to the commercialization of [00:49:00] therapy, I think it's to seek out, sort of, a good relationship with a professional as a substitute for good relationships in just your life. That might be a danger, and that's called, uh, therapist dependency, where people become too dependent on their therapist. 

I think therapy can be really useful to help you get those relationships in your real life. Um, to form romantic relationships, to form and improve friendships, to hopefully improve the relationships with your family. I don't think there's ever, there's no substitute. A therapist is never going to be a substitute for those relationships. 

As humans, we're wired to be a social species. And I guess if there's some sorts of psychotherapy dystopia, I can imagine it's one where no one has like a strong sense of community, but everyone has a one on one therapist. And uh, maybe i'm making your arguments for you. You've just written a black mirror [00:50:00] episode. 

Yeah Yeah, yeah, it's food for thought. I mean it's just like it's sort of i'm kind of going off on a tangent But just thinking about sort of more our hunter gatherer ancestors and about how you know living in in small social groups and things He would have always had access to to close knit people in which he can you know In that sense everyone's acting as their own therapist. 

So certainly in the sense that they can You Have someone to offload to, someone to problem solve with, someone to build a therapeutic alliance with. So I'm just thinking now, I mean, it perhaps is a good time to talk about this because, you know, I think by the very nature of us having these kinds of sitting down and having these conversations, the fact that we can do that in this field, I think it does highlight both one of the strengths, but also a big weakness of the field. 

And that is that a lot of it. It's hard to for people to reach a consensus on on many of the things in mental [00:51:00] health like what is a mental illness? How do we treat them? How do we, you know, those kind of things as a practitioner working in that field? Sometimes it can feel a bit overwhelming that lack of real sense of cohesion and sort of guidance. 

Couple that with the fact that, you know, we've not really had any major breakthroughs in the last real 50 years or so. Um, and. The other thing I often find as well is that when I'm, you know, I'm trying to kind of broaden my mind and think about things holistically, I come across all kinds of different theories that make me rethink my, my understanding of, of the field. 

All of this can be, I can, I can see positives in it, but it can also be really quite overwhelming, um, and make me feel a bit sort of lost. Is this something you, you experienced? Is this something that you can sympathize with? Yeah. So you come out of medical school. You've kind of [00:52:00] mostly been trained in the biomedical model with, you know, some lip service, as we said, to the psychological and social aspects. 

And then me personally, when I was in my training, I started to expose myself to all these different schools of thought. Even within psychotherapy alone, there's so many schools of thought and that's without even getting into sociology, evolutionary psychology, nutrition, and all of these different fields, the kind of personal philosophy I've developed is I do think exposing yourself to all those different schools of thought is very important, but I think the danger is, especially if your mind works in a very particular way. 

You try to get certainty, too much certainty, especially too soon. So you're sampling all of these different schools of thought and your mind has this tendency to go But I just want to know the answer and I know the truth And I don't think [00:53:00] that's helpful because that puts a lot of pressure on you as a practitioner. 

It's a lot of pressure on your Consultations. Unconsciously probably puts a lot of pressure on your clients for your patients. Whereas I think actually, you know, there's a reason why they call it the practice of medicine. Like you are practicing, you are doing your best to sharpen the sword slowly over a very long period of time, you know, obviously trying to be as safe as possible. 

And as you said at the beginning, doing no harm, but I think every practitioner has to reconcile themselves with the fact that they're going to be developing a skill set slowly across time, especially if you're still in training. But even once you're finished with training, you're slowly slowly getting better and and part of that is not rushing to truth and certainty, which can be very elusive, but trying at every moment in time [00:54:00] to do the best job you can as a practitioner, while continuing to learn and taking new information and taking new information and try and be intellectually rigorous, which is again, one of the reasons I started this podcast is so I could formulate a set of ideas, say in an essay, and I could put it out and I can get people to tell me what they think. 

And then I can have a dialogue with my audience or I can interview a guest and I can tell them what I think and then I can start a dialogue with them. But then if I, uh, interview a guest who's very much positioned in one area, I can then interview someone who's at the opposite area and then I can compare and contrast. 

