Licensed to Ill?

Most of my posts on this blog attempt to reach some conclusion. Not this one. I haven't managed to come up with a neat propositional statement that does justice to what I think about the topic. This blog-post is about the term "Mental Illness", specifically the "Illness" bit, and more specifically the question "is it appropriate to say 'mental illness' to talk about the sorts of misery that some people experience under the rubric of 'mental health problems'?"

On one view it's an open and shut case: the answer is "No!" Virtually none of the experiences so inadequately described by the DSM can be regarded as "illnesses"; they are "problems" at most, and they are caused not by a brain malfunction, but by life experiences. This view is held by some to be the more sympathetic and humanistic one. Its advocates are fed up with being, or seeing others, fobbed off with a label and some pills. They're fed up with people being written off as "chronic" and with the lowered expectations that lock service users into institutionalised and restricted lives. I largely agree. I have seen how people get treated in hospitals; how badly resourced services warehouse them and are able only to offer paltry shadows of what we would properly call "care". Calling people "ill" can work the neat trick of attributing all that is wrong with a person to the illness, and overlooking the problems caused by the ways they have been treated.

How can we prevent the "illness" debate resembling a plane crash?

Where's the debate then? Why would I even ask whether "illness" is a relevant term when there are so many people (perhaps you are one) for whom it very definitely isn't? Practically I don't generally have to adjudicate over whether people are ill, as a psychologist I am more concerned with understanding and influencing the things that they think. Thought can obviously be influenced by physical pathology but I am not medically qualified to treat that, so you can see how it might be in the professional interest of people like me to limit the use of the word "illness".

Theoretically I used to be convinced by the argument that disease or illness is what we say about problems where there are not only symptoms (unpleasant experiences) present, but also agreed-upon biological events which explain them. This argument is based on a definition sometimes attributed to Rudolph Virchow, who died over 100 years ago but it is arguably only relevant if you think that the criteria by which we decide can have been fixed back then for all eternity. Furthermore, it assumes that we can only say "illness" when we have agreed on the explanation.*

Unfortunately, it's a simple definition which no longer seems adequate for our purposes. What counts as an illness is not only a question of similarity to other things we already call illnesses, but also of how far we choose to extend the use of the word illness. As a clinician rather than a sufferer, I don't feel confident that I can define illness from the outside and the ultimate criteria for helping me to do so don't appear to exist. The dictionary definitions are circular and unhelpful:

Mirriam-Webster: "an unhealthy condition of body or mind"
Oxford: "a disease or period of sickness affecting the body or mind"
Dictionary.com: "unhealthy condition; poor health; indisposition; sickness"

As if to make my point for me, there is an interesting symmetry at work. Activists seek to call some experiences "illnesses" even though there is doubt over whether they meet Virchow's definition. In the case of M.E., for example, sufferers are horrified when doctors suggest that there isn't a biological underpinning that would warrant an "illness" designation. They feel ill, and suggest that we should start from this place in determining the status of the diagnosis.

Meanwhile, in mental health, many first hand accounts describe something so like an illness that it just seems callous or pig-headed for an outsider not to agree. William Stryon describes his experience of depression thus:

“When I was first aware that I had been laid low by the disease, I felt a need, among other things, to register a strong protest against the word "depression"...a true wimp of a word for such a major illness." (Darkness Visible: A Memoir of Madness)

If Stryon seeks any redescription it is toward a more severe, more pathologising language which would honour the experience of being taken over by something that seems quite alien.

Kay Redfield Jamison is very firmly of the view that her Bipolar Disorder is an illness:

“No amount of love can cure madness or unblacken one's dark moods. Love can help, it can make the pain more tolerable, but, always, one is beholden to medication that may or may not always work and may or may not be bearable” (An Unquiet Mind: A Memoir of Moods and Madness)

Elsewhere she acknowledges the unique mixed quality that mental health problems have:

"It is an illness that is biological in its origins, yet one that feels psychological in the experience of it"(An Unquiet Mind: A Memoir of Moods and Madness)

Some people may agree with Jamison and Stryon, others may wonder if they're even on the same planet. I bring them to the table because they seem to be at odds with the first hand experiences so readily appropriated by those who seek to combat the medical model. If, like Boyle, you regard "illness" as something with a clear and agreed definition, you will recruit the service user accounts that flatter your own, and possibly stop hearing those that don't. Given the continued ambiguity in the debate, this seems an unwise maneuvre. Before we make assertions about what is and is not an illness, we need to decide what we want the word to do for us. In the meantime, I consider myself lucky that it isn't my decision to make.

