Wednesday, 23 January 2013

The Ethics of Psychiatric Diagnosis

A London Philosophy Club talk by Peter Kinderman: 
The Ethics of Psychiatric Diagnosis. Polly Mortimer

Peter Kinderman is pretty much a hero of mine, along with his colleague Richard Bentall. Kinderman is Professor of Clinical Psychology and Head of the Institute of Psychology, Health and Society at the University of Liverpool, and Bentall is a Professor there. Kinderman started with his conclusion: that it was now is the time to take action. The disease model is inappropriate and the current realm of ‘diagnosis’ fails on validity, utility, biology and humanity. We should be concentrating on helping people live their lives better and fulfilling their potential, not treating problems as illnesses. 

He took us back to a debate in the Commons a while back where a number of MPs revealed their own mental distress. This disclosure was met in a positive manner, thus paving the way for differing approaches to the whole field. He did however, also quote concerning statistics regarding the increase in suicides in this time of economic uncertainty; it has been found that a thousand suicides per year could be as a result of depression caused by economic hardship. In also informed us that there has been a 30% increase of calls to helplines in the last few years.
Carefully unpicking the diagnoses that are commonly bandied around, he found 

them devoid of meaning.  What is needed is a bespoke response to clients’ needs. There are reasons for mental distress – natural human consequences of trauma and adversity. We are all mad at times. But the trend now is to medicalise normality. 
I agree with Kinderman: what is needed is alternatives to the disease models. He put forward lots of suggestions: parenting tutors, narrative approaches, a colleagues scheme, Think First for offenders, and a plea to treat things for what they are. This is underpinned by a psychosocial formulation approach. A huge change must take place and it involves many different agencies: teachers, professionals, textbooks, judges, insurance companies, pension firms, among others. 

As we are at a crossroads with the revision of DSM underway, I believe it is an ideal time to proceed with change. This can happen by signing petitions, and those in the frontline talking and taking action. The stranglehold of the pharmaceutical companies needs to be released and a new framework of understanding reached.  Solutions can be developed – working on the cause of the distress. Work with nurses will be crucial; they can initiate relaxation, exercise, early warning systems etc. 
I found the talk extremely refreshing and sensible and left hoping that change was in the air and the disease model will be consigned to history. Long overdue!


  1. Training for medical students at the University of Sheffield centres on biopsychosocial formulations of a patient and their disease. Note: in my training there has always been a specific avoidance of labelling patients as their disease – social labelling theory has, for the better, made its mark. This approach was particularly emphasised in the case of mental health problems (I personally despise the negativist term “mental illness”). It was made abundantly clear to me by our psychiatrist teachers that a diagnosis should not get in the way of a holistic understanding of the problems faced by people within the context of their psychology, social environment and their biology - these three components were given equal weighting.

    Unfortunately, health service funding relies on the classification of people by disease so as to establish population level efficacy and thus inform commissioning. A social health program is built on the foundation of public health principles – the NHS as an organisation treats the British public not each individual British person. I agree that a individualised narrative approach is preferable and I suggest that as much as possible, specialist services provide individualised therapy through the cooperation of psychiatrists with nurses, counsellors, psychologists, social workers and occupational therapists. I suppose such comprehensive and multidisciplinary services might not be the norm in the UK but I would argue in very strong terms that they should be and will continue to grow to become so. At any rate, for now a discursive approach to mental health does not assist health providers in achieving its ideal of just distribution of highly limited health resources. A diagnostic system does so, not well I accept but it gets us part the way there. The car is faulty but at least it runs.


  2. Whilst medications are still the mainstay of psychiatric treatment the implied scenario that it is the only service offered by medical professionals is misleading, offensive and unhelpful. NICE guidelines advocate the use of talking therapies as first line in the primary care treatment of mild to moderate depression/anxiety and as an adjunct in severe depression/anxiety. Of course this approach relies on the use of psychiatric diagnostic categories. However, physicians are not as restricted by such definitions as much as one might imagine. Diagnoses are not based on DSM/ICD10 criteria alone and a consideration of a given patient’s psychological and social context are a key part of any diagnosis. Certainly modern medical training in general focuses increasingly on the holistic consideration of a patient along with a partnership style approach. Have you never wondered why your GP asks you what you think might be the cause behind your complaint? Such questions become particularly pertinent when a patient complains of mental health issues.

    So, in summary, whilst I do not disagree in the slightest with the argument that we should be “concentrating on helping people live their lives better and fulfilling their potential” I do counter the unfounded allegation that the disease model of mental health difficulties retards this process. There is ample evidence that a significant proportion of people seeking help for mental health problems from the medical profession do benefit from the assistance that is provided. I agree that there HAS BEEN a trend towards medicalising normality but I have observed personally that this trend is already abating if not reversing. Physicians do their best to provide a “bespoke service” to “clients” but within the constraints of a relatively universal health care service and the breadth of medical issues any given non-specialist physician needs to be prepared to handle there are limitations as to just how individualised such services can be. What is needed is cooperation between the various health professionals, recognition that the current mental health care service is unsustainable in the light of the expense of training and employing psychological specialists and an end to the vitriol between physicians and psychologists which has its basis in outdated arguments of the 1960s (an era preceding a significant proportion of health service users as the vast majority of providers). Finally, I accept that the diagnostic classification approach is fundamentally flawed, I am yet to see a realistic attempt to replace it with a viable qualitative approach that will serve the needs of the NHS and social medicine commissioning. What is needed is the continued mixing of quantitative and qualitative approaches by people who are highly motivated towards the development of a health service that best serves patients’/clients’ needs rather than merely arguing in favour or against meaningless and unhelpful philosophical idealisms.

    Jarrod Franklin, BSc, PhD, final year medical student, University of Sheffield.