Division of Clinical Psychology Position Statement Final Version

Division of Clinical Psychology Position Statement

on the Classification of Behaviour and Experience in Relation to
Functional Psychiatric Diagnoses
Time for a Paradigm Shift
The DCP is of the view that it is timely and appropriate to affirm
pulicly that the current classification system as outlined in DS!
and "CD# in respect of the functional psychiatric diagnoses# has
significant conceptual and empirical limitations$ Conse%uently#
there is a need for a paradigm shift in relation to the experiences
that these diagnoses refer to# towards a conceptual system not
ased on a &disease' model$
Context
Classification is fundamental in medicine. To be effective, it requires a reliable and
valid system for categorisation of clinical phenomena in order to aid communication,
select interventions, indicate aetiology, predict outcomes, and provide a basis for
research. edical diagnosis is the process of matching an individual!s pattern of
symptoms and biological signs to a standard pattern in the classification, and
ensuring that similar but alternative patterns are discounted in the matching " the
process of differential diagnosis. The patterns themselves are commonly categorical#
if it is one it cannot be the other, but several can co$occur %co$morbidity&.
'n psychiatry, diagnoses rely on the use of the Diagnostic and Statistical anual of
ental Disorders %DS (& and the 'nternational Classification of Diseases)
Classification of ental and *ehavioural Disorders %'CD$+,&. The regular revision of
these t-o ma.or classification systems is a clear recognition that they are, and
remain, -or/s in progress. The need for revision is a consequence not only of the
need to accommodate evidence$based advances in thin/ing and practice, but also
reflects more fundamental concerns about the development, personal impact and
core assumptions of the systems themselves.
The development and use of these classification systems for psychological distress
and behaviour has never been free of controversy. any of the issues that arise in
relation to psychiatric diagnosis stem from applying physical disease models and
medical classification to the realms of thoughts, feelings and behaviours, as implied
by terms such as 0symptoms! and 0mental illness! or 0psychiatric disease!. The
Division of Clinical Psychology %DCP& has historically held mi1ed vie-s about
psychiatric classification and its implications in theory and practice, reflecting its
position as representing clinical practitioners in a -ide range of specialisms and as a
scientific body. The DCP recognises that the current classification systems have
underpinned much research and theory in the area and have shaped the structure
and delivery of mental health services. Secondly, these systems provide seemingly
0tangible! entities for use in administrative, benefits, and insurance systems. Thirdly,
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Division of Clinical Psychology Position Statement Final Version
they are broadly accepted by most professional groups, many service users, the
media and the general public.
2t the same time it should be noted that functional psychiatric diagnoses such as
schi3ophrenia, bipolar disorder, personality disorder, attention deficit hyperactivity
disorder, conduct disorders and so on, due to their limited reliability and questionable
validity, provide a fla-ed basis for evidence$based practice, research, intervention
guidelines and the various administrative and non$clinical uses of diagnosis. This has
been a matter of cross$professional concern for many years %e.g. *ar/er, 4,++# *PS,
4,,,, 4,++# *oyle, 4,,4# *entall, 4,,5# *rac/en et al., 4,+4# Coppoc/ 6 7opton,
4,,,# 8ohnstone, 4,,9# oncrieff, 4,+,&. The current classification systems are less
controversial for conditions -ith an identified biological aetiology such as in the fields
of neuropsychology, the dementias, and moderate " severe learning disability.
:evertheless, serious concerns have been raised about the increasing
medicalisation of distress and behaviour in both adults and children %*PS, 4,++#
Conrad, 4,,;&. The 0functional! diagnoses, for -hich there is substantial evidence for
psychosocial factors in aetiology, and very limited support for a disease model, give
rise to a -ider range of vie-s and positions and are the primary focus of this
statement.
This position should not be read as a denial of the role of biology in mediating and
enabling all forms of human e1perience, behaviour and distress %Cromby, 7arper 6
<eavey, 4,+=&, as is demonstrated, for e1ample, in emerging epigenetic research
%e.g. <ead 6 *entall, 4,+4# S3yf 6 *ic/, 4,+=.& 't recognises the comple1ity of the
relationship bet-een social, psychological and biological factors. 'n relation to the
e1periences that give rise to a functional psychiatric diagnosis, it calls for an
approach that fully ac/no-ledges the gro-ing amount of evidence for psychosocial
causal factors, but -hich does not assign an unevidenced role for biology as a
primary cause, and that is transparent about the very limited support for the 0disease!
model in such conditions. Such an approach -ould need to be multi$factorial, to
conte1tualise distress and behaviour, and to ac/no-ledge the comple1ity of the
interactions involved, in /eeping -ith the core principles of formulation in Clinical
Psychology %DCP, 4,++&.
The Role of Clinical Psychologists
'rrespective of -hether the psychiatric diagnosis refers to a condition -ith an
established primary biological basis or not, there is clearly an identified role for
psychological assessment, formulation and intervention in addressing psychosocial
factors, ta/ing into account the influences of biological contributions. The same
pertains to applied psychology in health, -here the role of psychologists is to identify,
formulate and offer interventions relevant to the biopsychosocial factors that may
predispose to physical illness and -ill materially influence its course, outcome and
impact.
The Rationale for a Paradigm Shift
The statement outlines the rationale for this paradigm shift and ma/es
recommendations for developing a ne- approach. The phrase 0psychiatric diagnosis!
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Division of Clinical Psychology Position Statement Final Version
-ill be used as a short hand for the current classification scheme of the functional
diagnoses.
The /ey conceptual issues and concerns can be summarised as follo-s)
Core "ssue () Concepts and models
'nterpretation presented as ob.ective fact) Psychiatric diagnosis is often presented
as an ob.ective statement of fact, but is, in essence, a clinical .udgement based on
observation and interpretation of behaviour and self$report, and thus sub.ect to
variation and bias %e.g. >ir/ 6 >utchins, +??5&.

