Better late than never: thoughts on the mental health system and the DSM5

I drafted a post in May to coincide with the publication of the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM5). Having pitched it to a multi-author news and analysis site which didn’t bite, I then promptly forgot about it. Doing some blog housekeeping this morning I spotted the post squirrelled away in my draft folder, and decided to resurrect and refashion it for uploading here. Apologies in advance for repeating some messages and for linking to green open access papers addressed in other, previous, posts:

As was reported in the spring, the process of revising the DSM prompted fresh debate over the recognition, naming and causation of mental health conditions. For some biological psychiatrists the new DSM has been premature, arriving ahead of advances in understanding promised by genetic, brain imaging and other basic science research. Elsewhere, in a statement released in May members of the British Psychological Society’s Division of Clinical Psychology argued for an entire shift away from psychiatric classifications on the grounds that these lack validity.

So far as I am aware the DSM is not widely used in the UK. Here the day-to-day experiences of people using, and providing, mental health services may not be much affected by its revision. What the furore has been a reminder of, however, is the extent to which knowledge and practice in the mental health field remain open to contest. I have written before about the development of a system of mental health care in the UK, and how knowledge has been important in supporting professional claims to fulfil roles and to do certain types of work. This includes the work of deciding what should be done in response to people who are distressed, and whose thoughts, feelings and behaviour are perplexing and a cause for concern to others. In the case of the profession of psychiatry, its authority has been built on a biomedical knowledge base and on the development and application of associated treatments. Throughout its history, however, psychiatry has also been divided. Some of its sternest critics have come from within.

Historically, as the UK’s mental health system transformed into one in which more and more services were provided in the community new opportunities opened up for other professions, each claiming specific underpinning knowledge to inform their work. Modern mental health teams are staffed by psychiatrists, nurses, psychologists, social workers, occupational therapists and others. For each of these groups public statements and standards appeal to the distinct contributions their members make. In reality the boundaries between staff are often blurred, and the relationships between professions and their tasks are fluid.

All of this makes the UK’s mental health system an interprofessionally complex one. It is also only in the last 10 to 15 years that the challenge of improving mental health has been taken seriously by policymakers. But the problems to which policy action might be directed are not self-evident. They have to be named, and remedies proposed, implemented and defended. Recent policy for mental health has moved through phases. In the late 1990s ‘the problem’ was presented as one of community care failure. New types of team (for example, providing crisis resolution and home treatment, and assertive outreach) were set up as part of the solution. A controversial amendment to England and Wales’ Mental Health Act made provision for compulsory treatment in the community.

Later policy emphasised ‘new ways of working’. This explicitly encouraged professionals to do work previously done by others. Examples include nurses and other health workers taking on the role of approved mental health professional and therefore carrying out tasks previously done exclusively by social workers.

Now, in a context of austerity policy has strands concerned with the promotion of public mental health and wellbeing, and with enabling ‘recovery’ and personalised care for people using specialist services. As Simon Wesseley has argued, for most people using or working in the UK’s mental health system a more immediate and pressing concern than the publication of the DSM5 is protecting existing provision at a time of service retraction.

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