|Let's together remove the life-long burden on young people of the attributional stigmatisation of mental health diagnosis.|
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
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
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
University of Liverpool