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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Essay
Comment
Identity
Nationalism
Politics
15 min read

Could a constitution capture the essence of Englishness?

A proposal for St George’s Day.
A St George's Cross flag flutters on a tower.
St Helen's Church, Welton, Yorkshire.
Different Resonance on Unsplash.

Somewhere behind the concrete-and-glass façade of modern official Britain, one can still find some traces of England: folklore and folk music, country customs and local traditions – wassailing, maypoles, cheese rolling and bounds beating – that neither brutal 19th century industrialisation nor callous 20th century deindustrialisation could completely erase.  

This idealised ‘Quaintshire England’ lurks somewhere in the psycho-geographic triangle formed by Anthony Trollope’s Barchester, Thomas Hardy’s Casterbridge and Geraldine Granger’s Dibley. It is always indeterminately, reassuringly, old. It has a lot of past, but not much future. Yet its traditions are neither stagnant nor dying. Take, for example, the recognition of St George’s Day. Once upon a time, and not so very long ago, St George’s Day came and went with hardly anyone noticing. It was relegated to handful of nasty, shaven-headed, right-wing cranks. Now St George’s Day is marked by respectable newspapers and by the media classes, through the annual ritual of the Great Debate About Englishness.  

For those not familiar, the Great Debate About Englishness takes the form of a stylised conflict between two sides: the Guardians and the Telegraphs. The Guardians start, with a stick-knocking assault on Saint George and all his works: he was Turkish (or, better still, Palestinian); he never visited England (which is just as well, because, as they are eager to insist, England does not really exist anyway, and if it did it would be hopelessly white and racist). Then the Telegraphs move forward, with Scruton bells on their toes, to lament the fact that we no longer celebrate St George, and how all the ills of the world are the fault of the kind of people who say ‘Mumbai’ when they mean ‘Bombay’. At this, the Guardians caper forth, wielding Billy Bragg quotes about ‘progressive Englishness’ in an intricate manoeuvre known to afficionados as a ‘Full Toynbee’. This done, the Guardians retreat before the onslaught of the Telegraphs, who counter-attack with the clincher than English is an ethnic marker, which necessarily excludes anyone whose ancestors were swarthier than a Flemish Huguenot. So concludes the ritual, which is then forgotten about until the following year. 

England, becoming everything, has thereby become nothing. It is the only nation in the United Kingdom without a political life of its own. 

These cathartic ritual confrontations rarely acknowledge that debating the nature of Englishness is itself a symptom of the English nation’s statelessness. Like Kashmiris, Kurds and Uyghurs, the English must debate the nature of their existence because England is – to borrow the term used by Austrian Chancellor Metternich to refer to pre-unification Italy – ‘a geographical expression’.  

The institutions, symbols, and icons of political identity are all British. Despite its historical position at the core of the Union and the Empire, England remains a curiously under-developed nation in constitutional terms. It has almost no formal recognition as a national community. Indeed, England’s dominance over the United Kingdom has had the paradoxical effect of denying England – as England ­– a voice in its own affairs. England, becoming everything, has thereby become nothing. It is the only nation in the United Kingdom without a political life of its own. There is no English Government, nor English Parliament. Even the banal markers of national identity that people might have in their pockets, like coins, stamps, and passport, are British, not English. The absence of such markers means that English identity has high barriers to entry. In other words, we obsess about the ethnic and cultural boundaries of Englishness, because there is no English civic, legal, or political community – let us call it a ‘constitutional community’ – of which one can be a member as a matter of legal right.  

Such a ‘constitutional community’ could take two forms. It might take the form of an independent England, re-founded as a nation-state after Scotland, Wales and Northern Ireland have freely gone their separate ways. Alternatively, given the need for collective defence and international clout in a dangerous world, it could take the form of an England which remains one of four constituent states in a voluntary, equal, confederal Union.  

Either way, an English constitution, understood as a codified supreme and fundamental law, should establish political institutions of England’s own: an English Parliament, an English government, an English judiciary, and an English civil service. Only by this constitutional means can England, now that the British Empire is no more, become a normal nation, make peace with itself, and re-find its place in Europe and the world.  

