New BPS Guidelines on Diagnostic Language are a Move Against Pluralism

(A commenter on this blog-see below- has pointed out that I did not include reference to the scope and purposes of the document I am writing about. To try and address their concerns I have edited the post, striking out some sentences and inserting a few new ones in blue.)

Something incomprehensible and unpleasant happens to a person. It behooves them to make sense of it. Into this vacuum of understanding steps language: an attempt to give form to an experience in a way that allows them to live with it.

The BPS's Division of Clinical Psychology has released new guidelines on the use of language in official documents which pertain to such circumstances.

Consisting of three principles (guiding on language to avoid and language to adopt)  It is a clear statement that illness-talk and disorder-talk are out:

Such guidance is on a clear continuum with other efforts to discard the language of disorder, and concerns the organisation has raised about the DSM, a manual which can itself be viewed as a hyper-regulatory set of guidelines about how to talk. 

I am all for questioning the language of the DSM. Naming people "disordered" or "ill" is often experienced by them as an insulting effacement of subjectivity. What is more, once illness-language gets into the pool of possible interpretations it seems to hand power to the only people with sufficient expertise to deal with illnesses, the healthcare professionals (who of course stand to gain from their status as knowers).

But there is calling into question and there is discouraging ruling out. The problem with an official language (the DSM is a dictionary rather than the "bible" it is often claimed to be) is that it sets up a seemingly "correct" and an "incorrect" way of talking. In some cases this is necessary (the much scorned "political correctness" is an appropriate effort to rule out ways of talking which offend minority groups in society), but there is always a trade off. The downside of being "PC" is that it can make people less considerate about their linguistic choices, while leaving them feeling righteous nonetheless. Think of the character Gareth in The Office, bemoaning the fact that his dad says "darkies, instead of coloureds"

This is one way in which the new BPS guidelines look to me like a misstep. Moving from "mental illness" to "mental distress" is superficial in itself. Language surely interacts with habits of thought, but a guideline like this just replaces one jargon with another.

The Turn Against Pluralism:

If this were my only complaint then I would lump it. We should be careful about language, and sometimes guidelines are the only way to do that. But the language of mental health is different from the language of race. There are racial terms so bound up with hate that officially discarding them is the only sensible choice. The same is not true of "illness", "OCD" and "Anxiety Disorder". 

We don't yet have the definitive account of who is and and who is not ill (defining illness turns out to be a dreadful philosophical tangle) so for all practical purposes there is no fact of the matter. One way of dealing with this uncertainty is to adopt a form of pluralism which allows for multiple frameworks for understanding. 

Some people see themselves as ill, others don't. Some people think of themselves as ill because they feel themselves to be ill. While not unproblematic, pluralism puts a person's experience at centre stage, affirming their chosen framework as a way to make sense of them. This is a principle I thought I saw affirmed in the "Understanding Psychosis" document released last November:

Plenty of first person accounts attest to the value of "illness-talk" (some of them in Understanding Psychosis itself), but the BPS has just discounted those experiences in a stroke. The approach adopted in the new guidelines is a solution that DSM-detractors have been descrying for decades. Rather than expand the repertoire of explanatory terms, this document shrinks it. Some language is good, some bad; some frameworks more correct than others. This works for people who are served by the new official language (those for whom "mental distress" is personal preference), but it alienates anyone who falls outside the charmed circle. Given how strongly the BPS has opposed the regulating languages of official psychiatry, I am astonished they have chosen this route. 

Election 2015: Those Pathetically Vague Mental Health Pledges in Full

I'm working on a longer post about the manifesto pledges that have been made on mental health. Manifestos are supposed to help people decide which party to vote for on the basis of concrete promises for which they could later be held to account. As I read through the different parties' mental health pledges I noticed that many of them were so vague as to amount to no promise at all. In this post I bring you the crappest and most hopeless mental health election pledges of 2015.

Conservative:

How's this for conjuring an empty promise out of thin air and giving it the veneer of credibility despite the total absence of any concrete objective? The Tories seem to suggest that there are not already therapists in "every part of the country", but this seems like a hard claim to defend. Do they mean in every town, in every borough, in every post code? Exactly which parts of the country have no therapists, and when can this promise be judged to have been fulfilled? The Tories here acknowledge that there could be more therapists, but without saying what they are committing themselves to precisely zero action on changing the status quo. Crafty!

