Review
Books
Care
Comment
Psychology
7 min read

We don’t have an over-diagnosis problem, we have a society problem

Suzanne O’Sullivan's question is timely
A visualised glass head shows a swirl of pink across the face.
Maxim Berg on Unsplash.

Rates of diagnoses for autism and ADHD are at an all-time high, whilst NHS funding remains in a perpetual state of squeeze. In this context, consultant neurologist Suzanne O’Sullivan, in her recent book The Age of Diagnosis, asks a timely question: can getting a diagnosis sometimes do more harm than good? Her concern is that many of these apparent “diagnoses” are not so much wrong as superfluous; in her view, they risk harming a person’s sense of wellbeing by encouraging self-imposed limitations or prompting them to pursue treatments that may not be justified. 

There are elements of O-Sullivan’s argument that I am not qualified to assess. For example, I cannot look at the research into preventative treatments for localised and non-metastatic cancers and tell you what proportion of those treatments is unnecessary. However, even from my lay-person’s perspective, it does seem that if the removal of a tumour brings peace of mind to a patient, however benign that tumour might be, then O’Sullivan may be oversimplifying the situation when she proposes that such surgery is an unnecessary medical intervention.  

But O’Sullivan devotes a large proportion of the book to the topics of autism and ADHD – and on this I am less of a lay person. She is one of many people who are proposing that these are being over diagnosed due to parental pressure and social contagion. Her particular concern is that a diagnosis might become a self-fulfilling prophecy, limiting one’s opportunities in life: “Some will take the diagnosis to mean that they can’t do certain things, so they won’t even try.” Notably, O’Sullivan persists with this argument even though the one autistic person whom she interviewed for the book actually told her the opposite: getting a diagnosis had helped her interviewee, Poppy, to re-frame a number of the difficulties that she was facing in life and realise they were not her fault.  

Poppy’s narrative is one with which we are very familiar at the Centre for Autism and Theology, where our team of neurodiverse researchers have conducted many, many interviews with people of all neurotypes across multiple research projects. Time and time again we hear the same thing: getting a diagnosis is what helps many neurodivergent people make sense of their lives and to ask for the help that they need. As theologian Grant Macaskill said in a recent podcast:  

“A label, potentially, is something that can help you to thrive rather than simply label the fact that you're not thriving in some way.” 

Perhaps it is helpful to remember how these diagnoses come about, because neurodivergence cannot be identified by any objective means such as by a blood test or CT scan. At present the only way to get a diagnosis is to have one’s lifestyle, behaviours and preferences analysed by clinicians during an intrusive and often patronising process of self-disclosure. 

Despite the invidious nature of this diagnostic process, more and more people are willing to subject themselves to it. Philosopher Robert Chapman looks to late-stage capitalism for the explanation. Having a diagnosis means that one can take on what is known as the “sick role” in our societal structures. When one is in the “sick role” in any kind of culture, society, or organisation, one is given social permission to take less personal responsibility for one’s own well-being. For example, if I have the flu at home, then caring family members might bring me hot drinks, chicken soup or whatever else I might need, so that I don’t have to get out of bed. This makes sense when I am sick, but if I expected my family to do things like that for me all the time, then I would be called lazy and demanding! When a person is in the “sick role” to whatever degree (it doesn’t always entail being consigned to one’s bed) then the expectations on that person change accordingly.  

Chapman points out that the dynamics of late-stage capitalism have pushed more and more people into the “sick role” because our lifestyles are bad for our health in ways that are mostly out of our own control. In his 2023 book, Empire of Normality, he observes,  

“In the scientific literature more generally, for instance, modern artificial lighting has been associated with depression and other health conditions; excessive exposure to screen time has been associated with chronic overstimulation, mental health conditions, and cognitive disablement; and noise annoyance has been associated with a twofold increase in depression and anxiety, especially relating to noise pollution from aircraft, traffic, and industrial work.” 

Most of this we cannot escape, and on top of it all we live life at a frenetic pace where workers are expected to function like machines, often subordinating the needs and demands of the body. Thus, more and more people begin to experience disablement, where they simply cannot keep working, and they start to reach for medical diagnoses to explain why they cannot keep pace in an environment that is constantly thwarting their efforts to stay fit and well. From this arises the phenomenon of “shadow diagnoses” – this is where “milder” versions of existing conditions, including autism and ADHD, start to be diagnosed more commonly, because more and more people are feeling that they are unsuited to the cognitive, sensory and emotional demands of daily working life.  

