Debate on DSM-5: a false dichotomy?
A recent statement by the BPS Division of Clinical Psychology (DCP) attacking the DSM-5 gained substantial visibility in the media, including a high-profile article in the Observer (12 May 2013) accompanied by opinion pieces by Professor of Psychological Medicine Sir Simon Wessely and author and child psychologist Oliver James.
According to the Observer article, the DCP representatives claimed that ‘it was unhelpful to see mental health issues as illnesses with biological causes [italics ours]… On the contrary, there is now overwhelming evidence that people break down as a result of a complex mix of social and psychological circumstances – bereavement and loss, poverty and discrimination, trauma and abuse’.
The DCP representatives in the media appear to predicate their argument on a false dichotomy between genes and environment, which seems to presume that search for genetic risk factors equals drive for medication and that demonstration of environmental risk calls for psychological therapy. We do not know of any informed researchers who would make a simplistic proposal like this. The pronouncements in the media also give the impression that ‘psychological and social circumstances’ are something that transcends biology. Yet anyone who has done their homework in keeping up with the research in the past 20 years should be able to draw the following simple conclusions for which the evidence base is unequivocal:
I Individuals’ psychological circumstances do not exist without biology. Only a committed dualist would make this argument. Therefore, to understand psychological disorders, we cannot ignore biology.
I There are substantial individual differences in how people react to ‘environmental’ risk factors and overwhelming evidence that genetic factors play a role in susceptibility to both bad and good environments.
I ‘Environmental’ factors cannot be assumed to be causal or free from genetic influences.
The above points should be taken into account by DCP representatives who are in danger of muddying mental health issues by ignoring the biology. Their present stance will fail to deliver help for those who suffer from mental health problems. Unfortunately, this advice will be lost on those who are not slowed down by a need for an evidence base, but instead irresponsibly make unsubstantiated and alarmist pronouncements about child abuse causing schizophrenia. However, representatives of the DCP should know better. It is regrettable that the Observer appears to value a provocative soundbite over an informed debate on the issues of mental health and give column inches to die-hards like Oliver James.
As Sir Simon Wessely points out in his response piece to the Observer article, naturally the diagnostic ‘map’ changes as the scientific evidence comes in. And because the mechanisms that result in vulnerability to mental ill health are complex, the refinement of our understanding will not happen overnight.
The National Institute of Mental Health in the USA has indicated that they will direct their funding towards research that is not restricted by the current diagnostic criteria. As far as we can see, the purpose of their statement has not been to advocate a wholesale rejection of DSM-5 in current clinical practice, but instead to encourage new advances in our understanding of the symptoms that mark mental illness – particularly and explicitly with regard to biological vulnerability.
Current treatment methods for the symptoms of mental illness (whether these consist of medication or ‘psychological’ treatments) are far from universally effective. It is therefore critical that we do indeed endeavour to understand the complex factors that lead to mental ill health and that we do not write biology off in the process.
Professor Essi Viding
University College London
Professor Uta Frith
University College London
Recent media coverage suggests that the debate between clinical psychology and psychiatry has become polarised; that the latter group proposes a strictly biomedical conception of mental ‘illnesses’ and that the former is opposed not only to the DSM project and the over-medicalisation of distress, but to the idea of classifying people’s problems at all. However, clinical psychological research opens up a third position between these extremes, allowing us to think differently about what a psychological ‘diagnosis’ could mean.
Validity is a central theoretical concern to psychology, so it is no
surprise that the DSM’s lack in this regard should be felt by clinicians
to be an embarrassing indictment of the manual’s clinical utility.
However, it is a mistake to infer that a lack of validity in
actually-existing-diagnosis precludes the possibility of a valid system
of diagnosis. Psychology is founded on statistical and psychometric
tools which allow us to identify meaningful classifications and approach
the question of whether there is a coherent concept ‘out there’ or not.
Psychologists measure, with some degree of success, such abstract
concepts as ‘attachment’, ‘stigma’ and ‘theory of mind’, and there is
nothing inherent to mental health problems (as opposed to DSM
categories) that suggests they could not be categorised in the same way.
