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| Let's together remove the life-long burden on young people of the attributional stigmatisation of mental health diagnosis. |
We
are writing to commend the immediate
and comprehensive use of the DCP
statement on formulation to all of our
colleagues. It has appeared at the very time
when the shortcomings of psychiatric
diagnosis have been exposed
in
the critical international response to the
publication of DSM-5 by the American Psychiatric
Association. Our current
context
then provides the profession of clinical
psychology with a unique historical
opportunity to adopt a clear position
of scientific humanism.
DSM
and other forms of psychiatric nosology
are incompatible with a psychological
approach to helping people with
their problems, which should be both
humane and scientific. Our approach to
helping others should be
based on identifying
specific
problems (defined by
clients themselves but, for obvious
practical
purposes reflecting a common lexicon)
and working with them to develop
individual and context-bound
formulations.
These would include the unique
events in a person’s life past and present,
the meanings they invest in, or
attribute
to, those events and strengths to build
upon that he or she has exhibited to date
in coping with challenges in their
life.
David Pilgrim
Professor of Health
and Social Policy
Peter Kinderman
Professor of
Clinical Psychology
Richard Bentall
Professor of
Clinical Psychology
University of
Liverpool
As
210 clinical psychologists
and mental health
professionals, we support
the DCP’s call for a
paradigm shift in how
we
think about mental distress
and the need to move
away from
psychiatric
diagnosis. We are
pleased by the media coverage
and the debate this
has stimulated in the wider
public.
It
is essential that diverse
voices are heard and
that rather than
considering
individuals as
receptacles of disorders, deficits
and distortions, we
make sense of distress in
more helpful and
evidence-based
ways. We need
to focus far more on
people’s
lives, experiences and
social contexts and to
consider how people embody
and are shaped by
the world around them.
We
note that organisations
such as the Hearing
Voices Network
and
Mental Health Europe, which
represent the service-user
perspective, have
recently challenged the
diagnostic and
professional
expert-driven status
quo, and we believe
that
clinical psychology needs
to support and work with
these groups. We need
to step out from the
shadow of biological
reductionism
and consider
the multifaceted
nature of what
it is to be human and
to be part of the world around
us. We wish to
support
the DCP and the growing
number of service users,
carers, professionals and
organisations who are questioning
the dominant paradigm.
This
is a very important
step for the profession
and one that
is
long overdue.
Dr Mel Wiseman
Wellingborough
and 209 other signatories
(For the full list
see the html version in ‘Letters’ at www.thepsychologist.org.uk)
Following
the publication of the DCP’sPosition
Statement on Diagnosis, which we
have already endorsed, the Psychosis
and
Complex Mental Health Faculty is keen
to work on bringing about thechanges
in practice and conceptualisation
that
it envisages in our services. Most of us
in the Faculty work closely with colleagues
in other professions in a team
context,
so that collaboration, both with them
and with service users and carers, is a
priority. We are seeking to further this
agenda
at the Faculty conference and AGM
to be held on 20 November at the BPS
London office under the heading
‘Developing
the narrative – Creating a shared
paradigm shift towards a holistic view
of mental health’. This
should further the process of moving
beyond restrictive, illness-based
conceptualisations
in partnership with the other
groups and professions concerned with
complex mental health, in line with
the
second recommendation at the end of the
position statement.
Isabel Clarke
Chair of the PCMH
Faculty of the DCP on
behalf
of the Faculty Committee
We welcome
contributions to the debate that has been raised
by the DCP Position Statement on
Classification, which can be
read in full at
http://dcp.bps.org.uk/dcp/ the_dcp/news/dcp-position-statement-onclassification.cfm
The statement is not
about DSM specifically but about
conceptual systems ‘based on a “disease”
model’. This would
include ICD. Nor do we
see it as an ‘attack’ but as a
thoughtful critique based on a two-year process
of reviewing the
evidence and
consulting within all the DCP Faculties, where
it has widespread support.
It is difficult to
convey a complex argument through the
media. We regret that some of the
reporting has badged this as a psychiatry versus
psychology battle.
We have been working
hard to counter this. The statement
itself makes it absolutely clear that,
to quote: ‘This position should not be
read as a denial of the role of biology
in mediating and
enabling all forms of
human experience, behaviour and distress…
It recognises the complexity of the
relationship between social, psychological
and biological factors’ (p.2).
We are unhappy with
responses that, quite wrongly,
represent us as presenting ‘a false dichotomy
between genes and
environment’ and hope
that all members of the Society will
take the opportunity to correct such
misinterpretations.
