RAT responds to the independent review into prevalence and support for mental health conditions, ADHD and autism
Ten months ago, erstwhile Health Secretary Wes Streeting commissioned a review to examine rising demands and diagnostic rates for mental health conditions, autism and ADHD. Earlier this month, the final report from this review, chaired by Prof Peter Fonagy, was published.
Though the review was not specifically about post-traumatic stress, its contents could have considerable impact on how trauma is understood, recognised and treated. So we have gone through and pulled out a few themes that we think will help our cause, and a few that raise some concerns for us - especially with the government’s 10-year mental health plan in development as we speak.
Acknowledgements that give us hope
People aren’t making up distress
“The rise in mental health problems is real, is affecting everyday functioning, and cannot be explained by greater awareness alone”
The review - and indeed, the interviews Prof Peter Fonagy has given about it - have been clear on this above all else: the recent rise in mental health related needs is genuine. It does not deny that mental health problems, autism and ADHD might be being overdiagnosed in some instances - but it also recognises that in others, they could be being underdiagnosed and/or misdiagnosed as well.
This is crucial, because it takes blame and stigma away from people coming forwards with needs, and instead spotlights diagnostic, support and data collecting systems as needing revision and adaptation to the pressures of the modern day.
Where the interim report barely mentioned trauma at all, the full report acknowledged many times that traumatic experiences are contributing to the increase in mental distress. It sounds obvious, but the word being used really helps to take us out of an exclusively inside-out perception of mental health problems and point to the need for changes in people’s circumstances, not just our heads.
Diagnoses are concepts, not facts
“Diagnostic systems have always reflected an interaction between scientific evidence, clinical observation and wider social understanding.”
The review does well to balance widespread concerns about changing goalposts for diagnosis, with a reminder that diagnostic definitions are not and never have been timeless truths. In fact, it uses the example of the eventual inclusion of post traumatic stress disorder in the 1980 edition of the DSM as an example of this. That happened thanks to urging from clinicians and veterans following the Vietnam War, with the ‘hard science’ catching up much later.
Our world is changing, and changing at speed. Adversity is being experienced in heightened, broader and new ways. The review acknowledges that these external shifts are impacting the presentation and prevalence of mental distress, and symptoms associated with neurodivergence. Since trauma is inherently caused by adversity, presentation and prevalence of it will also be affected by these shifts.
We urgently need to address health inequalities
“People living with [severe mental illness] experience some of the poorest health and social outcomes of any group considered in this Review. Rates of unemployment, economic inactivity, housing instability and social exclusion remain exceptionally high… Physical health inequalities are profound, contributing to reduced life expectancy… these frequently occur alongside substance use disorders, trauma histories, personality difficulties and social adversity.”
The review points to many ways in which people with co-occurring conditions and life challenges are currently being let down by systems that don't have appropriate pathways for them. It identifies how many people with ‘severe mental illness’ also live with physical disabilities and experience social adversity, and spend far longer in hospital than is necessary because of poorly managed co-existing needs.
Trauma is necessarily an intersectional issue - being a (series of) health concern(s) brought about by exposure to adversity. We were struck by the similarities between the difficulties people living with ‘severe mental illness’ face when they have comorbidities, and those faced by members of our community. Long-term trauma can place huge pressure on the body as well as the mind (1), and healing often requires changes in our circumstances as well as our psyches (2) - so the longer we ignore the true natures of post-traumatic stress and the many ways in which our society breeds it, the more we will see suffering needlessly prolonged from efforts to treat isolated symptoms.
Many people who experience these problems may not be identified under this ‘severe mental illness’ label - but the comparable pattern is important.
We must respond to needs, not labels
“Support should be available according to a person’s needs before, during and after assessment, and not be withheld while waiting for a diagnosis.”
This is possibly the strongest actionable conclusion of the review: availability of treatment currently depends too much on having diagnoses that can take years to gain, and even then only give us a small piece of the puzzle. We need to be able to respond immediately to what we do know people are facing, rather than waiting to try to name what we don't know.
This hits home very strongly for many of us affected by trauma. Complex post-traumatic stress has only been recognised by the International Classification of Diseases (ICD) since 2022, and still isn't by the Diagnostic and Statistical Manual of Mental Disorders (DSM).
The review identifies that diagnostic frameworks can be valuable in supporting people to understand major features of how we function - and it is also valuable from a public health research perspective to be able to group experiences. So there is still a real value in pushing for further recognition of complex trauma. But no better imminent change could come for survivors from this review, than getting access to some kind of support as soon as it is sought, rather than depending on a diagnosis that many are not used to naming yet.
