No the DSM is not like Astrology

I am genuinely ambivalent about the broad line of arguments we can call "the case against the DSM". I don't mean ambivalent in the modern sense ("a bit confused and unsure what to think"), I mean ambivalent in the classic psychoanalytic sense; harbouring strong feelings in both directions. On the one hand there is the interesting and essential level of critique which brings to our attention the experience of feeling labelled and the unsettling bureaucratisation of medical terminology. This line of argument I feel very positive about and engaged with. On the other there is the ever resounding echo chamber of over-confident assertions about the malign intentions of the APA and the total unusability of the DSM for research or clinical purposes. One recurring theme in the latter category is the quip that the DSM is no better than astrology. It appears in this (otherwise excellent) piece by Edward Shorter, in this interview with Richard Bentall, and in many other places besides.

DSM diagnoses would be just like the signs of the zodiac 

if  it weren't for the fact they're very different in many ways.

In the Bentall profile, the New Scientist interviewer opens by asking if comparing the DSM with astrology isn't "a bit strong". "No" says Bentall. I happen to agree with him, but not with the reasons he gives. Comparing the DSM with astrology isn't "a bit strong" (criticism of something you dislike should be strong) it's wildly off the mark. Why? Well although you can derive some superficial comparison between the categories of the DSM and the signs of the zodiac (both describe classes of people; both aspire to some degree of reliable prediction) there are also clear differences.

The most obvious and important difference is the way the way the categories are derived and assigned. The signs of the zodiac are assigned to people on the basis of their date of birth and based upon the idea that these dates are linked to personality characteristics in a meaningful way. Meanwhile DSM diagnoses are applied on the basis of set of criteria describing patterns of behaviour. Someone designated as having, say, OCD, can be expected to resemble a particular broad set of clearly defined features. However a Libra is not just someone who is "on an even keel" (which may way not be an unreasonable classification in itself) but someone who was born between the 22nd September and 23rd October and is regarded as "on an even keel" in virtue of this fact. In short, astrology makes a needless jump--the linking of birth dates and personality traits--that the DSM doesn't.

Why does this matter? It's not as though it puts the DSM above criticism after all. My answer is that the debate about mental health and diagnosis is very important, but if we want a serious discussion about DSM's flaws we need to accord some respect to considerations of plausibility. You can hate the very guts of the manual and its creators and still martial the strongest possible case against it. If you spin off into crowd-pleasing claims and ignore reality people will stop listening.

Aberrant Salience and a New Meaning of "Lynchian"

Fans of the director David Lynch have a clear sense of what it means for something to be "Lynchian", but if we are pushed to put into words what this adjective captures we confront an extremely difficult task. Urban Dictionary gives us this: "having the same balance between the macabre and the mundane found in the works of filmmaker David Lynch." but that definition seems almost circular. Lynch isn't the only person to balance the macabre and the mundane (see also the ubiquitous slasher films of the late 70s and 80s) and we are left with a sense that the word just means "Lynch-like". David Foster Wallace had a go at a definition in the essay here, but was still forced to admit that it is "ultimately definable only ostensively – i.e., we know it when we see it."

There is something that unites all Lynch films for me, and that is the sense that one is being invited to take as significant and sinister various encounters in the plot which turn out to have no ultimate explanation or meaning. I have been struck how this reminds me of the Aberrant Salience account of psychosis. The aberrant salience theory arose out of a brilliant review by Shitij Kapur positing that the mesolimbic dopamine system regulates the salience of elements of our environment, and that it is this process which becomes dysregulated in psychosis and gives rise to phenomena like delusions. When faced with a feeling that something is inexplicably salient or significant humans, story telling creatures that we are, cook up a story to account for the feeling. Part of the beauty of the theory is the way it offers a means for thinking about the interaction between the biological and the psychological. Kapur's language also makes the idea wonderfully intuitive:

By Kapur's account, a dysregulated dopamine system is "the wind of the psychotic fire" and helps us to understand how people can get wrapped up in terrifying implausible stories, but what does any of this have to do with David Lynch? 