This need not entail a classification of people who manifest these
problems, and it need not entail the assumption that the problems
in question are ‘illnesses’ with a poor prognosis.
In fact, much current clinical psychological research, even where it rejects the categories of the DSM, points toward the possibility of a more effective underlying classification. A recent example is Longden et al.’s (2012) comprehensive review of the role of dissociation and trauma in voice-hearing. Longden and her colleagues suggest that a phenomenon once considered to be a ‘symptom’ of schizophrenia can more usefully be regarded as the result of dissociative processes that emerge as a result of traumatic experiences. Although this represents a welcome turn from the ‘medical model’ of psychosis, it nonetheless assumes a reliably observable process occurring in voice-hearing, one that helps both to distinguish and explain cases of the phenomenon. Identifying a common dissociative process is not to mark people out for social isolation or shame, but to understand why their minds have manifested their distress in a way that is, on the face of it, so confusing.
As a trainee clinical psychologist, I find formulation invaluable and idiographic research an essential corrective to the epistemic and social costs of categorisation; ultimately diagnosis should come to be seen as complementary to and not in conflict with these forms of knowledge. Ideally it would even be derived from something like a formulation and would be used in such clinical, research and administrative situations as require a short descriptive label.
Something like this may already be happening anyway, albeit without
explicit acknowledgement; the sorts of arguments that get used against
diagnosis themselves often rely on the same essential epistemological
shortcuts that are currently clumsily provided by systems like DSM. A
useful example is the diagnosis of ‘borderline personality disorder’.So
called borderline personality disorder is immensely controversial;
it is widely acknowledged that it is a stigmatising term, even an insult. Psychologists have shown that it is less a disorder than a particular psychic response to complex childhood trauma (e.g. Fonagy et al., 2003). Encouragingly, appropriate treatments have emerged in the form of manualised and evidence-based psychotherapies (e.g. Bateman & Fonagy, 2004; Linehan, 1993). In many ways, this has been a case of a category successfully tackled head on by psychological researchers and activists alike.
This success nonetheless relies on the existence of a common language between researchers and within services. Campaigners can’t simultaneously deny the existence of the phenomenon whilst continuing to successfully discuss it as though it were real. The extreme nature of the problem (which can involve severe self-harm and suicide) makes it particularly important to have a shared language with which to understand it.
In abandoning the DSM, the Division of Clinical Psychology has
dispensed with a particular set of names and their problematic
assumptions concerning medical-genetic underpinnings. However to abandon
classification altogether would be to dispense with the conceptual
means for addressing real clinical and social problems. The absence of
any form of common language would send nomothetic clinical research and
the organisation of mental health services
into a communicative impasse.
Trainee clinical psychologist and PhD student
City University of New York
Bateman, A. & Fonagy, P. (2004). Psychotherapy for borderline personality disorder: Mentalization-based treatment. Oxford: Oxford University Press.
Fonagy, P., Target, M., Gergely, G. et al. (2003). The developmental roots of borderline personality disorder in early attachment relationships: A theory and some evidence. Psychoanalytic Inquiry, 23(3), 412–459.
Linehan, M.M. (1993). Cognitive behavioural therapy of borderline personality disorder. New York: Guilford Press.
Longden, E., Madill, A. & Waterman, M. (2012). Dissociation, trauma and the role of lived experience: Toward a new conceptualization of voice hearing. Psychological Bulletin, 138(1), 28–76.
Fanning away the smoke
I had long observed that non-nicotine factors can stop people quitting smoking (‘Why is it so hard to quit smoking?’ May 2013). Even anti-smoking ads with pictures of cigarettes or of pregnant women wreathed in smoke can arouse desire. So the trouble with e-cigarettes is that they are too much like real ones. I have also noted how many people begin smoking for something to do with their hands in a social situation.
My granddaughter was revealed to me as a two-years smoker, when she had decided she wished to stop. She is a noted drama-queen in international TV and video-making, working in a climate of smokers. I gave her a dozen cheap pretty folding hand-fans and ideas about how to flaunt them, and be a trend-setter. There was also a laugh in using them too.
