Diagnosis under fire
SCOTT (Letters, June 2006) argues the case for clutching onto his charred copy of the DSM IV-TR when making treatment decisions on the grounds that (i) DSM diagnoses are used to select patients for clinical trials; (ii) NICE uses them to organise their clinical guidelines; and (iii) he believes there is no evidence that formulation-based CBT is superior to CBT targeted at DSM categories. The first two of these arguments are not convincing and the third is frankly confused.
Although DSM diagnoses are often used to select participants for clinical trials, this is not invariably the case. Some trials are targeted much more broadly (for example, at ‘unexplained medical symptoms’ or ‘schizophrenia spectrum disorders’) and others select patients suffering from particular symptoms (for example, auditory hallucinations).
While it is true that the NICE guidelines are organised around categorical diagnoses, unthinking observance of these criteria when making treatment decisions will almost certainly lead to undesirable consequences. For example, the DSM criteria for schizophrenia require that a combination of symptoms must have been present for one month and that evidence of illness must have been present for at least six months. However, it would be unethical to turn away a highly distressed patient on the grounds that only some of the necessary symptoms were present or because the duration criteria were not met.
Finally, it is difficult to imagine an experimental design that would allow one to compare the effectiveness of formulation-based CBT versus CBT targeted at problems defined according to DSM, not least because (I would hope) therapists conducting CBT for patients selected according to DSM criteria would nonetheless use individualised formulations before proceeding with treatment.
A broader and more important issue not addressed by Scott is whether DSM diagnoses can be used to predict treatment response. After all, when we visit a doctor with a physical complaint we expect a diagnosis to have precisely this function. There is ample evidence that diagnoses are poor predictors in the case of pharmacological interventions (tricyclic and SSRI ‘antidepressants’ are as effective with anxious patients as patients suffering from depression, and that antipsychotics are effective in the treatment of patients diagnosed as suffering from bipolar disorder as well as in the treatment of patients diagnosed as suffering from schizophrenia). Given the very wide range of conditions that have been shown to respond to CBT, it seems very unlikely that DSM diagnoses will be of much utility when predicting who will respond to this kind of intervention.
University of Manchester
I AM dismayed to see that devoting one single issue of The Psychologist to a critique of the orthodoxy on diagnosis – a view that is, by definition, less often articulated – is to be dubbed ‘totalitarian’. It is equally worrying if such a critique – again, by definition usually underrepresented – is immediately accused of occupying a ‘privileged’ status when it makes a rare appearance in print. Everyone has the right to make up their own minds on the issue, but it seems to me that the ‘defensive rhetoric when dissenters have the audacity to question….authority’ characterises last month’s letter writers and not, as one of them argued, the original authors. This kind of emotive response indicates that something much more complex than a disinterested scientific debate is going on.
The issue of psychiatric diagnosis is essentially very simple. Yes, we need ways of categorising the world; but no, we do not need this one, given that there is no evidence for the primarily biological causal mechanisms that would justify describing psychiatric conditions as disease processes. They are not; and a mountain of evidence (for example, on the role of trauma in ‘psychosis’) points to the relevance of psychosocial factors instead.
If we are, essentially, dealing with people with problems, rather than patients with illnesses – in other words, with human suffering in all the varied forms it can take, depending on the individual’s experience and the sense they make of it – it becomes nonsensical to expect it to fall into the discrete, neatly demarcated entities necessary for the kind of classification system that is the basis of the natural sciences.
I must admit to bewilderment that so many psychologists continue to buy into the diagnostic system, especially when we have valid alternatives to offer. Formulation is not a perfect answer to the problems of diagnosis, as critical psychologists themselves have pointed out, and certainly has its own limitations (Boyle, 2001; Johnstone & Dallos, 2006.)
However, it does in principle offer a way of collaborating with service users to produce a personally meaningful account of their distress with implications for a way forward (or, as Rufus May put it, ‘exploring frameworks that enable meaning to be made of a person’s experiences and actions…decoding the meaning in madness’). If we are really listening to service users, this is exactly what we should be doing and indeed exactly what our professional training equips us to do.
Formulation is based on the assumption that the nature and content of your distress is personally meaningful, while a diagnosis assumes that it is meaningless, being simply the symptom of an ‘illness’. These assumptions cannot both be true. I think it is obvious which side of the fence psychologists should be on.
Bristol Clinical Psychology Doctorate
Boyle, M. (2001). Abandoning diagnosis and (cautiously) adopting formulation. Paper presented at the BPS Centenary Conference, Glasgow.
