Wednesday, 20 March 2013

Six Problematic Arguments Used Against Psychiatric Diagnosis (Part 1)

Diagnosis in mental health is extremely unpopular at the moment, and perhaps with good reason. Service user movements in the UK and the US have led to a rise in articulate accounts of the misery of first being “labelled” and of feeling misunderstood by a medical establishment which then fails anyway to administer the sort of help that would know, help.

However, it sometimes looks as though the complex problems of mental health care are too easily explained away by a crusade against diagnosis, which runs the risk of diverting people’s reasonable anger to a part of psychiatry which oughtn't to be taking all the blame.

Across two blog posts I will be highlighting six of what I think are some of the non-starter arguments that get used by those who hold what the psychologist Paul Meehl would have called “Antinosological bias”

1. Because Mental Health Problems aren't Diseases, they are not recognisable entities:

In her marvellous book “Schizophrenia, A Scientific Delusion", Mary Boyle argues that Schizophrenia is not a unified disease concept, a position which is then frequently extended to the whole system of classifying mental health problems. I can’t argue with her position (in fact I’m not sure how many people do). However, the fact that this term doesn't refer to an entity that shows both signs and symptoms (Boyle’s chosen definition of a disease), doesn't lead inexorably to the fact that there is no phenomenon (i.e. psychosis) worthy of understanding or treatment.

Moods are not diseases, but they are (roughly) classifiable. We recognise, feel and talk about them. They have the potential to be problematic, even devastating. 

Diagnosis is not just a process of placing something in the category “disease”, it is a process of classifying. To be useful to clinicians, Diagnosis needs to mark out a distinct phenomenon (rather than a person) as worthy of recognition, study, and indicate specific treatment approaches.

2. Because some diagnoses are useless or absurd, so too is the entire system (i.e. Diagnosis=DSM):

It is common in arguments against diagnosis to bolster one’s case by citing the most absurd sounding examples from the forthcoming DSM. This rhetorical sleight of hand is supposed to achieve the effect of extending to the whole edifice of psychiatric diagnosis an air of the ridiculous. This is precisely what clinical psychologist and academic Peter Kinderman does here in an article published by the BBC. Kinderman makes the case that a “new diagnosis of ‘disruptive mood dysregulation disorder’ will turn childhood temper tantrums into symptoms of a mental illness”. If doctors believe that something as trivial sounding as “temper tantrums” could be an illness, he implicitly suggests, then all of their other psychiatric “illnesses” must be flawed as well.

While it can be readily agreed that the over-medicalisation of “temper tantrums” could have pernicious effects (who wants to over-medicate kids?), it is a mistake to infer from this that the act of labelling a cluster of behaviours is itself inherently unwarranted or ridiculous. Consider the use of the phrase “temper tantrum” itself, which connotes a phenomenon that can be recognised instantly, without recourse to a complex description of behaviours or imputed emotions. We immediately that it refers to a welling up of anger that is too much for the child to bear, and which will manifest itself in crying, screaming, shouting, and possibly stiffening of the limbs and kicking or hitting. We can also recognise that it refers to a common situation in which the entire behavioural sequence is likely to be self limiting, that the child will eventually tire and wear itself out. This shared sense of a phrase is a kind of natural language diagnosis, and it resembles what clinicians are doing when they label psychiatric disorders that they recognise in the people who come to them for help.  

3. Diagnoses preclude the possibility of thinking sensitively about people’s problems and developmentally about their causes:

The fact that diagnosis is a short verbal label is often taken as meaning that it can never do justice to the complexities of our human suffering. This line of argument is fallacious for two reasons. First, labels have more meaning than we give them credit for. A diagnosis of a blood infection doesn't say how the infection was acquired, how upsetting it is to have it, or how likely it is to happen again. However, it does describe a particular form of problem and suggests measures which will be helpful in its management. It contains information. I am not suggesting that mental health issues are anything like as simple or straightforwardly treatable as blood disorders, but to suggest their categorisation contains no meaning about a person’s predicament  is to overlook the possibility that clinicians could have a shared and sympathetic sense of what it might mean to talk of “depression” or “anorexia”. More information is always necessary, but that doesn’t mean that there isn’t value in grouping together types of problems to improve our knowledge of how to solve them.

A second point here is that the use of a label does not preclude the parallel use of efforts to achieve detailed understanding of a person’s history and problems. However much it has historically been the case that people are simplistically treated as though they were “just a diagnosis” and allocated impoverished services, there is no reason why the activity of diagnosing should make this so. 

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