Introduction: Embracing a paradigm shift in mental health and neurodiversity

If the demand for services is any indicator, society appears to be going through a growing mental health crisis. Mental health services both for adults and children and young people (Child and Adolescent Mental Health Services, or CAMHS) are facing unprecedented demand, a pattern which has been developing for many years, with ever-growing waiting lists for diagnostic assessment and treatment services. This pattern is echoed in learning disability services, particularly those focused on Special Educational Needs and Disabilities (SEND) in children and young people; demand for diagnostic assessment is rising, as is the number of children subsequently receiving a Statement of Special Educational Needs and therefore additional support in schools.

Aside from the difficulty of meeting this rising demand, from a public health perspective this prompts the question of what is causing it. Most medical disorders have relatively clear (though sometimes complex) causes. They can be genetic; however in this case the changes in demand are too rapid to be explained by genetic changes in the population. They can be communicable diseases, which can of course spread rapidly; but these are not. They can be caused by biochemical changes created by factors such as smoking and poor diet; while there is evidence that lifestyle changes can improve mental health and wellbeing, it is far from clear that such factors can specifically cause diagnosable mental disorders.

More pertinently, they can be caused by biochemical changes brought on by psychosocial factors. This is closer to the likely mechanism behind many or most mental health problems. Even here an emphasis on the biochemical changes rather than the psychosocial factors can distort the understanding of the individual experience and the response to it, but psychosocial factors can change rapidly enough that they are a credible reason for the rapidly rising demand for services. Such factors can include trauma and adverse experiences, which are at the heart of many mental health problems; social structures that encourage people to seek diagnoses (e.g. benefits and educational support systems that require medical diagnosis before help is offered); and changing patterns of expectation in the public of what sort of range of experience is considered to be “normal” and healthy.

There is a long history of critiques of biomedical approaches to mental health, most notably going back to RD Laing and the antipsychiatry movement that came to the fore in the 1960s. Most psychiatrists would now endorse what is known as a “biopsychosocial” model of mental health, recognising the importance of psychological and social factors in addition to biochemical ones. However this still sees mental health and learning disability in a medical framework – there is a defined disorder that can be diagnosed and treated, at least with the aim of mitigating the symptoms. But if psychosocial factors are indeed driving the increase in demand, the appropriate response is to tackle those factors that are affecting on people’s lives and experiences in a profoundly negative way, rather than to see the individual’s experience as the problem.

If that is to be achieved, the landscape of mental health and neurodiversity support needs a radical transformation, moving away from traditional diagnostic-centric approaches to a more inclusive, nuanced, and holistic understanding of individual experiences. And a new emphasis is needed on public mental health – on promoting those factors that protect people from poor mental health, and on tackling factors that cause it. This report sets out some of the key ways in which this transformation could be achieved.

Chapter One begins with an overview and critique of mainstream medical models of mental health and learning disability.

Chapter Two delves into the pattern of mental health problems in Cumberland, at this point utilising mainstream diagnostic categories – as this is how the data are currently collected. It shows the demand for services and the poor outcomes we see in Cumberland, including through high mortality associated with substance misuse and suicide.

Chapter Three illuminates the profound impact of trauma on mental health. It explores trauma theory, the prevalence of traumatic experiences, and the imperative to transition from diagnostic and treatment-oriented models to trauma-informed care. By emphasising safety, trust, compassion and healing, this chapter advocates for services that support individuals in processing trauma rather than solely focusing on clinical diagnoses and treatments.

Chapter Four considers societal expectations surrounding mental health. It unpacks the prevalent misconceptions that lead individuals to seek clinical support for emotions and thinking patterns that fall well within the spectrum of normal human experiences. This chapter advocates for a more inclusive approach that encourages the recognition of everyday emotional struggles as normal, with support offered outside of professional interventions.

Chapter Five extends this thinking to some categories of learning disability, neurodiversity and special educational needs. It provides an overview of patterns of demand for SEND services, then goes on to explore why individuals seek clinical diagnoses for traits that could be seen as part of normal cognitive diversity. This chapter advocates for mainstream services such as schools to adopt inclusive approaches that support diverse thinking styles and personalities without solely relying on diagnostic labels.

The implications of implementing these progressive approaches within local mental health services are far-reaching. Chapter Six therefore offers recommendations on reshaping services to adopt trauma-informed care, strengths-based assessments, recovery-focused models, inclusive practices, and collaborations with diverse stakeholders to create supportive environments that accommodate diverse learning and mental health needs without rigid diagnostic boundaries.

In essence, this report calls for a substantial focus on public mental health in Cumberland, and a seismic shift in how mental health and neurodiversity support are approached – a shift that prioritises empathy, compassion, inclusion, empowerment and individual strengths, creating pathways to wellbeing that honour the diversity of human experiences.

There are two crucial caveats to what is set out in this report. First, nothing in this report should be read as an absolute. It does not apply to several health problems that fall under the general heading of mental health or learning disorders, notably degenerative brain disorders including dementia, acquired brain injury, and profound learning disorders that have a significant impact on people’s ability to function independently – though some, like Foetal Alcohol Syndrome, can present in very similar ways to some neurodiverse characteristics. While it argues for an approach that resists over-medicalisation and the dependence on diagnostic categories, some people find diagnosis extremely helpful in aiding their understanding of their experiences; and pharmaceutical interventions undoubtedly have their place in supporting people. The aim is to promote an alternative view where this would be helpful, not to reject the role of medicine altogether.

And second – nothing in this report is intended to suggest that any mental health or learning challenge is in any way invalid, not “real”, or the fault of the people experiencing it. The distress and difficulties that people face are very real, and usually driven by external factors; the question is how we help people to respond to these, and how we can change society to reduce the negative external factors. This is the essence of public mental health.