Psychiatrization of Society: A Conceptual Framework and Call for Transdisciplinary Research

Silent reflections remain unheard

OBJECTIVE

To consider the contribution of non-clinical factors in the rising rate of mental health presentations and explore the associated silence within the psychiatric profession.

CONCLUSION

Medicalisation, concept creep and group think, alongside societal demand and expectations, have collectively contributed toward a distorted view of mental health and illness. Equitable service provision has been hindered by the silence of important perspectives.

Is the mainstream construction of mood disorders resistant to systemic thinking?

Introduction

In this study we explore how the diagnostic category of mood disorders is constructed in two handbooks of Psychopathology as an example of the mainstream construction of psychopathology. Despite the increasing criticism and lack of evidence, the debunked chemical imbalance theory of the etiology of depression still dominates the professional and pop/folk understanding and interventions.

Methods

We analysed the breadth of the inference field and the type of etiopathogenetic contents of the explanations of mood disorders using the "1to3" Coding System.

Results

Our findings show that the dominant explanations draw almost exclusively onto monadic explanations, followed by limited dyadic ones. Intrapersonal etiopathogenetic contents prevailed, and biomedical explanations were dominant in both textbooks.

Discussion

We critically discuss the underpinnings of these results and address the clinical implications of these biased representations, as well as potential alternative approaches to psychopathology.

Feasibility and Efficacy of Intensive Dialectical Behavior Therapy Skills Training in An Outpatient Setting for A Group of Patients with Extensive Care Needs - A Transdiagnostic Approach

PURPOSE

Dialectical behavior therapy (DBT) is a treatment originally developed för chronically suicidal adults. It is common to adapt it by using one specific component, the DBT skills training (DBT-ST) and apply it in a group therapy setting for a variety of mental disorders. The primary aim of the study was to explore whether patients with extended care needs would report improved mental health after participating in an intensive form of DBT-ST. The secondary aim was to explore whether the use of psychiatric inpatient care for the group would decrease.

METHODS

Thirty-seven participants completed the Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM), and visual analogue scale (VAS) at three time points: pre-intervention, post-intervention and at 6-month follow-up after intensive DBT-ST.

RESULTS

One-way ANOVA showed a significant effect for time on the CORE-OM: F (2,35) = 7.93, p = .001, η2 = 0.312 (large effect size). Post hoc tests indicated a significant difference between pre-intervention and post-intervention (p = .001) and between pre-intervention and follow-up (p = .01). A Friedman test indicated a statistically significant difference in the VAS scale scores across the three time points, with p-values between 0.00 and 0.05. There was no difference in psychiatric healthcare consumption.

CONCLUSION

These study results confirm to some extent the feasibility and effectiveness of the intensive DBT-ST in a transdiagnostic clinical setting. The participants had a positive outcome from the skills training program, but psychiatric healthcare consumption did not decrease.

Socioeconomic disparities in attention deficit hyperactivity disorder (ADHD) in Sweden: An intersectional ecological niches analysis of individual heterogeneity and discriminatory accuracy (IEN-AIHDA)

We aimed (i) to gain a better understanding of the demographic and socioeconomical distribution of ADHD risk in Sweden; and (ii) to contribute to the critical discussion on medicalization, i.e., the tendency to define and treat behavioural and social problems as medical entities. For this purpose, we analysed the risk of suffering from ADHD in the whole Swedish population aged between 5 and 60 years, across 96 different strata defined by combining categories of gender, age, income, and country of birth. The stratified analysis evidenced considerable risk heterogeneity, with prevalence values ranging from 0.03% in high income immigrant women aged 50-59, to 6.18% in middle income immigrant boys aged 10-14. Our study questions the established idea that behavioural difficulties conceptualized as ADHD should be primarily perceived as a neurological abnormality. Rather, our findings suggest that there is a strong sociological component behind how some individuals become impaired and subject to medicalization.