* This paragraph has been corrected, it used to say: "Theoretically I used to be convinced by the argument (made, for example, by Mary Boyle) that disease or illness is what we say about problems where there are not only symptoms (unpleasant experiences) but also signs (biological events which explain them). This argument is based on a definition sometimes attributed to Rudolph Virchow, who died over 100 years ago but it is arguably only relevant if you think that the criteria by which we decide can have been fixed back then for all eternity." Mary Boyle, to whose "Schizophrenia: A Scientific Delusion?" I was referring, does not define signs and symptoms this way. 

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:

“@MHRUKCharity: Worried you might have #bipolardisorder? See these FAQs: http://t.co/xktQgsaEQx" No, please don't! There's no such 'illness'
— Lucy Johnstone (@ClinpsychLucy) July 6, 2013

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

'Mental illness' is a misleading term why do you promote it when it itself creates stigma? @TimetoChange why not demedicalise confusion?
— Rufus May (@Rufusmay) July 15, 2013

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.

Making a Straw Man of the DSM

I have now twice made the same mistake in print. In a letter to The Psychologist I said that the DSM entailed assumptions about "medical-genetic underpinnings". In an article for Clinical Psychology Forum, I said that "DSM-5’s authors are erroneously committed to considering them [mental health diagnoses] as ‘brain diseases’".

Neither of these statements is true. Here is how the DSM-5 defines a mental disorder:

"A mental disorder is a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved responses to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above."

Further to that, here is how the DSM suggests a clinician should determine the cause of any given "disorder":

"The case formulation for any given patient must involve a careful clinical history and concise summary of the social, psychological, and biological factors that may have contributed to developing a given mental disorder. Hence, it is not sufficient to simply check off the symptoms in the diagnostic criteria to make a mental disorder diagnosis. Although a systematic check for the presence of these criteria as they apply to each patient will assure a more reliable assessment, the relative severity and valence of individual criteria and their contribution to a diagnosis require clinical judgement. The symptoms in our diagnostic criteria are part of the relatively limited repertoire of human emotional responses to internal and external stresses that are generally maintained in a homeostatic balance without a disruption in normal functioning...The ultimate goal of a clinical case formulation is to use the available contextual and diagnostic information in developing a comprehensive treatment plan that is informed by the individual's cultural and social context."

The intention of both of my pieces of writing was to complicate and critique the arguments that get made against diagnosis, so how have I fallen into the cognitive trap of making a straw man? Presumably the answer is that when you spend enough time engaging with a group and absorbing its norms, you develop a sort of false consciousness. So often we hear it said that it is the intention of the DSM to medicalise the field that we can easily start believing it without actually reading the manual. It looks like I might actually be falling prey to the first and second of the three myths I have written about here.

Over-medicalisation is problematic when it represents a needless simplification of reality and stands in the way of our responding effectively to mental health problems. It certainly goes on, and the DSM certainly plays a role in facilitating the process. However, the culturally prevalent idea that any given "disorder" has a single simple cause cannot just be laid at the door of the DSM. If we got rid of the manual we would not see a rapid disappearance of the assumption. Instead, the simplification arises from a complicated network of research findings, news articles, educational experiences, drug promotion and "common sense". When an aspect of our reality is as hard to understand as mental health, we can be expected to latch onto any explanation we can understand. When we dislike the results of this heuristic bias, we can be expected to find a culprit. The DSM is an easy target.