Lynch's films, by my account, do a similar thing with our tendency to tell ourselves explanatory stories. Lynch can't dysregulate your dopamine system for you (that's a bit too "This is Your Brain on Cinema" for me), but what he can do is obey nearly all of the conventions of straightforward story telling while artfully ignoring others. Thus we have a series of wonderfully opaque and seemingly significant moments throughout Lynch's oeuvre. Each one seems to add something highly meaningful to the plot, but we can't be sure what. Who is the Cowboy who appears to Adam Kesher (Justin Theroux) in Mulholland Drive to tell him how to cast his film? We don't know, but the exchange has all the hallmarks of a plot-changing moment and we wait eagerly to find out what sinister forces lie behind this sinister man's authority: 

Mulholland Drive's Cowboy: A Vagueness we Are Forced to Explain

What we are doing here, filling in a story in the absence of being let in on its details, bears a striking similarity to what Kapur describes in the formation of a delusion. Something salient has happened and our minds go into overdrive to impose meaning on it. Something similar takes place when Betty and Rita visit Club Silencio and are moved to uncontrollable sobbing as they watch the singer's rendition of Llorando:

Club Silencio

The sense of significance is reinforced by the appearance in Betty's hands of a locked blue box, which appears to be a key clue for understanding the entire film. Unfortunately, no clear resolution exists, and we are left with a plurality of efforts to untangle the multi-layered plot. Film critics have tried but can't agree, and the Internet is home to an endless quantity of logorrheic accounts cooked up by obsessive fans. 

Mulholland Drive is just one example of the way an entire Lynch plot can feel like it hangs on a meaningless symbol. Apparent clues abound in nearly everything Lynch makes. In Twin Peaks, agent Dale Cooper solves the mystery of the death of Laura Palmer after a dream in which he is told "that gum you like is going to come back in style":

The Red Room

Has he solved the crime, or is he just subject to the feeling that something highly significant has happened? What about the severed ear on the lawn which opens Blue Velvet? To the viewer here is a moment that seems so macabre that it must explain something. Whose ear is it? Why was it cut off and by whom? The human tendency to paranoia goes into overdrive and is never resolved.

Blue Velvet's Ear on a lawn: The Macabre and the Banal in spades

Lynch's last film, Inland Empire, consisted almost entirely of such floating signifiers; bedside lamps and bizarre unconnected characters; extended sequences with rabbits talking gibberish. As Laura Dern navigates this confusing world she finds herself outside Room 47, which seems (from the horrified look on her face and the lingering camera work) like it must be a scene of some highly significant event. 

Inland Empire: One Long Paranoid Detour

But like the rest of the film, there is little in the way straightforward resolution to this encounter. Something profoundly creepy happens right afterwards (I'll let you find the clip on YouTube if you're curious) but with no explanation as to why. In many ways Inland Empire was the logical end point of Lynchian cinema. Over the last few films he had eroded the coherence of his plots and emphasised the apparent meaningfulness of moments, symbols and exchanges. The two most recent films especially look like an exercise in discovering how much you can ask the viewer to fill in for themselves. Because of the reliable beauty of Lynch's imagery, and his mastery with creating salient episodes, we go along with him. The resulting experience is an exquisite paranoia, more chilling and rich than almost any other thriller. 

Useful Guides Which Limit our Thinking

This quote is a follow on from this previous post. I came across it while reading Heinz Kohut and Ernest Wolf on Self Psychology. Like the earlier Freud quote, it has relevance to the modern debate on psychiatric diagnosis:

"The best efforts of the past [...] are no exception to the rule that the simplified correlation of specific patterns of manifest behaviour with universally present psychological conditions which of necessity forms part of any such typology will, in the long run, impede scientific progress. Why then, do we persist in the attempt to devise characterologies? The answer is that such classifications, even though we must be aware of the fact that they may eventually limit our thinking and stand in our way, can for a while be valuable guides in psychological territory in which we feel not yet at home."

