'Our aims are to improve care, and we do have alternatives'

Peter Kinderman introduces an open letter to those developing diagnostic manuals.

Some people, some colleagues, express frustration at the long-running debates over the use of diagnosis in mental health care. Conventional psychiatric practice now routinely and publicly avows that (for example): “mental illness is consistently associated with deprivation, low income, unemployment, poor education...”. That much is obvious, welcome, and reassures many that we now have a genuinely biopsychosocial shared vision. It is tiresome, I’m often told, to continue to look for arguments about language use, especially when many users of mental health services themselves are quite content to describe themselves as, occasionally, “ill”. What we should be doing instead, my critics say, is campaigning for better services, greater public understanding, and collegial cooperation.

But, the issue remains of direct and practical relevance... which is why I have joined colleagues in sending an Open Letter to the leaders of the major diagnostic systems.

As an active researcher (and clinician), psychiatric diagnoses have always been present. Early in my career, I uncritically used these labels in my work; being relaxed in discussing ‘mental disorder’, ‘bipolar disorder’, ‘schizophrenia’, and even ‘personality disorder’. Over time, the exposure to critically-minded colleagues and the available evidence forced me to reconsider.

While mainstream medicine certainly recognises the impact of social and environmental factors on our mental health, the conceptual frame of a ‘biopsychosocial model’ continues to be one where social factors are thought to moderate the progress of what are still regarded as ‘medical conditions’... “just like heart disease or diabetes”.

This matters, because it affects how we are offered care. If mental health problems are seen as diseases or disorders ‘just like heart disease or diabetes’, then it is unsurprising that the remedies are similar. Yes, of course, there are policy calls for attention to the social determinants, but the day-to-day experience is of psychiatry as a branch of medicine. Prescription of dependence-forming psychiatric drugs has reached terrifying proportions. One in five of us now takes a psychiatric drug, with widespread problems of dependence, and therefore physical and psychological harm. The United Nations Special Rapporteur Dr Dainius Pūras has pointed out that prescription follows diagnosis and “the excessive use of diagnostic categories [can] lead to excessive medicalization”.

I therefore continue to campaign on this issue. As I age, I can see slow improvements in service provision and public attitudes, but I remain worried about the parlous state of our mental health services. We need to move away from the assumption that our more difficult emotions are merely symptoms of mental illness. This is only one way of thinking about them, with advantages and disadvantages. Biomedical psychiatry does not have a monopoly of understanding, and there are alternative perspectives – valid and based on sound scientific evidence – that deserve to be given consideration. This is much more than merely acknowledging the (obvious, undisputed) role of social factors on what are nevertheless seen as disorders or illnesses. It means a paradigm shift.

That’s why I’m still campaigning. And, now, why I’m a signatory on an Open Letter to the leaders of the American Psychiatric Association, the World Health Organization, and others developing psychiatric diagnostic manuals, asking these leaders to reflect on the purpose and aim of diagnostic systems (as a mechanism for the marketing of medications and professions versus a genuine attempt to improve well-being), address financial conflicts of interest, permit democratic oversight and governance, incorporate a breadth of scientific and philosophical perspectives, and address the scientific failings of conventional approaches.

This is a development for me, too. I have, perhaps, spent too much time discussing language, or even conceptual models. There’s much more to discuss. As a colleague on Twitter said, the discussion of diagnosis is an opportunity to “critique the broken and corrupt system that makes the rules for the rest of us”. This means thinking about the conceptual system that labels our responses to abuse and trauma as ‘disorders’. But it also means asking about the financial links between the diagnostic system and the pharmacological industry. It means asking who leads these initiatives, and what level of plurality and inclusion is reflected in the people making up the committees deciding on such matters. It means ensuring that, when debating issues of psychiatric diagnosis, we respect all points of view, including those who value a biomedical perspective, but also ensuring that we offer choice to those who value a genuinely psychosocial vision.

And, finally, it’s important to recognise that those of us who espouse a psychosocial vision are not luddite loom-breakers. Our aims are to improve care, and we do have alternatives. The British Psychological Society’s ‘Power Threat Meaning Framework’ uses psychological perspectives among others to explain mental health difficulties in non-medical terms, with a particular focus on the dynamics of power operating in our lives; the kinds of threats we are exposed to, and the ways we have learned to make sense of and respond to them. And, although rarely mentioned, either in clinical practice or in the academic literature, both diagnostic systems (the American DSM and the World Health Organisation’s ICD) include the option of a scientific or ‘phenomenological’ approach to mental health problems.

The open letter to the leaders of the American Psychiatric Association and World Health Organization invites a debate about all these issues. Read it now: there's an opportunity for members of the public to offer their support.

Peter Kinderman is Professor of Clinical Psychology at the University of Liverpool

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