DSM 5, the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders – often referred to as the ‘psychiatric bible’ – has now been released in the wake of huge controversy and debate. The alternative classification system, ICD, is based on exactly the same principles. Some of the world’s most eminent psychiatrists have spoken out about the current system.
The former director of the US’s largest funding body for mental health research, the NIMH, recently described DSM as ‘totally wrong, an absolute nightmare’. The chair of the DSM 5 committee admitted that ‘We have been telling patients for several decades’ that the biological causes of distress are about to be discovered, but ‘We’re still waiting.’ Another senior psychiatrist said, ‘Patients deserve better.’ In the UK, clinical psychologists have challenged the use of diagnosis and the ‘illness’ model.
The Hearing Voices Network, alongside many of our professional allies in psychology and psychiatry, has serious concerns about the way we currently understand, categorise and respond to mental distress . We also recognise the confusion that can be caused when accepted facts, often presented to service users as truths, are challenged.
We believe that people with lived experience of diagnosis must be at the heart of any discussions about alternatives to the current system. People who use services are the true experts on how those services could be developed and delivered; they are the ones that know exactly what they need, what works well and what improvements need to be made. This statement outlines the main issues, as we see them, and invites people on the receiving end of a diagnosis to have a voice in this debate.
HVN Position Statement on DSM5 and Diagnoses: Download & distribute
Psychiatric diagnoses are scientifically unsound:
- No objective tests: Unlike most fields of medicine, psychiatric diagnoses are not provided on the basis of objective tests or measures.
- They’re artificial: There is strong evidence that diagnoses do not represent meaningful clusters of problems or link to known biological abnormalities. Diagnoses are voted into existence by committee, representing opinion rather than scientific fact.
- Drug company involvement: There is growing concern that new diagnoses are both suggested and shaped by (initiated by) drug company funded research and interests.
- Unreliable: The diagnosis you receive from a psychiatrist is based on their opinion about what you have told them. Different psychiatrists often have different opinions about the same person, leading to multiple diagnoses. Two people with the same diagnosis may have nothing in common.
- Limited explanation: Whilst diagnosis seems to provide an explanation for people’s problems, this isn’t the case. People are told they have ‘schizophrenia’ on the basis of their unusual thoughts, experiences, feelings & behaviour. If they then ask why they are having these unusual experiences, they are told it is because they have ‘schizophrenia’. This circular argument explains nothing.
- Limited use: The issues raised above mean that diagnoses are a flawed basis for deciding on treatment, predicting outcomes and carrying out research.
Psychiatric diagnoses have damaging consequences:
- Misses the point: Increasing evidence demonstrates mental distress is an understandable reaction to adversity, including: bereavement, loss, poverty, discrimination, trauma, abuse and victimisation. By focusing on ‘what’s wrong with you’, diagnoses can stop professionals asking ‘what’s happened to you’.
- Missed opportunity: Psychiatric diagnoses can stop people addressing the links between social and economic policy and mental distress. Essential funds are used in the ongoing futile search for genetic markers instead of addressing the societal issues we know lead to mental health problems.
- Disempowers: Psychiatric diagnosis ignores people’s own explanations for their distress and encourages them to defer to an ‘expert’ for treatment. Having your reality redefined in terms of illness and biology is an incredibly powerful experience that can set the scene for a lifelong psychiatric career.
- Medication-focused: In diagnoses such as ‘schizophrenia’ treatment is primarily medication, which is becoming increasingly criticised for its harmful effects and lack of efficacy. Medication does nothing to address underlying difficulties.
- Human rights: People are expected to accept diagnoses for fear of being labelled as ‘lacking in insight’ and having treatment forced on them, violating their basic human rights. Others may, understandably, hide their voices or visions to escape forced treatment – blocking them from receiving help to cope with their experiences.
- Takes away hope: Diagnoses such as schizophrenia and personality disorder, seen as a life-long condition, can unnecessarily take away people’s hope for a meaningful recovery.
- Discrimination: People diagnosed with ‘severe and enduring mental illnesses’ are often subject to stigma, discrimination and exclusion. They may have trouble getting insurance, security clearance to travel overseas, and difficulty fostering or adopting children.
A Way Forward
Finding the best way to support those of us who are suffering and struggling to cope without relying on diagnoses and the existing system is a challenge. It can be hard to see what is possible when all we have known is what is available. Still, we want to engage people with lived experience of diagnosis and our allies, in a discussion to create a way forwards.
Our initial ideas include:
- Seeing mental distress as human and, ultimately, understandable: Rather than seeing voices, visions and extreme states as symptoms of an underlying illness, we believe it is helpful to view them as meaningful experiences – even if we don’t yet know what that meaning is. We believe it’s important to use human language when describing human experiences rather than medical terminology. Given the role of trauma and adversity, we need to start asking ‘what has happened to you?’ rather than ‘what is wrong with you?’
- Keeping the person in the driving seat: We want people to have the freedom to define their own experience. Support should be based on need, not diagnosis. Equally, people need to access a wide range of alternatives to understand and manage their experiences. Medication is just one way, amongst many, that people may choose. We need information about the pros/cons of each approach – true choice and collaboration, no coercion.
- Supportive communities: Mental distress is not just the domain of mental health services. Communities have an important role to play in supporting those who are struggling to cope. Community based options can run alongside, and as alternative to, psychiatry. Equally, these approaches must go hand in hand with greater awareness of the causal impact of social factors such as poverty, gender and racial inequalities, unemployment, deprivation and abuse, on mental distress