THE PSYCHOLOGIST - JULY 2013 ISSUE - LETTERS PAGE POWERFUL DEBATE :"Stepping from the shadow of biological reductionism into the light of scientific humanism." - RESPONSES TO THE DIVISION of CLINICAL PYSCHOLOGY (BPS) POSITION STATEMENT ON CLASSIFICATION OF MENTAL HEALTH - JUNE 2013

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 


              

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.