When I read in O’Sullivan’s book that a lot more people are asking for diagnoses, what I hear is that a lot more people are asking for help.

O’Sullivan rightly observes that some real problems arise from this phenomenon of “shadow diagnoses”. It does create a scenario, for example, where autistic people who experience significant disability (e.g., those who have no perception of danger and therefore require 24-hour supervision to keep them safe) are in the same “queue” for support as those from whom being autistic doesn’t preclude living independently. 

But this is not a diagnosis problem so much as a society problem – health and social care resources are never limitless, and a process of prioritisation must always take place. If I cut my hand on a piece of broken glass and need to go to A&E for stiches, I might find myself in the same “queue” as a 7-year-old child who has done exactly the same thing. Like anyone, I would expect the staff to treat the child first, knowing that the same injury is likely to be causing a younger person much more distress. Autistic individuals are just as capable of recognising that others within the autism community may have needs that should take priority over their own.   

What O’Sullivan overlooks is that there are some equally big positives to “shadow diagnoses” – especially as our society runs on such strongly capitalist lines. When a large proportion of the population starts to experience the same disablement, it becomes economically worthwhile for employers or other authorities to address the problem. To put it another way: If we get a rise in “shadow diagnoses” then we also get a rise in “shadow treatments” – accommodations made in the workplace/society that mean everybody can thrive. As Macaskill puts it:  

“Accommodations then are not about accommodating something intrinsically negative; they're about accommodating something intrinsically different so that it doesn't have to be negative.” 

This can be seen already in many primary schools: where once it was the exception (and highly stigmatised) for a child to wear noise cancelling headphones, they are now routinely made available to all students, regardless of neurotype. This means not only that stigma is reduced for the one or two students who may be highly dependent on headphones, but it also means that many more children can benefit from a break from the deleterious effects of constant noise. 

When I read in O’Sullivan’s book that a lot more people are asking for diagnoses, what I hear is that a lot more people are asking for help. I suspect the rise in people identifying as neurodivergent reflects a latent cry of “Stop the world, I want to get off!” This is not to say that those coming forward are not autistic or do not have ADHD (or other neurodivergence) but simply that if our societies were gentler and more cohesive, fewer people with these conditions would need to reach for the “sick role” in order to get by.  

Perhaps counter-intuitively, if we want the number of people asking for the “sick role” to decrease, we actually need to be diagnosing more people! In this way, we push our capitalist society towards adopting “shadow-treatments” – adopting certain accommodations in our schools and workplaces as part of the norm. When this happens, there are benefits not only for neurodivergent people, but for everybody.

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Short story
Comment
Wildness
18 min read

The Eagle - a new short story

A fable.

Theodore is author of the historical fiction series The Wanderer Chronicles.

An eagle wheels against a purple stormy sky cut by lightening.
Jason Hudson on Unsplash

I dreamed of an eagle soaring high over a verdant valley. The sun blazed and splintered into a thousand sword-points of light, spilling with joy and gladness over the slopes and streams, over the hanging woodlands, and the orchards growing there and carpeting the floor.  

There was gladness in the heart of the eagle too. The valley was good. The valley was secure. With his piercing eye, he kept watch over his brethren. The animals of the valley fed and met and played and slept. The smaller birds swooped and spun in the barmy air far below him. All was well.  

And then to the east, to the east his eye was drawn. A cloud rising in the east. A change was come. Black billows, dark with portent, rising skeins of thick grey smoke. The land that way rose to an upland pass. The little valley came tumbling down from its heights. To the north, a jagged range of peaks, black and sharp as wolf teeth. To the south the same, shutting the valley in. Protecting its flanks. But by the eastern horizon, a way did lay open. And now the eagle saw burning flames. A fire raging, devouring flame racing over tree and scrub, tearing at the grass, a snarl of heat and swirling smoke. A consuming fire. An angry fire. A fire fuelled on resentment, blown by the winds of hate. A fire hungry for the valley and everything in it.  

