“The rationale for a paradigm shift
The statement outlines the rationale for this paradigm shift and
makes recommendations for developing a new approach. The phrase
‘psychiatric diagnosis’ will be used as a shorthand for the current
classification scheme of the functional diagnoses.
The key conceptual issues and concerns can be summarised as follows:
Core issue 1: Concepts and models
■ Interpretation presented as objective fact: Psychiatric diagnosis is
often presented as an objective statement of fact, but is, in
essence, a clinical judgement based on observation and
interpretation of behaviour and self-report, and thus subject to
variation and bias (e.g. Kirk & Kutchins, 1994).
4 Time for a paradigm shift
■ Limitations in validity and reliability: As a consequence of the
above, numerous critiques testify to the resulting problems in
reliability and validity, and the issues have surfaced once again in
the process of developing DSM-5 (Bentall, 2004; Frances, 2012;
Kirk & Kutchins, 1994).
■ Restrictions in clinical utility and functions: The above limitations
diminish the utility of functional diagnoses for purposes such as
determining interventions, developing treatment guidelines,
commissioning services, and research based on these categories.
■ Biological emphasis: The dominance of a physical disease model
minimises psychosocial causal factors in people’s distress, experience
and behaviour while over-emphasising biological interventions such
as medication (Boyle, 2013; Cromby & Harper, 2013).
■ Decontextualisation: Psychiatric diagnosis obscures the links
between people’s experiences, distress and behaviour and their
social, cultural, familial and personal historical context.
■ Ethnocentric bias: Psychiatric diagnosis is embedded in a Western
worldview. As such, there is evidence that it is discriminatory to a
diverse range of groups and neglectful of areas such as ethnicity,
sexuality, gender, class, spirituality and culture (e.g. Bayer, 1987;
Busfield, 1996; Fernando, 2010; Shaw & Proctor, 2005).
Core issue 2: Impact on service users
The needs of services users should be central to any system of
classification. Service users express a wide range of views on
psychiatric diagnosis and the DCP recognises the importance of
being respectful of their perspectives. Some service users report that
diagnosis is useful in putting a name to their distress and assisting
them in the understanding and management of their difficulties,
whereas for others the experience is of negativity and harm. Some of
the key concerns include:
■ Discrimination: Research has demonstrated discrimination due to
negative social attitudes towards those with a psychiatric diagnosis.
This can create and compound social exclusion (Read, Haslam,
Sayle & Davies, 2006).
Time for a paradigm shift 5
■ Stigmatisation and negative impact on identity: The language of
disorder and deficit can negatively shape a person’s outlook on
life, and their identity and self-esteem (Barham & Hayward, 1995;
Estroff,1993; Honos-Webb & Leitner, 2001).
■ Marginalising knowledge from lived experience: Service users
often emphasise the primary significance of practical, material,
interpersonal and social aspects of their experiences, which only
constitute subsidiary or ‘trigger’ factors in the current system of
classification (Beresford, 2013).
■ Decision-making: Decisions about how to classify a person’s
behaviour and experience are often imposed as an objective fact,
rather than shared in a transparent and open manner. For
example service users’ disagreement with their diagnosis can lead
to being labelled as lacking insight, without acknowledgement of
the limitations of the current system (Terkelsen, 2009).
■ Disempowerment: The current classification systems position
service users as necessarily dependent on expert advice and
treatment, which may have the effect of discouraging them from
making active choices about their recovery and the best means
of achieving it. Many recovery narratives include a rejection of
diagnoses (Deegan, 1993; May, 2000; Bassman, 2007; Longden,
■ As noted above, diagnosis can lead to an over-reliance on
medication, while underplaying the impact of its physical and
psychological effects (Moncrieff, 2008).
The DCP believes there is a clear rationale and need for a paradigm
shift in relation to functional psychiatric diagnoses. It argues for an
approach that is multi-factorial, contextualises distress and
behaviour, and acknowledges the complexity of the interactions
involved in all human experience.” http://www.bps.org.uk/system/files/Public%20files/cat-1325.pdf
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…
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