Beyond the Label: Rethinking Mental Health Diagnosis

The dominant paradigm we use to understand mental health is the “medical model”, also referred to as psychiatric diagnosis. People are sorted into labels: we say “you have social anxiety disorder” or “you have major depressive disorder”. The problem with this is that these labels are stigmatising and unhelpful, and also unscientific.

Despite a century of research, we cannot find any biomarkers - things we can measure in the body - to identify if someone has a “disorder”. For example, the serotonin theory of depression has been widely discredited (Moncrieff et al., 2023). Therefore, we rely on functional diagnosis: we observe their behaviour and try and label people based on what we can see. This leads to different clinicians giving different labels, a problem known as “inter-rater reliability”.

Nor do these labels tell us much about what a person is experiencing. At least 50% of clients meet the criteria for multiple categories. Clients rarely come in presenting with only social anxiety: they typically have generalised anxiety and low mood, and often other features as well. This is known as the “everyone has everything problem” (Johnstone & Boyle, 2018).

The problem with labels

If clients do not fit into these boxes, and these boxes tell us nothing about what is going on inside of someone, and therefore how we might be able to help them, what purpose do these labels serve? While some people may find them validating, most people find them to be unhelpful because they risk telling clients that they are victims of an illness, rather than empowering them to make positive changes.

If these labels are unhelpful, why do they exist? While there is no straightforward answer to this question, it is worth asking whose interests they do serve. Treating mental health issues as an illness has been highly profitable for drug manufacturers, for example. And being able to sort people into boxes with specific drugs or CBT protocols works well for health insurance companies. But it doesn’t work well for clients, who find that the root cause of their distress is not addressed.

It also serves the interests of those in positions of power. We live in a world where inequality is growing. Here in the UK (and elsewhere), working-class people are facing a cost-of-living crisis. For example, 14% of nurses use food banks because they cannot afford groceries. Even working full-time is no longer a guarantee that you will be able to meet your basic needs for rent, heating, and food. People are burnt out, anxious, and depressed for understandable reasons. Telling people they have a “mental disorder” depoliticises the real cause of suffering: the legitimate burnout caused by the increasing unfairness in our society.

How do we move beyond labels?

Moving beyond these labels, then, how can we best help clients? A good starting point might be changing the question from “what is wrong with you?” to “what has happened to you?” Many of you will already do this, I am sure. Using a trauma-informed approach helps us to understand how a client arrived at their current difficulties and what needs are currently going unmet. For example, identifying safety or acceptance allows us to help a client gather their internal and external resources to meet these needs.

Using a narrative-style formulation allows us to put difficulties in their social context, and to put our clients front and centre rather than focusing on the symptoms or the “disease”. In over a decade of practice, I have never yet met a client who experiences distress without experiencing other adversities in their life.

However, untangling ourselves from the medical model is not easy. Services are set up around diagnostic labels, and funding is often linked to specific labels. Research grants are often similarly funded, and measurements are typically based on label-specific tools. Reflecting on my own teaching, I have a library of courses containing lessons on specific labels, as this is typically what students ask about.

Where do we go from here? What are your thoughts? How do you navigate these challenges in your own work? I would love to hear your thoughts. Join the discussion in the student community or send me a direct message.

References

Johnstone, L. & Boyle, M. with Cromby, J., Dillon, J., Harper, D., Kinderman, P., Longden, E., Pilgrim, D. & Read, J. (2018). The Power Threat Meaning Framework: Towards the identification of patterns in emotional distress, unusual experiences and troubled or troubling behaviour, as an alternative to functional psychiatric diagnosis. Leicester: British Psychological Society.

Moncrieff, J., Cooper, R. E., Stockmann, T., Amendola, S., Hengartner, M. P., & Horowitz, M. A. (2023). The serotonin theory of depression: a systematic umbrella review of the evidence. Molecular psychiatry, 28(8), 3243-3256.