 Kohut, H., Wolf, E.S. (1978). The Disorders of the Self and their Treatment: An Outline. Int. J. Psycho-Anal., 59:413-425.

6 Effective Ways to Avoid Engaging With Quantitative Data in Mental Health

1. Imply that Quantitative Data is Inherently Flawed:

One of the most effective ways to undermine anyone trying to appeal to principles of empirical research is to remind them and everyone else that the whole project of obtaining supposedly "objective" data is doomed to begin with. We all know that all research in psychiatry is hopelessly biased by its connections to Big Pharma, so be sure to muddy the waters and block further discussion by asking profound sounding rhetorical questions like "what research? conducted by whom?" Ignore the fact that questions about prospective bias, methodology and misuse of statistics are already central to the effective interpretation of any research and that some of the most effective ways to guard against them are statistical procedures.

If you don't feel that accusations of an inevitable and pervasive bias are a strong enough slur against the principle of empirical data collection, be sure to make bold assertions to the effect that the whole principle of obtaining quantitative data on people is an act of "violence" on the holistic truth about humanity.

2. Remember that a Focus on Subjective Experience is the Only Worthwhile source of Knowledge:

Researchers are supposed to be interested in experience right? So why are they all faffing around with experiments and longitudinal surveys? There are plenty of people around who have actually had experiences and their testimonies should be entirely sufficient. Be sure to remind researchers of this whenever they suggest the spurious use of numbers to try and figure things out.  You are more than just a number!

3. Remind People that You Aren't Interested in the Entity Being Studied:

"Not everything that counts can be counted, and not everything that can be counted counts" Einstein said that didn't he? Or was it Eleanor Roosevelt, or Winston Churchill? It doesn't matter, the principle is sound. Maybe researchers want to pigeonhole people into entirely irrelevant categories and measure things about them, but why should the rest of us give a stuff? They say that they are interested in learning about groups of people who meet a set of agreed upon characteristics, but it is pretty clear this is just a front for the propagation of a sinister medical model. Further proof of this can be seen in the fact that almost no researchers ever mention a strict biological conception of mental illness; they're keeping it under wraps!

4. Accuse Anyone Deploying Empirical Reasoning Of "Scientism":

This one is particularly effective because very few people actually know what it means. Sciencey people all hate religion don't they; so if you accuse them of an irrational faith in the power of science you can win any debate while simultaneously getting on their nerves. Ignore the fact that a belief in the use of the best available empirical evidence is not even close to being scientism proper, anyone who dabbles in science is unlikely to have retained their common sense and will almost certainly be out of touch with reality. If someone has used "Schizophrenia" or "Bipolar Disorder" in their work then they plainly believe these entities to be illnesses just like Hepatitis or diabetes and certainly don't have any curiosity regarding their ontological status. They are no better than mystics or astrologers, and anything they say can be dismissed.

5. Remind People of the Nazis:

Scientists always drift back towards biology and genetics, they can't help themselves. Even if they are only suggesting that genetics and constitutional physiology account for a relatively small proportion of variance in any given problem, there is no telling how long it will take before they drift towards a policy of eugenics and ethnic cleansing. You are only ever doing anyone a favour by reminding them of phrenology, eugenics and--ideally--the Nazis before they walk foolishly out onto this slippery slope.

6. ...Continue to draw on Data when it Suits You:

None of this should leave you feeling that you can't preface your own views with comments to the effect that "it has been shown..." or "data proves..." In fact, now that you have an arsenal of tools to discount any research that doesn't back up your own case, you are free to deploy research of any quality; it cannot be countered by anyone else's!

