Psychiatry On The Defensive, But Ceding No Ground

On May 27, The Lancet Psychiatry published an editorial titled This year’s model.  The article is a response to the British Psychological Society Division of Clinical Psychology’s  Guidelines on Language in Relation to Functional Psychiatric Diagnoses, which was published in March of this year.

The paper was produced:

“…to support clinical psychologists in the development of documents using language consistent with the Division of Clinical Psychology (DCP) position on functional psychiatric diagnoses.”

The paper cites two reasons for dissatisfaction with the present concepts and language:

1. lack of validity of current systems (DSM and ICD)
2. growing evidence that the experiences listed in the diagnostic manuals can be better understood as responses to various psychosocial factors, such as loss, trauma, poverty, inequality, unemployment, discrimination, etc…

The paper espouses three principles:

“Principle 1: Where possible, avoid the use of diagnostic language in relation to the functional psychiatric presentations.”

“Principle 2: Replace terms that assume a diagnostic or narrow biomedical perspective with psychological or ordinary language equivalents.”

“Principle 3: In situations where the use of diagnostic and related terminology is difficult or impossible to avoid, indicate awareness of its problematic and contested nature.”

Various examples are provided of alternatives to medical diagnostic terms, e.g. “difficulty” for “disorder”; “suspicious thoughts” for “paranoia”; “compulsive checking/cleaning” for “obsessive compulsive disorder”; etc….

The language guidelines end with a restatement of the DCP’s commitment to change:

“This is an evolving set of guidelines designed to support the practical implementation of moving beyond functional psychiatric diagnosis.  We welcome additional suggestions and general feedback.”

The BPS’s Division of Clinical Psychology has attracted a fair amount of attention in the past year or two by publicly expressing dissatisfaction with psychiatry’s so-called diagnostic system.  The language guidelines are the latest chapter in this process.  The DCP statements are a very significant development in this field.

For almost a hundred years, psychologists who work in this field have gone along with the travesty of psychiatric diagnosis, even though the flaws of such a system are clear to anyone with even cursory training in psychology.  What the DCP is saying, if I understand them correctly, is that they will no longer play along with this charade.  They will no longer pay lip service to these invalid concepts as the entrance fee to work in their chosen profession.

The potential impact on psychiatry is enormous, because, if psychologists revolt today, perhaps social workers, counselors, and psychiatric nurses will follow suit tomorrow.  And psychiatry cannot function without its army of so-called ancillary workers.  This is the context in which The Lancet Psychiatry editorial has been published.  There is a crack in the dike!

. . . . .

The editorial opens with characteristic psychiatric assertiveness:

“Language matters, especially so in mental health, and everyone has an opinion on the terms that should be used to discuss mental illness.”

The central issue in this debate is that the various problems catalogued in the DSM (other than those clearly identified as being due to a general medical condition) are not illnesses.  But with its opening sentence, the editorial sets this entire argument at naught.  And note the truly exquisite contradiction. On the one hand,  “Language matters…”:   the words we use to describe something have a profound effect on our response.  But on the other:  “… the terms that should be used to discuss mental illness.”  By calling these problems “mental illnesses”, they’ve already closed the door to any meaningful consideration of alternatives.

And that’s just the opening sentence!

Then there’s a nice piece of psychiatric chicanery.  The editorial refers to the DCP guidelines and asserts:

“The document states that ‘as a profession, we have publicly [affirmed] the need to move towards a system which is no longer based on a “disease” model’. The basis for such a change is, the authors say, ‘a large and growing body of evidence suggesting that the experiences described in functional diagnostic terms may be better understood as a response to psychosocial factors such as loss, trauma, poverty, inequality, unemployment, discrimination, and other social, relational and societal factors’.”

Let’s take a look at what the Guidelines actually say:

“The DCP’s position statement on Classification of Behaviour and Experience in Relation to the Use of Functional Psychiatric Diagnoses highlights the lack of validity of current systems (DSM and ICD), as acknowledged by both critics and those who support the idea of diagnosis in principle. The full statement is available on the Society’s website (www.bps.org.uk/system/files/Public files/cat-1325.pdf)” [Emphasis added]

and then

“Alongside these developments, there is a large and growing body of evidence…”

In other words, the DCP gave two reasons for issuing the language guidelines:

1. because the various problems embraced by psychiatric “diagnoses” are not real illnesses, i.e. they lack validity.
2. because these problems are better conceptualized as responses to adversity, etc.

