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Royal College of Psychiatrists: Abolish use of formal psychiatric diagnostic systems like ICD & DSM

Abolish use of formal psychiatric diagnostic systems like ICD & DSM

Psychiatric diagnoses are not valid.
Use of psychiatric diagnosis increases stigma.
Using psychiatric diagnosis does not aid treatment decisions.
Long term prognosis for mental health problems has got worse.
Psychiatric diagnosis imposes Western beliefs about mental distress on other cultures.
Alternative evidence based models for organizing effective mental health care are available.

 
To sign the petition please go to this link:

To read the full evidence based arguments view the ‘No More Psychiatric Labels’ paper at
http://www.criticalpsychiatry.net/?p=527 which is reproduced below:

Modern Western psychiatry has secured many important advances in the care of people with mental distress. We have a variety of pharmacotherapies that can help manage distressing symptoms alongside an even greater variety of psychotherapeutic approaches that help people in distress make sense of their experiences and find new ways to deal with them. The old asylums have been emptied and community care has developed a rich variety of services from early intervention to crisis management. Researchers have identified many biological and environmental factors associated with greater likelihood of having or developing mental health problems and so our understanding of mental distress has improved. Reflecting this, the academic community, studying mental distress from a variety of angles has grown in numbers and sophistication with many journals and thousands of articles being published each year. These are worthy achievements and this progress has no doubt helped thousands of people across the world.

However, despite all these achievements, psychiatric theory and practice has reached an impasse. Prevention has proved elusive with mental health diagnoses becoming more not less common despite a large increase in services in most developed countries. There still isn’t a diagnosis listed in the major psychiatric diagnostic manuals (such as ICD and DSM) that is associated with any sort of physical test and so, unlike the rest of medicine, aetiology has an insignificant part to play in organising diagnostic practice. Whilst reliability in making diagnoses has improved for some research purposes, this does not necessarily translate to clinical practice and the more important issue of validity remains poorly addressed. Most importantly there is no evidence to show that using psychiatric diagnostic categories as a guide for treatment leads, through evidence based choices, to improved outcomes. There is some evidence to suggest that applying a psychiatric diagnosis and theoretical models associated with them instead leads to a worse outcome for some.

This campaign therefore proposes that the time has come to help theory and practice in mental health move beyond this impasse by abolishing formal psychiatric diagnostic systems like ICD and DSM. By incorporating the latest evidence from epidemiology, cross-cultural studies and treatment outcome studies, the campaign highlights the extent to which the data is inconsistent with the dominant, diagnostic based, medical model remaining as the organising paradigm for practice. Continuing to use formal diagnostic systems to organise research, training, assessment, and treatment for those in mental distress is inconsistent with an evidence based approach capable of improving outcomes. Whilst the important task of sketching out what services may look like once we discard ICD and DSM from routine clinical practice is not the primary purpose of this campaign, a few pointers are also mentioned to highlight that alternative paradigms are already available and easy to incorporate into practice and in a way that can improve outcomes.

Aetiology

The failure of basic science research to reveal any specific biological abnormality or for that matter any physiological or psychological marker that identifies a psychiatric diagnosis is well recognised. Unlike the rest of medicine, which has developed diagnostic systems that build on an aetiological framework, psychiatric diagnostic manuals such as DSM-IV and ICD-10 have failed to connect diagnostic categories with any aetiological processes. Thus there are no physical tests referred to in either manual that can be used to help establish a diagnosis. The critique that highlights the lack of progress on aetiology is not limited to those less biologically minded psychiatrists as researchers in genetics are also arguing that the use of categorical diagnoses (such as schizophrenia) is handicapping their studies too, where, they argue, a dimensional approach seems more appropriate;3,4 although it should be noted that dimensional approaches in the rest of medicine often focuses on a very small percentage of ‘outliers’ (e.g. growth hormone treatment for short stature) rather than the large numbers currently attracting the gaze of psychiatry.

The one notable exception to the lack of aetiological organisation is the diagnosis ‘Post Traumatic Stress Disorder’ (PTSD) which attributes symptoms to being the direct result of trauma. This diagnosis did not develop out of new scientific discoveries but as a result of legal procedures (the construction of ‘PTSD’ came largely as a result of legal battles involving US military veterans of the Vietnam War) and its use implies that other diagnoses are not related to trauma. However, there is a substantial body of evidence linking states regarded as the most serious in psychiatry, such as the experience of hearing voices and psychosis, to trauma and abuse including sexual, physical and racial abuse, poverty, neglect, and stigma. 5, 6,7,8,9,10,11,12,13,14 This is why it is important to attempt to understand psychotic experiences in the context of the person’s life story. Not to do so can be harmful because it obscures and mystifies the origins of problematic experiences and behaviour that has the potential to be understood.14

Validity

If we were to apply the standards found in the rest of medicine then the validity of a diagnostic construct depends on the extent to which it represents a naturally occurring category. If it does, then there should be some identifiable biological property in those who have the diagnosis that can distinguish them from those who don’t. Despite years of searching for biological correlates, the failure of basic science research to reveal any specific biological marker for any psychiatric diagnostic category reveals that current psychiatric diagnostic systems do not share the same scientific security of belonging to the biological sciences as the rest of medicine. Mainstream practice understandably views this as a problem. However, the attempted solution of continuing to spend the bulk of mental health research time and effort trying to correct this deficit by relentlessly searching for evidence of biological correlates continues to deliver nothing clinically useful. Our failure to find biological correlates should not necessarily be seen as weakness. Instead of continuing with scientifically and clinically fruitless research we should view this failure as an opportunity to review the dominant paradigm in order to develop one that better fits the evidence.

Invalid anomalies are prevalent in DSM/ICD. For example, in DSM defined ‘depression’ there is one exception to the diagnosis (even if the patient has the required number of symptoms for the required number of weeks) – bereavement. This is anomalous in at least two ways. Firstly it breaks the ‘rule’ that diagnostic categories in DSM are descriptors that do not imply aetiology. Secondly, because bereavement is considered a ‘normal’ reaction, even if the full complement of DSM defined symptoms of depression are present, then one must ask: why is ‘bereavement’ specifically singled out? Why are many other life problems for which intense sadness is a common response – such as losing a job, break up of a marriage, bullying and so on – not also counted as legitimate exceptions?16

The frequency with which patients are given more than one diagnosis also raises a concern about the specificity of diagnostic categories. Widespread co-morbidity (making more than one diagnosis in order to encompass patients’ problems) indicates basic deficiencies in our understanding of the natural boundaries of even the most severe conditions we are diagnosing in psychiatry.17,18,19 It is also common to find the ‘dominant’ diagnosis changing in any individual, almost exclusively on a subjective rather than empirical (such as physical test results) basis. Unlike in the rest of medicine where the reason for the patient’s symptoms is clarified by a diagnosis, psychiatric diagnoses serve empirically as nothing much more than descriptors. Thus, when a clinician claims that a patient is ‘really’ depressed, or has ADHD, or has bipolar disorder, or whatever, not only are they trying to turn something based on subjective opinion into something that appears empirical, but they are engaging with the process of reification (turning something subjective into something ‘concrete’). The problem with turning concepts into something that appears as if it exists as a fact in the natural world is that it can cause ‘tunnel vision’ for all concerned; a dominant story that limits alternative more functional possibilities for any individual.20 Thus if someone believes ADHD is a ‘real’ disorder that exists in their brains and is potentially lifelong, that person and those who know them may come to act according to this belief, thus helping to fulfil its prophecy.

There is also a poor correspondence between levels of impairment and having the required number of symptoms for many psychiatric diagnoses (even though ‘impairment’ is often included in the diagnostic criteria). Literature reviews and field trials to examine clinical significance criteria were not included in the preparation of DSM-IV. Thus many below the threshold for a diagnosis have higher levels of impairment than those above, with many who reach the cut off for a diagnosis having relatively low levels of impairment. 21,22,23

Reliability

Reliability is the extent to which clinicians can agree on the same diagnoses when independently assessing a series of patients. Over the last thirty years or so, academic psychiatrists have worked hard to improve the reliability of psychiatric diagnoses. This is partly in response to critics of psychiatry who pointed out that many of the common diagnoses in use at the time were meaningless because of poor levels of agreement between psychiatrists about key symptoms. Rosenhan’s 1973 study spurred on new attempts to ‘standardise’ diagnostic practice after he demonstrated that psychiatrists were often unable to discriminate between sane and psychotic people.24 Formal diagnostic systems like DSM and ICD attempted to address these problems by imposing diagnostic agreement on the profession through the use of standardised check-lists of symptoms for diagnostic criteria. Because of the repeated claim that this approach has improved reliability significantly, the diagnostic systems now in use give the impression of being reliable in an empirically verifiable way.

However, analysis of the studies involved in developing the first diagnostic manual that took this approach of ‘operationalising’ diagnosis through the check list of symptoms approach (DSM-III), found no diagnostic categories for which reliability in these studies was uniformly high. The ranges of reliability for major diagnostic categories were found to be very broad and in some cases ranged the entire spectrum from chance to perfect agreement, with the case summary studies (in which clinicians are given detailed written case histories and asked to make diagnoses – an approach that most closely approximates what happens in clinical practice) producing the lowest reliability levels.25 No studies of the reliability of DSM as a whole when used in natural clinical settings have shown uniformly high reliability, with many finding reliability ratings that are not that different than those in the pre-DSM-III studies. 25,26,27 To overcome this, developers of subsequent DSMs have simply de-emphasised the reliability problem, claiming this to have already been solved by the approach developed in preparing DSM-III.

Treatment and outcome

The technological paradigm is the dominant one that organises the way psychiatric services and treatments are delivered in most industrialised countries. This paradigm is predicated on the assumption that the technical aspects of medical and psychological care are of primary importance, and that these can be applied through making diagnoses and then applying corresponding treatment protocols.

However, there is a large literature on psychotherapy confirming that it is generally speaking a safe and effective intervention for common mental health problems as studied in Western populations, but there is little to suggest that a positive outcome is strongly related to selecting the ‘correct’ psychotherapeutic technique and much to suggest that the ‘common factors’ such as developing a strong therapeutic alliance, are more important.28,29,30 For example, several studies have shown that most of the specific features of Cognitive Behaviour Therapy (CBT) can be dispensed with, without adversely affecting outcomes. 31,32 The same holds for other forms of psychotherapy for depression. For example, The National Institute of Mental Health’s Treatment of Depression Collaborative Research Project (TDCRP), the largest trial to date comparing different treatments for depression (CBT, Inter-Personal Therapy [IPT], anti-depressants, and placebo) found that patients in each group had significant improvements, with no overall difference in outcome between each treatment group. However, the best predictor of outcome across all four groups was the quality of the relationship between patient and therapist (as perceived by the patient) early in treatment. 33,34, 35, 36

Recent meta-analyses have drawn similar conclusions. The quality of the therapeutic alliance accounts for most of the within-therapy variance in treatment outcome, and is up to seven times more influential in promoting change than treatment model. 28,37 Such data, when combined with the observed superior value, across numerous studies, of clients’ assessment of the relationship in predicting the outcome, makes a strong empirical case that the non-specific aspects of psychotherapy, or ‘know-how’ in building a strong therapeutic alliance, are more important than specific techniques being used. This is also evident in ‘real life’ clinical encounters not just research projects. For example, in a review of over 5000 cases treated in a variety of National Health Service settings in the UK, only a very small proportion of the variance in outcome could be attributed to psychotherapeutic technique, as opposed to non-specific effects such as the therapeutic relationship.38

The same principles can be found operating when using psychoactive drug treatments (that non-specific factors are more important than matching a drug to a diagnosis). Thus a number of psychiatrists have argued that instead of correcting imbalances, the evidence supports the view that pharmacological agents may be conceptualised as inducing particular psychological states which, though not specifically related to diagnosis, is nonetheless the basis for their usefulness.39 This reflects clinical practice where the few categories of psychoactive medications used in psychiatry (the SSRIs, major tranquilisers, benzodiazepines, Lithium, and anti-epileptics) are often used in a non-diagnosis specific way. For example, SSRIs are claimed to be efficacious in conditions as disparate as borderline personality disorder, depression, obsessive compulsive disorder, anorexia nervosa, bulimia, panic disorder, social phobias, and so forth. As a psychoactive substance SSRIs would appear to do ‘something’ to the mental state, but that something is not diagnosis specific. Like alcohol, which will produce inebriation in a person with schizophrenia, obsessive compulsive disorder, depression, or someone with no psychiatric diagnosis, SSRIs will also impact individuals in ways that are not specific to diagnosis. Similarly, major tranquilisers (misnamed anti-psychotics) have also been advocated for the treatment of depression, anxiety disorders, bipolar affective disorder, personality disorders, ADHD, as well as schizophrenia, a list that contains considerable overlap with that found for SSRIs.

