Jacqui Dillon, national Chair of the Hearing Voices Network in England, tells a story of her first brush with the psychiatric services. A survivor of long-term, ritualised childhood sexual abuse, she suffered a mental breakdown after the birth of her daughter.
‘Bear in mind that the people who abused me, like many that abuse children on an industrial scale, were very sophisticated in grooming and terrorising children to ensure we didn’t speak. I’d been told I would be killed; that people wouldn’t believe me; they’d think I was mad and I’d be locked up. And then, guess what? The psychiatrist I told this to, said, “Jacqui, we have lots of people in here who describe these kinds of experiences and when we get their families in and we all talk about it together, they realise this is just part of their illness.” The horror and outrage of having the words of my abusers reiterated to me by the people who were meant to be offering me support was absolutely devastating. It happens to people all the time and it’s so wrong.’
Dillon is a frequent speaker at the roadshow events organised by A Disorder for Everyone!, a national campaign launched by psychotherapist and activist Jo Watson and clinical psychologist Lucy Johnstone that questions what they see as the insidious colonisation of counselling and psychotherapy language and practice by medical-model diagnosis. Dillon’s experience is, Watson says, a graphic example of the iatrogenic harm a diagnostic approach can do to someone experiencing mental distress.
‘I launched the campaign out of desperation and frustration,’ she says. ‘I was seeing more and more evidence that counsellors are colluding with the medicalisation of distress. It’s a particular problem in training courses, including continued professional development training. We seem to be routinely talking about distress using medical phrases and slipping into diagnostic language, which inevitably colours our understanding of a client’s experience.’
Her view – and she is by no means alone – is that psychiatric diagnoses stop the counsellor exploring how a client’s distress may be linked to the context and history of their lives. ‘Because medical-model thinking is all-pervasive, many counsellors automatically interpret emotional distress in diagnostic terms as “mental illness”, and there is no scientific evidence that this is so,’ Watson says. ‘There is no doubt in my mind that people’s “behaviours” can be better understood as responses to trauma and adversity, and as ways of managing and surviving their pain and fear. In fact, behaviours that are called “dysfunctional” in medical-model terms are often resourceful as well as essential coping strategies.’
Biological myth?
‘I believe that all that distress, no matter how difficult and complicated it may seem, will make sense in the whole jigsaw of a person’s life,’ Watson says. ‘Surely it is our job to help the client make sense of that? A diagnosis just serves to shut this process down. It obscures the stories of our clients’ lives.’
Indeed, numerous research studies have found that mental distress is very much linked with people’s life experiences, rather than a biological cause.1 James Davies’ book Cracked2 also skewers the belief that psychiatric diagnosis is a scientific process. Davies interviewed leading figures in the production of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), now in its fifth edition. In the book, Allen Francis, chair of the committee of psychiatrists charged with producing the fourth edition, admits readily that most of the decisions about what diagnoses to include were ‘arbitrary’ and warns that the additions of yet more diagnoses in DSM-5 ‘will rapidly expand the realm of psychiatry and narrow the realm of normality’, rendering millions more people without a mental disorder ‘psychiatrically sick’.
In America, a DSM-listed diagnosis is essential to get health insurance companies to pay for treatment: no diagnosis, no treatment. In the UK, with its national health system, this is less crucial, but diagnoses are widely regarded as a valid way of communicating a shared understanding of patients’ symptoms and prescribing the best treatment. This is all well and good when dealing with physical disorders, where the causes can be identified through physiological tests. To date, however, no scientific test has produced consistent biological evidence for physical causes of mental disorders; diagnosis, as Francis admits in Cracked, is a very subjective process. It becomes, as Dillon’s tale so painfully demonstrates, one person’s subjectivity against another’s, and if one is a patient and the other a medical professional, the opinion of the professional is always going to win out.
So how and why do counsellors and psychotherapists, who have no powers to diagnose or prescribe, come to be using this language, and if they are, what’s the problem?
The problem for counselling, says Pete Sanders, person-centred counsellor and author of numerous books on the person-centred approach, is that pinning diagnostic labels on people’s experiences is totally incompatible with its principles. Person-centred counselling is about the person: the role of the counsellor is ‘to get out of the way and just listen’, he says. It is not to impose judgements on their clients, and that’s what a medical diagnosis is.
‘Everyone’s distress is different. When counsellors and psychotherapists say that everyone is unique, it should not be a trite cliché. It must be a banner of truth under which people in distress and psychological practitioners can gather, knowing that all stories of fear, darkness, pain and joy will be heard patiently, fully and without judgement. Here lies the actual expertise of a counsellor and psychotherapist,’ Sanders says.
It is, he argues, the difference between the counsellor as companion and collaborator and the counsellor as expert, professional and technician. He asks: does counselling aim to facilitate the fulfilment of potential and celebration of personhood and diversity, or does it simply seek to help the client towards the restoration of what is perceived to be ‘normal’ health?