Johnstone, L. & Dallos R. (Eds.) (2006). Formulation in psychology and psychotherapy: Making sense of people’s problems. Hove: Routledge.
WITH regard to your special issue on diagnosis; it is interesting to note the current situation in the transsexual (trans) community. The trans community is split in their appreciation of the diagnosis of gender identity disorder (GID) in the DSM IV-TR or its equivalent; transsexualism in the ICD 10. The split occurs because pre-operative people require diagnosis in order to gain access to medical interventions, whereas post-operative people quite rightly do not wish to be regarded as mentally ill as they are not incapacitated by being trans people.
In my opinion, incapacity must be at the heart of a fair diagnostic system. It is unreasonable to have a diagnosis such as homosexuality (which has been removed from the DSM) or GID (which has not) on the grounds that those identities may be a causal factor in another condition such the depressive or anxiety disorders. This is for two reasons; firstly, that it is often the social situation of the identity which causes the ‘problem’; and secondly, that there will be groups of healthy people who will fall into that diagnosis.
I am not wholly opposed to separate diagnoses for causal factors, but there should be some coherence in the system; either symptomology and casual factors or just symptomology.
Perhaps I could suggest some more causal factor
diagnoses to illustrate: fiscal insufficiency disorder (for those not paid enough to live); mortal fear disorder (for those afraid of death); media engendered disorder (for those whose disorder is engendered by apocalyptic news stories); abusive childhood disorder (for those whose disorder stems from having an abusive childhood); the list goes on. A fair diagnostic system then, discovers and attends to specific, incapacitating, areas of experience; without the need to infer extra erroneous information from that diagnosis. A fair diagnostic system should also not have categories that are used solely as a means to access services, as in the case of well-adjusted trans people.
University of Hertfordshire
THE reaction of the three correspondents (Scott, Congdon and Egan, Letters, June 2006) to Mary Boyle’s critique of psychiatric diagnosis highlights one of several paradoxes about its survival. From a socio-historical perspective, the intriguing question now is not what is wrong with diagnosis (empirical, logical and sociological critiques have existed about it for over 50 years). What is of greater interest is how it has survived, despite these attacks; a question that can only be addressed by examining the social, economic and cognitive assumptions and objectives of several communities of interest (Pilgrim, in press).
The authors and correspondents are one manifestation of that complexity. It is not sufficient to point to medical dominance as the only factor in survival – after all some of the most trenchant critiques of diagnosis have come from psychiatrists themselves. By contrast, many psychologists, in pursuit of research grants, have been content to adhere to diagnostic-related groups (DRGs). And Scott is correct to point up the yoking effect of studying CBT of particular DRGs. CBT has its origins not in cognitivism but in the pragmatic interests of clinicians (Beck, a psychiatrist, is cited correctly as seminal in this role.)
The pharmaceutical companies also continue to profit from reified DRGs, using common labels such as ‘schizophrenia’ and ‘depression’ that fail standard scientific criteria about concept validity and etiological and treatment specificity (Bentall et al., 1988; Pilgrim & Bentall, 1998).
Patients and their relatives respond in a mixed way to the ambiguity of single labels that cover a range of different personal experiences in variegated social contexts. For example, the relatives-dominated National Alliance for the Mentally Ill in the USA asserts dogmatically that depression is a brain disease. Some exotic diagnoses like ‘dissociative identity disorder’ seem to be anxiously sought after by patients, much more than damning ones like ‘borderline personality disorder’. As for ‘ADHD’ and ‘dyslexia’, these have been contested by many groups for many years.
A final set of considerations about the survival of diagnosis relates to the a priori philosophical assumptions framing these debates. Any psychologist or other contestant in the argument could reflect on whether they were naive realists, critical realists or social constructionists. Our discipline does contain all three, as the offending article and the views of the correspondents clearly demonstrate.
Blackburn with Darwen PCT
Bentall, R.P., Jackson, H. & Pilgrim, D. (1988). Abandoning the concept of schizophrenia: Some implications of validity arguments for psychological research into psychotic phenomena. British Journal of Clinical Psychology 27, 303–324.
Pilgrim, D. (in press). The survival of psychiatric diagnosis. Social Science and Medicine.
Pilgrim, D. & Bentall, R.P. (1998). The medicalisation of misery: A critical realist analysis of the concept of depression. Journal of Mental Health 8, 3, 261–274.
