Evolution not revolution: My thoughts on the DCP’s call for a paradigm shift
For those that don’t know, there has been a long standing debate in mental health. At its simplist, it is an argument about whether biological or social factors are the predominant cause of mental health problems, including those difficulties at the most severe end of the spectrum, including schizophrenia, bi-polar, severe depression and personality disorders. Debates that follow from this, orientate around the extent to which commentators and researchers endorse or dispute the ‘medicalisation’ of mental health. Debates such as whether diagnostic categories are a useful way of understanding mental health problems, whether psychiatric medication is over prescribed, whether the social influences on human suffering are overlooked in favour of biological, medical explanations. Recently the Division of Clinical Psychology (DCP) released a position statement, basically arguing for a ‘paradigm shift’, away from psychiatric diagnoses, in favour of a ‘formulation’, and context specific understanding of mental ill health.
I am an avid follower of this debate. I always, since the start of my career in psychology, have been. It has, as different stages, fascinated me (“I can’t believe there are such different ways of understanding the same thing”), filled me with professional confidence (“I am sure my way of understanding these issues is the most helpful for clients”), filled me with uncertainty (“I really thought my way was the ‘best’, and now I’m not so sure”), and most recently, left me feeling perpetually conflicted, and at times, markedly irritated.
That’s why, when I found out Lucy Johnstone, one of the most outspoken advocates of the hotly debated ‘paradigm shift’ in mental health, was speaking at the Manchester University’s Clinical Psychology Annual Review, I jumped at the chance to attend.
As a Twitter follower of Dr Johnstone’s, I had a good idea of what her position would be, but the chance to hear her elaborate on some of her ideas was genuinely exciting to me.
I find myself in an almost constant state of conflicted ambivalence about this debate, most likely attributable to the unpleasant and unhelpful polarisation that has taken place within the field in recent years (this being at its most distilled and distasteful on social media). Would the talk by Lucy Johnstone in Manchester help me with my own search for a greater sense of certainty and understanding? Would it help me feel more aligned to my professional bodies’ recent position statement. Or, conversely, would I have greater confidence in challenging some of the assumptions on which it is based? The answer…..none of the above. What it did do is spur me on to write this blog, to express in writing some of the thoughts and ideas that I find myself pondering on a near daily basis.
The Caricatured Professional
One of the main concerns I have had with this debate is the polarisation that has taken place. The ‘us’ versus ‘them’ positioning I have seen emerge between many psychologists and psychiatrists involved. This happens on both sides of course. At Johnstone’s talk there was an undeniable caricaturing of psychiatrists. I say it was undeniable, but Johnstone did indeed deny this when it was suggested by the chair of the event. To paraphrase, according to Johnstone, a typical psychiatrist is likely to list a client’s historical adversities and conclude by suggesting something along the lines of “and on top of all this you have gone on to develop ‘x’ mental illness”, as though the historic traumas have nothing to do with the client’s current psychological difficulties. This simply does not tally up with my experience of working with many psychiatrists. Maybe it’s because I’ve spent most of my career in CAMHS, maybe I have just been lucky, but I am not convinced that the majority of psychiatrists view historical adversity and trauma as unrelated to adulthood psychological problems.
The caricaturing goes both ways. I often hear complaints that Clinical Psychologists are motivated simply by power; they are resentful of the dominant position psychiatrists have in mental health services and want to overthrow the hegemony for their own professional gains. I have worked very closely with many psychologists staunchly critical of psychiatry, and I can honestly say their motivation and drive is centred around the welfare of clients, and by their belief that changing the system will honestly improve outcomes for those they work with.
Maybe it’s a lack of vision on my behalf, but I can’t envisage a mental health system that does not involve medication and forced hospitalisation for clients at their most confused and distressed. On the other hand, I find it peculiar that medics are the default clinical leads for services in a field where psychological and social factors are so central. Similarly, why do medics hold ultimate clinical responsibility for mental health clients they work with? Senior psychologists and social workers should be able to take these positions, and even better, some kind of multidisciplinary panel should share clinical responsibility for the most complex clients, rather than one professional with one professional (at present medical) perspective.
