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ADHD, Advocacy, Clinicians, Diagnosis, Mental Health, Psychology, Stigma

British Psychological Society endorses stigmatisation of ADHD

D: Second Update to Original Post (see A, B & C below)

Thursday, 7th June, We’ve just learnt that it looks as if the Power Threat Meaning Framework has been adopted as policy by the Division of Clinical Psychologists at the British Psychological Society. An email has been received by other psychologists which says “Statements of Interest are invited to join the DCP Power Threat Meaning Framework (PTM) Working Group, that reports directly to the DCP Committee.”

We have been working hard on our report about the PTMFramework and are now compiling the results into a coherent whole so that it can be presented along with our letter of complaint.  This has not been easy and has taken a while as the Framework itself is a poorly researched and poorly written mishmash of outdated ideas as well as being unintelligible in sections.

C: Second Update to Original Post (see A & B below)

As of today, Monday, 30th April, we’ve still not had any kind of a reply from the British Psychological Society regarding their stigmatising and discriminatory attitude towards people with ADHD.  We sent the BPS & authors of the Power Threat Meaning Framework a note today, via Twitter, to say that unless they promise by Friday, 4th May, in writing, that ADHD will be deleted from the PTMFramework we will be taking further action.

FYI, work on this further action is well underway!

In the meantime, we note that Lucy Johnstone, a consultant clinical psychologist and one of the two lead authors of the framework, tweeted at 5:10 pm on Tuesday, 24th April the following:

Capture

As you see, Lucy Johnstone declares that all diagnoses lack validity even if people actually find them to be helpful.  And she says, psychologists should be honest and tell us that our diagnoses are invalid.  That is an arrogant and harmful statement that devalues the experience of service users.

And before any of the authors think about contacting us to claim that the PTMframework is an alternative option to the DSM (Diagnostic and Statistical Manual of Mental Disorders), we will state right here and now that we are not fooled! At the same time they tell everyone that their framework is an alternative option,  they also deny the validity of the DSM.  No options allowed!

Basically, in the PTMframework the authors claim that the symptoms we experience (ADHD included) are expressions of emotional distress caused by “relational and social adversities” such as poverty, discrimination, inequality, violence and abuse. Furthermore, they state that there are no ” consistent associations between functional psychiatric diagnoses [e.g. ADHD] and any biological pathology or impairment, and nor have any biomarkers been identified” (Johnstone, 2018, 7). In short, the authors dismiss the results of genetic and screening research. The framework is not backed by reliable research and the authors lack the depth of knowledge and experience of the DSM authors.

While the framework may be helpful for those people whose distress has been solely caused by relational and societal adversities (although they will still need the utility of the DSM), it will not help those whose distress results from the impact of complex interactions between genetic and environmental influences amplified by relational and societal adversities.  In fact, in these instances the framework will only serve to disempower people by denying the validity of their experiences.  It will increase feelings of failure and despair.

Unlike the PTMFramework, the DSM  is designed as a classification system that provides cross-border mental health professionals with a common diagnostic language that is useful for both treatment and research efforts.  While some of the DSM authors recognise that it is a flawed system, in part because knowledge about mental ill health is evolving and changing, they also acknowledge that the DSM contains much practical information and experience and is better than anything else currently available (and when used properly does a good job).

The two main criticisms levelled against the DSM (and psychiatry in general) are first, that it medicalises normal behaviours and turns them into illnesses and disorders to be treated with drugs and secondly, that the DSM’s authors (and psychiatrists in general) have conflicts of interest because they have links with the pharmaceutical industry.

The critics, including the authors, using these arguments conveniently overlook the fact that researchers from both the medical field and the pharmaceutical industry need to work together in order to find and develop effective treatments. They overlook the fact that in the UK the pharmaceutical industry is heavily regulated. Additionally, as we’ve noticed with the BPS and some of their members, many of these same critics fail to declare their own financial and personal interests.

Please don’t misunderstand us.  We’re not against debating the meaning and definition of illness and disorder, we’re not against improving the validity of  specific diagnoses, we’re not even against changes to the classification system; so long as changes are in line with improvements in knowledge about causes of and experiences with mental ill health.

