Saturday, 20 July 2013

The Strange Case of Lucy Johnstone, Rufus May and the Mental Health Charities.

The Clinical Psychologists Lucy Johnstone and Rufus May have recently criticised mental health charities for their continued use of the word "illness" and diagnostic terms taken from the DSM:

May called out Time to Change on their use of "Mental Illness":

This is not the first occassion for such a debate, Lucy Johnstone and Mind had this exchage earlier in the year:

What are we to make of all this? The blogger and mental health nurse Phil Dore recently called it an "ideological pissing contest" (great phrase that) in a blog post concluding that Johnstone and May (and others) should pick their battles elsewhere. I am entirely sympathetic to this view, but in this post I would like to go a little bit further and ponder if there even is a valid battle to be picked.

The form of Johnstone and May's criticism is that these disorders "don't exist". Both clinicians are motivated by an admirable desire to raise consciousness of the contingent nature of DSM's construction. However, such a simple and categorical statement as "DSM Disorder X does not exist" is complicated by the fact that it has at least three meanings:
  1. The categories of the DSM do not exist in the sense that there is no biological illness process to which they can be said to refer. 
  2. The categories of the DSM do not exist in the sense that there is no emotional/psychological process/phenomenon to which they refer.
  3. The categories of the DSM do not exist in the sense that nobody uses them; service users do not get told they have them; services and interventions are not planned on the basis of them and they are not used to design and conduct clinical research.
I am pretty sure that Johnstone & May do mean to imply statement 1 but do not mean to imply statement 3 (I am unclear how they stand in relation to statement 2; perhaps they would like to comment on this post). The problem is that without clarification they are sending out a confusing message. More importantly, they are not acknowledging the legitimate reason for which the charities continue using the terminology they do.

Service Users and others who seek support & information from a mental health charity might reasonably expect to be able to find out what is known about the problem classification terms that they have heard in use. Whatever we think of those terms, there is a wealth of information available about which groups of problems are and are not amenable to which sorts of support. Off the top of my head:
  • People diagnosed with psychotic-problems should be able (without launching into a literature review) to find out that CBT has limited efficacy, but that research is ongoing and it is available on the NHS if they wish to try it for themselves. There are other psychological interventions being researched which may have better outcomes.
  • People with a diagnosis of Borderline Personality Disorder should be able to find out (without scouring the tedious NICE guidelines) that unless they are have received in-patient DBT, they haven't yet had exposure to one of the most intensive psychological interventions available on the NHS.
  • People with a diagnosis of depression should be able to discover (without having to delve into the enormous "common factors" literature) that a very wide range of psychological therapies have been effective in similar cases and are worth pursuing. If they don't like CBT, they can advocate for an alternative approach. 
Both May and Johnstone invoke the literature on stigma to endorse their claims, but the implications of this literature are not as simple as we might like them to be. First of all, the empirically validated existence of stigma does not change the fact that DSM terms have broad societal currency and organise the provision of mental health services. Second, the literature supports a complex picture of which terms are and are not stigmatising and in what ways. For instance, a recent study suggests the term "mental illness" is no more stigmatisting than "mental health problem" (seemingly refuting May's point). Another finding is that some terms ("Schizophrenia") are stigmatising while others ("Depression") are not.

I say all this not because I seek to "save" the medical model (whatever that even is), but because I seek to complicate the criticisms and defend, on pragmatic grounds, the actions of these charities. Given the present confusion about the ontological nature of mental health problems, all recipients of a diagnosis should certainly be offered the information that there are good reasons to call the classifications into question and a lively debate about whether they are even appropriate. To somehow "ban" DSM terms from the public discourse would not be as helpful a step as it first appears; some people would be delighted, others profoundly alienated. It remains unclear why some service users find diagnoses powerfully explanatory while others reject them altogether. For as long as we are stuck with a muddled mix of languages in which to discuss these issues, the dogmatic promotion of "one true God" (Phil Dore's phrase again) is entirely premature.


  1. Thanks for another interesting post. I usually agree with a lot of what you say, but I strongly disagree with this:

    "all recipients of a diagnosis should certainly be offered the information that there are good reasons to call the classifications into question and a lively debate about whether they are even appropriate."

    I think one problem with that is: would it apply to just psychiatry, or would it apply to clinical psychology as well? There is a 'lively debate' over formulation too. Do you think all clin psych clients should be told about the many problems Keith Laws identifies with formulation, and the contradictions about formulation in the BPS' own guidelines? If you don't think they should, why should psychiatric patients alone "certainly" get a prefatory warning?

    Sorry to pick on one line of your important post, but as a service user I already get a hefty chunk of information about the potential side effects of meds (in the form of patient information leaflets and warnings from psychiatrists), so I think clinical psychology gets it much easier than psychiatry when it comes to informing service users. The idea that diagnosis should come with its own warning is a step too far for me, unless the whole mental health field (and medicine too) follows suit.

  2. Thanks for this Chasingdata. I think you're concern is that this can start to look like one "side" criticising the other and not having their own practices questioned. Of course, we know there are not really "sides", or there shouldn't be. In fact when I say service users should be alerted to the debate I mean the debate in its entirety. Diagnosis is one form of knowledge; formulation another. I would also be interested in other sources of information. We have to sort of triangulate and there is no final answer (no "one true God") about people for us to "discover". All we have to go on is what seems to work for people, which we have to try and measure with data and by asking people about their experiences.

  3. Thanks Hew. Really enjoy ur writing. Regarding the issue that chasing data raises, my view is that we should be careful not to present anything to a client in a polarised, glamorised or demonised manner. When I do the pre-treatment work with someone starting my DBT program I am always clear that this intervention does not work for everyone, that it is very hard work and that it might make them feel worse. When I present a formulation, it is always tentative and im sure to check what the clients feel will make it more meaningful. If discussing a diagnosis, I often explain that it is merely a label to describe a bunch of experiences that sometimes cluster together, but which are likely to miss some of the unique aspects of that individual's expereinces.

  4. Lucy Johnstone's "A Straight Talking Introduction to Psychiatric Diagnosis" may be more helpful?

  5. Lucy Johnstone's "A Straight Talking Introduction to Psychiatric Diagnosis" may be more helpful?