I am delighted and honoured to join the distinguished group of correspondents on this website. It gives me the chance to explore a theme that has pre-occupied me for many years - how can we abolish DSM and psychiatric diagnosis, and what do we replace it with?
Readers will be aware of the huge amount of controversy about the forthcoming 5th edition of DSM, and I am proud that my professional body, the Division of Clinical Psychology (a sub-division of the British Psychological Society), played such a key part in triggering this debate. Its robust dismissal of every single one of the proposed new ‘disorders’ was not based on an extended critique of the inadequate field trials, links to the pharmaceutical industry, low reliability and lack of validity of the categories and so on, alarming though these aspects are. It was quite simply a refusal to accept that these so-called ‘disorders’ can be understood as medical illnesses analogous to cancer, diabetes and so on, and diagnosed and treated as such.
In the words of the official DCP/BPS response, drawn up by the past DCP Chair, Professor Peter Kinderman: ‘Clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences… but which do not reflect illnesses so much as normal individual variation… This misses the relational context of problems and the undeniable social causation of many such problems.’
We have known for a long time that terms such as ‘schizophrenia’ are scientifically meaningless. They are not actually ‘diagnoses’ in a medical sense, since they are not based on patterns of bodily symptoms or signs. Instead, the criteria consist of a ragbag of social judgements about people’s thoughts, feelings and behaviour. The people who are so labelled may well have difficulties and be in urgent need of help, but this is not the way to help them.
In Biblical times, people were firmly convinced that disturbed or disturbing behaviour could be explained by the presence of evil spirits. No one could actually see them, but everyone knew they were there. We are equally convinced today by the explanation that extreme distress is a sign of, in effect, possession by entities such as ‘schizophrenia’. No one can detect the ‘biochemical imbalance’ or the ‘genetic vulnerability’ that would confirm its existence, but we just know that the ‘illness’ is lurking in there somewhere. Clearly, the reason people hear voices is because they have ‘schizophrenia’. And how do we know they have ‘schizophrenia’? Because they hear voices, of course!
For obvious reasons the DSM 5 debate has been most prominent in the USA, but it also received extensive coverage in the British press. Leading clinical psychologists such as Professor Richard Bentall speculated that ‘…the main beneficiaries will be mental health practitioners seeking to justify expanding practices, and pharmaceutical companies looking for new markets for their products.’ Professor Til Wykes warned: ‘The proposals in DSM 5 are likely to shrink the pool of normality to a puddle.’ Professor David Pilgrim described DSM as ‘a form of collective madness for all those complicit in the continuing pseudo-scientific exercise.’
Meanwhile, critical psychiatrists led by Dr Sami Timimi courageously submitted a petition to the Royal College of Psychiatrists urging the abolition of formal psychiatric diagnostic systems. Asked to comment on the subsequent minor revisions to DSM 5, I stated that ‘The DSM is wrong in principle, based as it is on re-defining a whole range of understandable reactions to life circumstances as “illnesses”, which then become a target for toxic medications heavily promoted by the pharmaceutical industry….The DSM project cannot be justified, in principle or in practice. It must be abandoned so that we can find more humane and effective ways of responding to mental distress.’
As we say in the UK, this is fighting talk. Journalists tell me that it has been very hard to find anyone to support DSM and provide the ‘balance’ that their articles require. Suddenly, few people are prepared to mount a strong defense of the current system. In fact there have been signs of disquiet and shifting positions for some time. For almost a hundred years, ‘schizophrenia’ has been ‘the prototypical psychiatric disease’ (Boyle 2002). In the words of a British psychiatrist, ‘Without schizophrenia there would be no psychiatry’ (Holmes 2011); hence the enormous controversy that has surrounded its definition, aetiology and treatment since the term was coined. Recently, however, there has been some acknowledgement of the evidence for the role of trauma in severe emotional distress with the suggestions for new categories of ‘traumatic psychosis’ or ‘dissociative psychosis’ and so on.
Even biologically-minded psychiatrists are increasingly substituting the term ‘psychosis’ for ‘schizophrenia’ - although a moment’s thought shows that this vague and woolly concept is even less reliable than the one it replaces. In Britain we call this ‘shifting the goalposts’ – defending your position by changing the terms of the debate. But this manoeuvre won’t fool people forever. It is a sign of a paradigm under serious strain, and history tells us that the weight of evidence and public and professional opinion cannot be resisted indefinitely.
It is important to realise how much is at stake. Psychiatric diagnosis underpins the whole biomedically-based model of mental health. Any science needs to be able to demonstrate that it is based on a reliable and valid classification system, in order to develop testable hypotheses and hence the general laws that constitute a body of scientific knowledge. If this cannot be established, the whole model breaks down and all psychiatry’s other functions – indicating treatment, carrying out research and so on - will be fundamentally undermined. In the words of Peter Breggin (1993), psychiatry would then become ‘something that is very hard to justify or defend – a medical specialty that does not treat medical illnesses.’ And, of course, numerous other personal, professional and business interests depend on the system as it is.
It is not hard to see why the debate about DSM is so heated. It is also not hard to see how fragile the foundations of psychiatric classification are. The disorders are, in effect, voted into existence, and the entire system only survives because a consensus of sufficient numbers of people is prepared to support it. As soon as we reach a tipping point where enough professionals and professional organisations are willing to join service users/survivors in admitting that the emperor has no clothes, it is at risk of collapsing in a heap.
‘Diagnosing’ someone with a devastating label such as ‘schizophrenia’ or ‘personality disorder’ is one of the most damaging things one human being can do to another. Re-defining someone’s reality for them is the most insidious and the most devastating form of power we can use. It may be done with the best of intentions, but it is wrong - scientifically, professionally, and ethically. The DSM debate presents us with a unique opportunity to put some of this right, by working with service users towards a more helpful understanding of how and why they come to experience extreme forms of emotional distress.
We already have a situation where the strongest defence of DSM is: ‘We know it’s flawed, but it’s the best we have - what could we do instead?’ The simple answer is, ‘Stop diagnosing people.’ This would at a stroke render redundant all the well-meaning but (as research shows) ineffective campaigns to reduce the stigma of ‘mental illness’. But faced with all the power and vested interests of the current system, we may need to describe alternatives in more detail. I have some ideas about what this might look like, and they draw on the theory and practice of psychological formulation. This will be the subject of my next post.
Boyle, M (2002) Schizophrenia: a scientific delusion: 2nd edn, New York, London: Routledge
Breggin, P (1993) Toxic psychiatry. London: Fontana
Holmes, J. (2011) Book review. British Journal of Psychiatry, 198:79
Beyond Psychiatric Diagnosis: Lucy writes about replacing psychiatric diagnosis with a formulation-based approach that explores personal meaning within relational and social contexts, and she reflects on the challenges of working within biomedically-based services. See her book: A Straight Talking Guide to Psychiatric Diagnosis.