A straight talking guide to psychiatric diagnosis

By Lucy Johnstone:  Straight Talking Introduction to Psychiatric Diagnosis

Do you still need your psychiatric diagnosis? The answer for practical purposes is probably ‘Yes.’ In the current system, diagnosis is essential for accessing services and benefits and, particularly in the USA, for covering your treatment costs. But do you need to believe in your diagnosis? Do you have to accept this particular attempt to explain your difficulties, and to take it on as part of your identity by becoming one of the ‘mentally ill’? In the words of the blurb for my book, one of the ‘Straight-talking introduction to….’ Series, which has just become available in the US:

A revolution is underway in mental health. If the authors of the diagnostic manuals are admitting that psychiatric diagnoses are not supported by evidence, then no one should be forced to accept them. If many mental health workers are openly questioning diagnosis and saying we need a different and better system, then service users and carers should be allowed to do so too. This book is about choice. It is about giving people the information to make up their own minds, and exploring alternatives for those who wish to do so.

As far as I am aware, this is the first book to provide a concise, accessible and inexpensive summary for service users, carers and others which:

• Summarises the complex debates for and against psychiatric diagnosis
• Looks at the impact of psychiatric diagnosis at every level from the individual upwards
• Outlines the alternatives to diagnosis
• Supplies a lists of reading, resources and organisations which can help you to think about alternatives for yourself if you decide to do so.

In the book, I’ve been very open about my own position. I am opposed to the use of psychiatric diagnosis (with obvious exceptions for conditions like dementia) at all. But it’s not going to go away overnight, and I recognise that for many people, it has helpful aspects. I also recognise that it is never easy to question fundamental aspects of our assumptions and identities, even if they cause us pain. Many of the accounts I have quoted testify to this.

The first part of the book explains what we mean by diagnosis and takes the reader through some of the arguments for and against applying this model in mental distress. It tackles some common questions such as ‘So what is the role of medication if you don’t use diagnosis?’ and ‘Surely you need to categorise things somehow?’ It then moves on to discuss the personal impact, positive, negative and mixed, of receiving a diagnostic label. This is placed in the context of service responses, social consequences, and the wider role of psychiatry.

One of the most important aims is to find a midway between two polarised positions that have been described as ‘brain or blame’. This refers to the difficulty that we seem to have as a society in finding ‘a middle ground between “You have a physical illness, and therefore your distress is real and no one is to blame for it” and “Your difficulties are imaginary and/or your or someone else’s fault, and you ought to pull yourself together”’ (p.2.) There are descriptions of the emerging alternatives to the diagnostic tradition, including constructs, narrative approaches and psychological formulation, which can provide non-blaming and constructive ways forward. In essence, the alternative to psychiatric diagnosis is to find your own story. Often, though not always, these are stories of trauma, loss, neglect, abuse, discrimination and deprivation; and often, though not always, psychiatric services have compounded rather than relieved the original problems. This process starts when people’s reality is defined by an expert in terms of a medical diagnosis.

In the current state of conflict, controversy and crisis in psychiatry, I do not believe it is professionally, scientifically or ethically justifiable to continue to present psychiatric diagnosis to service users and carers as an undisputed fact or truth. The Chair of DSM IV has described the manual as ‘deeply flawed and scientifically unsound’ and the Chair of DSM 5 has admitted there are no biomarkers to validate the categories; the former NIMH director has described DSM as ‘totally wrong, an absolute scientific nightmare’ while the current one confirms that its categories ‘lack validity’; and NIMH has embarked on a massive project to re-write the diagnostic manuals from scratch. How can any professional think it is acceptable to conceal these vital debates from service users and carry on as before?

Informed consent is expected for most interventions, in order that people can make meaningful decisions about their healthcare. For example, we want people to be aware of all the advantages and disadvantages of medication before agreeing to take it (although sadly in psychiatry, individual wishes can be overruled in some cases.) I believe that it’s time for people to be offered an informed choice about whether to accept, or at least whether to believe, a psychiatric diagnosis with all its subsequent consequences, both positive and negative. I hope this book will be a contribution to that process.

Get the book here on pre-order: Straight Talking Introduction to Psychiatric Diagnosis