Green

Perhaps because they have the least to lose (no-one anticipates a Green led government after May, sorry!) the Greens actually have the most concrete list of promises on offer. However, this one stood out. Which party is not going to "invest in dementia services", and in what sense will the Greens' offerings be different than anyone else's in terms of "support"?

Labour:

Let's get this clear, you're going to "encourage" social and emotional skills. How will you "encourage" them exactly? Billboards? A daily radio broadcast? This is a sentence comprised almost entirely of rather zeitgeisty hot-air with "mindfulness"crowbarred in as a very tokenistic buzzword.

Liberal Democrat:

The Liberal Democrats are going to get kudos for developing probably the most detailed plans on mental health (though it's a close race between them and the Greens), but this bullet point struck me as a little weird. First there is this idea of a "clear approach" which, in the absence of detail is actually anything but. Second, there is the notion of the well being equivalent of the "Five a Day" campaign. I have no idea what it is that one should do to improve mental resilience that is "the equivalent" of eating five pieces of fruit or veg. The Liberal Democrats clearly don't either. 

Another strikingly vague promise from the Lib Dems here. I can't argue with the sentiment , but neither can I tell you what it really means

UKIP:

UKIP win the competition for the greatest number of half arsed bullshit empty pledges.

What would the mental health world do without UKIP? In these two promises they affirm that people should be directed to mental health professionals "when appropriate" (begging the more interesting question of when UKIP feel it actually is appropriate) and that there is "often a link" between addiction and mental illness. Excuse me while I completely reconfigure everything I thought I knew about psychiatry! Why offer a specific policy formulation when you can have the half-baked wittering of some bloke in a pub?

Here's another half arsed thought:

Gee...thanks guys. UKIP seem to have heard of stigma but, unclear exactly what it means, they offer some vague handwaving around the issue, assuming apparently that it mainly has to do with not having a job. Feeble.

Book Review: A Prescription For Psychiatry

This month I have a review of Peter Kinderman's "A Prescription for Psychiatry" in the BJP. This post is a more extended version of the text published there.

      "Is the problem you're allergic

       To a well familiar name?
       Do you have a problem with this one
       If the results are the same?"

           -The White Stripes:

Girl You Have No Faith in Medicine

Battle-fatigued psychiatrists could be forgiven for wanting to steer clear of what looks like another attack on their profession. More waggish readers may wonder about responding with their own “formulation for clinical psychology”, and then there is the combative note. Does not the title seem to indicate a barely concealed desire to give psychiatrists a taste of their "own medicine"?

However, such aversion would be a tremendous shame, for while there is some familiar ground trodden here, there is also much that is new, positive, and well worth some serious thought. There is also an idea that is more audacious and direct than usually be found in books about psychiatry.

The book is made up of nine chapters, the first three of which occupy just over half the space. In this first half, more than in the second, there is a focus on criticism. The “disease model”, the use of diagnosis, and the role of medication are all subjected to scrutiny. Some of this ground is wearyingly familiar. On the subject of illness as opposed to “psychosocial problem”, we must ask whether Kinderman is giving full due to all the available evidence. The roles of trauma and of life events in schizophrenia are offered to raise our credence that this problem is best considered a psychological reaction. A major alternative theory, that some manifestations of this behavioural presentation may best be considered a developmental disorder, (after all, not everyone who meets the DSM criteria will have been abused or suffered other traumas) is not even mentioned, let alone appraised.

On diagnosis: It is quite right that psychiatry should face the shameful aspects of its history. The tremendous psychic damage wrought by pathologising homosexuality for decades, and the odious debacle of draetopmania are not to be lightly dismissed. However, given the intentions of the present book, Kinderman might have done more to explain why these despicable examples have a substantive bearing on the question of modern diagnostic practice in general. The DSM is a problematic and contested document, but while we should feel queasy about its politics and many of its categories (“Oppositional Defiant Disorder” gets a justified grilling), even the most sceptical clinician cannot shy away from asking whether we can as easily dissolve those two major categories “Schizophrenia” and “Bipolar Disorder”.

