To cite this article: Ruger, Michelle (2018). Is Schizophrenia a Diagnostic Construct? A Critique of the Medicalisation of Human Distress, The Millennial [Online], Available at: (this page URL).
Up until 1980, the DSM was heavily influenced by psychoanalytically informed ideas. The DSM III however introduced more of a scientific, biologically based approach, and was stripped of the non-empirical principles such as the Oedipal complex and the nature of dreams. Whilst previous versions of the DSM had been designed to take into hand the individual’s social relationships and interaction with others, the newer versions rejected all theories of social aetiology, instead focusing on positivist empirical evidence, mirroring the natural sciences. The definition of physical disorders and those of mental health therefore became similarly defined as objective “diseases”. Since 1980, four versions of the DSM (DSM-III, DSM-III R, DSM IV and DSM V) have been published all drawing on an evidence base of studies which are predominantly underpinned by positivist epistemology (Rapley, Moncrieff & Dillon, 2011). As a result such studies arguably frequently fail to capture the personal lived experience of the individuals whom they are suggested to be representing. Nevertheless such research is heavily relied upon as informants of conceptualising and treating psychological distress.
In viewing psychological distress in such a manner, the self became viewed as a material body, whereby psychological symptoms are explained by chemical imbalances that are commonly caused by genetic factors, a combination of which form a diagnosis. Such a position implies a Cartesian ontological position, taking the mind and body to be separate. This is undoubtedly the predominant conceptualisation of psychological distress in the current Western mental health sector (Thomas & Bracken, 2011). Thus, mental health became medicalised, consequentially leading to the symptoms behind a schizophrenia diagnosis being taken as objective and decontextualized phenomena indicative of psychopathology.
The field of Counselling Psychology (CoP) has existential phenomenological underpinnings and a humanistic value base, thus the prevailing medical model creates a philosophical and practical tension for our profession, as the subjective experience of the client is heavily underemphasised (Van Deurzen 2005, Orlans 2009). Regardless of such a tension, in today’s western society the medical discourse continues to dominate the mental health sector, both in terms of the reliance on a predominantly positivist research base and the subsequent approaches to practice, such as CBT. As counselling psychologists are reflective-scientist-practitioners, we are ethically obligated to investigate how such assumptive frameworks within society are created and their impact on how we view, formulate and therapeutically engage with psychological distress (BPS, 2014). In this paper therefore the medical model of schizophrenia is critically evaluated, in terms of Criterion A of the DSM V. The definition of schizophrenia in the DSM V is as follows:
A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):
3) Disorganised speech
4) Grossly disorganised or catatonic behaviour
5) Negative symptoms
Here, consideration is given to how the current medical model fails to sufficiently acknowledge the literature-linking trauma with the causal likelihood of being assigned a diagnosis of schizophrenia, and the implications to the client of doing so. There is thus an invitation to discuss how one could draw upon existential-phenomenological theory to attend to the needs of individuals who appear to be experiencing symptoms associated with the schizophrenia diagnosis.
Evidence for Trauma
By medicalizing symptoms associated with the schizophrenia diagnosis, the functions or meaning of the symptoms can often be ignored. Instead, treatment focuses on removing the various symptoms; this is inline with the DSM criterion, which imply that the experiences are impersonal and unhelpful symptoms of a medical ‘disorder’. However, this approach of depersonalisation and objectification of individual symptoms fails to be substantiated with evidence. For example, there is significant research that suggests evidence to the contrary presenting a causal effect between childhood trauma and the likelihood of later being assigned a schizophrenia diagnosis. Read, has researched extensively the relationship between trauma and psychosis. His, work refers to “trauma” as events mainly in childhood including sexual and physical abuse and other forms of neglect. In spite of this longstanding evidence base, until recently, psychiatrists orientated in the biological mechanisms of schizophrenia, continued to disregard the notion that traumatic events in childhood are contributors to such symptoms referring to such discussions as “heresy”. In 2004 a survey found that for every psychiatrist who believes that trauma relates to schizophrenia diagnoses, 115 believe that the diagnosis of psychosis is caused purely by biological factors. This is a disconcerting finding given the discipline’s assertion that its treatment choices are drawn from the empirical evidence base. In 2009 a review paper of studies during the previous 10 years, published findings that illustrated 11 studies had been conducted with 10 showing that maltreatment as a child is significantly related to psychosis onset, yet this is not reflected in the medical model (Buckley, Miller, Lehrer, et al. 2009) .
