Interview: The sense and non-sense of psychological labels

Autism, ADHD, schizophrenia, depression, borderline: the number of psychological labels that are given to people is increasing. Does this help with the treatment of symptoms or is it counterproductive?

By Maaike Borst, Dagblad van het Noorden

Is someone feeling unhappy? Is a child lively and unmanageable? Is someone failing to engage with society?

It is easy to attach a psychological label. The DSM, the manual for psychologists and psychiatrists, describes over 300 different disorders. Depression, ADHD, autism: these are all psychological disorders that are documented in the manual. Do you meet enough of the characteristics of such a label, then you are eligible for treatment or medication.

‘The DSM is getting thicker each time,’ says psychologist Marieke Pijnenborg, who carries out research on psychotic disorders at the University of Groningen (UG), about the successive editions of the manual. ‘This initially led to enthusiasm among psychologists. We keep on discovering more, that was the thought; our knowledge is growing. Nowadays, the response is usually: we keep on inventing more.’

Prejudices

The criticism of the classic classifications of the DSM (Diagnostic and Statistical Manual of Mental Disorders) and their use is increasing. That is because it is not always helpful to those who, for example, are labelled as having depression, ADHD, or autism, for they may, consequently, encounter prejudices in society.

‘We still assume far too often that such a disorder is something intrinsic to a person,’ says psychologist Laura Batstra from the UG, well-known for her research on and criticism of the diagnosis and treatment of ADHD. ‘As if there is something wrong with your brain. In fact, psychological problems are far more often related to circumstances. Experiencing a trauma, for example, or having financial worries, may lead to major psychological dysregulation. That is upsetting. A psychiatrist is often still considered a brain specialist.’

Sense and non-sense

Pijnenborg and Batstra consider themselves part of a new generation who view psychological problems in a different light. In their opinion, we must get rid of the DSM, that association with the brain, and terms such as ‘disorder’.

‘We are in the middle of a shift,’ say Pijnenborg. ‘When I started 20 years ago, we—as psychologists—were far more focused on treating symptoms. It is now more about what is important to someone to lead a meaningful life. If you hear voices as the result of a psychosis, it is also possible to figure out how you could learn to live with those voices.’

If an individual is unable to keep up with society, we often try to find out what is wrong with that person. However, you could also look at what is wrong with a society that leaves so many people unable to keep up. Batstra: ‘There are children who are not welcome at any school because they cause additional challenges. We refer to those children as “ill”, while it is a symptom of our overburdened and overstrained educational system.’

Understanding

A psychological label is not always negative. It can provide clarity and certainty to patients and those around them. It feels like an explanation for why someone is unable to do certain things. ‘But ADHD is not really an explanation. It is a description of certain behaviours or emotions, not their cause.

A label can help with being met with understanding and compassion. ‘I think that it is very sad that a label is necessary to receive understanding and support. But because that is the way it works, I understand that parents want a label for their child.’

A label may lead to understanding, but also to prejudices. ‘Major stigmas are attached to psychological labels,’ says Pijnenborg. ‘I know plenty of examples of people who are rejected as soon as they reveal their diagnosis.’

Future

Dutch psychologists and psychiatrists can barely do without the DSM. To get treatments and medication reimbursed, health insurance companies require adults to have a DSM classification. ‘This is no longer the case in youth care, thank goodness,’ says Batstra. ‘But also when it comes to youth care, institutions are still not really able to stop thinking and acting in terms of DSM disorders. After all, they have been told to use those for decades.’

The DSM was once initiated to develop a ‘common language’ for treating practitioners. What do we mean when we refer to ‘depression’? Which characteristics are associated with this?

‘It has got out of hand; even some authors of the DSM agree,’ says Batstra. That is due to the large number of disorders in it and the significant value that is attributed to it. ‘It leads to odd situations,’ according to Pijnenborg.

Psychologists must classify people to get a treatment reimbursed, while this classification may sometimes do patients more harm than good. Pijnenborg: ‘A label such as ‘schizophrenia’ does something to your hopes for the future.’

Moreover, such a classification is not necessary to determine what treatment or medication is required. ‘That must always be patient-specific; you must know what is going on or what has happened in someone’s life. Some medications or treatments work well for one person and not for another. That is a matter of trial and error. There is no standard treatment plan for schizophrenia.’

Alternative

A psychological condition is different from a broken knee. ‘That is the problem with the DSM,’ says Batstra. ‘You cannot apply the medical model to psychological problems. ’There is not yet an alternative to the DSM, but Batstra and Pijnenborg are seeing a change happening. Pijnenborg is trying to draw up better guidelines for diagnosis, mainly from within, while Batstra is more activist and frequently gets angry about, for example, incorrect information about ADHD. ‘You have to make noise to change something,’ is her experience.

‘Far too often, we look at the individual for the problem,’ says Batstra. ‘We make too little effort to change the unfavourable social circumstances that cause psychological need. We make too little effort to change poverty, the education system, the performance society. Do you know what we should be doing? Draw up a DSM of societal problems. But who wants to invest in that? Not the pharmaceutical industry.’

• Psychologist Marieke Pijnenborg carries out research on psychotic disorders . She is head of research dept. of psychotic disorders GGZ Drenthe.

• Psychologist Laura Batrstra, well-known for her research on and criticism of the diagnosis and treatment of ADHD, is chairman at Board Pedagogical Education Foundation and teacher at the Pedagogical Education Foundation.