The challenge of shifting current psychiatric conceptualisations
The British Psychological Society’s Division of Clinical Psychology (DCP) issued a position statement on psychiatric diagnoses in May 2013. The statement highlights many of the limitations of psychiatric classification systems, theoretically, empirically and clinically. In making the case for a ‘paradigm shift’, the DCP’s statement draws attention to the impact of psychiatric diagnoses on the life of those in distress including: the marginalisation and decontextualisation their lived experiences, stigmatisation and dehumanisation. Further, the statement alerts readers to the ‘Ethnocentric bias’ inherent to current conceptualisations which can lay the foundation for discriminatory practices.
Debates around the statement and the usefulness of psychiatric diagnoses more generally, continue to rage. Many have been heated and passionate. They have been located both within and outside clinical psychology. Much of these have been constructive and necessary. Some, I have struggled with. Many have qualified attempts at problematising current diagnostic practices as ‘turf war’ stemming from clinical psychology’s long term ‘competition’ with psychiatry. Others, have posited that as long as service users find psychiatric classifications useful, then psychologists and others ought to lay issues of reliability and validity to rest. It has been also argued that those ‘pushing’ for this ‘paradigm shift’ may be politically motivated. Some have even attempted to frame the issues at stake in terms of language positing that focussing on the ‘names’ we give to mental health problems matter little. That if they do matter, they should matter a lot less than our core business, the business of supporting people in distress.
Vested interests and criticisms
Whilst issues of professional identity, boundaries and power are no doubt engaged here, some healthy rivalry between psychology and psychiatry can and has historically brought several clinical and theoretical advances many of which have translated into service improvements, for example the more widespread use of formulation. As to the point about ignoring issues of scientific rigour if diagnoses help service users make sense of their experience, such a position would seem quite difficult to sustain ethically. The charge of ‘enforcing’ or pushing a particular worldview onto service users, has left me quite perplexed, though it is often argued that more socio-political conceptualisations of distress are ‘agenda based’ and propagate an ideology or worldview. And that this is of course, undesirable.
Such criticisms imply that current conceptualisations of mental health problems do not impart particular worldviews and ideologies. That they are simply neutral reiteration of what is, of what exists objectively. These criticisms perpetuate the fallacy of neutrality and propose that personal experience of distress and conceptual ‘preferences’ can be extracted from socio-political contexts and separated from issues of power, agency, and history and from their deriving social relations. Despite the fact many theorists from a wide range of scientific (and non-scientific) backgrounds have unequivocally demonstrated the myth of neutrality, it persists. And, it persists for various reasons. Firstly, neutrality provides practitioners with a ‘pass’ from exploring some of the ethical dilemmas that arise from more socially situated mental health practice. In other words, it narrows the focus of our ethical reflections.
Secondly, it legitimises the status-quo. It does so by obscuring the very fact that the relationship to the world assumed by current conceptualisations and the scientific stance which is illustrated by our positions on mental distress, are themselves products of particular worldviews and epistemologies. In other words, it erases the socio-political and historical location of neutrality and its underlying worldviews. Thirdly, and arguably more importantly, neutrality masks the particular interests of both social and professional groups who claim it. In doing so, it increases professional (and social) credibility, legitimacy and thus power. For example, decisions on mental health matters (such as funding priorities, service configurations, ‘treatment’ options etc.…) are deferred to those who are seen to be neutral since after all, their collective interests both professionally and socially are presented as being inconsequential, there is thus no need to reflect on potential conflict of interests, beyond the most obvious.
Cultural hemogeny and choice
Cultural hegemony refers to the belief systems and explanatory models which primarily serve the interests of privileged or dominant groups but which become imposed and accepted as the cultural norm. It universalises ideologies that encompass the nature of things and, underlie the social, political, and economic status-quo which is in turn rendered natural, inevitable and in service of everyone (rather than a system based on artificial social constructs which benefit certain groups). Within mental health services the dominant ideology includes very fundamental precepts such as the existence of mental ‘illnesses’, the pathologisation of certain behaviours/beliefs deemed socially unacceptable and the location and the causes of mental distress.
But of course, as has been argued quite powerfully by many, locating mental health problems within individuals, means the unequal and unjust social order which benefits the most privileged and, at the very least, provide the conditions for psychological distress to arise, remains out of focus. Thus, the cultural hemogeny, within mental health services similarly serves the interests of socially powerful groups. In that sense, having the masses buy the idea of biological defects or dysfunction serves the status-quo. But…, what of people who use services and choose to use psychiatric diagnoses? Why are psychologists set on ignoring that mental health service users do find psychiatric diagnoses helpful subjectively? Well, I don’t think we are.
Firstly, it is problematic to assume that amongst psychologists who challenge psychiatric classifications, there is not amongst them, people who have used or use mental health services. Further, the above questions, raise even more fundamental questions: how does one know the proportion of service users who find diagnoses helpful, damaging and indeed re-traumatising? There is little empirical data to give an answer to such a question positively. And, assuming that only a small minority of people with lived experience of distress found current classification systems damaging, would it be ethical to ignore their needs and experiences-do we close our eyes on the fact some people will take their own life upon being diagnosed? Indeed, is there space to reject psychiatric classifications within current mental health configurations? What of social ethical issues or of concerns beyond individuals’subjectivities? And more crucially perhaps, can we really presently sustain the notion of choice?
Using praxis to help shift psychiatric conceptualisations
We are all socialized into dominant discourses and we internalize them often believing we do so by choice. I can chose to accept a diagnosis of psychosis and find it useful. However, the fact remains that not doing so may well mean that I cannot access services, that I am deemed to lack insight and thus subjected to more oppressive forms of ‘treatment’. That is to say, there are serious social consequences and costs for those who resist hemogenic forces and interrogate prevailing dominant ideologies and significant privileges for those who uphold them; both in society generally and in mental health services, specifically. As a result, the cultural hemogeny becomes part of our socialisation and influences our belief systems. It shapes the ways in which we think about ourselves and others, and how we relate to the world.
It seems futile to ask anyone to interrogate the hemogeny of mental health services without providing them with the tools to do so and, unless people who use services and others are able to critically interrogate current structures without suffering adverse consequences, I would argue that it is simply misconceived and indeed unethical to flaunt the notion of choice. Freire argued that marginalised groups may accept individualistic explanations of their experiences because of a need to identify with those with more power. A (Freirian) praxis based approach would involve reconciliating subjective aspects of mental health distress with more objective structurally based realities so that individuals can gradually perceive their personal and social realities as inherently intertwined and in constant dialectical communication.
This is the precondition of the praxis: a critical engagement with change through reflection and social action. Indeed, increasing a sense of ourselves as socially situated persons or as members of an oppressed group, will make us less likely to be satisfied with explanatory models which ignore the socio-political and take away our agency. A praxis based approach would thus necessarily entails a co-intentional and co-constructed conceptualisation of experience with both practitioners and mental health service users coming together to apprehend reality and to re-create the knowledge necessary to take action to ameliorate the unequal and unfair social order which creates and exacerbates distressed subjectivities. This is far from simply being a matter of language. To many of us, that is our core business. That should be an intrinsic part of the business of supporting people in distress.
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