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.

Frege in the Clinic

This month, Clinical Psychology Forum have published a paper in which I address a philosophical argument made about the relative merits of psychological formulation over psychiatric diagnosis. the BPS do not make this text available online, so I offer a brief overview of the argument here.

The case I am responding to is in this fascinating article by Stijn Vanheule. Vanheule draws on Gottlob Frege's theory of linguistic reference, which is an important move because the philosophy of language is an extremely promising lens for thinking about the conceptual viability of diagnosis.

Gottlob Frege

Frege revolutionised the philosophy of language by better articulating what it is for words to refer to something. He has been called a Descriptivist about meaning, and although it is beyond the scope of this post to go into what that means, the Stanford Encyclopedia of Philosophy has a good explanation here.

Frege's position led him to differentiate three elements of linguistic reference: the thing being referred to, or referent of the sign (Bedeutung), the shared sense of the sign (Sinn) and the individual representation/idea of the sign (Vorstellung). In other words, Bedeutung is to the thing we are talking about when we use a word, Sinn is the definition of the word we use to talk about it, and Vorstellung is the "representation that occurs in the mind of the individual". A philosopher would probably take me to task for this fast and loose definitions, and Vanheule's paper provides more detail if you're interested.

Vanheule claims that the DSM, in its project to disambiguate the shared sense of mental illness labels (the Sinn), has overlooked the "person-specific ideas and representations" (the Vorstellung). He concludes that classification style diagnosis is thus "unworkable" for psychotherapy and that psychological formulation should be considered instead.

My article acknowledges the value of this approach, but I suggest that an unnecessary dialectic has opened up between Case-Formulation and Diagnosis. Vanheule's use of Frege can also be adopted in the reverse fashion; to make the case for diagnosis. If it is unhelpful to neglect one of Frege's three elements of linguistic reference, then the effacement of "Sinn" is just as unworkable as the effacement of "Vorstellung". Rather than discard diagnosis altogether we need to continue to improve it and use it alongside approaches that emphasise the personal aspects of meaning.

Rise of the Headclutchers

It was recently brought to my attention by Twitter user @sectioned_ that there is an alarming new breed of mental health sufferer called the Headclutcher. So prevalent are these people that the media have started to use them to illustrate nearly every story they run about mental health. As a way of documenting emerging cases I have started to upload them to this blog. Please get in touch (in the comments section) with any new examples and I will add them here. The disorder seems almost exclusively to effect women, so any cases recorded in men will be especially helpful. 

Is this lady distressed because of an undisclosed mental health problem or because she has been chosen to illustrate such a laughably dichotomous and poorly put together debate piece about mental health diagnosis?

This photo almost certainly does not actually depict the suicidal lady in this report who was told to have a cup of tea when she phoned an NHS helpline, unless perhaps she is holding the phone extremely close in order to hear the operator.

Like something out of The Ring, the pyjama'd child, who was used to illustrate this story on Mental Elf, is perhaps lamenting the fact that she is so small she can fit in the palm of an enormous hand.

The Mail reported that women experience 40% more mental health problems than men, and used this picture showing two women playing hide and seek to try and cheer themselves up.

The Guardian reported on the same study and used this photo of a 1960s Californian folk musician trying to compose a song about the issue.

This lady is trying to hide her identity so that we don't associate her with this sloppy comment piece in The Mail arguing for the societal exclusion of mental health patients, under the false premise of "breaking the taboo".

The BBC was lucky to find this lady who was willing to pose for a photo and was just as dismayed about the publication of DSM-5 as Peter Kinderman in his piece on their website.

This lady's headclutching began, if The Guardian is to be believed, when the DSM-5 was published. The disorder has not yet advanced to clutching with the second hand, so there is still hope for her.

Twitter user @suzyg001 alerted me to the fact that, what with this example from The Guardian and the lady at the top of my post: "Deep ribbing on the sleeves of one's jumper appears to be associated with this condition"

This example from a therapy website would seem to offer confirmation of the link.

Yet more evidence of the ribbed-jumper-headclutching link, courtesy of @chasingdata, who found this article on The Daily Mail. Of course this looks like headclutching, but given this lady's attire it may well be a dance or yoga position. She may also be dismayed that The Mail has only now cottoned on to the over-30 year old change from "Manic Depression" to "Bipolar Disorder".