We are, however, against mental health professionals working outside their area of expertise and not declaring their lack of knowledge.  We are also against the same professionals resorting to misinterpreting the conclusions of more knowledgeable colleagues and making attention-grabbing and unfounded pronouncements such as the ones they make about psychiatrists and psychiatric diagnoses.  The authors allege that psychiatric diagnoses are neither descriptively accurate nor evidence-based and cannot be considered “professionally, scientifically or ethically justifiable” (Johnstone, 2018, p. 314). We are against mental health professionals attempting to enhance their own professional reputation by using these sorts of  tactics to discredit the work of other colleagues.

Additionally, we think it is unethical and unprofessional, to say nothing of being harmful, for the authors of the PTMFramework to justify their own work by perpetuating distrust of psychiatry amongst people with negative experiences and by undermining the trust of those who’ve had helpful experiences.

Finally, we will point out to all those mental health professionals who feel disturbed by the implications of the PTMFramework but are staying silent, thereby implying acceptance, the framework authors’ failure to recognise their own limits, biases, prejudices, professional and power interests will not only cause harm to many service users, it will also damage the reputation of psychology as a helpful profession. And those of you who do not speak up will be seen as complicit.

There will be more on these as well as additional points later!

B: First Update to Original Post (see A: below):

As of today, Tuesday, 27th March 2018 we’ve had no reply whatsoever from the British Psychological Society.  Never mind; we’ve been working hard on a comprehensive follow-up which we will send to certain parties as well as publish here.

In the meantime, we note that on 1st March 2018 Lyn Romeo, Chief Social Worker for Adults, at the Department of Health not only introduced the Power Threat Meaning Framework as a radically different perspective on mental health on her official government blog but also allowed Phil Wilshire, principal social worker for Avon and Wiltshire NHS Partnership Trust to write a guest blog promoting the framework.

Phil does acknowledge that some professionals and some service users have been critical of the framework so he tries to argue that the framework is an “optional conceptual resource” and that it is not anti-medication. His efforts, however, are deliberately misleading given that in the first paragraph on page 314 of the framework the authors clearly state that while they affirm “people’s right to describe their difficulties as they wish, we affirm the equally important principle that professionals, researchers, trainers, lecturers, charities, policy-makers and others involved in the mental health field should use language and concepts that have some claim to be descriptively accurate and evidence-based. Because psychiatric diagnosis does not meet these standards, it follows that it can no longer be considered professionally, scientifically or ethically justifiable to present psychiatric diagnoses as if they were valid statements about people and their difficulties.” You see; they are actually trying to take away our right to accept our ADHD diagnoses by calling them unprofessional, unscientific and unethical. What’s more they haven’t provided any valid evidence at all for this opinion.

By the way; Phil Wilshire probably should have declared his interest in the Framework as he’s listed on page 3 as having “significant input into Chapter 8” which is titled “Ways forward” and contains the following sections: 1. Public health policy. 2. Mental health policy. 3. Service principles. 4. Service design, commissioning and outcomes. 5. Access to social care, housing and welfare benefits. 6. Therapeutic interventions. 7. The legal system. 8. Research. 9. Use of language.

Mr Wilshire, of course, is advocating an eventual “collective shift towards a non-diagnostic paradigm.” (p. 264)  Well . . . . good luck!!

And just in case Phil and Lyn have been chatting about how to implement the Framework, we suggest that since they both work for public bodies, they might like to ask themselves how their support for the framework complies with their public sector equality duty under the Equality Act 2010. And if they’ve overlooked their legal obligations, here’s a reminder: “those subject to the equality duty must, in the exercise of their functions, have due regard to the need to: Eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act. . . etc.“!!!

A: Original Post (rev. edn. published 26th January 2018):

On Tuesday, 16th January, AADD-UK was alerted to a furious Twitter row that began Friday, 12th January when the Division of Clinical Psychology (DCP), a Division within the British Psychological Society (BPS),*  held an actively promoted launch at the Friends House, across from Euston Station, London for the Division’s recently published “Power Threat Meaning Framework: Towards the identification of patterns in emotional distress, unusual experiences and troubled or troubling behaviour, as an alternative to functional psychiatric diagnosis.” 

