Shifting paradigms in psychology

There are fundamental problems with diagnosis in relation to lack of validity, and increased stigma and how we, as psychologists, risk losing sight of the multiple factors that might contribute to an individual’s distress when relying just on a psychiatric diagnosis. As such, viable non-diagnostic alternatives which psychologists can consider to improve quality of care for people experiencing psychological distress need to be considered. These alternatives include collaborative formulation, community psychology and the Power Threat Meaning Framework. These ideas have been developed around the world, which is a testament to the international recognition that psychiatric diagnoses are not the only option and can adversely affect the social, personal and emotional lives of people accessing support.

Diagnosis: what’s the problem?

The medical model of mental health is founded upon the assumption that an individual’s distress is a form of pathology, with unidentified biological signs which link to ‘symptoms’. This approach enables a shorthand description of what is happening to people and indicates an expected treatment course, which links to particular symptoms. However, it has also been shown to be unhelpful and even harmful for people accessing services through increased stigmatisation and adverse psychiatric treatment side effects. To date, psychiatry has failed to demonstrate the specific components and mechanisms of pathology, and consequently there is no biological test for any ‘mental illness’. In 2013, Tom Insel, Director of the US National Institute of Mental Health (NIMH) spoke publicly about how the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013) lacked validity and subsequently declared that the NIMH would not continue to fund research based solely on diagnostic categories. More recently, it was noted by the UN Special Rapporteur that policies on mental health should attempt to address ‘power imbalances’ rather than ‘chemical imbalances’, which heralded an international call to reconsider mental health service provision worldwide.

One of the key resistances to the medical model is that clustering similar ‘symptoms’ across different presentations to signify one diagnostic category, over-simplifies the problem. Furthermore, by theorising biological causal factors such as chemical imbalances and genetics as the primary explanation for people’s distress, we risk dismissing experiences such as trauma or discrimination as reasons for enduring mental health difficulties in people’s lives. As such, the emphasis is often on what is wrong with the person, rather than what has happened to them. We are also underestimating the person’s agency as a survivor of possible adversity, through positioning them as a ‘sick patient’ who needs to be ‘treated’ by a professional. Moreover, a diagnostic label can lead to internalisation of negative public perceptions of ‘mental illness’ impacting on a person’s sense of self. Therefore, diagnostic labels applied with the intention of helping a person may inadvertently contribute further to their distress. Locating the problem within the person and their biology can result in less empathy towards their experiences, at a time when people need compassion more than ever.

In aligning itself with psychiatry and the medical model, psychology has adopted associated constructs such as ‘symptoms’, ‘diagnosis’ and ‘treatment’ (Johnstone, 2000). For example, by focusing on ‘dysfunctional cognitions’ as a ‘symptom’ of a ‘disorder’, cognitive behaviour therapy (CBT) can be said to locate the problem as a deficit within the individual, implying that the way the person thinks about the world needs to change, rather than the world itself. However, it is well documented that distress is often a result of experiences of inequality, discrimination, poverty, isolation and deprivation, and that these factors can lead to fear, shame, powerlessness and hopelessness. As such, by medicalising and individualising distress, clinicians risk ignoring the need to address the social, relational and political factors which may have caused their distress in the first place and inappropriately blaming clients’ personal characteristics and cognitions for their problems (Johnstone, 2000).

In addition, there is an increasing amount of evidence that people who are experiencing psychological distress are having an understandable reaction to unusual or overwhelming events (Bentall, 2009). However, discrete diagnostic categories create a false dichotomy between ‘we’ who are well and ‘they’ who are ‘mentally ill’, by obscuring the idea that psychological problems exist on a continuum, and that anyone can suffer circumstances that lead to distress. Furthermore, the use of diagnostic labels can negatively impact a clinician’s judgement of their clients’ engagement, response and perceived risk. In this way, by sticking steadfastly to a pre-conceived diagnostic framework rooted in the medical model, we detract from the opportunity to co-construct meaning with our clients and incorporate other factors which are known to contribute to distress.

Alternatives to psychiatric diagnosis

Collaborative formulation

The assessment, formulation, intervention, and evaluation model of therapy is central to good practice as a psychologist. Formulation is an iterative and collaborative process, taking the form of a working hypothesis based on a shared psychological understanding between the psychologist and person in need of support. Psychological formulation enables exploration of the messy and complex human experiences which account for distress, moving away from linear treatment as promoted through the ‘assess – diagnose – treat’ model. Depending on the approach that is most useful, formulation can take various forms and can integrate ideas from differing therapeutic models.

If mental health is understood, at least in part, as a social problem, then the inclusion of oppression, power, poverty, race, sexuality, gender, employment, etc. within the formulation is essential. Smail (2013) explored the notion of ‘outsight’ as opposed to ‘insight’, with regards to psychologists’ role in facilitating an individual’s development of awareness of political and oppressive external factors which are impacting on them. By developing outsight, problems which may have been considered as personal failings are more accurately understood as “deficits within their social environment, and possibly that where such deficits can be identified it may be within their power to correct them to some extent” (Smail, 2013 p. 38). As such, integrating these ideas into therapeutic conversations, might shift the focus from exclusively addressing ‘cognitive deficits’ towards more holistically supporting clients in the process of addressing social deficits of their environments.