Despite such a wealth of evidence indicating the contrary, an individual diagnosed with schizophrenia is categorised as having external signs of an internal pathology; the context in which they have arisen is often not considered at depth and the information they convey is disregarded (Aho, 2008). Such heavy focus on whether the external signs (i.e the content of speech and the nature of their body language and motor movements) meet the diagnostic criteria results in the subjective importance of the meaning behind the output of information being ignored. In fact, communications from an individual burdened with the diagnosis of schizophrenia are commonly considered subordinate to a “healthy” individual (Cromby and Harper, 2009; Reid 2002).
Considering the heavy link between childhood abuse and schizophrenia diagnoses, disregarding the content of the hallucinations or delusions may result in the clinician missing links with the abuse suffered and therefore the narrative of the client. Within the DSM V, and within nosology, the phenomenological experience of the person is dismissed, along with sociocultural information and the individual’s own attempt at making logic of their experiences. For the client then, the unique nature of their human distress remains grouped and, consequently, ignored and dehumanised.
Therefore, every aspect of the individual’s communication is overlooked, resulting in their lived experience, whereby their distress is a reality in a strange and isolated world, being unnoticed. In other words, the client’s experience is real for them and in referring to their experiences as ‘unreal’ hallucinations and delusions, and their general behaviour as grossly disorganised, one is sure to create mistrust, anger and further isolation; feelings associated with poor post therapeutic outcome (Stanghellini, Bolton & Fulford, 2013). In addition, when taken together with the likelihood of the client having suffered severe and enduring relational traumas as a child which often may have gone unnoticed or been disbelieved, their longstanding relational experiences of feeling disbelieved and marginalised potentially get reaffirmed and their need to adopt a way of being-in-the-world, desiring to disconnect them from the Other, will likely become greater. Therefore, it seems that perhaps the best treatment for the client may be in the restoration of their faith in relationship, through the offering of a new and safe one within the psychotherapeutic frame, where they are heard and respected for their individual subjective experience.
It is therefore vital for practitioners to empathise with the subjective reality of the client, by aligning with CoP’s phenomenological underpinnings wherein the client’s own view on the world is prioritised (Van Deurzen, 2005). This is a challenging endeavour for practitioners currently given the prevailing medical discourses in the mental health sector and society more broadly. Practitioners such as ourselves face the difficulty of holding biases that they may have adopted as a result of the DSM’s powerful influence over the field and wider society. Hence it is likely to be difficult to ascertain whether the client’s experiences are viewed through the tinted glasses of our own objectively influenced theories (Bentall, 2014). However, holding this possibility in mind and reflecting on it will surely assist in the therapist’s attempts to meet the client where they are.
How can CoP offer a different way of conceptualising and attending to such psychological distress?
Interpreting a client in terms of the symptoms detailed in Criterion A can be seen as dehumanising as it restricts the individual expressing how their behaviour and suffering is related to the external world. The dehumanising nature of the DSM’s diagnosis of schizophrenia arises from the identification of it as “disease”, understood by bio-psychiatry as a biophysical condition that can be treated with certain xenobiotics.
