The limitations of psychiatric diagnosis

The Power Threat Meaning (PTM) Framework provides a way of helping people create a hopeful narrative about their lives and personal difficulties (see BPS News item with links to full framework and a shorter overview). It is a very impressive, well-referenced document. It attempts to provide an over-arching structure, as an alternative to functional psychiatric diagnosis, for identifying patterns of meaning-based threat responses to the negative operation of power causing emotional distress, unusual experiences and troubled or troubling behaviour.

I have always tended to emphasis the limitations of psychiatric diagnosis rather than suggesting a need for an alternative (eg. see previous post). Psychiatric diagnosis needs to be recognised for what it is. It is more important to ask how people are responding and to what, rather than look for a name for their problems. The primary focus should be on understanding the conditions of their mental responses rather than be concerned about symptoms and disease. The person should, therefore, be the essential element in assessment and there will be inevitable uncertainty in practice. Here I totally agree with the PTM Framework.

I just think that this focus on formulation does not necessarily lead to the abandonment of psychiatric diagnosis. Diagnosis can be justified as an attempt to manage clinical complexity and the PTM framework itself does recognise patterns of responses. There will inevitably be fuzzy boundaries between different groupings with no absolute distinctions. Certainly I’m not suggesting there are natural kinds of mental disorders. Diagnostic categories can only be justified by their clinical utility and should be no more than working concepts for clinicians. They are merely unobservable hypothetical constructs, more of a prototype or ideal type. The problem is that psychiatry too easily reifies diagnostic concepts by assuming that they are entities justifying psychiatric treatment. Here I think the PTM framework provides a valuable counter to this tendency.