The launch by the American Psychiatric Association in May of the latest edition of the Diagnostic and Statistical Manual (DSM 5) is not only of interest to those in the trade. This revised ‘psychiatrist’s bible’ immediately precipitated a very public controversy, a dispute so divisive the centre may not hold. Tensions that have been simmering for decades, conflicts that could well Balkanise the field, have been unleashed. But before drawing out the implications for consumers and carers, who perennially get the short straw, a brief account of current debates provides some context.
Most obviously, there is a point of view that psychiatry, especially when it concerns the so-called worried well, is in the business of medicalising everyday human troubles. This criticism has been inflamed as the new DSM edition takes a further, and some say outrageous, step in this process by giving a label to children’s temper tantrums (‘Disruptive mood dysregulation disorder’), to shyness (‘Social phobia disorder’), to grief, hoarding and so forth. As well, the criteria for some existing disorders have been expanded, an evolution that will broaden the number of people who are diagnosed. But however vibrant this concern may be for many, it is only one of the front lines in a larger war.
The DSM is not the only, but it is certainly the most used and respected diagnostic schema. Given its position what is shocking is that its legitimacy, literally its scientific validity, is now being disputed by the world’s most prestigious research body. The Director of the National Institute of Mental Health (NIMH) in the United States has recently said the Institute is ‘reorienting its research away from DSM categories … [because] mental health patients deserve better’.
‘The weakness [of DSM 5]’, he says, ‘is its lack of validity’. What is wanted is a new approach to psychiatric diagnosis that is truly scientific rather than one based on ‘description’—meaning ‘clinical observation’. In fact the NIMH wants an approach that uses neural imaging, genetic scanning and other such tools that, it is claimed, will offer a new system of diagnosis a properly objective foundation.
It is high-risk to stake everything on the hope that technology can deliver certainty: that science will provide a stable rationale for one group being granted naming rights in a field that is better framed as inherently uncertain and context-dependent. If this field is contingent, it is at best ambitious, and may well be grandiose, to seek the diagnostic exactitude present in, say, coronary medicine or endocrinology. DSM is not and can never have the status of the Periodic Table. It is meant to be an instrument that offers reliability, not validity, although some of its advocates have not been shy in over-egging the status of their claims.
The dispute between the American Psychiatric Association (who sponsor the DSM) and the NIMH is truly radical. Here are two pillars of the establishment slugging it out publicly when we are used to heavyweight stakeholders keeping their differences locked away behind closed doors. This public spat can be likened to witnessing the stock exchange run a campaign accusing capitalism of being commercially illiterate. Yet, as striking as this public argument is, it is only one of the dimensions in the controversy. A different kind of attack, an accusation from an entirely different quarter to the NIMH, has also been mounted against the DSM.
The Division of Clinical Psychology (DCP), a specialist group within the United Kingdom’s British Psychological Society, has called for a reverse ‘paradigm shift’ to the one proposed by the NIMH. Whereas the NIMH wants to commit its efforts to building a sterner kind of science to underpin psychiatric diagnosis, the DCP rejects the view that mental health issues are illnesses that have biological causes. In their view it is far better to view ‘breakdowns’ as the result of complex psychological, and to some extent, social circumstances such as bereavement and loss, trauma and abuse. This group does not believe the emphasis should be on diagnosis. To put the emphasis there, they say, is not to be informed by research.
At this time it is not clear how other bodies representing psychology will position themselves with respect to the question of diagnosis. This is a key point as the claim to status and utility presented by psychology has, so far, been explicitly couched in terms of propositions such as this: cognitive behavioural therapy is effective in treating conditions such as anxiety and depression. De-coupling their claim to credibility from its historical reliance on diagnosis is therefore a manoeuvre entailing a significant risk: if this campaign to undermine the centrality of diagnosis goes amiss psychology’s game plan (to overtake psychiatry) will be brought into disrepute.
In the current contretemps are long-standing professional rivalries around ‘jurisdictions’. In these campaigns the psychiatrists are the reigning champs, but have found themselves under attack by an up-and-coming cadre of confident psychologists. This emerging group see themselves as righteous warriors, even saviours, who can bring light to what they regard as the medieval practices that sustain medical privilege. Good intentions noted, the new group are also commercially on the make and have seen their material position flourish dramatically in Australia since their services have been registered with Medicare. Now, with war more or less formally announced, the gloves are off. The veneer of collegiality has evaporated.