Individual differences in the expansiveness of mental disorder concepts: development and validation of concept breadth scales

BACKGROUND

What people consider to be a mental disorder is likely to influence how they perceive others who are experiencing problems and whether they seek help for their own problems. However, no measure is available to assess individual differences in the expansiveness or breadth of concepts of mental disorder. Four studies aimed to develop and validate two such measures. The Concept Breadth-Vertical (CB-V) scale assesses variability in the severity threshold at which unusual behavior or experience is judged to reflect disorder, whereas the Concept Breadth-Horizontal (CB-H) scale assesses variability in the range of phenomena judged to be disorders.

METHODS

In a pilot study (N = 201) for the CB-V, participants read vignettes of varying severity for each of the 10 mental disorders, and rated whether the subject had a disorder. Study 1 (N = 502) used exploratory factor analyses to examine 10 CB-V items from the pilot study and 20 vignette-based items for constructing the CB-H. Study 2 (N = 298) employed confirmatory factor analysis to validate the scales' structure and examined their convergent validity with a measure of harm concept breadth and their discriminant validity with measures of mental health literacy. Study 3 (N = 298) explored associations of the scales with other mental health variables, including stigma and help-seeking attitudes.

RESULTS

Study 1 supported the unifactorial structure of each item set, refined each set into a scale, and demonstrated acceptable reliabilities. Study 2 provided support for the scales' convergent and discriminant validities. Study 3 showed that the scales were associated negatively with stigma, and positively with help-seeking attitudes and self-reported mental health problems. Studies 2 and 3 further indicated that younger and more politically liberal participants hold broader concepts of mental disorder.

CONCLUSIONS

The new concept breadth scales are psychometrically sound measures of a promising new concept in the study of beliefs and attitudes about mental health. Potential future research directions are discussed.

Have the concepts of 'anxiety' and 'depression' been normalized or pathologized? A corpus study of historical semantic change

Research on concept creep indicates that the meanings of some psychological concepts have broadened in recent decades. Some mental health-related concepts such as 'trauma', for example, have acquired more expansive meanings and come to refer to a wider range of events and experiences. 'Anxiety' and 'depression' may have undergone similar semantic inflation, driven by rising public attention and awareness. Critics have argued that everyday emotional experiences are increasingly pathologized, so that 'depression' and 'anxiety' have broadened to include sub-clinical experiences of sadness and worry. The possibility that these concepts have expanded to include less severe phenomena (vertical concept creep) was tested by examining changes in the emotional intensity of words in their vicinity (collocates) using two large historical text corpora, one academic and one general. The academic corpus contained >133 million words from psychology article abstracts published 1970-2018, and the general corpus (>500 million words) consisted of diverse text sources from the USA for the same period. We hypothesized that collocates of 'anxiety' and 'depression' would decline in average emotional severity over the study period. Contrary to prediction, the average severity of collocates for both words increased in both corpora, possibly due to growing clinical framing of the two concepts. The study findings therefore do not support a historical decline in the severity of 'anxiety' and 'depression' but do provide evidence for a rise in their pathologization.

What is a mental disorder? Evaluating the lay concept of Mental Ill Health in the United States

PURPOSE

How "mental disorder" should be defined has been the focus of extensive theoretical and philosophical debate, but how the concept is understood by laypeople has received much less attention. The study aimed to examine the content (distinctive features and inclusiveness) of these concepts, their degree of correspondence to the DSM-5 definition, and whether alternative concept labels ("mental disorder", "mental illness", "mental health problem", "psychological issue") have similar or different meanings.

METHODS

We investigated concepts of mental disorder in a nationally representative sample of 600 U.S. residents. Subsets of participants made judgments about vignettes describing people with 37 DSM-5 disorders and 24 non-DSM phenomena including neurological conditions, character flaws, bad habits, and culture-specific syndromes.

RESULTS

Findings indicated that concepts of mental disorder were primarily based on judgments that a condition is associated with emotional distress and impairment, and that it is rare and aberrant. Disorder judgments were only weakly associated with the DSM-5: many DSM-5 conditions were not judged to be disorders and many non-DSM conditions were so judged. "Mental disorder", "mental illness", and "mental health problem" were effectively identical in meaning, but "psychological issue" was somewhat more inclusive, capturing a broader range of conditions.