So that's been really useful. You know, I've interviewed people who are very much ensconced within the conventions of psychiatry. So that's been really useful. Simon Wesley, Robert Murray, but then more recently, more, uh, people who are critical of psychiatry, Mark Horowitz and so on. And you don't have to have a podcast to do this, but [00:55:00] creating that internal ecosystem of like, okay, I want to formulate an argument. 

I want to find the counter argument. I'm going to find the counter argument to the counter argument. Again, not trying to be perfectionistic, um, but trying to, I think the right mindset is sharpen the sword. Um, so that you can, you know, someone gives you a position, you can say, okay, I think I know the pros of the cons of the position. 

I can show you the cons of the position. I can show you where I personally am situated. You can ground that in your own practice, get your anecdotal data from your practice as well, because I think that's really important for any clinician. And I think that's what's. sort of developing as a practitioners all about. 

And I think approach in a certain way, it can actually, the mystery can be very enjoyable because who would want to work in a specialty where everything is kind of super defined and certain? Like that's definitely when AI is going to take your job, when everything's super certain. But that's just my view. 

[00:56:00] That's, that's how I approach things. I think as well to add to that, I think there's a danger of discrediting AI. The value in what we do, because we can't necessarily fully explain it or we don't have all the answers and therefore you can write things off, but actually, you know, we know that we help people, we can see it in the clinic, we can see and there may be more than one, there may be many explanations for, for how we, how we have got there, but we do get there and that, and that can be rewarding nonetheless. 

Yeah, one of my main, like I'm, as a psychiatrist, I'm very willing to critique psychiatry. One of my main criticisms of the anti psychiatry movement, especially what I see online is, a lot of them seem to ascribe to psychiatrists dislike. strong innate desire to control people and to wish bad things for them and to try and use diagnosis, medication, the mental health [00:57:00] act, and things along those lines to just put people in boxes and, and um, make them submit to their power or authority. 

And I'm not excluding that some psychiatrists are going to be bad actors. Some are not going to be, have the most psychological integrity. Some are going to be, you know, Probably operating through conscious or unconscious malevolence. That's the thing. There's enough psychiatrists in the world and I'm sure that can happen. 

But personally, my experience and my experience of my colleagues is that psychiatrists or people who just work in mental health are just trying their best to help people who are experiencing problems and they're using the knowledge and toolkits that they have, albeit with the limitations of those toolkits. 

Um, and I, my other criticism would be a lot of people who are more potently anti psychiatry often don't really have any experience of what it's like to work in an A& E at 3am and have to make really difficult decisions around people who are suffering a lot and where there's a lot of risk involved. [00:58:00] And that's a really tough job, and that's a criticism I mainly level at someone like Foucault, who talks a lot about the misuse of power, like Foucault was never in an A& E at 3am, so he has some really valid ideas, but I also think being in a position of responsibility is has a weight all of its own. 

And largely my experience is people who are in that responsibility are genuinely just trying their best to improve the quality of lives, the quality of the lives of the people they're seeing. That's my experience of like the vast, vast majority of practitioners. I'm curious to hear what your experience is, if it's similar. 

I mean, it certainly applies to me. And I, I, I, I, yes, I agree with you. I think the vast majority of practitioners I've encountered would be, would feel the same way. Um, And, you know, as you said, it's kind of like making the best with the tools that you've got. Um, and I mean, perhaps that segues into us, into thinking a little bit about, um, [00:59:00] perhaps the, one of the biggest problems to, to psychiatry, um, and to most, um, areas of medicine, you know, and beyond, um, we can't have a podcast about the kind of issues in this area without talking about funding and money. 

And so, you know, it's no, it will be no surprise to anyone that that mental health services are drastically underfunded. Um, we feel it, we feel it every day working in terms of, um, I mean, I could go, go into all kinds of different areas that I feel it, but maybe we'll just keep it general to start with. Um, it can feel really disheartening working in that environment, especially when you know there's a, you have a standard of care that you would like to be able to deliver. 

And then there's the standard of care that you can actually deliver. Um, and there's quite a big way between them sometimes. How do you cope with that kind of discrepancy? Yeah, it's a very difficult problem. [01:00:00] And I would start by saying this is like how to lobby government, how to help influence policy to create more funding is really far from my area of expertise. 

