A Call to “Drop the Language of Disorder”

Kermit Cole
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Researchers Joanna Moncrieff, Richard Bentall, John Read and Peter Kindemann have published a call for “a wholesale revision of the way we think about psychological distress” in the journal Evidence-Based Mental Health, saying “Diagnostic systems in psychiatry have always been criticised for their poor reliability, validity, utility, epistemology and humanity. With great effort, and standardised approaches, it is possible for reliable diagnoses to be generated. But such practices are rarely adopted in clinical settings, and as we know, it is entirely possible to reliably diagnose invalid diagnoses.”

Abstract → More from the paper:
“We need a wholesale revision of the way we think about psychological distress. We should start by acknowledging that such distress is a normal, not abnormal, part of human life—that humans respond to difficult circumstances by becoming distressed. Any system for identifying, describing and responding to distress should use language and processes that reflect this position. We should then recognise the overwhelming evidence that psychiatric symptoms lie on continua with less unusual and distressing mental states. There is no easy ‘cut-off’ between ‘normal’ experience and ‘disorder’. We should also recognise that psychosocial factors such as poverty, unemployment and trauma are the most strongly evidenced causal factors for psychological distress2 although, of course, we must also acknowledge that other factors—for example, genetic and developmental—may influence the magnitude of the individual’s reaction to these kinds of circumstances.

“There are alternative systems for identifying and describing psychological distress that may be helpful for the purposes of clinical practice, communication, record-keeping, planning and research, such as the operational definition of specific experiences or phenomena. Some international effort will be needed to develop a shared lexicon, but it is relatively straightforward to generate a simple list of problems that can be reliably and validly defined; for example, depressed mood, auditory hallucinations and intrusive thoughts. There is no reason to assume that these phenomena cluster into discrete categories or other simple taxonomic structure. Indeed, the extent to which the phenomena co-occur may be a function of development and social circumstances. As with many other areas of medicine (particularly primary care) and wider civil society, such problems lend themselves to communication between professionals and the planning of services, especially if it is recognised that the operational definition should include some measure of severity.

“While some people find a name or a diagnostic label helpful, our contention is that this helpfulness results from a knowledge that their problems are recognised (in both senses of the word), understood, validated, explained (and explicable) and have some relief. Clients often, unfortunately, find that diagnosis offers only a spurious promise of such benefits. Since, for example, two people with a diagnosis of ‘schizophrenia’ or ‘personality disorder’ may possess no two symptoms in common, it is difficult to see what communicative benefit is served by using these diagnoses. Surely a description of a person’s real problems would suffice? A description of an individual’s actual problems would provide more information and be of greater communicative value than a diagnostic label.

“For researchers, trying to understand the causes of, and proper responses to, such distress is actively hampered by the diagnostic systems currently used. Whether we are pursuing biological, psychological or social causes of human distress, an invalid diagnostic system is an active hindrance—if there is no validity to a label such as ‘schizophrenia’, how can researchers finds its cause? Researchers would be better advised to study the nature of, causes of and proper response to specific, identified problems. Indeed, this process has already begun, with a rich literature on social origins, biological substrate and consequences of particular psychiatric phenomena (eg, hallucinations, paranoid delusions and thought disorder) emerging over the last 20 years.

“Clinicians are also likely to be more effective if they respond to an individual’s particular difficulties rather than their diagnostic label.”

 

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Kermit Cole
Kermit Cole, MFT, founding editor of Mad in America, works in Santa Fe, New Mexico as a couples and family therapist. Inspired by Open Dialogue, he works as part of a team and consults with couples and families that have members identified as patients. His work in residential treatment — largely with severely traumatized and/or "psychotic" clients — led to an appreciation of the power and beauty of systemic philosophy and practice, as the alternative to the prevailing focus on individual pathology. A former film-maker, he has undergraduate and master's degrees in psychology from Harvard University, as well as an MFT degree from the Council for Relationships in Philadelphia. He is a doctoral candidate with the Taos Institute and the Free University of Brussels. You can reach him at [email protected]

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