CONCLUSION

These findings clarify important issues surrounding how laypeople conceptualize mental disorder. Our findings point to some significant points of disagreement between professional and public understandings of disorder, while also establishing that laypeople's concepts of mental disorder are systematic and structured.

Trends in sales of antidepressants in Brazil from 2014 to 2020: A time trend analysis with joinpoint regression

BACKGROUND

This study aimed to investigate the trends in antidepressants sales in Brazil.

METHODS

We performed a joinpoint analysis of antidepressants sales in Brazil from 2014 to 2020, recorded in the Brazilian National Controlled Products Management System. The primary outcomes were the defined daily dose per 1000 inhabitants per day (DID) and the market shares for each antidepressant per year. We used joinpoint regression to assess the changes in antidepressant consumption in DID to obtain the average annual percent change (AAPC) and 95 % confidence intervals (95 % CI). Changes in market shares were tested by chi-square trend test (p < 0.05 as significant).

RESULTS

From 2014 to 2020, 42,252,989 antidepressant sales were recorded in the system. Antidepressant sales increased from 13.7 to 33.6 DID in the period (AAPC: 15.7; 95 % CI: 13.0-18.4; p < 0.001); the largest increases were observed for serotonin reuptake inhibitors and 'other' antidepressants (including serotonin-norepinephrine reuptake inhibitors), whereas tricyclics remained steady. Escitalopram and sertraline were the most sold drugs. Market share of serotonin reuptake inhibitors decreased, particularly for paroxetine (13.1 % to 6.5 %; p = 0.016), while 'other' antidepressants' market share expanded from 21.9 % to 33.3 % (p = 0.027), especially for desvenlafaxine (2.9 % to 14.3 %; p < 0.001).

LIMITATIONS

The dataset does not include antidepressants dispensed in hospitals, public services, and compounding pharmacies, neither their therapeutic indications.

CONCLUSION

Sales of antidepressants significantly increased in Brazil from 2014 to 2020, which were mainly driven by higher prescriptions of serotonin reuptake inhibitors and 'other' antidepressants classes. Market share changes seem to be driven by novelty of products.

Introducing Peer-supported Open Dialogue in changing mental health care

The need to transform mental health care toward person-centered, recovery-based, and network-oriented care is recognized worldwide. Open Dialogue (OD) is seen as a hopeful approach in the context of this transformation and is introduced in countries around the globe. Five Dutch mental health care organizations spread over the Netherlands introduced the Peer-supported Open Dialogue (POD) approach, which adds an explicit role of peer-support workers to the OD approach. It appeared that (P)OD-trained professionals face issues in introducing the (P)OD approach in existing MHC settings. One of the reasons, which is the focus of this study, may be that they encounter difficulties in explaining to non-(P)OD-trained professionals what (P)OD entails. The main objective of this study is to provide guidance to and contribute to making (P)OD better understandable for non-(P)OD-trained professionals. In this study, we used a qualitative design and conducted 23 semi-structured interviews with POD-trained professionals with various backgrounds, to cultivate a rich understanding of which aspects could contribute to a better understanding of POD for non-POD-trained professionals. We used a hybrid approach to analyze the data, meaning that the technique of both inductive and deductive thematic analyses has been applied. From these analyses, six aspects emerged that could give guidance to and contribute to making (P)OD more understandable for non-(P)OD-trained professionals: (1) Experiencing (P)OD by attending treatment network sessions, (2) a coherent and profound narrative about (P)OD, (3) adjusting terminology to better fit the context, such as the two terms "principles" and "responsibility" in this study, (4) the order in which (P)OD elements are introduced in the narrative, (5) bringing the elements "presence," "reflecting," and "expertise by experience" more to the foreground, and (6) conceptualizing the main elements in a "talking paper." A better understanding of (P)OD might be one of the building blocks for improving (P)OD adoption in existing MHC practices, which are on their way toward person-centered, recovery-based, and network-oriented care.

