Sunday, 26 October 2014

Five Halloween Costumes to REALLY be Scared of

This time of year has come to be marked by a familiar woe as various costume companies and theme parks market a peculiar brand of offensive mental health paraphernalia in the name of Halloween entertainment. From experiential tours of a "scary Asylum" to "mental patient" fancy-dress, if you want to spend a surprising amount of money buying into stereotypes that are deeply hurtful to a large number of people, then there is a company which can help you do it. I won't catalogue examples here as Sectioned has a good page detailing comprehensively the various offenders. Instead, I am going to do my bit for mental health stigma by offering some alternative fancy dress options for anyone seeking to truly terrify their friends this Halloween. All of these are far scarier than any imagined "mental patient" and are made more so by their ubiquity and relative invisibility. Here are 5 Costumes to REALLY be scared of this Halloween:

1. The Pharmaceutical Sales Rep:


The Pharmaceutical Sales Rep's only job is to flog medicines to healthcare organisations Although a science background can "boost your credibility", it is by no means a requirement in a field which principally requires that you "sell sell sell" and raise the profile of your brand. The pharmaceutical sales rep is the perfect example of the shady figure tacitly manipulating the minds of others to see that his ends are met. He is especially scary because although his knowledge might be low, his influence can be high. Some doctors may be unable to resist his creepy powers of mind control!

You Will Need : A grey suit and a bland tie. 

2. The Healthcare Administrator:


The Healthcare Administrator makes life and death decisions about whether to fund particular treatments and services. Poised between the world of political decision making and healthcare provision, he is aptly positioned to draw on the worst of both. Although the healthcare administrator is capable of using his powers for good, he is also capable of much evil. Last seen in a helicopter over Connecticut, deciding whether to pay for a 9 year old's cancer treatment.

You Will Need : A grey suit and a bland tie. 

3. The Public Relations Expert:


The Public Relations Expert's job is to present something as good, even if the thing itself is not that good; even if it is actually rather bad. While there's nothing scary about doing the promo material for, say, a poorly written book, the work this guy will do to help people cover up fairly egregious errors (and get wealthy in the process) is a little more sinister. 

You Will Need : A grey suit and a bland tie. 

4. The Arms Dealer:


Let's ramp things up a notch. If you are insufficiently scared by the murky antics of the Sales Rep, the Administrator and the PR Expert, you can't fail to be terrified by the downright horror of the Arms Dealer. Utterly unconcerned by anything other than turning a profit, the Arms Dealer will happily sell weapons to anyone willing to pay. The ideal scenario for the Arms Dealer is a protracted and bloody war in which he can offer his wares to both sides over the longest possible period, getting rich as his customers shoot one another indefinitely. As a major player in most western economies, the Arms Dealer is seriously scary! 

You Will Need : A grey suit and a bland tie. 

5. David Cameron:


He's real, he's the Prime Minister, and he's coming for YOU!

You Will Need : A grey suit and a bland tie. 

Tuesday, 21 October 2014

From "Diagnosis" to "Characterisation"

What a lot of difficulty there is in trying to talk about psychiatric diagnosis. We try to say one thing but can easily end up meaning something else.

I have often taken a position that defends the value of diagnosis in mental health. People have often refuted that position by citing the failings of the DSM project, as though diagnosis and the DSM were the same thing. For a while I tried to resist this by pointing out (over and again) that I was not necessarily referring to that complex and troubled manual but to something like "classification plus a probable explanatory story". The point has never stuck, and I have to face the possibility that some of the fault is mine.

Why persist in talking about diagnosis? Why not seek a word that doesn't alienate people? Diagnosis seems to suggest "knowing", which it isn't if we're honest.

Perhaps instead of diagnosis, we could talk of "characterisation". When someone understands a problem in a particular way they characterise it, describe it as having a particular nature. "Your avoidance of parties is a social phobia, exacerbated by your ongoing avoidance and we can expect forms of exposure therapy might help." or "Your mood changes are like those that have been called "Bipolar", and when people have taken this or that drug they have found them easier to live with."

This way of talking can resemble formulation (the first example) or it can resemble diagnosing (the second), but it isn't supposed to be more like one or the other. Formulation tends, in this debate, to mean the idiosyncratic and "intelligible"; the formation of "meaningful narratives" (Boyle and Johnstone, 2014). Diagnosis tends to emphasise the regularities across cases, with "intelligible" referring to explanation in terms of medical as well as psychological processes (Hayes and Bell, 2014).

The idea of characterisation is consistent with either of these approaches. You can characterise a problem as psychosocial, as medical, or as a combination of both. If what we are doing is characterising, then we can take seriously the idea that someone is unwell when their mood consigns them to their bed for a fortnight. We can benefit from pattern recognition (Characterising the problem as a depression), without appearing to commit ourselves to belief in an entity that we can't yet describe (the "underlying" illness).