The Power Threat Meaning Framework (PTMF)

In 2018, a group of British clinical psychologists and people with lived experience coproduced the Power Threat Meaning Framework (PTMF) as an alternative to psychiatric diagnosis (Johnstone & Boyle, 2018). This approach offers a new perspective on multiple forms of suffering including confusion, fear, despair, and troubled or troubling behaviour, and notably moves away from using stigmatising language used to describe distressing experiences. The framework summarises the impact of power and its misuse on people’s lives, providing opportunity to understand how we make sense of difficult experiences and how we have learned to respond to them. In the medical model, these responses would be labelled as symptoms of a disorder. The framework is based on the continuum model of distress which acknowledges that we all have the potential to have these experiences as they are part of what it is to be human. The PTMF can be summarised in the following questions, which can apply to individuals, families or social groups: What has happened to you? (How is power operating in your life?); How did it affect you? (What kind of threats does this pose?)

What sense did you make of it? (What is the meaning of these situations and experiences to you?); What did you have to do to survive? (What kinds of threat response are you using?).

Community psychology

This area of psychology prioritises social change, collective action, society-wide compassion, and by connecting otherwise isolated people, it promotes the recognition that people are not alone in their struggle. The approach extends beyond individual psychological interventions by facilitating intervention at the community and societal level (e.g., awareness raising and campaigning for policy change). In this way, community psychology suggests that a key task for psychologists is to facilitate dialogue and/or action with community members in order to establish, from their perspective, which interventions might lead to improved collective wellbeing. Importantly, interventions are designed with the community, as opposed to for them. As such, community psychology removes the power imbalance inherent in a one-to-one relationship, which can further undermine the agency of already vulnerable people, and instead acknowledges their expertise in knowing their own lives. In this way, such an approach may lead to an increased sense of belonging, empowerment and self-efficacy, and feelings of self-worth. As a working example of community psychology in action, Psychologists for Social Change have formed a public organisation in the United Kingdom that works alongside community groups to lobby and create social change by drawing attention to the social determinants of mental health and the ways in which government policy can exacerbate distress.

From theory to practice

Psychologists generally identify with the terms ‘scientist-practitioner’ and ‘reflective-practitioner’. As scientist-practitioners, we apply our varied and flexible skills to develop a pragmatic, evidence-based approach to supporting people in distress. As reflective practitioners, we provide space for people accessing services, colleagues and ourselves to consider our biases, prejudices and assumptions, and the ways in which our identities impact the therapeutic process. In addition, Psychologists for Social Change are now using the term ‘activist-practitioner’, a model for psychologists to consider addressing the social and political context of mental health (Psychologists for Social Change, 2017). The model suggests that psychologists use their understanding of socio-cultural-political factors and their professional power to lobby for social change alongside communities, in order to impact psychological wellbeing at both an individual and population level.

In relation to the alternatives to psychiatric diagnosis outlined above, we invite the reader to consider how these ideas might apply to their own practice, with particular reference to their professional identity and their perceptions of the experiences of the people whom they support. We have developed six questions for psychologists to consider:

For more information and examples of these ideas in practice visit Mad in America, Asylum magazine, The Hearing Voices Network, APS social determinants of health and APS Community Psychology.

Potential challenges

As in many parts of the world, funding for mental health services in Australia currently relies on diagnostic criteria. As such, this can make it challenging to consider how to shift to alternative paradigms of understanding in your practice as a psychologist. However, the concepts presented above provide alternative ways of understanding and responding to distress. Therefore, even within a diagnostic context, these concepts can shape the way we respond to individuals, communities and systems related to mental health in our everyday work as psychologists. For example, when working with an individual, it may be helpful to hold in mind that there are multiple ways of understanding a person’s experience without reducing it to a single label, and that this can be communicated non-diagnostically, even in a diagnostic context i.e. “Susan reported that she has been a victim of domestic abuse in her life and that her circumstances, in which she continues to experience deprivation and violence, are understandably causing her to experience extreme anxiety at times”.

This type of reaction can be described as ‘panic attacks’ or ‘panic disorder’. In order to support Susan, it is important that we address her early experiences, explore the current factors that are contributing to her distress and empower her within these circumstances while also enabling her to develop ways to cope’. Psychologists have a responsibility to use their knowledge to influence societal constructions of mental health, so that people are responded to with more compassion and empathy, through genuine attempts to understand what has happened to them. Finally, it is important that psychologists use their individual and collective power to influence the policymaking systems that both contribute and perpetuate distress.

Considering the approach

The medical model and associated use of psychiatric diagnosis has failed to accurately conceptualise distress in a way that truly reflects the lived experiences of people in the mental health system. As a result, it is increasingly important for psychologists to consider alternative ways in which we can conceptualise psychological problems and support people who have accessed mental health services. These approaches provide opportunities to emphasise the individual’s story and their own sense-making, as well as considering the systemic and social factors which contribute to distress. We encourage psychologists to consider these ideas and the potential implications for their practice.

The first author can be contacted at [email protected]