Many psychiatric drug treatments, like psychological treatments, rely more on non-specific factors than disease-specific therapeutic effects. For example, it is generally assumed that drugs marketed as ‘antidepressants’ work through their pharmacological effects on specific neurotransmitters in the CNS, reversing particular states of ‘chemical imbalance’. However, the evidence points to placebo effects being more important than any neuro-pharmacological ones. Thus several meta-analyses have concluded that most of the benefits from ‘antidepressants’ can be explained by the placebo effect, with only a small amount of the variance (about 20%) attributable to the drug, a small amount moreover that is unlikely to be clinically significant for the vast majority of patients.40,41 Studies investigating the degree to which non-technical factors such as therapeutic relationship affect outcome, have found that even with psychoactive drug treatments these factors are far more influential than the drug alone. Thus having a good relationship with the prescribing doctor is a stronger predictor of a positive response to an ‘anti-depressant’ than just taking the drug regardless of who prescribes it. 28,42

The lack of treatment specificity is not limited to the more common and less severe presentations. Thus, although drugs marketed as ‘antipsychotic’ are often claimed to reverse a biochemical imbalance in psychotic patients, no such imbalance has been demonstrated. Furthermore, researchers have long been aware of a perplexing finding in cross-cultural studies. Research, including that carried out by the World Health Organisation, over the course of 30 years and starting in the early 1970s, shows that patients outside the United States and Europe have significantly lower relapse rates and are significantly more likely to have made a ‘full’ recovery and show lower degrees of impairment when followed up over several years despite most having limited or no access to ‘anti-psychotic’ medication. It seems that the regions of the world with the most resources to devote to mental illness – the best technology, medicines, and the best-financed academic and private-research institutions – had the most troubled and socially marginalised patients.43 Once again the impact of our psychiatric technologies seem to be minimal compared to common factors, in this case most likely to be the effects of ‘extra-therapeutic’ factors such as family support, community cohesion and tolerance for behaviours and experiences considered a sign of ‘illness’ and ‘dangerousness’ in the West.

Prognosis

Unlike the rest of medicine, no overall improvement in prognosis has been demonstrated in Europe and North America over the past century for those diagnosed with a mental disorder. Some studies indicate the opposite, that compared to the pre-psychopharmacology period there are more patients who have developed chronic conditions such as chronic schizophrenia than in the past. For example, in 1955, there were around 350 thousand adults in the US state and county mental hospitals with a psychiatric diagnosis. During the next three decades (the era of the first generation psychiatric drugs), the number categorised as disabled from mental illness rose to 1.25 million. By 2007 the number of people categorised as disabled mentally ill grew to more than 4 million adults. Similarly, the numbers of youth in America categorised as having a disability because of a mental condition leapt from around 16 thousand in 1987 to 560 thousand in 2007.44

Studies that have compared outcomes for psychotic disorders such as schizophrenia have repeatedly found that outcomes are better in poorer, non-developed countries when compared to richer, more industrialised ones.41 For example, the World Health Organisation’s international outcome in schizophrenia studies found that after 2 years about two thirds of the patients in the poor countries were doing well compared to only a third of the patients in the developed countries. The researchers concluded that “being in a developed country was a strong predictor of not attaining a complete remission.”45 Thus the progress attributable to modern mainstream psychiatric diagnostic based practice does not extend to improved prognosis.

One problem with medical model diagnostic approaches is that many of the diagnoses (such as schizophrenia, bi-polar disorder, dysthymia, ADHD, autism, OCD etc.) are conceived as conditions that are genetic and lifelong in nature (i.e. conceived as chronic conditions that are ‘hard-wired’ with little chance of making a complete recovery), where the best one can hope for is gaining some control over symptoms (through, for example, life-long use of medications). This constructs and often imposes a narrative of despair on those diagnosed with these ‘chronic’ conditions. As such psychiatric diagnoses can foreclose meaning by transforming a range of experiences and possible meanings that can be applied to these experiences into a narrow disease framework, limiting the cultural imagination to expecting largely negative outcomes.

Prognosis for those with mental disorders is also further hampered by the stigma associated with the medical model.46 Nearly all studies that have looked at the question of public attitudes toward mental illness have found an increase in biological causal beliefs across Western countries in recent years.47 However, biological attributions for mental illness are overwhelmingly associated with negative public attitudes such as a belief that patients are unpredictable and dangerous with associated fear of them and greater likelihood of wanting to avoid interacting with them. 48 Conversely, in studies where members of the public are given a psychosocial explanation for the sufferer’s symptoms (such as serious life events, loss, trauma etc.) they are much less likely to give negative attributions.48 Yet again, the ‘medical model’ diagnostic approach has a significantly negative impact causing an increase in stigma rather than a reduction.

Similar findings emerge in personal stories of those diagnosed with a ‘mental illness’. Through social action, the survivor movement has created safe spaces in which individuals can start the process of telling their own stories. Many of these stories show that users of mental health services felt stigmatised and marginalised by a psychiatric diagnosis, experiencing this as something that leads to the loss of ‘citizenship’.46,49 Being labelled with a chronic ‘genetic’ condition such as ‘schizophrenia’ interferes with a person’s identity and biography. Indeed, the presence of ‘insight’ (as defined by doctors) in schizophrenia has been found to lower self-esteem and can lead to despair and hopelessness.50 Paradoxically, it has been found that the presence of this type of ‘insight’ (meaning accepting you are mentally ill and need medical treatment) is negatively correlated with emotional well-being, economic satisfaction and vocational status. 51,52, 53 Thus accepting the medical model attitude to diagnosis brings expectations of a gloomy outlook with lifelong dependency on psychiatric treatment and little chance of a good recovery. For some therefore, rejecting the diagnosis (or ‘lack of insight’) may be understood as a positive way of coping with the implications of the diagnosis for personal identity.52,53

In summary it seems we now have good evidence that the diagnostic ‘illness like any other illness’ approach is likely to be contributing to a worse prognosis for those diagnosed, not better.

Colonialism

For the last few decades Western mental-health institutions have been pushing the idea of ‘mental-health literacy’ on the rest of the world. Cultures are viewed as becoming more ‘literate’ about mental illness the more they adopted Western biomedical conceptions of diagnoses like depression and schizophrenia. This is because of a belief that ‘modern’, ‘scientific’ approaches reveal the biological and psychological basis of psychic suffering and so provide a rational pathway to dispelling pre-scientific approaches that are often viewed as harmful superstitions. In the process of doing this we not only imply that those cultures that are slow to take up these ideas are therefore in some way ‘backward’, but we also export disease categories and ways of thinking about mental distress that were previously uncommon in many parts of the world. Thus conditions like depression, post-traumatic stress disorder, and anorexia appear to be spreading across cultures, replacing indigenous ways of viewing and experiencing mental distress.54,55 In addition to exporting these beliefs and values, Western drug companies see in such practice the potential to open up new and lucrative markets.54,56

Despite copious evidence from research in the non industrialised world, that shows the outcomes for major ‘mental illnesses’, is consistently better than in the industrialised world and particularly amongst populations who have not had access to drug based treatments,43,44,45 the World Health Organisation, together with the pharmaceutical industry, has been campaigning for greater ‘recognition’ of mental illnesses in the non-industrialised world, basing their assumptions on the idea that ICD/DSM descriptions are universally applicable categories.57 Like other marketing campaigns, this strategy has the potential to open up huge new markets for psychiatric drugs that maybe ineffective and can have serious side effects, at the same time as painting indigenous concepts of, and strategies to deal with, mental health problems, as being based on ignorance, despite their obvious success for these populations.

The idea of the individual as the locus of the self is a relatively recent Western invention and such a framework creates the psychological pre-conditions necessary for accepting the ‘atomised’ social worlds that have been created. Yet, mental well-being seems closely connected to social and economic factors. Several international studies have concluded that more important than poverty per se is the degree of inequality. Thus the greater the inequality (in economic and social resources) in any society, the poorer is the mental health of that society.58,59,60,61,62

A more subtle source of impact on cultural beliefs is due to psychiatric diagnoses inadvertently setting standards for ‘normality’, by categorising what emotional and behavioural traits and experiences should be considered ‘disordered’. As the criteria for diagnoses are arrived at by subjective judgments rather than objective evidence (being literally voted in or out of existence by committees), they will have an automatic bias toward the cultural standards found in economically dominant societies (who also tend to control what counts as ‘knowledge’ globally). This sets in motion a diagnostic system vulnerable to institutional racism in the dominant societies and colonialism in others, as other standards of normality will, at least to some extent, come to be viewed as ‘primitive’, ‘superstitious’ etc. and their populations will be viewed as needing to be (psycho)educated. As a result then, for the majority of the world, all manner of complex somatic/emotional complaints have to be re-categorised, spiritual explanations have to be denounced, parenting practices viewed as oppressive and so on.

Thus imposing Western medical model DSM/ICD style psychiatry on non-Western populations risks a number of things including: adoption of Western psychiatric notions of ‘psychopathology’ to express mental distress, undermining of existing cultural strategies for dealing with distress, more not less stigma for those with mental health problems, and the imposition of an individualistic approach that may marginalise family and community resources and divert attention from social injustice.

Cultural and Public policy impact

Despite adopting a DSM/ICD approach causing many problems for translating the subjective process of attaining a psychiatric diagnosis into a reliable and objective one in clinical practice; it has nonetheless had a significant impact on service provision and public and professional beliefs about mental distress. As a result of popularising the diagnostic systems created by DSM/ICD, it is widely argued that a significant proportion of the population suffers from mental illness, that this amounts to a significant economic burden, and that there is a strong case for investing in improved mechanisms of detection and treatment for these disorders. Across several surveys in the industrialised nations only about a third of those identified as suffering a mental health problem (according to DSM/ICD criteria) sought or were interested in seeking professional help.63,64,65,66 This has been interpreted as unsatisfactory case detection, provision and treatment, due to public and professional ignorance. However, there is little evidence to support the idea that popularising mental health diagnoses, convincing professionals and the public about the high prevalence of mental disorders, and convincing policy makers of the need to diagnose and treat more people, benefits the mental health of the society.

In order to increase rates of diagnosis and treatment, a variety of campaigns have been undertaken. For example, in the UK the Royal College of Psychiatrists and Royal College of General Practitioners launched their ‘Defeat Depression’ campaign in the early nineties. 67 It was intended to raise public awareness of depression, reduce stigma, train general practitioners in recognition and treatment, and make specialist advice and support more readily available. Unfortunately, evaluations of treatment and education guidelines in the UK following the ‘Defeat Depression’ campaign failed to detect significant improvements in clinical outcome.68,69,70 However, other effects of the campaign included a rapid increase in antidepressant prescribing and increased medicalisation of unhappiness and distress. As has been noted above, medicalisation of mental distress through promotion of the idea that mental health problems are best understood as ‘illness like any other illness’, increases rather than decreases stigma.

