Monday, 27 January 2014

Making the Case: Thoughts on Social Construction in Psychiatry

I have written a post for the blog maintained by the Salomons Clinical Psychology course. The piece is available here and some really interesting comments are unfolding "below the line".  

Tuesday, 14 January 2014

3 Questions (and 3 answers)

At this point in the "psychodiagnosticator" project, I keep meaning to review my thoughts on psych diagnosis. So far I have never found a good organising structure for a post; there is lots I want to say as a sort of recap but my ideas have been too sprawling. Then, last week @agteien posed three questions on Twitter and cc'ed me in for a response. I have taken the opportunity to write a self-indulgent review of where my thinking is at the moment.
I am not especially positive towards existing diagnostic structures-I see that it is insulting and disempowering to speak of "personality disorders", that Schizophrenia is probably not an unitary illness construct, capturing people with divergent (not always pathological) experiences; that the DSM is still too embedded in its past (American psychoanalytic psychiatry) to claim "theory neutrality". Equally, once I started interrogating the case-against, I found that the most sound arguments seemed to be for revisions to particular diagnoses, additions to the diagnostic system, possibly a new way of diagnosing. Critics who put all these elements together into a general call to reject diagnosis entirely are trying to make a case which is more than the sum of its parts. In some versions of the debate, the idea of diagnosis per se seems to become a blank screen onto which all the angers and frustrations of mental health get projected, with the accompanying promise "if only we stopped diagnosing people, then we could have a humane mental health system". I don't buy it. I am not especially positive toward keeping today's psych diagnosis system, but I think it has acquired a near-mystical status of evil in some people's eyes, and that stymies interesting debate.
Maybe this one is the question best fitted to me, I not only struggle to imagine doing without some form of classification, I think that DSM's critics can't do without one either. In his new year "message from the chair", Richard Pemberton of the DCP reflected on the division's statement against the DSM-5 back in May. In the same paragraph he announced forthcoming DCP publications "understanding depression" and "understanding psychosis". You don't, of course, need to construe depression or psychosis as medical "illnesses", but the DCP's use of these terms raises an interesting question about what we necessarily do when we classify. If we reject an illness model of mental health problems but nonetheless continue to speak of them as distinct entities then we are not travelling very far from the position of diagnosing. Depression and psychosis remain things that are worth talking about and "understanding"; they remain things about which clinical psychologists presume to write and explain. If we think we can develop an understanding of their causes, course and potential interventions, in what way are we doing anything radically different from those who "diagnose"? To recognise a problem and believe you can generalise from other similar cases to provide help is, to my eyes, to confer a diagnosis. The broad rejection of diagnosis starts to look more like a turn away from a specific type of diagnosis and it's historical/theoretical implications.
In the spirit of a debate that is a bit more developed than can be allowed on Twitter, I would encourage people to whom this last question is aimed to reply to it in the comments section on this post; I too would be interested in the answer.