Making a good mental health diagnosis: Science, art and ethics (original) (raw)
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Ethical Decisions in the Classification of Mental Conditions as Mental Illness
Since the early 1990s, the philosophical debate over broad accounts of mental illness has stalled. Although there remains unresolved tension between mixed and medical models of mental illness, bioethics seems to be moving from a naturalistic account of mental illness to one in which illness is determined by applying an evaluative notion of function. Nonetheless, existing models often underestimate the role of social norms in defining illness. Most important, such models have paid inadequate attention to the relevance of wider philosophical assumptions about the objectivity of ethics and the concept of personhood to our understanding of illness. I attempt to demonstrate that these concepts are integral for differentiating mental illnesses from the vast array of irrational and pre-rational drives and personality traits for which we usually wish to hold the bearer morally responsible. In emphasizing the normative component in accounts of mental illness, I am not attacking psychiatric expertise, but rather endeavoring to bring philosophical discussion closer to the actual, informal decisions that psychiatrists (in particular forensic psychiatrists) regularly make when asked to determine someone's moral responsibility for a mental condition.
Classification in psychiatry: Inevitable but not insurmountable
The debate about psychiatric nosology was reignited last year when the fifth edition of the Diagnostic and Statistical Manual (DSM) was published to widespread criticism. Critics cite a number of problems with ‘psychiatric diagnosis’, though it is sometimes unclear which classificatory practices are included under this broad heading. Although it may be possible to avoid the problems inherent in the DSM system, other difficulties associated with classification (labelling, stigma) may prove harder to escape. The first part of this article argues that some form of psychiatric classification is made inevitable by the communicative, epistemic and ethical pressures on psychiatry. In the second half it is suggested that there are ways to think differently about our relationship to psychiatric classification, and that these could play a role in mitigating the harms outlined by diagnosis’ critics.
Epistemic Injustice and Psychiatric Classification
Philosophy of Science (forthc.)
This paper supports calls for an increased integration of patients into taxonomic decision- making in psychiatry by arguing that their exclusion constitutes a special kind of epistemic injustice: Pre-emptive testimonial injustice, which precludes the opportunity for testimony due to a wrongly presumed irrelevance or lack of expertise. Here, this presumption is misguided for two reasons: (1) the role of values in psychiatric classification and (2) the potential function of first-person knowledge as a corrective means against implicitly value- laden, inaccurate, or incomplete diagnostic criteria sets. This kind of epistemic injustice leads to preventable epistemic losses in psychiatric classification, diagnosis, and treatment.
BMJ Open
IntroductionDeveloped in dialogue with WHO, this research aims to incorporate lived experience and views in the refinement of the International Classification of Diseases Mental and Behavioural Disorders 11th Revision (ICD-11). The validity and clinical utility of psychiatric diagnostic systems has been questioned by both service users and clinicians, as not all aspects reflect their lived experience or are user friendly. This is critical as evidence suggests that diagnosis can impact service user experience, identity, service use and outcomes. Feedback and recommendations from service users and clinicians should help minimise the potential for unintended negative consequences and improve the accuracy, validity and clinical utility of the ICD-11.Methods and analysisThe name INCLUDE reflects the value of expertise by experience as all aspects of the proposed study are co-produced. Feedback on the planned criteria for the ICD-11 will be sought through focus groups with service users a...
Un-diagnosing mental illness in the process of helping
A medical diagnosis of a mental illness is a powerful symbol of both the presumed nature of the person’s experience and the authority of the person making the diagnosis. RICHARD LAKEMAN and MARY EMELEUS consider the meaning of diagnosis, its place in the ritual of health care, and the practical problems associated with not diagnosing and un-diagnosing. The traditional approach of western medical practice is to undertake an assessment and arrive at the correct diagnosis, which in turn determines the right treatment. Service users present frequently to helping agencies with a diagnosis of mental illness conferred already. This colours the therapeutic encounter and raises expectations of what needs to be done. The therapeutic potential and practical problems of deferring psychiatric diagnosis or ‘un-diagnosing’ mental illness in the context of providing care to people with complex presentations is critically considered. Un-diagnosing mental illness can be an important part of the care ...
This dissertation explores the entanglement of ethics and epistemology in the domain of psychiatric research, considering the ways that measurement practices and ethical values interrelate. If psychiatric clinicians, researchers, and patients are not acutely aware of the relationship between experimental configurations and the meaning of scientific data, unhealthy realities that take psychiatric constructs as fixed parts of nature will persist. The core of this work consists of case studies on the emergence and stabilization of two psychiatric diagnostic categories, Attention Deficit Hyperactivity Disorder (ADHD) and Depersonalization Disorder (DPD). Carefully examining the experimental configurations employed in the measurement of psychiatric disorders, this study shows how the neurobiological description of a psychiatric disorder is produced by employing a broad array of measurement techniques including psychopharmacological interventions, neuropsychological assessments, self-rating scales, historical studies, behavioral observations, psychophysical apparatuses, brain scanning devices, guided interviews etc. The dependence of each of these techniques upon others demonstrates the highly contingent status of diagnostic categories. The findings of this study include the claim that the current best-confirmed neurobiological description of ADHD, the catecholamine hypothesis, could not have been developed without the treatment and measurement of the disorder with psychostimulant medications. This observation and others suggest that the knowledge produced regarding psychiatric diagnostic categories needs to be carefully examined to avoid treatment plans that implement research data that is not well understood. I conclude that researchers, clinicians and patients are responsible for the data produced in scientific studies, and should therefore take a critical stance to conclusions drawn from scientific data when making decisions about treatment.
Psychiatric diagnosis as a political device
Social Theory & Health, 2010
Diagnosis in psychiatry is portrayed as the same type of activity as diagnosis in other areas of medicine. However, the notion that psychiatric conditions are equivalent to physical diseases has been contested for several decades. In this paper, I use the work of Jeff Coulter and David Ingelby to explore the role of diagnosis in routine psychiatric practice. Coulter examined the process of identification of mental disturbance and suggested that it was quite different from the process of identifying a physical disease, as it was dependent on social norms and circumstances. Ingelby pointed out that it was the apparent medical nature of the process that enabled it to act as a justification for the actions that followed. I describe the stories of two patients, which illustrate the themes Ingelby and Coulter identified. In particular they demonstrate that, in contrast to the idea that diagnosis should determine treatment, diagnoses in psychiatry are applied to justify predetermined social responses, designed to control and contain disturbed behaviour and provide care for dependents. Hence psychiatric diagnosis functions as a political device employed to legitimate activities that might otherwise be contested.