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Citation
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Rodger J, Timimi S, Moncrieff J, Behr G, Beuster C, Bracken P, Browne I, Evans C, Fernando S, Huws R, Johnson B, Kingsnorth N, Martindale B, Middleton H, Summerfield D, Thomas P, Wallace J. Br. J. Psychiatry 2014; 205(6): 497. |
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Affiliation
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James Rodger, South Devon CAMHS, Devon Integrated Children's Services, Exeter, email: j.rodger@nhs.net; Sami Timimi, Lincolnshire Partnership NHS Foundation Trust Child and Family Services Horizons Centre, Lincoln; Joanna Moncrieff, Department of Mental Health Sciences, University College London, London; Graham Behr, Central and North West London Foundation NHS Trust, London; Carl Beuster, independent psychiatrist, UK; Pat Bracken, Centre for Mental Health Care and Recovery, Bantry General Hospital, Bantry, Ireland; Ivor Browne, University College Dublin, Dublin, Ireland; Chris Evans, East London NHS Trust, London; Suman Fernando, Faculty of Social Sciences & Humanities, London Metropolitan University, London; Rhodri Huws, Eastglade Community Health Centre, Sheffield; Bob Johnson, Quay Street Clinic, Isle of Wight; Navjyoat Kingsnorth, consultant psychiatrist, Galway, Ireland; Brian Martindale, private practice, Newcastle upon Tyne; Hugh Middleton, School of Sociology and Social Policy, University of Nottingham and Nottinghamshire Healthcare NHS Trust, Nottingham; Derek Summerfield, CASCAID, Maudsley Hospital, London; Philip Thomas, University of Bradford, Bradford, UK; Jeremy Wallace, HUS, Peijas Hospital, Vantaa, Finland. |
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Abstract
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The validity and utility of psychiatric diagnoses have long been a bone of contention between and within different professional and patient groups. This was clearly shown by the nearly 70 rapid responses to a 2001 BMJ article that proposed that post-traumatic stress disorder was a social construct with little clinical utility. The reponses were emotive and polarised, with an equal proportion of patients and professionals in each camp: those who felt diagnoses were important and life-changing, and those who felt outraged and negated by the medicalisation of social suffering. In their recent editorial Craddock and Mynors-Wallis frame this diagnostic debate in terms of ‘benefits and limitations’; possible ‘disadvantages’ are acknowledged but mention of potential harms is conspicuously absent.
They advocate ‘embracing complexity’, but for the rest of their article this does not ring true. They reel off the standard list of apparent advantages to diagnosis - providing reassurance and reducing blame, shame and stigma - but without reference to research findings. (Nowhere in their paper is any patient-led or collaborative research cited.) Also conspicuously absent in their list is the necessity of a diagnosis to guide treatment. Is this a tacit acknowledgement that there is little evidence to support such a claim and that, in mental healthcare at least, ‘common factors’ linked to the therapeutic alliance, alongside extra-therapeutic factors, explain the majority of treatment variance? In spite of this, they then go on to assert ‘there are no issues about diagnosis (or indeed treatments) that are unique to psychiatry’ (for the counter-argument see Bracken et al and related correspondence).
Their erroneous linkage between diagnosis and stigma reduction stands out as particularly misleading. There is now an abundance of evidence, including a comprehensive review published last year in this journal, that biomedical framing of mental illness tends to increase personal and social stigma and public desire for distance.
The authors may counter that a diagnosis does not imply biological causality, and they seem to endorse the standard biopsychosocial frame of reference. The problem is, as Roland Littlewood points out, it is more or less impossible to hold a ‘personalistic’ view of the self as agentic and intentional while at the same time subscribing to a ‘naturalistic’ view of being a product of biology, or even of the environment. One position always elides into the other. If this is true for professionals, it is certainly true for patients. And the dominant cultural understanding of diagnosis is that of biology, as it is with de facto psychiatric practice.
Craddock and Mynors-Wallis seem to want to be reasonable; identifying themselves, with other psychiatrists, as ‘reflective and tolerant of strongly opposing views and ideologies’. First, however, they resort to an unsubstantiated moral and emotive appeal to their position: ‘This can be to our patients’ disadvantage if we allow these views [i.e. critical of standard diagnostic practices] to be unopposed by suggesting that our patients are somehow less deserving of a psychiatric diagnosis than a physical diagnosis’. Then, just in case we are still equivocating, using the College’s Good Psychiatric Practice to bring us into line (as if this too was some ahistorical and acultural document), they pronounce: ‘This [use of standardised diagnosis] is not an issue of personal choice for a practitioner. It is a professional responsibility to the patient’. Their penultimate reference (entitled ‘Time to end the distinction between mental and neurological illnesses’) betrays their own ideological foray....
Language: en |