Maudsley Debate: Enabling or Labelling?

The 48th Maudsley Debate took place earlier this month, to a packed audience at the Institute of Psychiatry. Indeed, the event was so busy that two rooms were required: the main lecture hall had some 250+ attendees, while the spillover room in which the debate was shown on a live feed was also verging on full, with latecomers sitting on the floor around the door! The topic was obviously one of immense interest: given the debate on Twitter and the questions asked, clinicians, trainees and service users were all well represented.

The motion read that: “This house believes that psychiatric diagnosis has advanced the care of people with mental health problems”. Professor Tony David began the session by speaking for the motion, although stating that diagnosis is not a rigid medical paradigm but a social process. However, he regarded reductionism as a necessary first step in understanding the world, and diagnosis thus assists scientific research and advances in treatment.

However, Dr Felicity Callard, senior lecturer in social science at Durham University (and one of the researchers in the university’s interdisciplinary Hearing the Voice project) was particularly compelling in her arguments against the motion. Indeed, until she pointed it out, neither I nor those I spoke with afterwards had noticed that the motion was in the past tense (thus suggesting the historical, and not the potential, use of diagnosis) and also specifically focused on care. The potential of diagnosis for clinicians to gain a shared understanding of mental health conditions (something for which Professor Norman Sartorius argued) was thus, Dr Callard stated, irrelevant to the discussion. Mental health care has, she went on, been advanced by a variety of changes in past decades, including community mental health provision, staff training, environmental improvements, peer support and crisis intervention, none of which rely on diagnosis.

Professor Sartorius countered that the problems that Dr Callard reflected on (the potential of psychiatric diagnosis to result in ‘civil death’: the loss of a person’s legal and civil rights) were simply caused by a ‘mis-use’ of diagnosis. Diagnosis, he stated, was a tool that (like any other tool) could be used well or badly. This drew importance to the impact of debates like this one within psychiatry: how else do we decide on how a tool is to be used? This was something Dr Pat Bracken (speaking against the motion) saw as a sign of scientific maturity in the discipline.

One could hardly imagine a similar debate in other branches of medicine, Dr Bracken noted. Psychiatry, however, is a field that demands debate, which cannot be carried out through using a causal model of classification. Although not against diagnosis in itself, he felt that this represented only a tiny portion of the work of a psychiatrist. Great advances in care had occurred despite the efforts of clinicians to force mental health into the biomedical model used in other fields of healthcare. In the future, he hoped, psychiatry would have the courage to stand alone, and accept that ‘the mind is not simply another organ of the body’.

The excellent points put forward by both sides testified to Dr Bracken’s faith in the importance of debate. Indeed, he and Dr Callard swayed some fifty members of the audience into the ‘Against’ camp (although this was still just under two thirds of those who stood by the motion). The discussion, we hope, will not end here. Our forthcoming Museum of the Mind will cover both perspectives under the heading of ‘Labelling and Diagnosis’ and we welcome your comments on either side of the debate.

A recording is now available online at: http://www.kcl.ac.uk/iop/news/debates/index.aspx. Meanwhile, Dr Callard’s ‘Storify’ covers the wealth and breadth of responses to the topic: http://storify.com/felicitycallard/maudsley-debate-institute-of-psychiatry-enabling-o.

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