Reviewer Polly Mortimer
This short usefully sized book is part of the excellent Straight Talking Introductions series from PCCS that covers a range of mental health issues. Pocket sized and clearly written, they aim to dispel myths, raise awareness and generally help those in need of information and clarity in a world that is too often clouded by assumption taken as fact, and medically led ‘treatments’.
Allen Frances, coauthor of DSM IV and, to some extent since then, gamekeeper turned poacher on psychiatric matters, states recently ‘Our current systems of psychiatric diagnosis are all crude, heterogeneous approximations that will seem silly and invalid as we slowly and painstakingly acquire deeper knowledge.’
Lucy Johnstone, a clinical psychologist who worked in the NHS for a long time, takes the bull by its horns, not necessarily in a way that Allen Frances would totally endorse, but all the better for it. She states at the outset that ‘psychiatric diagnosis is not a valid or evidence-based way of understanding the difficulties and distress that people experience.’ (p1) From its inception in the early 1950s successive volumes of the Diagnostic and Statistic Manual of Mental Disorders have held sway over much of the world’s psychiatric community, and have grown from a slim volume – a postwar response to the catalogue of war and post-war neuroses being seen in returning troops, as well as surviving civilians and others – to become a Leviathan of ‘disorders’ including, shockingly, homosexuality until 1973. DSM IV bulged with ever more diagnoses: for example, ‘manic depression’ disappeared and was replaced by ‘bipolar disorders 1 and 2’, hugely over-diagnosed and ‘treated’. Cynically this explosion could be seen as pharma-driven; new disorders created to be ‘treated’ by new drugs. The DSM IV mood disorder committee all had links to the pharmaceutical industry and the medicalization of behaviours that are to be expected, and are not extreme, is continued in DSM V. All this has led to dangerous over-diagnosis, and dangerous over-prescription, especially to children.
Johnstone’s book, very readable – and with those experiencing distress right at its heart – interrogates the power of a diagnosis, and whether it’s the best way of getting to the heart of that distress. She posits that there could be better ways of understanding. As it stands, diagnosis seems to decide criminal responsibility, and is instrumental in gaining benefits and health insurance cover. She suggests that, like ‘possession’ in earlier times, and ‘moon madness’ and ‘wandering womb’ of the Victorian era, these labels could be abandoned; as a psychologist she is used to working with the whole person, not with a diagnosis. That is where she, and many others, feel that professionals should be; no-one should have to accept un-evidence-based diagnosis.
In Chapter 3 Johnstone drills down to the problems inherent in the system as it stands today – the assumption that the person with the diagnosis is suffering from a ‘medical illness’ for starters. There is no proof. The biopsychosocial model still implies an underlying illness, though it at least accepts the role of life events in causation. She sees diagnosis as propping up the idea that psychiatry is a branch of medicine and, taking us through some of the controversial diagnoses – ‘personality disorder’ being one – the idea is aired that diagnoses are a series of judgments; there is no objectivity.
Visiting the cross-cultural context she exposes the subjectivity and bias of the Western psychiatric model and suggests there is a valid argument to be made that Western diagnoses cannot be applied in non-Western cultures, based as they are on a mind/body split or, to quote Suman Fernando (2002), ‘psychiatric imperialism’. (p37)
Midway through the book (Chapter 4) there’s a useful Q and A to deal with some of the thorny issues that inevitably arise when critiquing such a bastion as psychiatry and its methods. The role of psychiatric drugs is a major one and Johnstone debunks some of the myths, while not dismissing some drug treatments that can be useful. Huge amounts of money are being spent, and vast scanners and imaging equipment built, to hunt for the elusive gene, brain pattern or biomarker. Nothing yet! How great it would be if this money was diverted to the here and now, to help those in distress practically, emotionally and holistically. Chapter 5 neatly sums up the impacts of diagnosis from the ‘sick role’ to ‘the treatment barrier’ to ‘loss of personal meaning’ and Chapter 6 contains powerful personal testimony from service users and survivors.
In Chapter 7 Dr Johnstone examines the ‘recovery model’, pioneered in the UK (2009). Originally conceived of as an alternative to the medical model but, ‘when used by policy makers and professionals … frequently seen as running alongside the traditional approach’ (p73), causal factors are divided roughly into two groups: social circumstances and relationship factors. Her remarkably simple, but very true and telling, question to those in distress would be to ask them what their problems are; lived experiences need to be listened to. The fact that life stories are suppressed (doctors tend to talk about bowels and sleep – it’s easier and less emotionally taxing) is very serious; service users’ histories, frequently the core of their distress, are often muffled.
When I was given a diagnosis, at first I was relieved. It put some sort of name to what I had been experiencing, and made some sort of sense. ‘Manic Depressive Psychosis’ – I could tell people that my complete withdrawal and deep physical and emotional inertia had a name. My GP told me I was lucky not to have been diagnosed ‘schizophrenic’ as I may have been in the US; manic depression was what the middle classes seemed to get as a diagnosis! However as the years wore on I was pretty keen on freeing myself, and recovering, from the label as well as from the disordered moods, and not being defined by my diagnosis. I did it, but it was hard.
So what to do? Lucy Johnstone sets out her stall in the section on Psychological Formulation already part of the psychology landscape. The psychologist and the service user work together to create a ‘best guess’ as to what has caused the distress. It’s all about shared understanding evolving over time – a collaborative, non-hierarchical way of creating meaning out of despair and guiding the person forward. Other kinds of understanding include the ‘trauma-informed model’ (Dillon et al, 2012) and the groundbreaking Hearing Voices Network where ‘constructs’ are used to make sense of life history.
As the book concludes, valuable information is given on how to proceed, where to go, who to read and how families and the profession can truly help, not hinder. All in all this is a tremendously valuable book punching holes in tradition and psychiatric conservatism, finding lights at the end of very dark tunnels, valuing the individual, giving them space and time and their story back.
Lucy has also written other valuable books, including, with Rudi Dallos (2006), one that carries the theme from this book on into more depth.
Polly Mortimer is librarian at the Minster Centre and has had personal experience as a voluntary and sectioned patient in the psychiatric system.
Dillon, J., Johnstone, L., & Longden, E. (2012) Trauma, Dissociation, Attachment and Neuroscience: A new paradigm for understanding severe mental distress Journal of Critical Psychology, Counselling and Psychotherapy 12(3) pp145-155
Fernando, S (2002) Mental Health, Race and Culture (2nd ed.) Basingstoke/New York: Palgrave
HM Government (2009) New Horizons: A shared vision for mental health London: Department of Health
Johnstone, L., Dallos, R. (Eds) Formulation in Psychology and Psychotherapy: Making Sense of People’s Problems Hove, East Sussex: Routledge