Psychologists v Psychiatrists 2

Here is the British Psychological Society Division of Clinical Psychology Position Statement on classification, released 13-5-13

I do think that this is a fascinating and important debate.

 

Division of Clinical Psychology Position Statement Final Version
Division of Clinical Psychology Position Statement
on the Classification of Behaviour and Experience in Relation to
Functional Psychiatric Diagnoses
Time for a Paradigm Shift
The DCP is of the view that it is timely and appropriate to affirm
publicly that the current classification system as outlined in DSM
and ICD, in respect of the functional psychiatric diagnoses, has
significant conceptual and empirical limitations. Consequently,
there is a need for a paradigm shift in relation to the experiences
that these diagnoses refer to, towards a conceptual system not
based on a ‘disease’ model.
Context
Classification is fundamental in medicine. To be effective, it requires a reliable and
valid system for categorisation of clinical phenomena in order to aid communication,
select interventions, indicate aetiology, predict outcomes, and provide a basis for
research. Medical diagnosis is the process of matching an individual’s pattern of
symptoms and biological signs to a standard pattern in the classification, and
ensuring that similar but alternative patterns are discounted in the matching – the
process of differential diagnosis. The patterns themselves are commonly categorical;
if it is one it cannot be the other, but several can co-occur (co-morbidity).
In psychiatry, diagnoses rely on the use of the Diagnostic and Statistical Manual of
Mental Disorders (DSM 5) and the International Classification of Diseases:
Classification of Mental and Behavioural Disorders (ICD-10). The regular revision of
these two major classification systems is a clear recognition that they are, and
remain, works in progress. The need for revision is a consequence not only of the
need to accommodate evidence-based advances in thinking and practice, but also
reflects more fundamental concerns about the development, personal impact and
core assumptions of the systems themselves.
The development and use of these classification systems for psychological distress
and behaviour has never been free of controversy. Many of the issues that arise in
relation to psychiatric diagnosis stem from applying physical disease models and
medical classification to the realms of thoughts, feelings and behaviours, as implied
by terms such as ‘symptoms’ and ‘mental illness’ or ‘psychiatric disease’. The
Division of Clinical Psychology (DCP) has historically held mixed views about
psychiatric classification and its implications in theory and practice, reflecting its
position as representing clinical practitioners in a wide range of specialisms and as a
scientific body. The DCP recognises that the current classification systems have
underpinned much research and theory in the area and have shaped the structure
and delivery of mental health services. Secondly, these systems provide seemingly
‘tangible’ entities for use in administrative, benefits, and insurance systems. Thirdly,
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Division of Clinical Psychology Position Statement Final Version
they are broadly accepted by most professional groups, many service users, the
media and the general public.
At the same time it should be noted that functional psychiatric diagnoses such as
schizophrenia, bipolar disorder, personality disorder, attention deficit hyperactivity
disorder, conduct disorders and so on, due to their limited reliability and questionable
validity, provide a flawed basis for evidence-based practice, research, intervention
guidelines and the various administrative and non-clinical uses of diagnosis. This has
been a matter of cross-professional concern for many years (e.g. Barker, 2011; BPS,
2000, 2011; Boyle, 2002; Bentall, 2004; Bracken et al., 2012; Coppock & Hopton,
2000; Johnstone, 2008; Moncrieff, 2010). The current classification systems are less
controversial for conditions with an identified biological aetiology such as in the fields
of neuropsychology, the dementias, and moderate – severe learning disability.
Nevertheless, serious concerns have been raised about the increasing
medicalisation of distress and behaviour in both adults and children (BPS, 2011;
Conrad, 2007). The ‘functional’ diagnoses, for which there is substantial evidence for
psychosocial factors in aetiology, and very limited support for a disease model, give
rise to a wider range of views and positions and are the primary focus of this
statement.
This position should not be read as a denial of the role of biology in mediating and
enabling all forms of human experience, behaviour and distress (Cromby, Harper &
Reavey, 2013), as is demonstrated, for example, in emerging epigenetic research
(e.g. Read & Bentall, 2012; Szyf & Bick, 2013.) It recognises the complexity of the
relationship between social, psychological and biological factors. In relation to the
experiences that give rise to a functional psychiatric diagnosis, it calls for an
approach that fully acknowledges the growing amount of evidence for psychosocial
causal factors, but which does not assign an unevidenced role for biology as a
primary cause, and that is transparent about the very limited support for the ‘disease’
model in such conditions. Such an approach would need to be multi-factorial, to
contextualise distress and behaviour, and to acknowledge the complexity of the
interactions involved, in keeping with the core principles of formulation in Clinical
Psychology (DCP, 2011).
The Role of Clinical Psychologists
Irrespective of whether the psychiatric diagnosis refers to a condition with an
established primary biological basis or not, there is clearly an identified role for
psychological assessment, formulation and intervention in addressing psychosocial
factors, taking into account the influences of biological contributions. The same
pertains to applied psychology in health, where the role of psychologists is to identify,
formulate and offer interventions relevant to the biopsychosocial factors that may
predispose to physical illness and will materially influence its course, outcome and
impact.