A superficially appealing argument raised here is that "abnormal psychology" is an unreasonable field of study; after all, we don't speak of "abnormal physics". There is an important idea here with which I find myself aligned. Using the word "abnormal" is indeed a needlessly unpleasant way of speaking about people, but the physics analogy doesn't fly. All physical phenomena are subject to the same basic laws (as far as we know), but that hasn't prevented the fruitful subdivision of their study into solid state physics, condensed matter physics, and so forth. When people have experiences of psychological distress, these tend to manifest in a propensity toward particular states of mind. Is it really so unreasonable to study these states in their specificity, cautiously categorising them until some better framework is offered?

Kinderman favours a dimensional approach to mental distress, and a recent international survey of psychiatric attitudes (Reed et al, 2011) suggest that close to half of psychiatrists could feel the same way. A more significant question is whether this is really inconsistent with a system of classification; unless mental health problems could somehow be incorporated on the same single dimension (as opposed to a psychotic spectrum, an affective spectrum etc.), there is no reason it should be.

The book is, in my relatively ill-informed view, sensibly skeptical on medication, suggesting (via Joanna Moncrieff) the adoption of a “drug centred” model, with prescription based on anticipated effects of a compound rather than the anticipated imbalances caused by a disease. Such caution seems laudatory, though there is an interesting debate about how to judge the risks and benefits of specific medications, and Kinderman prefers to leave this in the hands of others.

Those readers who get beyond the first half will find themselves on more interesting territory. Books that criticise psychiatry are common enough, but a considered and viable set of suggestions for improvement of the mental health system is much harder to come by. A number of the issues Kinderman raises are very important, and the book is good on linking its own position to the debates that are taking place within the profession of psychiatry itself. What is more, many of the suggestions made in the last six chapters are not dependent on his having won over the reader in the first three. Alzheimer’s is a brain disease, but that shouldn't rule out the provision of psychosocially oriented residential care for sufferers. Down’s Syndrome is a genetic disorder, but it would be extremely myopic not to provide care and support of an imaginative and holistic nature for this population.

Thus, regardless of his audience’s prior commitments on the nature of mental health problems, Kinderman is going to find much more agreement on the broad thrust of chapters 4 to 9. Many of these questions go well beyond a simple question of which profession is dominant and which intervention is the “correct” one. He is quite right to advocate a holistic approach to wellbeing, and his proposal for comfortable, decent residential care (“a place of safety”) over psychiatric hospital wards should be a public health priority. These latter can be traumatising and chaotic (not to mention expensive) places, and the “medical” context can place unnecessary limits on the nature of the care that is provided. Under Kinderman’s model, a new generation of local authority funded homes would provide safe, calm places for “respite” rather than “cure”. A suggestion that mental health nurses be renamed “psychosocial therapists” (on the grounds that “nurse” is overly medical) seems, to my mind, unnecessary given that the verb to nurse has thoroughly humanistic connotations.

Hanging over all this is the audacious idea referred to above. In "Our Necessary Shadow", Tom Burns doubted psychiatry would even exist without Schizophrenia and Bipolar Disorder. Kinderman's most radical conclusion pushes that logic to it's ultimate conclusion. In a chapter on promoting health, he suggests that psychiatrists add little value to mental health beyond a general medical consulting role. In his breathless (and well thought out) penultimate chapter he even insinuates that we could save considerable expenditure if our mental health system did without them altogether.

While it has often occurred to me that other professionals could perform many of the legal and leadership roles currently undertaken by psychiatrists, to argue they are entirely redundant relies on the acceptance of a conclusion that Kinderman has already taken for granted. Namely, that the field currently denoted by those two headline diagnoses is one devoid of anything resembling an illness or disorder. I am considerably more agnostic than Kinderman on this score, so while I have to credit him for such an invigorating interrogation of the “value added” of psychiatrists, I don’t think the argument has been won. Further, even if you do accept such a premise, the expertise required to distinguish "organic" psychiatric presentations from "functional" ones (yes this is something like a dualism, but it's really just a loose way of talking: think of the distinction between a drug induced psychosis and a psychosis whose causal factors are more diffuse) is not something psychologists are trained to develop.

This is a rip-roaring book; readable and broadly constructive. Like the broader debate of which it is a part, it succeeds where it is most surprising and lets down where it is most predictable.