Since then I have offered playing with fans to other girls entrapped in smoking by social factors. To my knowledge they have all stopped smoking. Of course, other factors hold too – a disapproving grandmother may well be one.
Dr Valerie Yule
In good humour
The articles in your April edition attest to the therapeutic
power of humour, comedy and laughter. I was therefore a little surprised to see no mention of Frank Farrelly, founder of Provocative Therapy, the cutting edge in the clinical use of humour and reverse psychology in psychotherapy.
Farrelly (1931–2013) began his professional life as a psychiatric social worker at Mendota State Institute in Madison, Wisconsin, a psychiatric hospital for patients with severe, complex mental disorders. Trained in the Rogerian method of client-centred therapy (today known simply as ‘counselling’) his psychotherapeutic methodology changed dramatically in 1963 as the result of a single encounter with a very ill, chronic schizophrenic inpatient. Farrelly had counselled this patient for 90 sessions with no discernible effect. In the 91st session he realised that empathy, warmth and genuineness (the cornerstones of counselling) were simply not working and his patient remained pessimistic about his prognosis and chances of ever leaving the hospital.
In his seminal text on the subject, Provocative Therapy (Meta Publications 1973), Farrelly describes how he ‘gave up’ and said to the patient: ‘Okay, I agree. You’re hopeless. Now let’s try this for 91 interviews. Let’s trying agreeing with you about yourself from here on out.’ The patient responded immediately both in more assertive body language and by telling Farrelly that he disagreed with this hopeless assessment of his case and that he was ‘not that bad’. As an intrigued Farrelly persisted with this innovative paradoxical approach, the patient continued to argue animatedly against his devil’s advocate-like assessments and six weeks later felt so much better that he discharged himself from hospital.
Emboldened by his success with this, the first tool of Provocative Therapy (‘There is no solution to your problem’) Farrelly developed dozens of further tactics such as ‘Play the Blame Game’, ‘Do more of the same!’ and ‘What’s wrong with that?’ He went on to teach Provocative Therapy to therapists all over the world. Many would not exclusively use Provocative Therapy, but most would learn how to use humour and reverse psychology effectively and safely in their practices.
The golden rule of Provocative Therapy is to ensure that you have ‘a twinkle in the eye and affection in the heart’ when you use it. The client finds that his/her aberrant behaviour and thoughts are being therapeutically satirised but s/he as a whole person feels validated, understood and cared for – all much in the spirit of Carl Rogers but strategically very different.
Laughter is by far the most common outcome in a session of Provocative Therapy although all forms of catharsis are possible. When clients get their inner jokes, the funny side of how they are preventing themselves from finding fulfilment in life, a window of opportunity for meaningful change opens up for them. The goal of Provocative Therapy is essentially to change clients’ behaviour by therapeutically provoking them with humour and reverse psychology to locate, verbalise, own and enact their own solutions to their problems.
Dr Brian Kaplan
As someone who has made a detailed study of humour – it was my PhD topic, I believe that more cognisance should be taken of Freud’s (1905/1976) triad of wit, the comic, and humour.
In brief, wit comprises contrived jokes, originally often ‘put-downs’ but today also word-play and similar mind games involving incongruities. The comic refers to visual humour, born from poking fun at those considered deformed or inferior, thus giving a boost to one’s feeling of superiority. Humour, by contrast, is an attitude or personality trait that enables us to make sense of an ambiguous situation where logic fails: it is a survival mechanism requiring creativity. Much wit is cruel, and it is believed that the relief provided by laughter once one has ‘got’ the joke originated from a primitive ‘roar of triumph’ of the victor in an ancient jungle duel (Pettifor, 1982). The loser, if still alive, showed submission with the ‘smile of appeasement’ (Raskin, 1985); thus the smile originated in a completely opposite manner to the laugh.
