Going beyond the norm

Anne Cooke

I’ve been a bit itinerant this year. The response to Understanding Psychosis and Schizophrenia, the report I edited for the British Psychological Society, has been amazing and I’ve been invited to speak about it in Washington, New York, Seville, Dublin and most recently Milan. So it was great to get an invitation to do something nearer home last month, in our local town of Tunbridge Wells.  I was part of a panel at the annual Critical Voices event. Critical Voices? To tell the truth I wasn’t totally clear about it either. It describes itself like this:

‘The space of medicine, health and wellbeing is one we all inhabit. It is at once complex, often highly technical and grounded in power, politics and debate. It is a space where we have made life changing advances. Yet it is also where we are at our most vulnerable, where our most intimate times of birth, illness, treatment, life and death are played out. Critical in every sense.  Critical Voices provides an opportunity for conversations that explore the voices in this space as we strive to bring together doctors, surgeons, psychologists, patients, carers, campaigners, researchers and academics - intertwined with the expressive insights from film, music, poetry and literature.’

As you might expect, it was a mighty interesting day.  I did a ten minute double-act with my friend and colleague Peter Kinderman, talking about our vision for the future of psychological health care when we stop dividing people into ‘normal’ and ‘mentally ill’. A video of the event is embeded below or you can watch it on Youtube here. 

Mad, bad or maybe merely human

Peter Kinderman

Is a mental health diagnosis
necessary to avoid prison?
Photo: Liam Quinn

The British Psychological Society’s report ‘Understanding Psychosis and Schizophrenia’ has challenged many commonly held beliefs about serious mental health problems. While the report has been widely welcomed, it has also prompted questions, particularly focusing on the report’s key recommendation that we move beyond seeing distress as a symptom of disease:

‘services should not insist that people accept any one framework of understanding, for example the idea that their problems are symptoms of an underlying illness’. 

This issue has been addressed on this site on a number of occasions and it’s clearly one that arouses strong feelings. The disease-model of modern psychiatry views emotional distress as the result of illnesses or disorders. Treating such problems in this way, as healthcare issues, is often seen as essential for ensuring that people get the help they need, and vital in avoiding inappropriate treatment.  In particular, some colleagues have suggested that viewing people as ‘mentally ill’ prevents them being blamed for actions for which they are not responsible. Rather than being seen as bad you can be mad (or more accurately sick) and more likely to be treated rather than simply punished.  Removing this protection (the argument continues) may even result in people being sent to prison inappropriately. These are clearly serious concerns and deserve careful consideration.

We need brave people to speak out

Angela Gilchrist on the launch of ‘Understanding Psychosis and Schizophrenia’ , a new report from the British Psychological Society

This is a critical moment in mental health history: never have so many decision makers wanted things to change. That’s according to the National Clinical Director for Mental Health, Dr Geraldine Strathdee, speaking last week at the launch of ‘Understanding Psychosis and Schizophrenia', a report from the British Psychological Society’s Division of Clinical Psychology.

The event, described by many as 'ground-breaking and momentous', was remarkable in that it brought together numerous and disparate voices in the mental health community including psychiatrists, psychologists, policy makers, third sector workers and people with lived experience of psychosis. Among the guests were the Shadow Minister for Public Health and Mental Health, Luciana Berger; and the founder and principal theorist for the Hearing Voices Movement, Professor Marius Romme.

Guest post: But they look like you and me!

Jo Mueller investigates how parents could hold the key to tackling mental health stigma

Alien? Or simply struggling? Views about
mental health are formed early.
Photo: nadja robot

When it comes to attitudes to mental health, things are getting worse. Despite the high-profile campaigns, stigma and discrimination against people with mental health problems seem to be on the rise. Part of the reason may be that our campaigns are promoting the wrong message. The way we often address stigma is to promote the idea that mental health problems are illnesses. The rationale is noble. Rather than give the impression that someone is weak or blameworthy, isn’t it surely better to say they are sick?

The danger of this is that the idea of something going wrong with people’s brains can be scary and alienating. Put this together with the ‘1 in 4’ idea - that one in four of us will suffer ‘mental illness’ at some point - and it can add up to a frightening message: there’s a dangerous disease out there that might strike at us any time.