The gladness in the eagle’s heart vanished in a moment - as if it, too, had been burned to ash in the raging blaze. The eagle watched the flames claw their way down the upland spurs of the valley. Disquiet now ruled in the place of gladness. His piercing glance dropped to the animals frolicking in the valley below, but they saw no danger. They knew no danger. They knew nothing but that he would tell them was to come. 

At last his cry broke from his throat. He looped back on the burgeoning wind, circling round the better to send his shrill warning spiraling down to the verdant floor and its folk. But to his dismay, not one looked up. Not one took heed.  

And now to the west his gaze rose. And his disquiet turned to horror. 

For there the mirror to the eastern pass did lie. Smooth, lower, a lesser rampart of earth and rock. The easier to scale. And seeping, creeping over its worn shoulders came a foul and noxious fog. Purple of hue, odious even to the eye. Yet the eagle needed no telling that it would be fatal to the lungs. A cloying, lying, coiling fog, slick to the touch, choking and blinding in its confusion. And something in the look of it told the eagle it was yet more than this. A maddening fog, a self-devouring, self-immolating poison, which once inhaled could nevermore be expelled. 

Once more, his cry rang out around the four walls of the valley. Once more, the animals below did not look up from their play, from their busy, busy play…. 

Seeing their oblivion, he fell on them with such force and directness that he risked his own neck. For only with skill and strength could a bird of his dimensions flare out from such a death-dive. His throat burned in his effort to scream his warning. But only at the last did any of the valley-folk look up. 

Those that saw ducked their heads and took fright to see this terrible sight. The little ones especially, the soft-hearted ones, the natural prey of great predators like himself. Wails of fear broke from the lesser throats. They cringed and hid and some even were angry. The mothers rushed to their young. The fathers bristled and ready themselves for a fight. Shocked and afeared by this sudden threat to the peace of the valley, and the disturbance to the busy plans they had for their day.  

When the eagle pulled up and neatly landed on the peak of a small outcrop that broke from the valley floor, his voice was hoarse from his warning cries. The animals were bolder now, seeing the flash of danger past. And as the tide of fear receded in their hearts, seeing the threat was not as they feared, it left behind sharp stones of anger and indignation.  

“What do you mean by this horrible screaming?” the first of them did demand. “You puffed up popinjay! You scare the life out of us with your terrible aspect and the dizzying violence of your approach.” 

“It is only of necessity,” he began, breathlessly, “on account of what I saw—“ 

But he was not allowed to finish. In one united and sudden clamour, all the animals, emboldened by the first, unleashed their fear (together with their indignation) on him, so that none could truly have heard what any of the others had to say, or even what came forth from their own mouth. 

“Renegade!” 

“Bully!” 

“Impostor! Attacker!” 

And there was worse. “Murderer! Villain! Terrorist!” 

“There is blood on your hands!” 

“But I tell you - from my great height, among the peaks and the thinning air, I saw something none of you can see,” he pleaded anew. 

Now the clamour turned to jeers. “Oh, you saw, did you? You who see so much indeed!” cried the first of the animals. He was a fox who always liked to have the highest place in any council. And yet had not, even now, gained the trust of the eagle’s heart. “You always did think yourself superior to us earth-bound folk.” 

“That thin air has gone to his head, if you ask me,” said the king buck of the forest. “What he mistakes for clarity is nothing better than a spell of dizziness. Besides, no one asked him to look out for us, did they? We have wisdom enough for ourselves. We know our world. And look to ourselves as needs will be.” Here the noble-looking stag gave the twelve points of his antler-crown a flourish.  

“Get away, you hook-beak menace!” cried a creature from the crowd.  

“Stop stirring up trouble, you screeching flapper,” scowled a second. 

“Back up to your lofty skies, you preening prig,” sneered yet a third. And soon all the animals were hurling the worst of their insults at the eagle, seeing he was in no hunting mood after all, and glad for a chance to vent the spite they felt for many little things that had nothing to do with him. 

