Replies, Replies, to Dr. Pies
It would be a shame if Dr. Pies stops contributing to this debate. I think we’re addressing important things here, and debate between well-meaning people with different opinions is often very illuminating.
That said, we shouldn’t get into ‘tit-for-tat’. But I think we should continue to talk.
I completely agree with Dr. Pies’ suggestion that a controlled trial of the relative reliability, validity and utility of traditional diagnoses and alternative approaches should be conducted. Indeed, since (as Dr. Pies says) all good clinicians base their care on a comprehensive formulation, my more robust claim is that diagnoses are either irrelevant (add nothing) or are actively unhelpful (leading to the negative consequences I discussed). That’s a bold claim, and an empirical one, and we should put our heads together to design and conduct that kind of study.
I do feel I need to defend my colleagues over the implication – I’m sure unintended – that we see clients with a different range of problems than do psychiatrists. That first of all doesn’t make sense, since many of us criticizing DSM and the ‘disease model’ of psychiatry are psychiatrists (Pat Bracken, Phil Thomas, Sami Timimi etc), and – at least in the UK – psychiatrists, clinical psychologists and nurses work together in multidisciplinary teams, sharing responsibility for their clients. For myself, my clinical work has always (until recently, when management pressures became overwhelming) focused on in-patient wards and people with psychotic experiences. Indeed, Dr. Pies was kind enough to make reference to some of my research – with people with the most serious problems. For those interested, there are many case examples of these alternative ways of working with people who have psychotic experiences available in the clinical and scientific literature. Our problem, to be honest, isn’t that we don’t work in this field but rather, as we try to do our work with the most disturbed individuals, the ethos and traditional practices mitigate against a recovery-based, psychosocial mode of working.
I am genuinely surprised that a proponent of the diagnostic approach referred (as Dr. Pies did) to the “heterogeneity” of the diagnoses of both ‘major depressive disorder’ and ‘schizophrenia’. Our claim, my point, is that these diagnoses are invalid because (among other things) they are heterogeneous – that when two people with the same diagnosis can have absolutely nothing in common (different ‘symptoms’, arising from different etiologies and responding to different care), this undermines the idea that the diagnosis itself is either valid or useful. Heterogeneity is not quite a synonym for invalidity… but it’s close. And heterogeneous isn’t quite a synonym for unhelpful, but I’m not sure how a diagnosis of “schizophrenia” communicates anything helpful… we wouldn’t know, given its heterogeneity, what the person’s difficulties are, what’s caused them and what a recommended course of treatment would be.
I should, also, just mention predictive validity of such issues as substance abuse risk and suicide risk. These things must be assessed as part of any decent clinical intervention. But I’m afraid these are ‘transdiagnostic’ issues; past personal history and social factors are decent predictors of these kinds of issues – diagnoses are very poor. So poor, in fact, that it is actively dangerous for clinicians to assume suicide risks are low in one condition and risk of harm to others is high in others. These things are, as Dr. Pies says more than once, heterogeneous.
In respect to the wisdom of the use of medication and prescription on a “drug-centred” rather than “diagnosis-centred” basis, I would much prefer the evidence-based, coruscatingly scientific and humane approach of colleagues such as Jo Moncrieff than the idea that, because Galen and Hippocrates did a particular thing, we should continue. Personally, I hope we’ve progressed a little. When Galen and Hippocrates were the epitome of medical expertise, the recommended treatments for madness included advice to shave a person’s head, split open a live pigeon and apply said pigeon to said head. Galen himself was a strong believer in the humoural theory, and was therefore a fan of warm baths and purgatives. As people wiser than me have said, it’s often a mistake to follow authority figures without question. The data, from Jo Moncrieff, from Richard Bentall and from Bob Whitaker, just simply don’t support Dr. Pies’ confidence in medieval medicine.
It is for readers, I think, to judge for themselves how humane routine psychiatric care is. I don’t particularly want to list its miseries. But, I agree – and apologize. I absolutely don’t wish to tar an entire profession (that would be hypocritical, since I’ve just reiterated how this is a debate within psychiatry as much as a ‘guild dispute’). I do not think psychiatrists are inhumane – I think they are noble and principled healers, shackled to an ignoble and unhelpful paradigm. And, since we’re here, can I absolutely ally myself to Dr. Pies condemnation of my fellow professionals – psychologists – who have shamed themselves and their profession in cooperating in the abuse and torture of people under the guide of a ‘war on terror’. I would mention that I’ve been in press on this issue and drafted the British Psychological Society’s robust condemnation of this behavior, which is, incidentally, a model others could adopt. But Dr. Pies is absolutely right – psychiatry as a profession is a noble and caring profession and many (many) psychologists can be entirely unethical (we could have a long discussion over my profession’s guilt over the issue of eugenics).
Finally… I don’t really want to apologize for my skepticism of committee-driven, rather than evidence-driven, approaches (including the commercial links and secrecy involved). Dr. Pies is right – of course – we need to get together to discuss these things, and so inevitably ‘committees’ are involved. In the case of DSM-5, however, I don’t think the process yielded a glorious result. It may be because the members of the committees in question have stronger links than is healthy to the pharmaceutical industry. It may be because the traditions of their profession are ripe for the paradigmatic change that Pat Bracken and colleagues desire. It may be that professional interests got in the way of the data. But it is clear that the outcome is a manual that has attracted unprecedented criticism and field-trial kappas that are falling with each iteration of the franchise.