There are many claims to being the world’s oldest joke, but it would be difficult to go further back than a riddle found among the hieroglyphics in the tomb of Pharaoh Snefru (2613–2589 BC). One could not openly criticise someone who was considered to be a god without risking execution, but a tomb architect obviously wanted posterity to know something about this deity that was not discussed in polite circles during his lifetime. The architect therefore compiled the following revealing riddle: ‘How do you entertain a bored pharaoh? – You sail a boatload of young women down the Nile, dressed only in fishing nets, and invite the pharaoh to go and catch a fish!’ Although it might lose something in the translation, with only a few changes to the wording
it can be made a topical witticism that can be applied to some of our contemporary politicians, sports personalities and entertainers. Indeed,
it seems that life has not changed much over four and a half thousand years!
Dr Michael Lowis
Freud, S. (1976). Jokes and their relation to the unconscious. Pelican Freud Library Vol. 6, J. Strachey (Ed. and Trans.) and A. Richards (Ed.). Harmondsworth: Penguin. (Original work published 1905)
Pettifor, J.L. (1982). Practice wise: A touch of ethics and humour. Personality and Individual Differences, 13(7), 799–804.
Raskin, V. (1985). Semantic mechanisms of humour. Dordrecht: Reidel.
The Laws of Stupidity
It has long been my contention that we psychologists spend far too much time studying intelligence whilst that other great human faculty, stupidity, receives scant attention. Even a cursory glance at history shows that our stupidity has had a far greater effect on events than our much vaunted intelligence. (Warfare in its various forms is a good example; don’t get me started on the tobacco industry.)
Careful consideration of the field leads me to propose that there exists a set of underlying Laws of Stupidity, on a par perhaps with Newton’s Laws of Motion or the Laws of Thermodynamics in their universal applicability. There appear to be four of these:
1. Stupidity is a universal human faculty, not found in animals. – This means, inevitably, that you are stupid and so am I.
2. Stupidity is not the opposite of intelligence, they are orthogonal dimensions. – This means that it is possible for someone to
be highly intelligent and extremely stupid at the same time.
3. Whilst the stupidity of others is obvious, one’s own is entirely invisible, irrespective of magnitude. – This accounts for the common illusion that one is the only intelligent being on the planet.
4. Unlike intelligence, stupidity is additive, so that the stupidity of a group equals the sum of the stupidity of its members. – Groups, such as corporations or governments, are therefore capable of acts of stupidity which far exceed anything any individual could manage by themselves.
These laws explain a great deal. A wider acceptance of their universality would do much to obviate unnecessary hand-wringing over humanity’s foibles, providing an understanding that our highly evolved ability to be stupid makes recurrent disasters simply inevitable. Nikolaas Tinbergen, the great ethologist and Nobel Laureate, clearly recognised this when he said: ‘I believe that I have discovered the missing link between animals and intelligent life: it is us.’
Let it not be said that I have been slow to apply these insights to my professional work. I write a lot of reports for the courts. In a recent one, I offered a diagnosis of stupidity, hedging this round with an acceptance that this did not exactly comprise a recognised DSM-IV category. I argued that this was the only possible interpretation of the person having accidentally set fire to their bed (with themselves in it) on not just one, but no fewer than three occasions. The director of the agency that provided the instructions promptly had kittens about this unconventional diagnosis, but the court and the referring solicitors appeared to have no problem with it at all.
There have been some moves in the right direction. A recent edition of New Scientist devoted its cover article to stupidity, recognising the Second Law above and commenting that the stupidity of intelligent people is particularly dangerous because of their ability to convert their folly into action. Nevertheless, we shall probably have to wait for some time before a Faculty of Stultology is established at a university. And I still haven’t heard from Stockholm.
FORUM column: Survival guide
Here’s an interesting question to ask any scientist: If you were to receive no more research funding, and just focus on writing up the data you have, how long would it take? The answer tends to go up with seniority, but a typical answer is three to five years.
