Is psychiatric diagnosis a cult?
The current categorisation of mental disorders is popular, but it isn't evidence-based.
The way we classify distress is typically based on psychiatric diagnosis: you get told you have a “disorder”. But is this scientific? The answer is much less so than we might assume.
Long before I was a psychologist, I was a humanist, and spent much time debating with religious cults. Today, as a psychologist, I spend my time debating with those who defend psychiatric diagnosis. Increasingly, their arguments are the same.
Let’s dive into what I mean by that.
What is psychiatric diagnosis?
Psychiatry often uses a medical model or disease model of distress. For example, you might be told you have social anxiety disorder, major depressive disorder, or borderline personality disorder.
These are modelled on diseases: it suggests there is something wrong with you and that if we can fix that thing within you, you will be “normal”. You have a mental illness, and we aim to cure that illness.
This isn’t the only lens to view distress, though. Viewed through a social lens, anxiety, depression, and other forms of distress are a result of the social circumstances a person finds themselves in. It’s not an illness but the natural consequence of a society that has let someone down.
Where does the science point?
Those who support psychiatric diagnosis will say that they have all of the evidence. Almost all available research is done based on the disease model.
Unfortunately for them, though, the evidence points in the exact opposite direction.
If distress was an illness, we would expect to find something, like the serotonin theory, that would explain why someone becomes depressed, and fix it simply by giving them more serotonin. We would then be able to identify depressed people by measuring their serotonin levels.
This has not happened. The serotonin theory has fallen apart and been largely abandoned. In fact, after 50 years of well-funded research, we haven’t got a single diagnostic test that can look at biomarkers and tell us what “mental illness” someone has.
I will say that again: not one single test. After 50 years of research.
Absence of evidence
The fact that the research has been so well funded is important because cult leaders and psychiatric diagnostic supporters alike will say “absence of evidence is not evidence of absence”.
But this is not always the case. It’s true that if I haven’t looked in my fridge, that isn’t evidence there is no butter in there. But if I open my fridge, search every corner of it for butter, and find no butter, that is good evidence there is no butter in the fridge.
We have looked for the biomarkers. We can’t find them. We can’t find them because they’re not there.
Still, cult members are unfazed. It doesn’t matter how many times the prophet fails to appear; the cult members just keep saying “next time will be the time they appear”. Just as those who support psychiatric diagnosis keep saying “just one more study and we’ll find the biomarkers”.
It’s worth saying that I am willing to be wrong about this. If we find a reliable biomarker that we can then target with a treatment and solve the “illness”, I will welcome that.
Correlation and causation
Even if we did find some biomarkers, it would not necessarily tell us anything. We know that distress is mediated through the body. Anyone who has had a panic attack will be able to tell you how physical it is.
We used to believe that low serotonin caused depression. Even if we did identify that link, which has since been abandoned, it could still be a classic case of mixing up causation and correlation: depression may well cause low serotonin rather than the other way around. Good science would not only need to find the biomarkers, but show there was a causal relationship between them.
Does science have any answers?
You might conclude at this point that science has no answers to these questions. But it does, in fact, provide some pointers.
And those point to the social model of distress. We do have a marker that can predict depression much more accurately than someone’s body chemistry: their bank balance.
We know that when people live in a society with high inequality, their mental health gets worse.
We also know that if we put social supports in place, people’s mental health gets better. A really clear example of that is making reasonable accommodations for autistic people. If you give them a less noisy office, they feel less overwhelmed and become more productive.
The hypothesis of the social lens is that distress is an intelligible response to the circumstances someone finds themselves in. And the evidence agrees.
Quality over quantity
Another retort from the psychiatric diagnosis cult is that almost all research and systems are built around psychiatric diagnosis and therefore it must be correct.
This is like arguing, as many did, that the Earth is the centre of the universe and that Copernicus and Galileo are minor voices not worth listening to.
It’s a deeply unscientific position because it ignores what the evidence points toward. Despite that, you might fairly ask, “but why has this become the dominant view of mental health?”
We know the answer to this, and it is multi-faceted. First, psychology wanted to gain the respect of the medical profession and therefore attempting to copy it, however flawed, probably seemed like a good idea.
Second, the current system of classifying everything into individual disorders suits the needs of the American health insurance system. You need to be able to classify and measure distress into discrete categories to bill for it.
Third, blaming individuals for their distress suited the neoliberal agenda. The traditional model of workers being distressed because of poor conditions didn’t suit the deregulation of Thatcher and Reagan, whereas the “you are unhappy because there is something wrong with you” did.
In short, there is an assumption that because so much research is done on the disease model, it must be because it’s inherently correct. This is bad science: when we check this assumption, as all good science does, we see there is no evidence for this and a convincing explanation as to why else it has happened.
Working within the system
Some might call me a hypocrite: I rail against labels, and yet you can come to my clinic and undergo an assessment for these labels.
I don’t hide that. That’s the system we are working in at present. If you want to access supports and legal protection under the Equality Act 2010, you need to get a label.
However, it is important to point out that these labels rarely get used by us in a therapeutic setting. These labels have little value in treating distress: they are purely a social tool.
Clients often find labels useful. They make us feel less alone with experiences that are often both distressing and confusing. However, the same thing could be achieved with labels that did not place all of the responsibility on the individual.
Conclusion
Mental health disorders don’t exist. These are labels that describe clusters of symptoms. These labels may have some value, but what they are not is a description of an underlying mental illness.
Given that the evidence supports this, we might conclude that psychiatric diagnosis is a cult.
It is important to say, though, that its numbers are much smaller than we might imagine. Many clinicians, myself included, find ourselves forced to work within such a framework, even though we reject its ideas.
In that sense, it might be more comparable to the Anglican Communion. Nobody really believes anymore, but somehow they still run the local school and the parish council.
Whatever it is, it isn’t evidence-based medicine.