Unlike other areas of public health, mental health in those societies with the most developed services appears to be the poorest. In such societies ‘epidemics’ of psychiatric diagnoses (e.g. ADHD, autism, depression, bipolar disorder) have only emerged and become popularised in recent years. Whilst there are complex political, social and cultural reasons for this, they are in part based on new categories and ideas about personhood, the nature of distress etc. and so are at least in part the result of creating, broadening and popularising psychiatric diagnoses.

Conclusion

For any diagnostic system to establish itself as a scientifically useful paradigm that leads to greater knowledge of the natural world, it should be able to show that the categories ‘carve nature at its joints’ such as being able to demonstrate distinct aetiological links. For any diagnostic system to establish itself as clinically useful it must show that use of diagnostic labels aids treatment decisions in a way that impacts on outcome. As reviewed above there is little evidence to support the ICD/DSM paradigm being able to provide either the basis for collecting scientifically useful knowledge or clinically useful treatment decisions. There is much evidence to suggest that instead they can cause significant harm. The only evidence based conclusion that can be drawn is therefore that formal psychiatric diagnostic systems like ICD and DSM should be abolished.

New paradigms

Relying on DSM/ICD diagnostic categories to organise research, services, and treatment does not contribute to improved outcomes for those experiencing mental distress and is associated with considerable harm.

Alternatives to ICD/DSM are therefore needed. We can and should do better. We have all the evidence we need to work on re-organising our approaches locally, nationally, and internationally to develop services that are evidence based and can reduce the amount of harm DSM/ICD has caused at the same time as improving outcomes. New paradigms that draw on the existing evidence for what improves outcomes and that incorporates the views of those who matter most – service users – can easily be developed and implemented. The following represents some good starting points:

1. Aetiology: As discussed in this paper there is a strong association between trauma, particularly early childhood trauma, and adversity and the subsequent development of mental disorders including psychosis. There is also a strong association between the degree of socio-economic inequality and levels of mental distress in any society. Other associations include dietary, lifestyle, family functioning and attachments. Research that examines the relationship between contextual factors and degrees of impairment, without trying to link them to formal psychiatric categories, has a greater likelihood of succeeding in developing useful scientific knowledge about mental distress. Moving the focus away from the eugenic-like search for genetic and neurological abnormalities will allow for greater acceptance of human diversity, and decrease the likelihood of human rights, political and social issues being inappropriately medicalised. Given the strong relationship between increasing acceptance of the diagnostic medical model and increasing stigma, abolition of DSM/ICD will also help in the fight against stigma.

2. Clinical: Decades of outcome research into treatment of psychiatric disorders shows, that despite the development of many new techniques, the outcomes being achieved in studies 40 years ago are similar to those being achieved now. In other words our advances in therapeutic techniques have not yet led to improvement in overall outcomes for service users. Research has found that certain intra-therapeutic factors such as the therapeutic alliance has a much greater effect on outcome than model or technique used and that extra-therapeutic factors such as social support has an even greater impact on outcome than intra-therapeutic ones.28,30,42 A variety of studies (in areas as diverse as psychotherapy services, community mental health services, substance misuse, and marital counselling) have found that incorporating ideas from this outcome literature, such as using session by session feedback on outcome and therapeutic alliance, can improve outcomes.30,42 The message from this research is that services can improve outcomes, not by using diagnostic categories to choose treatment models, but by concentrating instead on developing meaningful relationships with service users that fully includes them in decision making processes. International service user led movements, such as the ‘recovery’ movement, that focus on the inclusion of people in recovery from mental health problems as collaborators in research, service development, and treatment model development provide good examples of how this evidence can be developed to change institutional culture.71,72,73 Services in non-Western settings should be able to incorporate local beliefs and practices and the wholesale export of Western ethno-psychiatry can be stopped.

Developing the knowledge base and services in this manner would give mental health services and practitioners a better chance of improving the lives of those they work with. It will also help with breaking long standing barriers between mental health services and the rest of medicine, by allowing the mental health professions to focus on developing paradigms that are evidence based and which properly incorporates an understanding of how physical and mental well-being are closely related to each other. These non-diagnostic based paradigms can then assist in helping the many patients who present with physically unexplained symptoms or chronic conditions, which inevitably impact on their mental well-being, without needing to label them as ‘mentally ill’.

The real gift of psychiatry is what it can offer the rest of medicine that is more unique to this field, which is an understanding of the person in their context. Psychiatry has to sit at the confluence of a variety of disciplinary discourses (Sociology, anthropology, psychology, philosophy, medicine, cultural studies, politics, theology etc.) and it is this broader understanding of the human and their health and well-being that psychiatry ‘brings to the table’. By lazily importing the diagnostic model from general medicine we end up miss-selling and under-utilising the unique skills the profession of psychiatry brings to healthcare by the ‘dumbing down’ of what we do into simplistic diagnosis driven protocols that has more to do with successful consumer culture marketing than science. Changing to more evidence compatible paradigms is now long overdue.

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39. Moncrieff, J. (2009) The Myth of the Chemical Cure. Basingstoke: Palgrave MacMillan.
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Sami Timimi
Consultant child and Adolescent Psychiatrist
Director of Medical Education
Lincolnshire Partnership Foundation NHS Trust
Visiting Professor of Child and Adolescent Psychiatry
Faculty of Health and Social Sciences
Lincoln University
 
International Critical Psychiatry Network

See my Author’s page on the ICPN website
Join the ‘No More Psychiatric Labels’ International campaign
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What is your Opinion of Psychiatric Diagnosis?

This is an important paper written by Steven Coles and colleagues about psychiatric diagnosis. What do you think? Have your say!

What is your Opinion of Psychiatric Diagnosis?

What is your view on psychiatric diagnosis? Should the diagnosis of schizophrenia be abolished as the Campaign for the Abolition of the Schizophrenia Label wish? For both those working in mental health services and those on the receiving end, how important is diagnosis to your life? There are many different views on psychiatric diagnosis from fierce advocates to those who decry the practice. A number of survivors, academics, professionals, and service users have criticised diagnosis. However, within mental health services psychiatric diagnosis remains dominant. Psychiatrists (and other professionals) claim they use diagnosis to understand people’s experiences, behaviour and distress.  Diagnosis shapes how services are organised, who will be helped and how services will support or “treat” people. Psychiatric diagnosis also has a major impact on whether people are detained against there will in hospital – the civil liberties of people with a psychiatric diagnosis are at a greater risk than anyone else in society (other than suspected terrorists). Diagnosis influences whether people are forced to take major tranquilizers (“antipsychotics”), and whether they receive financial benefits.

Despite the immense controversy surrounding diagnosis, my experience is that the debates around diagnosis are not openly discussed between staff or with people using (or forcibly brought into) mental health services. Psychiatric diagnosis has become an everyday and often unquestioned part of mental health practice. Is this simply because critics of diagnosis have weak arguments? Is it because the scientific basis of psychiatric diagnosis is so strong? Is there no alternative? A group of Clinical Psychologists working in East Midlands Adult Mental Health Services have looked at the issue of psychiatric diagnosis and written a position paper (Coles & SPIG, 2010). They conclude that “psychiatric diagnosis does not meet its scientific and expert claims” and does not deserve to be so dominant in mental health services.

The East Midlands group highlighted a number of negative effects of psychiatric diagnosis. They note that diagnosis places the cause of difficulties on the individual; the group feel more attention should be paid to people’s life experiences, such as abuse, poverty, discrimination and disempowerment. The position paper also observes that the language of diagnosis is barrier to communication between staff and people using services. Furthermore, diagnosis is not aware that it is based upon dominant western (often male) ideas of what is normal, and ignores that other cultures and subcultures might have different or a broader idea of what is normal. The paper also notes some modest alternatives to moving beyond diagnosis (for access to the document see www.bps.org.uk/dcp-sigpr/publications-%26-documents/publications_home.cfm).

The East Midlands Paper is accessible at the above link, as well as on the Hearing Voices Network website. The group is hoping to open up a debate around diagnosis and would welcome people’s thoughts on the paper and on diagnosis. The East Midlands paper suggests that the current dominance and use of diagnosis is part of the problem and not part of the solution as psychiatry claims. What do you think? What is your experience of diagnosis?

References

Coles, S. & SPIG (2010).  Position on Psychiatric Diagnosis. East Midlands: Psychosis and Complex Mental Health Special Interest Group

Steven Coles

Clinical Psychologist

steven.coles@nottshc.nhs.uk

Demedicalising Misery: Psychiatry, Psychology and the Human Condition.

Demedicalising Misery: Psychiatry, Psychology and the Human Condition. Co-edited with Mark Rapley  and Joanna Moncrieff. Published by Palgrave Macmillan.

Thomas Szasz (1960) suggested that the myth of ‘mental illness’ functions to ‘render more palatable the bitter pill of moral conflict in human relations’. The medicalization of distress enables the mental health professions to manage the human suffering that they are confronted with, and also the suspicion that there is little that they can do to help. But the medicalization of misery and madness renders people unable to comprehend their experiences in ordinary, meaningful terms. In this collection we restore to everyday discourse a way of understanding distress that, unlike contemporary psychiatry and psychology, recognises and respects the essential humanness of the human condition. De-medicalizing Misery is a shorthand term for this project. The book resists the psychiatrization and psychologization of human experience, and seeks to place what are essentially moral and political – not medical – matters back at the centre of our understanding of human suffering.

Notes on Contributors
Preface; R.Dallos
Carving Nature at its Joints? DSM and the Medicalization of Everyday Life; M.Rapley, J.Moncrieff & J.Dillon
Dualisms and the Myth of Mental Illness; P.Thomas & P.Bracken
Making the World Go Away, and How Psychology and Psychiatry Benefit; M.Boyle
Cultural Diversity and Racism: An Historical Perspective; S.Fernando
The Social Context of Paranoia; D.J.Harper
From ‘Bad Character’ to BPD: The Medicalization of ‘Personality Disorder’; J.Bourne
Medicalizing Masculinity; S.Timimi
Can Traumatic Events Traumatise People? Trauma, Madness and ‘Psychosis’; L.Johnstone
Children Who Witness Violence at Home; A.Vetere
Discourses of Acceptance and Resistance: Speaking Out About Psychiatry; E.Speed
The Personal Is the Political; J.Dillon
‘I’m Just, You Know, Joe Bloggs’: The Management of Parental Responsibility for First-Episode Psychosis; C.Coulter & M.Rapley
The Myth of the Antidepressant: An Historical Analysis; J.Moncrieff
Antidepressants and the Placebo Response; I.Kirsch
Why Were Doctors so Slow to Recognise Antidepressant Discontinuation Problems?; D.Double
Toxic Psychology; C.Newnes
Psychotherapy: Illusion With No Future?; D.Smail
The Psychologization of Torture; N.Patel
What Is To Be Done?; J.Moncrieff, J.Dillon & M.Rapley
Figure: Papers Using Term ‘Antidepressant’ On Medline 1957-1965
Index

‘Despite longstanding awareness of the limitations of the medical model when applied to difficulties of human behavior and adjustment, the fields of psychiatry and psychology continue to accede to the pressures of medicine and the drug industry in their conceptualization of these human realities. Ironically, however, this medical model, eager as it is to fit so much of people’s experience into diagnostic categories, is a social construction. This book represents a significant effort to de-mystify, de-medicalize, and reclaim important aspects of the human condition.’ – Kenneth D. Keith, Professor, Department of Psychological Sciences, University of San Diego, USA

 

De-Medicalizing Misery has assembled an impressive cast of leading mental health experts. Together they challenge the simplistic and pessimistic biological model of human distress that has, with eager support from the pharmaceutical industry, dominated the mental health field for far too long. This evidence-based, humane and optimistic book not only explains where biological psychiatry went wrong, it spells out the alternatives.’ – John Read, University of Auckland, New Zealand and Editor of ‘Models of Madness’

 

  ‘The psychiatrist or psychologist is expected to do something for every patient sitting in front of him or her, but how robust is the intellectual basis of psychiatric science when psychiatric ‘diseases’ are merely symptom clusters – clustered by us, not by nature? We are in indeed in the age of the medicalization of everyday life, when Lord Layard, economist and architect of the IAPT programme, can write in the BMJ that ‘mental illness’ has taken over from unemployment as our greatest social problem. But what is the test of ‘mental illness’? In DeMedicalizing Misery the authors examine some of the domains lamentably absent from orthodox psychiatry and psychology training programmes, with their medical model focus, and in so doing raise the IQ of the whole debate. And not just for clinicians.’ – Dr Derek Summerfield, Consultant Psychiatrist & Senior Lecturer, Institute of Psychiatry, King’s College, London, UK.
 