Does this academic backlog matter? We’ve all done failed studies with inconclusive results, and it would be foolish trying to turn such sow’s ears into silk purses. But I suspect there’s a large swathe of research that doesn’t fall into that category, but still never gets written up. Is that right, given the time and money that have been expended in gathering data? Indeed, in clinical fields, it’s not only researchers putting effort into the research – there are also human participants who typically volunteer for studies on the assumption that the research will be published.
I think the backlog stems from the incentive structure of academia. If you want to make your way in the scientific world, you have to get grant funding and publish papers. When I started in research, a junior person would be happy to have one grant, but that was before the REF. Nowadays heads of department will encourage their staff to apply for numerous grants, and it’s commonplace for senior investigators to have several active grants, with estimates of around one to two hours per week spent on each one. Of course, time isn’t neatly divided up, and it’s more likely that the investigator will get the project up and running and then delegate it to junior staff, then putting in additional hours at the end of the project when it’s time to analyse and write up the data. The bulk of the day-to-day work will be done by postdocs or graduate students, and it can be a good training opportunity for them. All the same, it’s often the case that the amount of time specified by senior investigators is absurdly unrealistic. Yet this approach is encouraged: I doubt anyone ever questions a senior investigator’s time commitment when evaluating a grant, few funding bodies check whether you’ve done what you said you’d do, and even if they do, I’ve never heard of a funder demanding that a previous project be written up before they’ll consider a new funding application.
I don’t think the research community is particularly happy about this: many people have a sense of guilt at the backlog, but they feel they have no option. So the current system creates stress as well as inefficiency and waste. I’m not sure what the solution is, but I think this is something that research funders should start thinking about. We need to change the incentives to allow people time to think. I don’t believe anyone goes into science because they want to become rich and famous: we go into it because we are excited by ideas and want to discover new things. But just as bankers seem to get into a spiral of greed whereby they want higher and higher bonuses, it’s easy to get swept up in the need to prove yourself by getting more and more grants, and to lose sight of the whole purpose of the exercise – which should be to do good, thoughtful science.
Dorothy Bishop is Professor of Developmental Neuropsychology
at the University of Oxford. Read the full version of this column at http://deevybee.blogspot.com. This column aims to prompt debate surrounding surviving and thriving in academia and research.
Disabled scientists invisible?
It’s 2013, and where is the recognition of the disabled scientist? How many readers of The Psychologist know of a disabled adolescent who chose to study a scientific subject? At university, I was one of two reading psychology and neither of us received much support. Now a Fellow of the BPS, I still have a 100 per cent record of rejection of applications to committees.
I sense that colleagues look at the quantity of published papers, not what you’ve actually achieved. The lack of knowledge concerning the real experiences of a disabled person means that I have to read some very insensitive comments in our journals. Referees either have no idea, or don’t care about the damage caused by ill-informed opinions expressed as fact. Errors and distortions aren’t corrected, perpetuating myths and undermining best practice.
The fact is that there are disabled scientists who can make a contribution to the alleviation of suffering even though they are housebound. Example: Who was instrumental in creating awareness of the illness now known as chronic fatigue syndrome in the early and mid-1980s? I expect that few will know of my involvement because severely disabled scientists, bar one, are invisible. And in my view, our expertise is not valued. There is no scientific equivalent of the Paralympics. Shouldn’t we, of all the professions, be challenging what is essentially pure discrimination?
Psychology A-level teaching
A perennial issue in the teaching of A-level Psychology is the qualifications of those teaching it. This was most recently raised by Caroline Rigby (Letters, October 2012), who referred to Ofqual’s ‘A-level Reform Consultation’ document and put in a plea for the number of qualified subject specialists available to teach psychology to be increased as a matter of priority. However, I am aware that there has been much debate about the quality of training, the number of training places available and a general feeling of ‘malaise’ in relation to psychology as an academic discipline at pre-tertiary level.
Psychology is not regarded as a valuable subject in the Key Stage 4/5 curriculum by the present Education Secretary, who does not seem to understand the complexity of the subject. This is despite the fact that it is classed and funded as a STEM science, and has one of the highest numbers of candidates at A-level. In some schools, it is because of popular subjects like psychology that minority A-level subjects remain viable.
