I’m giving a talk in a couple of weeks and I thought that, as a ‘cheaty’ blog post I would put up my text that I’m preparing for that talk.
This is something of a work in progress, and also a little long… But any comments or feedback would be gratefully received.
In this talk I hope to open something of a discussion around some of the issues that are currently troubling me in both my clinical and academic practice. My background is in Psychiatry and I am currently a higher trainee in forensic psychiatry, although I am at the moment taking three years out from full time clinical practice to complete my PhD.
In terms of outline for this presentation I want to loosely framework my argument as a discussion, or review, of Daniel Leader’s recent book, ‘Strictly Bipolar’ and the issues that it raises for me. I hope that we can view this as more of a discussion than monologue though – I’m not claiming a position of expertise here in terms of being able to provide answers and I want to hear from the experiences of others. For this talk I’m also going to try and present a couple of case vignettes that I hope serve to illustrate some of the issues we’ll be discussing [I’m not going to put case examples in the blog post].
As a sketch outline to my argument I want to think about a debate that has emerged recently in the psy discipline community around the nature and role of diagnosis and mental disorder. My position is that diagnosis is here to stay and that we need to work within this, enforced, framework. I’m going to begin however with a few words to provide something of a framework explaining the background to my training and current position.
In the UK most people will decide to go into medical training when they are 18 years old. There is a change to this pattern but, as far as I’m aware, this is still the predominant point of entry. My entry into medicine was somewhat more circuitous as I first did a degree in Chemistry and also had the opportunity to work, for a brief time, as a synthetic chemist in the pharmaceutical industry on a ‘Sandwich placement’. On completing a four year masters programme in Chemistry I then decided to train as a doctor and applied to entry to medical school.
Medical school can no longer teach its students ‘everything’ they need to know as doctors and instead seeks to introduce frameworks for learning and approach to the practice of medicine. The two predominant frameworks espoused at my medical school were an outline model of practice together with the concept of ‘evidence based medicine’. I want to say something more about ‘evidence based practice’ later, but for now I just want to outline the stages of clinical assessment and management I was taught, briefly they are:
- History taking
- Physical examination
- Monitoring and response
I don’t want to say too much more about this process at this stage apart from to say that the concept of Diagnosis is central here – the first three steps in the process lead to Diagnosis, which then informs treatment and is reflexively monitored according to response. This was the central point of my clinical training as both a medical student and junior doctor, but I want to present a case example that, at least for me illustrates a difficulty with this approach.
Introduction to ‘Strictly Bipolar’
I want now to turn to the book ‘Strictly Bipolar’ to explain how, I hope, it will hopefully move my argument forward. Darian Leader is a Lacanian analyst practicing in London. The title of this book is drawn from a quote from a participant in a research study asked to share the experience of having a diagnosis of bipolar disorder:
“I’m strictly bipolar, I having nothing else going on” (p10)
For me this quote refers to a central interaction between the concepts of diagnosis and personal identity that I will return to later.
This book continues in a sequence of previous writing in which Leader challenges the extension of medical diagnoses while commenting on the expulsion of personal meaning and significance from these diagnoses, as well as the pharmaceuticalisation of modern society. In his two previous books – ‘What is Madness’ and ‘The new black’ he turns his attention to the concepts of psychosis and depression. In these projects he joins a wide range of other voices that seek to critique the concepts of psychiatric diagnosis. The concept of ‘pharmaceuticalisation’ is not a term that Leader himself uses, but I insert it here because I think that it is a social process that can not be ignored as it is highly important and only relatively recently beginning to receive a focussed scrutiny from sociology and other disciplines. Pharmaceuticalisation for me represents the incorporation of medication as object into our social processes and lives – one good example would be the incorporation of simple analgesia (paracetamol and ibuprofen for example) into our daily lives. This may seem to be a simple process, and self-evident ‘good’ but what are the implications? Access to analgesia can also be read as a pressure to maintain ‘productivity’ in a way that has not historically been positive, possibly a good thing, but when combined with other dynamics within neoliberal society is this necessarily a benign process? I choose the example of analgesics carefully here as it is difficult to see them as controversial, but I believe that even this simple process can be readily problematised.