Frustrated at their stubbornness, the eagle glanced to the skies again. So often he had used his sharp eyes and sharper talons to win his way, but seldom his voice. He was not used to seeking sharp words withal to defend himself from such a barrage of slur and rejection. He looked to the skies again, always the place of solace for him. And there he saw but faint traces of the fire raging high and to the east. But then something else caught his attention. Some great shadow casting a gloom upon the air. In a moment, the caterwauling crowd was forgotten, and now in urgency, he beat his wings once more, his spiralling flight carrying him back up to airy reaches far above the valley, just as the valley-folk had scolded him to do. 

Only he went not at their urging, but in heed of a still more pressing call in his own heart. A dread of what could cast such a shadow, even through all the bright flames of the wild furnace that he had spied. He turned his head to the east, his eyes reaching and reaching deep into the billowing smoke and fire. And then he saw it. And his blood ran cold as the ice-water tumbling out of the hills into the valley below. 

A monstrous figure strode among the fire and the smoke. Tall as ten oaks from toe to head and with a flaming sword raised aloft. The monster had the body of a giant, and yet its head was that of a bull, double-horned, and snorting great angry blasts of flame from its nostrils, its eyes green and flashing like emeralds that held the sun. Its huge limbs swung with grim purpose as it drew closer, striding down from the upper reaches of the valley. Hulking shoulders with bulging veins that glowed red and gold and copper, as if the hot blood of hate were like to burst clean out of its char-black skin and shower the land with its poison. 

For a moment, the eagle’s steady gaze faltered, feeling some unfamiliar tremor through his heart. Fear. For so it must be. Fear so deep he knew not where to turn. 

But then his wits caught up with him at length. And at the sound of a long and sibilant sigh on the breeze from the west, he banked that way now. And to his horror, he saw thence too came striding a figure wreathed in the purple fog. Not so large as the bull-headed giant, and yet unlike that titan of shadow and flame, this one possessed some strange inexorable draw, so that the eagle found once his eye had settled on its shimmering shape, he could no more have torn it away than he could have stopped the earth from its turning. 

While the eagle would have flown far from the fiery giant, the shifting silver and purple shimmer on this other was in certain ways more terrifying. Its head was crowned with dark jewels over long and flowing silver-white hair. Its eyes were simpering and womanly in their glance, yet something hard and cold lurked in their centre, too, even as a mirthless smile played over a curved and shapely mouth. As if the giantess held some joke over all the world, some secret which amused her only. Beauty corrupted, pleasures perverted, good things turned to wicked. These things and many more the eagle read in her wanton gaze. And as she walked the purple fog swirled around her silver-slick limbs, clothing in a way her modesty, yet inviting all the same. And the eagle felt the twin goads of revulsion and yet its mirror. And only by chance noticed that even from so far, the scent on the fog, both sweet and yet putrescent, was putting lead in his eyelids. For a moment, he felt his head loll in weary sleep, a thick narcotic lethargy leaching all life from his steel-strong sinews and suddenly he found his flight was stalling, stalling… and only by the roar of the rushing air did he realise he was falling to the crushing earth.  

With force of will he had never before had need to call upon, he wrenched his wingspan to its fullest stretch, and braced his mighty shoulders to catch the air and snatch him from his doom. At least for now. Shocked at his own weakness but recovered, he now flew like lightning-bolt, arrow-straight, to the valley meeting point, whence bare moments before he had been expelled. 

“Alarm! Alarm!” he cried again. And this time, he would brook no silencing. “Alarm! Alarm!” he shrieked, with the last gasp of his breath. 

“You again,” went up the cry. And much that was far worse. “Did we not rid ourselves of you once and for all time?” barked the fox. 

“You solitary creature, go back up to your aerie,” declared the noble stag. “It is with good reason the Great Maker gave you a hermit’s home far from the valley floor. For in his wisdom, he knew none of us earth-bound folk could abide your company. No, nor should we have to.” 

“That may be true,” confessed the eagle. “But heed me all the same, just for this moment and but a few more. I see you from my height above and though you care not for me, I have long learned to care for you. And just as you say, I abide in the Maker’s will. He has given me eyes to see and a lonely nature, whereof I soar on the wind He breathes, and far-seeing I may behold things which escape the eyes of you lower folk.” 

“Lower!” jeered the wolf. “Hark at him! There all the truth is known. He thinks himself a higher breed to us forest-dwellers.” 

“Nay, far from it,” pled the eagle, seeing he had misspoke. “I come not to bandy words but only to warn that you may flee the coming purge.” 