Global Mental Health in South Lebanon: Psychoeducation, Translation, and Culture

In this article I examine the unintended consequences of global mental health reform in postwar South Lebanon. I follow the integration of mental health in primary health care centers. Three key tensions emerge: First, integrating mental health led to separating mental health from socioeconomic conditions. Second, culture was simultaneously conceived as a barrier to therapy and a local context requiring adaptation. Third, the use of personality disorders as psychological interpretations of social life resulted in psychologizing gender and class. The article contributes to growing ethnographic research on global mental health and calls for attention to structural competence in similar settings.SECOND LANGUAGE ABSTRACTفي هذا المقال، أستكشف العواقب غير المقصودة لإصلاحات الصحة النفسية العالمية في جنوب لبنان بعد الحرب. أتابع دمج الصحة النفسية في مراكز الرعاية الصحية الأولية. تظهر هنا ثلاث معضلات رئيسية: أولاً ، أدّى دمج الصحة النفسية إلى فصلها عن الظروف الاجتماعية والاقتصادية المحيطة بها. ثانيًا، تم تصوير مفهوم الثقافة كحاجز أمام العلاج النفسي من جهة وكسياق محلي يتطلب تكيفا وترجمة. ثالثًا، أدى استخدام تشخيصات اضطرابات الشخصية كتفسيرات نفسية للحياة الاجتماعية إلى نفسنة الجنس والطبقة. يساهم المقال الى البحوث الإثنوغرافية المتنامية حول الصحة النفسية العالمية ويدعو إلى الاهتمام بالكفاءة الهيكلية للصحة النفسية في بيئات مماثلة                        .

ADHD and reification: Four ways a psychiatric construct is portrayed as a disease

Introduction

The descriptive classification Attention-Deficit/Hyperactivity Disorder (ADHD) is often mistaken for a disease entity that explains the causes of inattentive and hyperactive behaviors, rather than merely describing the existence of such behaviors. The present study examines discourse on ADHD to analyze how authors passively and actively contribute to reification-a fallacy in which a concept is represented as a thing existing on its own.

Methods

Critical Discourse Analysis and Qualitative Content Analysis of academic textbooks, scientific articles, websites and videos were used to analyze how ADHD is reified.

Results

The analyses reveal four ways in which inattentive and restless behaviors are presented as an entity by means of the ADHD classification: language choice, logical fallacies, genetic reductionism, and textual silence. First, language choice, such as medical jargon and metaphors aid in representing ADHD as a disease entity. Second, several logical fallacies do the same, including the relatively unknown "ecological fallacy" that refers to the erroneous belief that average group findings, such as average brain size of groups of those with an ADHD classification, can be applied on an individual level. Third, genetic reductionism is often achieved by overstating the results of twin studies and being silent about the disappointing molecular genetic research. Such textual silence is the last identified mechanism of reification and includes instances in which societal factors that affect the ADHD construct are often omitted from texts, thereby obscuring the extent to which ADHD is a limited heuristic.

Discussion

It is essential that discourse communities do not repeat these four ways of reifying behavior and social relations into an alleged entity with the acronym ADHD. The errors and habits of writing may be epistemologically violent by influencing how laypeople and professionals see children and ultimately how children may come to see themselves in a negative way. Beyond that, if the institutional world shaped to help children is based on misguided assumptions, it may cause them harm and help perpetuate the misguided narrative. To counter the dominant, reifying and medicalizing view, guidelines such as the recently published "Dutch ADHD Psychoeducation Guidelines" might be helpful.

Psychiatrization in mental health care: The emergency department

BACKGROUND

In the light of high incidences of diagnosed mental disorders and the growing utilization of mental healthcare services, a progressing psychiatrization of society has been hypothesized as the underlying dynamic of these developments. Mental healthcare institutions, such as psychiatric hospitals, may play a decisive role in this. However, there is a scarcity of research into how psychiatrization emerges in hospital settings. This paper explores whether the emergency department (ED) can be considered as a site where psychiatrization happens, becomes observable, and which factors in the context of the ED may be its potential drivers.

METHODS

Two cases as encountered in an interdisciplinary ED will be presented in the following in an anonymized way. Although the cases originate from individual consultations, they can be considered as prototypical. The cases were collected and discussed using the method of interactive interviewing. The results will be analyzed against the backdrop of current theoretic concepts of psychiatrization.