The leit motif within much of Leader’s writing is the divorcing of meaning from the diagnostic process. Diagnoses are made but they often carry little direct personal relevance to the experience of the individual. Consider for example the experience of hallucination and diagnosis in the diagnosis of Schizophrenia – certain forms of auditory hallucination or ‘bizarre’ delusional belief are taken as being pathognomonic; voices offering a running commentary on the individual’s behaviour, or an ability to influence the weather for example. But these symptoms in themselves are taken as being meaningless – for Leader this indicates a divorce of the symptom from its signification and therefore from the realm of the symbolic.
For Leader, as a Lacanian, certain concepts are key – language use and linguistic structure requires careful consideration and concepts such as signifier, signified and foreclosure are used as an explanation for the genesis of symptoms. Central to much of his argument is the resolution of the Oedipus complex leading to three functions – the situation of the self, the positioning of libido and the relationship to ‘the Other’. Much of the book ‘What is Madness’ focuses on the implications of varying resolutions to this initial complex.
What is most important for Leader’s position however is the recurrence of themes within experiences of ‘madness’ or ‘mania’. Through considering these themes, and their phenomenological experience for the individual, we can begin to uncover structure and understanding. For example in ‘Strictly Bipolar’ Leader returns to the concept of ‘Manic depression’ – positioning this as a phenomenon characterised not by its ‘Bipolarity’ but instead by signification within each phase and the individual’s relationship with the other. Mania therefore becomes an effort to become ‘closer’ to the other, or to ‘repay debt’ to the other. The depressive position is characterised by its fear of having been destroyed by the other, which is phenomenologically distinct from the experience of mourning or melancholia where the object is perceived as lost, or having been destroyed by the individual.
For Leader diagnosis remains significant as a representation of experience – but what is most crucial is the manner in which the individual relates to their experience and its significance for them. His call is therefore for a humane approach to the individual that focusses on addressing the significance of their experience in a compassionate manner:
“We need to return to an earlier, more humane approach; one which attends to the particularity of each case, and which offers the manic-depressive person the chance to assume – however slowly, however painfully – what can be assumed of their history, and to find a way to live with what they can’t.” Strictly Bipolar p88
In this statement Leader echoes his previous distinction made in ‘What is Madness’ between ‘being mad’ and ‘going mad’. That is the distinction between living in a stable fashion, albeit whilst holding beliefs that others find unusual, versus a noisy desperate search for stability. Leader emphasises the possibility of a ‘quiet madness’ that is not incompatible with daily life and that it is the role of the therapist to allow the individual to reach this point of stability, he draws an analogy here with the work of a secretary:
“A secretary will often ask their boss to slow down, to repeat a word they didn’t catch, or remind them of something. This is a work of punctuation, and the full stops, commas and dashes that it creates will allow a history to be constructed. Yet punctuating goes well beyond this semantic discussion. Through the rhythm of sessions, their frequency, their timetabling and their endings, a different kind of punctuating also takes place, one that affects the libido as well as the question of meaning and history.” What is Madness p306
There is a parallel here in the role of diagnosis with the medical framework outlined at the beginning of this talk. This needs further exploration to address the question – what is the role of diagnosis? I think that at its simplest level diagnosis can be seen as fulfilling three potential functions:
- It communicates a disease entity – this is obviously the case in, for example, a bacterial pneumonia; but can be seen as being more complex in diagnoses such as Diabetes (where the underlying cause is unclear), Hypertension (defined for its impact on other diagnoses and on the basis of physiological variables) and Depression (defined for its impact on personal function and the presence of symptoms)
- It summarises symptoms / signs – Diagnosis can be used to summarise the experience of an individual – so for example the individual with appendicitis can be expected to experience pain in the right iliac fossa (right lower abdomen).