Responses must come from sectors beyond healthcare
“Support should be person-centred and recognise that recovery and participation depend on much more than clinical treatment alone. Education, employment, relationships, housing, debt, gambling-related harms and other social determinants all influence mental health and should be considered as part of care.”
RAT is built on an understanding that any society that is truly committed to addressing post-traumatic stress will take action on the causes of traumatic experiences, at least as readily as it meets the healthcare needs of survivors.
The nervous system responses underpinning trauma are not in themselves faulty: in fact, they are indicative of a healthy survival instinct that should be celebrated. Post-traumatic stress often occurs when a nervous system has been stretched too far for too long because of the circumstances in which it operates. Often, the results are that we respond as if to an emergency when there is none; but also often, we respond as if to emergency when we perceive subtle but genuine signs of danger that others cannot foresee.
When we pathologise legitimate distress, we not only teach survivors to distrust our minds and our bodies; we send a strong message to survivors that their safety does not matter. Beyond keeping people in avoidable adversity, this knocks survivors’ senses of self-efficacy, self-esteem and self-worth - impacting our capacity for self-care and making us increasingly dependent on the systems that are failing us. Acknowledging and responding to the sources of trauma aren't adjacent to trauma care, it is a crucial part of it (3).
This review many times acknowledges that the increase in mental health conditions is no doubt connected to the mounting pressures, challenges, conflicts and injustices of the current time, and that joined-up approaches with other sectors to meet people's external needs are vital for any chance of real improvement. We think that is true for improvement in people already living with post-traumatic stress, and for future prevention.
Similarities between trauma and neurodivergence
The review mentions instances in which a neurodivergent person might be known to have experienced trauma, and so their neurodivergent traits might only be put down to being traumatised; and others in which a traumatised person might be assumed to be neurodivergent, and treated for that rather than being invited to talk about their experiences.
The value of this observation goes beyond noting that long-term treatment needs will probably differ between someone with trauma and someone with a neurodivergence like autism or ADHD. Indirectly, it also acknowledges that many traits of trauma are very similar to traits of neurodivergence.
This is a hot topic, with many different causality theories going around - from those implying that all neurodivergence initially starts as trauma (4), to others highlighting how much more likely people born neurodivergent are to go on to experience strong post-traumatic stress symptoms (5), with many shades of grey in between the two. It is a little surprising that the review doesn't reference any of these theories or the discourse growing around it, considering their direct relevance to questions or underdiagnosis, misdiagnosis or overdiagnosis across mental health struggles, autism and ADHD.
What feels important to us about the whole discussion, is the recognition that complex and/or developmental trauma can affect survivors like a neurodivergence: something that has fundamentally affected how our brains process information (6). Something that, though clinical treatment can help us to manage, is better worked with, rather than against, by expanding the window of tolerance (7).
The review doesn't go quite so far as to make that connection, and we’ll talk about that under the concerns section of this post - but the explicit acknowledgement of similarities in symptoms, and the risks associated with considering only one or the other, is a great start.
Also a great start, is the observation that living with neurodivergence can expose someone to traumatic experiences in a world that doesn't know how to integrate us - so for that, if no other reason, neurodivergence and post-traumatic stress often co-occur. The review’s recommendation for training and commitment to neurodivergent-friendly schools and workplaces is very welcome.
Lived experience involvement in co-design of treatment and support is crucial
“Co-design with people with lived experience, families, carers and communities is essential if services are to build trust, reach underserved groups and remain responsive to changing needs.”
It will be no surprise that this was music to our ears. The review does well to point to the range of reasons why people with lived experience should be part of designs. It isn't only about proving interventions to be trustworthy; it's also about genuine knowledge of how the science does and doesn't translate to real lives, shifting circumstances, varying backgrounds.
Making that explicit is really important because, when it is just seen as a quality mark, lived experience experts are often treated as tokens in processes, and given very little authority or influence. It would have been even better if the review had pointed out any of the evidence around how much harm can be caused to survivors when lived experience engagement is tokenistic, and how important it is to define the intended scope of involvement so survivors really know what they are consenting to do (8).
Peer support is a valuable intervention while people are waiting for clinical support
“Waiting should include active monitoring, evidence based psychoeducation, practical support, parenting support, peer support and planned review, supplemented where appropriate by evidence-assured digital tools.”
This acknowledgment is a little squashed into a long list of other things that would help - but it's there, and we’re here to make sure it doesn't go unnoticed!
Recent research into pathways to complex trauma care, in which we were involved and which in part informed our production COMPLEX, has identified that peer support is almost universally what helps survivors most while trying to navigate the labyrinthine obstacles to clinical support - including not only waiting lists but also misdiagnoses, iatrogenic harm, culturally insensitive responses, and rejection from treatments for being “too complex”, among other things (9).