FINDINGS

The ED can be seen as an important area of contact between society and psychiatry. Decisions whether to label a certain condition as a "mental disorder" and to therefore initiate psychiatric treatment, or not, can be highly difficult, especially in cases where the (health) concerns are rather moderate, and clearly associated with common life problems. Psychiatrists' decisions may be largely influenced in favor of psychiatrization by a wide array of disciplinary, institutional, interpersonal, personal, cultural, and social factors.

CONCLUSIONS

The ED appears to be a promising field for research into the mechanisms and motives through which psychiatrization may emerge in mental healthcare settings. Psychiatrists in the ED work within a complex sphere of top-down and bottom-up drivers of psychiatrization. Encounters in the ED can be an important step toward adequate support for many individuals, but they also risk becoming the starting point of psychiatrization by interpreting certain problems through the psychiatric gaze, which may induce diagnoses of questionable validity and treatment of little use.

Psychiatrization of adoption practices in contemporary Poland

In this article, I propose to take a closer look at the practices of kinning in the context of adoption in contemporary Poland. I am interested in the social production of this 'unfamiliar kind of kinship' and the positions of various actors involved in defining the "adoptable" children and the "families of excess" capable of adopting. My focus will be on the ways in which the psy-knowledge and practices are implied in these social processes of defining and delimiting the norm, the proper, and the ideal. This process can be called a progressing psychiatrization of kinning, this time developing on a specific terrain of adoption (i.e., the most desired state of exception from ideal family-nuclear, heteronormative, based around married, and non-divorced couple). I will consider both top-down and bottom-up processes within which the individuals, state institutions, and psy-knowledge interact. Thus, I propose to look at a sub-process of psychiatrization, which takes place in the specific ethnographic context at the intersection of family and social policies, medicalization and psychologization of familial relations, and troubled, disconnected biographies. Throughout the article, I discuss how the adoptive families become patient-consumers within the system of healthcare. It is despite the fact that when they enter the adoption network, they start to take part in the political process of solving the social problem. In fact, they become a part of the network, which enables privatization of the social problem and works toward individualizing the responsibility for solving it.

Using Crisis Theory in Dealing With Severe Mental Illness-A Step Toward Normalization?

The perception of mental distress varies with time and culture, e.g., concerning its origin as either social or medical. This may be one reason for the moderate reliability of descriptive psychiatric diagnoses. Additionally, the mechanisms of action of most psychiatric treatments and psychotherapeutic interventions are generally unknown. Thus, these treatments have to be labeled as mostly unspecific even if they help in coping with mental distress. The psychiatric concept of mental disorders therefore has inherent limitations of precision and comprises rather fuzzy boundaries. Against this background, many people question the current process of diagnosing and categorizing mental illnesses. However, many scholars reject new approaches discussed in this context. They rather hold on to traditional diagnostic categories which therefore still play a central role in mental health practice and research and. In order to better understand the adherence to traditional psychiatric concepts, we take a closer look at one of the most widely adopted traditional concepts - the Stress-Vulnerability Model. This model has originally been introduced to tackle some problems of biological psychiatry. However, it has been misapplied with the result of drawing attention preferentially to biological vulnerability instead of a wider array of vulnerability factors including social adversity. Thus, in its current use, the Stress-Vulnerability Model provides only a vague theory for understanding mental phenomena. Therefore, we discuss the advantages and allegedly limited applicability of Crisis Theory as an alternative heuristic model for understanding the nature and development of mental distress. We outline the problems of this theory especially in applying it to severe mental disorders. We finally argue that an understanding of Crisis Theory supported by a systemic approach can be applied to most types of severe psychological disturbances implying that such an understanding may prevent or manage some negative aspects of the psychiatrization of psychosocial problems.