In this contest it should not be assumed that psychology is a homogeneous group professionally, or indeed theoretically. Clinical psychologists may be the spearhead troops in psychology’s quest for greater public status, but this sub-group itself is currently engaged in a program to swat down their internal rivals, the more numerous, but arguably less scientifically credentialed, counselling psychologists. Now is not the time to tease out that internal dispute, but suffice to say the claim to superiority put forward by clinical psychologists over their less prestigiously titled siblings has historically rested on a purported differential in the clinical group’s ability to accurately diagnose disorders and conditions—an argument the basis of which some of their own spokespeople are now hell-bent on rejecting.
Where does this disturbance leave consumers and carers? Many consumers have found a degree of comfort and containment in having their troubles understood and named as illnesses. Think about it: after years of having others tell you you’re not responsible enough to properly manage my life, it can be settling, and in one sense de-stigmatising, to be told by the competent authorities that you have an illness called manic depression. And, as someone with an illness, a condition you didn’t choose, you cannot be blamed for the troubles you have experienced.
Carers, too, often have a stake in this dynamic. As grief provoking as it is to hear that someone you love has a condition, as much as this kind of announcement can call up a deep foreboding, it can also prompt a renewed sense of purpose and hope: At least we now know what we are dealing with! On the other hand, many consumers welcome the chance to contest the imperial authority of traditional psychiatry to categorise and officiate: They do not know about me. I am the only one who has my lived experience and personal history.
But it is not only consumers and carers, or in-the-field mental health teams, who will have to find a way to manage the fact that the covert war is now out in the open. Non-government bodies in the Australian mental health sector, like Beyond Blue, are also likely to be caught up in tussles around what should be regarded as ‘real’ evidence, science and diagnosis. This is an issue especially for groups who have the mission to medicalise depression, anxiety and the like. Not-for-profit advocacy and service organisations like Mind will also have to position themselves carefully, as will specialist bodies like ForensiCare (who have the responsibility for managing forensic patients in Victoria).
None of these groups will be safe from the crossfire. Imagine how matters will be played out in the courts as both prosecutors and the defence will be free to go to town on the validity of what the experts say. If the world’s leading research body regards the DSM as unsound how will this dissonance play out in an adversary legal system? A representative from Forensicare recently informed members of the Crown Prosecutors Office that he would be relying on the International Classification of Diseases (ICD 9)—a somewhat fusty, but still-standing alternative to DSM.
Many years ago the anthropologist and psychiatrist Robert Barrett reported that the mental health patient could be understood as a contested ‘worksite’ where different professional groups contend to take and hold territory: ‘We know best about the brain’, say group X. ‘But, we know best about behaviour!’ say group Z. ‘No’, says group X, ‘the brain and its chemicals control behaviour!’ to which group Z counters, ‘No, behaviour conditions attitudes and feelings which …’ (In this loud argument groups A and B speak up about ‘functional assessments’ and ‘context’, but the big boys hear none of this). Status games, territory, hubris, a concern for the person who is troubled and a process of objectification are all concurrently in the mix in these tussles.
A colleague once heard a lecturer in a statistics class refer to people who were overweight as ‘obesians’. This is as offensive as referring to someone as a ‘schizophrenic.’ We do not call someone who has the flu as a ‘flu-ic’ or a person with cancer as a ‘cancer-ic’, so how is it ever right to talk of schizophrenics? There is no excuse for objectifying those who have a mental health problem by using their difficulty to totalise their identity.
The demands of consumers and carers are interdependent. Both groups want to be recognised and influential, even though the consumer focus is on person-centred recovery efforts, not on the game of which professional body gets the naming rights around diagnosis, while carers tend to stress resourcing and coordination issues.
These priorities should trump the efforts of professional and research groups to objectify and to colonise. However worthy, this prospect is currently quixotic as the momentum to commercialise is accelerating: insurance companies require a diagnostic code for a service to be reimbursed; hospitals receive their funded on the basis of treating ‘diagnostic-related groups’; pharmaceutical companies recognise the nexus between diagnosis and profit. This trend may be particularly prevalent in the United States, but it is also a globalised phenomenon. The question then arises: if mental health is an inevitably disputed patch how is it that the big boys—the received authorities and on-the-make newbies—have an alibi for continuing to write the rules and own the game?