Framing a complex human problem such as distress under the umbrella of just one causal factor does not do it justice. For decades psychiatric diagnosis has been seen only through the guise of the biomedical model (Deacon, 2013; Benning, 2015; Wheeler et al, 2016). Which as this critique will debate has provided a one-sided perspective that influences resources, policy solutions and possible avenues for social change. Psychiatric diagnosis in its current state should be totally dismantled and redeveloped under a wider consideration of the human condition, to include possible approaches such as continuum frameworks, psychological formulation, trauma informed and intersectionality conscious perspectives and models such as PTMF (power threat meaning framework).
How the grip of the biomedical model came into force is a long history which can be found detailed by authors such as Deacon (2013). It appears at times to be a dark and oppressive space, one that devalues protected human characteristics such as gender, sexual orientation, race and disability throughout its history (Wheeler et al, 2016; Taylor 2022). The biomedical model is inextricably linked to Psychiatric diagnosis. Cromby et al (2017) present a variety of causal factors outside of the biological and propose a wider view that needs to be considered – the interplay of social, cultural and political forces. This perspective of widening the lens away from just the biological is supported by a variety of researchers (Bentall, 2004; Deacon, 2013; Taylor, 2014; Wakefield, 2013).
One of the main critiques of the biological model is that its aetiology, the reliability and validity of its causal factors, core assumptions and propositions are invalid (Kinderman, 2019). The disease focused explanation of human distress, even with decades and millions if not billions of pounds of research has not yet been able to find one reliable sufficient cause for any form of mental distress (Deacon, 2013), just pharmaceutical corrupt intervention (Crowell-Williamson, 2021). No specific biological impairments or markers have been associated with diagnosis (Cromby et al, 2017). This is not to say that biology and genetics have no interplay with human distress, the mind and body are inevitably and completely entangled (Cromby et al, 2017). However, when we do not have the scientific evidence to back up the long-term neuroleptic and antidepressant coma that much of the world’s population is under, can we really call psychiatry an ethically based field?
Many of the theories that underpin a medical basis for diagnosis in the past few decades have been strongly discredited (Menkes, 2022; Moncrieff et al, 2022). Such as the serotonin hypothesis, which even lead researchers supporting the hypothesis renounced (Moran et al, 2018). Furthermore, the classification manuals the DSMV and others such as ICD have come under huge scrutiny (Callard, 2014; Wheeler et al, 2016; Bredström, 2017). Callard (2014) goes on to use the temporal positioning of many before her to outline the issues raised by the DSMV. That it “privileges certain ethical positions and formulations,” focusing solely on classification, rather than diagnosis being “a complex, highly mediated process.” These manuals and processes do not consider the “boundaries between normal and abnormal, between everyday experience and distress” (Cromby et al, 2017. P 116). There is a complex wider social, environmental and political conversation.
Furthermore, the DSMV (the bible of Psychiatry) has been constructed not on science but by votes from their task force (APA, 2013) which detrimentally has often been one classification of person, white and male (Cooper, 2014; Davies, 2017; Taylor 2022). This imposition of unethical categorization does not consider the wider cultural recognition of symptom variance and undermines anything other than a white western-centrism strategy for dealing with distress. “Psychiatry is arguably more politics and social constructions than science” (Taylor, 2022, p4).
The reliability of diagnosis is in question. The heterogeneity of symptoms for many of the classifications of mental distress is abundant. Looking closely at MDD (major depressive disorder) one can see that there are over 1000 combinations of unique symptom profiles (Fried & Nesse, 2015). This is also seen in BPD (borderline personality disorder) (Cavelti et al, 2021), the schizophrenia classifications (Bentall, 2004; Kinderman, 2019; Liang & Greenwood, 2015) and many other classifications within the DSMV. “The diagnostic systems currently employed are not well equipped to capture the substantial clinical heterogeneity observed for most psychiatric disorders” (Liang & Greenwood, 2015, abstract). If people have such different symptoms, unique narratives and contingency how can we pigeonhole their distress into one category? The natural borders for classification of distress have been demonstrated to be fluid and ever moving, a convincing argument to consider alternatives to a medically biased diagnosis framework. As Bentall (2021) writes “mental illness is a continuum – one that all of us are on” (para. 29).
Validity is also of concern for psychiatric diagnosis. The effectiveness and desired outcomes are often filled with stigma, self-deprecating recovery, pharmaceutical coercion and political distortion of facts. A study found “effect sizes of general psychotherapy for various mental disorders range from 0.73 to 0.85, while the effect sizes of antidepressant medications is much lower, within a range of 0.17-0.31” (Migone, 2017, p136). This and many other sources (Bentall, 2004; Sharfstein, 2005; Longden, 2013; Kinderman, 2019) have discovered that even though the facts are clear that medicating populations of distressed people does not have the intended all round positive outcomes. Psychiatry is still offering a pill as the first line of treatment. Ignoring the evidence base is ethically corrupt and a form of malpractice. Longdon & Read (2016) discuss the impact of neurological changes from long-term neuroleptic prescriptions and there is a wider question to be asked about the efficacy of lifelong diagnosis and medicating of people. Taylor (2022) questions why personality disorders, “notoriously hard to get removed from women’s medical records” (p87) are given such lengthy prognosis when 85% of cases can be seen to be in remission after 10 years. This can be contrasted with the research around psychosis and schizophrenia (AlAqeel & Margolese, 2012; Longden & Reed, 2016; Bowtell et al, 2018).