Chartering for teachers of psychology
I HAVE been a teacher of A-level psychology for nearly three years (and a graduate member of the Society for 10). I recently enquired into the possibility of gaining chartered status through the Division of Teachers and Researchers. After making contact with other psychology teachers in order to ask their advice about gaining chartered status, I was presented with several stories of others in my position who have now given up in their endeavours. Many describe the DTRP as a ‘closed shop’, while others imply that schoolteachers are implicitly excluded from becoming full members. As I made enquires via the Society I discovered the same problems.
Like many A-level psychology teachers, I am essentially a one-person department. I entered teaching through the Postgraduate Certificate in Education where, due to the inequality of opportunity for psychology graduates in teaching secondary education, I trained as a teacher of religious education. As a newly qualified teacher I took over a fledgling subject at the school where I am still employed and have spend my time since 2004 building what has become a very successful and popular subject area. Like the majority of A-level psychology teachers, I do not know any members of the Division; and, like many others, it has been many years since I graduated. It therefore remains virtually impossible for me (and many others) to fulfil the requirements set down by the Division. One teacher was also informed that psychology teachers in schools must have experience of teaching at two key stages (it is assumed that this means teaching psychology at two key stages).
While psychology remains a highly popular subject at A-level (key stage 5) it is very rare to find it taught at GCSE (key stage 4) adding to the obstacles of full divisional membership.
I would be interested to hear from any teacher of psychology who has managed to achieve chartered status through this route as many of us do not believe it to be possible.
Dominic Upton, Chair of the Division of Teachers and Researchers in Psychology, replies: Thank you for your letter and the points you raise. It is a shame you consider the DTRP a closed shop – it is anything but! We have been trying to increase the membership and widen access to all those that would benefit from the services we offer.
However, to address the substantial points in your letter. In order to achieve full membership of the Division, the very basic criterion was recently changed from three years to five years in order for the Division to come in line with the rest of the Society, such that: ‘Full Membership is open to Members of the Society with the Graduate Basis for Registration who have demonstrated their competence in teaching or research after the equivalent of five or more years of supervised and assessed professional activity.’
In addition to this, the Division’s Rules state that applicants for full membership of the Division should also meet the requirements for chartered status on the basis of their training in the teaching of psychology. For chartered status, the Society looks for applicants to demonstrate that they are competent to practise independently. Representatives from the Division on the Society’s Admissions Committee assess these applications individually.
In terms of receiving an adjectival title in relation to the Division, the DTRP is not authorised by the Trustees via the Membership and Professional Training Board to award this, although the Division has been working with The Society’s Boards to obtain approval of this.
Both the Division of Teachers and Researchers in Psychology and the Psychology of Education Board have acknowledged the growing number of psychology teachers and how best for the Society to serve them. A number of discussions have been held, so
I would advise all teachers to watch this space!
Richard Latto a Trustee and Chair of the Psychology Education Board adds: The Society has been aware for some time that it is not serving those working in the very flourishing schools and FE sectors well. The Trustees have therefore asked the Psychology Education Board, which includes representatives from this sector, to develop ways of enhancing what we offer to both staff and students. We have opened membership to school students and are about to introduce changes to membership for those teaching in schools. More importantly we are actively looking at the services we can provide to members in schools. If you or anyone else has other suggestions please write to Kelly Auty our Policy Adviser (Education) on [email protected]. All ideas will be welcomed and considered carefully.
TV and child development
WHILE I agree wholeheartedly that television can be bad for young infants and even older children (see News, June), the far more interesting question is why it is bad.
Observe a young child watching a cartoon. They are mesmerised and their eyes hardly move. This is because cartoons usually represent movement by a person or object remaining in the foreground centre of the screen with the background moving behind. For adults, this will indeed give the strong visual impression of movement. But for the young infant’s visual system, focused on the centre of the screen, this is static. So, a first step would be to make the cartoons such that the foreground figure actually moves across the screen and the child’s eyes must track it.
I agree that it is not wise parenthood to leave an infant alone in front of the TV. But parents also leave their infants in their cots watching a mobile that moves around their central vision, which doesn’t stretch the infant visual system as would, say, movement from peripheral vision across central vision. Some complain that instead of seeing things on a screen, children need to manipulate things, but should a parent avoid showing their infant a picture or film of an elephant simply because they cannot manipulate it?
Another interesting aspect of this debate is videos produced specifically for infants. Many play on parents’ desire to give the very best to their child, but are also completely devoid of all the scientific knowledge that we now have about infants. This is a missed opportunity, given that in very early development, videos can be much more stimulating for the infant visual system than static books. The right video, watched together with encouragement to be an active participant, is just as rewarding as books, games and the like.
