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What’s your problem? Should we drop the diagnosis?

6th July, 2019

Rob Woollen



When we are training managers in mental health, there is one course requirement that always comes up: “Understand the signs and symptoms of common mental health conditions” - or words to that effect. Sounds reasonable doesn’t it?

 

I had a great conversation with a friend and former colleague this month. We were bouncing some ideas around about how Virtual Reality might be of use (as opposed to being the latest gimmick) in wellbeing.

 

We ended up discussing whether it could ever be used to give an immersive experience of living with some form of psychosis. For example, to give people a sense of what it is like trying to have a conversation with someone whilst experiencing subtle but pervasive auditory or visual hallucinations.

 

I am sure this is possible. I am absolutely sure our digital partners could do it. I even think we could probably sell it! I am also sure that I never will.

 

My initial reservations were around the potential to inadvertently traumatise the participant - or awaken some latent but powerful previous trauma - and these still stand.

 

But as we spoke, my biggest objection was that it is contrary to my entire philosophy on mental health. This is that everybody’s experience is different, and that diagnoses are simple broad groupings of conceptually similar facets. In my opinion, we don’t need to understand - we need to accept.

 

 

I am not arguing against medical treatment and classification for mental health

 Our collective knowledge of mental health conditions grows constantly. This is reflected in the fact that the current version of the Diagnostic and Statistical Manual for psychiatry contains nearly three-hundred categories of mental disorder, compared to the seventeen in the initial version published in the fifties https://www.psychiatry.org/psychiatrists/practice/dsm/history-of-the-dsm.

 

Medical diagnosis of a mental health condition has its uses. Certainly, a diagnosis of PTSD is preferable to how we dealt with it in the first world war. At that time people with PTSD were branded cowards and shot by the very army in whose service they had incurred psychiatric injury.

 

In a similar vein, a diagnosis of binge-eating disorder is infinitely better than labelling people greedy and ill-disciplined. But this has only been recognised for a relatively short time.

 

For a highly trained medical practitioner, a diagnosis can be the foundation for an individual treatment plan. It has (limited) predictive power about how the patient may respond in certain situations - and to certain treatments.

For a person who has been struggling with their experiences or emotions, some argue that a diagnosis also provides some identity and understanding; some common ground for someone who has felt very alone.

 

I am arguing against medicalisation of mental health in the workplace

 To become a psychiatrist takes around 13 years. One member of my team has an MSc in Health Psychology (having studied for 4 years) and is not legally allowed to use the term health psychologist without completing another 2-3 year programme.

 

The British Association for Counselling and Psychotherapy (BACP) suggest that you should take 3-4 years to qualify as a psychotherapist. If you want to understand mental health conditions, this is the level of commitment that you require.

 

This is not surprising to me. Mental ill-health is complex and varied - this stuff is confusing! Take a look at the (surprisingly readable) mental health condition section of the website of the Royal College of Psychiatrists https://www.rcpsych.ac.uk/mental-health/problems-disorders and you will see why. Below are just a few examples of the complexities found there: -

  • Panic attacks are an anxiety disorder; 50% of people with depression will have panic attacks
  • Depression is one of the listed symptoms of generalised anxiety disorder
  • Symptoms of depression are present in many other disorders such as schizoaffective disorder and schizophrenia

Add to this the argument made by the British Psychological Society https://dxrevisionwatch.files.wordpress.com/2012/02/dsm-5-2011-bps-response.pdf , that “it is entirely possible for two individuals with the [schizophrenia] diagnosis to share no characteristics or symptoms” and we can see that with just a day or two’s training, trying to “understand the signs and symptoms” is too tall an order.

 

Low mental wellbeing without a mental health condition needs attention too

Until the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), low wellbeing due to bereavement was specifically excluded as a condition.

 

Whatever your views on the removal of this exclusion, it highlights a point that is imperative. The view was that feeling low after a death was a perfectly normal reaction to a tough situation, not a mental health condition.

 

But don’t we all experience tough situations in our lives? Why should being cared for by your employer be the preserve of people who are ill? The focus on mental health conditions - rather than mental wellbeing risks alienating those who do not meet the thresholds for diagnosis, but would benefit from some kindness and flexibility.

 

Towards a better way

When we train managers, of course we bring to life the very real challenges that mental health conditions can present in terms that make this perfectly clear. But we steer clear of in-depth analysis of lists of tables relating specific symptoms to conditions.

 

We ask a simple question. Based on a day’s training, if a direct report discloses a mental health condition to you, will the name of that condition make any difference at all to the way that you work with them?

 

Of course, the answer is no. So why even ask what their condition is? The four questions below are far more relevant: -

  • How does your condition affect you?
  • How might this impact your work?
  • What support do you have in place?
  • What support can we provide and how do we implement it?

Whether we go with the 1 in 4, the 1 in 6 or the BITC’s https://wellbeing.bitc.org.uk/system/files/research/mental_health_at_work_2018_-_summary_report-compressed.pdf  1 in 3 statistic, the fact is that almost every manager will work with numerous people with mental health conditions in their career.

 

Resilient teams are those that can make adjustments for how colleagues feel in a pragmatic and person-centred way. So how about rewording that learning outcome?

 

I like “Understand that signs and symptoms of mental health conditions are different for everyone, and how to create an environment where people can talk about their feelings and experiences in the knowledge that efforts will be made to accommodate them” - perhaps a little wordy…

Rob Woollen

Rob Woollen is Head of Wellbeing for PeoplePlus Group and holds an MSc in Work and Wellbeing. Having left school at sixteen he understands issues faced by both manual and professional workers in high pressure environments. Rob lectures at Manchester Metropolitan University Business School; he contributed to the pan-European Resilience Project, and assessed the Workplace Wellbeing Charter. He has trained hundreds of wellbeing champions and mental health first responders across the UK in a wide range of organisations. For many years, Rob developed health improvement qualifications for the RSPH and he is an academic reviewer for their journal Public Health

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