Guest post. The manufacture of madness? Why social construction in psychiatry is not as simple as it seems

Huw Green

Mental health problems: Constructed or discovered?

Anyone who has spent time reading or listening to psychologists recently is likely to have encountered the idea that mental health problems are ‘social constructs’. What is meant by this is that entities such as depression or schizophrenia and personality disorder, which we might ordinarily think of as diseases; are actually descriptions that flow out of our culture and moment in history. There may be good reasons for thinking about mental health in this way. Anybody who claims that there is no social construction involved in the disorders outlined by the American Psychiatric Association (APA) is unaware of the way the manual is written. Prior to 1952 there was no DSM, and every 15 years or so since, a revision has appeared. These updatings are usually chock full of new diagnoses, many of which have been regretted by the very people who helped bring them into existence. Indisputable though this may be, it is a form of description which can stand in the way of understanding the true complexity of such problems. If they are just constructs then why do so many of the people who experience them find the experience so like a disorder; so real? In order to be clearer about this we need to ask exactly what we mean by social construction.

For some commentators, the implication seems to be that if we stopped talking about ‘schizophrenia’ or ‘personality disorder’, then they would more or less disappear. This is the argument which Mary Boyle appears to make in the final chapter of Schizophrenia: A Scientific Delusion? In this line of reasoning, there is much to be gained from demonstrating that life events, social inequality, abuse, and even the mental health system create ordinary, understandable distress, which then gets inaccurately and arbitrarily labelled. It is likely that this depiction is true in a good many cases.

Guest Blog: Dancing with DSM

Psychiatrist Glen Simblett reflects on what DSM diagnosis might mean in the consulting room and offers the unusual metaphor of dance to think about how we might best help people.

Doctor and DSM

Photo: Dino ahmad ali

Bring up the topic of DSM 5 and you are immediately engulfed in controversy. It is an intensely polarising topic with people either challenging the relentless medicalisation and drug treatment that it seems to represent, or conversely pointing to the many examples when people have found DSM diagnosis and drug treatment helpful.

DSM does tend to pull people into particular positions in relationship to it, and in the process, often produces conversations that collapse us all into argument and challenge of the “opposing” viewpoint. Rather than engage in debate about whether DSM is good or bad for people, as a therapist I am a lot more interested in exploring different questions. Here’s a question that has meant more to me:

‘What types of relationships and conditions are needed for DSM knowledge and practices to add to personal agency and assist people in reclaiming their lives from problems?’ 

To answer this, I have to understand some of the dangers that lurk within DSM knowledge and practices. Then, I think I need to develop some different understandings and ways of working in order to counter those dangers. I have to understand how I can dance with DSM in different ways and different styles as a person, a therapist and psychiatrist. 

The Lament of a Black Swan: I don't need my defamatory label!

Fay Thomas

Now surplus to requirements?
Photo:  christmasstockimages.com 

The first time I told someone about my bipolar label, it was an agonisingly big deal. I rehearsed and thought it through carefully. Finally, using the language of the times, I declared my manic depressive 'otherness' to a friend. I was met with a hug, some questions and reassurance. It makes no difference to those who hold you with affection. But other situations can get tricky. Do you spill the beans on a first date and if so, how? Or do you wait until it's serious and then cope with the feelings of betrayal and humiliation that arise? Do you tell before you meet his parents, or wait until the night before you move in?

I remember one partner who was happy to have a manic-depressive writer for a girlfriend. A journalist with a formidable reputation, my mental health status fulfilled his romantic notions of living out life Bohemian style. The first time he witnessed my ascent into full blown mania he seemed intrigued but stayed around to discuss it. After all, someone who stays up all night to order flowers for everyone they know, might be a fun person to live with (sometimes). But descent into the murky depths of a depressed hell usually followed my upswings. Most partners find it difficult to fathom why you're still not dressed at 3 o'clock or can't find the energy to get out of bed. And prior to marriage there were hurtful discussions about children and whether or not you could/should have them. What was the risk of offspring being similarly afflicted?