Nevertheless, our
position, supported by a great deal of
evidence, is that it is neither accurate nor helpful
to conceptualise the experiences that may
lead to a functional
psychiatric diagnosis
within a ‘disease’ model, in which
biological causal factors such as genes or
biochemistry are
hypothesised to be the
primary causal ones. We do not do
this for other responses to life
events – for example, bereavement – and by
analogy, our argument is that the
increasing amount
of evidence for the
causal role of all kinds of traumas and life
circumstances in psychiatric
breakdown makes it implausible to do so
in many of these cases as well. The DCP
is, in conjunction
with the BPS Media
Centre, monitoring the media coverage
closely and working to correct any
distortions of our message.
The point is well made
that we need to explore the
possibility of alternative clustering systems,
and internationally there are a number of
groups engaged in this task. The DCP has
funded its own project to outline the
principles of an approach that
identifies common patterns of responses, both
psychological and
biological, to life
events and social circumstances, and
that might supplement and support the use of
individual formulation.
Clearly, the existing
classificationsystem will be with us
for some time. However, the DCP
believes that it is
vitally important to ‘achieve
greater openness and
transparency about the uses and limitations
of the current system’ and ‘to open up
dialogue with partner
organisations, service
users and carers, voluntary agencies and
other professional bodies in order to
find agreed ways
forward’ (p.4).
Richard Pemberton
Chair, BPS Division
of Clinical Psychology
Professors Viding and Frith(Letters, June 2013) excoriate
critics of DSM-5 who, they say, ‘are in danger of muddying
mental health issues by ignoring… biology’. They write approvingly of Simon Wessely’s Observer article (12 May 2013) and endorse his claim that ‘a classification system is like a map. And just as any map is provisional, ready to be changed as the
landscape changes, so is classification.’
Let me outline how history illustrates the value of this metaphor of mapping the mind.
In 1952, when the first Definitely Scientific Map (let’s call it ‘DSM-1’) was published, only 106 cartographic entities
were in the atlas. A good index of the success of the cartographers of the mind is the phenomenal productivity
of their subsequent explorations – new islands, continents, rivers, mountain ranges, swamps, and so on, were added, and although
many old ones were thrown out they achieved an average rate of increase over the next 42 years of close to one every eight weeks: DSMap-4 (1994) showed 365 entities.
How had they achieved this fecundity? Untiring effort was the answer. Year in, year out their exploration vessels sailed the seven (7.34 ± 1.56) seas, proudly flying the Cartographers’ flag, a banner inscribed ‘BP’. (Crew members gave different answers when asked what the letters stood for: ‘Big Pharma’, said some,
‘Big-time Psychiatry,’ said others, but the groups worked
together as one big happy family regardless). It was not always smooth sailing. For example, when explorers sent descriptions
of the landscape to the head office of the Cartographers of
the Mind Association (CoMA) for official rulings, one might be told that a tenant was on Mount Skitzos while a second tenant in the same building was on the Isle of Catatonia, a third on Lake Normalia.
But none of this impeded the enlightened help BP could provide to the inhabitants – the holds of the vessels of exploration were brimming with curative chemicals that were equally effective
everywhere on the Map.
There were of course sceptics, people who thought, for example, that it might be more effective to build warm buildings in (bi?) polar regions instead of filling inhabitants with chemicals
that made them complain less about the cold. As a gesture of
goodwill (and to try to rid themselves of the distractions
of repetitive complaints), exploration vessels started to carry small amounts of building material, pumps to drain swamps, and so on. CoMA itself even professed to subscribe to a Bio-Psycho-
Social model of disorder: their banners accordingly now read
‘BPS’ not ‘BP’. (This new image has perhaps brought to light
a little-researched version of the Stockholm syndrome, with scientists who are not members of the BP team taking up cudgels on the team’s behalf). Sceptics even argued that the metaphor itself is flawed. Geographic cartographers, they say, draw representations of things we are reasonably sure exist independently of the maps drawn of them: mountains, islands, and so on, they disingenuously claim, are real. DS Maps of mental disorders, they say, are different. They are not
representations of realities: the entities they purport to describe are constructions of the minds of Cartographers of
the Mind. They are Maps of Wonderland.
Professor Justin Joffe
London N2
The American critic H.L. Mencken once remarked, ‘For
every subtle and complicated question, there is a perfectly
simple and straightforward answer, which is wrong’. The
question of how to respond to psychological distress is subtle
and complicated. The answer that has dominated recent
Western thinking, namely that there exist mental illnesses and that these are illnesses like any other, has the virtue of being simple and straightforward. But it may also be wrong – or at least,
partial, misleading and, in some cases, actively unhelpful.
The DCP’s recent statement is to be commended for not trying to replace one ‘simple, straightforward and wrong’ answer with another. The document acknowledges the subtle and complicated
nature of the issues. Contrary to what some commentators
have suggested, it does not pit clinical psychology against
psychiatry or deny the role of biology – indeed, it states
explicitly that what is required is ‘multi-factorial and contextual approach, which incorporates social, psychological and biological factors’. It highlights problems with the current system of classification, but does not object to classification per se.
