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.