Leigh Emery
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| Debates over psychiatric diagnosis: an ideological smack-down? Pic: Battle Cry of Freedom by James McPherson |
On Sunday the12th of May, The UK Observer ran a front-page article stating that the Division of Clinical Psychology (DCP), a
subdivision of the British Psychological Society (BPS), was releasing a position statement calling for a ‘paradigm shift’ in mental health. The proposed
shift was away from a view of mental health problems as illnesses with biological
roots, and towards greater consideration of psychological and social factors.
The DCP did its best to get the
media interested and was rewarded with extensive coverage. The Observer and
Guardian website included an online poll
and other articles
and commentaries that explored the debate in some depth. The Daily Mail ran a piece the following day.
Lucy Johnstone and Richard Bentall, both Clinical Psychologists and critics
of the ‘disease model’ of psychological distress, appeared on Radio 4 and Peter
Kinderman, a former DCP Chair, was on telly in Canada.
The release of the statement was a
significant move in the world of mental health.
The DCP was making an uncharacteristically vocal stand against the medicalisation
of distress. The timing was also interesting being just before the publication
of the DSM-5, the 5th (and most extensive) edition of
the controversial manual for mental health diagnoses. Naturally, this ruffled a few feathers, but
even those who disagreed with DCP’s stance could appreciate the value of
bringing the debate into the public domain?
And surely the public would get on board with such an important issue?
Well, sort of. While there was some intelligent, thoughtful
discussion, comments from the public on the Guardian website ranged from positive
to indifferent through to vitriolic. Comments on
a website aren’t necessarily the greatest measure of public attitudes, but they
nevertheless made for thought-provoking reading. Two emerged as of particular interest. The first was the idea the psychologists are
basically charlatans. Here are a couple of comments from an, alas, far wider
pool:
‘…this psychology thing is pure quackery. Psychiatry at least kept the
symptoms in control whereas a faith healer like a psygologist [sic] would not
have been able to do anything.’
‘I have never trusted so-called psychological
therapists. Any crank can set themself [sic] up as a therapist and fleece the
worried-well of their money. Even those with some qualifications in psychology
have no real insight into mental illness…If you have chest pains you see a
cardiologist. If you suffer from clinical depression you need a psychiatrist.’
As a trainee clinical
psychologist, such remarks made uncomfortable reading and are perhaps indicative
of a PR failure on the part of psychology. Psychologists place great emphasis on the role
of the ‘scientist-practitioner’, someone whose work is informed by research and
who contributes to the evidence base by carrying out their own research in the
field
However, even if you accept that
psychologists are not quacks, there is still the issue of professional vested
interests. Some comments suggested that this might underlie the DCP stance.
‘[Medicalising mental health is]
good business for psychologists and psychiatrists so all they're arguing about
is who should get the booty.’
‘This sounds
like turf wars to me - the psychologists want to claim all mental disorders for
themselves.’
While it’s
worrying that the debate has been framed as ‘psychology versus psychiatry', there
are some obvious reasons why it may be perceived in that way. The Observer headlined their front-page article
as ‘Psychiatrists Under Fire in Mental Health Battle’ and debates in the news
have invariably featured a psychologist and a psychiatrist in conflict. It’s a neat narrative, but an inaccurate
one.
In her Radio 4 interview
on on 13 May, Lucy Johnstone opened by saying ‘This really isn’t an argument
between psychologists and psychiatrists’.
The Critical Psychiatry network has issued a statement explicitly
rejecting the idea of a ‘guild dispute’. While psychologists and psychiatrists sometimes
have different views, most psychiatrists I’ve encountered recognise the importance
of social and psychological influences. Likewise most psychologists acknowledge
biological factors. Placing the two professions in direct conflict stimulates
defensiveness, dismissiveness and a closing of ranks which could be detrimental
to our understanding of what is arguably the most significant issue in mental
health.