The (Un)real Existence of ADHD-Criteria, Functions, and Forms of the Diagnostic Entity

The contemporary conceptualization of Attention Deficit Hyperactivity Disorder (ADHD) as a complex, multifactorial neurodevelopmental disorder cannot be understood as such without a complex assemblage of political, economic, and cultural processes that deem the conceptualization to be valuable and useful. In this article we use the notion of psychiatrization as a lens through which to see parts of these processes that make up ADHD what it is. In the first part of the article, we critically assess the scientific basis of the ADHD diagnosis via examining its diagnostic criteria as presented in the current fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM), the so called "Bible" of modern psychiatry. The second part of the article asks what is done with the ADHD diagnostic entity and with the idea that it represents a natural neurodevelopmental state within an individual-something an individual has-as represented in the DSM-5. Drawn from our previous research, we analyze how ADHD becomes real in discourse practice as a powerful semiotic mediator through analysis of the various functions and forms in which it takes shape in institutional, social, and individual levels. We conclude that the frequent changes in the diagnostic criteria of ADHD do not reflect any real scientific progress. Among other reasons, they change to match better the maneuvers of individuals when navigating an increasingly psychiatrized society in the search for recognition, support, category membership, immunity, sympathy, and sense of belonging.

The Lost Social Context of Recovery Psychiatrization of a Social Process

From being a concept questioning the core of psychiatric knowledge and practice, recovery has been adopted as a guiding vison for mental health policy and practice by different local, national, and international organizations. The aim of this article is to contextualize the different understandings of recovery and its psychiatrization through the emergence of an individualizing and de-contextualized definition which have gained a dominant position. It ends with an attempt to formulate a new definition of recovery which integrates people in their social context. Research results from various follow-up studies showing the possibility of recovery from severe mental distress have stressed the importance of societal, social and relational factors as well of the person's own agency when facing their distress and reactions from their environment. These researches were published in the 1970s and 80s; a period of struggle for liberation from colonialism, of struggle by women and black people for their civil rights, and a time of de-institutionalization of services directed toward the poor, elderly, handicapped, prisoners, and people with mental health problems. Recovery research pointed at the central role of individuals in their recovery journey and it was understood as a personal process in a social context. However, with neo-liberal political agenda, the personal role of individuals and their own responsibility for their well-being was stressed, and contextual understandings and the role of social, material and cultural changes to promote recovery faded away. Thus, during recent decades recovery has been mostly defined as an individualistic journey of changing the persons and their perception of their situation, but not of changing this situation. Contextual aspects are almost absent. The most quoted definition accepts the limits posed by an illness-based model. This kind of definition might be a reason for the wide acceptance of a phenomenon that was initially experienced as a break with the bio-medical paradigm. Recently, this dominant individualized understanding of recovery has been criticized by service users, clinicians and researchers, making possible a redefinition of recovery as a social process in material and cultural contexts.

Psychiatrization of Resistance: The Co-option of Consumer, Survivor, and Ex-patient Movements in the Global South

This article examines contemporary examples of psychiatrization as a tool of disciplinary control and repression, focusing on new research on the co-option of consumer/survivor/ex-patient movements within the Global South. Here, we understand psychiatrization as (1) the process of imposing certain interpretive limits on states of difference and distress and (2) the conceptualization of treatment and recovery through the teleological notion of normalcy. By interpreting difference solely in psychiatric terms, psychiatrization functions as a tool of disciplinary control in both domestic and international contexts by reterritorializing efforts to resist hegemonic norms and political institutions of gendered and racialized oppression, colonialism, and imperialism. After setting out our understanding of psychiatrization as a political process in the sense that it enacts a particular "ontological politics", one that foregrounds psychiatric interpretations of difference and dissent to the exclusion of other possible meanings, we examine the reach and complexity of psychiatrization in the suppression of political and social movements that attempt to resist oppressive norms and institutions. We then present new research within the consumer/survivor/ex-patient and psychosocial disability movements in the Global South to show how psychiatrization can thwart activist's aims of transforming how we view both the end goals of mental health treatment and the political valence of mental distress.

