A Psychological Vision of Life Beyond the Disease Model

A review of the DSM-5 discussion at APA in Honolulu and the ongoing progress towards reforming diagnosis.

By Peter Kinderman, PhD

Peter Kinderman, PhD It's easy to become jaded about academic conferences. You fly at enormous expense across many time-zones to enjoy the dubious delights of corporate tourism – natural Edens questionably enhanced by international capitalism with a thin veneer of local colour. To justify the tawdry tourism, we see poorly-attended seminars presenting work that hasn't (yet) managed to squeeze past peer-reviewers and ‘networking' opportunities that seem more to do with alcohol and reinforcement than the challenging of received wisdom.

Having got all that off my chest, I am delighted to have attended the American Psychological Association's Annual Convention in Hawaii in August. Lucy Johnstone, Richard Pemberton and I joined colleagues from Division 32, the Society for Humanistic Psychology, to hold a seminar and a workshop. We were, of course, inspired by our international collective effort to discuss the implications of, and alternatives to, traditional psychiatric diagnosis and the "disease-model" dominant philosophy of psychiatry and mental health care. What we experienced was a near-perfect example of what academic and professional psychology conferences can achieve--if we take forward the ideas we discussed.  

Colleagues from Division 32 and from the British Psychological Society's (BPS) Division of Clinical Psychology have, of course, been collaborating for about two years to develop a forum for critical debate over the development of DSM-5. We see ourselves to have been successful – it is genuinely difficult to find media commentaries of DSM-5 that do not include some synonym of "controversial". Hawaii offered a venue for us to come together, to share perspectives on the current debate over diagnosis and, through the benefits of face-to-face meeting, to discuss the practice of clinical psychology in the emerging immediate future – a world without the disease model of psychiatry, in a world which helps people realize their potential and develop their psychological well-being.

Our symposium on Saturday 3 rd August perfectly summarized many of our scientific and professional concerns about DSM-5, diagnosis and the disease-model. Joshua Clegg opened the symposium by discussing the procedures through which the American Psychiatric Association cultivated the development of DSM-5 and the involvement of psychologists in that process. It was important, I think, that Joshua separated the discussion of ideas from a conflict between professions. Joshua reminded us of how the task force developing DSM-5 were motivated by noble aspirations, despite the apparent links of many participants to commercial interests. And Joshua reminded us that both psychologists and psychiatrists are active on all sides of the debate. Brent Robbins discussed the role of both the BPS Division of Clinical Psychology and Division 32 in responding to the DSM-5 task force in developing an ‘Open Letter' petition signed by thousands of individuals and institutions expressing some of our concerns, and in developing an international coalition of mental healthcare professionals who continue the debate and discussion on the internet at DxSummit.org and at upcoming conferences and international working groups.

Nancy McWilliams, Philip Cushman, and Joan Chrisler gave different but powerful accounts of how traditional psychiatric diagnosis fails to meet the needs of individuals in distress, of clinicians and of society. Nancy deconstructed the notion of "personality disorder" and explored how value judgments about what are essentially normative rules for appropriate behavior are transformed into criteria for the diagnosis of "psychiatric illnesses", with all the implications for assumptions about "aetiology" and "treatment" that inappropriately follow. Philip returned to the origins of the DSM diagnostic system – in addressing the traumatic effects of conflict. In a masterful speech, Philip illustrated how labeling our natural and normal reactions to unsustainable trauma as "symptoms of mental illness" emerged as a cynically predictable response to industrialized warfare, but obscures our necessary human and humane, psychological and political, response to war. Joan referred to the ways in which the politics of gender again transform stereotypes into diagnostic criteria and demonstrated this with some very clever research findings.

And I spoke too . Much of what I said was unnecessary – the earlier speakers addressed my agenda with much more eloquence than I could muster. I spoke about things that I've said before . I suggested that traditional psychiatric diagnosis, and its partner of the "disease-model", are unscientific, unhelpful and inhumane. I commented that DSM-5 is merely likely to make a bad situation worse.

But what was particularly good about Hawaii, why it was worthwhile attending a conference thousands of miles from home, was that we discussed the future and shared plans. We didn't conspire in the shadows – we presented our ideas in public (and I'm writing about them now). In our symposium, and in a subsequent workshop given by Richard Pemberton and Lucy Johnston, we talked about more than mere criticism of DSM-5. It was, I believe, right to organize critical debate internationally in response to the publication of DSM-5. But we can do more. We can look forward to a world in which psychologists and colleagues help people to recover from psychological distress, maximize their well-being and fulfill their potential in life without recourse to medicalised diagnosis, the "disease-model" of psychiatry and, of course, without assuming that life-time medication is the only salvation.

We don't need to invent a "new alternative". We need to stop doing the wrong things, and we need to use those established approaches that offer an existing, proven and effective alternative. I am proud, for instance, of my chosen profession as a clinical psychologist. As Richard and Lucy illustrated presenting the BPS's Division of Clinical Psychology's work on formulation , accurate, objective and operationally useful definitions of psychological phenomena (of all kinds) has always been the basis of our science and our profession. We don't need to diagnose, but we don't need to wait for a new alternative – we have the alternative already. For decades, psychologists have resolutely and systematically developed scientifically valid ways to define, observe and if appropriate to quantify psychological phenomena. We have no need to "diagnose" – artificially and invalidly to group these phenomena and associate them with putative "illnesses". Yes, we should criticize inanities such as DSM-5. But we shouldn't fall into the trap that we have to wait for new technologies to be invented before we have an alternative. We have – and we practice every day – the alternative now.

So, Hawaii may well have been both useful and a little bit of a turning point. We shared our views, and we thought carefully and critically about the issues before us. We celebrated our success in promoting wise and humane – albeit critical – debate. But also, by meeting and sharing conversation, we recognized the transition from a campaign to point out the inadequacies of diagnosis and the "disease-model", to a more positive promotion of the possibility of a psychological vision of life beyond the disease model.