The DSM dust-up: Whingeing cranks, turf wars and epistemological disputes
On Sunday the12th of May, The UK Observer ran a front-page article stating that the Division of Clinical Psychology (DCP), a subdivision of the British Psychological Society (BPS), was releasing a position statement calling for a ‘paradigm shift’ in mental health. The proposed shift was away from a view of mental health problems as illnesses with biological roots, and towards greater consideration of psychological and social factors.
The DCP did its best to get the media interested and was rewarded with extensive coverage. The Observer and Guardian website included an online polland other articlesand commentaries that explored the debate in some depth. The Daily Mail ran a piece the following day. Lucy Johnstone and Richard Bentall, both Clinical Psychologists and critics of the ‘disease model’ of psychological distress, appeared on Radio 4 and Peter Kinderman, a former DCP Chair, was on telly in Canada.
The release of the statement was a significant move in the world of mental health. The DCP was making an uncharacteristically vocal stand against the medicalisation of distress. The timing was also interesting being just before the publication of the DSM-5, the 5th (and most extensive) edition of the controversial manual for mental health diagnoses. Naturally, this ruffled a few feathers, but even those who disagreed with DCP’s stance could appreciate the value of bringing the debate into the public domain? And surely the public would get on board with such an important issue?
Well, sort of. While there was some intelligent, thoughtful discussion, comments from the public on the Guardian website ranged from positive to indifferent through to vitriolic. Comments on a website aren’t necessarily the greatest measure of public attitudes, but they nevertheless made for thought-provoking reading. Two emerged as of particular interest. The first was the idea the psychologists are basically charlatans. Here are a couple of comments from an, alas, far wider pool:
‘…this psychology thing is pure quackery. Psychiatry at least kept the symptoms in control whereas a faith healer like a psygologist [sic] would not have been able to do anything.’
‘I have never trusted so-called psychological therapists. Any crank can set themself [sic] up as a therapist and fleece the worried-well of their money. Even those with some qualifications in psychology have no real insight into mental illness…If you have chest pains you see a cardiologist. If you suffer from clinical depression you need a psychiatrist.’
As a trainee clinical psychologist, such remarks made uncomfortable reading and are perhaps indicative of a PR failure on the part of psychology. Psychologists place great emphasis on the role of the ‘scientist-practitioner’, someone whose work is informed by research and who contributes to the evidence base by carrying out their own research in the field.
However, even if you accept that psychologists are not quacks, there is still the issue of professional vested interests. Some comments suggested that this might underlie the DCP stance:
‘[Medicalising mental health is] good business for psychologists and psychiatrists so all they’re arguing about is who should get the booty.’
‘This sounds like turf wars to me – the psychologists want to claim all mental disorders for themselves.’
While it’s worrying that the debate has been framed as ‘psychology versus psychiatry’, there are some obvious reasons why it may be perceived in that way. The Observer headlined their front-page article as ‘Psychiatrists Under Fire in Mental Health Battle’ and debates in the news have invariably featured a psychologist and a psychiatrist in conflict. It’s a neat narrative, but an inaccurate one.
In her Radio 4 interview on on 13 May, Lucy Johnstone opened by saying ‘This really isn’t an argument between psychologists and psychiatrists’. The Critical Psychiatry network has issued a statement explicitly rejecting the idea of a ‘guild dispute’. While psychologists and psychiatrists sometimes have different views, most psychiatrists I’ve encountered recognise the importance of social and psychological influences. Likewise most psychologists acknowledge biological factors. Placing the two professions in direct conflict stimulates defensiveness, dismissiveness and a closing of ranks which could be detrimental to our understanding of what is arguably the most significant issue in mental health.
The real debate is about how we view people who experience distress. The biomedical approach implies that we should view people first and foremost as clusters of symptoms and locates the problem (primarily) within the brain. The biopsychosocial model favoured by the DCP argues that this only tells part of the story. It is a plea to view the person in the context of their lives, relationships and experiences as well as their biology. This is an important debate with implications that reach well beyond than professional one-upmanship. It’s about whether a diagnosis such as ‘schizophrenia’ is either necessary of sufficient to understand someone. It calls us to think about whether current mental health services are up to the task and invites us to think about viable alternatives. At its broadest, it asks us whether placing the causes of madness inside an individual distracts attention from the interpersonal, social, cultural, economic or political factors that influence all of us. Engaging the public in an open discussion about models of mental health is overdue. It just seems that this discussion hasn’t quite got off the ground.