Sick or Sad? A Qualitative Study on How Dutch GPs Deal With Sadness Complaints Among Young Adults

Feelings of sadness among young adults related to a certain phase of life or to societal factors run the risk of being interpreted as an individual medical problem. Therefore, healthcare professionals should more often widen their perspective and consider de-medicalization as being part of their professional responsibility too. This article presents results from a qualitative interview conducted with 13 GPs in different phases of their career to get more insight into the way they deal with complaints of sadness among young adults. All participants acted proactively but in different ways. Based on the interviews, a typology of three types of general practitioners has been created: the fast referrer, the expert, and the societal GP. There seems to be a paradox in the way GPs think about de-medicalization on a macro level and the way they act on a micro level. Elaborating on Parsons'(1951) classical concept of the sick role, this study introduces the term semi-legitimized sick role to clarify this paradox. The third type, "the societal GP", appears to be the most able to show a more multifactorial view on complaints of sadness. Therefore, this type connects the most to a course of de-medicalization.

The Political Economy of the Mental Health System: A Marxist Analysis

The present paper analyses the functions of the mental health system in relation to the economic organisation of society, using concepts derived from Marx's work on political economy and building on previous critiques. The analysis starts from the position that mental health problems are not equivalent to physical, medical conditions and are more fruitfully viewed as problems of communities or societies. Using the example of the United Kingdom, it traces how a public mental health system evolved alongside capitalism in order to manage the problems posed by people whose behaviour was too chaotic, disruptive or inefficient to participate in a labour market based on exploitation. The system provided a mixture of care and control, and under recent, Neoliberal regimes, these functions have been increasingly transferred to the private sector and provided in a capitalistic manner. Welfare payments are also part of the system and support those less seriously affected but unable to work productively enough to generate surplus value and profit. The increased intensity and precarity of work under Neoliberalism has driven up benefit claims at the same time as the Neoliberal state is trying to reduce them. These social responses are legitimised by the idea that mental disorders are medical conditions, and this idea also has a hegemonic function by construing the adverse consequences of social and economic structures as individual problems, an approach that has been particularly important during the rise of Neoliberalism. The concept of mental illness has a strategic role in modern societies, therefore, enabling certain contentious social activities by obscuring their political nature, and diverting attention from the failings of the underlying economic system. The analysis suggests the medical view is driven by political imperatives rather than science and reveals the need for a system that is more transparent and democratic. While the mental health system has some consistent functions across all modern societies, this account highlights one of the endemic contradictions of the capitalist system in the way that it marginalises large groups of people by narrowing the opportunities to make an economic contribution to society.

Why mental disorders are brain disorders. And why they are not: ADHD and the challenges of heterogeneity and reification

Scientific attempts to identify biomarkers to reliably diagnose mental disorders have thus far been unsuccessful. This has inspired the Research Domain Criteria (RDoC) approach which decomposes mental disorders into behavioral, emotional, and cognitive domains. This perspective article argues that the search for biomarkers in psychiatry presupposes that the present mental health categories reflect certain (neuro-) biological features, that is, that these categories are reified as biological states or processes. I present two arguments to show that this assumption is very unlikely: First, the heterogeneity (both within and between subjects) of mental disorders is grossly underestimated, which is particularly salient for an example like Attention Deficit/Hyperactivity Disorder (ADHD). Second, even the search for the biological basis of psychologically more basic categories (cognitive and emotional processes) than the symptom descriptions commonly used in mental disorder classifications has thus far been inconclusive. While philosophers have discussed this as the problem of mind-body-reductionism for ages, Turkheimer presented a theoretical framework comparing weak and strong biologism which is more useful for empirical research. This perspective article concludes that mental disorders are brain disorders in the sense of weak, but not strong biologism. This has important implications for psychiatric research: The search for reliable biomarkers for mental disorder categories we know is unlikely to ever be successful. This implies that biology is not the suitable taxonomic basis for psychiatry, but also psychology at large.

Not in Their Right Mind? Right-Wing Extremism Is Not a Mental Illness, but Still a Challenge for Psychiatry

Most research in psychiatry on extremism focuses on the question whether there is a connection between extremism and psychiatric diagnoses. In addition, practitioners are increasingly asked to take part in programs aimed at preventing and countering violent extremism by assessing risk for radicalization. However, an issue that remains largely unaddressed is that the rise of the far right in many countries during the last years poses a challenge for psychiatric services as working with right-wing patients can be a source of conflict for practitioners and patients alike. In this article, we assert that the narrow conceptual scope on psychological vulnerabilities and the practical focus on risk assessment contribute to processes of psychiatrization and limit the scope of research on right-wing extremism in psychiatry. By giving a brief overview of social research into right-wing extremism, the article argues that right wing beliefs should not be conceptualized as an expression of psychological vulnerabilities but rather as attempts to deal with conflict-laden social reality. Thus, a shift of perspective in psychiatric research on extremism is needed. On a conceptional level, the scope needs to be broadened to grasp the interplay of individual and social factors in radicalization with sufficient complexity. On a practical level, it is necessary to further investigate challenges for practitioners and institutions working with right-wing extremist patients.

