Monday, 17 June 2013

Debating diagnosis and rethinking the way we teach about mental health

The recent publication of the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (or DSM5) has led to a fierce debate both in the academic literature and in the wider media about how best to conceptualise psychological distress.  For example, an article in the Observer about the recent BPS Division of Clinical Psychology’s position statement (which makes the case for a paradigm shift away from diagnosis) has already received over 1,000 comments from readers.  An ipetition about DSM5 has over 14,000 signatures. 

Whilst in some media outlets this debate is being seen as a turf war between psychologists and psychiatrists in fact many psychiatrists have problems with DSM5 too.  Indeed, one of the most prolific critics of DSM5 is Dr Allen Frances who led the task force which produced the previous edition of the DSM.  In the UK, the Critical Psychiatry Network (a grouping of psychiatrists critical of biomedical reductionism) recently published a statement critical of the DSM.

The problems with psychiatric diagnostic systems like the DSM were discussed in a series of open access articles in a special issue of the Psychologist which I co-edited with John Cromby (University of Loughborough) and Paula Reavey (London South Bank University) in 2007.  They are also summarised in a recent open access article in the journal Evidence-Based Mental Health (EBMH) by three professors of clinical psychology (Peter Kinderman, John Read and Richard Bentall) and psychiatrist and researcher Dr Joanna Moncrieff.  They note that “diagnostic systems in psychiatry have always been criticised for their poor reliability, validity, utility, epistemology and humanity”. 

Many people appear to think that problems with the reliability of psychiatric diagnosis lie in the past but a recent editorial in the American Journal of Psychiatry reporting the results of field trials of DSM5 criteria reveal they are not.  Of 20 adult disorders only three had kappa reliability values over 0.6 (even schizophrenia only had a kappa of 0.46).  Even worse, Allen Frances noted that the definition of acceptable reliability had been lowered:  “When DSM 5 failed to achieve acceptable reliability by historical standards, the DSM 5 leadership arbitrarily decided to move the goal posts in and lower the bar in defining what is 'acceptable'.”

Given the longstanding problems with psychiatric diagnostic systems it is surprising that the contents of most psychology textbooks on mental health (also titled ‘abnormal psychology’, ‘clinical psychology’ or ‘psychopathology’) are almost entirely structured by classificatory frameworks like the DSM – a point noted recently by psychologist and broadcaster Claudia Hammond on BBC Radio 4’s All in the Mind in an interview with psychiatrist Simon Wessely about DSM5.  It is quite unusual within psychology for its approach to a phenomenon to be predetermined by another discipline’s framework.  Usually, in psychology, phenomena are operationally defined and understood using psychological theory.  Indeed, Kinderman et al note that this approach can be adopted in mental health too:  it is relatively straightforward to generate a simple list of problems that can be reliably and validly defined; for example, depressed mood, auditory hallucinations and intrusive thoughts. There is no reason to assume that these phenomena cluster into discrete categories or other simple taxonomic structure”

In a survey of psychology mental health modules in the UK a few years back John Cromby, Paula Reavey and I discovered that current teaching about mental health in the psychology undergraduate curriculum was a little dated.  For example, critiques of diagnosis tended to refer only to critics from the 1960s like Laing and Szasz rather than the more modern critiques noted above.  Moreover, teachers wished to have more involvement from clinical psychologists and other practitioners.  Perhaps because of this more recent developments within clinical psychology of psychotherapies for psychosis and alternatives to diagnosis like formulation do not seem to get as much coverage as they might in mental health modules on undergraduate psychology programmes.  The survey also found that although the mental health service user movement has become increasingly important in mental health practice, service users were barely involved with the teaching of students.

In an article in the Psychologist on the teaching of mental health to psychology undergraduates John, Paula, Anne Cooke, Jill Anderson and I questioned the tendency for psychology educators to “jump ship” by giving psychiatric rather than consistently psychological explanations of mental distress and we suggested there was a need to consider the implications of recent developments in psychological theory and practice.   This raises the question of how we might teach differently about mental health.

In a recently published textbook entitled Psychology, Mental Health & Distress, John, Paula and I plus a range of additional contributors argue that a truly psychological approach to distress should be experience-based rather than diagnostic category-based.  By this we mean to focus on broad commonalities in experience.  The book is in two parts.  The first part deals with a number of conceptual issues which are often skipped over in many textbooks but which are crucial if we are to think clearly about distress.  The second part deals with five broad forms of distress.

