Understanding Mental Health and Counselling. Группа авторов
by Nevova Zdravka
As you saw in the preceding chapters, a medical framework is one of the dominant ways of understanding the kinds of psychological distress and behaviours that are collectively referred to as ‘mental health problems’, ‘mental disorders’ and ‘mental illnesses’. This chapter will focus on the assessment and categorisation of mental health problems via the medical practice of diagnosis, using the sets of categories and criteria found in diagnostic manuals. In the UK, service users are given a psychiatric diagnosis from the International classification of diseases (ICD), currently in its eleventh revision (ICD-11; World Health Organization (WHO), 2018). This international manual covers both mental and physical health. Another manual, published by the American Psychiatric Association (APA), is also extensively used internationally: the Diagnostic and statistical manual of mental disorders (DSM), currently in its fifth edition (DSM-5; APA, 2013). This chapter will focus on the latter manual because it has a significant international impact (e.g. on research and on other manuals, such as the ICD) and because it has been the focus of significant scholarship and research.
In medicine, a diagnosis is used to:
categorise the type of problem a person has
identify treatment options and their likely outcome
provide access to other kinds of support
inform research
inform the planning of health services.
The following quotations are from two people who received a psychiatric diagnosis. The first, Mike Shooter, is a psychiatrist who chose to speak openly about his experiences of depression, while the second is a mental health service user.
When I was told that I was depressed it gave me a framework of understanding and a first grip on what was happening, not just for me but for my wife and children who had been equally frightened by my behaviour.
(Shooter, 2010, p. 366)
You only have to look at the definitions given in ICD 10 and DSM IV and read comments such as ‘limited capacity to express feelings … callous unconcern for others … threatening or untrustworthy’ … [o]ne thing that these comments have in common is that they are not helpful in any way.
(Castillo, 2003, p. 128)
This chapter explores why such opposing opinions exist, outlining why some service users find diagnosis helpful and why others find it unhelpful.
This chapter aims to:
provide a basic explanation of psychiatric diagnosis and the systems of psychiatric classification found in diagnostic manuals
explain what medicalisation is and understand its role in the categorisation of certain problems in living as ‘illnesses’ and ‘disorders’
understand the ways in which diagnoses have changed over time and some of the reasons for these changes
evaluate some of the conceptual, ethical and practical problems involved with diagnosis.
1 The first two editions of the DSM
The DSM is based on the premise that mental health concerns can be medicalised. Prior to the first edition of the DSM, a number of different diagnostic systems were in use. Often these were focused on gathering basic statistics about patients in asylums and concentrated predominantly on psychoses. In 1946 the US War Department published a classification system called Medical 203 (War Department Technical Bulletin, Medical 203, 1946) organised around a categorical system of diagnosis. This was a broad system that focused on two ‘types’ of problems: those seen as primarily organic in origin and those seen as more psychological in origin. The term ‘disorder’ was used to refer to major categories but, for subcategories, the term ‘reaction’ was used. This reflected a broadly psychodynamic tradition in US psychiatry that saw problems arising from a dynamic interaction of biology, personality and social circumstances.
Medicalise To treat mental health concerns as though they are medical conditions that can therefore be diagnosed and treated.
Categorical system of diagnosis A system of organising diagnoses that assumes that mental health problems are distinct – that they have clear boundaries – and can, therefore, be differentiated from each other using diagnostic criteria.
Published in 1952, the first edition of the DSM (APA, 1952) was designed to be consistent with the ICD-6 (WHO, 1949) – the term ‘reaction’ was used both in the DSM and ICD. The DSM was heavily influenced by Medical 203 and was essentially a nine-page list of categories and codes followed by a longer section providing definitions and symptom descriptions. The categories were organised based on presumed causes. Sections with presumed organic and biological causes, such as ‘mental deficiency’, were differentiated from disorders seen as having psychological origins, including ‘psychotic disorders’, ‘psychoneurotic reactions’ and ‘personality disorders’ (which had been included in Medical 203 as ‘character and behaviour disorders’).
The second edition of the DSM (DSM-II) was published in 1968 (APA, 1968) and was designed to be consistent with the new ICD-8 (WHO, 1968), the development of which had been heavily influenced by US psychiatrists. Both used the term ‘reaction’ much less, and anxiety and depression were categorised as neuroses rather than ‘reactions’. By the end of the 1950s most psychiatrists worked in outpatient clinics and private practice (Cromby, Harper and Reavey, 2013), so DSM-II covered a broader range of problems than the first edition, including a new section specifically devoted to ‘behaviour disorders of childhood and adolescence’. Although some categories were still influenced by causal theories, the foreword to DSM-II noted that, where there was some controversy about the nature or cause of a disorder, ‘the Committee has attempted to select terms which it thought would least bind the judgment of the user’ (APA, 1968, p. viii).
Neurosis A psychiatric term that refers to a psychological state that causes distress but is not characterised by being out of touch with reality. Depression and anxiety are common examples.
In summary, the DSM arose out of the need to collect statistics on the prevalence and demographics of various disorders, and to develop a classification system consistent with the ICD for use across the US. The system was influenced by ideas about the causes of certain problems and by the populations with which it was to be used.
2 Challenges to psychiatry’s legitimacy: the road to DSM-III
As discussed in Chapters 1 and 2, the 1960s and 1970s saw psychiatry face a number of challenges to its legitimacy, both within its own ranks (e.g. psychiatrists such as Thomas Szasz and R.D. Laing) and from scholars and activists in civil rights movements. Questions were being raised about links between mental health and social conditions, the notion of mental illness itself and its relationship with restrictive social norms. Some researchers took up the challenge to examine the scientific basis of psychiatry, chiefly the validity and reliability of psychiatric diagnosis.
Validity The utility of a diagnostic system (does it do what it intends to do?); the degree to which the classification system provides a way of conceptualising problems that corresponds to service-users’ experiences and provides a means of accurately classifying them.
Reliability The degree to which clinicians agree on a diagnosis for a service user.
2.1 Empirical challenges: the validity and reliability of diagnosis
Psychologists sought to apply to diagnosis the criteria they used when evaluating the validity of psychometric tests. For example, did diagnosis predict outcomes? Were interview-based