Authors: MARK RAPLEY is Professor of Clinical Psychology at the University of East London, UK. He is the author of The Social Construction of Intellectual Disability, Quality of Life Research and, with Susan Hansen and Alec McHoul, Beyond Help: A Consumers’ Guide to Psychology.
 
JOANNA MONCRIEFF is Senior Lecturer in the Department of Mental Health Sciences at University College London, UK and a Practising Consultant Psychiatrist at the North East London Foundation Trust. She has spent her academic career re-evaluating the nature and efficacy of psychiatric drugs and exploring the history and politics of psychiatry. She is the co-chair of the Critical Psychiatry Network, and has campaigned against the dominance of the biomedical approach to psychiatry, the extension of psychiatric coercion and the influence of the pharmaceutical industry, in alliance with service user groups. She is the author of The Myth of the Chemical Cure (Palgrave Macmillan), A Straight Talking Introduction to Psychiatric Drugs, and numerous papers and book chapters.
 
JACQUI DILLON is the National Chair of the Hearing Voices Network, UK, and a Director of Intervoice – the International Network for Training, Education and Research into Hearing Voices. She is a campaigner, international speaker and trainer specialising in hearing voices, psychosis, dissociation and trauma. She is the co-editor of Living with Voices: An Anthology of 50 Voice Hearers’ Stories of Recovery. She has published numerous articles and papers, is on the editorial board of the journal Psychosis: Psychological, Social and Integrative Approaches and is a member of the collective for Asylum, The Magazine for Democratic Psychiatry.


Exile (2008)

Produced by: Jenni Autio, Tea Latvala, Sampo Lehtinen, Oskari Pastila

Written & directed by: Sampo Lehtinen, Oskari Pastila

Exile is an experimental stage performance; a fusion of computer animations, documentary, fictional narrative, music and fashion design.

Exile tells the story of Kathryn, a woman who hears voices and who has built part of her personality based on them. Contrary to general prejudices she finds these voices helpful, even vital to her existence. How does she cope in the modern society where every alteration from the norm seems intolerable and problematised through social and commercial mechanisms.

The idea of Exile was based on a general view that there is no flawless analogy in our individual perceptions. Contextual structure of the work was build around a documentary recorded in London in March 2006 in association with The Hearing Voices Network.

On the soundtrack the fictional narrative intertwines with the documentary (audio) about an actual voice hearer who files an account about her life with voices. The stage act offers visual support to the narrative. Spectators witness the gradual effects a medical attempt to eradicate Kathryns internal voices have on her. While she gradually loses her control over the voices she also surrenders her physical composure and grip on reality.

Read More: http://www.bodynavigation.ru/en/participants/exile.php

In Your Head: Hearing Voices

Published in: Psychology Today, January 1, 2007, by William Lee Adams

Despite their association with mental illness, auditory hallucinations don’t always torment those who hear them. In fact, only one out of every three so-called “voice hearers” requires psychiatric help. The other two don’t experience difficulties and may even consider their voices supportive or inspiring.

“My voices know me better than anyone else, and they also protect and comfort me,” says Jacqui Dillon, head of a London support group for voice hearers. She and other group members report that voices can alert them to oncoming cars and suspicious passersby, provide encouragement during stressful times, and offer reminders to pick things up at the grocery store.

Whether they threaten or soothe, auditory hallucinations usually begin after trauma: Seventy percent of people who hear voices first detect them following physical or sexual abuse, an accident, or the loss of a loved one. “The emotion they feel about their trauma complicates how they interpret the voices,” says Sara Tai, a psychologist at the University of Manchester in England who studies why some hallucinators thrive while others end up in psychiatric care. Typically, the greater the trauma, the more likely voices will sound threatening.

Read More: http://www.psychologytoday.com/articles/200701/in-your-head-hearing-voices

Experts call for ban on schizophrenia ‘label’

Published in: Daily Mail, 9 October, 2006

Schizophrenia should be abolished as a concept because it is unscientific, stigmatising, and does not address the root causes of serious mental illness, a group of experts said today.

The diagnosis, which emerged in the 19th century, is flawed and harmful, they claimed. It not only grouped together patients with widely ranging symptoms, but offered no explanation for their illnesses.

Once given a diagnosis of schizophrenia, a person was labelled an incurable social misfit and placed at the mercy of a psychiatric system that mostly benefited the drug industry.

A new campaign called CASL (Campaign for the Abolition of the Schizophrenic Label) is said to be gaining increasing support from both patients groups and professionals.

It wants patients to be assessed according to their individual experiences and histories rather than blanket-categorised as “schizophrenic”.

Read more: http://www.dailymail.co.uk/health/article-409472/Experts-ban-schizophrenia-label.html#ixzz1H2oOhJEG

Critical & Alternative Perspectives

Critical & Alternative Perspectives

On The Web

The Campaign to Abolish the Schizophrenia Labelwww.caslcampaign.com
CASL is calling for the label of schizophrenia to be abolished on the grounds that it is outdated, unscientific, stigmatising and presents a barrier to effective and appropriate support to individuals diagnosed with the label.

Coming off Psychiatric Medicationwww.comingoff.com
Information about coming off psychiatric medication.

The Critical Psychiatry Networkwww.critpsynet.freeuk.com
The Critical Psychiatry Network provides a network to develop a critique of the contemporary psychiatric system.

The Freedom Centrewww.freedom-center.org
An American-based support and activism community for anyone experiencing mental health difficulties. Includes event lists, links and advice around medication.

The Icarus Projecthttp://theicarusproject.net
Support network started in the U.S. for people ‘navigating the space between brilliance and madness’

The International Critical Psychiatry Networkwww.criticalpsychiatry.net
Created by medical doctors as a forum (primarily for medical doctors) to discuss, critique, and publicise opinions, practices, literature, and events that support critical thinking and alternative approaches to psychiatry.

International Network Toward Alternatives and Recoveryhttp://intar.org/
Gathers prominent survivors, professionals, family members, and advocates from around the world to work together for new clinical and social practices towards emotional distress and what is often labeled as psychosis.

Peter Lehmann Publishingwww.peter-lehmann-publishing.com
Publishes excellent books available in English on alternative approaches to mental health problems.

Mad Chickswww.mad-chicks.org.uk
A new movement, which focuses on issues specific to women mental health service users, using creativity to achieve our aims and attract attention to our causes. Site contains info, creativity etc.

Mad Pride www.ctono.freeserve.co.uk
The all new website of this energetic mental health surivivors organisation. Includes details of future gigs & events, the origins of Mad Pride and their ‘Stop The Suicides’ campaign

MindFreedom Internationalwww.mindfreedom.org

MindFreedom International unites 100 grassroots groups and thousands of members to win campaigns for human rights of people diagnosed with psychiatric disabilities.

National Service User Networkwww.nsun.org.uk
Aims to create a network which will engage and support the wide diversity of mental health service users and survivors across England in order to strengthen the user voice.

No Free Lunchwww.nofreelunch-uk.org
This is the UK branch of an organisation that seeks to promote the distancing of health professionals from the influence of the pharmaceutical industry.

PCCS Bookswww.pccs-books.co.uk
Publisher of counselling and psychotherapy books and journals. Committed to reflexive, radical and critical contemporary psychology theory and practice

Soteria Networkwww.soterianetwork.org.uk
Soteria is a network of people in the UK promoting the development of drug-free and minimum medication therapeutic environments for people experiencing ‘psychosis’ or extreme states.

The Spiritual Crisis Networkwww.spiritualcrisisnetwork.org.uk
A UK based network set up to improve access to approaches that view psychosis as a spiritual crisis or spiritual emergence ideas.

Working to Recoverywww.workingtorecovery.co.uk
A site run by mental health trainers Ron Coleman and Karen Taylor emphasising recovery-orientated approaches to mental health care. Includes information about training events, useful links and an online bookshop.

World Network of Users and Survivors of Psychiatryhttp://wnusp.rafus.dk/
WNUSP is an international organization of users and survivors of psychiatry.

In Print

Asylum Magazinewww.asylumonline.net/subscribe.htm
Asylum magazine is a forum for free debate, open to anyone with an interest in psychiatry or mental health. We especially welcome contributions from service users or ex-users (or survivors), carers, and frontline psychiatric or mental health workers (anonymously, if you wish). The magazine is not-for-profit and run by a collective of unpaid volunteers.

Appignanesi, L. (2008) Mad, Bad and Sad: A History of Women and the Mind Doctors from 1800 to the Present. Virago Press.

Barker, P. Campbell, P. Davidson, B. (1999). From the Ashes of Experience. Whurr Publishers.

Bentall, R. (ed.) (1990). Reconstructing Schizophrenia. Hove: Routledge.

Bentall, R. (2003). Madness Explained: Psychosis and Human Nature. London: Penguin.

Bentall, R. (2009). Doctoring The Mind: Why Psychiatric Treatments Fail. London: Penguin.

Boyle, M. (1990). Schizophrenia: A Scientific Delusion? London, Routledge.

Bracken, P. and Thomas, P. (2005). Postpsychiatry: Mental Health in a Postmodern World. Oxford: Open University Press.

Breggin, P. (1991) Toxic Psychiatry: Why Therapy, Empathy and Love Must Replace the Drugs, Electroshock and Biochemical Theories of the New Psychiatry. Flamingo; (Reissue) edition (2010)

Breggin, P. (2008). Brain Disabling Treatments in Psychiatry. New York: Springer.

Chesler, P. (1972). Women and Madness. New York: Avon.

Cohen, C. and Timimi, S. (2008). Liberatory Psychiatry: Philosophy, Politics and Mental Health. Cambridge University Press.

Coleman, R. (2004). Recovery: An Alien Concept (2nd Edition). Fife: P&P Press Ltd.

Frame, J. (2008). An Angel At My Table. Sydney: Vintage.

Foucault, M. (1965). Madness and Civilization. New York: Vintage.

Greenberg, J. (1964). I Never Promised You A Rose Garden. New York: Holt, Rinehart & Winston.

Grof, S. (1985). Beyond the Brain: Birth, Death and Transcendence in Psychotherapy. State University of New York Press.

Grof, S. (1988). The Adventure of Self-Discovery: Dimensions of Consciousness and New Perspectives in Psychotherapy and Inner Exploration. State University of New York Press.

Hammersley, P., Langshaw, B., Bullimore, P., Dillon, J., Romme, M. and Escher, S. (2008). Schizophrenia at the tipping point. Mental Health Practice, 12(1), 14 – 19.

Hornstein, G.A. To Redeem One Person Is To Redeem The World: The Life of Frieda Fromm-Reichman. Free Press.

Hornstein, G.A. (2009). Agnes’s Jacket: A Psychologist’s Search for the Meanings of Madness. Rodale Press.

Johnson, B. (2005). Emotional Health. Trust Consent Publishing.

Johnson, B. (2005). Unsafe at Any Dose. Trust Consent Publishing.

Johnstone, L. (2000). Users and Abusers of Psychiatry. Hove: Routledge.

Joseph, J. (2003). The Gene Illusion. Ross-on-Wye: PCCS Books.

Joseph, J. (2006). The Missing Gene: Psychiatry, Heredity, And the Fruitless Search for Genes. New York: Algora.

Laing, R. (1959). The Divided Self. London: Tavistock.

Laing, R. and Esterson, A. (1964). Sanity, Madness and the Family. London: Penguin.