The Rationale for a Paradigm Shift
The statement outlines the rationale for this paradigm shift and makes
recommendations for developing a new approach. The phrase ‘psychiatric diagnosis’
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Division of Clinical Psychology Position Statement Final Version
will be used as a short hand for the current classification scheme of the functional
diagnoses.
The key conceptual issues and concerns can be summarised as follows:
Core Issue 1: Concepts and models
• Interpretation presented as objective fact: Psychiatric diagnosis is often presented
as an objective statement of fact, but is, in essence, a clinical judgement based on
observation and interpretation of behaviour and self-report, and thus subject to
variation and bias (e.g. Kirk & Kutchins, 1994).
• Limitations in validity and reliability: As a consequence of the above, numerous
critiques testify to the resulting problems in reliability and validity, and the issues
have surfaced once again in the process of developing DSM 5 (Bentall, 2004;
Frances, 2012; Kirk & Kutchins, 1994).
• Restrictions in clinical utility and functions: The above limitations diminish the utility
of functional diagnoses for purposes such as determining interventions, developing
treatment guidelines, commissioning services, and carrying out research based on
these categories.
• Biological emphasis: The dominance of a physical disease model minimises
psychosocial causal factors in people’s distress, experience and behaviour while
over-emphasising biological interventions such as medication (Boyle, 2013;
Cromby & Harper, 2013).
• Decontextualisation: Psychiatric diagnosis obscures the links between people’s
experiences, distress and behaviour and their social, cultural, familial and personal
historical contexts.
• Ethnocentric bias: Psychiatric diagnosis is embedded in a Western worldview. As
such, there is evidence that it is discriminatory to a diverse range of groups and
neglectful of areas such as ethnicity, sexuality, gender, class, spirituality and
culture (e.g. Bayer, 1987; Busfield, 1996; Fernando, 2010; Shaw & Proctor, 2005).
Core issue 2: Impact on service users
The needs of services users should be central to any system of classification.
Service users express a wide range of views on psychiatric diagnosis, and the DCP
recognises the importance of being respectful of their perspectives. Some service
users report that diagnosis is useful in putting a name to their distress and assisting
them in the understanding and management of their difficulties, whereas for others
the experience is of negativity and harm. Some of the key concerns include:
• Discrimination: Research has demonstrated discrimination due to negative social
attitudes towards those with a psychiatric diagnosis. This can create and compound
social exclusion (Read, Haslam, Sayce & Davies, 2006).
• Stigmatisation and negative impact on identity: The language of disorder and deficit
can negatively shape a person’s outlook on life, and their identity and self-esteem
(Barham & Hayward, 1995; Estroff, 1993; Honos-Webb & Leitner, 2001).
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Division of Clinical Psychology Position Statement Final Version
• Marginalising knowledge from lived experience: Service users often emphasise the
primary significance of practical, material, interpersonal and social aspects of their
experiences, which only constitute subsidiary or ‘trigger’ factors in the current
system of classification (Beresford, 2013).
• Decision-making: Decisions about how to classify a person’s behaviour and
experience are often imposed as an objective fact, rather than shared in a
transparent and open manner. For example service users’ disagreement with their
diagnosis can lead to being labelled as lacking insight, without acknowledgement of
the limitations of the current system (Terkelsen, 2009).
• Disempowerment: The current classification systems position service users as
necessarily dependent on expert advice and treatment, which may have the effect
of discouraging them from making active choices about their recovery and the best
means of achieving it. Many recovery narratives include a rejection of diagnoses
(Bassman, 2007; Deegan, 1993; Longden, 2010; May, 2000)
• As noted above, diagnosis can lead to an over-reliance on medication, while
underplaying the impact of its physical and psychological effects (Moncrieff, 2008).
Summary
The DCP believes there is a clear rationale and need for a paradigm shift in relation
to functional psychiatric diagnoses. It argues for an approach that is multi-factorial,
contextualises distress and behaviour, and acknowledges the complexity of the
interactions involved in all human experience.
Action Points from the Position Statement
Action point 1
To share within the DCP and through pre-qualification training and continuing
professional development, the issues raised by this statement. The aim is to
achieve greater openness and transparency about the uses and limitations of
the current system, and enhance service users’ and carers’ awareness and
understanding of the issues.
Action point 2
To open up dialogue with partner organisations, service users and carers,
voluntary agencies, and other professional bodies in order to find agreed ways
forward. This will necessarily include safeguarding access to health and
social care, benefits, work support, and legal and educational services that are
currently diagnosis-based.
Action point 3
To support work, in conjunction with service users, on developing multifactorial
and contextual approaches which incorporate social, psychological
and biological factors.
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Division of Clinical Psychology Position Statement Final Version
Action point 4
To ensure that a psychosocial perspective and psychological work are
included in the electronic health record.
Action point 5
For the DCP to continue to promote the use of psychological formulation as
one response to the concerns identified in this statement.