- It informs treatment and prognosis – A diagnosis informs the treatment that is received, or offered, and presumably will also offer some comment regarding the prognosis in terms of life expectancy, or return to ‘pre-morbid’ functioning for example.
Psychiatric diagnosis has always been the subject of debate and uncertainty, but this debate has become slightly more vocal than normal over the past year. One precipitant for this increase in discussion has been the publication of a new iteration of the American Psychiatric Associations Diagnostic and Statistical Manual – DSM-5. My personal research interest lies in the concept of ‘personality disorder’ diagnoses and these provide an interesting model for the wider debate.
Personality disorder diagnoses, like most other mental disorder diagnoses, are made on the basis of categorical, normative, definitions. Such claims are problematic however, for example as most people would consider personality to be based on a continuous, not categorical, variation – therefore why should states of ‘disorder’ be seen as categorically distinct? The personality disorder working group of the DSM-5 did make efforts to alter this situation, but the proposed changes were ultimately dropped by the overall editorial board and placed in the ‘for further research’ appendix. The World Health Organisation’s diagnostic manual – the ICD will also have a new version published within the next two years. The personality disorder working group within this publication have similarly recommended major changes to the diagnoses – the impact of these changes will require careful consideration.
The debate has been further stimulated by the publication of the British psychological society’s Division of Clinical Psychology report – ‘Understanding Psychosis and Schizophrenia’. This publication places psychotic experience on a continuum with normal experience, thus seeking to normalise the experience of psychotic phenomena. The report can be criticised, not least for its failure to include the voices of Black and Minority Ethnic populations, but the debate that it has promoted has been far reaching – including articles within the lay press. The debate has seen the reinstatement of old battle lines and fortifications between varying clinical frameworks – but it remains to be seen whether the outcome will be improved clarity.
One example of the debate generated by this report can be seen in the publication by the New York Times of an op ed column by Luhrmann, an anthropologist, titled ‘Redefining Mental Illness’. This, relatively mild, critique generated several responses, perhaps most notably from retired president of the American Psychiatric Association Jeffrey Lieberman, who asked – “What Does the New York times have against Psychiatry?”. In his critique Lieberman makes the following rhetorical statement:
“What other medical specialty would be asked to endure an anthropologist opining on the scientific validity of its diagnoses? None, except psychiatry. Psychiatry has the dubious distinction of being the only medical specialty with an anti-movement. There is an anti-psychiatry movement. You have never heard of an anti-cardiology movement, an anti-dermatology movement, or an anti-orthopedics movement.”
I would argue that Lieberman is incorrect in his assertion that only Psychiatry is exposed to critique by social scientists. But why does psychiatry become the focus of an ‘anti’ movement? Is psychiatry different to other medical specialties? I believe that it is different as its claims reach beyond the conventional biomedical framework in that it also directly shapes other social institutions, for example civil law in the form of the Mental Health Act. As such I personally feel that the existence of an ‘anti’ or ‘critical’ psychiatry position is justified, and indeed would situate myself within this camp; not from a desire to destroy the institution of psychiatry but instead as a position of Foucauldian critique – believing that psychiatry can ‘be better’ and therefore critique is necessary.
Implications of Diagnosis
One point to begin considering the implications of diagnosis is from a biological standpoint. The presence of diagnosis implies a biological process. I think that this argument can be viewed from two perspectives in terms of the strength of its claim, although in an effort to avoid splitting, or the construction of straw men, I think it’s important to recognise that there are shades of grey between these positions:
- The weak position: – We are biological, embodied, subjects. Therefore necessarily all processes we experience have a biological underpinning – neuroplasticity and genomic understandings and mechanisms provide us with a plausible route through which psychological and social processes inform the biological and likely vice versa.
- The strong position: – Diagnosis implies a deterministic biological process – that similar to disease processes such as pneumonia all mental illness are informed by biological antecedents.
