Insane Medicine. Sami Timimi.

Timimi, Sami. Insane Medicine. Independent publication 2021. NF; 9/21.

This is a surprisingly radical but for me wise and helpful look at modern psychiatry. Dr. Timimi is a UK child psychiatrist who will definitely be seen by the psychiatry and medical establishment, especially in the United States, as something of a crank. It looks like he published the book independently, suggesting that mainstream publishers may not have been interested for that same reason. But I think we need to hear his message of the inescapable subjectivity of what we call “mental illness” and of helping people with difficulty through reinterpretation of meaning of their problems and through relationships. It isn’t a perfect academic exercise, there are lots of grammatical glitches and intemperate outbursts. But this psychiatrist’s humility and dedication to doing a better job kept making me want to stand up and cheer.

As a student of science, Timimi insists that current psychiatric diagnoses are falsely construed as objective, defined in scientific-appearing terms that are misleading and bogus. Mental illnesses today are treated with drugs and particular therapeutic strategies that far from ever being proven by legitimate study as helpful consistently are shown to prolong suffering and make patients worse. Unlike orthopedic surgery and internal medicine there are no objective tests (x-rays, blood tests, physical findings) to define schizophrenia, for example. The whole biological-illness construct of emotional and mental abnormality is, he says, not factual but a particular point of view of the meaning of suffering. It’s seen as something physically the matter in the brain that requires straightening out (mostly with medication) not – as Timimi thinks it should be – as someone’s true and personal experience.

I was struck by this explanation of why a technical biologic approach to mental illness doesn’t work:

You cannot get a proper handle on what is happening in the mind by clever neuroimaging or giving people complicated puzzles to solve. The story of ‘breaking bad’ will not reveal itself by examining the TV hardware for patterns of electric current activity

… I think partly because this was a similar (and maybe a bit clearer) way of expressing my own thoughts about metaphysical realism and the mind-body problem reading Antonio Damasio’s summary of consciousness neurology The Feeling of What Happens:

… the completed physical explanation of a pianist and the operation of his instrument is not the tears we cry, much less the feeling of what happens, when we hear the music.

Dr. Timimi is political and can’t resist diatribes on what he calls neoliberalism, which he says is “… undoubtedly … the dominant global economic and political creed”. This understandable but to me unnecessary strong sentiment wouldn’t be taking into account left-wing absurdities like prohibition of “cultural approbation” and the presumption of sexual-impropriety guilt even after legal and logical proof of innocence. But this is just my quibble, far outweighed I would say by his strong critical arguments about current practice of psychiatry.

We are helped by simple metaphors like “McDonaldization” and a Hollywood picture of psychopathology and its treatment. Our culture is portrayed as interpreting difficult human experience and emotions as resulting from bad brain chemistry that can be made good: “…there is money to be made in the infantile fantasy that we can live our lives without suffering” he says. “The problem becomes the problem” when diagnoses like Attention Deficit Hyperactivity Disorder and Autism Spectrum freeze a child’s and her parents’ understanding of irritability and family conflict as a disease to be cured. He says that he often feels that when his practice focuses in that way it is fraudulent, and he says all psychiatrists ought to be feeling that way at least some of the time.

There is a paradigm shift coming, Timimi says. We will abandon in psychiatry the absurd metaphor, borrowed from the rest of medicine, of illness and cure and start seeing ourselves as philosophical guides who help patients to understand suffering, even psychosis, as a narrative that they own and to some extent control. Improvement as it may develop with this change is the success of the patient, not of the therapist or a medication.

I’ve felt the limitation of a lot of the work I do, especially when I treat people’s emotional and relationship troubles with medication as though they were sick. Realistically, accepting as I seem to some of Dr. Timimi’s ideas, I also agree with him that there are times when drugs that have a strong effect on someone’s brain are helpful. But temporarily! There is in other words a right time to do the wrong thing as long as we appreciate the limitations of what we’re doing.

This book for me is cautionary in that if in trying to talk about polarizing issues you slip into right- or left-wing language (“McDonaldization” for example) you can be mischaracterized as a wingnut and lose a lot of potential credibility. But setting this aside I don’t think you have to be left-wing or even working in healthcare to appreciate the value of this fine statement of a long-overdue proposed rethinking of the practice of psychiatry. Somehow this book’s being at times rough around the edges only helped me see it, like minor imperfections in something made by hand, as the real deal. Highly recommended.


About John Sloan

John Sloan is a senior academic physician in the Department of Family Practice at the University of British Columbia, and has spent most of his 40 years' practice caring for the frail elderly in Vancouver. He is the author of "A Bitter Pill: How the Medical System is Failing the Elderly", published in 2009 by Greystone Books. His innovative primary care practice for the frail elderly has been adopted by Vancouver Coastal Health and is expanding. Dr. Sloan lectures throughout North America on care of the elderly.
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