Wednesday, 27 September 2017

The psychiatric diagnosis debate does not exist

As someone who has a slightly excessive relationship to aspects of the psychiatric diagnosis debate, I was relieved to see Vaughan Bell's excellent post on the topic. It gave me a sense of an emerging clarity as a number of shibboleths were put to rest. But my equilibrium didn't last for long. In the comments section there soon appeared counter arguments that not only pushed back against the original post, but seemed to resist its entire intellectual framework. As ever some were really nasty.

The nastiness results - in part - from the fact is that the debate in question is not really one debate, it is a cluster of related debates, which subdivide further into a whole series of difficult questions. Those questions are distinct, but are nonetheless bound together in a tightly woven network such that it is hard to start to answer one of them without first taking a view on the questions in nearby nodes. Pick up one node and the others nearby come with it. So when you adopt one position it can seem to are endorsing others too. Nonetheless it might be possible for any given individual in the discussion to hold a view that answers this constellation of questions in a way that is entirely idiosyncratic.

No wonder it is so hard for anyone to agree. No wonder this has occupied people for so long. Unfortunately the unpleasantness doesn't make the debates any less important, just harder to have. One way to ease up on the twin vices of tribalism and triumphalism is to back away from the temptation to have more answers than questions. A switch to the interrogative brings forth a cascade of loosely grouped considerations:

The DSM debate:

Is the DSM any use?
Does it do more harm than good?
Are its categories ever reliable?
Are they ever valid?
If a diagnosis is invalid, does an expert in, say, Bipolar Disorder still have expertise?
What is the nature of that expertise?
How important is it that DSM diagnoses are formed by committee?
Is matching to criteria better or worse than prototype matching?
Is the DSM really atheoretical?
Should it be?
Were we better or worse off before the DSM? 
How seriously would one have to take the DSM in order to find some uses for it?
Is the DSM a primarily cynical enterprise?
Should it be replaced?
With what?

The diagnosis debate:

Does diagnosis have sufficient merit to be used for mental health problems?
What is a diagnosis?
Does it need to consist of more than purely descriptive terms?
Does a diagnosis necessarily efface a person's suffering/identity/personal understanding of their experience?
Is diagnosis a good thing?
Is diagnosis a bad thing?
How bad?
Is it as bad as punching someone?
As apartheid?
As Nazism?
Is diagnosis consistent with a formulation?
Is a formulation closer to the dictionary definition of "diagnosis" than most diagnoses manage to be?

The illness debate:

What makes something an illness?
Is it defined by biological marker?
Do people who experience chronic fatigue have an illness?
What about people who become depressed?
Or develop psychoses?
Or become manic?
Or tic?
Or rage?
Who decides whether someone is ill?
Someone who wrote a clever technical definition of illness?
Do we need to be consistent about it?
If some people who meet criteria for a diagnosis regard themselves as having an illness while others don't, what do we do about that?
Over what aspects of your behaviour do you retain responsibility when you are ill?
How could we come to agree about where the answers could come from? 

The aetiology debate:

Why do people come to develop anxiety/depression/psychosis?
Is it ever sensible to give a diagnostic label to experiences that result from trauma?
What would it mean for something to be genetic?
What would it mean for something to be environmental?
Is it eugenics to implicate genetics in mental illness?

The meta debate:

Why do we all get so het up about this?
Are we really debating what we think we are debating?
Is it worth it?
Is it better to take a strong, unequivocal view on these issues and stick with it?
Is it a guild dispute?
A turf war?
Is anyone helped?
Is it indecent to enjoy it?
Is it negligent to ignore it?

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