Madness has a lot to teach us and it has existed long before

counselling, so let’s be humble about it.

The categorisation of mental illness has always been

“psychiatric” in nature and essentially medical in its

approach

The need/desire for a classification of mental disorders has been evident throughout the history of medicine

In Ancient Greece, the first classification system for mental illnesses, including mania, melancholia, paranoia, phobias and Scythian disease (transvestism).

•Due to an imbalance in the 4 humours

10th CenturyAn elaborate

classification of mental disorders was

developed 17th CenturyThomas Sydenham

developed the concept of a syndrome, -individual

behaviours that had long been recognized came to be grouped together. This

group of associated symptoms having a

common course, which would later influence

psychiatric classification 18th and 19th centuries saw the development of the

scientific concepts of psychopathology (literally

referring to diseases of the mind)

The term "psychiatry" ("Psychiatrie") was coined in 1808, from the Greek "ψυχή" (psychē: "soul or mind") and "ιατρός" (iatros: "healer or doctor").

Spanning the turn of the century, German psychiatrist Emil Kraepelin advanced a new system. He grouped together a number of existing diagnoses that appeared to all have a deteriorating course over time —under another existing term "dementia praecox" ( later renamed schizophrenia).

Early 20th century schemes in Europe and the United States reflected a brain disease (or degeneration) model that had emerged during the 19th century, as well as some ideas from Freud's psychoanalytic theories

Mental disorders were first included in the sixth revision of the International Classification of Diseases (ICD-6) in 1949. Three years later, in 1952, the American Psychiatric Association created its own classification system, DSMdrapetomania

The categorisation of mental illness has always been

“psychiatric” in nature and essentially medical in its

approach

The International Classification of Diseases [ICD]

Published by The World Health Organisation

The Diagnostic and Statistical Manual of Mental Disorders

[DSM]Published by

The American Psychiatric Association

• In 1917, the American Medico-Psychological Association, formulated a plan that was adopted by the Bureau of the Census for gathering uniform statistics across mental hospitals

• In 1921, the American Medico-Psychological Association changed its name to the Committee on Statistics of the American Psychiatric Association.

• in 1952 the first edition of Diagnostic and Statistical Manual: Mental Disorders (DSM-I).

DSM-I (1952)DSM-II (1968) DSM-III (1980)DSM-III-R (1987)DSM-IV (1994)DSM-IV-TR (2000)DSM-5 (2013)

DSM• DSM contains criteria for the diagnosis of nearly 300

different mental disorders from schizophrenia, personality disorders and depression to acute medical conditions such as brain injury. The earlier versions were used to collect data for the census and hospitals, which is why it’s called a statistical manual.

• Many mental health professionals use the manual to determine and communicate a patient’s diagnosis after an evaluation; hospitals, clinics, and insurance companies in the US are generally require a DSM diagnosis for all patients treated. The DSM can be used clinically in this way, and also to categorize patients using diagnostic criteria for research purposes. Studies done on specific disorders often recruit patients whose symptoms match the criteria listed in the DSM for that disorder.

The first international classification edition, known as the International List of Causes of Death, was adopted by the International Statistical Institute in 1893.

The World Health Organization (WHO) was entrusted with the ICD at its creation in 1948 and published the 6th version, ICD-6 , which, for the first time, included a section for mental disorders.

ICD 10 has all diseases, is published by WHO and is worldwide

CD-10 was endorsed in May 1990 by the Forty-third World Health Assembly.

The 11th version, ICD-11, is now being prepared. The development phase will continue for three years and ICD-11 will be finalized in 2017.

An international survey of psychiatrists in 66 countries comparing use of the ICD-10 and DSM-IV found the former was more often used for clinical diagnosis while the latter was more valued for research.[

International Classification of Diseases (ICD)

• The ICD is produced by a global health agency with a constitutional public health mission, while the DSM is produced by a single national professional association.

• WHO's primary focus for the mental and behavioural disorders classification is to help countries to reduce the disease burden of mental disorders. ICD's development is global, multidisciplinary and multilingual;

• the primary constituency of the DSM is U.S. psychiatrists.

• The ICD is approved by the World Health Assembly, composed of the health ministers of all 193 WHO member countries;

• the DSM is approved by the assembly of the American Psychiatric Association,

• The ICD is distributed as broadly as possible at a very low cost, with substantial discounts to low-income countries, and available free on the Internet;

• the DSM generates a very substantial portion of the American Psychiatric Association's revenue, not only from sales of the book itself, but also from related products and copyright permissions for books and scientific articles.