At the Limits of Meaning

Here's a neat irony: so often is it said that psychiatric problems are"meaningful" that the statement itself is starting to sound rather meaningless. Used as a rallying cry to focus attention on the content of people's experience rather than viewing its form as a kind of pathology, the "distress is meaningful" idea has become diluted and distorted through careless use. This is a shame as, like most ideas in "critical" psychology and psychiatry, it has a worthwhile core which it is worth staying in contact with.

"Man's Search For Meaning":

Pareidolia: Making Meaning Where None Exists

To say "distress has meaning" can mean the tendency we have to imbue our health problems, like anything we experience, with special significance and form associations to them. In this sense even the most random or the most biologically determined forms of health-problem have "meaning". It is very meaningful to me that I am starting to notice the slow and inevtiable movement of my hairline towards my crown, but this doesn't mean I can halt it by "making sense" of it. More seriously, it is extremely meaningful when people with Alzheimer's start to lose their memory as a result of cortical atrophy, but this is because our grasp on our minds is very significant; it does not mean they are, say, trying to repress something.

The existence of this general sort of meaning making about our lives is uncontroversial and only a rather perverse and callous person would deny it. There is, however, another sense in which distress has been taken to "mean" something, and its conflation with the weaker form above has generated some confusion.

Symptoms as Messages:

Freud was prompted to develop the technique of Psychoanalysis when it began to seem to him that the symptoms of his patients weren't just manifestations of some physical problem ("degeneracy") but were a sort of communication about the contents of their minds.

Conversion Hysteria: Meaning's Search for Expression

Freud and Breuer had noticed that when they encouraged their patients to speak freely--and without the sorts of prohibitions that teenage Viennese girls were normally subject to--their symptoms cleared up (we'll leave for now the question of whether this really took place, and for the reasons they claimed). This led them to conclude that, in some circumstances, the body itself became a channel for communicating the sorts of emotions we normally communicate in speech. Although initially of interest in the case of "conversion hysteria" (a category which has fallen into relative disuse) Freud extended the principle to obsessional behaviour (where obsessions divert the energy created by resisting expressions of desire) and hallucinations (which acted to fulfill a resisted desire).

One result of the Freudian meaning of "meaningful" was that by the middle of the 20th Century, and especially in America, psychoanalysts came to be seen as a cabal of expert decoders, essential to tell us the real underlying meaning of our actions. With the decline of the dominance of this framework there has arisen a new skepticism about what our bodies and minds can ever be said to be telling us about our lives.

Nonetheless this meaning of "meaningful" has its modern counterpart in claims that (for instance) the voices heard in psychosis are expressions of emotions which the hearer has not yet dealt with; that bouts of intense paranoia reflect a feeling of danger which has its root in early experiences. I don't want to deny or defend these claims here, they appear to have their use in some situations and not necessarily in others. Instead, I want to draw attention to the fact that they form a stronger assertion than the more banal observation that everything means something to someone, and that these two can come to be thoughtlessly merged.

Psychoanalysts: The great decoders 

Why does this matter? The weak claim (that everyone's experiences come to have meaning) and the strong claim (that the meanings are central to the phenomena, which can be healed by the right kind of understanding) have different implications for treatment, but to carelessly fudge them allows us to overlook this. If you assert the weak form then you are simply saying we should pay attention to the meaning of people's distress and try to engage with the reasons for it. If you assert the strong form then you are claiming that the right sort of interpretation can essentially dissolve certain forms of distress. This belief can be expected to lead to an anti-medication ethic as people come to see the effects of medication as a violent denial of meaning. Such a belief (which virtually amounts to a superstition) should be kept separate from the very real problem of people being unnecessarily over-medicated and it should also be kept separate from the obvious fact that talking to people about what things mean to them is a kind and helpful thing to do.

Unless we are a bit more rigourous about this separation, it is unclear whether we are saying healthcare professionals should engage with the meaning of people's suffering or whether we are saying that healthcare professionals have a special access to its interpretation. The latter is a rather arrogant claim, promoting dependency on special interpreters with defintive answers, but it can be smuggled in alongside the more benevolent position if we don't look out.

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.