Saturday, 25 April 2015

New BPS Guidelines on Diagnostic Language are a Move Against Pluralism

(A commenter on this blog-see below- has pointed out that I did not include reference to the scope and purposes of the document I am writing about. To try and address their concerns I have edited the post, striking out some sentences and inserting a few new ones in blue.)

Something incomprehensible and unpleasant happens to a person. It behooves them to make sense of it. Into this vacuum of understanding steps language: an attempt to give form to an experience in a way that allows them to live with it.

The BPS's Division of Clinical Psychology has released new guidelines on the use of language in official documents which pertain to such circumstances.

Consisting of three principles (guiding on language to avoid and language to adopt)  It is a clear statement that illness-talk and disorder-talk are out:

Such guidance is on a clear continuum with other efforts to discard the language of disorder, and concerns the organisation has raised about the DSM, a manual which can itself be viewed as a hyper-regulatory set of guidelines about how to talk. 

I am all for questioning the language of the DSM. Naming people "disordered" or "ill" is often experienced by them as an insulting effacement of subjectivity. What is more, once illness-language gets into the pool of possible interpretations it seems to hand power to the only people with sufficient expertise to deal with illnesses, the healthcare professionals (who of course stand to gain from their status as knowers).

But there is calling into question and there is discouraging ruling out. The problem with an official language (the DSM is a dictionary rather than the "bible" it is often claimed to be) is that it sets up a seemingly "correct" and an "incorrect" way of talking. In some cases this is necessary (the much scorned "political correctness" is an appropriate effort to rule out ways of talking which offend minority groups in society), but there is always a trade off. The downside of being "PC" is that it can make people less considerate about their linguistic choices, while leaving them feeling righteous nonetheless. Think of the character Gareth in The Office, bemoaning the fact that his dad says "darkies, instead of coloureds"

This is one way in which the new BPS guidelines look to me like a misstep. Moving from "mental illness" to "mental distress" is superficial in itself. Language surely interacts with habits of thought, but a guideline like this just replaces one jargon with another.

The Turn Against Pluralism:

If this were my only complaint then I would lump it. We should be careful about language, and sometimes guidelines are the only way to do that. But the language of mental health is different from the language of race. There are racial terms so bound up with hate that officially discarding them is the only sensible choice. The same is not true of "illness", "OCD" and "Anxiety Disorder". 

We don't yet have the definitive account of who is and and who is not ill (defining illness turns out to be a dreadful philosophical tangle) so for all practical purposes there is no fact of the matter. One way of dealing with this uncertainty is to adopt a form of pluralism which allows for multiple frameworks for understanding. 

Some people see themselves as ill, others don't. Some people think of themselves as ill because they feel themselves to be ill. While not unproblematic, pluralism puts a person's experience at centre stage, affirming their chosen framework as a way to make sense of them. This is a principle I thought I saw affirmed in the "Understanding Psychosis" document released last November:

Plenty of first person accounts attest to the value of "illness-talk" (some of them in Understanding Psychosis itself), but the BPS has just discounted those experiences in a stroke. The approach adopted in the new guidelines is a solution that DSM-detractors have been descrying for decades. Rather than expand the repertoire of explanatory terms, this document shrinks it. Some language is good, some bad; some frameworks more correct than others. This works for people who are served by the new official language (those for whom "mental distress" is personal preference), but it alienates anyone who falls outside the charmed circle. Given how strongly the BPS has opposed the regulating languages of official psychiatry, I am astonished they have chosen this route. 


  1. As usual an erudite, topical and fair post.

    I would add that many of the examples used in the document as alternatives to medical terminology were distinctly minimalising and underappreciative of the complexity of some forms of what psychiatry calls illness. 'Bipolar disorder', for example, is not directly interchangeable with 'mood swings' as the document suggests. Bipolar mood states do not usually 'swing', they alter over a period of weeks to months, and are accompanied by changes in a wide range of other aspects of life (sleep, speed of thought, view of oneself, appetite, sex drive). In addition, one suggested alternative to a medical term, 'neuroleptic' instead of antipsychotic, is no less medical at all, and attached to archaic, innaccurate and misleading ideas about what those tablets do. It is a word heavily value-laden, and as you say, values are something we should be seeking to pluralise, not enforce.

    On a final point, I do not see how any reasonable groups of responsible professionals should need a document explaining the importance of, and how to, soften technical terms or use the patient's own language. The publication of this document itself shows tendentiousness.

