Just came across this…. I’m glad you like and trust us, travailler-vous, but I’m not sure how you concluded that I (I won’t speak for Anne and Peter) am part of some ‘CBT coalition.’ CBT is mentioned only very briefly in the BPS report, along with a whole range of other therapies and interventions. The report was a group effort and does not exactly represent any particular individual’s views. In fact I rarely use CBT. I am more interested in trauma-focused approaches. Report comment
Just came across this…. I’m glad you like and trust us, travailler-vous, but I’m not sure how you concluded that I (I won’t speak for Anne and Peter) am part of some ‘CBT coalition.’ CBT is mentioned only very briefly in the BPS report, along with a whole range of other therapies and interventions. The report was a group effort and does not exactly represent any particular individual’s views. In fact I rarely use CBT. I am more interested in trauma-focused approaches.
Thanks for this column. I have been bracing myself for a stream of media nonsense about ‘schizophrenia’ and its effects. I was contacted by BBC World Service at short notice for a comment about the mental health lessons we can learn from Nash’s life and managed to mention, in the 2 minutes allocated to me, that many prominent survivor activists have left this label behind, often recovering as he did without medication, and that current thinking suggests ‘schizophrenia’ may be an understandable response to life events and circumstances, as Nash himself also seemed to believe. It’s an uphill struggle against the dominant narratives!
This is a most curious post by James Coyne, because it bears no relation to the facts of the report at all.
Rather than excluding/silencing/marginalising/disrespecting service users/survivors, the report was co-authored with them.
Rather than solely representing narrow clinical psychology self-interests, the report has been publically supported by several of the most senior psychiatrists in the UK, by the two leading UK Mental Health charities, and by many other professional, service user and carer representatives and many others. It is fortunate that these alleged narrow interests seem to coincide with theirs as well….!
Rather than ignoring severe ‘psychosis’, the report draws from the expertise of several authors who have experienced, and documented, psychotic states at the far extremes of human suffering.
Rather than being racist, the report argues that psychosis should be understood within its personal, relational, social, spiritual and cultural context….. as opposed to the medical model that Coyne supports, and the ample evidence of racism in theory and practice based on traditional concepts of ‘schizophrenia’.
And so on and so on. I suspect the real threat comes from the report’s very reasonableness. It quite clearly isn’t imposing any simple or single model, and quite clearly has appeal across professional and service user groups. Even more threateningly, it argues strongly for a choice of models and interventions. By that it means a real choice: to use diagnosis and medication if that is found helpful, but also to choose non-medical understandings and interventions. Of course that is exactly what is NOT on offer at present, whatever the rhetoric about empowerment, and however damaging the evidence about the lack of support for diagnostic categories, the potential harm of medications and so on.
The potent mixture of strong support accompanied by strong backlash indicates the importance of these issues…. and the threat that is posed by the report’s humane and evidence-based recommendations. We live in exciting times!
Hi Isis, I agree that ‘borderline personality disorder’ is just about the worst label, with its messages of being both ‘bad’ and ‘mad.’ It is a judgement on someone as a person, with implications that there is something fundamentally and permanently wrong with who they are. Your personality is not something you ‘have’ – it is you! I’m pleased that it will apparently be dropped from ICD11 (although the general category of ‘personality disorder’ will remain.) And yes, how to undo the damage and self-stigma is a big question – one that my book has tried to address. There’s no simple answer, but I believe that along with becoming informed about the unscientific nature of diagnosis, sharing your story with others – for example on this website – and joining together to direct your anger outwards, are powerful antidotes. In fact this is true of all forms of psychological damage and abuse inflicted on people when they are vulnerable. It is the opposite of the shaming, isolating effects of being psychiatrically labelled.
Thanks for all these comments. Doctor-X has summarised the key message from my book – that even if you need to keep your diagnosis for the purposes of treatment reimbursement etc, you do not have to let it define your identity.
Incidentally, although the amazon.com page is showing it with a pre-order date of April 2015, I am told it will be available in the next few days.
Thank you for endorsing the broad messages of this report. It is not perfect, and although it has been widely welcomed we are happy to receive feedback about how it could be improved.
