May 18, 2024 (Updated on May 24, 2024)

A few years ago, I got into an online debate with someone who claimed that neurodiversity only included people with neurodevelopmental and learning disabilities like Autism, ADHD, and Dyslexia. In fact, this is the most popular usage of the term, but it’s incorrect. As Nick Walker, the scholar who formulated the neurodiversity paradigm, writes, “the prefix neuro doesn’t mean brain, it means nerve. The neuro in neurodiversity is most usefully understood as a convenient shorthand for the functionality of the whole bodymind and the way the nervous system weaves together cognition and embodiment. So neurodiversity refers to the diversity among minds, or among bodyminds.”

My interlocuter further argued that “mental illness is due to a chemical imbalance in the brain, and is therefore not a neurotype.” Whether mental illness can be considered a neurotype is a little more complicated, and I will discuss that later in this essay, but there is weak to no empirical support for the claim that mental illness is caused by a chemical imbalance. For example, a recent, comprehensive analysis by Moncrieff et al. has debunked the long-touted link between serotonin and depression.

I should clarify, however, that the idea that mental illness could be caused by a chemical imbalance would not in itself be a disqualifying factor for a psychiatric diagnosis being considered a type of neurodivergence. The idea that someone can be helped by medication neither implies that their condition is not an inherent part of their cognition nor that they are inherently “disordered.” If either was the case, then ADHD would also not qualify as being a part of neurodiversity.

Increasingly, people identify with their psychiatric diagnoses, as reported by the anthropologist, Manvir Singh, in a recent article in The New Yorker, and mental illness is often viewed as a lifelong condition, despite that there are no known biomarkers for any diagnosis. In 2009, in an essay for Psychiatric Times, the head of the DSM-IV Task Force, Allen Frances, wrote that “The incredible recent advances in neuroscience, molecular biology, and brain imaging that have taught us so much about normal brain functioning are still not relevant to the clinical practicalities of everyday psychiatric diagnosis. The clearest evidence supporting this disappointing fact is that not even 1 biological test is ready for inclusion in the criteria sets for DSM-V.” Recent reviews have found systemic flaws in previous research studies searching for biomarkers, and still no promising biomarkers for ADHD or psychosis have been identified. The upshot of all this is that a psychiatric diagnosis is not what should properly be considered a medical diagnosis, and so people self-identifying is just as legitimate as being diagnosed by an “expert.” (At a minimum, psychiatric diagnosis should be a process of dialogue and consent between doctor and client.)

In my case, although I have experienced periods of depression throughout my life, I identify as being disabled rather than mentally ill, because while the periods of illness are transient, existing in a society that relegates my needs and values to the margins is also chronically disabling. It shouldn’t be surprising that when one’s existence is fundamentally incompatible with the built society they live in, it can make people prone to depression and trauma, which is why autism has sometimes been called “wrong planet syndrome.” Similarly, although I have chronic anxiety, I consider my anxiety less a symptom of autism and more a consequence of the racism and ableism I experience. As Nick Walker writes, “where researchers working within the pathology paradigm would likely have framed social anxiety as a ‘symptom of autism’ or a ‘comorbid condition’ (thus implicitly framing autism as a pathology)… we recognized social anxiety as a symptom of the extensive social trauma that neurotypical society inflicts upon autistics from early childhood onward—in other words, we acknowledged that the social anxiety we sought to treat was a symptom of oppression.”

The biopsychosocial model

Much like the neurodiversity paradigm is complementary to the social model of disability, the biopsychosocial model of mental illness – which considers the influences of social, political, economic, and environmental factors in the presentation of mental illness – is analogous to the social model of disability although the models have distinct implications. In 2022, the Yale scholar and psychiatrist, Marco Ramos, cogently laid out the arguments for the biopsychosocial model of mental illness in an article titled, “Mental Illness Is Not in Your Head.”

While the biopsychosocial model raises important questions about the etiology and typology of mental illness, however, the social model of disability is less concerned about the nature of impairment than how society can accommodate and include disabled people to limit the impacts of impairment. But, as Karen Nakamura, an anthropologist at UC Berkeley, observes, the biopsychosocial model similarly “opens up the possibility for societies to change in ways that can accommodate or include more people with psychiatric disabilities while denying neither the underlying biomedical aspects of mental illness nor the socially constructed and culturally mediated aspects of psychiatry.”

While the biopsychosocial model resonates with me personally, especially as someone who has experienced mental illness but does not identify as mentally ill, I also acknowledge that for others, mental illness may be better understood as stemming from genetics and being either a chronic condition or permanent facet of their identities. For example, in Disability of the Soul, Nakamura describes a case of three siblings who all presented with psychotic symptoms that were found to be caused by malformed red blood cells and abnormal levels of creatine phosphokinase (CPK), a genetic condition called acanthocytosis.

The important overlap between the biopsychosocial model and the social model of disability is most evident in their antitheses, which are the biological (or biomedical) model of mental illness (aka the biological paradigm) and the medical model of disability, respectively. The biological model views mental illness as originating from neurological or genetic substrates, and because of this emphasis on pathophysiology, the disabled individual is often not considered the authoritative voice on their diagnoses and how to direct their treatment. It bears repeating that the biological paradigm, specifically as delineated in the DSM, has become the dominant approach to psychopathology in the 21st century despite lack of evidence supporting its usefulness.

