Wednesday, 17 April 2013

Diagnosis From the Inside: A Tale of Two Madnesses

The most powerful sort of opinion about psychiatric diagnosis comes not from people like me, who are idly trying to balance its philosophical and political aspects in their own muddled head, but from people who have been given one and experienced what it can do to a person. 

This post is a contrast between the stories of two remarkable people. I have selected them because they are both prominent advocates of diverging views of the role of psychiatric diagnosis and because they both have excellent TED talks in which you can see them in action for yourself. 

Eleanor Longden is a British psychologist who works for a mental health service in Bradford in England:

Longden argues psychiatry's central question should be not "what's wrong with you?" but rather "what's happened to you?". This is a good way of shifting the focus of a breed of psychiatry that is too hung up on the idea of illnesses and has viewed people as a-historical , but I think it misses an important point. To ask only "what's happened to you?" implies that events in a person's life are the only source of information about why they are seeking psychiatric help. The truth is that we all react differently to life events depending on how we have learned to respond and how we are able to respond. I might re-frame Eleanor's question as something like "What resources and styles did you have available to respond to what's happened to you?"

Elyn Saks is a legal academic and trainee psychoanalyst who teaches at the University of Southern California:

Saks' position is rather different than Longden's. Most notably, she talks as though the word and the concept Schizophrenia were an accurate way of characterising her experiences. This marks her out from many of the individuals I have seen talking about this sort of thing. Saks overlooks the controversy that exists over the word Schizophrenia, and instead talks as though what she were experiencing were an illness. In the light of Longden's talk, one is tempted to ask whether Saks has a sense that her life experiences have fed into her "disorder", whether there is anything that she deliberately avoids talking about. This is, of course, entirely her prerogative.

But how to make sense of these diverging sorts of experience? One way is to assume that while Longden has one sort of problem (we might call it "trauma-related-dissociative-voice-hearing"), Saks has another (Schizophrenia). However, this is to assume that Schizophrenia does exist and that what we need is a way of distinguishing it from the range of other psychotic phenomena that so often get called Schizophrenia when they are something else.

Another way of talking about this divergence is to suppose that labeling your experiences "Schizophrenia", or refusing to, are both entirely valuable and compatible strategies for managing a level of distress which society often finds hard to deal with. One model would imply an emphasis on past events and meaning making, the other would suggest an emphasis management by medication. They are not, of course, mutually exclusive.

This raises an interesting dilemma for mental health professionals. Anti-diagnosis advocates often claim to be opposed to the notion of "expertise", but they are actually proposing the replacement of one sort of expertise (medical-pharmacological) with another (psychological-therapeutic). The radical challenge posed by the plurality in this post is to somehow balance the different sorts of emphasis that people want to put on how they understand their experiences. The different "models" of mental health (medical, biopsychosocial, humanistic) are not competing for some ultimate judgement when one of them will be proved "right", they are responses to the multitude of ways in which people wish to manage their lives.


  1. "Anti-diagnosis advocates often claim to be opposed to the notion of "expertise", but they are actually proposing the replacement of one sort of expertise (medical-pharmacological) with another (psychological-therapeutic)."

    Thank you, this is a really important point.

    I wonder if the public decrying of expertise by some clinical psychologists is partly about being embarrassed by the power differential in the psychologist-client relationship? (I see attempts to sell formulation as somehow an equal collaboration. But it's not.)

    It's also why I think clinical psychology has a great deal to lose by prioritising anti-psychiatry (rather than promoting psychology) as a strategy. If expertise is really so bad, why should service users bother with clinical psychology (which, I would suggest, has the most 'expert' trappings of any of psychiatry's rivals)?

    1. Thanks for this. I think you have hit the nail on the head here; many clinical psychologists are embarrassed by the notions of "power" and "expertise". Perhaps they are right, but as you say, it is a problem if we create a straw man of "psychiatry" (as though there were such a single unified entity) to deal with the feelings. Another problem is selling the dream of a perfectly equal and collaborative psychology, as though utopia were always just around the corner.

      Power is an issue in all health professions (in fact in *all* public-facing administrative roles) and how we deal with it is extremely complex. We should talk about it openly and yes, as formulation's proponents suggest, we should aim to be collaborative. What we can't do is evaporate the power differential by discarding a single text. In the enthusiasm for demonising the DSM, I think some people overlook the fact that replacement categories (i.e. "hearing voices") are no less prone to the development of specialist knowledge, "owned" by a group of experts.