Exploring the culture of psychiatric diagnosis, creating change

21st February 2017

Dr Lucy Johnstone is a UK clinical psychologist, trainer, speaker and writer, and a long-standing critic of biomedical model psychiatry. In this article she talks about the importance of offering alternatives to the increasingly disputed diagnostic approach to mental distress.

We are in the middle of an epidemic of mental health problems. It sometimes seems as if the whole population will be soon be diagnosed and taking medication. Politicians of all parties are promoting anti-stigma campaigns, and celebrities are disclosing their personal stories almost every week. At the same time, there is a growing debate about psychiatric diagnosis. Some professionals and service users are rejecting these terms and calling for a different, non-medical understanding of distress. What is going on here? Are there alternative, and perhaps more effective, ways of understanding people’s problems and helping them to recover, and if so, what might those be?

There is no question that people really do feel desperate, panicky, and suicidal, or suffer extreme mood swings, or hear critical voices, and so on. But few people are aware that there is actually no evidence that these experiences are best understood as medical illnesses, perhaps inherited, leading to imbalances in your brain chemistry which need to be corrected by medication. It may come as a shock to learn that there is not, and never has been, any evidence to support these ideas. It may be even more surprising to hear that some of the world’s most senior psychiatrists, the very people who draw up the diagnostic manuals, are saying that the current system of diagnosing people’s difficulties is not safe or scientifically sound. In fact my own professional organisation, the Division of Clinical Psychology, has issued a formal statement calling for the end of diagnosis and the ‘disease’ model of mental distress. Articles appear in medical journals almost every month, with titles like:

‘Western psychiatry is in crisis.’ (Mental Health Europe, 2013)

‘Psychiatry in crisis? Psychiatry seems to have lost its way’ (BMJ, Richard Smith, 2016)

Most service users are not included in these debates. People are still being told, as if it was a simple true fact, that they have ‘schizophrenia’ or ‘bipolar disorder’ or ‘personality disorder.’ Since these diagnoses have such a powerful and lasting effect on people’s lives and identities, I do not think it acceptable to give people only half the picture, and not tell them about the many problems with diagnosis and the alternatives that are around. That is why I have written a short, accessible book ‘A straight talking introduction to psychiatric diagnosis’ (PCCS Books 2014) . Here is a quote from it:

If the authors of the diagnostic manuals are admitting that psychiatric diagnoses are not supported by evidence, then no one should be forced to accept them. If many mental health workers are openly questioning diagnosis and saying we need a different and better system, then service users and carers should be allowed to do so too. This book is about choice. It is about giving people the information to make up their own minds, and exploring alternatives for those who wish to do so.


It is an open secret that despite a lot of talk about recovery, many people in mental health services find it very hard to move on. There may be many reasons for this. People have mixed reactions to receiving a diagnosis, and for some it brings a sense of relief. Very few people can afford to give up their diagnosis entirely, since it is needed for access to benefits, services and so on. However, some people feel that the diagnosis has been a significant source of shame and hopelessness in itself, and others say that it has led to a narrow focus on medication which means that their life problems are not addressed or resolved. The service user/survivor movement includes many people whose recovery started when they were able to look beyond the diagnostic model. For all these reasons, it is important to offer people a range of approaches, not just a diagnostic one, so that everyone has the best chance of achieving their own personal recovery.

‘A disorder for everyone’ event

Psychotherapist Jo Watson feels just as strongly that people need to know about these debates. Mental health professionals need to ensure people are given the full range of information, and service users need to have a chance to decide what makes most sense to them.

So, we are jointly running a series of events to explore these issues. Our workshop, ‘A disorder for everyone’, will take place in Edinburgh on March 10th.  As the main speaker in the morning, I will be giving an accessible overview of the problems with the current system. I will then talk about other ways of understanding extreme distress, which are based on a growing amount of evidence about the impact of difficult events in people’s lives. Jo McFarlane, performance poet, will add a unique flavour to the day with her powerful poems about her experiences of mental health services. In the afternoon we will have a chance to discuss and try out some of these ideas and practices in more depth.

We hope to see you at this important and lively event.

Find out more about the ‘A disorder for everyone’ event. – This event is now full.


Dr Lucy Johnstone blogs on this and other mental health debates on the Mad in America website