The overemphasis on psychiatric diagnosis

Having a psychiatric diagnosis for some people may be important. It identifies that they are unwell: the implications of the diagnosis may have more social advantages for them than disadvantages. Others may not find a psychiatric diagnosis so helpful. For example, they may feel it hasn’t really helped them understand the problems they have with their mental health. 

I am thinking about these issues as I have just read The straight talking introduction to the Power Threat Meaning Framework (PTMF) by Mary Boyle and Lucy Johnstone. This book gives an introduction to what it calls an alternative to psychiatric diagnosis. Although it mentions psychological formulation, it doesn’t really talk about how mental health professionals undertake a history and mental state examination of people presenting with mental health problems. It provides, however, a valuable framework for obtaining and evaluating this information in terms of power, threat and meaning. 

If the aim of psychiatric assessment is to provide understanding of mental health problems, then a diagnosis may not necessarily be the most immediate concern. What is more important is to understand the family and personal context of these problems. Appreciating this context may not provide proof of what has caused them, but it may give some indications. Describing these reasons may well be more complex than what is conveyed by a single-word diagnosis. 

So, could psychiatry survive without a diagnostic system by focusing on providing understanding of mental health problems? Such a way of practising would have benefits, as it would avoid treating mental health problems as brain disease. But the trouble is that diagnosis is needed as a term for entry into the sick role in society. PTMF wants to abandon the connection between mental health problems and the sick role, which is why it is so controversial. 

PTMF admirably emphasises that damage to mental health can be caused by trauma and other external events, and that this damage is more to do with how people have been treated by others than what they have done themselves. In this sense, mental health problems are an understandable, even expected, response to people’s situations. But of course there are social consequences of mental health problems. Although psychological problems are the defining feature of why people present to mental health services, services cannot ignore the social dysfunction caused by these problems. Both psychological and physical ill health can cause social dysfunction. 

PTMF advises us not to see mental health problems as illness. However, if only because of the social dysfunction caused by both physical and mental illness, the term ‘mental illness’ can still be meaningful. Both mental and physical illness have personal implications. I’m not against other professionals besides doctors being able, for example, to sign a certificate that someone is not fit for work. But that’s essentially the same as what doctors do for illness in general. It seems unnecessarily strict to insist on not using the term ‘illness’ in relation to mental health problems. 

We do need to move on from an incorrect notion of mental illness as brain disease. But I think that getting caught up in the argument about whether mental health problems are illnesses is actually deflecting us from this more important task of critiquing mental illness as brain disease. The primary argument is that it is incorrect to reduce mental health problems to brain disease, not that mental health problems are wrongly seen as illnesses.