Del Loewenthal, Emeritus Professor of Psychotherapy and Counselling at University of Roehampton, agrees. ‘Psychological therapists just don’t have the knowledge to diagnose and treat, because therapeutic knowledge is not like that! One of the unique qualities of the therapist is precisely our ability to sit with not knowing, without putting a label on what the client brings and without recourse to technique-driven responses. I am concerned even about the assessment interview that so many counsellors and therapists use these days. It seems to me that therapists quite like it. When I see a client for the first time, it’s vital that I don’t know anything about them. I want to hear what the person tells me, and we see what emerges from that.’
Pragmatic approach
Chief Professional Standards Officer at BACP Fiona Ballantine Dykes feels that BACP needs to occupy what she believes is a large and important middle ground: appreciating that counsellors need to understand the language and application of diagnoses in order to work in some contexts, and in particular the healthcare system, while also recognising that the diagnostic process is incompatible with the holistic understanding of each unique individual that is fundamental to counselling.
‘We have to recognise the wider danger of turning human suffering and common life problems into medical issues, which can lead to increased use of medication as first-line treatment,’ she says. ‘But at the same time, in my experience, many clients are desperate for a diagnosis because, for them, it offers a meaningful explanation for what they are going through, and one that is understood by their families, friends, work colleagues and others around them. An ability to speak the language of diagnosis is also helpful when counsellors are talking to other health professionals. If therapists take a very purist approach and don’t use any labels, it can make these conversations very difficult. Often it is having that common language that pulls very disparate multidisciplinary teams together. I don’t think we can afford the luxury of not using diagnostic language at all.’
Rachel Shattock Dawson, Consultant Editor of Therapy Today and an integrative psychotherapist in private practice, says counsellors sometimes have to be pragmatic and be led by how their clients talk about their distress. ‘I think counsellors and psychotherapists should have a good, up-to-date working knowledge of psychiatric diagnoses, such as the so-called personality disorders and types of anxiety and depression – what they mean, what they may look and sound like, and what medications are likely to be prescribed for them. We work in the real world, often in or alongside the NHS, and we need to be able to have a proper professional dialogue with our medical colleagues. We don’t have to use the language of diagnosis ourselves, but we need to know it and be able to speak it.’
Many of her clients come through the door having researched and sometimes self-diagnosed their issues using the internet. ‘Some like a label. They like to know what it is, research it, tell it to their friends and family. It legitimises what they are feeling. They may need it for their employer or to access state support. For example, for children with Asperger’s or autism, these labels are very necessary for getting the right help if they are struggling with school, and a therapist might be able to support that,’ Shattock Dawson says.
Diagnosis is indeed an essential passport to our health and welfare system. This has led some mental health activists to argue that opposition to the diagnostic system should be halted during this period of ‘austerity’, when it is becoming harder and harder to claim benefits for any kind of illness, and mental distress in particular.3
Ironically, however, a diagnosis can bar some clients from accessing NHS treatment. Shattock Dawson has worked with three clients in the last three years who have been refused therapy on the NHS after being given a diagnosis of borderline personality disorder (BPD). ‘They have been offered medication but refused any therapy; they’ve been told there is no evidence that therapy helps with BPD. However, every one of them has since done well in therapy with me. We just talked – no treatment plans, no techniques, just a lot of listening, empathy and support. They thrived. And it makes me angry that they had to turn to the private sector when they were in such need. The NHS should have taken them in. If they had depression, they would have had some help.’
IAPT services come in for particular criticism in this respect. Within IAPT, diagnostic labels are introduced from the very first telephone assessment with a psychological wellbeing practitioner, as clients are filtered through the stepped programme of treatment. Gillian Proctor, Programme Leader of the MA in counselling and psychotherapy at the University of Leeds, recently interviewed counsellors working in IAPT services to explore the ethical dilemmas they face. ‘IAPT is built on diagnosis and it’s used to keep people out of the service,’ she argues. ‘IAPT is about processing people on a conveyor-belt system and you only get on the conveyor belt if you meet the diagnostic criteria. In my research, counsellors were doing what the system requires and then, in the counselling room, returning to the values of counselling and working relationally with their clients.’ The strain of juggling two different sets of values is huge and it’s vital that counsellors have a critical understanding of the differences between them, she says, ‘so they don’t find themselves absorbed into this consumerist-based system. My sense is that the profession has absorbed diagnostic labels into how we talk about clients and it’s now part of our language. I can understand that it’s hard to avoid using it as shorthand, but we need to be aware of the implications of that. We should be seeing people as whole people. By colluding with the medical model, we may be getting some of its reflected power but we are selling out our radical and transformative routes’.
Critical analysis
The Leeds MA programme is designed to give students information about the medical diagnostic and classification system and also a critical understanding of its flaws and negative implications for clients, Proctor says. ‘I get students to think about the environmental, relational causes of people’s distress, such as trauma, oppression and racism, and about how people respond in different ways. We have to be able to understand what diagnosis means for the individual client and to be able to critique what it entails.’