I digress though; what I am saying is that this caricaturing is bad, and often inaccurate. Like the one about critical psychologists holding their views in the absence of front-line work. It goes something like this, “if those psychologists saw how disturbed these patients were when they come in to hospital, they wouldn’t be denouncing the use medication, or terms such as mental illness”. Codswallop. Some of the most critical psychologists I have known, work in acute, inpatient mental health settings and are well aware of the severity of inpatients’ difficulties.
Why is caricaturing bad? Well I have personally seen colleagues on both ‘sides’ become more entrenched and polarised in their positions. They see and hear the over simplified arguments, and inaccurate representations of their profession and move away from the middle ground.
What is the Alternative?
I think I would find the whole ‘paradigm shift’ agenda far less difficult to consider if a clear alternative was set out. An alternative to how services are structured and research organised (if not according to diagnostic groupings).
Sticking to research for the moment, Johnstone was explicit in her opinion that research based on diagnostic categories had offered us absolutely nothing in furthering our understanding of mental health. Really?!? Do we not now know much more about which therapies are better for which problems. For example, DBT for people diagnosed with Borderline Personality Disorder1, IPT for Depression2 (but certainly not panic3), and most recently, Mindfulness based interventions for depression (but at present not anxiety disorders)4. Does research not tell us something about relapse rates and patterns for certain categories of distress5? Has research not told us the significantly increased likelihood of developing a diagnosable mental health problem if exposed to early life trauma6? In fact, aren’t most of the recommendations for psychiatric and psychological interventions for mental health problems set out by the National Institute for Clinical Excellence (NICE) based on research into diagnostic categories?
There will hopefully be improvements to research outcomes as refinements are made to how we group participants’ problems together. Like considering how people diagnosed with depression may have different information processing styles or different attachment styles7. But these changes would represent an improvement in the sensitivity of a categorical system, rather than the wholesale rejection of it.
Johnstone cited NIMH’s announcement that the research they funded would no longer be based on diagnostic categories, and instead they would look to other, trans-diagnostic processes and experiences on which to base research questions. Fair enough. I think a symptom/experience based focus could further our understanding of certain presentations, particularly when we remember that a proportion of people satisfying the criteria for a diagnostic category will not represent the archetype, and will sometimes have quite divergent experiences from one another. But, firstly, NIMH’s emphasis on trans-diagnostic processes seem, at the moment, to favour underlying biological processes; hardly a good example of how the mental health establishment is turning its back on a medical understanding of mental health. Secondly, any symptom/experience based approach to research would have to include some system for organising participants into meaningful groups. Some people who hear voices will do so in the context of substance misuse, some following a bereavement, some is the context of a brief emotional crisis, and some in the context of a much longer-standing course of psychological dysfunction. Some will have overt experiences of childhood trauma, many will not. Lumping all of these people together could be problematic for conducting reliable research, but separating them up is, essentially, just another way of categorising people.
Johnstone revealed that she was, along with some other high profile Clinical Psychologists, working on an alternative system for organising people with mental health problems, for the purposes of research and intervention. She admitted that this was proving difficult, and at present any details are sketchy at best. She indicated that their focus was on the identification of underlying psychological processes, such as, for example, guilt cognitions. She denied that this would operate anything like a categorical or clustering system, and that there would be no concept of co-morbidity in the system, as people could be identified as having any number of experiences without this being understood as representing multiple conditions.
Unclear? Me too. I just can’t conceptualise how one might start to meaningfully organise clients’ difficulties without using categories or groups. By the way, Psychologists are as partial to categorical systems as the next Mental Health professional (think attachment styles or personality types).
In saying all of this, DSM 5 was an omni-shambles and there is surely a more scientifically sound way of organising the presenting problems of service-users. I am all for developing new, more robust systems, but calling for a wholesale ‘paradigm shift’, when a workable alternative has not yet been developed, never mind validated, is a bit of a misstep in my opinion.
Regarding mental health services, this is an area of even greater personal conflict for me. I have worked on inpatient units, most recently with adolescents. I was concerned about the sheer quantity of PRN medication being used, and the essentially uni-professional (medical) running of the ward. The care of the young people I worked with could, and should be improved. But would the abolishment of a diagnostic system facilitate this? I think not. What the service did need was more funding, better training for staff of all levels, a team approach to understanding and working with very high levels of distress, and a truly multi-disciplinary approach to decision making and clinical responsibility. Do these changes require a less medically dominated system? Yes. Do they necessitate a revolution in mental health, and the abolishment of the very concept of diagnosis and categorical systems? I, personally, think not. What we do need is more money to train more staff, to spend more time with clients, to provide more evidence-based alternatives to PRN medication.