In part, this is a matter of good government. As the great post-war Commonwealth constitutional scholar Sir Ivor Jennings famously put it, ‘A Constitution is but a means to an end, and the end is good government.’ An English constitution would enable the renewal of a system of government that has become too centralised, too top heavy, and long overdue for reform. It would clarify the rules of political life where these have become contested, reinforce the boundaries of power where these boundaries have been pushed to breaking point, and restate the principles of public ethics which have been neglected. It would protect democratic institutions and norms from erosion by unscrupulous authoritarian populists.  

A list of priorities for consideration in an English constitution, enjoying support across the broad centre of the political spectrum, might include devolution to English cities and counties, electoral reform, reform of the Lords, codification of parliamentary conventions to limit the abuse of Crown Prerogatives, strengthening of the civil service and rebuilding of lost state capacity, restoring standards in public life, and better protection of civil liberties.  

If you are reading this in England...  you are probably not very far away from a place where old stones echo with the words and songs, the faith and the prayers, that have held the English nation together. 

Yet constitutions are more than dull, dry, legal charters of government. They are also national covenants. They set out a vision of who we are, who we want to be, what we stand for, and what we will not stand for. Aside from all the mechanical, institutional, provisions one expects to find in a written constitution, constitutions also contain what we might call metaphysical provisions: those that bear the identity, and bare the soul, of the nation. An English constitution would help to anchor English identity in the midst of changing times. 

While the mechanical constitution is in need of reform, England’s ‘metaphysical constitution’ is not so lightly to be tinkered with. It represents a mystical union of past, present and future, embodying an idea of English nationhood – and English statehood – stretching back to Anglo-Saxon times. At the heart of this metaphysical constitution is the ideal of Christian monarchy, institutionalised through constitutional relationships between the church, state, Crown and nation.  

While the institutional structures of the mechanical constitution are British – and essentially imperial, rather than national, in character – the metaphysical constitution has remained steadfastly English. The Church of England is the only major all-England public institution. The General Synod, which has power to enact Measures having the force of law in England in relation to ecclesiastical matters, is the only England-wide legislative body. England (not Britain, nor the United Kingdom, nor the British Empire, but something older and deeper) can most readily be found in its great cathedrals: Salisbury, Norwich, Wells, Lincoln, Ely, Gloucester, Hereford, Durham. It can be found, too, in the abundance of ancient village parish churches with hand-tapestried hassocks, musty smells, memorial plaques and an almost tangible presence of congregants gone by. England is etched in the moss and lichen of their old gravestones. It is haunted by the Ghosts of England Past, speaking the words of the Book of Common Prayer and the King James Bible. If you listen carefully, you can hear them. If you are reading this in England, even in the midst of a busy city, you are probably not very far away from a place where old stones echo with the words and songs, the faith and the prayers, that have held the English nation together over the centuries. 

Confusion arises, however, from the failure to distinguish between the mechanical and the metaphysical aspects of constitutions. 

That heritage is valued not only by Christians, but also by those who are not believing or practising Christians, but who are pleased to belong to a culture that has been shaped by Christianity. Cutting the Church totally loose from the state, by disestablishment, would abandon custody of this cultural and social heritage to a merely private organisation, having no public recognition, patronage, or connection to the national community. That would be a particularly savage form of cultural privatisation. 

England’s metaphysical constitution is mostly buried beneath the accumulation of ages. If you are good with the constitutional trowel, however, and know where to dig, it is not hard to unearth it. Sometimes it even pokes above ground, as easily seen as the billowy bench of bishops in the House of Lords. The topsoil of modernity is dramatically stripped away at the coronation, when the king swears not only to govern ‘according to the statutes in Parliament agreed on and the Laws and Customs of the same’, and to ‘cause law and justice in mercy to be executed in all [his] judgments’, but also to ‘maintain the laws of God, the true profession of the gospel, and the Protestant Reformed Religion established by law’. The King’s covenant with God and the nation is outwardly and visibly signified when, at the climax of the ceremony, he is anointed, by the Archbishop of Canterbury, with holy oil.  

Thus, the descendants, according to the flesh, of Anglo-Saxon kings, become at their coronation the descendants, according to the spirit, of David and Solomon. The birth of this metaphysical constitution can be traced to the baptism of King Aethelbert, the first Anglo-Saxon king to become Christian. As Bijan Omrani notes, in God is an Englishman, this act transformed the nature and expectations of English kingship, from pagan warlordism to a holy kingly office, responsible under God for bringing God’s peace and justice to England.  