Rachel Freeth is both a practising psychiatrist in the NHS and a person-centred counsellor. She has spent her professional career trying to bridge what might seem an unbridgeable gap between the two. She says it’s important to distinguish diagnosis from classification: ‘What people are really criticising when they talk about diagnosis is the process of using a classification system to frame people’s distress in terms of medical disorders.’
Freeth finds it incredibly challenging to be working in a system where her job requires her to use a language and a classification framework that don’t fit with her person-centred understanding of distress. ‘But that is my job as a psychiatrist. That is why the GP has referred someone to me. And very often, that is what patients want. Having a diagnosis validates their distress; if I didn’t provide it, they would think I didn’t believe them. It wouldn’t always be helpful to disregard it. But, ultimately, I don’t think a diagnosis offers any real understanding for the individual. It doesn’t say anything about the context in which their suffering arises and doesn’t tell us much about how best to treat it.’
She believes that is one of the major problems with our mental health system. ‘Practitioners don’t have time to get to understand the person, to build the relationship that helps us find out about our clients’ histories and worlds, and medication becomes the simplest option. But a lot of people don’t want to think about their situation, they just want a drug that numbs it.
‘Diagnosis simplifies; it provides clarity and order; it avoids having to deal with the complexity and messiness of people’s lives and situations and that is all some people crave. And I’m not just talking about the patient – I’m talking about the psychiatrist too.’
Like Proctor, she worries that counsellors, while often critical of diagnosis, aren’t able to articulate why they don’t agree with it – and they have to be able to do so if they are to challenge it. ‘Some people just don’t get it that these labels are only constructs; they don’t represent actual disease entities,’ she says. She is currently writing a book for counsellors on psychiatric classification and diagnosis, to be published later this year. ‘Counsellors should be able to talk much more intelligently about it, particularly in discussion with psychiatrists and doctors, and to understand their frame of reference. Rather than just say it’s rubbish, they need to understand and be able to articulate why it’s rubbish,’ she says.
Jo Watson believes the counselling and psychotherapy profession needs to flush the use of diagnostic labels out of the education system altogether. She points to the numerous CPD and counselling course modules devoted to ways of working with diagnoses. ‘If their teachers and trainers all use the language of diagnosis uncritically, then student counsellors will too,’ she says. ‘And from there, they start seeing the diagnosis as the explanation for this person’s distress and the therapy becomes all about how the client manages the “OCD” rather than how they understand their individual distress and how it manifests in their emotions and behaviour.’
What is the alternative?
For counsellors who don’t want to follow the diagnostic model, what is the alternative? Mind your language, says Pete Sanders. ‘Therapists are influencers. If we talk sick, our clients will think sick.’
‘Don’t just grab the nearest label from the shelf; use ordinary, non-pathologising language that is firmly rooted in people’s lived, subjective experiences,’ says Jacqui Dillon.
At a structural level, the recently launched Power Threat Meaning Framework (PTMF),4 developed by a group of clinical psychologists and service users, offers a way of conceptualising mental distress that avoids psychiatric diagnosis and categorisation altogether. The framework sees power, its misuse and abuse, as the key factor that drives people into ways of thinking and behaving that are currently diagnosed and labelled as ‘disordered’. The PTMF replaces the diagnostic question, ‘What is wrong with you?’, with ‘What has happened to you? How did/does it affect you? What sense do/did you make of it? What did/do you have to do to survive it?’ Importantly, it acknowledges the impact of the person’s wider social and political environment and how state systems and policies can produce and exacerbate distress.
It then asks: ‘What are your strengths?’ and ‘What is your story?’ ‘We are arguing that the person’s attempts to protect themselves from difficult or unbearable situations are what tend to get labelled as symptoms, when they are in fact serving important functions in helping the person escape, endure or survive,’ says Mary Boyle, Professor Emerita of Clinical Psychology at the University of East London and one of the lead authors of the PTMF. ‘This approach helps people think about how they might make their situation better and the resources they can call on, and then, by creating a coherent narrative of how it all fits together, helps them to find a way to move forward, in a way diagnosis does not.’
Jacqui Dillon found her own route to recovery with the help of a good psychotherapist: ‘I found someone who would walk alongside me and bear witness to what happened to me. For the first time, I got to speak my truth in the presence of another who was committed to hearing it. If psychiatrists just left people alone, it would do less harm than telling people the bullshit they do.’
Catherine Jackson is Editor of Therapy Today
References
1. Read, J, Bentall, RP, Fosse, R. Time to abandon the bio-bio-bio model of psychosis: exploring the epigenetic and psychological mechanisms by which adverse life events lead to psychotic symptoms. Epidemiologia e Psichiatria Sociale 2009; 18: 299–310.
2. Davies J. Cracked: why psychiatry is doing more harm than good. London: Icon Books; 2013.
3. Anonymous. Will the ‘Power Threat Meaning Framework’ help survivors on welfare? Asylum 25(3): 14–15.
4. Johnstone L, Boyle M et al. The Power Threat Meaning Framework. Leicester: British Psychological Society; 2018. bit.ly/2GRhNrU