Having no idea what this Framework was about & curious as to why there was such a ruckus, I downloaded a copy and began reading.

This is what happened:

The Framework seemed sturdy, 411 pages long, and reputable.   It’s on the BPS website, it has their logo (Tagline: Promoting excellence in psychology) as well as the logo for the Division of Clinical Psychologists. It’s clearly stated on the printer’s imprint and copyright page that the publication “has been produced by the British Psychological Society’s Division of Clinical Psychology as a Member Network publication and represents the views and expert contributions of its authors” and it was printed and published by the British Psychological Society.

So far so good.

Next, on page 5, under the heading ‘Document summary‘, I learnt the reason for the existence of the Framework as follows (please bear with me as I give you these somewhat tedious details, their relevance will be more evident later):

In 2013, the Division of Clinical Psychology (DCP) of the British Psychological Society
(BPS) published a Position Statement entitled “Classification of behaviour and experience in relation to functional psychiatric diagnoses: Time for a paradigm shift.” Recommendation 3 of the position paper is: ‘To support work, in conjunction with service users, on developing a multi-factorial and contextual approach, which incorporates social, psychological and biological factors’ (p.9). This document is the result of a DCP-funded project for work towards fulfilling this aim.

Since I tend to be overly conscientious as well as curious, I decided to read ‘Time for a paradigm shift‘ first so that I could understand the context for the PTMFramework so I downloaded a copy, thankfully only 9 pages long, and began reading (it’s publication format was the same as the Framework’s).

I was more interested when I recognised a few of the author’s names due to their interactions with the Twitter row. Things quickly became more interesting when, on page 2, I read the following paragraph (emphasis mine):

At the same time it should be noted that functional psychiatric diagnoses such as schizophrenia, bipolar disorder, personality disorder, attention deficit hyperactivity disorder, conduct disorders and so on, due to their limited reliability and questionable validity, provide a flawed basis for evidence-based practice, research, intervention guidelines and the various administrative and nonclinical uses of diagnosis.

After this, I carried on reading, paying closer attention to the references and source names, some of whom I also recognised, and by the time I reached the summary (below) on page 5, I’d already concluded that the ‘position statement‘ produced by the Division of Clinical Psychologists was a veiled attempt at undermining psychiatry and diagnoses, i.e. anti-psychiatry. The Twitter row wasn’t the only place I’d seen those names.

The DCP believes there is a clear rationale and need for a paradigm shift in relation to functional psychiatric diagnoses. It argues for an approach that is multi-factorial, contextualises distress and behaviour, and acknowledges the complexity of the interactions involved in all human experience.

The whole Division? I wondered how many psychologists were involved so I did a Google search.  I didn’t find numbers for psychologists but I did find an interesting page on the BPS website under “news”. It’s titled  “The future of clinical psychology in the Society” which mentions plans for a another UK association for Clinical Psychologists.  Intriguingly, there’s strange hints about unity (lack of?) along with a reminder that relationships with external organisations must advance BPS’ objects.  The policy is linked to this page.  Hmm! Keep all this in mind as you read on.

I returned to reading the Power Threat Meaning Framework.  Now, I freely admit that I was slightly distracted by the policy I’d just read and I was aware my bias filters were turned on.  I thought I knew what to expect.  I was wrong!

I was shocked! And this feeling intensified the more I read.  The authors’ tone, conveyed through their choice of words and viewpoint, is arrogant and patronising and their negative and disapproving attitude towards ADHD is stigmatising and discriminatory.  Make no mistake the ideology behind the Framework belongs to the anti-psychiatry movement.

I’m not going to analyse the arguments put forward in the Framework other than to say that while some of the ideas are  interesting, they aren’t discussed in any depth. The authors’ make some half-hearted attempts at describing different sides of an argument, but these are often spoilt by their habit of using adverbs to manipulate us into choosing their favoured option .

This post is getting too long so I’m only going to add 5 extracts from the Framework so that you have some sort of idea as to what it’s like.  I’ve put links to the Framework as well as to the Time for a Paradigm Shift at the very end of this post in the References section.  If you’re interested, you can download them and judge them for yourselves.