I think the debate has got off the ground but remains polarised. It seems to me that psychologists and psychiatrists need to recognise the common ground that they have, and work from there. Neither camp has a monopoly on the truth and both sides have important points to make.
ReplyDeletePolarised indeed. Though I wonder if the divide is psychology/psychiatry. There are plenty of radical psychiatrists out there and more than a few psychologists who are quite keen on a narrative of illness. John McGowan
ReplyDeleteI've just sent comments to the DCP about their statement. Waiting for a response.
ReplyDeleteThe statement acknowledges the complex relationship between social, psychological and biological factors. It points out the limitations of seeing 'biology as a primary cause' and the ''disease' model', making a distinction between the two.
However, it also refers to the problems caused by 'applying physical disease models and medical classification to the *realms* [my emphasis] of thoughts, feelings and behaviours' as if physical disease is nothing to do with thoughts, feelings and behaviours. They're not independent of course; psychological and social factors are emergent properties of interactions between biological factors and the environment and how people respond to those interactions. The three 'realms' are different levels of analysis of the same things.
I think some clarification of how terms are defined by different parties to the debate might avoid needless polarisation.
Interesting post.
ReplyDeleteYou say: "At its broadest, it asks us whether placing the causes of madness inside an individual distracts attention from the interpersonal, social, cultural, economic or political factors that influence all of us."
As a service user, I would ask: if the DCP got its wish for a paradigm shift and all psychiatric diagnoses (and presumably treatments) were swept away tomorrow, what approach would the DCP want to take its place? How would it pay attention to the interpersonal, social, cultural, economic and political factors? And where is the evidence the approach would work?
Several good questions there, and I'll try to answer them as best I can.
DeleteThe DCP position statement doesn't describe an alternative - mainly it says that the current "disease" model isn't fit for purpose, doesn't have the evidence to back it up and needs rethinking. However, many people who argue against the "disease" model prefer an approach that describes a person's problems using what's called a "case formulation". In lay terms, a case formulation is basically a description of what's happening for the individual.
I'll try to explain with a crude example. Imagine a man called John, who has a diagnosis of "paranoid schizophrenia". Instead of that diagnosis, John’s case formulation might say "John is a young black man who grew up in a rough neighbourhood. He was often in trouble with the police and experienced racial abuse. He was beaten up by his father and bullied at school. As a result, he has trouble trusting people, and sometimes feels like people are whispering about him. He sometimes hears voices that tell him not to go outside."
It's perhaps more long-winded, but gives a more detailed picture of John’s situation. As you can also see, the case formulation describes his problems and takes into account John's relationships, his ethnicity, his experiences and wider social problems such as crime, poverty and racism.
As for the evidence base, that's a slightly more tricky topic because it depends on what you mean by the approach "working". There’s evidence that case formulation can be used instead of diagnosis – it’s used widely in psychological therapies, and in some mental health teams. There’s also lots of evidence that social and environmental factors play a role in mental health problems.
As for whether it makes for better quality interventions, it becomes a bit more complex. The DCP isn’t arguing that current interventions/treatments for mental health problems should necessarily be abandoned, but it calls for more balance in what’s offered. If the disease model makes the assumption that mental health problems are primarily caused by “chemical imbalances,” then the first line of defence tends to be medication. The DCP are calling for a greater range of interventions (such as psychological therapies, family work or occupational therapy) to be offered as well as medication, and there’s lots of evidence that these interventions are effective.
I hope this answers your questions. If you want more information, you might want to look at Peter Kinderman's article on case formulation as an alternative to diagnosis here:
http://dxsummit.org/archives/197.
You can also read the DCP’s position statement here:
http://dcp.bps.org.uk/document-download-area/document-download$.cfm?file_uuid=CB57D38C-9D29-0589-848A-3380FE5DD661&ext=pdf
Leigh
I think this was probably just an unfortunate choice of wording, but what's being looked for here isn't 'balance' is it? It's actually the factors having the greatest impact.
ReplyDelete