“What purge, you feather-brained scoundrel?” 

“Death descends on all of you who dwell in the valley-floor,” he cried, his voice shrill. “A poison out of the west; dread fire from the east. They burn, they choke, they lay to waste all that lies in their path. And they mean to meet here in this green valley to some foul purpose, I am sure.” 

“Peace now, my brother of the wing,’ said a new voice, and though ready to shout down the eagle for their own part, all the gathering of animals turned to see one who perhaps had been there all this time. Yet only now had spoken up. It was the owl, sitting calm and moon-eyed, surveying the scene as if such fractious business barely concerned him. “Peace, I say.” It was as if there was a gentle, coaxing smile in his voice. “I, too, have flown higher than these other valley-dwellers. I, too, have felt the winds upon my beak. In all that I have seen; in all that I, in my wisdom,” - here he looked around as though to say, ‘does any here doubt it?’ - “have ever known, there is no true danger come to fall upon us. None but which we stir up among ourselves. Through misunderstanding, through a lack of love. Come, my brother of the wing. Admit thy mistake. It is no fault of thine. Imagination is a tricksome friend, I know. And indeed, who can truly say what they have seen at such heights? The fault would merely be not to admit to thy mistake. I tell you in all my journeying, I have seen nothing of these threats. Take counsel from wiser, older, gentler souls.’ 

“Nay,” insisted the eagle. “The difference is this. You fly by the light of the silvered moon. I fly by the sun. You see but by the reflected light falling upon a dead and mute circle of rock. I see by the light of the burning sun itself. Tis not the whole, you see, but mere shadows and play of darkness. I ride the wind, and see what the wind would show me.” 

At this, the smile in the owl’s voice leached away. “The hot wind of the fire you feel is the wind of the great eternal spirit calling you to love all of creation with a fiery love. Calling you to a warmer love of your fellow creatures. And as for the fog, you have it wrong there too, sir. ’Tis the sweet scent of compassion you smell, calling you to a compassion for all those things you do not yet understand―” 

“I understand them well enough. Well enough to perceive the danger―” 

“Silence!” the owl abruptly shrieked. “I had not finished speaking.” And here, the glare in his moon-eyes became sharp as flint. “Your hard days on the wing have hardened your heart. The thin air up there has made your heart cold with lofty conceit, and distanced from the rest of the Maker’s world. Truly you see only your own great capacity to soar, and think it makes you far-seeing, while the rest of us are blind. No, it is not by light that you see, but by ignorance. Your mind is closed because you do not open it to other ideas and influences, as I do. It is I who truly loves these valley-folk. I who converse with them, and learn from them. I who never judges them.” 

“But the fire!” cried the eagle. “But the fog!” 

“Silence!” returned the owl, and this time his voice carried real authority. “You say you see only by the sun, do we all not live under that same sun? Nay. Be humble now. Be silent for a time. Learn from those older and wiser valley-folk. Be silent, I say. We have indulged thy fanciful whims too long.” Here, the owl’s domed head swiveled in the direction of the stag. “Your grace, it is time for a little discipline. We winged creatures play our part, but the Maker has ordained thee king over us. This is known. The Maker means for all of us to submit to the sting of discipline now and then. Such may do us good.” He turned back to the eagle, and there was a sarcastic edge now in his voice. “Or do you consider yourself too good even for that? For such as the rest of us must endure?” 

“No, no, a thousand No’s!” replied the eagle impatiently. “I take my discipline when discipline is what I need. But see, even now, the towers of smoke rising in the far heights. Look, can you not see?” He gestured eastward with his great wingspan, but most of the gathered animals merely laughed at his madness. Any who did happen to glance that way had not his vision and saw nothing but the azure sky. “If it is falsehood I see, then I would gladly see myself corrected. But, by all the stars, I am not lying. And more, I see it true!” 

“He is a lost cause,” said the sly fox, for he had never much cared for the eagle. “Come, we waste time. Let’s get to the disciplining, and right quickly. I have an idea this one may lose patience, and then see - the sharp hook of his beak. The razor points of his claws. What mischief might he play with those when he chooses? See these little soft ones hereabout.” He gestured to the woodland creatures, the rabbits, the shrews, the squirrels. “He is a danger, this one. To every decent forest-dweller. Aye, and even to himself, I dare say. Look at them! Poor lambs - quite terrified out of their wits, they are. Terrorized half to death!” 