But The Lancet Psychiatry cited only the second reason, and made no mention whatever of the first.  And note that the first reason, which the DCP had clearly prioritized, was supported by a publicly available “full statement“, which runs to nine pages, and cites 34 references.  Here’s a quote:

“At the same time it should be noted that functional psychiatric diagnoses such as schizophrenia, bipolar disorder, personality disorder, attention deficit hyperactivity disorder, conduct disorders and so on, due to their limited reliability and questionable validity, provide a flawed basis for evidence-based practice, research, intervention guidelines and the various administrative and non-clinical uses of diagnosis.” [Emphasis added]

Incidentally, the term “functional psychiatric diagnosis” is an older psychiatric term that meant “as opposed to organic”.  It was a recognition, commonly held by many psychiatrists prior to about 1960-1970, that many of the problems that psychiatrists encounter were not caused by organic pathology.  The term was quietly slipped to the sidelines as part of psychiatry’s fraudulent promotion of the notion that all psychiatric problems were illnesses – “just like diabetes”.

What The Lancet Psychiatry has done essentially here is sidestep this whole question of whether or not psychiatric diagnoses are real illnesses.  Instead, they focus on the need to recognize (some might say, belatedly) the disempowering role of adversity in people’s lives.  But again, watch where they go with this:

“The DCP argument is worth considering. If mental-health disorders were treated more as distress than disease, might this benefit people needing help, by steering professionals towards a more holistic frame of mind, and putting the onus onto governments to sort out social problems for which clinical and social services might only be a sticking-plaster? Two points support this argument: first, governments could do much more to reduce social inequality; second, the simplistic view in support of biomedical explanations—that by making mental health problems no-one’s fault they are automatically destigmatising—is likely mistaken.”

So, they argue, perhaps there is something to be said for calling these problems distress rather than disease, because

1. practitioners might become more holistic, and
2. governments might “sort out” social problems

But note again, all of this is tangential to the real issue:  that psychiatric diagnoses are not real illnesses.  The reason for debunking the concept of psychiatric illness is not that it will make practitioners more holistic, or that it will pressure governments to “sort out” social problems, or that it might reduce stigma.

The compelling – indeed, I would suggest, the only – reason for debunking the concept of psychiatric illness is that the problems embraced by the term are not genuine illnesses.  Other considerations might have relevance and importance, but they are always secondary to this core point.

. . . . .

Having patronizingly conceded that there might be some merit to the DCP’s position, The Lancet Psychiatry quickly reasserts psychiatry’s claim to validity, righteousness, competence, and wisdom:

“However, although language is important, the simple relabelling of mental illness as mental distress is unlikely to achieve much; better care arises from action, not editing. Improved care needs professional communication and research, both of which are aided by concise and precise descriptors, and terms such as mood swings and altered state are certainly not precise. Furthermore, the human mind is capable of having experiences that are qualitatively hard to describe with everyday language. Of course, when talking to a patient, one must use language that he or she is comfortable with, which will often be unique to the individual. Any good doctor can (and does) manage this dozens of times a day. The DCP suggests that a conflict between technical and everyday language exists where, in fact, it does not; and the idea that technical terms such as bipolar disorder ‘assume a diagnostic or narrow biomedical perspective’ is misguided. It is based on a misunderstanding of how doctors are trained, and what the so-called disease model and diagnostic language actually mean to them..”

Again, note the nimble distortion:  “…simple relabeling of mental illness as mental distress”.  The issue is not a “simple relabelling”.  The labeling is secondary to a recognition that the problems are not illnesses, and therefore should not be called illnesses.  By referring to “simple relabeling”, the editorial is deceptively trivializing what in reality is the most profound issue facing psychiatry today.

“…terms such as mood swings and altered state are certainly not precise.”  The implication here being that terms such as “schizophrenia” and “bipolar disorder” with their inherently vague, polythetic definitions, are precise!

And more psychiatric arrogance:  “… that technical terms such as bipolar disorder ‘assume a diagnostic or narrow biomedical perspective’ is misguided. It is based on a misunderstanding of how doctors are trained…”  So that’s it – the magical power of medical training which we outsiders cannot possibly grasp.  All of which is a little hard to reconcile with the spurious, insultingly simplistic notions of “chemical imbalances”, and “illnesses just like diabetes”, which have become stock in trade for the great majority of psychiatrists.

And what are we to make of  “…the human mind is capable of having experiences that are qualitatively hard to describe with everyday language”.  Are The Lancet Psychiatry’s editors seriously suggesting that labels such as schizophrenia, bipolar disorder, obsessive compulsive disorder, attention deficit hyperactivity disorder, oppositional defiant disorder, dysthymia, etc., are more fitted to the task of describing the nuances and complexity of human thought and feeling than everyday speech?  Does the statement:  “I have major depressive disorder” better communicate a person’s emotional experience than the statement:  “I feel devastated with grief”?