Both the biological paradigm and the medical model of disability emphasize cure or treatment, and often center the voices of medical professionals in these matters over the voice of the disabled individual. One of the most poignant stories about the harms of the medical model of disability was shared by the late Stacey Milbern, who talked about how her doctors insisted that she have neck-straightening surgery as a child, not because it would necessarily improve her quality of life, but because it might make the people in society more “tolerant” of her existence. Often, medical experts will support interventions that either harm disabled people by trying to eradicate or cure our disability or are in service of an agenda of forcing disabled people to accommodate nondisabled and neurotypical society, not the other way around.

In the biological paradigm, the authoritative voice is similarly shifted to the psychiatrist and other mental health professionals, and the source of their expertise is predicated entirely on the supposition that patients with “broken minds” are unable to advocate for themselves and direct their treatment. Anosognosia, a controversial psychiatric diagnosis, presupposes that because mental illness is caused by damaged brain function or structure, people with mental illness may lack agency or self-awareness, which legally justifies the use of forced treatments and interventions.

The purpose of this essay is not to take sides in the debate on the biopsychosocial versus biological models of mental illness, but rather to describe how the normalization of biological thinking, aka reductionism, has justified lateral discrimination within the disabled community against neurodiverse people with psychiatric diagnoses, particularly by undermining our self-advocacy and self-determination.

This lack of cross-disability solidarity was most clearly seen in the way that the disabled community as a whole largely failed to organize and mobilize in opposition to Proposition 1 on the California primary ballot this year, one of the most important legal and policy battles in recent years impacting unhoused people and people with psych disabilities. Despite passing with the slimmest of margins (50.2 % in favor), Governor Gavin Newsom’s allies, which included NAMI California, spent over $14 million for the campaign in favor of expanding involuntary commitment of unhoused people and people with mental illness, compared to only $1,000 raised by the opposition, according to reporting by Cal Matters.

To give some sense of just how odious Prop 1 is, one of its major backers was the California prison officers union, and ads that ran in the state noticeably featured law enforcement rather than health care workers. Politico reported the campaign’s spokesperson stating, “We’re trying to speak to a broader audience, and maybe some of the Blue Lives Matter [supporters] as well will be inclined to support.”

Some of the groups that did show up for the disabled community included the League of Women Voters of California, Mental Health America of California, and Disability Rights California. That the results of the ballot measure were so close despite the lack of uproar from prominent disability advocates and advocacy organizations is all the more upsetting.

The neurodiversity paradigm

Within the disabled community, people’s understanding of neurodiversity often falls short in recognizing that there must certainly be other neurotypes, many currently undefined, that often present differently from autism and ADHD, especially when their needs and values are in conflict with the person’s environment. “Conditions” such as bipolar disorder and schizophrenia can be considered part of neurodiversity, although both of these diagnostic labels are inherently pathologizing and problematic, which makes them incompatible with the neurodiversity paradigm as they are currently defined in the DSM. Fortunately, many prominent scholars in the mental health field agree that the current diagnostic and classification system needs to be dismantled. My hope is that people with psych diagnoses can learn from the autistic movement to self-advocate and view themselves in a non-pathologizing lens, and concurrently that the neurodiversity movement embraces more people with psychiatric labels, especially those historically labeled as severely mentally ill.

To clarify, one doesn’t need to view one’s neurotype or psychiatric disability as being entirely positive in order to be considered neurodivergent, but if more of us listened to psychiatric survivors, we would be better informed about the ways that society has been conditioned to react to our behaviors in largely stigmatizing, pathologizing, dehumanizing, othering, and invalidating ways, which are significant sources of distress and need to be considered when understanding how mental illness presents and is interpreted. Just as existing as an autistic person in an ableist society can be disabling, so can existing as someone who experiences mania, hallucinations, and hears voices. These experiences may or may not be inherently distressing for individuals, but failing to accommodate and validate divergent needs and experiences certainly contributes to mental distress.

The most important takeaway of all, however, is to understand that identifying as neurodivergent is completely independent of being formally diagnosed. Neurotypical people often have a hard time grasping this and other fundamental principles of the neurodiversity paradigm, but so do autistic people and other disabled people. I believe this is largely because of the way that society has been conditioned through popular culture, social media, and advertising to view other types of neurodivergence through a biomedical lens. The normalization of pathologizing others (I’m less concerned about self-identification with psychiatric labels) using DSM terminology has been so thorough that these days everybody believes they are an expert in psychiatric diagnosis, often in a way that weaponizes psychiatric language and terminology. It’s not uncommon to encounter ableist comments in public forums such as Reddit, including, “The Joker is a cautionary tale about untreated mental illness.”

The securitization of mental health through public health campaigns built on recognizing “red flags” and “warning signs” have created an extremely dangerous and unsafe environment for neurodiverse people, where just existing as our true selves is often interpreted as a threat, especially around people who are overeager to weaponize their expert layperson knowledge (derived from watching Joker or too many episodes of CSI).

The liberating potential of the neurodiversity paradigm can only be fully realized when it is extended to every neuroatypical person, not just selectively towards one’s in-group. It saddens me to witness the lateral ableism against people with psychiatric diagnoses from people in the autistic community and the disabled community more broadly. I’m reminded of Douglas Baynton’s seminal article, “Disability and the Justification of Inequality in American History,” in which the author observes that throughout history, marginalized groups have sought to improve their social and political standing by pushing back against any characterizations that associated their communities with disability, and by distancing themselves by juxtaposition from other disabled communities.

I quote Baynton here, but substitute the word “pathologized” for “disabled”: “Rather than challenging the basic assumptions behind the hierarchy, they instead work to remove themselves from the negatively marked categories – that is, to disassociate themselves from those people who ‘really are’ [pathologized] – knowing that such categorization invites discrimination.”

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