  2. I am sorry to disappoint some of the more excitable Twitter users, but as someone who has actually read the BPS ‘Guidelines on Language’ I wanted to inject a note of sanity and reason into the hysteria emanating from (some) parties.
    I can only assume that your omission of the main purpose of the guidelines is deliberate, Huw. They explicitly state that their main purpose is ‘to support clinical psychologists in the development of documents…’ and ‘…new guidelines for language use in DCP professional documents and publications are needed…’ Obviously then, this does NOT apply to any other professions; does NOT apply to service user/carer personal language choices or writing; does NOT apply to clinical/therapeutic conversations; does NOT apply to health records or court reports; does NOT, indeed, apply to most of the work that clinical psychologists are engaged in (therapy, supervision, consultation, and so on.) The guidelines, as I read them, are simply an attempt to encourage thoughtful language use in official clinical psychology documents. They are not mandatory (since they are not ‘Standards’) and they explicitly leave room for individual decision (‘Some psychologists will have preferred terminology which is not included in this list…. It is left to authors to decide which might be most appropriate in a given context’). The guidelines also encourage feedback and further discussion (‘This is an evolving set of guidelines …We welcome additional suggestions and feedback.’) It’s not about narrowing down acceptable terms; it’s about avoiding terms which are intrinsically narrowing because of the assumptions they are based on, and about suggesting (not imposing) a range of more neutral terms which allow for, but do not assume, any particular model. I cannot imagine anything further removed from the rigid universal diktat that you seem determined to portray.
    I hope most clinical psychologists would agree that the language of our official documents should attempt to be psychological rather than medical wherever appropriate; and that in the light of criticisms of current diagnostic systems, it is desirable to use more neutral terminology when we can.
    By far the most interesting aspect of these modest suggestions for the careful use of language is the deeply threatened reaction they have evoked in some quarters. That really is a topic worth discussion. Huw, your distortions may make for a more provocative post but they certainly don’t encourage a mature and reflective debate.

  3. Hi anonymous, thanks for commenting. I do hope to be mature and not distort, so what you say about the guidance is important - thanks for adding it. Perhaps I can update the post a little to reflect the shift in emphasis, clearly indicating where I have done so.
    What you emphasize here is the intended scope of the guidance. This has implications for the *scope*, but not the *content* of my concerns. I still hope that as a profession we can be inclusive of many different forms of language, even in official documents. I also hope that what I have said in the post is sufficiently constructive that it can be taken as something like the "additional suggestions and feedback" alluded to in your comment and in the document itself. Even if you feel I am being provocative here, I hope that if there were anything of value to what I have written, that it might find its way into these evolving guidelines.

  4. I hope most clinical psychologists would agree that the language of our official documents should attempt to be psychological rather than medical wherever appropriate; and that in the light of criticisms of current diagnostic systems, it is desirable to use more neutral terminology when we can.

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  5. Great piece to which I fundamentally agree (and the comments from psychiatrysho), terminology will always raise criticism that's just a given but for me, as a patient/SU/human, prefer to have a recognition of my illness not as 'emotional distress' or as having a 'difficulty'. These terms may be useful for the management of relatively short-term occurrences e.g. to grief or loss, but I find them, as psychiatrysho mentions, quite dismissive of those who manage a longer term 'illness', and can lead to some people particularly in the media taking the stance of telling people to "man up". As for the position regarding it's only for documentation purposes and not for conversation with said 'patients', 'service users' or any other term that's current, what is termed in practitioner documentation will eventually be used in conversation. To say that these alternative terms are to be used only in docs is ridiculous, why would CPs use a different language amongst themselves? is it not naive to think that if used in guidelines/docs that they will not eventually begin to occur in conversations with others including service users? If any professional were to ever indicate that my lifelong struggle with depression, anxiety, and complex PTSD is a 'difficulty' I would walk straight back out the door believing that they had no understanding of what I was going through. Having been through many many years of psychoanalysis, CBT, eating disorder therapy and every other therapy that is considered the new panacea for 'emotional distress', I can say without any reservation that medication works for me. Therefore, if I must take medication in order to function in a way I consider 'normal' then I consider this to be an illness. As an illness I can understand it - it's not my fault - I can research it, I can do things to help myself stay as 'healthy' as I can just as with any other recurring illness but I can't do this without the medication, and believe me I have tried many times across the last 35 yrs. So, for me, it's a case of do I live with daily meds or do I need to be in therapy for the rest of my life, because that's what it would take. I fully agree with the fact there are issues in the diagnostic systems and over medicalisation of disturbances/illnesses/distress etc etc but neutralising the terminology must also be carefully considered in my opinion as this can also raise the already high levels of stigma and often sense of personal fault. Yes, there is certainly an understanding of having a normal reaction to an abnormal experience and it is often a hard balance to achieve but I believe there is a significant difference in someone who, having experienced emotional distress after a loss being given a diagnosis of being mentally ill, and someone who has suffered with a lifelong condition that affects their everyday life e.g bipolar. I have lived it, worked in various MH charities advocating for it, and studied the epigenetic impact of trauma at PhD level. So for me (and I am only speaking for me) too much neutralising simply doesn't cut the mustard. So thanks Huw, you're article made a lot of sense.