The Problem with the Neurodiversity Paradigm
The concept of neurodiversity is well-intentioned but dangerously misguided.
Posted Jul 28, 2018
Author's note: Please see my article with Ronald W. Pies, M.D., here tackling the harmful myth spread by antipsychiatry and the neurodiversity movement that mental disorders like schizophrenia, bipolar disorder, and autism are "fake diseases" or variations of normality.
It has become fashionable in recent years for some mental health professionals and social activists to assert that the problems called mental disorders are nothing more than normal variations of human cognitive experience—not illness or pathology, and not abnormal. Autism, attention-deficit/hyperactivity disorder, and even schizophrenia, it is insisted, are simply human differences that don't require treatment but rather social acceptance, tolerance, and inclusion. The concept of "neurodiversity" implies that normality and abnormality in the realm of mental functioning are not objective facts but rather invented, socially constructed categories.
It is easy to see why these claims have some appeal. There exists no objective, demonstrable biological test for mental illness and, admittedly, the progressive expansion of the psychiatric diagnostic system in recent decades has left some questioning the validity of psychiatry as a whole. These factors, coupled with the natural human inclination to avoid illness, have resulted in the growing popularity of the idea of neurodiversity.
But this attempt to reconceptualize mental illness as existing outside of the domain of medicine is nothing new. The history of psychiatry is filled with failed attempts to depathologize psychiatric illness—with harmful consequences.
While the concept of neurodiversity may have some validity for the milder psychiatric conditions, to insist that the schizophrenic patient—who may, for example, be experiencing command auditory hallucinations and having the delusional belief that an electrical device has been implanted in his brain by foreign entities to monitor his thoughts—is mentally "normal" and simply the victim of stigma and social intolerance is, to me, the height of absurdity. Those who make such claims may do so from the comfort of the ivory tower or the glorious seclusion of private practice with mildly ill patients, but such ideas become utterly unconvincing when faced with the clinical realities of the psychiatric emergency room.
Fighting the stigma associated with mental illness and the social challenges faced by those with psychiatric disease is a worthy endeavor, but it does not require the denial of the existence of these very real and abnormal problems in human mental functioning. One can simultaneously seek greater societal inclusion and acceptance of the mentally ill and accept the medical reality that the mentally ill are ill in the literal sense. See my article here on the myth of the claim that mental illness is merely a metaphor.
Try this one on for size: If classic autism, for example, is simply a normal variation of neurologic functioning, then congestive heart failure must be a normal variation of cardiac functioning—one that kills 5 million people a year. The psychiatrist Ronald Pies has perceptively noted that identification of all medical diseases—not just psychiatric disease—rests on a subjective determination about what constitutes abnormality (see Pies, 1979).
The great paradox of the neurodiversity movement is that while its stated intent is to eliminate stigma and improve the social condition of those diagnosed with mental illness, the result is likely to be just the opposite. If the problems called mental illnesses are to be celebrated as normal differences and not seen as medical disorders, then there becomes no need to invest in treatment. Inpatient hospitalizations will continue to get shorter, funding for outpatient treatment will continue to be cut, and the most seriously mentally ill will be left without adequate care. Of course, these problems existed before neurodiversity was in vogue, but they will only worsen.
To insist that mental illness—especially severe mental illness—is a normal experience to be celebrated and not treated is to do the most vulnerable in our society a grave disservice. What is needed most is not a dismissal of the reality of mental illness but rather an approach that realizes the severity of these problems and promotes the dignified and humane treatment of those so afflicted.
The author works in emergency psychiatry and maintains a private practice where he specializes in the psychotherapy of schizophrenia and severe mental illness.
Pies, R. (1979). On myths and countermyths: More on Szaszian fallacies. Archives of General Psychiatry, 36(2), 139-144.