This post is a short round-up of some extremely interesting work being done by psychologists in the UK, mostly connected to the Division of Clinical Psychology, taking a critical view of mental health services. It also introduces a brand new document they have produced, as well as two other important recent ones. Mental health nurses won’t be in the least surprised that psychologists do not always agree with psychiatry, and it would be foolish for us to suspend all critical thoughts about psychologists, too: one reason for a previous post from Jonathan Gadsby about the psychologisation of unemployment.
However, it is gratifying that there are a number of psychologists who are very critical about all ‘psy-diciplines’, and as such, their efforts are a really important part of what makes up an increasingly articulate, urgent and influential critical mental health scene in the UK. Anne Cooke’s collaborative piece, Understanding Schizophrenia and Psychosis is another significant contribution – and the CMHNN thoroughly recommends it as a plain-English introductory guide – imagine the impact of this document were it to be read on every mental health ward and CMHT in the UK!
Steven Coles is a clinical psychologist in Nottingham and one of the editors of a 2013 book called ‘Madness Contested, Power and Practice’, published by PCCS books. It is a very interesting collection of critical mental health writing and certainly one of the best of its kind in the past few years, and £20 that no mental health professional wanting to understand some of the controversies of their work could regret spending. In this post he writes about the steps which led to the Beyond Diagnosis Committee, of which he is chair, and particularly focuses on a document about the use of language by mental health professionals, which makes suggestions for terms which are less pathologising and do not rely on diagnoses.
It is this committee which has now produced a new information leaflet about diagnosis. The link to the leaflet in PDF form is here. We would greatly value mental health nurses and service-user feedback about this new leaflet. Specifically, nurses, this has been designed to be something you might give to a service user. Is that something you are going to do? If yes, why, if no, why not? And, if you are a user/recipient of mental health services, what do you think about this? Helpful? Or not? Please feel very free to comment below – and, as ever, Steven will see them and be able to respond.
Steven Coles: The topic of psychiatric diagnosis appears to cause significant emotional reactions for people and be a continuing source of debate – with a variety of opinions expressed within and between: professionals, people who are labelled, people who avoid being labelled, family members and the wider public. In 2011 the Division of Clinical Psychology started to work on a position statement on diagnosis (partially influenced by a statement by an East Midlands DCP subsystem statement on diagnosis) [link here]. This led eventually to a short statement that called for a movement beyond diagnosis and was released in May 2013 on the day of release of the new Diagnostic and Statistical Manual (DSM-5). This statement was not formed easily but came from much discussion, debate, consultation and eventually the formation of a shared position. The build up to and release of DSM 5 was controversial with many people and groups highlighting concerns about diagnostic practice, including psychiatrists and mainstream organisations, such as the director of the National Institute of Mental Health, who described that DSM’s “weakness is its lack of validity” – essentially it was scientifically meaningless. This statement from a mainstream organisation is astounding given the claims made of psychiatric diagnosis as being scientific and the vast amount of money that has gone into research.
Why is this important? For me, it is significant as psychiatric diagnosis shapes how we make sense of our lives. Finding and creating meaning out of our lives and our experiences is crucial for us as individuals and as communities. Currently within mental health services (spread to wider society) distress, unusual behaviour and experiences are classified based upon a medical framework which is more usually used to categorize problems with legs, lungs and livers. Usually medical diagnoses give an indication of the cause of a medical illness, its outcome and treatment, however, psychiatric diagnosis is unable to do this. However, we are still led to believe that the cause of our problems is some biological dysfunction, due to psychiatric diagnosis association with physical medicine. By focussing on the biological we marginalise the importance of abuse, poverty, poor employment conditions, housing, social inequality and so forth in making sense of our lives and it ultimately shapes how we respond to people who have been harmed by the world. This is not to say biology has no role to play, biology enables everything we do, including typing this paragraph, but biology is not necessarily the cause of what we do or what I write.
As a starting point, I believe we simply need to honest about psychiatric diagnosis and be transparent with people who enter mental health services and the wider public that it is a contested practice. It really does not seem ethical to me to give people a diagnosis as if it is a simple unproblematic fact, given that a wide range of people are critical of the practice. To support clinical psychologists to work in a manner that is consistent with the DCP position to move beyond diagnosis, brief guidelines (not a diktat!) were written in 2015 [link here], the key aspect to these guidelines were encouraging psychologists to describe behaviour and experience within its “personal, interpersonal, social and cultural context”. The basic principles are:
- Principle 1: Where possible, avoid the use of diagnostic language in relation to the functional psychiatric presentations
- Principle 2: Replace terms that assume a diagnostic or narrow biomedical perspective with psychological or ordinary language equivalents.
- Principle 3: In situations where the use of diagnostic and related terminology is difficult or impossible to avoid, indicate awareness of its problematic and contested nature.
Moving away from diagnosis is a long road as it is embedded within many of the organisations and systems people turn to for help, however, I believe it is important we step out on this journey. This journey is not just important for the people who enter mental health services, but important for all of us in improving how we understand our lives. If we don’t see the importance of the real causes of pain in society, how are we to build a better life for us all?
Clinical Psychologist (Assertive Outreach / CMHT), Rushcliffe CMHT (2nd Floor), George Road Medical Practice, 93 Musters Road, West Bradford, Nottingham, NG2 7PG