Psychology addresses key government priorities by equipping students with skills in science, communication and data handling. Students are trained in numeracy and statistics, scientific method, communication skills and ethics, as well as gaining a deeper understanding of the diversity of human behaviour. Not only that, but psychology is the science subject which addresses a major gender issue, as it is studied by many more girls than boys.
The government funds psychology as a STEM science, so it is classified with the other sciences, and yet the Training and Development Agency for Schools places it in ‘other subjects’ when it comes to ITT; in higher education, psychology is a science with BScs and MScs being awarded, but in teacher training (and Ofsted inspection) it is a social science. Schools will be left with little or no choice but to teach psychology with non-specialists, as student demands for psychology remains high while the supply of qualified subject specialists declines. This is problematic, given that it has been suggested that students taught by non-specialist psychology teachers often perform less well, particularly in research methods, statistics and cognitive psychology.
My local MP agreed to meet me to discuss my concerns further and we had a very productive 40-minute discussion after he observed one of my lessons. As a newly co-opted committee member of the Association for the Teaching of Psychology, I aim to continue to lobby the government on these issues. I am inspired by my own students, who describe psychology as ‘a disciplined scientific approach to understanding human behaviour’. We cannot let our students down by allowing psychology to be devalued by those who do not fully understand it.
The Chetwynd Centre, Stafford
Clinical psychology heartache
I wish to express my gratitude to Frances Harkness for her piece on breaking up with clinical psychology (Letters, May 2013). I was impressed with her frank discussion and filled with an overwhelming relief that it was not just me feeling this way.
I am a fourth-year undergraduate student and have been relentlessly pursuing volunteering opportunities throughout my undergraduate career, doing everything in my power to gain sought-after experience. I have been recently plagued with the dilemma of pursuing clinical psychology as a career, which would come at great cost to my finances, and time with the risk that it may be an unsuccessful pursuit. Due to naivety I often felt guilty for questioning the requirements and saw this as my lack of commitment and resolve. The heavy competition allows psychology to increasingly abuse graduates and I am fearful how long this can continue.
For many graduates it is simply unrealistic to be requested to work in minimum-wage support roles in pursuit of experience. This is leading to an elitist market in admissions, and will inevitably impact on the psychologist that the system produces. The nature of this system no longer reflects the values psychologists promote and has led me to question my faith in psychology. I feel inclined to take Frances’s message and invest my skills in a job which will reflect my personal values along with saving me five years of heartache.
I was recently at the Scottish BPS undergraduate conference and was delighted to listen to Society President Peter Banister comment on the wide range of skills psychology graduates gain, he described graduates as psychology’s ‘life blood’, and I was inspired by his take on the issue. Sadly, I feel the support for graduates is not reflected in the discipline and is increasingly dissipating their vital enthusiasm that psychology as a discipline could benefit from. By failing to nurture and support graduates I fear psychology is losing potential candidates like me, who would reflect the correct values required for clinical psychology training.
The validity of the virtual conference
I recently attended a virtual conference, curious to see how it would operate. It did not live up to my expectations. This letter discusses some of its pros and cons, encouraging debate over how appropriate virtual conferences are to meet the conventional aims of a conference.
Listing 23 advantages of a virtual conference on the conference website, a factor analysis of sorts would spawn only a handful. Whilst many were true (mainly regarding sustainability), I disagree that the event had the ‘same validity as face-to-face (F2F) conferencing’. Mostly, there was a distinct lack of socialising, which I was anticipating could have been enhanced online. From experience, the positive memories from the conferences. I have attended in my time as a PhD student, including BPS conferences, have been predominantly social. This event was merely a repository of papers.With no fanfare, there was no ‘real-time’ interaction (which could have been easily arranged). As such, there was no motivation to be online at any particular time. The most interactive it got was an e-mail informing that someone left a comment on your paper. The few times this happened – with zero comments on the majority of papers – I simply logged on and replied. This did not allow for a genuine discourse to develop. It in no way mirrored the sort
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