Laing, R. (1967). The Politics of Experience. London: Penguin.

Millett, K. (1990). The Loony-bin Trip. New York: Simon & Schuster.

Moncrieff, J. (2009). The Myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment. Palgrave Macmillan.

Mosher, L. et al. (2004) Soteria: Through Madness to Deliverance. Philadelphia: Xlibris.

Newnes, C. et al. (eds) (1999). This is Madness. Ross-on-Wye: PCCS Books.

Newnes, C. et al. (eds) (2001). This is Madness Too. Ross-on-Wye: PCCS Books.

Nightsky, O. (1999). The Bridge Between Two Worlds. A Shaman’s View of Schizophrenia and Acute Sensitivity. Keepwell (NZ) Ltd.

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Whitaker. R. (2002). Mad in America: Bad Science, Bad Medicine and the Enduring Mistreatment of the Mentally Ill. Cambridge, MA: Perseus.

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An extremely effective developer of services

I have known Jacqui Dillon for several years now — we first met in the early 2000s when she attended the London-based Critical Mental Health Forum, in which I was also involved.  Jacqui has been an extremely effective developer of services in the third sector.  She developed the London Hearing Voices Project and has also chaired the national Hearing Voices Network for several years.

She is a thoughtful and innovative worker who builds good collaborative relationships both with those who use mental health services and with mental health professionals.  She has also been very effective in securing funding for those organisations with which she works.

I work on a clinical psychology training programme and Jacqui has taught sessions on a range of topics on our programme for several years now.  Trainees have said that she is a very engaging and inspiring speaker who also has lots of practical advice about how to bring change in mental health services.

When I’ve seen Jacqui speak I also have been moved and inspired.  Given her earlier career as a journalist it is no surprise that she has been doing more writing, recently co-editing Living with Voices.  She has a national and international reputation and is approached by a range of media organisations for comments in relation to voice hearing and mental health more generally.

Dr Dave Harper, Reader in Clinical Psychology, University of East London. Academic Tutor on the Doctoral Degree in Clinical Psychology programme.

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Royal College of Psychiatrists: Abolish use of formal psychiatric diagnostic systems like ICD & DSM

Abolish use of formal psychiatric diagnostic systems like ICD & DSM

Psychiatric diagnoses are not valid.
Use of psychiatric diagnosis increases stigma.
Using psychiatric diagnosis does not aid treatment decisions.
Long term prognosis for mental health problems has got worse.
Psychiatric diagnosis imposes Western beliefs about mental distress on other cultures.
Alternative evidence based models for organizing effective mental health care are available.

 
To sign the petition please go to this link:

To read the full evidence based arguments view the ‘No More Psychiatric Labels’ paper at
http://www.criticalpsychiatry.net/?p=527 which is reproduced below:

Modern Western psychiatry has secured many important advances in the care of people with mental distress. We have a variety of pharmacotherapies that can help manage distressing symptoms alongside an even greater variety of psychotherapeutic approaches that help people in distress make sense of their experiences and find new ways to deal with them. The old asylums have been emptied and community care has developed a rich variety of services from early intervention to crisis management. Researchers have identified many biological and environmental factors associated with greater likelihood of having or developing mental health problems and so our understanding of mental distress has improved. Reflecting this, the academic community, studying mental distress from a variety of angles has grown in numbers and sophistication with many journals and thousands of articles being published each year. These are worthy achievements and this progress has no doubt helped thousands of people across the world.

However, despite all these achievements, psychiatric theory and practice has reached an impasse. Prevention has proved elusive with mental health diagnoses becoming more not less common despite a large increase in services in most developed countries. There still isn’t a diagnosis listed in the major psychiatric diagnostic manuals (such as ICD and DSM) that is associated with any sort of physical test and so, unlike the rest of medicine, aetiology has an insignificant part to play in organising diagnostic practice. Whilst reliability in making diagnoses has improved for some research purposes, this does not necessarily translate to clinical practice and the more important issue of validity remains poorly addressed. Most importantly there is no evidence to show that using psychiatric diagnostic categories as a guide for treatment leads, through evidence based choices, to improved outcomes. There is some evidence to suggest that applying a psychiatric diagnosis and theoretical models associated with them instead leads to a worse outcome for some.

This campaign therefore proposes that the time has come to help theory and practice in mental health move beyond this impasse by abolishing formal psychiatric diagnostic systems like ICD and DSM. By incorporating the latest evidence from epidemiology, cross-cultural studies and treatment outcome studies, the campaign highlights the extent to which the data is inconsistent with the dominant, diagnostic based, medical model remaining as the organising paradigm for practice. Continuing to use formal diagnostic systems to organise research, training, assessment, and treatment for those in mental distress is inconsistent with an evidence based approach capable of improving outcomes. Whilst the important task of sketching out what services may look like once we discard ICD and DSM from routine clinical practice is not the primary purpose of this campaign, a few pointers are also mentioned to highlight that alternative paradigms are already available and easy to incorporate into practice and in a way that can improve outcomes.

Aetiology

The failure of basic science research to reveal any specific biological abnormality or for that matter any physiological or psychological marker that identifies a psychiatric diagnosis is well recognised. Unlike the rest of medicine, which has developed diagnostic systems that build on an aetiological framework, psychiatric diagnostic manuals such as DSM-IV and ICD-10 have failed to connect diagnostic categories with any aetiological processes. Thus there are no physical tests referred to in either manual that can be used to help establish a diagnosis. The critique that highlights the lack of progress on aetiology is not limited to those less biologically minded psychiatrists as researchers in genetics are also arguing that the use of categorical diagnoses (such as schizophrenia) is handicapping their studies too, where, they argue, a dimensional approach seems more appropriate;3,4 although it should be noted that dimensional approaches in the rest of medicine often focuses on a very small percentage of ‘outliers’ (e.g. growth hormone treatment for short stature) rather than the large numbers currently attracting the gaze of psychiatry.

The one notable exception to the lack of aetiological organisation is the diagnosis ‘Post Traumatic Stress Disorder’ (PTSD) which attributes symptoms to being the direct result of trauma. This diagnosis did not develop out of new scientific discoveries but as a result of legal procedures (the construction of ‘PTSD’ came largely as a result of legal battles involving US military veterans of the Vietnam War) and its use implies that other diagnoses are not related to trauma. However, there is a substantial body of evidence linking states regarded as the most serious in psychiatry, such as the experience of hearing voices and psychosis, to trauma and abuse including sexual, physical and racial abuse, poverty, neglect, and stigma. 5, 6,7,8,9,10,11,12,13,14 This is why it is important to attempt to understand psychotic experiences in the context of the person’s life story. Not to do so can be harmful because it obscures and mystifies the origins of problematic experiences and behaviour that has the potential to be understood.14

Validity

If we were to apply the standards found in the rest of medicine then the validity of a diagnostic construct depends on the extent to which it represents a naturally occurring category. If it does, then there should be some identifiable biological property in those who have the diagnosis that can distinguish them from those who don’t. Despite years of searching for biological correlates, the failure of basic science research to reveal any specific biological marker for any psychiatric diagnostic category reveals that current psychiatric diagnostic systems do not share the same scientific security of belonging to the biological sciences as the rest of medicine. Mainstream practice understandably views this as a problem. However, the attempted solution of continuing to spend the bulk of mental health research time and effort trying to correct this deficit by relentlessly searching for evidence of biological correlates continues to deliver nothing clinically useful. Our failure to find biological correlates should not necessarily be seen as weakness. Instead of continuing with scientifically and clinically fruitless research we should view this failure as an opportunity to review the dominant paradigm in order to develop one that better fits the evidence.

Invalid anomalies are prevalent in DSM/ICD. For example, in DSM defined ‘depression’ there is one exception to the diagnosis (even if the patient has the required number of symptoms for the required number of weeks) – bereavement. This is anomalous in at least two ways. Firstly it breaks the ‘rule’ that diagnostic categories in DSM are descriptors that do not imply aetiology. Secondly, because bereavement is considered a ‘normal’ reaction, even if the full complement of DSM defined symptoms of depression are present, then one must ask: why is ‘bereavement’ specifically singled out? Why are many other life problems for which intense sadness is a common response – such as losing a job, break up of a marriage, bullying and so on – not also counted as legitimate exceptions?16

The frequency with which patients are given more than one diagnosis also raises a concern about the specificity of diagnostic categories. Widespread co-morbidity (making more than one diagnosis in order to encompass patients’ problems) indicates basic deficiencies in our understanding of the natural boundaries of even the most severe conditions we are diagnosing in psychiatry.17,18,19 It is also common to find the ‘dominant’ diagnosis changing in any individual, almost exclusively on a subjective rather than empirical (such as physical test results) basis. Unlike in the rest of medicine where the reason for the patient’s symptoms is clarified by a diagnosis, psychiatric diagnoses serve empirically as nothing much more than descriptors. Thus, when a clinician claims that a patient is ‘really’ depressed, or has ADHD, or has bipolar disorder, or whatever, not only are they trying to turn something based on subjective opinion into something that appears empirical, but they are engaging with the process of reification (turning something subjective into something ‘concrete’). The problem with turning concepts into something that appears as if it exists as a fact in the natural world is that it can cause ‘tunnel vision’ for all concerned; a dominant story that limits alternative more functional possibilities for any individual.20 Thus if someone believes ADHD is a ‘real’ disorder that exists in their brains and is potentially lifelong, that person and those who know them may come to act according to this belief, thus helping to fulfil its prophecy.

There is also a poor correspondence between levels of impairment and having the required number of symptoms for many psychiatric diagnoses (even though ‘impairment’ is often included in the diagnostic criteria). Literature reviews and field trials to examine clinical significance criteria were not included in the preparation of DSM-IV. Thus many below the threshold for a diagnosis have higher levels of impairment than those above, with many who reach the cut off for a diagnosis having relatively low levels of impairment. 21,22,23

Reliability

Reliability is the extent to which clinicians can agree on the same diagnoses when independently assessing a series of patients. Over the last thirty years or so, academic psychiatrists have worked hard to improve the reliability of psychiatric diagnoses. This is partly in response to critics of psychiatry who pointed out that many of the common diagnoses in use at the time were meaningless because of poor levels of agreement between psychiatrists about key symptoms. Rosenhan’s 1973 study spurred on new attempts to ‘standardise’ diagnostic practice after he demonstrated that psychiatrists were often unable to discriminate between sane and psychotic people.24 Formal diagnostic systems like DSM and ICD attempted to address these problems by imposing diagnostic agreement on the profession through the use of standardised check-lists of symptoms for diagnostic criteria. Because of the repeated claim that this approach has improved reliability significantly, the diagnostic systems now in use give the impression of being reliable in an empirically verifiable way.

However, analysis of the studies involved in developing the first diagnostic manual that took this approach of ‘operationalising’ diagnosis through the check list of symptoms approach (DSM-III), found no diagnostic categories for which reliability in these studies was uniformly high. The ranges of reliability for major diagnostic categories were found to be very broad and in some cases ranged the entire spectrum from chance to perfect agreement, with the case summary studies (in which clinicians are given detailed written case histories and asked to make diagnoses – an approach that most closely approximates what happens in clinical practice) producing the lowest reliability levels.25 No studies of the reliability of DSM as a whole when used in natural clinical settings have shown uniformly high reliability, with many finding reliability ratings that are not that different than those in the pre-DSM-III studies. 25,26,27 To overcome this, developers of subsequent DSMs have simply de-emphasised the reliability problem, claiming this to have already been solved by the approach developed in preparing DSM-III.

Treatment and outcome

The technological paradigm is the dominant one that organises the way psychiatric services and treatments are delivered in most industrialised countries. This paradigm is predicated on the assumption that the technical aspects of medical and psychological care are of primary importance, and that these can be applied through making diagnoses and then applying corresponding treatment protocols.