And it was true - there were some of them did seem alarmed.  

“Quite right,” agreed the stag. “Well, there be nothing for it but to teach the eagle his lesson.” And before the eagle had thought enough for his own safety and not the others, there was a guttural growl beside him, and suddenly the weight of the wolf’s claws upon his back, the hot billow of lupine breath as iron jaws closed around his neck. 

“To the punishment stone!” the fox cried heartily. “We’ll make of this one a milder creature before the sun is set!” And at once all the crowd of them took up his cry.  

The eagle found himself borne upon the tide of anger, mauled and spat at and scratched. But the wolf was strong, and dragged him with relentless might to the place of his ordeal. 

And yet, all the while, his fear was not for himself. No, it was still for his fellow creatures. For now, he could even smell the rank sweetness of the giantess’s noxious poison. For now, he could even hear the crack and spit of the rushing fire tearing through the forest. But the other animals were too distracted. Too fixed upon his own fate, and what they would see done to him. 

And a terrible lament rose within his heart: that he had failed. That seeing, he had yet wrought no good. His moment had come, perhaps the one moment for which the Maker had given him life, had given him wings to soar and eyes to see - but all he had won was his own demise. And then he thought, “So let it be. It is no more than I deserve, after all.” 

It is terrible to relate what those gentle, placid valley-folk did to the eagle in those following moments. Once they had bound him and raised him up for all to see, the fox and the wolf went to work. They pulled from his golden feet those proud talons, each and every one brandished and mocked and tossed down among the baying crowd. They bit him and tore out mouthfuls of feathers to spit back in his face. They broke and snapped right off the sharp hook of his beak, yelling with glee that he could hurt no other creature now.  

They worked on him for a long while, so that the sun had fallen low behind the western pass, and the sky was purpling like a spreading bruise across the heavens.  

“Better cut out his lying tongue,” said one. This was the owl, whose moon-eyes seemed greener somehow in the fading light. “The better to avoid discord among the good peace-loving folk of the forest floor.” At this, went up a rousing cheer. The idea seemed pleasing to them all. And so his tongue came out, and was thrown down as had his other parts. 

The eagle endured his punishment without a sound. Although inside his heart was weeping. But now he could never tell that he wept not for himself, but for all of them.  

“One more thing,” declared the noble stag, looking regal and solemn, his crowned head held high and strong. “His eyes must go, for it was they that caused all this trouble. After that, clemency. For we are not cruel of heart. We merely wish to preserve the peace and order of the valley.” 

“Allow me,” sniggered the fox to his partner in the punishment, and the wolf stepped graciously aside. 

The eagle looked not at his tormentors in that moment. Instead, his far-gaze searched one last time the blackening skies. Searched for an answer to the fire and the fog. Searched the heavens for some single shard of hope. For he knew now, no aid would come to his kindred creatures from among themselves. 

The fox flexed a claw. Flashed it before the eagle’s gaze. But he did not care to look at that. And the next moment was one of searing pain. One eye now was gone. But he minded it not. He could not cry out in any case, for his tongue lay severed in the mud. No, he still looked keenly upward with the last eye left to him. 

And then - as the fox made much of this final climax to his work, japing and frolicking before the crowd - he saw something. He saw a wonder. For though the sun had long set, some other light now appeared in the gloaming. No rising sun was this, for the light came not from the east, not even piercing through the smoke that now stained the night far above the heads of the foolish creatures below. No, the light rose in the north. Why? How? the eagle pondered, while the fox still milked his crowd. 

A second sun rising in the north, light building and building, though by now it should almost be night. Splinters, shards of colour, white and gold of searing brightness, like an army pouring over the high ridge of mountain peaks, the bulwark to the verdant valley. And with the light he saw, in the last seconds of his sight, a light that was all hope and power and blessing and glory and goodness and beauty.  

And though he knew that these next moments would be the last he would ever see, I saw in my dream that he was at peace. Because, though he had failed, his heart was certain that the light would not.  

A new light was rising in the north. A new sun had come. 

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