References
Barham, P. & Hayward, R. (1995). Re-locating madness: From the mental patient to the person.
London: Free Association books.
Barker, P. (2011). Psychiatric diagnosis. In P.Barker (Ed.) Mental health ethics: The human
context. Abingdon, New York: Routledge, pp.139-148.
Bassman, R. (2007). A fight to be: A psychologist’s experience from both sides of the locked
door. New York: Tantamount Press.
Bayer, R. (1987). Homosexuality and American psychiatry: The politics of diagnosis. New Jersey:
Princeton University Press.
Bentall, R. P. (2004). Madness explained. London: Penguin.
Beresford, P. (2013). Experiential knowledge and the reconception of madness. In S. Coles, S.
Keenan & B. Diamond (Eds.), Madness contested: Power and practice. Ross-on-Wye: PCCS
Books.
Boyle, M. (2002). Schizophrenia: A scientific delusion? (2nd edn.) Hove, New York: Routledge.
Boyle, M. (2013). The persistence of medicalisation: Is presentation of alternatives part of the
problem? In S. Coles, S. Keenan & B. Diamond (Eds.), Madness contested: Power and practice.
Ross-on-Wye, (pp.3-22) PCCS Books.
Bracken, P., Thomas, P., Timimi, S., Asen,E., Behr, G., Beuster, C.. et al. (2012). Psychiatry
beyond the current paradigm. The British Journal of Psychiatry, 201, 430–434.
British Psychological Society (2000). Recent advances in understanding mental illness and
psychotic experiences. A report by the British Psychological Society Division of Clinical
Psychology. Leicester: British Psychological Society.
British Psychological Society (2011). Response to the American Psychiatric Association: DSM –
5 development. Leicester: British Psychological Society.
Busfield, J. (1996). Men, women, and madness: Understanding gender and mental disorder.
London: Macmillan.
Conrad, P. (2007). The medicalization of society: On the transformation of human conditions into
treatable disorders. Baltimore: John Hopkins University Press.
Coppock, V. & Hopton, J. (2000) Critical perspectives on mental health. London: Routledge.
Cromby, J. & Harper, D. (2013). Paranoia: Contested and contextualised. In S. Coles, S. Keenan
& B. Diamond (Eds.), Madness contested: Power and practice. Ross-on-Wye: PCCS Books, pp.
23 – 41.
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Cromby, J., Harper, D. & Reavey, P. (2013). Psychology, mental health and distress.
Basingstoke: Palgrave MacMillan.
Deegan, P.E. (1993). Recovering our sense of value after being labelled mentally ill. Journal of
Psychosocial Nursing and Mental Health Services, 31, 7–11.
Division of Clinical Psychology (2011). Good Practice Guidelines on the use of psychological
formulation. Leicester: British Psychological Society.
Estroff, S. (1993). Identity, disability and schizophrenia: The problem of chronicity. In S.
Lindenbaum & M. Lock (Eds.), Knowledge, power, and practice: The anthropology of medicine
and everyday life. Berkeley: University of California.
Fernando, S. (2010). Mental health, race and culture (3rd edn.). Basingstoke: Palgrave.
Frances, A. (2012). DSM 5: How reliable is reliable enough? Psychology Today, Jan 18th.
Honos-Webb, L. & Leitner, L.M. (2001). How using the DSM causes damage: A client’s report.
Journal of Humanistic Psychology, 41, 36 – 56.
Johnstone, L. (2008). Psychiatric diagnosis. In T. Turner & B. Tummey (Eds.) Critical issues in
mental health. Hampshire: Palgrave MacMillan, pp.5-22.
Kirk, S. & Kutchins, H. (1994). The myth of the reliability of the DSM. Journal of Mind and
Behaviour, 15, 71–86.
Longden, E. (2010). Making sense of voices: A personal story of recovery. Psychosis:
Psychological, Social and Integrative Approaches, 2, 255-259.
May, R. (2000). Routes to recovery from psychosis: The roots of a clinical psychologist. Clinical
Psychology Forum, 146, 6-10.
Moncrieff, J. (2008). The myth of the chemical cure. Basingstoke: Palgrave MacMillan.
Moncrieff, J. (2010). Psychiatric diagnosis as a political device. Social Theory and Health, 8, 370-
382.
Read, J. & Bentall, R. (2012). Negative childhood experiences and mental health. British Journal
of Psychiatry, 200, 89-91.
Read, J., Haslam, N., Sayce, L. & Davies E. (2006). Prejudice and schizophrenia: A review of the
‘mental illness is an illness like any other’ approach. Acta Psychiatrica Scandinavica, 114, 303 –
318.
Shaw, C. & Proctor, G. (2005). Women at the margins: A critique of borderline personality
disorder. Feminism and Psychology, 15, 483 – 490.
Szyf, M. & Bick, J. (2013). DNA methylation: A mechanism for embedding early life experiences
in the genome. Child Development, 84 (1), 49–57.
Terkelsen, T. B. (2009). Transforming subjectivities in psychiatric care. Subjectivity, 27, 195
-216.
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