And for many, it isn’t a short-term sticking plaster. Peer support is often where people realise they aren’t broken, that there are others like them leading good lives, that they don’t have to put on a mask to find their people. The structures around peer support are also often far less arbitrary in terms of how many sessions someone may attend, how regularly, over what period of time: in trauma this is so valuable, because healing is almost never a linear process, and agency in how to approach it is crucial.
We aren’t claiming that peer support can replace clinical treatment - but in many cases it is needed at least as much, and (dare we say it) in some cases it may even be needed more.
We truly hope this small acknowledgement will make it easier to advocate for proper resourcing for ongoing peer support offers - and for freedom of survivors running them to do so as they see fit.
Things that raise concerns for us
The implication of hierarchies of trauma
“In many ways the fact that people are becoming more interested in using the language of mental health in everyday discourse is a good thing. But difficulties are more frequently framed now in terms formerly more restricted to professional discourse and diagnostic labels are viewed as part of personal identity. An expansion of mental health descriptors is used to describe phenomena well beyond the original meaning of a term, trauma being a characteristic example.”
It is disappointing, to our minds, that trauma is used as an example here - as well as inaccurate. The review challenges everyday use of the word “trauma” to describe experiences beyond the “original meaning” - but implies that the “original meaning” of the word was as a mental health descriptor, restricted to mental health discourse and diagnostic labels.
The word ‘trauma’ comes from Ancient Greek, meaning a wound; it first came into English language in the 1690s to mean a physical injury caused by external violence; was first used to refer to a “psychic wound” by William James around 1894 before being adopted as such by Sigmund Freud and other psychoanalysts who were studying hysteria and traumatic neuroses; and then expanded in the 1970s to describe severe emotional distress, adverse life events and the formal basis for post-traumatic stress disorder.
Which of these was the “original” meaning, according to this review? Clearly not the very first one, restricted to physical health. Are we not glad that the 1970s took us away from confining our understanding of trauma to misogynistic and otherwise bigoted concepts like hysteria and neuroses? Then what makes us so sure that it is fundamentally ‘wrong’ for us to expand our awareness of what experiences can cause trauma still further beyond those considered 50 years ago?
In a review that elsewhere acknowledges that diagnoses are concepts and not facts, that our understanding of them is shaped by many things other than scientific and clinical work, and that the presentation and prevalence of them changes in our fast-moving world, this negation of the range of experiences that can contribute to trauma seems inconsistent and destructive.
Again, we see the reviewers not engaging with growing modern evidence and discourse around trauma and post-traumatic stress. We know that no individual will respond to the same experience in the same way. Seemingly ‘small’ traumas may affect one person in a considerable way while seemingly ‘big’ traumas may hardly affect another person at all. Just in our own work, we often see survivors far worse affected by objectively ‘minor’ traumas than by objectively ‘major’ ones. So what good is it to try to create some kind of clinically objective hierarchy of trauma, when it tells us nothing about the clinical reality of need?
Slight belittling of people’s efforts to educate themselves and understand themselves
“A related but distinct concern is the growing volume of mental health and diagnostic content online… much of this content is simplified, decontextualised or inaccurate… The risk arises when authoritative-sounding content is repeatedly promoted without appropriate safeguards for accuracy, context or clinical nuance.”
In fairness, the review as a whole is reasonably balanced on the pros and cons of widespread discourse on mental health and neurodivergence on social media. There is acknowledgment both that helpful increased awareness of previously overlooked symptoms is contributing to increased demand for diagnostic assessments; and that a lot of information shared on social media is misleading. Both of these things are true.
But when detailed, currently considered ‘accurate’ information on topics around which so much is still being discovered can be so hard to find - especially for how it appears later in life and/or in women, where awareness is finally starting to grow - what are people supposed to do, other than take the information they can get? When official diagnoses take so many years to come through, can we really expect people to wait for confirmation before digesting whatever frameworks they can find for starting to accept and trust themselves? And when there is so much inconsistency in who does and who doesn't eventually get diagnosed, why should we base that understanding of ourselves on official diagnosis anyway?
This topic is particularly pressing for those of us living with long-term trauma, since - as we have already mentioned - complex trauma as an official diagnosis is so new, and so many of us remain undiagnosed.
We are certainly in favour of the recommendation that properly researched psychoeducation should be made available to people while they are waiting for diagnosis and/or clinical support. But it's worth mentioning that there aren't any truly infallible ways of proving the accuracy of any information related to mental health or neurodivergence: we can't circle it on an X-ray or confirm it from a blood test in the way we can many physical conditions. Factors that are considered to make information scientifically robust may be well-founded, but they are also subjective - and the process of producing such material is so lengthy that it can't always keep pace with clinical observation, social awareness and the speed of change of the society in which these conditions exist.
