On a Certain Queasiness Regarding the Word "Diagnosis".

Once again I have started having Twitter conversations about psychiatric diagnosis. It is like Tetris used to feel. "This is fun...I need to stop...oh go on, just one more round."

I am thoroughly confused about people's feelings around diagnosis. The DSM is widely disliked and mistrusted, and for very good reasons, but that dislike and mistrust extends beyond the DSM itself, infecting words and concepts in the vicinity and undermining the foundations of our discussions. We are encouraged to think there is a fight going on, with "diagnosis" in one corner and "psychological understanding" in the other. In my head this all starts to unravel when the meaning of diagnosis is brought into play. A conversation begins with a call to abolish psychiatric diagnosis. Later in the same conversation it is said that the problem with the DSM is that its classifications are not sufficiently similar to a diagnosis. Confused? You ought to be.

Another brick in the wall...or another drop in the ocean?

Allow for sake of argument that our knowledge of psychological causes and processes is excellent, far better than it is now. Imagine when are confronted with an experience like paranoia or depression that we can take a life history and determine with a high degree of accuracy what are the importance of various factors in it's aetiology ("you started to feel different when you were bullied at school; it made you withdrawn and quiet. Later in life this changed how people responded to you and you began to feel they didn't like you either, making you feel more depressed and more anxious") With this superior knowledge might we not start to notice that people with different sorts of problem would respond differently to different sorts of help? What we would have would be a way of knowing the nature of aetiology, the processes it fed into and how they became the presentation we see before us. Would not such knowledge equate to a diagnosis (in any widely accepted sense of the term)? 

Now perhaps we would be reluctant to call it a diagnosis. "Diagnosis" we might reason "sounds too much like something a doctor does. We aren't doctors, we want to think of different ways of helping". This may or may not be a sensible decision to make, but that is beside the point, it is a decision, and an aesthetic one at that. If we don't like the word "diagnosis" then we don't like it. I don't like the word "treacle" but if someone shows me a jar of something sweet, brown and viscous, I may have to concede at least its accuracy. So too with diagnosis. There are many reasons to feel funny about the DSM, one of them is that it fails to do what a diagnosis ought to, but isn't it rather strange then to simultaneously abhor the DSM and to abhor the thing it is failing to be?

The Sacred Whole: More Than the Sum of its Parts?

We have so frequently have reason to talk about the "whole person" in psychotherapy, but what is this sort of talk aiming to achieve?

In clinical settings, the appeal to "the whole person" is most often an effort to remind us that the people we care for have dignity, agency and rights. We can easily think of situations in which the rights of people have been effaced in a bid to attack what were thought of as illnesses inside them; ice packs, insulin comas, lobotomies. All of these were attacks on a part of a person that failed to acknowledge their wholeness. This same effacement seems to have been part of what people were objecting to recently during the satire of the DefeatAutism Twitter hashtag. "By trying to defeat Autism",  people protested, "you are trying to defeat me".

For some people, psychologist Bruce Hood is an example, the very idea of a self is an illusion. I'm not that compelled by Hood's thesis, which doesn't touch on the broader metaphysical questions about the experiences that arise out of the psychological processes he describes. In any case, in the early part of his book he points out himself that just because something is an illusion, it doesn't follow that it is not having a powerful real effect. So much for a putative lack of self, we still have something like "selfi-ness", and that is what we usually take to be important.

Not that kind of selfi-ness

But if we people are whole in some way, we are also made up of parts, definable, measurable and manipulable. In many cases we have some sovereignty over our parts (I find I can often improve my mood by thinking about how wonderful my life is going to be when I finish my PhD) but this is not total. Our parts can impact us in surprising and stupid ways. Behavioural activation is an example of this stupid direction of causality. Simply getting up and doing something can, to a limited extent, have knock on effects for our global level of self esteem; a "part" intervention that has ramifications for the "whole".

The parts/wholes distinction is almost as old as clinical psychology (or possibly older), and as so often is the way, Paul Meehl has been there before. In his 1949 book Clinical vs. Statistical Prediction, Meehl anticipates the familiar argument that says that there is more to people than that which can be reduced to numbers:

“A cannon ball falling through the air is ‘more than’ the equation S= ½ g  , but this has not prevented the development of a rather satisfactory science of mechanics”.    

Meehl's point perhaps is that of course we should be interested in the "whole person", but that this does not preclude our being interested in measuring their parts. A caricature of quantitative psychotherapy research says that any interest in numbers or symptoms sees humans as "robots" or "microbes". This is no more the case for the psychotherapist than it is for the doctor who tries to impact someone's rich and complex life by monitoring simple changes in their temperature. 