It offers no off-the-shelf alternative, calling instead for
wide-ranging dialogue to develop new approaches. Even
the document’s most striking letters 468 vol 26 no 7 july 2013
letters suggestion, a move away from the system of diagnosis
described by the DSM-5, is hardly radical. Similar arguments have recently been made by influential and mainstream groups such as Mental Health Europe (see tinyurl.com/bqdgos9) and the
US National Institute for Mental Health (see tinyurl.com/cl5ekbc).
That such a measured and non-polemical statement should provoke howls of outrage perhaps tells us something about the tenuous foundations of the medical model. If proponents had the
confidence of their convictions they would have nothing to
fear from – indeed would welcome – critical interrogation. By contrast, those who raise problems with diagnosis, or with the concept of mental illness as such, are accused of ‘anti psychiatry
prejudice’ and of having no interest in relieving suffering
(see tinyurl.com/no88tpb).
Most baffling of all is the response that criticising diagnosis is somehow antiscientific – particularly absurd when, as the DCP statement makes clear, many of the difficulties of the DSM arise
from a failure to follow the scientific method.
Although the DCP statement makes no new arguments, it performs a valuable service by bringing vital critiques of the medical model of mental illness to wider public attention.
Personally, I am proud to see the BPS finding its voice and
raising subtle and complex questions.
Dr Sam Thompson
Institute for Psychology, Health
and Society
University of Liverpool
Professors Viding and Frith(Letters, June 2013) excoriate
critics of DSM-5 who, they say, ‘are in danger of muddying
mental health issues by ignoring… biology’. They write approvingly of Simon Wessely’s Observer article (12 May 2013) and endorse his claim that ‘a classification system is like a map. And just as any map is provisional, ready to be changed as the
landscape changes, so is classification.’
Let me outline how history illustrates the value of this metaphor of mapping the mind.
In 1952, when the first Definitely Scientific Map (let’s call it ‘DSM-1’) was published, only 106 cartographic entities
were in the atlas. A good index of the success of the cartographers of the mind is the phenomenal productivity
of their subsequent explorations – new islands, continents, rivers, mountain ranges, swamps, and so on, were added, and although
many old ones were thrown out they achieved an average rate of increase over the next 42 years of close to one every eight weeks: DSMap-4 (1994) showed 365 entities.
How had they achieved this fecundity? Untiring effort was the answer. Year in, year out their exploration vessels sailed the seven (7.34 ± 1.56) seas, proudly flying the Cartographers’ flag, a banner inscribed ‘BP’. (Crew members gave different answers when asked what the letters stood for: ‘Big Pharma’, said some,
‘Big-time Psychiatry,’ said others, but the groups worked
together as one big happy family regardless). It was not always smooth sailing. For example, when explorers sent descriptions
of the landscape to the head office of the Cartographers of
the Mind Association (CoMA) for official rulings, one might be told that a tenant was on Mount Skitzos while a second tenant in the same building was on the Isle of Catatonia, a third on Lake Normalia.
But none of this impeded the enlightened help BP could provide to the inhabitants – the holds of the vessels of exploration were brimming with curative chemicals that were equally effective
everywhere on the Map.
There were of course sceptics, people who thought, for example, that it might be more effective to build warm buildings in (bi?) polar regions instead of filling inhabitants with chemicals
that made them complain less about the cold. As a gesture of
goodwill (and to try to rid themselves of the distractions
of repetitive complaints), exploration vessels started to carry small amounts of building material, pumps to drain swamps, and so on. CoMA itself even professed to subscribe to a Bio-Psycho-
Social model of disorder: their banners accordingly now read
‘BPS’ not ‘BP’. (This new image has perhaps brought to light
a little-researched version of the Stockholm syndrome, with scientists who are not members of the BP team taking up cudgels on the team’s behalf). Sceptics even argued that the metaphor itself is flawed. Geographic cartographers, they say, draw representations of things we are reasonably sure exist independently of the maps drawn of them: mountains, islands, and so on, they disingenuously claim, are real. DS Maps of mental disorders, they say, are different. They are not
representations of realities: the entities they purport to describe are constructions of the minds of Cartographers of
the Mind. They are Maps of Wonderland.
Professor Justin Joffe
London N2
The American critic H.L. Mencken once remarked, ‘For
every subtle and complicated question, there is a perfectly
simple and straightforward answer, which is wrong’. The
question of how to respond to psychological distress is subtle
and complicated. The answer that has dominated recent
Western thinking, namely that there exist mental illnesses and that these are illnesses like any other, has the virtue of being simple and straightforward. But it may also be wrong – or at least,
partial, misleading and, in some cases, actively unhelpful.
