Tuesday, January 23, 2018

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.


Unknown said...

Having read the Power Threat book, I applaud the contributors for their efforts. Certainly, considering environmental and social factors is essential in any reconceptualization of human behavior. I would like to, respectfully, suggest that other factors should also be considered. Another paradigm is available to replace the DSM and ICD that also considers human emotions as a driver of behavior, especially the emotion of shame. Self-Acceptance Psychology is a simple, but powerful new paradigm to describe and understand human behavior. It challenges the traditional ways of defining “mental disorders,” and reframes emotional and behavioral problems as adaptive and self-protective responses to fear, complex or chronic trauma, shame, and lack of secure attachment. These Five Causative Factors lead most people to have an inability to handle shame in healthy ways. It identifies poor shame tolerance as a key factor in development of anxiety, depression, personality disorders and other supposed mental illnesses. People adopt one of three Blame-Shifting Strategies that define essentially all unhealthy behaviors in relationships with self and others. Other-blamers lash out at others to offload shame (think of narcissistic, anti-social and borderline personality disorders, or just “toxic” and authoritarian people). Self-blamers attempt to manage shame through self-loathing, self-recrimination and perfectionism (think of OCD, anxiety, depression, social phobia, etc.) Blame Avoiders set up lives of distance and disconnection from others to avoid the shaming experience of criticism or failure.

Self-Acceptance Psychology completely reinvents the labels, definitions, and symptoms used in the DSM. This will enable the profession and the public to talk openly, accurately, and directly about behaviors. Unlike the DSM it also provides a description of a healthy, emotionally functional human: one with self-acceptance who can tolerate shame in non-reactive ways.

Case formulation focuses on the Five Causative Factors and considers things such as fear as a cause of hyper- or hypo-arousal and hyper- and hypo-reactivity (ADHD, anxiety, depression, schizoaffective disorder, etc, etc.). Other constructs in formulation include identifying unworthiness, identifying attachment trauma from childhood as a source of feelings of unworthiness, and attachment patterns (anxious, avoidant) etc. Unlike the DSM, Self-Acceptance Psychology also provides a solution that is directly derived from formulation: poor shame tolerance is resolved by improving self-acceptance or self-compassion. Learning to reducing feelings of unworthiness by treating one’s flaws and failures with kindness is essential to avoid reacting poorly when shamed or criticized by the self or by others. Lots more at www.HarperWest.co Harper West, psychotherapist

Anonymous said...

Yes it's an interesting project but yet more talk yet more conferences - no obligation to put any of it into practice. Who has benefitted so far Duncan? The same diagnostic labels will be used in a covert way anyway - and it is these which will follow individuals around on medical notes etc. You want it both ways instead of taking a clear stand - it 's not a philisophical debate for thse who who are impacted by offensice dehunamising diagnoses. Nevertheless thanks for your thoughtful blogs which bring these debates more into the public domain - they need to be publicised more widely