Undeniably there is something crucial to what we call "bedside manner"; that form of empathy and consideration that keeps the patient's experience in view even while working on the problem they present with. There is equally a power to seeing the impact of changes at the "parts"-level. Have you ever noticed how a simple change in something that bypassed your complex engagement with your self (something as simple as having a glass of water when you were thirsty) seemed nonetheless to enhance the way you felt at a more profound level? This is the direction that "symptom reduction" tries to go in, reduce the amount of time someone spends feeling bad and you can have immeasurable and intangible effects on their self as well. 

People talk about psychotherapy research as though it should all have the descriptive quality of poetry or a novel. For sure, qualitative research and service user testimonials are an indispensable part of how we understand what is going on in the world, and when it comes to safeguarding people's dignity there is no substitute for individual narrative accounts. However, this approach (like all approaches) has its limits. The effort to "do justice" to people in all their complexity is not the only thing at stake in the effort to find out "what works" for them. Complicated creatures that we are, that complexity emerges from somewhere, and while we might feel like we are more than the sum of our parts, taking care of those parts can be surprisingly important. 

CBTp, Psychiatry and the "facts on the ground": Thoughts on the latest Maudsley Debate

Though it is rarely framed this way, the folk who critique CBT for psychosis and the folk who defend it have an important piece of common ground it seems worth talking about. Both are concerned about the way the “facts on the ground” can be at odds with an evidence base. 

"Facts on the ground” are what powerful people change without recourse to the necessary forms of law or reason. Putin changed the facts on the ground by annexing Crimea and stationing 10,000 troops on the border of Ukraine. This change was important precisely because the international community did not want to respond in kind; Putin changed the question from “how can we negotiate a diplomatic solution to Ukrainian unrest?” to “how can we negotiate a diplomatic solution to an invasion?” 

Vladmir Putin riding to a psychotherapy session.

“Facts on the ground” is usually a military term used to highlight a contrast with efforts at governance. In mental health, what actually happens to people are the facts on the ground, while the evidence base is our governance.

Those who propose (qua the Maudsley debate from 2nd April) that CBT for psychosis has been “oversold” see facts on the ground about CBTp that are at odds with the provision of evidence-based care. NICE (along with many mental health professionals) is promoting a therapy which, according to the highest quality available meta-analyses, appears to offer virtually no benefit.

Among those who opposed the motion, we hear much talk of the actually-existing alternatives; lifelong neuroleptic medications, forced restraint; traumatic and chaotic sectioning procedures. These too are facts on the ground, at odds not only with the evidence base (prescribing practices are frequently out of line with evidence) but with our sense of how it’s decent to treat people.

I have spent a lot of my career in mental health, some of it in a CBTp milieu, and I have come to feel wary of the team-affiliations and self-protection that allow for therapeutic orientations to flourish and self-promote un-troubled by the voice of skeptics from outside. Perhaps this constitutes its own form of bias (the zeal of the apostate?), but I can’t help but be persuaded by the meta-analyses that show CBTp to have miniscule treatment effects. I am also persuaded by my own experiences trying (often rather ineffectually it seemed to me) to change people’s thoughts about experiences which seemed to powerfully disruptive of their thinking. Show me anecdotally positive cases if you like, but if you follow the “I know someone who found it helped” research methodology, there is virtually no imaginable treatment that doesn’t make the grade.

Where do we go from here?

This seems to be where most discussions of this topic leave off, but that is a highly unsatisfactory state of affairs. There is only so much interest to be gleaned from me telling you that, as things stand, I see little that is active or helpful in CBTp. What role should psychology have in psychosis?

We hear so often that being detained, locked up, forcibly medicated and released with no aftercare is traumatic and unhelpful. This ought to come as no surprise. Some people see psychiatry and psychology as by their very nature set up to create this kind of experience. I am more optimistic. What both professions ought to have in spades is ideas about how they could be different, and the research understanding to discover how.

It is surely structural changes that hold the most hope. With imagination we can structure services so people are checked in on more often, professionals are better supported and transitions from the community to hospital can be calmer and better planned. The Open Dialogue approach, which seeks to involve entire families in the early stages of a psychotic crisis is one way to re-imagine the point of entry. It is getting a tentative start here in New York, and from what I understand it is principally concerned with giving genuine respite in a time of crisis and bolstering the support given to people going through crisis.

Such structural changes are promising even if you are agnostic about the nature of psychosis. “Brain disease” or “trauma reaction”; both sorts of problem should respond to well structured well integrated care. Whether we decide CBTp has been “oversold” or not seems less relevant than the question of whether we can do something better than what is currently available. You’d have to be quite a pessimist to think that the answer to that is no.