Borderline personality disorder: Abandon the label, find the Person

Steven Coles

Borderline Personality disorder:
Society's illsdressed up as yours?
Picture: MargaritaJP

In 1980 the mental health industry invented a new diagnostic label, one of many, for the 3^rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM III). The American Psychiatric Association (APA) presented DSM III to the world as a scientific revolution in psychiatric understanding. If people suffering emotional distress had accepted the APA's statements about the new manual, they would have rejoiced that such a wealthy and powerful organisation had put its energies into making sense of psychological suffering. The vast majority of people receiving one of these new labels had experienced great trauma - sexual abuse, extreme life events and repeated abuses of power. Quite a progressive move by the APA then: understanding the effects of power on people. Psychiatrists could show care, understanding, and perhaps even provide a sense of solidarity to people who were marginalised. Unfortunately, in 1980 the APA willed Borderline Personality Disorder into being. The APA's idea of empathy and understanding led to vast numbers of survivors of abuse being labelled as disordered individuals.

In many ways the diagnosis of BPD is an easy target for criticism and satire. The diagnosis of BPD is defined by a series of social and moral judgements, applied to people who have been traumatised and dressed up as a medical problem. If we had a friend who revealed to us after years of secrecy and shame that they had been repeatedly sexually abused as a child, our first response is unlikely to be “your personality must be really disordered – no wonder I've felt like rejecting you”. Instead we would show care, be amazed at their survival and probably feel anger at the perpetrators of abuse - basic common sense and decency. Sadly when it comes to psychiatric diagnosis good sense does not prevail. The survival of psychiatric diagnoses is in many ways an astonishing feat of magic; its supporters have woven a spell that repels good sense, compassion, logic and evidence.

Is Life a Disease?

Anne Cooke and John McGowan

The DSM makes a handy lectern
Photo: Maciej Janowicz

As regular readers of this blog know, we are very interested in the pros and cons of psychiatric diagnosis. We try to discuss this issue in an accessible way and reach as broad an audience as possible. It was a great pleasure, therefore, to be invited by Lewes Skeptics (a Sussex branch of the Skeptics in the Pub network) to give a talk about mental illness, diagnosis, and some of the controversies raised by the new version of the psychiatric classification manual DSM-5. We've since been asked to make the talk available more widely, so we've posted it below. It's a video of the slides, accompanied by a soundtrack recorded on the night.

It was interesting to see that the event sold out in a few days. Since we’re hardly big names, we hope this says something about the level of public interest in mental health. The same happened the last time that the Skeptics put on a mental health-related talk (by psychiatrist Joanna Moncrieff), so something clearly strikes a chord. On the night of our talk the room was jammed, the temperature was hot and the controversy even hotter! Actually that last bit isn’t true. The debate was conducted in the most civil and decorous manner - not always easy when passions on this topic can run high.

We’d like to thank Lewes Skeptics (and in particular Eugene Gill) for hosting the event, and for their commitment to promoting public engagement with important topics. If you want to know more follow them @LewesSkeptics on Twitter. We are also grateful to John Warburton man of many parts, two of which were his very strong forearms. The fortitude with which he acted as a human boom for the recording equipment was admirable. Thanks also to the audience. The pub patrons of Lewes are clearly a thoughtful lot.

You can view the video either in the embedded version below or via the direct link on YouTube. 

There is also a recording of the discussion following the talk. The quality is slightly more variable as questioners were sitting in different parts of the room. The Q&A audio is embedded below or you can listen to it directly on Sound Cloud.

Guest blog: I believe in diagnosis but the DSM is just a door-stop

Over the last few months we’ve regularly featured pieces taking a critical line on the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and on psychiatric diagnosis more generally. We are nonetheless committed to offering a range of views on mental health. Today we feature an article taking a more pro-diagnosis position and offering a (possibly surprising) view on why the DSM is not always relevant to the consideration of distress. The author, Alex Langford, is a psychiatrist with clear views on both the value of diagnosis and the limits of classification schemes. What do you make of what he has to say? Alex has agreed to respond to comments over the next few days.

Is the nature of most mental health
problems obvious?
Illustration: catcher0frye

The heat from the release of the “psychiatric Bible” (DSM-5) is thankfully simmering down. In recent months, you couldn't throw a metaphorical brick on Twitter without hitting someone who had a strong opinion and wasn't shy of sharing it. I found this debate stimulating, frustrating and eventually repetitive. Rarely however, did I find it clinically relevant.