All this is very strange, and easy to mock. To paraphrase a famous scene in Monty Python’s ‘Holy Grail’, ‘supreme executive power derives from the confidence of the House of Commons, not from some farcical aquatic ceremony’. From a purely mechanical point of view, that is of course quite right. As Walter Bagehot’s The English Constitution said of Sir Robert Walpole, the first modern Prime Minister, ‘he ruled England because he ruled that House’. Confusion arises, however, from the failure to distinguish between the mechanical and the metaphysical aspects of constitutions. Many constitutional conservatives, eager to uphold the metaphysical constitution of England’s Christian monarchy, set their face against even moderate and beneficial reforms to the mechanical constitution. On the other hand, many constitutional reformers, eager to mend the broken mechanical constitution, would pave over the metaphysical constitution with all the misplaced zeal of a solar farm company. 

The established church is a particular target of the reformers’ wrath, evidenced most recently by a proposed amendment to the House of Lords (Hereditary Peers) Bill, seeking to remove bishops from the upper House. According to Lord Birt, former Director-General of the BBC, ‘Embedding the Church of England in our legislature is an indefensible, undemocratic anomaly.’ There are only two countries in the world, so we are informed, where clerics sit of right as legislators: the United Kingdom and Iran. The clear implication is that this connection puts the United Kingdom in bad company, as if having a couple of dozen bishops in the House of Lords were comparable to the rule of Ayatollahs. 

Incidentally, remarkably incurious of comparative practice, the people who say this always forget about Belize: a relatively stable and well-functioning Westminster Model democracy, whose tiny upper House includes a Senator nominated by the Belize Council of Churches and Evangelical Association of Churches. They also forget about tiny Tuvalu, a democratic Commonwealth Realm in the South Pacific, where the established church was planted by the London Missionary Society. Perhaps these examples do not fit the narrative that insists that church establishment must inherently be regressive and anti-democratic. 

To those of us who must live also in the here-and-now, not only as Christians but also as citizens of a particular nation and polity, it all looks very bleak.

Even without deliberate abolition, we must nevertheless admit that the metaphysical constitution of England, no less than the material constitution, is in crisis. The most recent census showed that, for the first time since the conversion of Anglo-Saxon England, Christians are now a nominal minority. Of course, the invisible church of born-again Spirit-filled believers was probably always a minority of the population, in England as in any nation. Nevertheless, from the Early Middle Ages until just a few generations ago, nominal Christianity was the norm, and Christian ideas held sway over the narratives, ethics, and assumptions of English society. Not everyone conformed to a model of Christian holiness and goodness – far from it – but there was a common view, shaped by the pervasive cultural, social, and educational influence of Christianity, of what holiness and goodness looked like

That Christian consensus is what has been lost in the social and demographic change – some might call it, a cultural revolution – since the 1960s. The Church of England is still doing excellent work in parishes up and down the land, multiplying the loaves and fishes of its limited resources to provide everything from foodbanks and debt advisory services to parent-toddler groups and pensioners’ clubs, filling the social gap that a failing state no longer even tries to fill. Yet, numerically, the Church of England – except in a few bright pockets of revival – is in free-fall. In the lands of St Ethelbert, St Edmund, and St Cuthbert, empty church buildings have been turned into private houses, gyms, carpet warehouses, soft play centres, mosques, pubs and nightclubs. Looking at things through a spiritual rather than natural lens, we should not be discouraged. We can of course have confidence that the risen King has triumphed, is triumphing, and will ultimately triumph – reconciling all things to the Father, and restoring the whole cosmos to glory. Nevertheless, to those of us who must live also in the here-and-now, not only as Christians but also as citizens of a particular nation and polity, it all looks very bleak. It is a spiritual trial, but a civilisational tragedy. 

Christianity – in particular in the form of mainline Protestantism - has provided the moral, ethical, sociological and institutional props on which constitutional democracy in the Anglosphere was built. Remove those props, and the whole edifice becomes a lot less stable. When we look at the egregious behaviour of Trump and his ilk, we get a taste of how rotten pagan politics would be, unseasoned and unpreserved by the salt and light of Christianity. 