Rare Male Headclutchers:

Thanks to @Sectioned_ we have documentary evidence of a male headclutcher! However, this poor chap only seems to have been used by the BBC because he illustrates the fact that men were more likely than women to kill themselves in 2011:

Stories about students are often an excuse for a picture of a female undergraduate, so hats off to The Guardian for using this guy to illustrate a story about mental health in universities. He is sad because his headclutching renders him unable to pick up any of the books surrounding him:

Is this gentleman clutching his head because his cup of tea has gone cold, or because he's perversely dismayed that a law has been passed to tackle mental health discrimination?

And Finally:

There is new hope for the treatment of Headclutchers, documented in this photo used by The Guardian, which appears to show a sufferer with her hands successfully restrained just behind her head. Presumably they were tied there by the blurry young man now gazing so intently at her:

Letter

I have a letter in this month's Psychologist magazine, which you can read here. The letter is my response to the overly dichotomous debate in the Observer triggered a few weeks ago when the DCP issued their statement rejecting DSM.

What Does the Narrative Fallacy Mean for Psychological Formulation

As part of my training to be a clinical psychologist, I am learning to construct formulations. These are short causal stories about a person's life which help us to understand why they are experiencing the things that have pushed them to seek help. It is premised on the idea that our experiences make us who we are, and that exploring a person's history explains why they are suffering. In the words of one phrase doing the rounds at the moment we should ask "not what's wrong with you, but what's happened to you?" Formulation is a self-evidently important part of all psychotherapy (which after all, generally deals in how people's experience has taught them to be who they are), and it has a particularly political role at the moment, as it has recently been proposed as an alternative to diagnosis by the British Psychological Society's Division of Clinical Psychology.

However, formulation has a thorny epistemological problem to contend with. In his book on the importance of rare events, "The Black Swan" Nassim Nicholas Taleb discusses the "Narrative Fallacy". This is Taleb's name for the phenomenon whereby humans, myth-making creatures that we are, make erroneous stories up to explain the facts that we encounter in our lives. This is particularly important in the realm of investment, where a causal understanding of the fluctuations of markets can allow traders to reap gains and avoid losses. Indeed, it is on an investment news blog that I found this fantastic example.

Information in a formulation is assumed to be in some way causally relevant, connected to an individual's current suffering in an explanatory way. But when do we decide that such information is causally relevant and when it isn't, especially when considering the nature/nurture mush that remains so difficult to parse? We can say that some events can be said theoretically to have a causal role, but we also know people are differentially susceptible to the adversity that they experience. A great deal rides on this. A clinician might decide, for the sake of an obvious example, that a person's voices arise from a dissociative response to a trauma, but they may also be due to an organic psychosis caused by an underlying pathology like a brain tumour. The consequences of such mis-specification could be devastating.

Psychiatric history is full of problematic causal stories; in the 1950s and 60s it was common to blame Autism on "refrigerator mothers", which came to be seen as essentially placing blame on mothers for a disorder we now think of as substantially genetic.

All theories are narratives, and formulation as described by the BPS has some good theoretical safeguards, being described as "hypotheses to be tested" in the BPS practice guidelines. This quote also comes from those guidelines:

"It should be acknowledged that all human beings are meaning-makers who create narratives about their lives and difficulties. Formulations differ from this kind of explanation by being strongly rooted in psychological theory and evidence." (p.7)

However, formulation, as a touted alternative to diagnosis, is subject to the same potential for epistemic misuse as the alternative. It has often been said that diagnosis is "just a hypothesis", but the case against it rides, in part, on the fact that it is too often taken as "gospel" truth (the DSM is "psychiatry's bible" after all right?)

The promotion of formulation is a testament (another bible reference!) to the idea that a sequence of events at the psychological/social level should be given an important role in constructing an explanation. This factors in important information that has historically been overlooked by psychiatry. However, taken without the necessary skepticism, it runs the risk of disregarding the possible irrelevance of psychosocial factors relative to biological factors in any given case. If formulation is to work responsibly we should remain open to the possibility that some of the problems people have are caused by the elements less visible to the narrating eye.