To understand why we have the ideas we do today it is vital to look at how those ideas were developed, so in our chapter on history in Part 1 we provide a survey of the different ways that distress has been understood and treated over the centuries. History shows how there have always been competing strands of explanation and treatment for distress, some primarily implicating the body and its organs and some primarily implicating experiences, meanings, thoughts and feelings. 

Our chapter on culture looks at how distress differs between societies. It discusses some of the great variability in the forms of distress, the variability in the ways that it gets linked to other aspects of experience, and the variability in the outcomes associated with it. As we have already suggested, distress is thoroughly bound up with culture and this chapter illustrates the extent and consequences of this.

Our approach to biology treats it as an essential part of distress, but does not make the unfounded psychiatric assumption that it is always the ultimate source of people’s difficulties. In the chapter on biology in part 1, we explain why there are problems with ‘biopsychosocial’ accounts of distress, and in their place offer an alternative view of the role of biology based upon biologist Steven Rose’s notion of lifelines. We then summarise evidence that supports this approach, drawing upon studies of attachment as well as upon recent work in psychology and neuroscience.

In the chapter on classification Lucy Johnstone examines how psychiatric diagnosis is both similar to, and different from, diagnosis in general medicine and she discusses how adequate formulation is as an alternative to psychiatric diagnosis.  The issue of causality is extremely important and we devote a whole chapter to it in Part 1, exploring not only how we might understand the ways that different causal influences upon distress interact with each other but also the extent to which research into the causes of distress is helpful to clinicians.  The next  chapter is written by leading British mental health survivors Peter Campbell, Jacqui Dillon and Eleanor Longden who describe what the service user/survivor movement is and why it is important including a discussion of the approach taken by the Hearing Voices Network.  The last chapter in Part 1 examines three main mental health interventions:  medication, psychological therapies and community psychology.  Many mental health textbooks adopt a somewhat uncritical approach to the use of psychiatric medication but this section, authored by psychiatrist and researcher Joanna Moncrieff gives a clear explanation of research on the efficacy of medication and argues for a more pragmatic approach to understanding its effects.  Paul Kelly and Paul Moloney discuss psychological therapies whilst Rae Cox, Guy Holmes, Paul Moloney, Paul Kelly, Penny Priest and Mike Ridley-Dash examine key issues associated with community psychology interventions.

In the second part of the book we focus in detail on five main forms of distress-related experience formulated in everyday language:  sadness and worry; sexuality and gender; madness (authored by John Read and Richard Bentall); distressing bodies and eating; and personality disorder.  We have structured these chapters into broad classes of forms of distress where there is a commonality in the underlying phenomenology of an experience.  Thus the chapter on sadness and worry deliberately treats together aspects (e.g. ‘anxiety’ and ‘depression’) that would usually be treated separately in other books, because of their DSM classification.  Similarly the chapter on madness includes elements that, in other texts, would be treated separately like ‘schizophrenia’ and ‘bipolar disorder’.  Although the number of different kinds of distress we discuss is smaller than other texts, on average these difficulties will account for the majority of the referrals received by mental health services.

Each of these chapters follows a similar structure, building on the insights of the first part of the book.  Given our wish to focus on experience, each chapter begins with a fictional case story describing key aspects of that particular form of distress.  Section headings in the chapters cover historical and cultural context; contemporary Western forms of distress (including prevalence and psychiatric diagnosis); causal processes  (social, psychological, biological and genetic) drawing on a lifelines approach; and the efficacy of a variety of mental health interventions including psychological therapies.  Personality disorder is a much contested category and it could be argued that many people receive this diagnosis not because of their distress but because of the reactions of others to their behaviour.  As a result a key question in this chapter is whether the notion of personality disorder is a helpful way of making sense of people’s difficulties in relating to others.

We see the book as an important step in teaching mental health differently but we appreciate that changing the content of teaching can feel challenging for many lecturers.  As a result, we aim to provide as much support as possible to lecturers wishing to take a different approach and, on the lecturer’s section of the publisher’s website for the book we’ve included an 18 page handbook answering key questions lecturers are likely to ask as well as powerpoint slides for each chapter.  The publisher’s website includes a range of other resources including a sample of the introductory chapter.

The debates about psychiatric diagnosis in the wake of the publication of DSM5 suggest this is a good time to rethink the way we teach about mental health.  Indeed, one enterprising teacher has even used the regular revision of the DSM as a way of imparting insights about the history of psychology.  Joshua Clegg (City University of New York) suggests that the revision process of DSM can be used in teaching to ‘demonstrate the evolving ways in which mental health and illness are conceptualized and can reveal the cultural, political, and economic forces that shape this process’.

David Harper

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