In one sense the strong position I have outlined is untenable as nobody would argue that any form of disease expression occurs in a setting divorced from psychological and social interactions. However there are echoes, in my opinion, of this strong position in arguments that for example favour the subcategorisation of mental disorder in terms of response to treatment – for example differentiation of bipolar disorder in terms of its response to treatment with Lithium.
At the risk of inducing a Cartesian split I think another framework through which to view diagnosis is drawn from a psychosocial position. Here diagnosis can be seen as informing psychosocial understanding through varying processes:
Normalisation: – The existence of diagnosis inherently implies that the ’sufferer’ is not alone with their experience and is therefore a powerful normalising action, the realisation that one is not alone is obviously a powerful experience. Diagnosis, when offered within a theoretical framework, can also offer some form of understanding that may also be a powerful experience.
Stabilisation: – The experience of mental distress is clearly a difficult experience. Psychosis for example is characterised by frantic searching for meaning in terms of one’s relation to the other – diagnosis can serve as a form of stabilisation to this process, as Leader comments:
“The DSM approach and that of many cognitive therapies encourage psychotic subjects and their families to see the symptoms of psychosis as external illnesses… the very gesture of naming and ‘objectifying’ symptoms may be helpful for some psychotic subjects. It has the function of pinning down meaning…” What is Madness p305
This externalisation and objectification of experience has implications for the manner in which we relate to our experiences. Psychologically there is perhaps a risk of inducing a split between ‘mad’ and ‘bad’. Socially we have implications in terms of learned experiences such as ‘the sick role’ and implications of lay understandings of concepts of ‘mental illness’ that may lead to a ‘treatment barrier’.
Such processes can be construed as a form of ‘identity work’ wherein the implications of diagnosis are worked through by the individual in relation to their personal sense of ‘who they are’.
Social Identity Forcing: – Diagnosis, as I have alluded to, may therefore also have negative effects and this is most clearly demonstrated in the concept of ‘Stigma’ where the individual’s personal identity is ‘spoiled’ through imposition of the role of social other. There is obviously much to be said here regarding the social processes at play in the desire of the ‘social group’ to force non-conformists from within it and the role that psychiatry, as well as other psy disciplines, have held, and can hold, within this process.
Do we need diagnosis?
While bemoaning the loss of ‘old psychiatry’ Leader still maintains an important role for diagnosis within his writing. Diagnosis forms a short hand representation for the relationship between the individual and the other.
I have described what I consider to be some positive and negative features of diagnosis, which raises the question. Do we need diagnosis? Can we develop an alternative that maintains the positive elements, but disposes of the negative?
One alternative that is proposed is the use of Formulation based approaches, Cabaniss describes formulation as follows:
“Formulating means explaining – or better still hypothesizing” – Psychodynamic Formulation, p3
From my positivist training the development of a hypothesis means to state a theoretically informed position that is testable and falsifiable through application of the experimental method. Similarly within clinical practice formulation can be seen as a theoretically informed effort to explain the nature of the individual’s current experience.
If formulation is theoretically informed, which in my opinion it must be in order that it generates workable predictions, then the question arises which theory? There are certainly an abundance of theoretical models available – but perhaps the answer to this question is does it matter? Trans-theoretical models of psychotherapy acknowledge core features necessary for positive change, for example: working alliance, safety and empowerment of the individual. In relation to this Leader makes an important observation that draws distinction between theoretical understanding and practice:
“A psychoanalytic theory of psychosis does not imply a psychoanalysis of psychotic subjects. All it really shows is how the concepts from psychoanalytic research can help us to think about clinical cases of psychosis and develop strategies for clinical work.” What is Madness, p294
An alternative position would be to suggest that clinicians have access to a range of theoretical frameworks and understandings, that they draw on the framework most appropriate to the manner in which the person they are working with seeks to understand and address their difficulties.
Formulation versus diagnosis?
