Peter Kinderman, Professor of Clinical Psychology at the University of Liverpool and member of Mental Health Europe, argues that labels are for products and not for people, as he focuses on psychological assessment
A benchmark test of a civilisation is the way it cares for its most vulnerable citizens. We need to develop humane, effective and compassionate ways of making sense of distress. In mental health, we can’t carry on doing what we’ve been doing – even with increased investment – and expect better, different, outcomes. In July 2017, the United Nations General Assembly endorsed a report from their Special Rapporteur Dr Dainius Puras, which concluded: “…a reductive neurobiological paradigm causes more harm than good, undermines the right to health, and must be abandoned…There is a need of a shift in investments in mental health, from focusing on “chemical imbalances” to focusing on “power imbalances and inequalities.” (1)
Organisations such as Mental Health Europe and the British Psychological Society called for concerted international action to implement the Special Rapporteur’s recommendations. (2) More recently, James Barnes argued (3)that we have, for too long, been “seduced and overwhelmed” by a reductive, materialist approach to ‘mental disorder’ and suggested that, unless we make the kinds of changes Puras recommended, we are ‘complicit’ in the harms caused. This need for change was picked up by Bryan McElroy, an Irish GP , who argued that “GPs must stop putting people into diagnostic boxes and pause before prescribing antidepressants”. (4)
Across Europe, governments are starting to listen. The Belgian Governmental Superior Health Council (5, 6) concluded that the two main diagnostic manuals used in mental health (the American Psychiatric Association’s DSM5 and the World Health Organisation’s ICD-11) are inappropriate for clinical or research purposes; diagnostic categories lack validity, reliability, and predictive power, and do not, as is commonly supposed, reduce stigma and discrimination. This is a position that Mental Health Europe has been advocating for a number of years. Their ‘Short guide to diagnosis’ (7)recommends changing from biomedical diagnoses that assume a fault, flaw, or disorder within a person, to alternative ways of assessing and understanding individuals’ problems in the context of their experiences and social circumstances.
Alternatives
Challenging this reductionist approach to mental health problems – understanding what happened to you, not what’s wrong with you – is difficult. Alternative frameworks of understanding, particularly the application of psychological science as opposed to biomedical praxis (Kinderman, 2019), already exist. But there are powerful forces opposing such change. Inertia, no doubt, has a role to play; politicians advocate for investment in public services but usually without awareness of complex conceptual challenges…so, we fund what already exists. Professional organisations especially established disciplines, protect their own. And, fuelling it all, there is the ever-present influence of the pharmaceutical industries. (8)
But there are exciting developments such as the ‘Power Threat Meaning Framework’. This ambitious document uses psychological perspectives to explain mental health difficulties, with a particular focus on the dynamics of power operating in our lives; the kinds of threats we are exposed to, and the ways we have learned to make sense of and respond to them. This builds on the idea of psychological formulations. These are hypotheses; tentative, co-produced, accounts of why people may be experiencing difficulties and what might help, based on psychosocial principles and with reference to psychological theories.
Formulations are understandings and explanations of problems individuals describe, rather than a diagnosis or a professional’s opinion. Formulations fit with and derive from objective descriptions of problems, such as low mood and lack of motivation, hearing voices, problems functioning at work, paranoia etc. That would be different than formulations of diagnoses like ‘major depressive disorder’ or ‘schizophrenia’. The diagnoses, in their heterogeneity, poor reliability and dubious validity, reflect entirely different causes, mechanisms, likely helpful interventions, and outcomes for any of us with the same diagnosis.
Ordinary language and real-world events
Although rarely mentioned, either in clinical practice or in the academic literature, both diagnostic systems (the American DSM and the World Health Organization’s ICD) include the option of a scientific or ‘phenomenological’ approach to mental health problems. For example, codes exist within both diagnostic manuals for identifying non-suicidal self-injury, anxiety, depressed mood, elevated mood, feelings of guilt and auditory hallucinations. With a public health perspective in mind, both ICD-11 and DSM-5 permit clinicians and researchers to record adverse life experiences and living environments, as well as offering traditional diagnoses.
These could allow us to document such factors as a personal history of sexual abuse or a history of spouse or partner violence. They include important and useful codes (e.g. low income, the threat of job loss, unemployment, poverty, and homelessness). Such events play a significant causal role in the development of psychological health problems, and, therefore, provide vital information both for clinicians, as we develop co-produced formulations, and for health service planners.
Humane, effective and compassionate ways of responding to mental health problems are within our reach. We can implement the vision of leaders such Dr Puras and move from “…a reductive neurobiological paradigm (which) causes more harm than good…” and move from a focus on “chemical imbalances” to addressing on “power imbalances and inequalities”. And, in doing so, we can assess, understand, and respond to the needs of people in great distress. In fact, the most valuable approaches may well be the most straightforward. But they might need a revolutionary change in assumptions.
References
1. http://ap.ohchr.org/documents/dpage_e.aspx?si=A/HRC/35/21
2. https://www.mhe-sme.org/open-letter-for-a-shift-away-in-mentalhealth-services/
3. https://www.madinamerica.com/2019/09/dsm-problems-mask-darkreality/
4. https://www.irishexaminer.com/breakingnews/views/analysis/gpsmust-stop-putting-people-into-diagnostic-boxes-and-pause-beforeprescribing-antidepressants-963584.html
5. https://www.thelancet.com/journals/lanpsy/article/PIIS22150366(19)30284-6/fulltext
6. https://www.health.belgium.be/sites/default/files/uploads/fields/fpshealth_theme_file/shc_9360_dsm5.pdf
7. https://mhe-sme.org/wp-content/uploads/2018/09/A-short-guide-toPsychiatric-Diagnosis-FINAL.pdf
8. https://www.mhe-sme.org/shedding-light/