One infant video series, Baby Bright (on which I was the scientific consultant), has endeavoured to make videos that encompass scientific facts about infant development. The baby’s eyes have to move frequently to track moving objects and to anticipate where they might appear next. Repetition of events followed by violation of expectation is frequently used. For instance, a train goes into a tunnel and reappears at the other end; after observing this several times a while the baby’s eyes will move to the exit of the tunnel in advance, anticipating where the train will appear; then, after a few repetitions, the train reappears at the same entrance as it went in, and the baby has to quickly correct his eye movement. Or an object may be shown on one side of the screen and then another part on the other side of a screen, or the whole object upside down, so that the infant must mentally complete or mentally rotate the representation of the whole object. These are the kinds of scientifically inspired sequences that can be stimulating for young children.
The point is that some television leaves babies mesmerised and passively entertained, and some includes them as active participants. It is time to replace emotional statements generalised to anything appearing on a screen with some serious scientific research. Perhaps nothing quite equates to the live interaction that children have with their parents and with other children. But television and baby videos, chosen and used judiciously and watched alongside the parent, are just as rewarding
for the baby’s cognitive development as books and toys.
Centre for Brain & Cognitive Development
Birkbeck, University of London
MUCH as I applaud any stratagem for bringing sluggish reviewers to heel, it seems to me that the one proposed by Hauser and Fehr (News, June 2007) would work only on those submitting to the journal for which they are (supposed to be) reviewing. This is of course quite likely to be the case. Nevertheless, if I sit on a paper sent to me by Journal A, resisting all pleas from the editor, no matter how fervently that editor vows to consign any future papers I submit to him to a dark cupboard until the Christmas after next, I can still submit to Journals B–Z and expect to have my paper promptly reviewed. We need to come up with other penalties for these dilatory reviewers. Something involving boiling oil perhaps?
2 Gaston Cottages, Little Bookham Street
Psychology - sold for 30 pieces of silver?
IN answer to the letter in the June issue concerning perceptions of psychology, I wholeheartedly agree with all the points made. But I do not think that it goes far enough in outlining the depths to which the concept of ‘psychology’ has sunk in the public consciousness. For example, in June viewers were invited by Channel 4 to tune in to watch ‘Britain’s top psychologists’ discussing the ‘action’ (sic) in the Big Brother house.
After 12 years of teaching pre-degree psychology (mainly A-level) I have recently curtailed this area of my work, principally due to my dissatisfaction with the continuing ‘dumbing down’ of the syllabus. During the last two to three years of my A-level teaching I felt that I was increasingly facilitating the writing of psychology-themed practice exam answers rather than teaching students about psychology. This is not a problem that is limited to psychology, given the teaching to outcome that has been enforced upon teachers at all levels by managers driven by National Curriculum/ Curriculum 2000 results targets. However, the impact that such a pedagogy has upon students’ potential to grasp the fundamental principles of such a complex and multifaceted subject area is devastating.
I, too, dealt with students who informed me that the reason they had selected psychology was because they thought that it was going to be ‘a doss’, and became puzzled and angry when they realised that they would have to deal with statistical calculation and extended essay writing. This was commonly the precursor for reference to what was said by ‘psychologists’ on last night’s reality-TV programme and a question about why we were not studying ‘what psychologists really do’. Two years ago, I was asked by a class of 17-year-olds if, now I had a PhD, I would be ‘good enough’ to apply to be a talking head on a reality show. When I explained why I would never do this, and moved the discussion into developing ethical understanding, most agreed that this was beside the point, and that the main deciding factor should be whether you could earn more as a teacher or a reality-programme adviser.
George Miller would have been unable to envision the outcome-driven education systems and celebrity-obsessed societies of the 21st century Western world when he spoke so passionately about ‘giving psychology away’ in 1969. Surely it is time to consider whether what we are doing now is not so much ‘giving psychology away’ as selling it to the masses for 30 pieces of silver?
17 Burr Tree Garth
Straight to the point…
‘Name and address supplied’ on the clinical psychology assessment process for limited training places: Is the process actually psychologically harmful, with its lack of continuity among assessment criteria, assessors and courses, its adequately detailed and poorly timed feedback, judgements made on the basis of interview performance, and no constant frame of reference on how to progress? Would it not be more helpful for both interviewer and interviewee if participants were more effectively able to demonstrate their capabilities through continuous assessment at personal and professional levels?
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