The pointless fight over mental health classification

In the wake of any mental health related story, in this case the death of Robin Williams, there is always a renewed flurry of criticism of the very concept of mental health diagnosis, as practiced by psychiatrists using the DSM or ICD classification. The neuroimaging scientists, geneticists and some psychologists are calling for paradigm shifts in our understanding of mental distress and illness. So what do they want, and what should we do about?

The DSM is a descriptive classification. It allows professionals to look at a person’s pattern of behaviour, thoughts and emotions and see whether they fit into a constellation of difficulties in which certain interventions have been found to work, so that a reasonable guess can be made at what is likely to help this individual. It’s obviously a bit more complicated than that, but that’s the gist of it.

Many researchers, and prominently the National institute for Mental Health in the US, want psychiatry to be more like the rest of medicine, guided by genetics and imaging to target intervention at biochemical or neurocomputational pathways, using the bleeding edge of technology to bring psychiatry into the age of the brain. I have two main problems with this: firstly the rest of medicine isn’t really like that. Ask a good GP how much of her practice is determined by blood tests or imaging, she’ll tell you not very much. Most of the time doctors act on what people tell them and what they see in front of them, and long may that continue. Secondly, the linkage between a particular gene or imaging finding and people’s actual problems is never as straightforward as excitable journalists or ambitious research scientists are keen to tell you. There’s a really good interview by Vaughan Bell which develops this theme.

On the other hand psychologists, notably Peter Kinderman and Lucy Johnstone of the British psychological society, seem to want a shift away from descriptive classification altogether. They argue that the DSM is too biological, and robs people of their psychosocial context. They want an approach which will “contextualise distress and behaviour, and to acknowledge the complexity of the interactions involved”. In a sense they want to give people their stories back. There’s a lot to recommend this approach, and it can be particularly helpful in regarding people’s distress as part of a process, rather than a fixed disorder. The trouble is, because everyone’s story is different, this approach isn’t as good at generating research data on what works in particular situations, because one person’s response cannot necessarily be generalised. The danger here is that you lose your evidence base, and planning intervention starts to look more like guesswork and theorising than science.

I’m also not sure that it’s meaningful to criticise the DSM for being too ‘biological’. As a  descriptive system, strictly the DSM is neutral as to the cause of these conditions. And unless you believe in a non-physical soul which animates the inert computer of the brain, all of these complex processes are, at some level, biological.

Finally, unless you also discard clinical diagnoses like constipation, migraine and IBS, this approach implies that diagnosis is fine for physical complaints, but not mental distress. But this introduces exactly the kind of unhelpful mind/body dichotomy that we’ve all been trying to avoid for years

Here I finally get to my point: each of these ways of describing people in distress is valid, each has its own limitations, but I can’t see that they are in any way mutually exclusive.

I realise this may have been rather heavy going so far, so let’s talk about Norman Price. Yes, Fireman Sam fans, that Norman Price.

There’s a story to tell about Norman. About his father who set off for Wrexham one morning, and never came back. About his mother’s weird mix of over-the-top terms of endearment and total failure to interact positively with him in any other way. About his struggle to be accepted in a peer group dominated by those airbrushed irritants Sarah and James. This story might lead you to useful conversations and reflections that move the situation on.

If you scanned Norman’s brain and his genome, you might find microdeletions on 15q, dopamine receptor depletion in the meso-accumbens pathway, whatever. This might suggest a helpful molecule that some bright spark has put in a pill. Or it may not.

Finally you could sit down with him, his mum and his teacher and work out whether his pattern of behaviour and cognition is similar enough to a group of people that you know about, that what worked for these people might be useful for Norman. Again, worth a try.

None of these is the right or wrong way to approach him- you could do all three. But equally the descriptive approach is not obviously the worst one. As I have argued before, it’s not so much the classifying, diagnosing approach that’s the problem, it’s when that’s the only approach on offer, and when decisions are distorted by perverse commercial incentives to diagnose, and treat, inappropriately. And when categories appear to have been made up out of the blue.

I’m sorry if it looks like I’ve spent a long time saying something fairly obvious, but in all the thousands of words written on the subject I’ve not seen anyone make the point that all of these people are talking about the same thing, just in slightly different ways. We need to move between these approaches according to which is going to help us address a given situation, stop picking needless fights with each other, and get on with it.

It saddens me to find organisations expending energy on attacking the way other people approach these problems when mental health services are being cut mercilessly, while NHS privatisation drives a consumerist model that will lead to over-diagnosis and over-treatment of those with the resources to access care, while the rest cling to the shrinking raft of what remains of public services.

So please, psychologists, psychiatrists, social workers, teachers, whoever, can we please stop squabbling over methodology and work together to help vulnerable and distressed people? Thanks.


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