This is, of course, is not to say one cannot have democracies in societies where Christianity has been less historically prevalent. Democracy can exist in a wide range of religious cultures, including in majority Muslim, Hindu and Buddhist societies. Nevertheless, at least within the Westminster Model, it depends upon an institutional subculture - a set of norms, values, traditions, expectations - which, even if successfully transplanted and adapted to different contexts, owe a lot to the kinds of Christianity that emerged from the English Reformation. The restoration of England’s Christian metaphysical constitution is, therefore, integral to restoring the health of the democratic mechanical constitution. By the works of the law – even constitutional law – shall no flesh be justified. Any constitutional refoundation of English democracy worthy of the name must be led and accompanied by a revival of the English Church and by the re-evangelisation of the English people.  

The cross atop the crown represents the principle that public authority has itself been humbled and crucified; the state exists not to be served but to serve the public

his case must be made with careful nuance. It could be misconstrued as an apology for Christian nationalism. Sadly, those who make the most noise about ‘Christian values’ all too often seem, judging by their attitudes and actions, to be reading a different gospel – one from which the Magnificat and the Sermon on the Mount have been expunged. It is galling to watch far-right authoritarian reactionaries parading their Christianity for public display, while pursuing compassionless policies that hurt the poor, the disabled, and outsiders.  

A restoration of England’s Christian metaphysical constitution would not limit freedom of religion, nor diminish the equal rights of all citizens regardless of their religion or lack thereof. The principles of religious liberty and non-discrimination, which go back to Catholic Emancipation and to the repeal of the Test and Corporation Acts in the early nineteenth century, should be guaranteed. Rather, establishment would simply give honourable public recognition to the place of Christianity in the nation’s heritage, grounding the state upon a core of shared Christian values, norms and traditions. If that core is maintained, tolerance and diversity can be built upon it, without undermining the nation’s historic character. In practice, this might involve a more prominent role for Christianity in public life. Public authorities might pay more attention, in their official pronouncements, to the church calendar, and less to those of other faiths, or of post-Christian causes. There might be a more obvious Christian influence in education. One of the by-products of the 1960s cultural revolution is that the clergy have retreated into a narrowly defined churchy role: the academic and the school master in holy orders have all-but vanished. Public broadcasting, too, might return to the broadly Christian assumptions of Lord Reith.  

One of the constitutional functions of an established church is to act as a reminder: to remind the King, Ministers, parliamentarians, civil servants, judges, magistrates, councillors, police constables, teachers, opinion-formers, and every citizen, that to govern is to serve. The cross atop the crown represents the principle that public authority has itself been humbled and crucified; the state exists not to be served but to serve the public. Without such a concept of ethically responsible servant leadership – grounded upon truth, justice, and compassion – democracy can easily deteriorate into cruel, crude, and crass populist perversions of itself.  

Another constitutional function of an established church is to remind us what freedom is for. If applied as mere abstractions, shorn from the Christian root from which they have sprung, and the teleological objectives towards which they point, human rights – valuable as they are – can produce absurd results, actually harming, rather than protecting, freedoms of conscience and expression. Taking the metaphysical constitution seriously again would certainly mean interpreting and enforcing our human rights laws in ways congruent to the Christian principles upon which they are based. After all, it is very odd, in a country where the king has sworn to maintain the true profession of the gospel, that people are being arrested for silent prayer, and that local councils are trying to ban street evangelism. 

Finally, the metaphysical constitution, no less than the mechanical, needs checks and balances. The church cannot perform this constitutional function, as the ethical conscience of the state, if it is – like, say, the Russian Orthodox Church – dependent upon the state. The establishment of the church must not, therefore, compromise the autonomy of the church, to govern itself synodically, and to choose its own bishops. The current process of episcopal selection through the Crown Nominations Commission might leave much to be desired, but going back to the days of political appointment by the Prime Minister is not a viable option. Rather, the principle should be acknowledged, at a constitutional level, that – in the words of Magna Carta - Anglicana ecclesia libera sit: the Church of England shall be free. If we can create constitutional rules that enable judicial independence, and the impartiality of bodies such as the Electoral Commission, we should be able to square this constitutional circle, too.