I think it's down to every practitioner, I think has some responsibility for crafting a career that can be proud of, they can be proud of. But at the same time, if you're working in the NHS. where to some degree the infrastructure you're working with is totally beyond your control. Uh, that, that's a huge problem. 

And I think if there's anyone listening to this, who's working in mental health and they feel like they have like, they're more politically inclined, they have that skill set or that interest in dealing with larger scale organizations with working on things on like a public health. level, then maybe that's the direction you should build your career in, in terms of actually, how can I [01:01:00] build a career where I do talk to government, negotiate with government, maybe on a local level, maybe on a higher level than that, because these things are really important. 

Speaking personally, I feel like my skillset lends itself more to education and educating the public. And that's why I've developed my career in the way I have and do things like podcasts. But I think if you're more inclined politically, I think that could be, I think that could and should happen. I do think some interesting things are happening. 

So I did a podcast in summer with, uh, Dr. Roberto Medzina about the Trieste model. Really interesting model of how you can treat. Mental health conditions in like a medium sized city with actually much better outcomes in terms of use of things like the Mental Health Act, uh, mandatory use of medication and things along those lines. 

And he is, as far as I'm aware, consulting for the South London [01:02:00] Trust, other trusts in the UK to actually set up pilot projects of how they can maybe mimic, uh, or take principles from the Trieste Model Act and actually apply them in the UK. So, to the extent. That those kinds of projects, uh, take off. I think that can be a really good thing and who knows what we might see, um, in the coming decades. 

I would also say a lot of this dealing with mental health problems, again, will not be about treatment at the psychiatric end. I think a lot of the reasons why mental health problems are on the rise is because of socio cultural issues. And I don't know, I, maybe we talked about this in the last podcast we did. 

Um, but things like the decline in religious institutions, the loss of meaning that a lot of people, that loss of meaning people feel in their lives day to day, uh, people are living more abstract, isolated existences, [01:03:00] loneliness, the breakdown of the family unit, lack of education about what constitutes like a good nourishing relationship with a partner, with friends, with family, with your children. 

Uh, I think all of these things are really. hugely contributing to mental health problems, even things like social media and young people. So I think if I hypothetically had some sort of position of power and authority, yes, I would be trying to allocate more funding to psychiatric care. But I would also be thinking, what can we do in terms of shifting the culture to help prevent mental health problems? 

And there's a lot that can be done. I think taking religion again, religion was a really good, One size fits all solution to a lot of problems. How do we keep the family together? How do we maintain a strong sense of morality and present prevent like a decline into decadence? [01:04:00] Uh, how do we give people a sense of meaning in their lives? 

And religion is not perfect. A lot of negative things came with religion. Um, but religion being in decline also took away a lot of elegant solutions to a lot of very important problems. We saw the ramifications of that in the 20th century with the rise of certain ideologies, and we continue to see it now. 

Uh, we have to figure out how we're going to address those problems. Uh, many people have referred, have referred to something called a meaning crisis or a spiritual blackout. And all the problems that go with that, that, and the other things we've talked about, we need to figure out how to start to shift culture, I think, in the right direction, um, because modernity and technological advances alone aren't conducive to good mental health. 

I do think we live in a kind of hyper rational society where we think [01:05:00] because we have an iPhone, we can all send emails. Now we can all use chat GPT. therefore we're these really rational beings and we don't need something like, oh, I don't know, emotional nourishment, but we really need those things. And perhaps we're more blind than we ever have been to the fact that we need those things, but the societal infrastructure isn't, is no longer very good at getting us those things. 

It used to be, I think it used to be a lot better in some respects. And now less so. So perhaps in a secular way, we need to figure out how to perhaps get some of those things back. Well, thanks Alex. It's been really interesting talking to you again. You've given me a lot of, uh, food for thought, um, and no doubt I will generate many more questions from the things we've talked about. 

Just like last time. Yeah. Thank you for coming. Thank you for the questions. I enjoyed doing the homework for this. I look forward to talking to you again and thank you very much everyone for listening.