Designed to offer these different occupations a nosology for mental disorders, the DSM does so without providing a theory, treatment approach, or aetiology for classified disorders. Stating the many different diagnoses in the DSM in such a manner inevitably leads to logical fallacies and inconsistencies. The word diagnosis can be defined as “identifying a disease from its signs and symptoms” (Merriam-Webster, 2013). The DSM therefore is categorising functional, social, behaviour and emotional concerns as physical “diseases”, which is a theoretical and ideological assertion. Despite such an assertion being repeated endlessly by commercial media, it ultimately rests on weak empirical evidence and illogical definitions (Boyle, 2002). By applying a phenomenological approach, the “disease” model can be seen as challenged by sticking to the term “psychological distress”, understood as the lived-experience of the individual and the how they respond to, exist with, and make sense of, the symptoms of schizophrenia described above.
In CoP, there exists a philosophical condemning of the depersonalisation of an individual as a bi-product from the positivist and deterministic medical model, which dehumanises those who are treated for mental health disorders. Counselling psychology is born from philosophical relativism whereby an individual’s past and present experience and interaction with the environment positions human engagement with themselves and the world as a dynamic, interactive relationship with the world (Van Deurzen, 2005). Taking this philosophy, alongside the belief that thinking precedes being, births the foundation of a phenomenological influence built upon the renowned notion that “existence precedes essence” (Sartre, 1956) whereby first I exist and interact with the world, postulating it later. This philosophy highlights the relevance and importance of observing and heeding a client’s creation of themselves and taking the narratives that exist within it. Therefore, the behaviours that are observed as symptoms of schizophrenia should be listened and paid attention to, a suggestion that conflicts with the current formulation of schizophrenia under the DSM V where they are encouraged to be eliminated with little consideration of there meaning.
Numerous existential philosophers have postulated the symptoms of schizophrenia as adaptive, natural and functional responses, whereby the psyche attempts to exclude anxiety, distress and unsolvable conflicts; feelings that can threaten the centre of an individual’s sense of self and their relationship to the external world. (Laing, 1960; Jaspers 1963). Indeed Paris Williams (2012), postulates that two existential dilemmas reveal themselves in such distresses. The first of these dilemmas for the individual is to maintain a balance between autonomy and belonging in the world at a tolerable level. The second is to keep a secure, stable sense of self, despite feeling a lack of foundation or connection with the world. Both dilemmas are philosophised to be central to human experience, thus, in terms of the DSM’s definition of schizophrenia, all five possible symptoms could be seen as attempts at coping mechanisms with the ontological insecurity produced from the meaningless loss, pain and suffering that life exudes, particularly in instances of severe trauma as has been shown to be the case for individuals assigned a diagnosis of schizophrenia (Van der Berg 1972, Yalom 1980). In line with this, it is not surprising that more recently studies have demonstrated that individuals who do not have a diagnosis also report symptoms associated with schizophrenia (Morgan & Fisher, 2007).
In sum, perhaps the hallucinations, negative symptoms, delusions and disorganised speech and behaviour, are merely the outcome of an individual struggling with the existential dilemmas of life. Indeed the individual’s unpleasant experiences of audio, visual or somatic output of information which are mistrusted as “psychotic behaviour” can now be seen as distress, the medicalization of which aims to treat a superficial, “disease”. In light of this it is important to consider the responsibility of society and culture in the development and perpetuation of schizophrenia, as opposed to merely situating the pathology within the individual.
By taking this approach to human distress, the biological model upon which psychiatry is based, becomes widened, accepting an individual’s social aetiology and their relational dynamic self, instead of the enclosed one dimensional body, allowing room to explore and externalise such experiences, placing distress into a situational, subjective and societal context. Instead of imposing objective and realist assumptions about an individual, by utilizing a hermeneutic phenomenological methodology with an open and explorative attitude, the meaning and contextualisation of their way of existence in response to the meaningless, isolated and inevitably fatal facts of living, is encouraged. (Van Deurszen 2005, Yalom 1981). In doing so an emphasis is put on the therapeutic relationship at the expense of a numbing, impersonal theory. A therapeutic space is therefore facilitated whereby the isolation, loneliness, and disconnection recedes and the containment and understanding of the individual grows, negating the felt unbearable experience. There is a wide array of evidence in the literature that shows that when a client becomes objectified, therapeutic efficacy reduces. It is therefore vital not just for counselling psychologists, but for healthcare professionals, to transition from treating clients who suffer from human distress with objectivity, to do so with empathic connection in order to understand their subjective experience.