We should treat ‘official’ scientific evidence, developing scientific theory, social theory and accounts of personal experience differently, yes; but we would do better to encourage people to access and understand these sources as complementing each other, than to herald any one of these sources as absolute universal truth.
Personality disorder is reported on without reference to controversy around the term
The researchers were called on to analyse diagnosis and prevalence of mental health conditions - so of course, we cannot expect them simply to miss out a frequently used diagnosis just because it is contested. But we would have expected data presented around personality disorder at least to be caveated with reference to these disputes.
It has been 34 years since Judith Herman pointed out the stigmatising effect of telling someone their personality is disordered by referring to it as a “sophisticated insult” (10) - so this controversy is nothing new. With it has come the frequent observation that such diagnoses can disguise trauma histories, blocking people from appropriate healthcare and interventions appropriate to their circumstances. More recently, research has made very clear how often receiving this diagnosis actively puts people in danger by exposing them to restrictive mental health care practices, making them less likely to be taken seriously in court proceedings, and more (11).
With that level of direct systemic threat to survivors, we would have wanted a review that addresses questions over the validity of mental health and neurodivergence diagnoses to invite readers to receive the data around personality disorder with a critical, or at least cautious eye.
Somewhat narrow definition of socially excluded and highly vulnerable populations
“Some groups with the greatest mental health needs are also among the least visible in conventional data. Household surveys and routine healthcare records depend on stable housing, contact with services and participation in research, and therefore under-represent people who are homeless, living in secure settings, or otherwise socially excluded.”
In the specific section of the review referring to socially excluded and highly vulnerable populations, it hones in on three groups: those in the justice system, those experiencing homelessness, and those with learning difficulties. Elsewhere, a lot of detail is given on veterans and looked-after children. These undoubtedly are socially excluded and highly vulnerable populations - but there are many, many others.
What about people who face bigotry throughout their lives? What about people who are in, trying to leave, or have left cults or high control religions, or other coercive situations? What about survivors of domestic abuse, intimate partner violence, child sexual abuse? People who have experienced many adverse childhood experiences? Or, indeed, what about people whose experiences of homelessness, the justice system, or living in care, are in the past - but who still carry the wounds?
The focus is explained because these groups are often missed in conventional data. But people from these other groups, while perhaps more likely to be captured in conventional data, are not logged as having these characteristics in most household surveys and routine healthcare records - so we still have no way of analysing prevalence of mental health struggles and neurodivergence among them purely from this information source. Many from these groups actively avoid contact with services, which also makes them less visible in conventional data.
It makes a lot of sense that we are seeing such a spike in mental distress from trauma since the pandemic, with reference to these groups. Domestic abuse cases skyrocketed during the pandemic (12). People lost loved ones and people on whom they depended, often very suddenly. People lost jobs, faced serious financial hardship. Children who might usually have been at nursery and school while many of these domestic pressures were processed by parents and carers were stuck at home, exposed to everything. Social media became our go-to way to communicate with each other, so we were mostly engaging with each other through screens (where lack of direct human contact makes it much easier to be less considerate of the emotional impact of our words) at a time when we were angry, grieving, and scared.
Since then, international conflicts and movement of people while we are trying to rebuild our economies are leading to surges in xenophobia, racism and faith-based bigotry, while continued social media exposure with algorithms that favour content that is likely to cause outrage and continued scrolling (13) is bringing more and more bigoted influences (14).
We can't help but notice that these are also groups of people who are likely to experience complex post-traumatic stress, which presents with additional symptoms to post-traumatic stress, including difficulty with forming and maintaining relationships, negative self-concept, and problems managing emotions. So the reasons for social exclusion and high vulnerability in these groups are different: often more subtle, and more akin to those associated with neurodivergence.
On the surface, they may seem less serious. But they are insidious, and without good support and awareness in wider society, they can lead to vicious cycles of retraumatisation. Survivors of child abuse are more likely to experience abusive adult relationships (15). Having many traumatic associations with relational or social settings can result in extreme isolation, all too often also involving self-neglect and addictions brought on by self-medicating (16). They can also create workplace challenges that make it difficult for people to maintain employment (17). And the spikes in symptoms can be so unpredictable that someone who has been pretty stable for years can very suddenly find their lives turning upside down again (18).
