Here, I’m interested in two ways of responding to worries regarding what I’ll call psychiatric over-pathologisation. By this, I mean the increasing tendency to view various ways of being as inherently pathological, in such a way that contributes to the medicalisation of normal life. I will argue that both responses to this are needed, but that one will tend to be more helpful than the other.
On the one hand are those who take what I’ll call the "anti-expansionist" approach. I refer specifically to those who focus their critique on psychiatric expansionism, which they take to occur when new diagnostic labels are developed. In practice, anti-expansionists mainly focus on criticising the validity and expansion of psychiatric classifications that come with each new edition of the DSM. This is a broad group, ranging from psychiatrists such as Allen Francis (who is in general pro-psychiatry, but against expansionism), to more vehemently anti-psychiatry critics such as the late Thomas Szasz, not to mention many other mental health professionals and service users.
I’ll call the second approach the “reclaimer” approach. This is best exemplified by neurodiversity proponents but might also be associated with the mad pride movement. Rather than trying to suppress such labels, neurodiversity advocacy has tended to embrace the reclaiming of psychiatric classifications such as autism or ADHD. In turn, much of the focus is then on using these to focus more primarily on making the world more neurodiversity friendly – broadening our conception of normality and making the world change to fit this broader conception. This draws on the social model tradition of disability rights advocacy, which identifies and challenges barriers that disable, and attitudes that stigmatise, minority groups. Unlike the anti-expansionists, this is a project wholly developed and led by neurodivergent people rather than professionals.
What causes over-pathologisation?
Both tactics just outlined are in some sense a response to the same worry, the increased medicalisation of things both anti-expansionists and reclaimers think is best understood as falling within a normal range. But each often contradicts the other in practice, and also, I would argue, reveals implicit differences in their underlying analyses of the problem.
On the one hand, I agree with the anti-expansionists that there are some proposed classifications that either have done (or will do) more harm than good. For instance, Borderline Personality Disorder is, arguably, a classification that we might have been better off without, given how stigmatised it is even by mental health professionals (although, importantly, BPD has also been reclaimed by some). Clearly too, it was catastrophically misguided to medicalise homosexuality (to use the historical term) as a mental illness. There are also legitimate worries about some classifications being co-opted by pharmaceutical companies who are interested in profit rather than patients’ best interests.
Still, in many cases, I would argue that the anti-expansionist critique is less effective when compared with reclaiming. This is because it focuses on the symptom rather than the cause, while reclaiming is more likely to deal with both.
Why? Consider that psychiatrists can, for the most part, only medicalise differences that have already implicitly been deemed pathological by the society they live in. For instance, psychiatrists only classified homosexuality as a mental disorder—and, importantly, only could have done so—because society was already deeply homophobic, and had already decided that being gay was a fundamentally bad, sick, thing. Today, if UK psychiatrists tried to re-medicalise being gay, they simply would not be able to because society would be so outraged (besides, UK psychiatrists would not want to do this today, since they are also members of our society and share its norms). It is society that mainly decides who is pathological or not, not psychiatry, as I've detailed in the case of autism, here.
In short, while it was of course vital to challenge the medicalisation of being gay, to think that the psychiatrists are the ones who pathologise relies on a fundamentally bad analysis that grants them far too much power. For the most part, they just officially medicalise ways of being that have already been pathologised (and marginalised) by society, and it is this broader societal pathologisation that is the underlying issue.
Reclamation, anti-expansionism, or both?
In so far as the above analysis is correct, I think trying to stop the expansion of psychiatric classifications mainly by criticising psychiatry itself will often not really be that helpful. This assumes that psychiatrists have a lot more power than they actually do, that they are the cause of pathologisation rather than the catalyst of pathologisation. It thus ends up focusing on the symptom more than the cause. Of course, sometimes it is necessary to focus on both, as with the medicalisation of homosexuality, where the cause was homophobia in society more broadly, and the symptom was its medicalisation. But, in many other cases, focusing on the symptom too heavily will detract from dealing with the cause, and will be less helpful.
Indeed, if the campaign to abolish any given classification was successful, in many other cases this will be harmful. If we wholly abolished or radically reduced the use of labels like "autism" and "ADHD", as many anti-expansionists argue we should, those so grouped will still be marginalised and suffering—it’s just that they won’t have any legal recognition of this, and moreover, they will likely be given more ill-fitting diagnoses just for the practical reason of helping them to access support.
By contrast, in focusing more on reclaiming classifications, the neurodiversity perspective both acknowledges the struggles of the classified group, and in turn, gives a basis for challenging the broader societal structures that led to their marginalisation and pathologisation in the first place.
I would argue that the more people support this, the more society is forced to change both its conception of what is normal, and its structures and practices to fit with this. The clearest example of this is with autism. While there is still a very long way to go, autistic self-advocacy has led to important removal of barriers, such as “autism-friendly” spaces in supermarkets or cinemas, as well as changes in how we think about schools and workplaces. These are very small steps, but ultimately the more neurodivergent friendly society is forced to become, our conception of normalcy will broaden in a meaningful way too.
In many cases, there's good reason to think that this route will be more successful in combatting the increased medicalisation of ordinary life. For the more we use reclaimed labels to force society to become neurodiversity inclusive, the less need there will be for psychiatrists to diagnose or classify new groups in the first place. At least, in so far as suffering in neurodivergent populations is caused by minority stress and marginalisation, the more we meaningfully challenge neuronormative societies, the more citizens of those societies will be able to flourish, thus preventing the need for new psychiatric classifications or diagnoses.
Here, I've argued that putting the overriding focus on anti-expansionism both misses the point and may even undermine attempts to reclaim. While it is vital to oppose psychiatric labels that are harmful, in many cases reclaiming will be a better tactic for those wanting to make meaningful structural changes that will combat the underlying causes of psychiatric expansionism, not just the symptoms. Saying this, in the long run, both anti-expansionism and reclaiming are needed, albeit in different instances. Moreover, in any given case, which route (if either) is chosen should be determined by those classified by the label, since they are the key stakeholders and experts in their own lives.