Dialogue as a Response to the Psychiatrization of Society? Potentials of the Open Dialogue Approach

In recent decades, the use of psychosocial and psychiatric care systems has increased worldwide. A recent article proposed the concept of psychiatrization as an explanatory framework, describing multiple processes responsible for the spread of psychiatric concepts and forms of treatment. This article aims to explore the potentials of the Open Dialogue (OD) approach for engaging in less psychiatrizing forms of psychosocial support. While OD may not be an all-encompassing solution to de-psychiatrization, this paper refers to previous research showing that OD has the potential to 1) limit the use of neuroleptics, 2), reduce the incidences of mental health problems and 3) decrease the use of psychiatric services. It substantiates these potentials to de-psychiatrize psychosocial support by exploring the OD's internal logic, its use of language, its processes of meaning-making, its notion of professionalism, its promotion of dialogue and how OD is set up structurally. The conclusion touches upon the dangers of co-optation, formalization and universalization of the OD approach and stresses the need for more societal, layperson competencies in dealing with psychosocial crises.

Concept Creep and Psychiatrization

Some aspects of psychiatrization can be understood as forms of concept creep, the progressive expansion of concepts of harm. This article compares the two concepts and explores how concept creep sheds light on psychiatrization. We argue that although psychiatrization is in some respects a broader concept than concept creep, addressing institutional and societal dimensions of the expanding reach of psychiatry in addition to conceptual change, concept creep is broader in other respects, viewing the expansion of psychiatric concepts as examples of the broadening of a more extensive range of harm-related concepts. A concept creep perspective on psychiatrization clarifies the different forms of expansion it involves, the centrality of harm to it, its benefits as well as its costs, its variations across individuals and groups, and the drivers of psychiatrization in the general public and in fields beyond psychiatry.

Designed to Clash? Reflecting on the Practical, Personal, and Structural Challenges of Collaborative Research in Psychiatry

Background: In the field of mental health research, collaborative and participatory approaches in which mental health service users actively contribute to academic knowledge production are gaining momentum. However, concrete examples in scientific literature that would detail how collaborative research projects are actually organized, and how they deal with the inherent challenges are rare. This paper provides an in-depth description of a three-year collaborative project that took place in the wider context of a mixed-method process evaluation of innovative models of psychiatric care in Germany. Methods: The in-depth description we provide here draws on a vast body of notes and records that originated from numerous meetings and sessions. The research group continuously and systematically reflected on their collaboration itself using the interpretative method of "interactive interviewing," which included that also the personal memories of the researchers were collectively re-discussed before and during the process of writing. Our concrete experiences as a group were then contextualized with and analyzed in the light of more general challenges that are central to collaborative research in general. Results: Performing collaborative research requires unconventional thinking and improvisation in order to find creative solutions for practical problems and to overcome the structural obstacles inherent to the process of academic knowledge production. An atmosphere of mutual trust and respect within the group is crucial, and continuous self-reflection or supervision can be largely beneficial. Challenges mainly originate from the vast heterogeneity that characterizes the researchers, usually including large differences in economic, cultural, and social capital. Conclusion: Collaborative research in the field of psychiatry is designed to bring together researchers with widely diverse backgrounds. Emerging conflicts are important parts of knowledge production but also exceptional opportunities to negotiate research ethics, and potential vehicles for personal growth and transformation. Success or failure of collaborative research largely depends on how divergences and conflicts are articulated, mediated, and reflected. This also holds true in the light of the power asymmetries within the research team and the structural power inherent to the engines of academic knowledge production.