However, there is a large literature on psychotherapy confirming that it is generally speaking a safe and effective intervention for common mental health problems as studied in Western populations, but there is little to suggest that a positive outcome is strongly related to selecting the ‘correct’ psychotherapeutic technique and much to suggest that the ‘common factors’ such as developing a strong therapeutic alliance, are more important.28,29,30 For example, several studies have shown that most of the specific features of Cognitive Behaviour Therapy (CBT) can be dispensed with, without adversely affecting outcomes. 31,32 The same holds for other forms of psychotherapy for depression. For example, The National Institute of Mental Health’s Treatment of Depression Collaborative Research Project (TDCRP), the largest trial to date comparing different treatments for depression (CBT, Inter-Personal Therapy [IPT], anti-depressants, and placebo) found that patients in each group had significant improvements, with no overall difference in outcome between each treatment group. However, the best predictor of outcome across all four groups was the quality of the relationship between patient and therapist (as perceived by the patient) early in treatment. 33,34, 35, 36

Recent meta-analyses have drawn similar conclusions. The quality of the therapeutic alliance accounts for most of the within-therapy variance in treatment outcome, and is up to seven times more influential in promoting change than treatment model. 28,37 Such data, when combined with the observed superior value, across numerous studies, of clients’ assessment of the relationship in predicting the outcome, makes a strong empirical case that the non-specific aspects of psychotherapy, or ‘know-how’ in building a strong therapeutic alliance, are more important than specific techniques being used. This is also evident in ‘real life’ clinical encounters not just research projects. For example, in a review of over 5000 cases treated in a variety of National Health Service settings in the UK, only a very small proportion of the variance in outcome could be attributed to psychotherapeutic technique, as opposed to non-specific effects such as the therapeutic relationship.38

The same principles can be found operating when using psychoactive drug treatments (that non-specific factors are more important than matching a drug to a diagnosis). Thus a number of psychiatrists have argued that instead of correcting imbalances, the evidence supports the view that pharmacological agents may be conceptualised as inducing particular psychological states which, though not specifically related to diagnosis, is nonetheless the basis for their usefulness.39 This reflects clinical practice where the few categories of psychoactive medications used in psychiatry (the SSRIs, major tranquilisers, benzodiazepines, Lithium, and anti-epileptics) are often used in a non-diagnosis specific way. For example, SSRIs are claimed to be efficacious in conditions as disparate as borderline personality disorder, depression, obsessive compulsive disorder, anorexia nervosa, bulimia, panic disorder, social phobias, and so forth. As a psychoactive substance SSRIs would appear to do ‘something’ to the mental state, but that something is not diagnosis specific. Like alcohol, which will produce inebriation in a person with schizophrenia, obsessive compulsive disorder, depression, or someone with no psychiatric diagnosis, SSRIs will also impact individuals in ways that are not specific to diagnosis. Similarly, major tranquilisers (misnamed anti-psychotics) have also been advocated for the treatment of depression, anxiety disorders, bipolar affective disorder, personality disorders, ADHD, as well as schizophrenia, a list that contains considerable overlap with that found for SSRIs.

Many psychiatric drug treatments, like psychological treatments, rely more on non-specific factors than disease-specific therapeutic effects. For example, it is generally assumed that drugs marketed as ‘antidepressants’ work through their pharmacological effects on specific neurotransmitters in the CNS, reversing particular states of ‘chemical imbalance’. However, the evidence points to placebo effects being more important than any neuro-pharmacological ones. Thus several meta-analyses have concluded that most of the benefits from ‘antidepressants’ can be explained by the placebo effect, with only a small amount of the variance (about 20%) attributable to the drug, a small amount moreover that is unlikely to be clinically significant for the vast majority of patients.40,41 Studies investigating the degree to which non-technical factors such as therapeutic relationship affect outcome, have found that even with psychoactive drug treatments these factors are far more influential than the drug alone. Thus having a good relationship with the prescribing doctor is a stronger predictor of a positive response to an ‘anti-depressant’ than just taking the drug regardless of who prescribes it. 28,42

The lack of treatment specificity is not limited to the more common and less severe presentations. Thus, although drugs marketed as ‘antipsychotic’ are often claimed to reverse a biochemical imbalance in psychotic patients, no such imbalance has been demonstrated. Furthermore, researchers have long been aware of a perplexing finding in cross-cultural studies. Research, including that carried out by the World Health Organisation, over the course of 30 years and starting in the early 1970s, shows that patients outside the United States and Europe have significantly lower relapse rates and are significantly more likely to have made a ‘full’ recovery and show lower degrees of impairment when followed up over several years despite most having limited or no access to ‘anti-psychotic’ medication. It seems that the regions of the world with the most resources to devote to mental illness – the best technology, medicines, and the best-financed academic and private-research institutions – had the most troubled and socially marginalised patients.43 Once again the impact of our psychiatric technologies seem to be minimal compared to common factors, in this case most likely to be the effects of ‘extra-therapeutic’ factors such as family support, community cohesion and tolerance for behaviours and experiences considered a sign of ‘illness’ and ‘dangerousness’ in the West.

Prognosis

Unlike the rest of medicine, no overall improvement in prognosis has been demonstrated in Europe and North America over the past century for those diagnosed with a mental disorder. Some studies indicate the opposite, that compared to the pre-psychopharmacology period there are more patients who have developed chronic conditions such as chronic schizophrenia than in the past. For example, in 1955, there were around 350 thousand adults in the US state and county mental hospitals with a psychiatric diagnosis. During the next three decades (the era of the first generation psychiatric drugs), the number categorised as disabled from mental illness rose to 1.25 million. By 2007 the number of people categorised as disabled mentally ill grew to more than 4 million adults. Similarly, the numbers of youth in America categorised as having a disability because of a mental condition leapt from around 16 thousand in 1987 to 560 thousand in 2007.44

Studies that have compared outcomes for psychotic disorders such as schizophrenia have repeatedly found that outcomes are better in poorer, non-developed countries when compared to richer, more industrialised ones.41 For example, the World Health Organisation’s international outcome in schizophrenia studies found that after 2 years about two thirds of the patients in the poor countries were doing well compared to only a third of the patients in the developed countries. The researchers concluded that “being in a developed country was a strong predictor of not attaining a complete remission.”45 Thus the progress attributable to modern mainstream psychiatric diagnostic based practice does not extend to improved prognosis.

One problem with medical model diagnostic approaches is that many of the diagnoses (such as schizophrenia, bi-polar disorder, dysthymia, ADHD, autism, OCD etc.) are conceived as conditions that are genetic and lifelong in nature (i.e. conceived as chronic conditions that are ‘hard-wired’ with little chance of making a complete recovery), where the best one can hope for is gaining some control over symptoms (through, for example, life-long use of medications). This constructs and often imposes a narrative of despair on those diagnosed with these ‘chronic’ conditions. As such psychiatric diagnoses can foreclose meaning by transforming a range of experiences and possible meanings that can be applied to these experiences into a narrow disease framework, limiting the cultural imagination to expecting largely negative outcomes.

Prognosis for those with mental disorders is also further hampered by the stigma associated with the medical model.46 Nearly all studies that have looked at the question of public attitudes toward mental illness have found an increase in biological causal beliefs across Western countries in recent years.47 However, biological attributions for mental illness are overwhelmingly associated with negative public attitudes such as a belief that patients are unpredictable and dangerous with associated fear of them and greater likelihood of wanting to avoid interacting with them. 48 Conversely, in studies where members of the public are given a psychosocial explanation for the sufferer’s symptoms (such as serious life events, loss, trauma etc.) they are much less likely to give negative attributions.48 Yet again, the ‘medical model’ diagnostic approach has a significantly negative impact causing an increase in stigma rather than a reduction.

Similar findings emerge in personal stories of those diagnosed with a ‘mental illness’. Through social action, the survivor movement has created safe spaces in which individuals can start the process of telling their own stories. Many of these stories show that users of mental health services felt stigmatised and marginalised by a psychiatric diagnosis, experiencing this as something that leads to the loss of ‘citizenship’.46,49 Being labelled with a chronic ‘genetic’ condition such as ‘schizophrenia’ interferes with a person’s identity and biography. Indeed, the presence of ‘insight’ (as defined by doctors) in schizophrenia has been found to lower self-esteem and can lead to despair and hopelessness.50 Paradoxically, it has been found that the presence of this type of ‘insight’ (meaning accepting you are mentally ill and need medical treatment) is negatively correlated with emotional well-being, economic satisfaction and vocational status. 51,52, 53 Thus accepting the medical model attitude to diagnosis brings expectations of a gloomy outlook with lifelong dependency on psychiatric treatment and little chance of a good recovery. For some therefore, rejecting the diagnosis (or ‘lack of insight’) may be understood as a positive way of coping with the implications of the diagnosis for personal identity.52,53

In summary it seems we now have good evidence that the diagnostic ‘illness like any other illness’ approach is likely to be contributing to a worse prognosis for those diagnosed, not better.

Colonialism

For the last few decades Western mental-health institutions have been pushing the idea of ‘mental-health literacy’ on the rest of the world. Cultures are viewed as becoming more ‘literate’ about mental illness the more they adopted Western biomedical conceptions of diagnoses like depression and schizophrenia. This is because of a belief that ‘modern’, ‘scientific’ approaches reveal the biological and psychological basis of psychic suffering and so provide a rational pathway to dispelling pre-scientific approaches that are often viewed as harmful superstitions. In the process of doing this we not only imply that those cultures that are slow to take up these ideas are therefore in some way ‘backward’, but we also export disease categories and ways of thinking about mental distress that were previously uncommon in many parts of the world. Thus conditions like depression, post-traumatic stress disorder, and anorexia appear to be spreading across cultures, replacing indigenous ways of viewing and experiencing mental distress.54,55 In addition to exporting these beliefs and values, Western drug companies see in such practice the potential to open up new and lucrative markets.54,56

Despite copious evidence from research in the non industrialised world, that shows the outcomes for major ‘mental illnesses’, is consistently better than in the industrialised world and particularly amongst populations who have not had access to drug based treatments,43,44,45 the World Health Organisation, together with the pharmaceutical industry, has been campaigning for greater ‘recognition’ of mental illnesses in the non-industrialised world, basing their assumptions on the idea that ICD/DSM descriptions are universally applicable categories.57 Like other marketing campaigns, this strategy has the potential to open up huge new markets for psychiatric drugs that maybe ineffective and can have serious side effects, at the same time as painting indigenous concepts of, and strategies to deal with, mental health problems, as being based on ignorance, despite their obvious success for these populations.

The idea of the individual as the locus of the self is a relatively recent Western invention and such a framework creates the psychological pre-conditions necessary for accepting the ‘atomised’ social worlds that have been created. Yet, mental well-being seems closely connected to social and economic factors. Several international studies have concluded that more important than poverty per se is the degree of inequality. Thus the greater the inequality (in economic and social resources) in any society, the poorer is the mental health of that society.58,59,60,61,62

A more subtle source of impact on cultural beliefs is due to psychiatric diagnoses inadvertently setting standards for ‘normality’, by categorising what emotional and behavioural traits and experiences should be considered ‘disordered’. As the criteria for diagnoses are arrived at by subjective judgments rather than objective evidence (being literally voted in or out of existence by committees), they will have an automatic bias toward the cultural standards found in economically dominant societies (who also tend to control what counts as ‘knowledge’ globally). This sets in motion a diagnostic system vulnerable to institutional racism in the dominant societies and colonialism in others, as other standards of normality will, at least to some extent, come to be viewed as ‘primitive’, ‘superstitious’ etc. and their populations will be viewed as needing to be (psycho)educated. As a result then, for the majority of the world, all manner of complex somatic/emotional complaints have to be re-categorised, spiritual explanations have to be denounced, parenting practices viewed as oppressive and so on.

Thus imposing Western medical model DSM/ICD style psychiatry on non-Western populations risks a number of things including: adoption of Western psychiatric notions of ‘psychopathology’ to express mental distress, undermining of existing cultural strategies for dealing with distress, more not less stigma for those with mental health problems, and the imposition of an individualistic approach that may marginalise family and community resources and divert attention from social injustice.