There may be a number of reasons for this. For one thing, DSM-5 is an American book; we use a different classification (ICD-10) here in Britain. Also, I currently work in an area of psychiatry that deals heavily with an illness that DSM doesn’t have a definitive role in, namely dementia. But mostly, I wasn’t too bothered because, to the probable surprise of non-medics and the public, most psychiatrists don’t really care about the finer points of classification.

When the Ads Don’t Work

Anne Cooke and Dave Harper 

Is your mind made up about mental illness?
This picture may dispel any doubts.
Photo: Giovanni Cassanese 

It’s a sobering thought that, for many people who use mental health services, other people’s reactions cause more distress than their original problems.   And attitudes may even be getting worse.  A recent report from the Department of Health found that whereas in 1997, 92% of people questioned agreed that ‘we need to adopt a more tolerant attitude towards people with mental illness’, in 2011 only 86% thought that we need to be more tolerant.   Worryingly, young people appeared to be the most prejudiced.

Relatively static attitudes to mental health stand in contrast to the changes there have been in attitudes about ethnicity and sexuality (we currently have a conservative Prime Minister advocating same-sex marriage).  It’s even more surprising given the effort that has gone into anti-stigma campaigns.  For example you may have seen the recent tube posters or TV ads from the government sponsored Time to Change campaign.   So what’s the problem?  Perhaps part of the answer is what campaign ads actually say. Or what they don’t. 

The DSM dust-up: Whingeing cranks, turf wars and epistemological disputes

Leigh Emery

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. 

What we’ve been reading: More DSM, women leaders after Maggie and gun control

The Editors

The first of an occasional series where we ask departmental staff to give a shout out on what they’ve been reading recently.

Does your child sing, laugh, run around and imagine things? Perhaps she has ‘Youthful Tendency Disorder’. We hadn’t come across this before, but the knowledgeable folks at The Onion enlightened us. It might come as shock to realise that the piece linked above was written in the year 2000, affirming the truism that satire gets overtaken by reality. In this case reality is the vast expansion of psychiatric labelling that is likely to result from the new DSM. With the DSM’s forthcoming publication, coverage of diagnostic labels seems especially relevant and we also had a recommendation for this blog by Philip Thomas. It details his complaints to the BBC about their coverage of neuroscience and mental health.

Thinking about different responses to distress we’ve also been looking at the new psychology textbook by Cromby, Harper and Reavy. It aims to be the first undergrad text that ‘reconsiders the traditional emphasis on the biological and psychiatric models’ of mental health. Psychology lecturers please take note.

In the week in which we lost Mrs T much of the discussion of course has been about what Maggie did, and didn’t, mean for women. Our own Jan Burns reckons:

‘The glass ceiling may not be completely broken, but is at least visible and somewhat shattered. What we should be more worried about is the “glass cliff”. Michelle Ryan and Alex Haslam’s ground-breaking work at the University of Exeter has shown how women and other minority groups find themselves in leadership positions. Interestingly though these are more commonly those with attached potential risk and criticism. This goes some way to explain those apocryphal tales of “ah, look what happens when a [fill in your particular minority] is in charge”.’

While we’re on conservative values, we also had a ringing endorsement of ‘Why be happy when you could be normal?’  by Jeannette Winterson.  ‘Thought provoking and inspirational, addressing issues of nature and nurture, overcoming adversity, creativity. A unique perspective on mental distress.' is the judgement of Celia Heneage.

For those of you following some of our thoughts on suicide it’s worth drawing attention to the thoughts of the practical ethicists at Oxford talking about current legal cases on assisted suicide. As you may know we also keep an eye on developments in gun legislation in the US. A difficult week for proponents of greater gun control but we hope, if John Cassidy in the New Yorker is to be believed, that it’s not the end of the line. 

Silver Linings: Is Sickness a Shield Against Stigma?

John McGowan

Silver lining or more rain?
Photo: By Im Unicke

I’d been avoiding Silver Linings Playbook. Nothing against it particularly, it’s just that Very Serious films about mental health always feel like a busman’s holiday. I got corralled into seeing it by the missus though, more observant than me, who had clocked that a) it was warmly sentimental, and b) it featured a dance contest. These days plucky young hoofers channelling Patrick Swayze are all I ask of a film. And if someone is also (spoiler alert) saved by the love of a good woman, then my cup runneth over.