Improving Mental Health Care: 3 Myths to Avoid

The Struggle of Good vs. Evil:

No Grey Areas Here

Howard Zinn’s massive book on American history is a gripping account of the ways in which the poor and dispossessed of the country have been oppressed and undermined by the financial interests of the financial and political elite. It has one major flaw; a tendency toward painting those elites as a coherent unit of baddies, explicitly motivated to work against the interests of the common man and actively choosing to do so at every turn. For this it was voted one of the least credible books by a poll on the History News Network. The charge is not that Zinn misrepresents the social consequences of financial injustice, but that he falls into the easy trap of inventing a coherent group of people whose malign intent is the cause of those consequences. In fact history is messier; events are caused by isolated individuals, subject to circumstance and acting in what seem to be their best interests at the time.

People on both sides of the debate about psychiatry persistently fall into the same trap and the Manichean narrative erupts all the time in unexpected ways. Jeffrey Lieberman does it here, drawing an unfortunate parallel between anti-psychiatry (which undoubtedly contains some ill thought through positions) and "racism, sexism and homophobia". His piece contains a reasonable point about the nature of debate over DSM; some people seem opposed to diagnosis and psychiatry as a matter of principle, but he can't resist his own anger at the way psychiatry is being criticised.

As if to make Lieberman's point for him, the psychologist and blogger Phil Hickey maintains a fairly constant stream of angry diatribes at his site Behaviorism and Mental Health. His posts (here's one about Lieberman himself) are characterised by an uncompromising rejection of any argument that gets made in psychiatry's favour, assuming it is necessarily being made cynically. Hickey's position is to start from the premise that psychiatry, drugs and diagnosis can never be a good thing and it is surprisingly influential. In debates with qualified clinical psychologists on Twitter I have been called a "pseudo psychiatrist" (as though that in itself were an insult) and seen genetic research into mental health baldly equated with "Nazism".

There is certainly a corrupting influence of big pharma on psychiatry. For my money this was described rather well in Richard Bentall’s Doctoring The Mind: Psychiatrists are treated to glamourous and all expenses paid international conferences; some people make hundreds of thousands of dollars, calling themselves "educators" to promote these drugs. However, this is not the result of some grand concocted scheme by a unified overarching "Psychiatry", it emerges through the collected actions of more or less well intentioned individuals, many of whom fall prey to cognitive biases and self-deception. There is an evil in such a state of affairs, but unfortunately it does not lie where it would be easiest to see and avert.

The notion of the Sacred:

Beware Sacred Cows!

One consequence of thinking in terms of an almost cosmological good and evil is that some ideas come to be seen as inherently unspeakable; a breach of the sacred (or at the very least, of simple common sense and decency). The result over time is that ideas are received, left unchallenged and assume the level of a received truth. This habit is evident among just as many of those who associate the "medical model" with all that is evil as among those that defend it.

Witness the final sentence of the fourth paragraph in this article by Susan Inman, the author of a book about having a child with mental health problems: "Books linking schizophrenia to capitalism have become bestsellers" she sighs. Inman may very well feel this line of sociological inquiry is a waste of everyone's time, but it is never enough to register it in a taken-for-granted tone of indignation. Why not link Schizophrenia to capitalism? If it turns out to be a crappy idea, explain why and show your workings. 

On the other side, all manner of sacred truths abound; diagnosis is "one of the worst things one human can do to another", "bio-genetic explanations" cause stigma and medical treatments do more harm than good. There are important facts that underlie these positions (diagnosis can cause social harms; certain bio-genetic explanations are overly simple and chemical/brain interventions often have damaging effects) but that they too easily become sacred cows which stop us from hearing evidence which contradicts our position. Become too attached to a position and you are vulnerable to the confirmation bias, our tendency to seek out evidence which affirms a position we have already decided is correct. 

Revolutionary Promise:

The Revolution Will Not be Tranquilised

There is no getting away from the fact that psychiatry and clinical psychology offer little consolation of a complete resolution of the problems they take on. We may talk of “treatments” in our field but any mention of “cures” prompts justifiable cynical laughter from practitioners and service users alike. Mental health problems are sufficiently complex (and involve a sufficient mixture of the bio-psycho and social in their cause) that any suggestion that we have discovered that miraculous silver bullet should be taken with a healthy dose of scepticism.