Why diagnostic categorisation• Autism is a disorder that's identified solely by behaviour -

there's no blood test, DNA screening or secret tattoo that tells you whether someone is autistic. So in order for a diagnosis of autism to have any meaning, everyone needs to agree on just what those behaviours are. It would be impossible to provide support, distribute funding or conduct research if we didn’t have a consistent understanding of what autism looks like.

• The different sets of diagnostic criteria were developed to provide this common language for identifying and describing autism. Put simply, they're a checklist of the behaviours that must be present before someone can officially be considered autistic.

Independent experts also say that it is hard to see how the world of mental health could function without diagnosis. "We know that, for many people affected by a mental health problem, receiving a diagnosis enabled by diagnostic documents like the DSM-5 can be extremely helpful," said Paul Farmer, chief executive of the mental health charity Mind. "A diagnosis can provide people with appropriate treatments, and could give the person access to other support and services, including benefits.“

The diagnostic categories are termed "disorders" and yet, despite not being validated by biological criteria as most medical diseases are, are framed as medical diseases identified by medical diagnoses.

However, there is no evidence that these experiences are best understood as illnesses with biological causes. On the contrary, there is now overwhelming evidence that people break down as a result of a complex mix of social and psychological circumstances – bereavement and loss, poverty and discrimination, trauma and abuse

Since the 1980s, psychologist Paula Caplan has had concerns about psychiatric diagnosis which is unregulated, so doctors aren’t required to spend much time understanding patients situations or to seek another doctor’s opinion. The criteria for allocating psychiatric labels are contained in the DSM, which can "lead a therapist to focus on narrow checklists of symptoms, with little consideration for what is causing the patient’s suffering". So, according to Caplan, getting a psychiatric diagnosis and label often hinders recovery.[50]

• Psychiatrist Joel Paris points out that psychiatrists like to diagnose conditions they can treat, and gives examples of what he sees as prescribing patterns paralleling diagnostic trends, for example an increase in bipolar diagnosis once lithium came into use. He notes that there was a time when every patient seemed to have "latent schizophrenia" and another time when everything in psychiatry seemed to be "masked depression", and he fears that the boundaries of the bipolar spectrum concept, including in application to children, are similarly expanding

• Critics claim that the American Psychiatric Association's increasingly voluminous manual will see millions of people unnecessarily categorised as having psychiatric disorders. For example, shyness in children, temper tantrums and depression following the death of a loved one could become medical problems, treatable with drugs. So could internet addiction.

• Jon Ronson, only half-joked in a recent TED talk: "Is it possible that the psychiatric profession has a strong desire to label things that are essential human behaviour as a disorder?"

• "In essence, instead of asking 'What is wrong with you?', we need to ask 'What has happened to you?'," Johnstone said. "Once we know that, we can draw on psychological evidence to show how life events and the sense that people make of them have led to the current difficulties.“

• Prescriptions of antidepressants increased nearly 30% in England between 2008 and 2011, the latest available data.

• A recent article in the online edition of the British Medical Journal suggested "that only one in seven people actually benefits" from antidepressants and claimed that three-quarters of the experts who wrote the definitions of mental illness had links to drug companies.

• the British Psychological Society released a statement claiming that there is no scientific validity to diagnostic labels such as schizophrenia and bipolar disorder.

• IN THE NEW MANUAL, DSM-5:• ■ Disruptive mood dysregulation disorder, or DMDD, for those diagnosed with abnormally severe and

frequent temper tantrums.• ■ Binge-eating disorder. For those who eat to excess 12 times in three months.• ■ Hoarding disorder, defined as "persistent difficulty discarding or parting with possessions, regardless of

actual value".• ■ Oppositional defiant disorder, described by one critic as a condition afflicting children who say "no" to

their parents more than a certain number of times.• OUT OF THE MANUAL• The term "gender identity disorder", for children and adults who strongly believe they were born the

wrong gender, is being replaced with "gender dysphoria" to remove the stigma attached to the word "disorder". Experts liken the switch to the removal of homosexuality as a disorder in the 1973 edition.

Division of Clinical Psychology Position Statement Final VersionMay 2013

• Core Issue 1: Concepts and models• • Interpretation presented as objective fact: Psychiatric diagnosis is often presented as an objective statement of

fact, but is, in essence, a clinical judgement based on observation and interpretation of behaviour and self-report, and thus subject to variation and bias

• • Limitations in validity and reliability: As a consequence of the above, numerous critiques testify to the resulting problems in reliability and validity, and the issues have surfaced once again in the process of developing DSM 5

• • Restrictions in clinical utility and functions: The above limitations diminish the utility of functional diagnoses for purposes such as determining interventions, developing treatment guidelines, commissioning services, and carrying out research based on these categories.