“. . .and psychiatric diagnoses are often explicitly used as explanations. But the impression of explanation is false and the reasoning behind it is illogical“. (2018, p.29)

We underestimate the difficulty of describing patterns in people’s behavioural or bodily problems and often ‘see’ associations which are not there (known as the illusory correlation). This is why medical researchers have developed the kind of rules we discussed earlier to try to ensure that the bodily patterns they describe are ‘real’ and not illusory. The combination of limited public understanding of diagnostic procedures and overconfidence in judgements of patterns, can confer credibility on psychiatric categories which is not justified by the evidence“. 2018, p.30)

The existence of particular categories can influence how people’s experiences are interpreted and how they express their distress. Aided by the illusory correlation, diagnostic categories can then become self-fulfilling prophecies, conferring further credibility as growing numbers of people seem to match them. And, especially if people do not have access to non-medical, non-blaming explanations, the process can become self-perpetuating as people increasingly request confirmation of self-diagnoses of ‘bipolar disorder’ or ‘ADHD’ and so on.” (2018, p.30)

All of this is reflected in psychiatric diagnosis’ inevitable dependence on social judgements, as we discussed in Chapter 1, and many critics have traced particular diagnoses back to the social norms they challenge: ‘borderline personality disorder’ for women who are too angry; ‘depression’ for women who are exhausted by domestic demands; ‘anorexia nervosa’ as a reaction to the unrealistic role and appearance standards faced by modern women; alcohol misuse and suicide for men whose socialisation does not permit the expression of despair in other ways; ‘ADHD’ for children who are not suited to educational regimentation, and so on . . .These rule transgressions can involve over-adaption to the ideal image, as well as failing to live up to it; . . . Similarly, it has been suggested that the enormous rise in diagnoses of ‘autism spectrum disorders’ and ‘Asperger’s’ may partly reflect demands made by highly industrialised and service-oriented economies for successful employees to display emotional behaviours such as (faked) sociability, warmth, gratitude, passion and so on – skills which do not come easily to everyone (Roberts, 2015). (NB: Although autism in its most severe forms fits the profile of a neurodevelopmental disorder of some kind, the debates about these diagnoses are particularly complex . .  . Given all this, it is hardly surprising that in many parts of the Global South, there may be no equivalent categories to the experiences that DSM and ICD label as ‘depression’, ‘anxiety’, borderline personality disorder, anorexia, and so on. In fact, the distinction between thought and emotion may not even be recognised (Cromby, 2015) and the very notion of an individual who exists in some sense independently from their social network may be alien.” (2018, p. 69-70)

From a PTM Framework perspective, the trauma-informed model has much to offer. It also has risks and limitations, including: Conceptualising the approach as an alternative explanation for ‘schizophrenia’, ‘bipolar disorder’, ‘ADHD’ and so on, perhaps by reducing adversities to the status of a ‘trigger’ and thus retaining diagnostic categories and thinking . . .”  (2018, p.276)

I apologise for the length of the quotes. I’m trying to give you an accurate picture by including some context.

Returning to my story: I revisited the Twitter row, partly because I was angry and looking for a fight and partly because I couldn’t believe that professionals still believed this kind of stuff in 2018.

I’m going to pause now and give myself a pat on the back, as once advised by a psychotherapist.

Despite being angry and upset, I managed to stay calm and polite, except for a couple of little jabs & swipes, as I asked questions and gave feedback to the authors, and yes the medication also helped even when my questions were evaded and ignored. I did, however, get replies from a registered psychologist, supporter of the Framework, who told me, via tweets, that ADHD diagnoses are invalid and damaging. I also saw a tweet from one of the Framework authors in which she stated, “IMO all DX are BS & giving psychoactive meds to kids is immoral. To view ADHD as valid DX seems remarkably lacking in critical thinking.” I’ve kept copies of these tweets.

Eventually, I realised I was wasting my time and energy, the authors didn’t want to hear, even questioned whether I’d read the framework,  and then said it was up to me how I used the Framework, I didn’t give the obvious reply!   Instead I decided to leave.

I was sorry though to leave behind some of the people I’d met (I’m using the word figuratively) .   Not all psychologists support the framework, and the same goes for my fellow service users.  In fact the people I met were kind, caring and open-minded, and some even had a wicked sense of humour and mischief.  I laughed out loud several times.