We accept the criticism about the failure adequately to address the perspectives of black and minority ethnic people in the development and content of the report. We are aware that there are ongoing discussions within the DCP/BPS about the kinds of structural changes necessary to avoid such problems in the future.
However, we are concerned that your comment may create the impression that these issues were not addressed at all. For example, the report has a section on the experience of ‘psychosis’ in ethnic minorities and non-Western cultures; discusses supernatural, religious and spiritual explanations at several points; discusses the role of discrimination and social deprivation in prevalence rates of ‘psychosis’ in migrant and minority ethnic groups; and calls for preventative action to tackle racial discrimination and oppression.
The report is intended to be supplemented by a website, which will give us the opportunity for collaborative exploration in greater depth of the aspects you have highlighted, via video clips, personal testimonies, signposting to other resources, and so on. We are also planning a document on ‘psychosis’ in BME groups and would welcome your input.
The overall message of the report, as you have correctly noted, is that the experiences that are referred to as ‘psychosis’ should be understood as meaningful responses to an individual’s personal, relational, social, spiritual and cultural context. We believe that if these central points are taken on board, and embedded into services, service users from all cultural backgrounds will benefit.
Lucy Johnstone and Dave Harper (contributors) Zenobia Nadirshaw (Chair of London DCP branch and expert in the field of BME)
Hi Rachel, I just wanted to echo what others have said about this powerful and beautifully-written post. I am sure I will be using it in future training sessions on the seductive dangers of diagnosis. Thank you.
At the risk of boring people with my favourite topic, I do believe that psychological formulation can be one alternative to the narrow, pathologising ‘story’ imposed by psychiatry. I imagine it might have made all the difference if the mental health staff had been able to help you to understand your experiences as a creative attempt to survive overwhelming pain. But to do this, they themselves would have needed the opportunity to undo their own brainwashing (or ‘professional training.’) Fantastic that you found this opportunity through the HVN, but it is tragic that so many people have to escape psychiatry, and unpick the damage it has done, before finding anyone who is able to listen.
Keep up the excellent work!
It’s good to hear that the young man is – well, perhaps ‘safe’ isn’t the right word given what we know about the things that can go on in psychiatric hospitals, but certainly alive.
Of course you don’t have ‘blood on your hands’ and would not have done so even if the outcome had been a tragic loss of life. Did you stand up in front of NAMI and say ‘By the way, I advise everyone here who is on medication to stop it immediately and run away from home?’ I don’t think so! But the worrying underlying message seems to be that people who are psychiatrically labelled should not be informed about the evidence on neuroleptics. This is not a defensible position – either scientifically, professionally or ethically.
What this incident does expose is the depth of the resistance to challenging the psychiatric orthodoxy, the enormously strong feelings that are stirred up – such that rational debate can get entirely lost – and the tactics that some people are prepared to use to silence critics. It’s not pleasant.
There are, of course, people and organisations with ‘blood on their hands’ for the enormous harm caused by psychiatric medications – but this is a classic case of ‘blame the messenger’ not the perpetrators.
Keep up the good work!
Joanna – thanks for posting the link above to the Members of Parliament guide to supporting constituents with mental health problems. I’ve rarely read a document that combines insult and inaccuracy in such a patronising way. We learn that these difficult people with mental health problems are liable to ‘direct anger unfairly at you’, be ‘unfocused or confused’ about their requests, need firm boundaries, become ‘angry or abusive’ and so on – and all because they may be suffering from a range of conditions such as ‘personality disorder’ (which involves being paranoid, anti-social, narcissistic etc), ‘bipolar’, ‘schizophrenia’, and so on. I am sure that MPs see many people who are angry, confused, unclear about their requests and so on – but to attribute all these qualities specifically to the ‘mentally ill’ is really shocking. And this is the combined effort of the Royal College of Psychiatrists and the UK’s 2 main mental health charities. The same charities who are promoting the anti-stigma ‘Time to change’ campaign! Read it and see what you think!
