Wednesday, May 22, 2013

UK Clinical Psychologists Call for the Abandonment of Psychiatric Diagnosis and the ‘Disease’ Model

This brief article comes from MadInAmerica, a great blog/site that offers counter-truth to the mainstream beliefs about mental illness and medicating mental illness. The article errs a bit in citing NIMH Director Thomas Insel's comment: ‘Patients…deserve better’ - Insel is completely on-board with the biomedical model, which is why he is rejecting the DSM-5. For Insel, the DSM-5 does not go far enough in making all mental health issues "brain-based." In fairness, Johnstone recognizes this a little later in the piece.

Some of the backlash against the BPS statement claims that they reject any biological components. But this is inaccurate - they simply recognize biological markers as one component of an often complicated etiology for mental illness.

For me, the biggest issue with the biological model is that they are looking at people with mental illness and identifying differences in their brains from those who do not have similar symptoms. The question is not in the differences, it's in the etiology. Researchers such as Allan Schore have written extensively on how developmental issues wire the brain in different ways. Schore's model combines insights from neuroscience, attachment theory, and psychodynamic processes into a more comprehensive etiology.

Likewise, Daniel Siegel and others have shown that the brain can be rewired - faulty attachment can be repaired through a healthy relationship with another person (sometimes, but not always, a therapist), and that we can do a great deal on our own to rewire the brain (neuroplasticity is the foundation of these models) through practices such as meditation, mindfulness, and active imagination.

UK Clinical Psychologists Call for the Abandonment of Psychiatric Diagnosis and the ‘Disease’ Model

Lucy Johnstone
May 13, 2013

In a bold and unprecedented move for any professional body, the UK Division of Clinical Psychology, a sub-division of the British Psychological Society, issued a Position Statement today calling for the end of the unevidenced biomedical model implied by psychiatric diagnosis. The key message of the statement is:
“The DCP is of the view that it is timely and appropriate to affirm publicly that the current classification system as outlined in DSM and ICD, in respect of the functional psychiatric diagnoses, has significant conceptual and empirical limitations. Consequently, there is a need for a paradigm shift in relation to the experiences that these diagnoses refer to, towards a conceptual system not based on a ‘disease’ model.”
In brief, the argument is that the so-called ‘functional’ diagnoses – schizophrenia, bipolar disorder, personality disorder, ADHD and so on – are not scientifically valid categories and are often damaging in practice. The statement argues that we already have alternatives, such as psychological formulation, and that there is a need to work in partnership with service users and professional groups, including psychiatrists, in order to develop these further.

The story made the front page of one of the UK’s best-known broadsheets, the Observer, sister paper to the Guardian, and there was a double-page spread inside (“Medicine’s big new battleground: does mental illness really exist?“, and “Psychiatrists under fire in mental health battle“). Within hours, over 500 comments (and counting) had been posted online, and the articles were being re-tweeted round the world. The articles quoted me, Professor Mary Boyle (author of ‘Schizophrenia: a Scientific Delusion?’) Eleanor Longden, researcher, campaigner and survivor, and Oliver James, psychologist and journalist, in support of the call for a non-medical approach to mental distress.

Needless to say, there has been as much backlash as appreciation. Perhaps most predictably, Allen Frances, outspoken opponent of DSM-5, described the document (without having read it) as ‘extremist posturing by British Psychological Society, just as silly as DSM-5 and NIMH – why not a balanced biopsychosocial model’ (@AllenFrancesMD 12.5.13.) Many took advantage of a somewhat unhelpful online headline to dismiss the debate as inter-professional ‘turf wars’, while others accused the DCP of ignoring the role of biology.

The actual statement makes it absolutely clear that these are misrepresentations. The DCP specifically states that ‘This position should not be read as a denial of the role of biology in mediating and enabling all forms of human experience, behaviour and distress.’ The statement also explicitly says that the argument is about ways of thinking, not about particular professions. The ‘turf wars’ accusation is particularly wide of the mark given that the DCP statement is simply a more measured reiteration of recent comments by some of the world’s most eminent psychiatrists: Allen Frances himself described DSM-5 as ‘deeply flawed and scientifically unsound’, while Dr Thomas Insel, NIMH director, said ‘Patients…deserve better’. Former NIMH director Dr Steven Hyman, was even blunter: he called DSM-5 ‘totally wrong, an absolute scientific nightmare’ and in response, the Chair of the DSM-5 committee, Dr David Kupfer, admitted “We’ve been telling patients for several decades that we are waiting for biomarkers. We’re still waiting.”

The main difference – and of course it is a crucial one – between the position of these eminent psychiatrists and the DCP is that the former are determined to pursue the biomedical model at all costs. Indeed, NIMH has (as discussed on this site) announced the intention of launching a 10-year programme to pin down, once and for all, the elusive biomarkers that have evaded researchers so far. The project starts from the remarkably unscientific position of assuming what needs to be proved: in their words that ‘mental disorders are biological disorders.’ Flawed as this enterprise is, it will allow traditionalists to continue to claim that ‘We’re getting there – honestly!’ In the meantime, the overwhelming amount of evidence for psychosocial causal factors is once again relegated to a back seat.

I was a member of the DCP working party which took 2 years to arrive, painstakingly and carefully, to this consensus statement. I believe there is nothing more important that a professional body can do than speak the truth about the evidence – and that is what this statement does. Nevertheless, given the nature of the issues, it is a brave move. I hope that other organisations will take heart – as they did from the original BPS response to the DSM-5 consultations in June 2011 – and join the DCP in calling for a more humane and evidence-based approach to mental distress.

Links to BPS consultation responses on DSM-5
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