I also met service users from the other side of the argument who were kind and helped me to understand and accept their very valid reasons for disliking diagnoses.  But my experiences with the professional supporters of the Framework had a completely different nature.  I’m not going to give details, it’s not fair.  And anyway, we’ve reached the point at which I return to the description I gave earlier of the publication details of the DCP’s position statement and the PTMFramework. My reasons for giving you those dull details at the beginning.

You see, I couldn’t just walk away telling myself that the fuss would die down in a few days and be forgotten. The reality is that the BPS allowed the PTMFramework, despite its evident bias and stigmatising attitude, to be published and available on their website.  Registered clinical psychologists promoted it on Twitter, and the BPS and DPC logos are displayed on its front cover.  And all this means the PTMFramework carries a backstory of reputability, reliability, and safety.  This apparent endorsement by the BPS will encourage the stigmatisation of people with ADHD.

That’s why, here at AADD-UK,  we talked and made a plan the first step of which was to send an open letter (below) to the British Psychological Society in which we set out our requests.  If these are met we will consider the matter closed as far as we are concerned.

We sent our letter, via Twitter, to BPS on Tuesday, 23rd January but to date we’ve not had a reply.

Never mind, the longer the delay, the longer the length of rope.

We will wait until end of day on Friday, 2 February for a reply.

Transcript of letter sent to BPS as a warning shot across their bows:

Tuesday, 23rd January 2018

Open letter to the British Psychological Society 

Re: The Power Threat Meaning Framework (PTMFramework) *

We are a service user organisation and via public promotion on Twitter by the authors and their supporters we were alerted to the open availability of the PTMFramework.

We read it and were shocked by the strong, stigmatising suggestion that ADHD is an illusory, unprofessional, unscientific and unethical diagnosis.

We joined the public Twitter debate & gave this feedback to the lead author as well to @BPSOfficial and @UKDCP. We also pointed out that our views were not sought before publication. We asked for your response.

None has been forthcoming regarding our feedback about these two matters although a registered psychologist, supporter of the framework, did send us inappropriate tweets.

As this has taken place on Twitter, we are using the same platform to ask that the current version of the PTMFramework be retracted to allow the removal of all specific references to ADHD as well as all assertions and/or suggestions that ADHD is an invalid diagnosis.

We also respectfully suggest that the Framework be amended to meet academic standards.

Finally, we ask that you issue a public apology acknowledging the distress and stigmatisation that ADHD service users are experiencing due to the open-access publication and ongoing public promotion of the current version. We suggest that you also respond regarding the unprofessional tweets from the registered psychologist.

If these requests are met, we will consider these specific matters closed as far as we are concerned.

Kind regards,

Susan Dunn Morua on behalf of AADD-UK
@AADDUK (other contact details supplied upon request)

Notes:

1.Many psychologists are NOT supportive of this framework. Additionally, there are service users who reject their diagnosis, for valid reasons, and thus support the framework. AADD-UK fully understands, accepts and supports their right to make this choice. Our letter is only addressing the stigmatising attitude displayed towards ADHD people who have benefited from a psychiatric diagnosis

2. The British Psychological Society is a registered charity which according the blurb on their website does the following:

“. . . acts as the representative body for psychology and psychologists in the UK, and is responsible for the promotion of excellence and ethical practice in the science, education, and application of the discipline.”

And:

As a society we support and enhance the development and application of psychology for the greater public good, setting high standards for research, education, and knowledge, and disseminating our knowledge to increase the wider public awareness of psychology and its importance.”

References:

Awenat, F. & Berger, M., Coles, S., et al. (2013). Classification of behaviour and experience in relation to functional psychiatric diagnoses: Time for a paradigm shift. DCP Position Statement. Leicester: British Psychological  Society

*Johnstone, L. & Boyle, M. with Cromby, J., Dillon, J., Harper, D., Kinderman, P., Longden, E., Pilgrim, D. & Read, J. (2018). The Power Threat Meaning Framework: Towards the identification of patterns in emotional distress, unusual experiences and troubled or troubling behaviour, as an alternative to functional psychiatric diagnosis. Leicester: British Psychological Society

Standards of Conduct, Performance and ethics for registered psychologists

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