Important benefits of the medical model
It seems vitally important at this stage to be mindful of where the DSM and diagnosis may offer individuals some safety and certainty in a period where their psychological distress is likely leaving them with the opposite. Existential theory acknowledges the anxiety that can be associated with uncertainty, and confrontation with the lack of meaning inherent in existence. It understands that humans strive to make meaning out of their experiences and thus the DSM and diagnosis may offer that very thing to many people (Dryden & Reeves, 2006). Thus it is important to continue to meet the client where they are in relation to their feelings around diagnosis, and acknowledge where one’s own negative biases towards diagnosis may be interfering with practitioner’s abilities to engage with the client’s worldview.
Additionally, it should be noted that the DSM V can be argued to have its uses, namely as a reference for the funding of healthcare costs. Moreover, many individuals appear grateful of medication and find it to alleviate their distress. Currently available psychotropic medication demands, at least to some extent, an engagement with mental health from a medical model. This is because medications are prescribed to populations of people, following the vigorous testing of their safety and efficacy under a positivist empirical evidence base.
Therefore whilst it is argued here that it is important to engage in dialogue, which seeks to navigate beyond the current medical model that dehumanises individuals, CoP must also draw upon its pluralist position to endeavour to recognise and value such necessary and potentially beneficial elements of the current medically orientated system in mental health. Indeed, CoP provides a very helpful platform from which to engage in such discussions, and as a relatively new discipline provides an exciting opportunity for future engagement with such topics and progression.
To conclude, by conceptualising the symptoms listed in criteria A as symptomatic of a cognitive dysfunction and psychopathology, one fails to acknowledge the lived experience of the person within their situatedness, disregarding their social aetiology and the contribution of this to human suffering. Furthermore, by attempting to “restore” the individual to a “normative” state through the realist notion of “recovery”, essentialist knowledge is prioritised above the way the client experiences and rationalises the world. The client-therapist relationship may therefore be negatively impacted as the information the therapist deems as “reality” is prioritised over the clients experienced reality, resulting in their distress being missed and subsequent feelings of isolation and distrust be exasperated.
Thus there exists the need to engage in progression towards a non-diagnostic framework, whereby the client’s subjective experience of the world is accepted and explored. The existential-phenomenological philosophy behind the Counselling Psychology ethos provides the ideal foundations for the client’s distress to be explored with respect to their subjective experience of the world. Such a non-stigmatising philosophy seeks to remove the still heavily prevailing “madness” discourse and endeavour to understand the social, environmental and cultural aetiology behind a client’s distress, allowing the practitioner to empathise with their true felt-reality. This in turn provides a more shared responsibility of psychological distress between the individual and their surrounding society. However, it has also been demonstrated that the current system serves many useful functions, such as in response to funding of services on a pragmatic level and the provision of a sense of certainty on an individual therapeutic level.
In light of the discussion presented here, regarding the recognition of the need to mitigate dehumanisation of individuals seeking psychological help, I am drawn to Irvin Yalom’s consideration of how to refer to individuals who attend psychotherapy, patient/client/helpee etc. Yalom appears to have creatively settled on the term “fellow travellers”. Such a term feels hopeful, in the quest to encourage the re-humanising of psychological distress (Yalom, 2003). Perhaps utilising such a term would reduce the inherent power dynamics between mental health professionals and individuals seeking help, and also enable practitioners to be continually reminded of the importance of the humanistic value base. Indeed the term invites us to get in touch with our own humanness and difficult journey through life, thus avoiding the hugely detrimental prospect of dehumanising the individual and objectifying or pathologising their response to the harsh existential realities of living.
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