Sunday, 24 March 2013

Six Problematic Arguments Used Against Psychiatric Diagnosis (Part 2)

In my last post I addressed some of the arguments that get used by activists who wish to abolish psychiatric diagnosis. While I generally admire these people's stated ends, I have the feeling that diagnosis in mental health unfairly becomes a totem for all that is wrong with psychiatry. Here are three more arguments that I take issue with:

4. Diagnosis itself is the cause of stigma about mental health:
The troubling fact of stigma towards people with mental health problems is often cited as a reason to abandon diagnosis. If people stop being “medicalised” runs the argument, then they will stop being seen as different or separate from “healthy” people, and will no longer be treated in de-humanising ways by the intolerant or afraid.

There are two problems with this argument. The first is that it makes an unsubstantiated empirical claim, assuming that the fact of diagnosis is itself a cause of mental health stigma. In fact it is possible to construct a perfectly plausible causal social explanation of mental health stigma without recourse to this assumption. People who present to mental health services often display highly unusual, or even dangerous and frightening forms of behaviour. If they didn’t many of them would never receive any attention at all. It is the job of clinical psychology to care for people in this situation and aim to understand behaviours that others find baffling, with the hope of alleviating the underlying distress. However, individuals with no mental health training feel no such obligation and deal with their fear by discriminating against those they think of as “odd” or “dangerous” (Incidentally there is also a psychological label for these processes: “stereotyping”). It is a fact that mental health stigma often trades in the crass and offensive language of insult, but the commonly used terms “looney” “nutter” and “psycho” derive not from the euphemistic language of any modern psychiatric system, but from cruel and simplistic vernacular.

The second problem is that validated and clinically useful non-psychiatric medical labels can just as easily be used in hateful ways, leading to their replacement as terms, not as categories. When I was at school it was common to hear people described as “spastic”, but the ugly misuse of this once medical word doesn’t mean that the category “cerebral palsy” doesn’t have a role in describing a valid medical condition. The solution in the latter case was to discard the now-offensive word and replace it with a label that described a condition rather than a person. The stigma attached to the term “personality disorder” is a fact which has long been recognised by researchers (here is a classic paper on the subject), but the presence of this problem suggests a need for a different label or categorisation rather than the abandoning of diagnosis itself.

5. Diagnosis itself, rather than the treatments it leads to, causes harm to people:

Lucy Johnstone  makes this point directly here when she says that “‘Diagnosing’ someone with a devastating label such as ‘schizophrenia’ or ‘personality disorder’ is one of the most damaging things one human being can do to another.” To say this is to equate a routine medical practice as on an ethical par with killing, mutilating or raping them, the sort of extreme rhetoric which risks alienating anti-nosologists from other mental health professionals.

Being told that you have “Schizophrenia” or “Personality Disorder” (for example) is problematic because these terms seem to contain two sources of information, one true and one untrue:

1.       The person faces extremely difficult but understandable life circumstances (true)


2.       The person has a purely biological disease/personality defect with a pessimistic prognosis (not true).

The second of sort of information is presumably where we can locate the damage referred to by Johnstone. In the case of “Schizophrenia”, this often means a lifetime of neuroleptic medications which can cause serious health problems . In the case of “Personality Disorder” it has meant that individuals are considered “untreatable” and regarded with mistrust by health professionals.

However, information of the first sort can be validating, conveying the sense that for the first time a person’s behaviour or feelings make sense to them and that they are in the company of a professional who can understand how to help.  If the only consequences of receiving these diagnoses (or similar ones) were that people received care that was appropriate and helpful, then the harm in receiving them would evaporate. It is the way that people think of mental health diagnoses (i.e. as illnesses which are more or less permanent and respond to only one form of intervention) that causes so many problems.

6. Discarding Classification altogether would represent progress:

There are many aspects of the medical approach to illness which have been extremely damaging, and hearing the stories of people who feel misunderstood and discarded by a callous medical machine can give one the sense that progress lies elsewhere than with medical psychiatry. However, it does not follow that the complete disavowal of everything concerned with the “medical model” would represent progress. For almost a century it was believed that fire burned because of a mysterious substance in combustible objects called phlogiston. Progress in our thinking about this came not when the entire idea of an atmospheric substance was discarded, but when the clumping theoretical entity phlogiston was replaced by the idea of Oxygen. Whatever is wrong with the DSM, it is a mistake to think that the only progressive alternative is a complete rejection of classification.

Classifications can have value even where they do not map neatly onto nature. Fields such as Epidemiology and Sociology frequently divide people up by traits which are dimensional (i.e. socioeconomic status, lifestyle) and still yield useful information. The fact that it is bizarre and offensive to speak about these categories as though they implied something essential about their members (poverty, for example, being a set of conditions, not a characteristic of humans) does not mean that there is not predictive information contained in them. Psychiatry and Psychology have yielded numerous categorical systems, not all of which overlap. Although it's easy to fall readily into condemning them for their over-zealous "medicalisation" of people, it is worth remembering that they also help us to avoid inappropriate treatments too. Drug treatments are severe, invasive and controversial, but the fact remains that some people (and there's a good example here) find them positively life-altering and helpful. A benefit of diagnosis is that it not only includes some people in groups considered "medication appropriate", it also excludes others. Thus a person with strong obsessive rituals that sound bizarre and magical to the person assessing them may be considered to be experiencing OCD rather than psychosis and spared the resort of powerful and unpleasant medications. 

Diagnosis remains an imperfect process, and the various competing diagnostic systems are grounded in different aspects of the human experience. I think they are best judged by the extent to which they manage to help rather than harm people, especially as an ultimate "true" system of classification seems highly unlikely. In future posts I want to explore further the extent to which diagnosis is helpful, and also to look at some of the alternative systems to DSM. 


  1. Interesting blog and thanks for writing on this important topic. I thought you raised some valid points and make a clear argument. What I noticed was that your ambivalence about diagnosis didn't seem to be coming through. Other than perhaps when you seem to want diagnosis but only want it to be 'good'; that is, helpful and benevolent.
    Unfortunately, this isn't how it works. Diagnosis is routinely used as a form of control (I'll resist saying state control) and enables the psychiatric profession to operate as a valid form of medicine.
    Reading the blog you seem to get more convinced that diagnosis is a useful tool. Thanks for writing this even though I think we have quite different views on the issue.

    1. There is truth in that. These first two posts are on the pro-side of the dialectic, but that is because I feel there exist bad anti-diagnosis arguments and not because I don't see there are good ones.
      Where I'm at now is that MH diagnosis is massively flawed, but that this may not completely negate its capacity to be useful to service users or clinicians. The point you make still pertains to how diagnosis is used and not necessarily to what it is (although I am still ready to be convinced!)
      I want to explore the flaws and merits of diagnosis more in future posts.