Cultural and Public policy impact

Despite adopting a DSM/ICD approach causing many problems for translating the subjective process of attaining a psychiatric diagnosis into a reliable and objective one in clinical practice; it has nonetheless had a significant impact on service provision and public and professional beliefs about mental distress. As a result of popularising the diagnostic systems created by DSM/ICD, it is widely argued that a significant proportion of the population suffers from mental illness, that this amounts to a significant economic burden, and that there is a strong case for investing in improved mechanisms of detection and treatment for these disorders. Across several surveys in the industrialised nations only about a third of those identified as suffering a mental health problem (according to DSM/ICD criteria) sought or were interested in seeking professional help.63,64,65,66 This has been interpreted as unsatisfactory case detection, provision and treatment, due to public and professional ignorance. However, there is little evidence to support the idea that popularising mental health diagnoses, convincing professionals and the public about the high prevalence of mental disorders, and convincing policy makers of the need to diagnose and treat more people, benefits the mental health of the society.

In order to increase rates of diagnosis and treatment, a variety of campaigns have been undertaken. For example, in the UK the Royal College of Psychiatrists and Royal College of General Practitioners launched their ‘Defeat Depression’ campaign in the early nineties. 67 It was intended to raise public awareness of depression, reduce stigma, train general practitioners in recognition and treatment, and make specialist advice and support more readily available. Unfortunately, evaluations of treatment and education guidelines in the UK following the ‘Defeat Depression’ campaign failed to detect significant improvements in clinical outcome.68,69,70 However, other effects of the campaign included a rapid increase in antidepressant prescribing and increased medicalisation of unhappiness and distress. As has been noted above, medicalisation of mental distress through promotion of the idea that mental health problems are best understood as ‘illness like any other illness’, increases rather than decreases stigma.

Unlike other areas of public health, mental health in those societies with the most developed services appears to be the poorest. In such societies ‘epidemics’ of psychiatric diagnoses (e.g. ADHD, autism, depression, bipolar disorder) have only emerged and become popularised in recent years. Whilst there are complex political, social and cultural reasons for this, they are in part based on new categories and ideas about personhood, the nature of distress etc. and so are at least in part the result of creating, broadening and popularising psychiatric diagnoses.

Conclusion

For any diagnostic system to establish itself as a scientifically useful paradigm that leads to greater knowledge of the natural world, it should be able to show that the categories ‘carve nature at its joints’ such as being able to demonstrate distinct aetiological links. For any diagnostic system to establish itself as clinically useful it must show that use of diagnostic labels aids treatment decisions in a way that impacts on outcome. As reviewed above there is little evidence to support the ICD/DSM paradigm being able to provide either the basis for collecting scientifically useful knowledge or clinically useful treatment decisions. There is much evidence to suggest that instead they can cause significant harm. The only evidence based conclusion that can be drawn is therefore that formal psychiatric diagnostic systems like ICD and DSM should be abolished.

New paradigms

Relying on DSM/ICD diagnostic categories to organise research, services, and treatment does not contribute to improved outcomes for those experiencing mental distress and is associated with considerable harm.

Alternatives to ICD/DSM are therefore needed. We can and should do better. We have all the evidence we need to work on re-organising our approaches locally, nationally, and internationally to develop services that are evidence based and can reduce the amount of harm DSM/ICD has caused at the same time as improving outcomes. New paradigms that draw on the existing evidence for what improves outcomes and that incorporates the views of those who matter most – service users – can easily be developed and implemented. The following represents some good starting points:

1. Aetiology: As discussed in this paper there is a strong association between trauma, particularly early childhood trauma, and adversity and the subsequent development of mental disorders including psychosis. There is also a strong association between the degree of socio-economic inequality and levels of mental distress in any society. Other associations include dietary, lifestyle, family functioning and attachments. Research that examines the relationship between contextual factors and degrees of impairment, without trying to link them to formal psychiatric categories, has a greater likelihood of succeeding in developing useful scientific knowledge about mental distress. Moving the focus away from the eugenic-like search for genetic and neurological abnormalities will allow for greater acceptance of human diversity, and decrease the likelihood of human rights, political and social issues being inappropriately medicalised. Given the strong relationship between increasing acceptance of the diagnostic medical model and increasing stigma, abolition of DSM/ICD will also help in the fight against stigma.

2. Clinical: Decades of outcome research into treatment of psychiatric disorders shows, that despite the development of many new techniques, the outcomes being achieved in studies 40 years ago are similar to those being achieved now. In other words our advances in therapeutic techniques have not yet led to improvement in overall outcomes for service users. Research has found that certain intra-therapeutic factors such as the therapeutic alliance has a much greater effect on outcome than model or technique used and that extra-therapeutic factors such as social support has an even greater impact on outcome than intra-therapeutic ones.28,30,42 A variety of studies (in areas as diverse as psychotherapy services, community mental health services, substance misuse, and marital counselling) have found that incorporating ideas from this outcome literature, such as using session by session feedback on outcome and therapeutic alliance, can improve outcomes.30,42 The message from this research is that services can improve outcomes, not by using diagnostic categories to choose treatment models, but by concentrating instead on developing meaningful relationships with service users that fully includes them in decision making processes. International service user led movements, such as the ‘recovery’ movement, that focus on the inclusion of people in recovery from mental health problems as collaborators in research, service development, and treatment model development provide good examples of how this evidence can be developed to change institutional culture.71,72,73 Services in non-Western settings should be able to incorporate local beliefs and practices and the wholesale export of Western ethno-psychiatry can be stopped.

Developing the knowledge base and services in this manner would give mental health services and practitioners a better chance of improving the lives of those they work with. It will also help with breaking long standing barriers between mental health services and the rest of medicine, by allowing the mental health professions to focus on developing paradigms that are evidence based and which properly incorporates an understanding of how physical and mental well-being are closely related to each other. These non-diagnostic based paradigms can then assist in helping the many patients who present with physically unexplained symptoms or chronic conditions, which inevitably impact on their mental well-being, without needing to label them as ‘mentally ill’.

The real gift of psychiatry is what it can offer the rest of medicine that is more unique to this field, which is an understanding of the person in their context. Psychiatry has to sit at the confluence of a variety of disciplinary discourses (Sociology, anthropology, psychology, philosophy, medicine, cultural studies, politics, theology etc.) and it is this broader understanding of the human and their health and well-being that psychiatry ‘brings to the table’. By lazily importing the diagnostic model from general medicine we end up miss-selling and under-utilising the unique skills the profession of psychiatry brings to healthcare by the ‘dumbing down’ of what we do into simplistic diagnosis driven protocols that has more to do with successful consumer culture marketing than science. Changing to more evidence compatible paradigms is now long overdue.

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Sami Timimi
Consultant child and Adolescent Psychiatrist
Director of Medical Education
Lincolnshire Partnership Foundation NHS Trust
Visiting Professor of Child and Adolescent Psychiatry
Faculty of Health and Social Sciences
Lincoln University
 
International Critical Psychiatry Network

See my Author’s page on the ICPN website
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What is your Opinion of Psychiatric Diagnosis?

This is an important paper written by Steven Coles and colleagues about psychiatric diagnosis. What do you think? Have your say!

What is your Opinion of Psychiatric Diagnosis?

What is your view on psychiatric diagnosis? Should the diagnosis of schizophrenia be abolished as the Campaign for the Abolition of the Schizophrenia Label wish? For both those working in mental health services and those on the receiving end, how important is diagnosis to your life? There are many different views on psychiatric diagnosis from fierce advocates to those who decry the practice. A number of survivors, academics, professionals, and service users have criticised diagnosis. However, within mental health services psychiatric diagnosis remains dominant. Psychiatrists (and other professionals) claim they use diagnosis to understand people’s experiences, behaviour and distress.  Diagnosis shapes how services are organised, who will be helped and how services will support or “treat” people. Psychiatric diagnosis also has a major impact on whether people are detained against there will in hospital – the civil liberties of people with a psychiatric diagnosis are at a greater risk than anyone else in society (other than suspected terrorists). Diagnosis influences whether people are forced to take major tranquilizers (“antipsychotics”), and whether they receive financial benefits.

Despite the immense controversy surrounding diagnosis, my experience is that the debates around diagnosis are not openly discussed between staff or with people using (or forcibly brought into) mental health services. Psychiatric diagnosis has become an everyday and often unquestioned part of mental health practice. Is this simply because critics of diagnosis have weak arguments? Is it because the scientific basis of psychiatric diagnosis is so strong? Is there no alternative? A group of Clinical Psychologists working in East Midlands Adult Mental Health Services have looked at the issue of psychiatric diagnosis and written a position paper (Coles & SPIG, 2010). They conclude that “psychiatric diagnosis does not meet its scientific and expert claims” and does not deserve to be so dominant in mental health services.

The East Midlands group highlighted a number of negative effects of psychiatric diagnosis. They note that diagnosis places the cause of difficulties on the individual; the group feel more attention should be paid to people’s life experiences, such as abuse, poverty, discrimination and disempowerment. The position paper also observes that the language of diagnosis is barrier to communication between staff and people using services. Furthermore, diagnosis is not aware that it is based upon dominant western (often male) ideas of what is normal, and ignores that other cultures and subcultures might have different or a broader idea of what is normal. The paper also notes some modest alternatives to moving beyond diagnosis (for access to the document see www.bps.org.uk/dcp-sigpr/publications-%26-documents/publications_home.cfm).

The East Midlands Paper is accessible at the above link, as well as on the Hearing Voices Network website. The group is hoping to open up a debate around diagnosis and would welcome people’s thoughts on the paper and on diagnosis. The East Midlands paper suggests that the current dominance and use of diagnosis is part of the problem and not part of the solution as psychiatry claims. What do you think? What is your experience of diagnosis?

References

Coles, S. & SPIG (2010).  Position on Psychiatric Diagnosis. East Midlands: Psychosis and Complex Mental Health Special Interest Group

Steven Coles

Clinical Psychologist

steven.coles@nottshc.nhs.uk

Demedicalising Misery: Psychiatry, Psychology and the Human Condition.

Demedicalising Misery: Psychiatry, Psychology and the Human Condition. Co-edited with Mark Rapley  and Joanna Moncrieff. Published by Palgrave Macmillan.

Thomas Szasz (1960) suggested that the myth of ‘mental illness’ functions to ‘render more palatable the bitter pill of moral conflict in human relations’. The medicalization of distress enables the mental health professions to manage the human suffering that they are confronted with, and also the suspicion that there is little that they can do to help. But the medicalization of misery and madness renders people unable to comprehend their experiences in ordinary, meaningful terms. In this collection we restore to everyday discourse a way of understanding distress that, unlike contemporary psychiatry and psychology, recognises and respects the essential humanness of the human condition. De-medicalizing Misery is a shorthand term for this project. The book resists the psychiatrization and psychologization of human experience, and seeks to place what are essentially moral and political – not medical – matters back at the centre of our understanding of human suffering.