Hi Joanna, I completely agree that psychiatry does not exist in a vacuum. Here in the UK, as you say, we are facing devastating attacks on the most needy, who are demonised as ‘scroungers’ while the privileged elite line their own pockets. There is overwhelming evidence that poverty, unemployment, social inequality, poor housing, discrimination etc lead to increased levels of mental distress. So yes, we need to fight against this kind of social injustice. One of the problems in the UK at present, as you will know, is that opposition and protest is currently so muted, and not just from psychiatric campaigners. It feels as if everyone is too scared to speak out, and indeed they may have good reasons for this feeling.
Our post is not specifically about diagnosis, but about the various ways in which the profession of psychiatry is seeking to preserve its power and status. Critics have, of course, argued for many years that its core function (not necessarily intended by the individual practitioner) is to silence dissent by re-defining the consequences of social policy as medical illnesses. If you accept this view, then campaigning needs to happen on both fronts. As you rightly
say, we need to highlight the injustices that lead to breakdown in the first place, along with challenging psychiatry for its role in concealing the causal factors behind unscientific and stigmatising labels, and for its many other dubious practices.
Meanwhile, of course people will need to use diagnoses to gain access to essential benefits – that is how the system works at present. It is not going to vanish overnight, and we all have to survive in the best way we can.
I like your recipe for the way forward!
Thanks to everyone for your supportive comments. I am sorry to be late in replying. The debate has taken off in a big way and life has been very busy. In answer to the last commentator: you’re right, I don’t think diagnosis has a role (with obvious exceptions like dementia in which biological causes are established). As a psychologist I prefer formulation as a means of helping people to feel understood, deciding on the best way forward (I wouldn’t use the word ‘treatment’) etc. But there are many other ways of achieving the same ends – the general principles are about listening to people’s stories, constructing meaning, and finding paths to recovery. And it wasn’t up to us in the DCP to call for psychiatrists to abandon dx – we can only establish a position for our own profession.
Sorry for the delayed response.Email me and I’ll do my best to advise. [email protected]
Thanks Heledd – a determined and critically-aware colleague who has successfully introduced this approach into a busy inpatient environment.
Email me for a more detailed account! [email protected] And there is a chapter on Team Formulation in the forthcoming 2nd edn of ‘Formulation in psychology and psychotherapy’ eds Johnstone and Dallos.
Thanks for this post. As a member of the International DSM Response Committee I can concur that the discussions have sometimes been difficult, and I sympathise about the personal impact this has had on you – it is always difficult to stick your head above the parapet, but please don’t give up!
From my perspective, the discussions have highlighted (at least) 2 areas of difference:
1) The US position vs that in other countries, specifically the UK. I am not used to thinking of myself as in a fortunate position in relation to dominance of psychiatric diagnosis, but it is obviously a huge advantage not (yet) to have the US billing system, and not to have salaries dependent on it. As an individual clinical psychologist, there is virtually no situation where I am absolutely required to use a diagnosis, although of course the mental health system itself is based on such terminology. For this reason, the wish to deprive DSM of its revenue etc perhaps seems less urgent for us.
2)The lack of an agreed and coherent critique of diagnosis in principle, aside from the specific issues relating to DSM 5. Clearly, not all the campaigners have objections to diagnosis per se. This is very frustrating for those of us who take what has been described as a ‘radical’ (my translation: absolutely obvious and common sense) view. Again, in the UK I think we are further ahead on this issue. The Critical Psychiatry group rejects the use of psychiatric diagnosis, and the robust response to the DSM 5 revisions by the British Psychological Society in 2011 took the same position. The official UK Clinical Psychology guidelines on psychological formulation state that it should ‘not be premised on a functional psychiatric diagnosis such as schizophrenia or personality disorder’) (DCP 2011.) A ‘Position Statement on Classification’ is currently under preparation by the UK Division of Clinical Psychology, and is likely to echo the above views. I have discussed all these issues in more detail in my blogs on this site.
So, for various reasons it may be right to work separately but alongside each other at present as we try to reach our common goal. Keep up the good work!
Incidentally, I have had some success in persuading UK psychiatrists to use the catch-all term ‘adjustment disorder’ if they have to supply a diagnosis. That can apply to absolutely all of us!
