Is it time to change our whole approach towards mental distress?
In May, the American Psychiatric Association will publish the fifth edition of the Dignostic and Statistical Manual of Psychiatric Disorders, otherwise known as DSM 5. Although originating in the USA, this publication is immensely influential, and is likely to form the basis for Psychiatric diagnosis the world over, as with the out going DSM 4.
Does it matter?
Well, the answer to this is YES. It matters on an individual level because all of us will be affected by mental disorder. One in four of us will be diagnosed according to one of the classifications above, so even if this is not you it will be someone you love or someone you work with. Lots of us feel a strange relief when distress is given a name – it suggests understanding, companionship, a removal of uncertainty and the possibility of treatment. However, for many these can easily become self perpetuating and destructive as they may have the effect removing responsibility, ownership and even hope, which some never find again.
It matters too on a sociological level. Our societies are increasingly regulated by psychiatry. We medicalise, medicate and plan ‘evidence based interventions’ into all sorts of human variation. This may simply amount to the application of science and knowledge to the alleviation of mental illness, but the question is whether this is ‘healthy’? Are we seeking to make a world in which the mess and gristle of life is edited out, tidied away, chemically suppressed? And is it working?
Psychiatric classification almost always demands treatment, so step forward the drug companies, with another product to push by fair means or foul. All those countless drug rep funded lunches, gadgets, even holidays, in the name of publicity for the next wonder drug. Even if the drugs do half of what they promise there is no doubt that our population is increasingly medicated. This from here;
Prescription Pricing Authority data shows that more than 30 million prescriptions for SSRIs (selective serotonin reuptake inhibitors) such as Prozac and Seroxat, are now issued per year, twice as many as the early 1990s. Researchers at the University of Southampton found 90 per cent of people diagnosed with depression are now taking SSRIs either continuously or as repeated courses over several years.
Professor Kendrick adds: “Our previous research found that although these drugs are said not to be addictive, many patients found it difficult to come off them, due to withdrawal symptoms including anxiety. Many wanted more help from their GP to come off the drugs. We don’t know how many really need them and whether long-term use is harmful. This has similarities to the situation with Valium in the past.”
Unsurprisingly, there is evidence that the current economic recession is also having an effect. This from the Telegraph;
The number of prescriptions for drugs such as Prozac has risen from 16 million to 23 million since 2006 with many GPs saying patients are increasingly expressing concern about the recession.
Figures obtained by the BBC under the Freedom of Information Act found the number of prescriptions for the most common group of antidepressants rose by 43 per cent during the period covering the banking crisis and housing crash.
If we can agree that in terms of practice, prescription and intervention psychiatry is increasingly involved in our lives, then the emergence of a new set of diagnostic criteria must be a considerable significance to all of us. We should also know then that this classification process, already controversial, is in the middle of a storm of criticism following the release of advance details of the new DSM 5.
Firstly, what could be regarded as the ‘tabloid headlines’. This from here;
Bereavement, which has always been excluded from the mood disorders, will become a mental disorder. Mild forgetfulness will become a mental disorder (“mild neurocognitive disorder”). Your child’s temper tantrums will become a mental disorder (“disruptive mood dysregulation disorder”). Even preferring one of your parents to the other will become a mental disorder! (Yes, really: “parental alienation disorder”).
You will need to display fewer and fewer symptoms to get labeled with certain disorders, for exampleAttention Deficit Disorder and Generalized Anxiety Disorder. Children will have more and more mental disorder labels available to pin on them. These are clearly boons to the mental health industry but are they legitimate additions to the manual that mental health professionals use to diagnose their clients?
You can listen to a short Radio 4 Today Programme debate on some of these issues between David Kupfer who chairs the DSM 5 committee for the American Psychiatric Association, and Peter Kinderman, professor and honorary Consultant Clinical Psychologist with Mersey Care NHS Trust about this between on this link.
Then there is the murky world of classification of ‘personality disorders’. Many people regard these as the ultimate examples of how abstract description of patterns of behaviour can become viewed as some kind of unassailable concrete ‘illness’, which then take on a reality in the same way as we might understand influenza or cancer.
DSM 5 complicates this further by adding more categories, for example “Apathy Syndrome,” “Internet Addiction Disorder,” and “Parental Alienation Syndrome”. This has raised so much concern that the American Psychological Association has begun an on line petition to allow people to express their concerns. This from here;
It is particularly concerning that a member of the Personality Disorders Workgroup has publicly described the proposals as “a disappointing and confusing mixture of innovation and preservation of the status quo that is inconsistent, lacks coherence, is impractical, and, in places, is incompatible with empirical facts” (Livesley, 2010), and that, similarly, Chair of DSM-III Task Force Robert Spitzer has stated that, of all of the problematic proposals, “Probably the most problematic is the revision of personality disorders, where they’ve made major changes; and the changes are not all supported by any empirical basis.”
How about this side of the Atlantic? This from the British Psychological Society (not renowned as a radical organisation) response to the consultation;
The Society is concerned that clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences which demand helping responses, but which do not reflect illnesses so much as normal individual variation. (p.1)
We believe that classifying these problems as ‘illnesses’ misses the relational context of problems and the undeniable social causation of many such problems. For psychologists, our well-being and mental health stem from our frameworks of understanding of the world, frameworks which are themselves the product of the experiences and learning through our lives. (p.4)
These comments go to the very heart of how we approach mental distress.
The Hearing Voices Network have been making a case for change for many years. Psychiatrist Marius Romme for example claimed that many people who hallucinate “are like homosexuals in the 1950s — in need of liberation, not cure.”
There is a change underway, akin to that of other great liberation movements and I believe that when we see chains on people it should be the intention and hope of the followers of Jesus to seek to break them. What is unfortunate is that the classification found in DSM5 do little to break chains. If anything DSM5 might yet forge new ones and as such, we should resist…
How might they be broken then? Here is my reading of (and my hope for) some of the changes;
Away from ‘illness’ towards ‘distress’
Away from ‘symptoms’ towards understanding that we develop different means of coping with this distress.
Away from restrictive labels towards listening to individual experience.
Away from medicalised interventions, towards encouragement and support of individual recovery.
Away from simplistic distinctions between ‘psychosis’ and ‘neurosis’ towards a greater interest and understanding of the effect of trauma.
Away from segregation and ‘otherness’ towards seeing mental distress as an essential part of the human experience and as such, part of all of our experiences.
Away from ‘maintenance’ towards, hope.