What are the relative merits of formulation versus diagnosis if these two are to be viewed as competitors then? One advantage of diagnosis that has led to its supremacy in most fields of medical practice is its compatibility with the positivist tradition of biomedical research. The clustering of individuals into ‘normal’ versus ‘abnormal’ groups through randomisation allows the application of powerful inferential statistical techniques that are the hallmarks of the ‘evidence based practice’ movements. Unfortunately it is painfully obvious that this process is not incorruptible however – neoliberal social forces drive the coercion of the research process supported by market forces – the impact of ‘pharmaceuticalisation’ and the pharmaceutical industry on this is difficult to overstate. The influence of market forces on the development of ‘diagnoses’ and ‘treatments’ is also hard to deny. However the underlying principle of practicing according to the ‘best available’ evidence is obviously overwhelmingly positive. A difficulty emerges however as we attempt to abstract information derived at this statistical level to the individual before us in clinical consultations. How can statistically informed information help us to make individual, non statistical, decisions? In some cases the answer is clear – if administration of a drug reduces mortality then that can be seen as a positive outcome. However no drug is free of side-effects and also all medication fulfils the role of a symbolic object, taking on signification of its own. Negotiation of individual treatment decisions becomes highly complex therefore, and beyond the provision of basic ‘evidence’ it is difficult to see how, aside from in the simplest cases, the ‘evidence base’ can inform the process.
This is where formulation clearly reaches its zenith. Inherently idiographic it allows us to collaborate directly with the person in front of us and reach mutually constructed models of understanding. This overcomes the negative aspect of evidence based care as decisions are fundamentally individual. However if we accept the positivist elements of evidence based care, and it is hard to argue against some of their most positive impacts, then formulation based approaches are inherently incompatible with this approach – inferential statistics can not be applied to formulation, dependent as they are on assumptions of uniformity. How therefore do we research formulation based approaches to clinical understanding? We can generate individual outcome measures, but can we replicate the positive outcomes from clinical research? Novel treatments (psychological or pharmacological) can be developed solely on a symptom level, without claims regarding disease process, but this requires the adoption of novel experimental techniques to allow development of a new evidence base.
These difficulties with new research paradigms are clearly not contraindications to a formulation based approach, they are merely complications – and fascinating ones at that. There is to my mind a greater difficulty however, that I feel means that diagnosis can never be fully supplanted. Diagnoses may be grounded within medical theory and practice – however I would argue that they have grown beyond this to become social objects in their own right; flowering independent of the medical soil from which they grew. Our relationship with ideas of ‘illness’ or ‘disorder’ is inherently symbolic in nature – representing our fear, or desire for, death and decay. Mental disorders in particular have come to represent our relationship with, and fear of, the Other.
It can be argued that many of the negative experiences associated with diagnosis, most notably stigmatisation, are inherently social processes – representing group desires within society. It is therefore, in my opinion, far from certain that the adoption of a formulation based approach as a direct replacement for diagnosis would overcome these difficulties.
Consider the example of the words Schizophrenia and Schizophrenic. Derived from Greek and implying splitting of the mind the word has historically been used to describe organisational institutional processes. For example John Humphrys, interviewing on the Today programme, describes an organisation, or political position as being Schizophrenic. He uses the term as a pejorative statement and is, perhaps rightly or wrongly, criticised for his language use. I am not seeking to take a position here, or to comment, but merely to point out the manner in which the word Schizophrenia is now used and its position as an object that can not be used in any way other than its current predominant position.
Diagnoses have come to take up a position within our society and are therefore independent symbolic objects representative of larger processes and dynamics. I think that, for better or worse, the idea that they can simply be expunged and replaced is naive. Some have argued that a replacement of the word Schizophrenia with an alternative would eliminate stigma – again I think this is unlikely. Stigmatisation, as I have said, represents a social process inherent to our group dynamic consciousness.
Diagnoses are, I would argue, here to stay. We need to think about how we move on from this and I want to pose a couple of closing questions:
- How do we work in parallel with diagnosis and formulation to embrace the strengths of each?
- How do we overcome the negatives of diagnosis, or rather the negative social processes that are associated with diagnosis?