• • Biological emphasis: The dominance of a physical disease model minimises psychosocial causal factors in people’s distress, experience and behaviour while over-emphasising biological interventions such as medication

• • Decontextualisation: Psychiatric diagnosis obscures the links between people’s experiences, distress and behaviour and their social, cultural, familial and personal historical contexts.

• • Ethnocentric bias: Psychiatric diagnosis is embedded in a Western worldview. As such, there is evidence that it is discriminatory to a diverse range of groups and neglectful of areas such as ethnicity, sexuality, gender, class, spirituality and culture

Impact on service users• Some service users report that diagnosis is useful in putting a name to their distress and assisting them

in the understanding and management of their difficulties, whereas for others the experience is of negativity and harm. Some of the key concerns include:

• • Discrimination: Research has demonstrated discrimination due to negative social attitudes towards those with a psychiatric diagnosis. This can create and compound social exclusion

• • Stigmatisation and negative impact on identity: The language of disorder and deficit can negatively shape a person’s outlook on life, and their identity and self-esteem

• • Marginalising knowledge from lived experience: Service users often emphasise the primary significance of practical, material, interpersonal and social aspects of their experiences, which only constitute subsidiary or ‘trigger’ factors in the current

• system of classification

• • Decision-making: Decisions about how to classify a person’s behaviour and experience are often imposed as an objective fact, rather than shared in a transparent and open manner. For example service users’ disagreement with their diagnosis can lead to being labelled as lacking insight, without acknowledgement of the limitations of the current system

• • Disempowerment: The current classification systems position service users as necessarily dependent on expert advice and treatment, which may have the effect of discouraging them from making active choices about their recovery and the best means of achieving it. Many recovery narratives include a rejection of diagnoses

• • As noted above, diagnosis can lead to an over-reliance on medication, while underplaying the impact of its physical and psychological effects

• in 2007 nearly one person in four (23.0 per cent) in England had at least one psychiatric disorder and 7.2 per cent had two or more disorders

• in 2007 5.6 per cent of people aged 16 and over reported having ever attempted suicide but were not successful

• the proportion of women (aged 16-74) reporting suicidal thoughts in the previous year increased from 4.2 per cent in 2000 to 5.5 per cent in 2007

• • people aged over 75 common mental disorders (CMD) were higher in

women than men (12.2 per cent of women compared to 6.3 per cent of men)

• the largest increase in rate of CMD between 1993 and 2007 was observed in women aged 45-64, among whom the rate rose by about a fifth

• the survey demonstrated a strong association between the presence of a disorder and a low adjusted household income.

Pros & Cons of Diagnosis PROS

• Can help individual to make sense of what is happening

• Can help the family to anticipate (in cases of history of disease) occurrence

• Diagnosis may bring access to certain supports within the system - medical, personal, financial.

• Diagnosis process as a safety device for professionals and community in some cases.

• For some patients there can be a safety in abdicating personal responsibility.

• Creates common language . Can make communication easier between professionals

CONS

• It could be frightening for patient to be ‘labelled’

• It could influence patient to "fit in" to diagnosis and then this becomes a self-fulfilling prophecy

• It can shape other’s perception of the individual [label not person]

• Diagnosis could be inaccurate/wrong• Diagnosis infers a treatment regime: - side effects and inflexibility• Stigma of Mental Health devaluing of

individual by society and by him/herself.• Could be used as a form of social control.• Gender, cross-culture, education, social

culture and disability issues • Social /Financial discrimination

…along comes counsellingUSA

Counseling developed in the late 1890s and was interdisciplinary most counseling was in the form of advice or information.

Most of the pioneers identified themselves as teachers and social reformers/advocates. They focused on teaching children and young adults about themselves, others, and the world of work.

The word counseling appeared in the professional literature in 1931. A first theory of counseling was formulated by E. G. Williamson and his colleagues at the University of Minnesota.

• UKThe first counselling services to develop

in the UK were offered by voluntary-sector organisations - the Marriage Guidance Council (now known as Relate) brought counselling services to the UK around the beginning of the second World War to support families and help keep marriages together and this London-based initiative spawned a network of similar initiatives post-war

Evolving out of marriage guidance, and inspired in part by the ideas of Rogersthe term “counselling” began to be used in the 1950s to describe the work done by trained volunteers who provided those in distress with “someone to turn to”

…..and it developsUSA

•school counseling, still known as guidance in the 1930s, became more of a national phenomenon.•Furthermore, the government established the U.S. Employment Service in the 1930s. And this agency published the first edition of the Dictionary of Occupational Titles (DOT) in 1939.

•Carl Rogers in 1942 publishes Counseling and Psychotherapy, which challenged the counselor-centered approach of Williamson as well as major tenets of Freudian psychoanalysis..