Characterising is more than classifying (because it speaks to how you view the classification), but less than diagnosing. It is a bit like formulating, but without the assumption that the explicable processes take place at the level of meaning. It's a clunky term, and not one that can be expected to "catch on", but when I talk about the value of diagnosis, it is this I am trying to describe.

Tuesday, 14 October 2014

How to Critique the DSM

I've just finished reading Rachel Cooper's excellent, and remarkably unsung new book "Diagnosing The Diagnostic And Statistical Manual of Mental Disorders". It came out in May and it's hard to believe I hadn't run across it until now. In a debate that becomes polarised and heated with alarming speed, Rachel Cooper is a calm and insightful voice. Her book (replete with a brilliantly irreverent cover, which makes you wonder at first if it's part of the "official" series of companion texts published by APA) is only 60 pages, but it packs more substance into that space than many of the books on psychiatry I have read recently.

Given the book's relatively low profile (at least, apparently, in clinical circles), here is a summary of the its arguments:

- Cooper is unsure about what to call those protagonists in her story who receive diagnoses. She finds "survivor" "too angry" (something I like about a certain strain of philosopher is that they openly admit the role of personal temperament in their thought) and makes the point that "client" can be disingenuous. The nature of mental health care is such that, in many instances, it simply isn't the case that an individual is paying, in the manner of client, for a service that they straightforwardly want to receive. She opts for "patient".

-Cooper is skeptical about the APA's own attempts to manage the financial relationship between the DSM and the pharmaceutical industry. Limiting the present pharmaceutical interests of clinicians involved in the DSM is simply inadequate when the relationship between doctors and drugs companies is ongoing over the course of a career. Such relationships are more like what anthropologists call a gift relationship where "gifts are given and received over time, and thereby create real but non-explicit obligations for reciprocation in the future" (p. 15). Cooper suggests that only complete independence from the pharmaceutical industry can save the DSM from this sort of malign influence, but that this sort of step would require "nothing less than a revolution" in the way research is funded.

-The APA invited patient involvement for the creation of DSM-5, but this was, in Cooper's view, largely tokenistic. How informative can it really be for the working groups to hear information in the random, bitty way invited by the online-comment feedback structure it provided? Drawing on the sociology of science Cooper points out that the questions that get researched, and the conclusions that are drawn are partly a function of who does the asking. She advocates for the presence of "patient researchers" who are trained to do research but also happen to be patients. This seems a sound proposal, though it is hard to imagine some critical mass of patient-researchers being reached without an extraordinary recruitment drive. Perhaps the best model is Hearing The Voice, which tries to amalgamate the tools of researchers with the priorities and subjective experience of people with first hand encounters. Charles Fernyhough describes the project in this Lancet article.

-It is not just big pharma that drives the inclusion of new diagnoses. Hoarding Disorder is new in DSM-5 and was, Cooper argues, the result of a combination of public awareness (Hoarding has become quite popular on Channel 4 in recent years) and of the development, by Randy Frost, of a specific CBT protocol, replete with inclusion criteria. Cooper suspects Hoarding Disorder is a bad thing, and suggests that it is more analogous to an "unwise" habit like eating unhealthily than a psychiatric disorder. As such, it might be better suited to interventions which bear a resemblance to Weight Watchers than to the ministrations of health professionals.

-Fascinatingly, the standards for reliability seem to have shifted quite a lot between DSM-III and DSM-5. In 1980, Spitzer and his colleagues set a kappa (a metric for estimating reliability) of 0.7 as the "acceptable" threshold. In the field trials for the latest edition, the goalposts have shifted and kappas in the order of 0.5 and 0.6 are now regarded as acceptable (the issue is handled more extensively in this post by 1 Boring Old Man, which Cooper herself cites). Cooper suggests this may be the result of greater attempted precision in the latest manual, but her main concern is how to make sense of the question of reliability. In her survey of the changes in the definition of "acceptable" reliability, Cooper brings out the sense of how little agreement there is over how to use this metric. More work is needed on what, for a psychiatric diagnosis, constitutes reliable enough.

-Ultimately Cooper concludes that the DSM's days are numbered; not because an anti-psychiatric tide will wash away psychiatric diagnosis for good (Cooper explicitly distances herself from anti-psychiatric positions), but because of the likely rise of other classification systems in research (like the RDoC) and of other psychiatric jurisdictions in which mental health care is expanding (such as in China). She advocates not the abolition of diagnosis, but a more flexible thinking along the lines of philosopher John Dupre's "promiscuous realism". Interestingly Richard Bentall has recently advocated this in the case of psychosis.

This is a refreshing and constructive book. One approach to the DSM is to reject diagnosis altogether, but this sets up a seemingly unbridgeable divide between those who do and those who don't reject diagnosis. Cooper's approach is more painstaking. There is plenty wrong with the DSM and Cooper has thought hard about it. Not content with critique, she also tries to envision remedies.