We can use the problems with validity and reliability of diagnosis to critique it further by showing that clinicians consistently cannot agree on the same outcome from patient to patient, through the discipline’s aetiology, its unapparent and arbitrary markers and that causes of distress appear to be synergistic with causality being probabilistic and deeply complex (Cromby et al, 2017).
And what about the impact of individualism on psychiatric diagnosis. Individualism in the West and the lack of collectivism, community and families not being close together and providing structures and support for those in distress? Individualism is a growing social force that we have seen rise with capitalism and the force of the internet (Houston, 2014). Is it possible that the western “psychiatric gaze” (Van Os, 2022), with its ignorance of cultural understanding and management of distress are also having an impact on the individual. That we are seeing an increase in need to medicate and sedate a population of people who do not have an underlying social community and support structure? Kinderman (2019) certainly believes that mental health is not an individual issue but a political one. One in which we see ‘big pharma’ impacting the politics, funding streams and services of the very support frameworks that are meant to make a difference (Kinderman & James 2019).
The language we use around human distress is important to both internalised stigma and the stigma received by others because of how it affects our thinking. Language and terminology as discussed by (Cromby et al. 2017) are not free from value and often not neutral. The words we use come loaded, they can disregard the social, political, environmental factors that could be main aggravators to distress. Medicalised terminology can feel a long way off from lived experience and the description of living moment to moment. These words can take away autonomy and independence; remove accountability from toxic structures; increase powerlessness/helplessness and hopelessness and rely on dominate power structures.
Yalom (2003) argues that there is a danger that professionals will treat someone as a diagnosis rather than as a human being, with diagnosis acting as a “self-fulfilling prophecy” (p5). Stigma research (Peter et al, 2021) shows us how damaging and belittling stigma from mental health diagnosis can be. It is pervasive and it creeps in at the edges of society and keeps us from functioning fully. Keeps us in boxes and doesn’t allow us to freely speak about what is happening to us. It tells society what is acceptable and what is not. Which varies from culture to culture and timeframe to timeframe.
The history behind the schizophrenia diagnosis is a helpful one in critiquing psychiatric diagnoses. As Van Os (2016) states “we don’t know enough to diagnose real diseases, so we use a system of symptom-based classifications” (para. 7) as in the DSMV. The cultural and environmental impact of what Schizophrenia has been defined as at various times is a crucial element of the psychiatric gaze and shows us how diagnosis has morphed and developed. Bentall (2004) goes into great depth about this timeline and shows the reader the multitude of symptoms that have been put forward since Kraepelin’s first attempts at classification of what is now known as schizophrenia. Including when Mary Boyle offered a totally different viewpoint of symptoms due to the epidemic of 1916-27 demonstrating the uncertainty of such a closed association.
History shows us that an attempt has always been made to classify and put under the microscope anything that we do not understand or that falls outside of ‘normal’. That our culture and environment have a huge amount to do with what at that time was/is considered normal. For example, being a woman and homosexuality were at times also considered a diagnosable psychiatric condition (Taylor, 2022).
Whilst reading around this area it is hard not to feel the voices of the feminist movement. The voices are loud and clear about the damage that has been done to women over centuries of malpractice by the institution of psychiatry and the wider patriarchy (Wheeler et al, 2016; Taylor 2021; Taylor, 2022). An example is the dive into BPD research, which raises concerns for this diagnosis being purely a list of natural symptoms that would occur after trauma from relational violence towards women, often from men, (Taylor, 2021; Taylor 2022; Capes-Ivy, 2020; Cavelti et al, 2021; Whitbourne, 2022). There is also a wider very clear intersectionality of concerns around the oppression of people from all walks of life, whilst reframing their trauma as a biological fault (Üstün & Kennedy, 2009; Carr & Spandler, 2019; Kunorubwe et al, 2022; Ahmed et al, 2021).
This is not just a feminist exchange, it’s a need for social consciousness of how humanity, and more recently Psychiatry, has managed people who do not fit in with the current social norms and perspectives of that time. This interpenetrates the social, cultural and political forces that impact psychiatric diagnosis. Who decides what constitutes the symptoms and classifications of distress, and why should they over others? Causality research has shown us that distress is “multiple, complex and over-determined” (Cromby et al, 2017, p134). This essay has tried to demonstrate that over time distress looks different, that classifications such as Schizophrenia are fluid and constantly evolving (Bentall, 2004). That there is a current pandemic of over medicalising and shaming people for their distress and ignorance of the wider causal factors.
There are better alternatives to psychiatric diagnosis, for those who experience distress. A revision of the way we speak and see mental distress, starting from the bottom up listening to lived experience and what helped and hindered progress to states of wellbeing. Diagnosis can influence distress, through often invisible structures that affect our lives in an unconscious and unseen way. A more integrated approach is required, one that looks at the individual narrative, considers the social, environmental, and political, whilst deconstructing power structures – the promulgation of the continuum model (Peter, et al. 2021), awareness of the spectrum, uniqueness and diversity of the human condition and the impact of real-world trauma (Sweeney et al, 2018).
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