This fact is regularly rehearsed in relation to new biological treatments; anti-psychotics and anti-depressants are debunked as mere dampeners of experience and the internet genre of neuro-criticism (as exemplified by bloggers Neuroskeptic, Neurobollocks and Neurocritic). It is less often raised in response to the utopian claims of social constructivists. In blithely asserting that “we would halve the amount of emotional distress in this country if we had the more equal, relatively cohesive, less debt-ridden political economics of our European neighbours”, Oliver James all but torpedoed his own case by making it implausible. Any talk of revolutions or "paradigm shifts" in clinical psychology should be met with suspicion, not because revolutions are necessarily unwelcome (although it is true that their dangers are easily overlooked) but because they often represent a promise that is then dismally betrayed.

The best possible response to mental health problems probably doesn't lie just over some ever receding social horizon, it is an ongoing process of improvement and research, integrating more kindness and better understanding into our services. 

Accuracy vs. Stigma: Is There a Conflict?

Another day another paper (1) examining the links between stigma and the public understanding of mental health problems. The paper (a series of meta-analyses) concludes that "biogenetic explanations" can exacerbate stigma by increasing people's "pessimism" about the outcome of psychological disorders. On Twitter Keith Laws questioned the implications of the message:

Should we be offering explanations to people of their 'mental health' problems based purely on whether it is associated with stigma or not
— Keith R Laws (@Keith_Laws) June 25, 2013

Those who responded to this question on Twitter pointed out correctly that it is "absurd" and morally problematic to ignore or suppress the truth about the cause of mental disorder in favour of the narrative you want to tell. I agree, but these answers don't do justice to the most interesting possible ramifications of the research. In their conclusion to the paper, the authors make it fairly clear that they are not advocating the promotion of inaccurate accounts:

"Mental health professionals should not misinform their clients and the public by withholding information about the biogenetic factors that underpin psychological problems." (emphasis mine)

Unfortunately, the waters muddy somewhat when it comes to describing what they are advocating:

"However, our findings indicate that this must be done with considerable caution. Explanations that invoke biogenetic factors may reduce blame but they may have unfortunate side-effects, and they should not be promoted at the expense of psychosocial explanations, which appear to have more optimistic implications." 

What the second half of this passage sadly misses, in its haste to decry the dominance of "biogentic factors", is that the best explanations of the causes of mental health problems would accurately communicate the complexity of genetic causation. It is this complexity that can easily get lost in public debate and everyday healthcare. Having a genetic predisposition to a particular problem doesn't always mean the same thing in the public imagination as it does in reality.

Biology is one determinant of our thoughts, feelings and behaviour; at the same time we retain some quantity of agency (possibly itself biologically determined, but let's steer clear of that philosophical rabbit hole for now), which we are able to exercise to change them. This capacity is not limitless and it varies with the nature of mental health problems, but it is real. People are changed, to some degree, by how they think of themselves (this is what is meant by Ian Hacking's idea about the "Looping Effects of Human Kinds") and if they weren't, there would be no point in any psychotherapeutic intervention.

We can't know very much from this paper about the nature of the disorders or the explanations that are being studied, but it does raise two possibilities that should be further explored. When people with mental health diagnoses attribute their problems to "bio-genetic causes" they may be 1. failing to do justice to the richness of what this really means and 2. buying into an unwarranted therapeutic pessimism that impacts on prognosis.

I'd be among the first to point out that this sort of research gets hijacked and over-simplified by well-meaning advocacy groups who just want to replace one narrative with another, but the fact remains that what it means for genes to have an impact on behaviour is frequently misunderstood. Highlighting the potential public health ramifications of overly simple, overly certain forms of understanding is an important part of public science communication.

1: Kvaale, E. P., Haslam, N., & Gottdiener, W. H. (2013). The ‘side effects’ of medicalization: A meta-analytic review of how biogenetic explanations affect stigma. Clinical Psychology Review.