UK

•Over the ensuing decades, counselling was taken up by other voluntary-sector organisations as a way of drawing on the capacity of volunteers to respond to the needs of people affected by a wide range of issues including alcohol problems, bereavement, mental health problems, domestic abuse, drug problems, serious illnesses, and many others

…and it begins to change USA

With the advent of World War II, the U.S. government needed counselors and psychologists to help select and train specialists for the military and industry

After the war, the U.S. government further promoted counseling through counselor training institutes

In addition, the VeteransAdministration (VA) funded the training of counselors and psychologists by granting stipends for students engaged in graduate study. The VA also “rewrote specifications for vocational counselors and coined the term ‘counseling psychologist’”

Counseling psychology, as a profession, began to move further away from its historical alliance with vocational guidance.

UK

Rogers ideas were taken up by British voluntary-sector organisations from the 1950s onwards to endorse the logic of counselling as a practice in which counsellors are positioned as their clients’ peers, rather than as expert professionals Rogers’ ideas also provided a robust rationale for insisting that counselling training was best served by the practice-based development and refinement of existing relationship skills, rather than by the extensive “book learning” or academic study associated with training for professional occupations. Consequently, there were no academic pre-requisites for counselling training, and adults who had left school without any qualifications trained alongside university graduates. Training was offered free at the point of delivery in return for a commitment to volunteer for a few hours each week.

USA

1950’s the decade produced at least five major events that dramatically changed the history of counseling:

1. The establishment of the American Personnel and Guidance Association (APGA);

2. The charting of the American School Counselor Association (ASCA);

3. The establishment of Division 17 (Society of Counseling Psychology) within the American Psychological Association (APA);

4. The passage of the National Defense Education Act (NDEA); and

5. The introduction of new guidance and counseling theories

UK

Thus, in contrast to most professional-client interactions, in which clients are assumed to occupy lowlier positions than those from whom they seek help, the origins of counselling are bound up with a commitment to foster egalitarian, non-hierarchical relationships between practitioners and clients, for which, at least at the time, professional status was considered antithetical.

During the 1970s, as more and more voluntary-sector organisations began to take up the idea of counselling, new networks developed that forged links amongst those using similar approaches in different settings. One expression of this was the creation of the Standing Council for the Advancement of Counselling in 1971, which became the British Association for Counselling (BAC) in 1976,

USA

Professionalism within the APGA and the continued professional movement within•Division 17 of the APA also increased during the 1960s. In 1961, APGA published a “sound•code of ethics for counselors” (Nugent, 1981, p. 28). Also during the 1960s, Loughary, Stripling,•and Fitzgerald (1965) edited an APGA report that summarized role definitions and training•standards•for school counselors. Division 17, which had further clarified the definition of a counseling•psychologist at the 1964 Greyston Conference, began in 1969 to publish a professional•journal, The Counseling Psychologist, with Gilbert Wrenn as its first editor.

UK

1971 Foster Report was a first attempt to turn “psychotherapy” into regulated profession

1981 a private member’s bill tried to create a statutory regulation for counselling and psychotherapy

2007 in the White Paper “Trust Assurance and Safety” the UK government proposed that counselling and psychotherapy be regulated by the Health professions Council [HPC] A loud voice within the profession objected to being regulated under this particular body because of the alignment to a medical model and prevented this.

USA

State Licensure begins in the mid-1970s but has only been completed across the USA in the past 8 years so that all states now legally regulate counselors

in 1992 counseling became a primary

mental health profession, for the first time in the health care human

This recognition put Counseling on par with other mental health specialties such as psychology, social work, and psychiatry.

By the beginning of the 21st century, it was estimated that there were approximately

100,000 counselorsin the United States

UK

The development of IAPT is another attempt to regulate the profession started in 2007 and now well developed with the support of BACP. It has been led by NICE recommendations about effective ineterventions

2011 the DoH paper Enabling Excelence: autonomy and accountability for health workers evidences a move away from statutory regulation and a move towards enhanced voluntary registers and BACP and other organisations are now moving towards the creation of a quality assured voluntary register (under the Professional Standards Authority)

CONCLUSION AND REFLECTIONS

Mental Health has fallen within the remit of medicine for centuries and doctors diagnose

Counselling is very much a new-comer into this arena and emerges from a different culture

As society becomes better informed and new models of research gain credibility, other mental health professions see the grave limitations of diagnostic categories in the treatment of people

Our clients often clothe themselves with diagnostic labels or they present with a range of symptoms which are commonly understood to fall into a diagnostic category

As counsellors we know very little about diagnosis and sometimes there lurks a danger of dismissing this with a form of inverted snobbery.

It is relevant to know something about “diagnosis” and this may also be relevant to how we work with our clients and what expectations are appropriate