Similarly, I agree with Johnstone’s calls for mental health services to have, at their heart, a psychosocial perspective, with intervention driven by a formulation-based approach. Can this only exist in the absence of a diagnostic system? I don’t think so. I really don’t see why the two approaches must be mutually exclusive. One of the therapy models I practice is Interpersonal Psychotherapy (IPT). It takes the approach that depression is an illness. It emphasises the utility of making a diagnosis of depression, and also welcomes the use of anti-depressant medication if therapy is not progressing as expected, and the client is inclined to use meds based on an understanding of the evidence base around medication usage. At the same time, this illness is understood to have been brought about by problematic relationship experiences, life changes or loss. It is completely formulation driven. It focuses immediately on the life changes required to increase the chances of a positive outcome from therapy. It focuses thereafter on supporting the client to reflect on and adapt how they relate to others, and how they work through and come to terms with major life changes or bereavement. Calling depression an illness, and making a diagnosis simply has not, in my experience, undermined the therapy, and may well have optimised it.
Similarly, Dialectical Behaviour Therapy (DBT), another intervention I use regularly, emphasises the biological and social underpinnings of emotional dysregulation or, for adults, Borderline Personality Disorder (BPD). Personally I despise the name BPD, but, at the same time, certainly see the value in having a group or category that captures the kind of difficulties often experienced by this group of clients. Again, as psychologists I think we use categories all the time. We might prefer to describe BPD as an ‘emotional dysregulation difficulty’ or a ‘complex trauma reaction’. Were these concepts formalised, they would have their own value and drawbacks, but would constitute categories none the less.
A phrase I have written a few times throughout this blog is ‘at the same time’. Whilst I share some of my colleagues’ concerns regarding the relative dominance of a medical model for understanding human suffering, I think both can exist together, at the same time. The balance of influence should be re-dressed, but I fear that the recent calls for a wholesale abandonment of diagnosis, and a general denial of the value of psychiatric input is both unnecessary and unhelpful. I would call for evolution rather than revolution. A combination of perspectives is always favourable, surely?
1. Dialectical behavior therapy for borderline personality disorder: A meta-analysis using mixed-effects modeling.
Kliem, Sören; Kröger, Christoph; Kosfelder, Joachim
Journal of Consulting and Clinical Psychology, Vol 78(6), Dec 2010, 936-951
2. Interpersonal Psychotherapy for Depression: A Meta-Analysis
Pim Cuijpers, Ph.D.; Anna S. Geraedts, M.A.; Patricia van Oppen, Ph.D.; Gerhard Andersson, Ph.D.; John C. Markowitz, M.D.; Annemieke van Straten, Ph.D.
Am J Psychiatry, 2011, 168:581-592.
3. A randomized clinical trial of cognitive behavioral therapy and interpersonal psychotherapy for panic disorder with agoraphobia
Vosa, S.P.F, Huibers, M. J. H., Dielsa, L., Arntza, A
Psychological Medicine, Volume 42, Issue 12, 2012, pp 2661-2672
4. Mindfulness-Based Interventions for People Diagnosed with a Current Episode of an Anxiety or Depressive Disorder: A Meta-Analysis of Randomised Controlled Trials.Strauss C, Cavanagh K, Oliver A, Pettman D
PLoS ONE, 2014, 9(4)
5. A meta-analysis of relapse rates with adjunctive psychological therapies compared to usual psychiatric treatment for bipolar disorders 1
Jan Scott, Francesc Colom, Eduard Vieta
Int J Neuropsychopharmacol, 2007, 10(1):123-9
6. The link between childhood trauma and depression: Insights from HPA axis studies in humans Christine Heim, D. Jeffrey Newport, Tanja Mletzko, Andrew H. Miller, Charles B. Nemeroff
Psychoneuroendocrinology, 2008, 33 (6), 69 – 710
7. Attachment Theory, Psychopathology, and Psychotherapy:
The Dynamic-Maturational Approach
Crittenden, P. M.
Teoria dell’attaccamento, psicopatologia e psicoterapia: L’approccio
dinamico maturativo. Psicoterapia, 2005, 30, 171-182.