Diagnosis, Political Correctness and Identity

Names are of profound importance. Psychological research summarised in this lovely New Yorker article  suggests that the sight and sound of the words we read, indeed the very shape of the letters that comprise them, is having an impact on how we think about what they represent. The relevance of this to the words that are used in the purportedly neutral medical field is obvious. Look at the word "Schizophrenia" below. Consider the unusually dense package of consonants which opens the word and then the harsh angular "Z" which cuts it in two. The Greek derivation of the two component elements (Skhizein & Phrenos) leads to a baroque and unusual spelling, which in turn lends a mystical, "other" quality to the word:

This visual example is taken from a benign text book about how to manage the social effects of Schizophrenia, but it still has a difficult and severe (some would even say stigmatising) label emblazoned right on its cover. In mental health, these labels are all around us.

Apart from the visual quality of mental health labels, there is also the troubling habit of slipping into using them as metanyms. Metanym is the substitution of a proper name with an alternative which actually represents something with which it is associated. This is what is going on when a health-care professional refers to someone as, say, "the depressive in room 10". I have seen many people object to the use of "Schizophrenic", and they are right to. While someone may meet the criteria for Schizophrenia, no-one is a "Schizophrenic"; it is not what the word is for.

Political Correctness:

One response to these problems of language and thinking is the judicious application of Political Correctness. Political Correctness is often maligned (with the derogatory "PC brigade" operating as a powerful if unfair rebuttal to well intentioned campaigners), but I'm with Stewart Lee, who mocks the naysayers and points out that it's an "often clumsy negotiation towards a formally inclusive language":

A politically correct and formally inclusive language of mental health problems would presumably not use words that are themselves unpleasant and would carefully caution against the over-extension of the labels beyond their originally intended use. The implications of disease (which implies infection) and of mental health problems as in some way characterologically definitive (as in personality disorders, where a person is seen as in some way defined by the label) should be strenuously resisted if clinicians want to avoid their diagnostic labels becoming simple insults.

Identity Politics:

Another approach is Identity Politics. A fantastic example is contained in this marvellously strident tweet by @ukschizophrenic:

Just to clarify: I believe that individuals aiming to change the name of schizophrenia are cowards, idiots & the worst agents of stigma!
— TheSchizoPodcaster (@ukschizophrenic) June 4, 2013

An alternative to "politically correct" re-namings of DSM terms is for service users to accept them; to take them on as identities in themselves and, from this position, to assert their right to experience things in a particular way. I am unclear whether this stands as a reaction against diagnosis or a tacit validation of it. However, the gist of this tweet seems to be that @ukschizophrenic identifies to some extent with "Schizophrenia" and is simultaneously unimpressed by the notion that it is something to feel ashamed of. Just as LGBT groups took ownership of "queer" and "dyke" in order to neutralise their toxicity, there seems to be an emergence of a mental health identity politics online; Twitter's "Schizo-Tribe" is a brilliant example.

This movement makes it difficult for anti-diagnosis campaigners to say that they have the monopoly on taking patient experience seriously. If diagnosis is a useful way for people to make sense of their experience (and proponents of formulation have already accepted that the criterion we're interested in is "usefulness" rather than "truth") then to highlight the problems with diagnosis' validity seems irrelevant. Meanwhile, by claiming that a diagnosis is "stigmatising" or "colonising", anti-nosologists are privileging one group's experience over another's.

We seem to be left with an impasse; some people dislike diagnosis aesthetically and politically; others don't. A politically correct renaming of diagnostic terms may be worthwhile, but existing terms sometimes accurately capture the experience of those who receive them. The debate will not be won or lost on this territory.

Unwarranted Certainty: Psychiatry's Common Enemy

Across The Great Divide:

The raging debate on diagnosis in mental health is at fever pitch right now, and I find myself drawn into discussions on Twitter that are sometimes fun, sometimes interesting and sometimes feel like trying to suck Marmite through a straw. Although the two sides of this great divide are extremely heterogeneous, and though there are more bridges than is sometimes apparent, there is often a sense that some differences are too great to be reconciled. When intellectual rifts emerge it is all too easy to find yourself positioned (sometimes by your own lazy thinking; sometimes by that of other people) on one or other side of the divide. Theoretical positions become ossified and it gets harder to be heard across the gulf that has opened up. There are good and reasonable arguments coming from both directions.

