Diagnosis special issue - Introduction

Moving beyond diagnosis: Practising what we preach

Despite years of well-founded criticism, psychiatric diagnosis is still widely used – not only by psychiatrists, but psychologists too. Why? In this special issue, we address this conundrum.

Most psychologists' knowledge of mental health is limited to what they remember from undergraduate 'abnormal psychology' courses. Yet a recent survey we conducted, funded by the Higher Education Academy Psychology Network (Cromby et al., in press) found that the vast majority of these courses use textbooks structured by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders; present very dated critiques of psychiatry; and fail to develop a specifically psychological approach to their topic.

The pages of The Psychologist have often featured debates about psychologists and diagnosis (see, for example Pilgrim, 2000). However, many psychologists continue to use it. The standard defence is that, whilst problematic, diagnosis provides a useful 'shorthand' form of communication important for multi-disciplinary work. 

Yet if the diagnosis is unsatisfactory, why should we use it? Is the problem simply one of finding other ways of talking about distress, or is it also an issue of turning around the supertanker of psychiatric classification (no easy task, with the latest version of the DSM selling 600,000 copies and yielding a turnover of $44m)?

This issue is not only relevant to clinicians – psychiatric frameworks inform postgraduate professional training in educational, forensic, occupational and counselling psychology. Yet the legacy of outdated undergraduate teaching is that some practitioners might be unaware of effective psychological models, and ignorant of recent developments in theory, practice and policy. 

Moreover, since one in four of us will experience mental health problems at some point in our lives, another legacy may be that we possess a restricted set of conceptual frameworks when we, or the people we know, encounter mental health problems. 

In the first article Mary Boyle, a clinician and researcher, reviews some of the problems with diagnosis and argues that it obscures, rather than improves, our understanding. She also suggests reasons why diagnosis nevertheless continues to be used.

Since diagnosis is problematic, one alternative research paradigm is to attempt to study people's actual experiences. Richard Bentall, another clinician and researcher, outlines an experimental paradigm for doing just this, focusing on experiences such as voice-hearing or unusual beliefs.

It is frequently suggested that the widespread use of psychiatric drugs supports the validity of diagnosis. Joanna Moncrieff, a consultant psychiatrist and academic, questions this. She argues that rather than curing diseases, psychiatric medications simply create their own 'abnormal' brain states.

All too often, discussion about diagnosis remains at an abstract level, but Peter Campbell's article looks at the impact diagnosis has on those who actually use mental health services. Peter is uniquely qualified to comment, both because he has been a mental health system survivor for many years and because of his extensive involvement in campaigning, teaching and writing.

The report on psychosis from the Society's Division of Clinical Psychology (2000) proposed a move away from diagnosis and toward a psychological formulation-based approach. Rufus May, a practising NHS clinical psychologist who has also been a mental health system survivor, goes beyond this in urging clinicians to utilise the insights of community psychology and the user movement to develop innovative interventions and facilitate social change.

In the final article, we (with Jill Anderson and Anne Cooke) argue that the developments outlined here need to inform both undergraduate and postgraduate training. We suggest that rather than jumping ship and adopting a psychiatric perspective when faced with people's distress, we should instead try to develop a consistent psychological approach.

We hope you enjoy reading these articles and that you too will be inspired to start practising what we preach – to move beyond psychiatric diagnosis.

References

Cromby, J., Harper, D. & Reavey, P. (in press). Mental health teaching to UK psychology undergraduates: Report of a survey. Journal of Community & Applied Social Psychology.
Division of Clinical Psychology (2000). Recent advances in understanding mental illness and psychotic experiences. Leicester: British Psychological Society.
Pilgrim, D. (2000). Psychiatric diagnosis: More questions than answers. The Psychologist, 13, 302–305.

Weblinks

• DCP report on psychosis 
• Soteria Network's Beyond Diagnosis conference
• Critical Psychiatry Network