I can’t see anything to disagree with here. In answer to your first point: Yes, we certainly have been here before. As I hope I made clear at the start of my post, formulation is just one of the most recent expressions of the long-standing controversy about whether madness is meaningful or not. It is a battle that we have to fight again and again, in numerous different forms and arenas. Many many people, Carl Rogers among them, have argued that the essence of healing is to be found by exploring meaning within a trusting relationship. At this juncture, we have a vitally important opportunity to take the fight to the foundation of psychiatry, ie the diagnostic system, and for this purpose we do, I think, need to strengthen our arguments by demonstrating that there are workable and effective alternatives to the current classification system. This is where formulation comes in – an old idea in new clothing, but in one that is, I believe, well-suited to this particular challenge. (Depending how you do it!!!)
And yes, I do agree about the need to acknowledge the embodied nature of trauma and indeed of all our experiences, and this should also be apparent in our formulating.
Thanks – and I agree with your caveat that formulation is probably most useful WITHIN the psychiatric system. If people manage to stay out of the system altogether and create their own meanings and narratives out of distress (as most of us do most of the time), then so much the better. There is an interesting contrast with the Hearing Voices Movement idea of a ‘construct’ here. A construct is a way of making sense of your voices in the context of your life experiences and their significance to you, BUT there is no implication that it has to be facilitated by a professional. Friends, allies or other voice-hearers might do as well or better. Developing a construct is thus a more radical alternative to diagnosis than formulation is. However, I believe that formulation may have more credibility and power as an alternative strategy WITHIN the psychiatric system. In order to change psychiatry we need to use the most effective weapons at every level of a multi-faceted campaign.
Thanks for your comments. Yes, there are many reasons for keeping madness meaningless, with drug company profits being one of the most powerful drivers – see Ethan Watters’ post for a horrifying example of how the medical model was exported to Japan. The huge vested interests in supporting the status quo mean that any attempt to change things has to be sophisticated and multi-level. Formulation can perhaps be a useful strategy at one of those levels.
Some of these ideas are unfamiliar to me, but there is a lot I can agree with – such as meditation, being aware of the role of trauma, and treating people with respect. Thank you.
Thank you for your comments!
Yours is a horrifying story. It is also a vivid illustration of the fact that, as I wrote above:
‘If hearing voices, or believing you are being poisoned by your relatives, or feeling so low that you can’t get out of bed, or so frightened that you are trapped in your house, or so overwhelmed that you can only find relief in self-harm, are ‘symptoms’ of a ‘disease’, it makes no more sense to enquire further into them than into the meaning of a rash, or the content of delirious speech in a fever.’
It seems almost unbelievable that no one asked you WHY you were behaving in that way, but that is, I’m afraid, the logical consequence of the diagnosis-based medical model – even though the alternative seems in some ways, as John Hoggett’s comment noted, ‘bloody obvious.’ Which raises the question: Why aren’t we doing what is bloody obvious? And my partial answer is because professionals (and certainly not just psychiatrists) are brainwashed and blinded by their model.
In the situation you describe, I would want to, quite simply, sit down with the person and hear their story, and see if we could make sense of the situation together and come to a shared way forward. Sounds as if it would have to involve the family as well, in this case. I would call that formulating. Another way of describing it is just being compassionate, human and humane.
Thanks for this useful reply – this is not an area that I know much about.
Just to say that the theory that psychiatry’s damaging and silencing consequences are not just its effect, but to some extent its purpose, does not in any way imply conscious bad intent on the part of mental health professionals (of whom I am one!) The vast majority are dedicated and hard-working people with a genuine desire to help. But we do need to explain why psychiatry continues in its current form, given that it fails so badly on almost every measure you can think of – including cost. It is very expensive, in all sorts of terms, to create patients and lifelong disability. Richard Warner’s book ‘Recovery from schizophrenia’ makes this argument very convincingly, I think, even though in many respects he is an orthodox psychiatrist who uses diagnosis.