On the one hand, classifying people's problems is a prerequisite for understanding their nature in a scientific way. You can't say with confidence that a person's mental distress is, say, a response to traumatic experiences unless you are able to draw on knowledge gleaned from other similar cases that confirms this to be a possibility. A person's problems may seem like they constitute such a response, but how can you know if you aren't able to confidently say that you have seen cases of this nature before and can rule out alternative conceptions?

On the other hand, reasoning about individual cases from general information is a probabilistic business. Such statistical information as we have about mental health problems is well equipped to inform us about the relative likelihood of particular causes and of therapies/medications being effective. It is less help in providing a straightforwardly biological understanding akin to that we have about physical health problems. This is why extra sources of case information are so useful in this field and why approaches like psychological formulation are a worthwhile technique for conceptualising the contextual and cognitive contributions to any given person's situation. In fact the DSM-5 itself recognises this fact in an opening section on clinical case formulation:

"The case formulation for any given patient must involve a careful clinical history and concise summary of the social, psychological, and biological factors that may have contributed to developing a given mental disorder." (DSM-5, 2013)

Fighting The Common Enemy:

This brings me to the real common enemy that should be uniting the psy-professions; unwarranted certainty. There is much mud slung between the anti and pro diagnosis positions about the extent to which either side is "scientific", but to the extent that they have any common ground in this regard, it is over the problematic tendency of human clinicians to be more certain about their conclusions than they have reason to be. Unwarranted uncertainty is a highly unscientific way of thinking--although some commentators, noting the tendency of overly-certain people to claim a scientific position, get this back to front. This is what seems to have happened in this David Brooks Op-Ed in the New York Times, in which he calls psychiatry a semi science and psychiatrists "heroes of uncertainty". Psychiatry may well be a semi-science, but that has more to do with the fact that it involves ethical and political reasoning which science can guide but not determine, than with the fact its practitioners are "heroes of uncertainty". It is also probably this confusion which accounts for the moment in this interview in which Tom Burns implies that being "ultra-scientific" in psychiatry is a bad thing. In fact being ultra-scientific would entail precisely the kind of skepticism and careful humane thought that Burns appears to be advocating.

The essence of the strongest argument against diagnosis is it can blinker clinicians and limit their capacity to see beyond the boundaries they define. Many of the evils identified by Peter Kinderman here and elsewhere are the consequences not of diagnosis per se, but of mental health staff naively taking a diagnosis to mean a particular sort of thing. It is not classification that leads to over-medicating of people with psychosis; it is the belief that a classification like "Schizophrenia" picks out a disease that cannot be treated any other way (incidentally, doesn't the quote from DSM-5 above suggest that the authors don't intend for clinicians to think in those terms?). The enterprise of "critical psychology" often lays claims to undermining this kind of unwarranted semantic certainty, but really it is the business of all psychology to bear uncertainty about the nature of its constructs and to explore them further. Mary Boyle's book on Schizophrenia undermines the "disease construct" not by drawing not on evidence from some sub-discipline called "critical psychology" but from...psychology.

Of course, the reification of formulation and psychological narrative is no less of a problem than the assumption that diagnosis is the same thing as disease. Information about how a person's problems have been affected by their life story and consequent beliefs is essential for the practice of psychotherapy, but if we drift into unwarranted certainty about that information's importance we aren't doing scientific clinical work anymore, we're just seeking confirmation of our biases.

I often find myself agreeing in debates that DSM is taken too seriously and in the wrong way; that its use can represent a confident assertion of knowledge that is unwarranted by the reality of what that a diagnosis picks out in nature. Noticing this is an important step for the well-being of service users, but it is not sufficient to conclude from it that diagnosis is conceptually impossible. Although it is frequently claimed that the diagnosis debate is not a turf war, there can be no doubt it is becoming increasingly war-like. A clarification of what is at stake helps us to direct our energies against the real common enemy.