As well as Jennifer Lawrence’s Oscar, the talk on the internet has been about how realistic SLP is (or isn’t), and what it tells us about social attitudes to mental illness. Opinions are split between those who see it as a ground-breaking and nuanced portrait of people having emotional difficulties, and those who view its happy ending as idealised and simplistic. Lawrence has been lauded for her portrayal of Tiffany, the aforesaid good woman, who is frequently a bad girl as she seeks to drown the pain of widowhood. This makes her, according to your point of view, either an ideal candidate or the worst possible bet to get things together by dancing/falling in love with fellow recoverer Pat (Bradley Cooper).

Gazza, Lance and the difficulties of psychiatric diagnosis

John McGowan

What do you call someone who tells lies persistently? In recent weeks the answer is probably Chris Huhne, the latest in a line of hubristic politicians who have told a stream of big porkies to cover up a small one. You may have already forgotten that before the erstwhile next leader of the Lib Dems bowed out, the deceiver du jour was cycling champ (technically ex-champ) Lance Armstrong. I've written about the ethics of Armstrong’s fall from grace elsewhere, suggesting that, while his doping to win the Tour de France wasn't great, his unpopularity has far more to do with his deceit and with our disappointed expectations of a previously heroic figure.

Pinocchio. Worrying signs of psychopathy
in childhood! Picture:  Ropa-To.

However, what should we call him? Is he a ‘jerk’ (his own suggestion), or one of many more colourful names suggested on various comment threads of the web? As well as the stream of abuse, some of Lance’s ex-fans also seem eager to offer a more nuanced appraisal in the form of psychiatric labels. Is he a psychopath or a sociopath or, as an article in the Atlantic a couple of weeks back suggested, an ‘aggressive narcissist’? What, I wonder, do these labels tell us about him that conventional monikers do not?

I’m sicker than I thought I was

Anne Cooke

DSM: Get your hernia belt
on for the fifth edition.

One thing I like about being a psychologist is that you get the occasional call from journalists asking interesting questions. The one who phoned the other day was making a radio programme about new mental illnesses. She was referring to the soon-to-be released fifth edition of the diagnostic ‘Bible’, the DSM (Diagnostic and Statistical Manual of the American Psychiatric Association). This newest version is set to classify even more experiences and behaviours as ‘mental disorders’ than its predecessors. For example, binge eating is to become a disease, and in future you may also need expert treatment if you spend too long in front of your computer (‘internet addiction’). Each edition of the DSM introduces us to new diseases. The first edition, published in 1952, was 132 pages long. The 1987 edition (DSM III-R) was 569 pages. By the time the current edition was published in 2000, it had swelled to 943 pages. I wonder how many pages long DSM-V will be, and how many strong men it will take to lift it.

What we often lose sight of is that calling certain emotional states, or ways of thinking and acting ‘mental illnesses’ is just one way of thinking about them, rather than the only way. All we really know is that people sometimes feel or act in certain ways. For example, if I feel sad and hopeless, and stay in bed all day staring at the ceiling, I am likely to be diagnosed with depression. I may be told that I have an illness, and this way of understanding my situation does have its advantages. I can go to my GP and hopefully find a sympathetic ear, maybe some tablets to take the edge off things and perhaps be referred on to someone I can talk to. If I’m feeling so bad that I can’t work, I can take time off sick and even claim benefits. So the idea of mental illness definitely has its plus sides: it gives us a way of talking about difficult things and a framework for offering help. However, I often wonder whether overall, the whole enterprise of finding medical labels and drug ‘treatments’ for what are often arguably problems of living, or in some cases lifestyle choices, actually causes more problems than it solves. To continue the example, thinking of myself as mentally ill might well be a huge blow to my self-confidence. I might conclude that there is little I can do to help myself except to keep taking the tablets. Depending on my diagnosis, I might begin to fear turning into people’s image of a mental patient - strange, unable to function and perhaps even potentially violent. Other people who know that I am ‘mentally ill’, might be prejudiced and treat me as inferior or even frightening. I would find it harder to get a job and, as someone once said to me, “I’m mentally ill” is hardly the best chat up line is it?’ I would also lose some of the human rights I had always taken for granted: people with ‘mental disorders’ are the only group that can be locked up without trial and injected with drugs against their will.