Interestingly, I wasn’t seeing this hypothetical example as drawing particularly on psychodynamic theory, but as being rooted in the evidence and practice of the Hearing Voices Network. But obviously there is an overlap. Their version of a formulation is a ‘construct’ which overlaps with, but is not identical to, the concept of formulation.
Thanks to both of you, and I think you are making fair points, which relate to my statement that ‘it all depends how you do it.’ In my example, I am assuming that the formulation does emerge out of a genuinely respectful and collaborative conversation and a trusting relationship, and (the ultimate test) that it makes sense to Jane – if it doesn’t, then it is pretty much worthless. But of course, there is no guarantee that the process of formulation will NOT done in a rigid, expert-derived way, in which case it is perhaps more correctly seem as a kind of psychological diagnosis which is in some ways not a lot better than a psychiatric one. I will be talking further about ‘best practice’. The absolutely key issue is whether formulation is seen as an addition to, or an alternative to, psychiatric diagnosis. That will be subject of my next post.
The shift to ‘psychosis’ is worth a post on its own – in fact I wrote a chapter about this very subject (‘Can traumatic events traumatise people?’ in ‘Demedicalising Misery, eds Rapley, Moncrieff and Dillon, 2011.) As with so many of the key terms in psychiatry, like ‘biopsychosocial’, it is used in a number of different senses, some of them narrower than others. But all usages convey the impression that the person is suffering from some kind of (probably) biological/medical condition OVER AND ABOVE A NORMAL REACTION TO THEIR LIFE EXPERIENCES. And that is the problem. Why do we make such an assumption, and is it justified? And what are the consequences of framing people’s experiences in this way? I will return to this issue….
Thanks, and I am very pleased to make contact. I have ordered your book and will read it with interest. Szasz is a wonderful source of powerful quotes.
In the UK, and I guess it is the same in the US, Laing has become almost a taboo figure – only mentioned in the context of the terrible crime of family-blaming that he (allegedly) committed. While it is certainly possible to make criticisms of the man and his methods, his central message, that madness has meaning, is still absolutely relevant. I look forward to reading your account.
I agre 100% that diagnosis is the foundation and cornerstone of the whole system; nothing will fundamentally change unless or until we abandon it. A couple of favourite quotes that back up this view:
‘Diagnosis is the Holy Grail of psychiatry and the key to its legitimation’
(Kovel J 1981 in D Ingleby ‘Critical Psychiatry’, Penguin.)
‘The critique of diagnosis is the critique of psychiatry….Diagnosis locates the parameters of normality and abnormality, demarcates the professional and institutional boundaries of the mental health system, and authorises psychiatry to label and deal with people on behalf of society at large’
Brown P (1990) The name game. In J of Mind and Behaviour 11, 385-406.
And another favourite quote, this time from Mary Boyle’s book ‘Schizophrenia: a scientific delusion?’ 2002
‘The crucial difference between medicine and psychiatry can perhaps be summarised by saying that whereas medical scientists study bodily functioning and describe patterns in it, psychiatrists behave as if they were studying bodily functioning and as if they had described patterns there, when in fact they are studying behaviour and have assumed – but not proved – that certain types of pattern will be found there.’
In other words, psychiatrists are engaged in a kind of parody of legitimate medical practice – they use the same words and rituals but are actually doing something fundamentally different.
Many of my favourite quotes are quite old… but alas, the same arguments still need to be made, and they have never been made better than by some of the earlier critics.
I am an admirer of Paula Caplan and frequently cite her work. Thanks for adding the website address. There are many people campaigning against psychiatric diagnosis, as I am sure visitors to this site will know. There is also, of course, the petition launched by the Society of Humanistic Psychology at http://www.ipetitions.com/petition/dsm5
I do think that psychiatrists and clinical psychologists in the UK have a little more freedom to express their views, since they are not (yet) tied to insurance systems – the vast majority work in the National Health Service. However, there are still a great many powerful forces opposing challenges to the system. My own career is an example – the training course in clinical psychology that I used to lead was closed down despite a lengthy battle (it’s a complicated story!) to be replaced by one that is, in clinical psychology terms, as orthodox as you can get. But I am optimistic that 2013 and the publishing of DSM 5 will serve as a watershed.