The editorial continues to sing the praises of medical training and psychiatrists:

“Medical training involves developing autonomy, the ability to make good decisions under acute and chronic pressures, experience of life in often extreme circumstances, and communication with a broad range of people from all socioeconomic and cultural backgrounds. Good psychiatrists know that even the best drug treatments have limited effectiveness in the face of extreme social adversity. To repeat: medical training is not just a process of learning scientific terms of health and illness; it is also about experiencing humanity.”

To which I can only respond that if this is indeed an accurate portrayal of psychiatric training, then most of the psychiatrists I’ve encountered either didn’t get the message, or quickly forgot it when they started to practice.

. . . . .

In the final paragraph, the editorial stakes out the turf:

“Doctors can and should work within a multidisciplinary team, and be able to reconcile different perspectives.”

Firstly, note the term “Doctors”.  They’re referring to psychiatrists, but the use of the more generic term is, I suggest, an attempt to piggy-back, undeservedly, on the value of real physicians, and their consequent prestige and standing within the community.

And then the assurance that psychiatrists should, through interdisciplinary dialogue and collaboration, be able to reconcile different perspectives.  But in fact, the two perspectives:  depression is an illness vs. depression is not an illness, are irreconcilable.  So reconciling the differences inevitably means that the so-called ancillary professionals will get into line.

And in case there’s any residual doubt as to what that means:

“The biomedical view is an essential component. New research techniques have proliferated in the past few years, promising much information about the function of the brain and mind; neuroscientists will press ahead with this work regardless of the philosophical bias of services.” [Emphasis added]

So the great neuroscience breakthrough is at hand.  Now where have we heard that before?

. . . . .

Then a mild rebuke:

“It would be lamentable were the providers of mental health care simply not able, or not inclined, to put these findings into practice.”

Note the phrase “not inclined”.  So the psychologists in the DCP are baulking against the great neuroscientific breakthroughs (which haven’t actually happened yet), because they’re simply “not inclined” to do so.  Such wanton cads!

. . . . .

And finally:

“Medical training is a help, not a hindrance, to thinking about mental health.”

Medical training is indeed a great help in dealing with medical matters.  But it is very much a hindrance in dealing with matters that are not.  And this is the crux of the issue that psychiatrists – including the author of this editorial – will not address.  Depression is not an illness; distractibility/impulsivity is not an illness; childhood misbehavior is not an illness; persistent apathy/inactivity is not an illness.  And the history of psychiatrists fraudulently applying medical concepts and practices in the misguided attempt to treat these problems has been nothing short of disastrous.

This issue – whether the problems are illnesses or not – is by no means academic.  This battlefield is strewn with the dead and wounded victims of psychiatry’s relentless, and blatantly self-serving, drive to medically pathologize every conceivable human problem.

Psychiatry has been shaken by recent criticism, including some from within its own ranks, but they remain remarkably resistant to anything remotely akin to critical self-scrutiny, and, as The Lancet Psychiatry’s editorial makes clear, they are ceding no ground.

. . . . . 

And Incidentally

Note the title of the editorial:  “This year’s model”.  I’m not entirely sure what this means, but I think it’s a subtle disparagement of the DCP’s position:  another fad!

On The Lancet Psychiatry’s home page, the journal expresses a commitment to publish  “…news and comment about all aspects of psychiatry…including psychosocial approaches to all psychiatric disorders…and new ways of thinking about mental illness promoted by social psychiatry.”

But apparently the editors are not receptive to the notion that the various problems embraced by psychiatry’s “diagnostic” manuals are not actually illnesses.  So they will consider all aspects of the matter, except those that pose a threat to their anomalous hegemony in a non-medical area.

And Finally

Recently Niall Boyce, MD, PhD, the Editor of The Lancet Psychiatry, was interviewed by The Scientific 23.  In response to the question, “What do you most dislike about your job?,” Dr. Boyce replied:

“What I dislike is almost the flip side of what I like about it, which is that mental health is quite a young field in terms of what we now understand about the human mind and brain. What this means is that although there is lots more up for grabs because there is less known about it than about other medical specialities, there is often quite acrimonious controversy. You have to have a thick skin to navigate these sorts of arguments. It is a painful experience when you know people, you know that they are fundamentally nice and that they want the best for patients, but they disagree in the most awful and sometimes personal ways over issues.”

I strongly suggest that Dr. Boyce needs to recognize that articles and editorials such as the one discussed here, which promote psychiatry’s unsubstantiated assertions, and preemptively dismiss challenges to the spurious medicalization of all human problems, are a major contributor to the kind of rancor and acrimony that he bemoans in the quote above.