@imitations in validity and reliability) 2s 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 DS ( %*entall, 4,,5#
Frances, 4,+4# >ir/ 6 >utchins, +??5&.
<estrictions 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 carrying out research based on
these categories.
*iological emphasis) The dominance of a physical disease model minimises
psychosocial causal factors in people!s distress, e1perience and behaviour -hile
over$emphasising biological interventions such as medication %*oyle, 4,+=#
Cromby 6 7arper, 4,+=&.
Deconte1tualisation) Psychiatric diagnosis obscures the lin/s bet-een people!s
e1periences, distress and behaviour and their social, cultural, familial and personal
historical conte1ts.
Athnocentric bias) Psychiatric diagnosis is embedded in a Bestern -orldvie-. 2s
such, there is evidence that it is discriminatory to a diverse range of groups and
neglectful of areas such as ethnicity, se1uality, gender, class, spirituality and
culture %e.g. *ayer, +?9;# *usfield, +??C# Fernando, 4,+,# Sha- 6 Proctor, 4,,(&.
Core issue *) "mpact on service users
The needs of services users should be central to any system of classification.
Service users e1press a -ide range of vie-s on psychiatric diagnosis, and the DCP
recognises the importance of being respectful of their perspectives. Some service
users report that diagnosis is useful in putting a name to their distress and assisting
them in the understanding and management of their difficulties, -hereas for others
the e1perience is of negativity and harm. Some of the /ey concerns include)
Discrimination) <esearch has demonstrated discrimination due to negative social
attitudes to-ards those -ith a psychiatric diagnosis. This can create and compound
social e1clusion %<ead, 7aslam, Sayce 6 Davies, 4,,C&.
Stigmatisation and negative impact on identity) The language of disorder and deficit
can negatively shape a person!s outloo/ on life, and their identity and self$esteem
%*arham 6 7ay-ard, +??(# Astroff, +??=# 7onos$Bebb 6 @eitner, 4,,+&.
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Division of Clinical Psychology Position Statement Final Version
arginalising /no-ledge from lived e1perience) Service users often emphasise the
primary significance of practical, material, interpersonal and social aspects of their
e1periences, -hich only constitute subsidiary or 0trigger! factors in the current
system of classification %*eresford, 4,+=&.
Decision$ma/ing) Decisions about ho- to classify a person!s behaviour and
e1perience are often imposed as an ob.ective fact, rather than shared in a
transparent and open manner. For e1ample service users! disagreement -ith their
diagnosis can lead to being labelled as lac/ing insight, -ithout ac/no-ledgement of
the limitations of the current system %Ter/elsen, 4,,?&.
Disempo-erment) The current classification systems position service users as
necessarily dependent on e1pert advice and treatment, -hich may have the effect
of discouraging them from ma/ing active choices about their recovery and the best
means of achieving it. any recovery narratives include a re.ection of diagnoses
%*assman, 4,,;# Deegan, +??=# @ongden, 4,+,# ay, 4,,,&
2s noted above, diagnosis can lead to an over$reliance on medication, -hile
underplaying the impact of its physical and psychological effects %oncrieff, 4,,9&.
Summary
The DCP believes there is a clear rationale and need for a paradigm shift in relation
to functional psychiatric diagnoses. 't argues for an approach that is multi$factorial,
conte1tualises distress and behaviour, and ac/no-ledges the comple1ity of the
interactions involved in all human e1perience.
+ction Points from the Position Statement
+ction point (
To share within the DCP and through pre-qualification training and continuing
professional development, the issues raised by this statement. The aim is to
achieve greater openness and transparency about the uses and limitations of
the current system, and enhance service users and carers awareness and
understanding of the issues.
+ction point *
To open up dialogue with partner organisations, service users and carers,
voluntary agencies, and other professional bodies in order to find agreed ways
forward. This will necessarily include safeguarding access to health and
social care, benefits, wor support, and legal and educational services that are
currently diagnosis-based.
+ction point ,
To support wor, in con!unction with service users, on developing multi-
factorial and conte"tual approaches which incorporate social, psychological
and biological factors.
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Division of Clinical Psychology Position Statement Final Version
+ction point -
To ensure that a psychosocial perspective and psychological wor are
included in the electronic health record.
+ction point .
#or the DCP to continue to promote the use of psychological formulation as
one response to the concerns identified in this statement.
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