Notes on Contributors
Preface; R.Dallos
Carving Nature at its Joints? DSM and the Medicalization of Everyday Life; M.Rapley, J.Moncrieff & J.Dillon
Dualisms and the Myth of Mental Illness; P.Thomas & P.Bracken
Making the World Go Away, and How Psychology and Psychiatry Benefit; M.Boyle
Cultural Diversity and Racism: An Historical Perspective; S.Fernando
The Social Context of Paranoia; D.J.Harper
From ‘Bad Character’ to BPD: The Medicalization of ‘Personality Disorder’; J.Bourne
Medicalizing Masculinity; S.Timimi
Can Traumatic Events Traumatise People? Trauma, Madness and ‘Psychosis’; L.Johnstone
Children Who Witness Violence at Home; A.Vetere
Discourses of Acceptance and Resistance: Speaking Out About Psychiatry; E.Speed
The Personal Is the Political; J.Dillon
‘I’m Just, You Know, Joe Bloggs’: The Management of Parental Responsibility for First-Episode Psychosis; C.Coulter & M.Rapley
The Myth of the Antidepressant: An Historical Analysis; J.Moncrieff
Antidepressants and the Placebo Response; I.Kirsch
Why Were Doctors so Slow to Recognise Antidepressant Discontinuation Problems?; D.Double
Toxic Psychology; C.Newnes
Psychotherapy: Illusion With No Future?; D.Smail
The Psychologization of Torture; N.Patel
What Is To Be Done?; J.Moncrieff, J.Dillon & M.Rapley
Figure: Papers Using Term ‘Antidepressant’ On Medline 1957-1965
Index

‘Despite longstanding awareness of the limitations of the medical model when applied to difficulties of human behavior and adjustment, the fields of psychiatry and psychology continue to accede to the pressures of medicine and the drug industry in their conceptualization of these human realities. Ironically, however, this medical model, eager as it is to fit so much of people’s experience into diagnostic categories, is a social construction. This book represents a significant effort to de-mystify, de-medicalize, and reclaim important aspects of the human condition.’ – Kenneth D. Keith, Professor, Department of Psychological Sciences, University of San Diego, USA

 

De-Medicalizing Misery has assembled an impressive cast of leading mental health experts. Together they challenge the simplistic and pessimistic biological model of human distress that has, with eager support from the pharmaceutical industry, dominated the mental health field for far too long. This evidence-based, humane and optimistic book not only explains where biological psychiatry went wrong, it spells out the alternatives.’ – John Read, University of Auckland, New Zealand and Editor of ‘Models of Madness’

 

  ‘The psychiatrist or psychologist is expected to do something for every patient sitting in front of him or her, but how robust is the intellectual basis of psychiatric science when psychiatric ‘diseases’ are merely symptom clusters – clustered by us, not by nature? We are in indeed in the age of the medicalization of everyday life, when Lord Layard, economist and architect of the IAPT programme, can write in the BMJ that ‘mental illness’ has taken over from unemployment as our greatest social problem. But what is the test of ‘mental illness’? In DeMedicalizing Misery the authors examine some of the domains lamentably absent from orthodox psychiatry and psychology training programmes, with their medical model focus, and in so doing raise the IQ of the whole debate. And not just for clinicians.’ – Dr Derek Summerfield, Consultant Psychiatrist & Senior Lecturer, Institute of Psychiatry, King’s College, London, UK.
 

Authors: MARK RAPLEY is Professor of Clinical Psychology at the University of East London, UK. He is the author of The Social Construction of Intellectual Disability, Quality of Life Research and, with Susan Hansen and Alec McHoul, Beyond Help: A Consumers’ Guide to Psychology.
 
JOANNA MONCRIEFF is Senior Lecturer in the Department of Mental Health Sciences at University College London, UK and a Practising Consultant Psychiatrist at the North East London Foundation Trust. She has spent her academic career re-evaluating the nature and efficacy of psychiatric drugs and exploring the history and politics of psychiatry. She is the co-chair of the Critical Psychiatry Network, and has campaigned against the dominance of the biomedical approach to psychiatry, the extension of psychiatric coercion and the influence of the pharmaceutical industry, in alliance with service user groups. She is the author of The Myth of the Chemical Cure (Palgrave Macmillan), A Straight Talking Introduction to Psychiatric Drugs, and numerous papers and book chapters.
 
JACQUI DILLON is the National Chair of the Hearing Voices Network, UK, and a Director of Intervoice – the International Network for Training, Education and Research into Hearing Voices. She is a campaigner, international speaker and trainer specialising in hearing voices, psychosis, dissociation and trauma. She is the co-editor of Living with Voices: An Anthology of 50 Voice Hearers’ Stories of Recovery. She has published numerous articles and papers, is on the editorial board of the journal Psychosis: Psychological, Social and Integrative Approaches and is a member of the collective for Asylum, The Magazine for Democratic Psychiatry.


Exile (2008)

Produced by: Jenni Autio, Tea Latvala, Sampo Lehtinen, Oskari Pastila

Written & directed by: Sampo Lehtinen, Oskari Pastila

Exile is an experimental stage performance; a fusion of computer animations, documentary, fictional narrative, music and fashion design.

Exile tells the story of Kathryn, a woman who hears voices and who has built part of her personality based on them. Contrary to general prejudices she finds these voices helpful, even vital to her existence. How does she cope in the modern society where every alteration from the norm seems intolerable and problematised through social and commercial mechanisms.

The idea of Exile was based on a general view that there is no flawless analogy in our individual perceptions. Contextual structure of the work was build around a documentary recorded in London in March 2006 in association with The Hearing Voices Network.

On the soundtrack the fictional narrative intertwines with the documentary (audio) about an actual voice hearer who files an account about her life with voices. The stage act offers visual support to the narrative. Spectators witness the gradual effects a medical attempt to eradicate Kathryns internal voices have on her. While she gradually loses her control over the voices she also surrenders her physical composure and grip on reality.

Read More: http://www.bodynavigation.ru/en/participants/exile.php

In Your Head: Hearing Voices

Published in: Psychology Today, January 1, 2007, by William Lee Adams

Despite their association with mental illness, auditory hallucinations don’t always torment those who hear them. In fact, only one out of every three so-called “voice hearers” requires psychiatric help. The other two don’t experience difficulties and may even consider their voices supportive or inspiring.

“My voices know me better than anyone else, and they also protect and comfort me,” says Jacqui Dillon, head of a London support group for voice hearers. She and other group members report that voices can alert them to oncoming cars and suspicious passersby, provide encouragement during stressful times, and offer reminders to pick things up at the grocery store.

Whether they threaten or soothe, auditory hallucinations usually begin after trauma: Seventy percent of people who hear voices first detect them following physical or sexual abuse, an accident, or the loss of a loved one. “The emotion they feel about their trauma complicates how they interpret the voices,” says Sara Tai, a psychologist at the University of Manchester in England who studies why some hallucinators thrive while others end up in psychiatric care. Typically, the greater the trauma, the more likely voices will sound threatening.

Read More: http://www.psychologytoday.com/articles/200701/in-your-head-hearing-voices

Experts call for ban on schizophrenia ‘label’

Published in: Daily Mail, 9 October, 2006

Schizophrenia should be abolished as a concept because it is unscientific, stigmatising, and does not address the root causes of serious mental illness, a group of experts said today.

The diagnosis, which emerged in the 19th century, is flawed and harmful, they claimed. It not only grouped together patients with widely ranging symptoms, but offered no explanation for their illnesses.

Once given a diagnosis of schizophrenia, a person was labelled an incurable social misfit and placed at the mercy of a psychiatric system that mostly benefited the drug industry.

A new campaign called CASL (Campaign for the Abolition of the Schizophrenic Label) is said to be gaining increasing support from both patients groups and professionals.

It wants patients to be assessed according to their individual experiences and histories rather than blanket-categorised as “schizophrenic”.

Read more: http://www.dailymail.co.uk/health/article-409472/Experts-ban-schizophrenia-label.html#ixzz1H2oOhJEG

Critical & Alternative Perspectives

Critical & Alternative Perspectives

On The Web

The Campaign to Abolish the Schizophrenia Labelwww.caslcampaign.com
CASL is calling for the label of schizophrenia to be abolished on the grounds that it is outdated, unscientific, stigmatising and presents a barrier to effective and appropriate support to individuals diagnosed with the label.

Coming off Psychiatric Medicationwww.comingoff.com
Information about coming off psychiatric medication.

The Critical Psychiatry Networkwww.critpsynet.freeuk.com
The Critical Psychiatry Network provides a network to develop a critique of the contemporary psychiatric system.

The Freedom Centrewww.freedom-center.org
An American-based support and activism community for anyone experiencing mental health difficulties. Includes event lists, links and advice around medication.

The Icarus Projecthttp://theicarusproject.net
Support network started in the U.S. for people ‘navigating the space between brilliance and madness’

The International Critical Psychiatry Networkwww.criticalpsychiatry.net
Created by medical doctors as a forum (primarily for medical doctors) to discuss, critique, and publicise opinions, practices, literature, and events that support critical thinking and alternative approaches to psychiatry.

International Network Toward Alternatives and Recoveryhttp://intar.org/
Gathers prominent survivors, professionals, family members, and advocates from around the world to work together for new clinical and social practices towards emotional distress and what is often labeled as psychosis.

Peter Lehmann Publishingwww.peter-lehmann-publishing.com
Publishes excellent books available in English on alternative approaches to mental health problems.

Mad Chickswww.mad-chicks.org.uk
A new movement, which focuses on issues specific to women mental health service users, using creativity to achieve our aims and attract attention to our causes. Site contains info, creativity etc.

Mad Pride www.ctono.freeserve.co.uk
The all new website of this energetic mental health surivivors organisation. Includes details of future gigs & events, the origins of Mad Pride and their ‘Stop The Suicides’ campaign

MindFreedom Internationalwww.mindfreedom.org

MindFreedom International unites 100 grassroots groups and thousands of members to win campaigns for human rights of people diagnosed with psychiatric disabilities.

National Service User Networkwww.nsun.org.uk
Aims to create a network which will engage and support the wide diversity of mental health service users and survivors across England in order to strengthen the user voice.

No Free Lunchwww.nofreelunch-uk.org
This is the UK branch of an organisation that seeks to promote the distancing of health professionals from the influence of the pharmaceutical industry.

PCCS Bookswww.pccs-books.co.uk
Publisher of counselling and psychotherapy books and journals. Committed to reflexive, radical and critical contemporary psychology theory and practice

Soteria Networkwww.soterianetwork.org.uk
Soteria is a network of people in the UK promoting the development of drug-free and minimum medication therapeutic environments for people experiencing ‘psychosis’ or extreme states.

The Spiritual Crisis Networkwww.spiritualcrisisnetwork.org.uk
A UK based network set up to improve access to approaches that view psychosis as a spiritual crisis or spiritual emergence ideas.

Working to Recoverywww.workingtorecovery.co.uk
A site run by mental health trainers Ron Coleman and Karen Taylor emphasising recovery-orientated approaches to mental health care. Includes information about training events, useful links and an online bookshop.

World Network of Users and Survivors of Psychiatryhttp://wnusp.rafus.dk/
WNUSP is an international organization of users and survivors of psychiatry.

In Print

Asylum Magazinewww.asylumonline.net/subscribe.htm
Asylum magazine is a forum for free debate, open to anyone with an interest in psychiatry or mental health. We especially welcome contributions from service users or ex-users (or survivors), carers, and frontline psychiatric or mental health workers (anonymously, if you wish). The magazine is not-for-profit and run by a collective of unpaid volunteers.

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Whitaker, R. (2010) Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. Crown Publishing Group (NY).

An extremely effective developer of services

I have known Jacqui Dillon for several years now — we first met in the early 2000s when she attended the London-based Critical Mental Health Forum, in which I was also involved.  Jacqui has been an extremely effective developer of services in the third sector.  She developed the London Hearing Voices Project and has also chaired the national Hearing Voices Network for several years.

She is a thoughtful and innovative worker who builds good collaborative relationships both with those who use mental health services and with mental health professionals.  She has also been very effective in securing funding for those organisations with which she works.

I work on a clinical psychology training programme and Jacqui has taught sessions on a range of topics on our programme for several years now.  Trainees have said that she is a very engaging and inspiring speaker who also has lots of practical advice about how to bring change in mental health services.

When I’ve seen Jacqui speak I also have been moved and inspired.  Given her earlier career as a journalist it is no surprise that she has been doing more writing, recently co-editing Living with Voices.  She has a national and international reputation and is approached by a range of media organisations for comments in relation to voice hearing and mental health more generally.

Dr Dave Harper, Reader in Clinical Psychology, University of East London. Academic Tutor on the Doctoral Degree in Clinical Psychology programme.