All of the above is avoidable. And - considering how many people who have contact with the justice system, experience homelessness, join the military, or have to have their children taken into care have themselves experienced considerable and complex trauma - taking complex trauma support seriously equates to prevention of these more recognised forms of social exclusion and high vulnerability, too.
No mention at all of complex trauma or complex post-traumatic stress
This, for us, is probably the most troubling feature of the whole review. Admittedly, there will only be four years’ worth of data to share about complex post-traumatic stress disorder diagnoses - and, considering how little information there is about prevalence of long recognised conditions, information about prevalence of complex trauma is undoubtedly scarce. But surely, the diagnosis that has most recently become recognised, that has so much cross-over with so many other mental health and neurodivergence symptoms, that has whole NHS clinics dedicated to it with waiting lists spanning as long as 4 years, deserves a mention?
It certainly begs the question: why the omission? Are the researchers unaware of it? Seems highly unlikely. Do they not believe in it? Also seems relatively unlikely, considering that the review on the whole shows reasonable balance and impartiality. So is it purely a statistical availability thing? If so - does this not point to a huge gap in the nature of information considered?
Conclusion
At the heart of our concerns here, is an underlying impression from the review that trauma is still being perceived by the researchers through outdated descriptors. In a way this is understandable, as the review was called on to respond to diagnostic trends, and general diagnostic habits are far behind the most up-to-date research and understanding of the many forms trauma can take.
But the idea of action being taken to address the rise in mental distress and demand for diagnoses, amid fears of underdiagnosis and misdiagnosis as well as overdiagnosis of conditions that have so many other symptoms in common with complex trauma, without acknowledging how likely complex trauma is to be playing a part in many of these instances, is frightening.
Not only will people continue to be diagnosed in ways that are inaccurate, incomplete and/or even damaging. But on a societal level, we will continue to underestimate just how much of a public health threat is posed by causes and exacerbators of complex trauma throughout a person’s life - not just while they are in a situation and for a short time afterwards.
The Chair of this review, Prof Peter Fonagy, is also at the helm of the research building towards the government's upcoming 10-year mental health plan. We are encouraged by his enthusiasm for prevention (while not counting our chickens, remembering that prevention was also the intended direction when the government last created a mental health plan), responding quickly to need without reliance on diagnosis, and for cross-sector action to address causes of rising mental distress as well as treating it when it appears.
We will be making every effort to get the point across that trauma, in the plethora of ways we now understand it to exist and to be caused, is one of our most profound and widespread causes of mental distress - and we cannot afford to wait until there are enough years’ worth of data to produce thorough evidence about it before recognising it, equipping health services and wider society to meet it, and approaching its causes as urgent public health risks.
We will soon be announcing an exciting new initiative that RAT will be running. If improved and updated recognition of trauma matters to you, and you are as keen as us to see survivors at the helm of change, please sign up to our mailing list and keep an eye on our socials for more information.
Noteboom et al. (2021), The long-lasting impact of childhood trauma on adult chronic physical disorders
Rousseau, Danielle (2026), Trauma and Healing: An Intersectional Analysis of Moving Past Trauma, 2026
https://www.cptsdeducation.com/blog/validation-and-complex-ptsd
Maté, Gabor (1999), Scattered Minds: The Origins and Healing of Attention Deficit Disorder
Prosser R et al. (2026), Post-traumatic stress disorder in autistic and non-autistic adults: The impact of appraisals on reactions to traumatic events.
Bush, Matt (2024), Complex Trauma Is A Neurodivergence
Siegel, Dan (2003), Healing Trauma: Attachment, Mind, Body, and Brain
Frederick, Chris (2025), Lived Experience Is Not Enough: the Illusion of Inclusion in Mental Health Spaces
Herman, Judith (1992), Trauma and Recovery: The Aftermath of Violence—From Domestic Abuse to Political Terror
Platfform (2026), The Hidden Harm of the Diagnosis of Personality Disorder: Mental Health and Human Rights
Anderberg D. et al (2022), Quantifying domestic violence in times of crisis: An internet search activity-based measure for the COVID-19 pandemic
Brady WJ et al (2021), How social learning amplifies moral outrage expression in online social networks
Sugiura, Lisa (2025), How the ‘manosphere’ spreads through online gaming, influencers and algorithms
Impact of child abuse on later life, Crime Survey for England and Wales, year ending March 2016
Lien C et al (2016), Narratives of Self Neglect: Patterns of Traumatic Personal Experiences and Maladaptive Behaviors in Cognitively Intact Older Adults, 2016
Brenner L et al (2019), Symptom burden and work-related impairment among patients with PTSD and complex PTSD
Wang SK et al (2023), Psychological trauma, posttraumatic stress disorder and trauma-related depression: A mini-review
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