The DCP’s recent statement is to be commended for not trying to replace one ‘simple, straightforward and wrong’ answer with another. The document acknowledges the subtle and complicated
nature of the issues. Contrary to what some commentators
have suggested, it does not pit clinical psychology against
psychiatry or deny the role of biology – indeed, it states
explicitly that what is required is ‘multi-factorial and contextual approach, which incorporates social, psychological and biological factors’. It highlights problems with the current system of classification, but does not object to classification per se.
It offers no off-the-shelf alternative, calling instead for
wide-ranging dialogue to develop new approaches. Even
the document’s most striking letters 468 vol 26 no 7 july 2013
letters suggestion, a move away from the system of diagnosis
described by the DSM-5, is hardly radical. Similar arguments have recently been made by influential and mainstream groups such as Mental Health Europe (see tinyurl.com/bqdgos9) and the
US National Institute for Mental Health (see tinyurl.com/cl5ekbc).
That such a measured and non-polemical statement should provoke howls of outrage perhaps tells us something about the tenuous foundations of the medical model. If proponents had the
confidence of their convictions they would have nothing to
fear from – indeed would welcome – critical interrogation. By contrast, those who raise problems with diagnosis, or with the concept of mental illness as such, are accused of ‘anti psychiatry
prejudice’ and of having no interest in relieving suffering
(see tinyurl.com/no88tpb).
Most baffling of all is the response that criticising diagnosis is somehow antiscientific – particularly absurd when, as the DCP statement makes clear, many of the difficulties of the DSM arise
from a failure to follow the scientific method.
Although the DCP statement makes no new arguments, it performs a valuable service by bringing vital critiques of the medical model of mental illness to wider public attention.
Personally, I am proud to see the BPS finding its voice and
raising subtle and complex questions.
Dr Sam Thompson
Institute for Psychology, Health
and Society
University of Liverpool
Given the importance they attach
toevidence, it is surprising that
Essi Vidingand Uta Frith (Letters, June)
should usethe words ‘attacking the DSM-5’,
implying both aggression and lack of
justification,for what is in fact a thoughtful,
evidence based
statement by the Division of Clinical Psychology (DCP) on
psychiatric classification.
In criticising the statement and subsequent ‘pronouncements in the
media’, Viding and Frith present
the current situation in mental health
as one led by evidence, in which
researchersand clinicians take due account of
both environmental and biological
factors in
understanding ‘the symptoms that
mark mental illness’. This is far from
the case.
For the last 30 or 40 years,
research and practice in this area has been
dominated by approaches which privilege
genes and
problems as akin to physical
illnesses,and systematically de-emphasise
the potential causal role of people’s
social
and personal contexts. This is in
spite of a poor evidence base for all three
of these
stances. This situation itself has
a social
context, which may help explain
both its
persistence and the strength of
feeling
often evoked by attempts at change
(Boyle, 2011; Cromby et al., 2013;
Pilgrim, 2007).
And contrary to Viding and Frith’s
claims, the DCP argument is not
based
on a ‘false dichotomy between
genes and
environment’. It does position
itself for a
reconceptualisation of the role of
biology
and against a model that sees
mental,
emotional and behavioural
difficulties as
symptomatic of biologically based
illness.
It also argues for due
acknowledgement
of the vast amount of evidence
that many
of these difficulties are
meaningful
responses to often
extremely
challenging life
circumstances.
Finally, Viding
and Frith imply
that those who
claim a causal
link between
child abuse and
‘schizophrenia’ are ‘not slowed
down by
a need for an evidence base, but
instead
irresponsibly make unsubstantiated
and
alarmist pronouncements’. This is
completely unjustified. There is
good
evidence, some of it cited in the
DCP
statement, that the links between
child
abuse and psychosis are likely to
be
causal, and such claims are not
made
lightly. This evidence may be
difficult for
many to hear and unfortunately,
Viding
and Frith’s ad hominem response,
rather
than one engaging with the
evidence, is
not untypical.
I hope the DCP statement will encourage truly informed debate on
these issues to the benefit of
researchers, clinicians and, above all, service users themselves.
Professor Mary Boyle
University of East
London
References
Boyle, M. (2011). Making the world go away, and
how
psychology and psychiatry benefit. In
Rapley, M.,
Moncrieff, J. & Dillon, J. (Eds.) De-medicalising
misery. London: Palgrave Macmillan.
Cromby, J., Harper, D. & Reavey,
P. (2013). Psychology,
mental health and distress. London: Palgrave
Macmillan.
Pilgrim, D. (2007). The survival of psychiatric
diagnosis.
