Moving Beyond Psychiatric Diagnosis: Lucy Johnstone, PsyD

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From Psychiatric Times/Conversations in Critical Psychiatry: “If you have a reasonably complete hypothesis, based on someone’s life experiences and the sense they have made of them, about why they are having mood swings or feeling suicidal or self-injuring, then you don’t need another, competing hypothesis that says, ‘And it is also because you have bipolar disorder/clinical depression/borderline personality disorder.’ Even if we think these are valid categories, the diagnosis is now redundant . . . Moreover, these hypotheses are based on contradictory core messages: ‘You are experiencing an understandable reaction to your life circumstances’ and ‘Your problems are the symptoms of a medical illness.’ This is not just theoretically confused—in practice, it gives mixed messages to the client about causality, responsibility, and so on . . .

Diagnosis—however we choose to understand it—has no place in this field, and nor does the diagnostic thinking that it supports and perpetuates. All human experience has biological aspects, but not all forms of suffering are medical illnesses. We are dealing with people with problems, not patients with illnesses, and the whole paradigm—the ‘DSM mindset’ as clinical psychologist Mary Boyle puts it—needs to change.”

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26 COMMENTS

  1. I urge everyone to read the full interview. Lucy gives brilliant answers to the interviewer, who is himself a “worthy opponent” with trenchant questions. It’s interesting to see him get defensive but she doesn’t back down and I hope what she said will guide his thinking in future.

    • I will look more carefully at the interview, though if the context of these arguments is an aspect tied to how we learn throughout our lives, then the very nature of our “held and discovered knowledge” is to unpack for others. To discover the space in which we UNDERSTAND in time, without the added burdens or junk piled into the treatment. In viewing a documentary through Kanopy, about Howard Gardner, “The Quest for Mind” would be discovered in the 80’s. The reality is not so much the names, the interviews, though in watching film, then the artistry by which a video is carefully edited to relate story. The process not being too different from the “clips” of experiences held within a mediated space. More later….. thanks for the encouragement.

  2. I LOVE Dr Johnstone. Dr Aftab seems hostile and argumentative rather than interested in exploring Dr Johnstone’s position. This is the hallmark of a closed mind, shows a lack of authenticity, and has no place in scientific discourse. She handled him brilliantly. I found it interesting that two psychiatrists were given the opportunity to rebut her statements about their positions. I could be wrong but I don’t recall seeing this opportunity extended to Frances’ ideological opponents at the end of his recent interview with Aftab. I also recall Aftab sort of gushing and fawning over Dr Frances while his hostility toward Johnstone and the PTMF seemed thinly veiled. I don’t find him to be a unbiased interviewer in that respect. I think a better interviewer would be a philosopher outside of the psy disciplines.

    Still, Dr Johnstone nailed it!

    On a personal note, since Dr Paul McHugh was mentioned and he was my psychiatrist’s advisor during her residency at Johns Hopkins, I thought it worth mentioning that she may very well have saved me from a schizophrenia diagnosis by warning me to stay away from Hopkins in my early years caught up in psychiatry as McHugh supposedly thought the DID diagnosis was really evidence of schizophrenia. Although I have concluded for years now that the DID diagnosis is complete nonsense, and I’ve personally grown beyond needing that narrative, it did at least serve to justify my distress as a response to extreme chronic trauma. However, the addition of the bipolar (2) diagnosis (among others) muddied the waters and reduced my struggles to a concrete illness. I’m super glad to see clinicians like Johnstone pushing back against these illogical inconsistencies. Patients can’t be best served with being told their problems are both understandable reactions AND a discreet illness that can be medicated away.

    I agree with Dr Johnstone that there does seem to be an ideological divide across the pond, with American doctors (and the public) much more resistant to the idea that difficult life circumstances can precipitate great distress. I think American culture is much more individualistic even than UK culture which lends itself to the public and doctors dismissing the psychosocial factors that lead to distress. “We all have problems.” is a common refrain in America for dismissing others complaints without having to think or care about them. I think the concepts of not bothering others with your problems and not airing your dirty laundry fed people neatly into the narrative to seek professional support. We’ve lost our communities by no longer leaning on each other as we seek professionals to deal with our issues while concurrently being told how important it is to have a robust support system. The entire treatment arena is a land mine of inconsistencies in America.

    I was a skeptic of the PTMF but the more I have read, the more I appreciate this work and hope that it’s principles will be applied more widely.

  3. “epistemic injustice14—in other words, people are systematically denied the knowledge that they need in order to create their own meanings about their experiences.” Excellent point about what stigmatization with the DSM disorders accomplishes.

    And I will say once the medical evidence of the abuse of my child was handed over, and the medical evidence that my PCP’s husband was the “attending physician” at the “bad fix” on my broken bone was picked up. I had the knowledge of the motives behind why my PCP wanted me defamed and neurotoxic poisoned by psychiatrists, as well as why the people who abused my child wanted me defamed and neurotoxic poisoned by psychologists and psychiatrists. And the truth shall set you free.

    “We are dealing with people with problems, not patients with illnesses, and the whole paradigm—the ‘DSM mindset’ as clinical psychologist Mary Boyle9 puts it—needs to change.” I agree. Interesting interview.

