Psychiatry’s worst idea

Here’s a typical news story from a local paper – about a police call that led to a house search prompted by smelling cannabis.

“The search of the property unearthed two dozen plants being cultivated with a hydroponic system in a cupboard and two more in a nearby wardrobe, said Mr David Swinnerton, prosecuting. Police estimated the crop had a potential yield of over £7,000.

However it was claimed at court that […] might have been pressured into growing the drugs. Mr Thomas Griffiths, defending, said unemployed […] who had several previous convictions and had recently become a father, suffered from a personality disorder and might have been exploited by others because of his naivety.

What does it mean to say that a defendant in a case like this has a personality disorder?  Here’s the answer from the NHS website

“A person with a personality disorder thinks, feels, behaves or relates to others very differently from the average person. There are several different types of personality disorder. This page gives some information about personality disorders in general, linking to other sources for more detail.”

In other words, personality disorder is a diagnostic label attached to who you are. To my mind this is psychiatry’s worst idea – the use of diagnostic labels to describe somebody’s personality.

Here’s an edited version of what I said in my book Undertstanding and Responding to self-harm

“There are real problems with this way of thinking. First, and rather obviously, it leads to an emphasis on the individual as the source of their problems and therefore downplays the role of other people and circumstances…

…Second, the diagnosis is often experienced as a way of saying ‘the problem is about who you are as a person’ and it is widely used in a critical or dismissive way by professionals in health and social care. The person on the receiving end can easily be stigmatised and become (rightly) angry – that anger then being used as further evidence of what’s wrong with them. Not surprisingly, lots of people given this diagnosis don’t like it and don’t like the effect it has on the way others treat them.

This isn’t to say that people don’t have recognisable and enduring characteristics. We all know somebody who is particularly obsessional, prickly, paranoid or prone to emotional outbursts. Sometimes these characteristics do indeed seem important in explaining self-harm. For example, impulsivity is a tendency to act on the spur of the moment, without much thought and without consideration of the consequences. This characteristic is quite commonly associated with self-harm, especially when it is coupled with negative ways of thinking.

What isn’t right is elevating these observations into diagnostic statements – putting people into categories as if somebody’s personality is a mental disorder – which is indeed where personality disorder sits in the main diagnostic systems used worldwide.

There’s another practical problem with this ‘diagnostic’ approach to personality, which is how little use it is in explaining anything… circular reasoning is really common in practice, [for example] using repeated self-harm as part of the basis for diagnosing a personality disorder and then using the diagnosed ‘condition’ to explain the repeated self-harm.”

And that’s not to mention the observation that a “disorder” that’s inherently part of who you are tends to “get better” over quite short periods of time.  

It’s perfectly possible to practice psychiatry, and the law, without this diagnostic practice. Time we all started doing just that.