  4. Wow…the interviewer, Dr. Aftab, comes across as smug and condescending. This interview is a perfect example of the mental gymnastics psychiatrists engage in to avoid acknowledging or dealing with the consequences of the fact that the DSM diagnostic system is not valid. It also demonstrates the contempt psychiatry has for psychology which is viewed as inherently inferior. I have the utmost respect for Dr. Johnstone. She is brilliant, articulated her case with class and strength, and didn’t let him get away with it. We need to see more exchanges like this in high profile places. I for one would be delighted to be able to “rebut” the remarks of a psychiatrist in such an exchange, though I think the best person for that job is Phil Hickey!

  5. Thanks everyone for your comments. The whole thing was a very strange experience. Dr Aftab did not tell me he was going to invite additional comments – no other interviewee has had extra contributions inserted at the end – and I am at a loss to know how I misrepresented their views (although they certainly misrepresented mine.) The wider reaction on Twitter was extraordinary. I was called everything from arrogant, vicious, reductionist, dangerous, flaky, misguided, hostile and bullying to ‘morally depraved’…..and all of those comments were from professionals. None of those who disagreed with the views I put forward (as they have a right to do) actually engaged with the arguments. I think this says a lot about the fragile foundations of psychiatry…. Robin Murray is regarded in the UK as an open-minded critic of many aspects of his profession, probably much more so than his US counterparts, but it appears that there is an line of criticism that you must not cross. You can go so far and no further. I’m pleased people liked the content, but the process was even more interesting….

  6. I’m sorry you had to endure all that Twitter hate, Lucy. Nature of the beast, I guess. It sounds so obvious, but you’ve not only pointed out an elephant in the room but also had the temerity to be a woman while doing so, and the inherently patriarchal/paternalistic field of psychiatry just can’t tolerate it!

  7. This is actually part of a series of interviews with academics/clinicians with a critical perspective on psychiatry. It’s quite interesting to read and provides some intellectual armoury against the nostrums of psychiatry. I rejected psychiatry from the get go and have always understood my difficulties in a social context but have nonetheless been ground down by the the psychiatric process. Obvious benefit could have produced less adversity from being better informed. These are interesting interviews but I wonder if like always the arguments are being presented merely to give the psychiatric establishment occasion to refute them. The PTMF is grounded in an understanding that our problems start in our experience of the world and what we make of it. Psychiatry has no time for real life experience. However psychology is often no better, engaging in tick box exercises to confirm a diagnosis for psychiatry or counselling coping strategies that while sometimes effective up to a point also place the locus of responsibility in the individual.
    I have considerable admiration for a long line of psychologists who in their work acknowledge actual adversity but I’m doubtful that they’ve had much impact on clinical practice very often in Britain as elsewhere. So often critiques of psychiatric practice pull their punches at the point of acknowledging adversity and often merely at the adversity people sometimes experience in psychiatry. After that they just continue with the process of tinkering about inside our heads. It’ll be a massive job of work to undo the damage done by this mindset.

  8. Yes, kudos to Dr. Johnstone! She has incredible insights that actually help rather than harm (as psychiatry so often does). Dr. Aftab was rather prickly but Dr. Johnstone held her own very well. I give Dr. Aftab some credit for engaging in critical psychiatry interviews and hopefully it’s possible for him to become more open-minded and accepting of methods that can actually help people.

    • This is a serious question: what if the roles were reversed? What if a high-profile psychologist invited a high-profile psychiatrist to be interviewed, in a similar back-and-forth-manner? To be followed by several high-profile psychologists rebutting the remarks of the psychiatrist? As far as I know, this has never happened. I have extensive experience trying to arrange such a conversation/debate. There is a reason it has never happened.

      In a brief window in time, decades ago, such an exchange sort of took place in this journal issue: https://psycnet.apa.org/PsycARTICLES/journal/pre/1/2. Kind of, but not really. Shortly after this joint journal was started, launched in the spirit of collaboration between psychiatry and psychology, psychiatry elected to disengage from it.

      Irving Kirsch threatened the house of cards too much because he had a mountain of compelling scientific data to support his position. He had the temerity to observe that antidepressants don’t work, according to the scientific methods we use to evaluate how a drug work. Psychiatry (i.e., the APA) decided the journal was not in its best interests to continue to support. Thus endeth the “scientific” collaboration between the professions.

      The first rule of the DSM’s lack of validity is that you do not talk about the DSM’s lack of validity.

      The second rule is that you DO NOT talk about the DSM’s lack of validity.

  9. I think it’s important to remember that Dr. Aftab should probably be considered an ally to those of us in the critical psychiatry camp: https://www.madinamerica.com/2020/07/bridging-critical-conceptual-psychiatry-interview-awais-aftab/. His attempts to bring nuance to the debate may be frustrating to those in the anti-psychiatry camp who want to burn it all down, but my reading of that interview was a very careful dance he did, allowing Lucy to have a clear voice on her position while articulating many of the refutations, deflections, and many other spurious arguments the mainstream psychiatrists would suggest to ignore and caricature any who oppose the status quo. He has an audience that many will never have, and if he alienates it with the passionate rhetoric of those in either of our camps, he will lose his chance to continue to move those who are moveable. I know that’s not what the victims of psychiatry want to hear, but it is reality.

    Thank you, Lucy, for putting yourself out there especially in light of the ‘refutations’ at the end and the haters on Twitter.
    Sam

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