How Psychiatrists Navigate the Complexities of Diagnostic Reasoning

 

With mental health problems being more openly discussed in public, and individuals with mental health issues becoming an increasingly important and sometimes critical voice in mental health care, the way psychiatrists practice their craft has also become an object of deeper interest for a broader audience. One central aspect of psychiatric practice is diagnostic reasoning. 

When you visit a psychiatrist because you are suffering, you expect them, among other things, to determine whether you suffer from a mental disorder and, if so, which one. While it's crucial to recognize that this is part of a psychiatrist's job description, what is not trivial is the further question: how exactly does a psychiatrist arrive at the diagnostic conclusions they write in their reports and communicate to their patients? How does the psychiatrist know what the patient’s mental disorder is?

A swift response that someone at least vaguely familiar with psychiatry might give is, “Well, they ask the patients for their symptoms and compare these to the list of mental disorders in the DSM/ICD, which tells them what the diagnosis is,” or something along those lines. Though tempting to close the matter here, it is not that easy. Criteria and symptom lists do not apply themselves to patients; it has to be judged whether they apply to the patient. Furthermore, patients are imperfect sources of information. Imperfect in the sense that they will not automatically and correctly tell you all their symptoms, and sometimes they may claim to have symptoms but misjudge their problems. 

For example, some patients think it is normal to be socially isolated as they have been so for many years, so they will not mention social isolation as one of their problems. On the other hand, patients may say they ruminate about something, while the pattern of cognition that constitutes their “rumination” is more accurately classified as generalized worrying, in the language of psychopathology. These cases show that the process of psychiatric diagnostic reasoning implies more complicated patterns of reasoning and information gathering. A truism for any clinician supporting this is: You can't just pick up a DSM and be good at diagnostics; diagnosing is a skill to learn.

Just picking up the DSM isn't enough; diagnosing is a skill!

If this is so, how does proper psychiatric diagnostic reasoning work? Not many philosophers of psychiatry have attempted to provide a theory of this practical aspect of the epistemology of psychiatry. Some work can be found among scholars committed to the Phenomenological Tradition of psychiatry, some in the works of those focusing on the interpersonal quasi-hermeneutic sense-making processes between clinicians and patients, and finally, some thoughts are to be found among philosophers of psychiatry approaching the field from the perspective of philosophy of science.

In my recent book “How Does The Psychiatrist Know?”, the first book-length treatment of psychiatric diagnostic reasoning, I side with those approaching it from a philosophy of science perspective. I argue we should consider how the procedures of clinical psychiatric diagnostics typically look, i.e., what is taught in many of the central textbooks on psychiatric diagnostics and the standards of the leading psychiatric expert communities. Based on this, psychiatric diagnostic reasoning can largely be seen as a cognitive modelling process, quite similar to the procedures we see in scientific modelling.

For clinicians, philosophers, and anyone else willing to dig through an academic textbook to get an idea of the whole story I put forward, the book is available open access.

 

Adrian Kind is a postdoctoral researcher at the Charité Medical University in Berlin, Germany. He holds a PhD in Philosophy and master degrees in Philosophy as well as Psychology. He is a psychodynamic psychotherapist in advanced training. His main areas of interests are philosophy of psychiatry, philosophy of psychology and philosophy of medicine. He also works on philosophy of sports and philosophy of religion.

Workshop report: Feeling and Being Understood (Day 2)

 On the 6^th and 7^th of February, EPIC project members Lisa Bortolotti and Jodie Russell spoke at the conference "Feeling and Being Understood" which was organised by the Phenomenology of Health and Relationships (PHaR) group at Aston University and took place over two days. 

You can read about the first day here.

The second day involved a series of talks on delegates' work in order to stimulate further discussion and thought along the themes of the previous day.

The first event was a lively workshop, led by Charlie Gunn (Aston University), that participants could really sink their teeth into, titled “A better recipe: collaborative, accessible study design and participant information through the use of edible and creative methodologies when working with vulnerable participants”. Delegates were invited to use a range of edible materials, including iced biscuits, fudge, icing sugar and food colouring, in order to construct a response to the prompt “What does good workplace mental health support look like?” 

In this process, we got first-hand experience of working with an accessible experience-making activity designed by Charlie to find that ‘sweet spot’ of a research method that encourages communication with vulnerable adults. Charlie also introduced us to the participant information sheets she created for the project with accessibility in mind. You can see them here and learn more about the project here.

"Eyes are windows to the soul": inspired by the concept of 'sonder' one group interpreted good workplace mental health as acknowledging that everyone has a rich inner life.

This workshop was followed by the first talk of the day, titled “The use of creative prompts to support an IPA interview”. Speaker Laura Martin (Sheffield Hallam University) led us through her work with probation officers, highlighting how it is a job with complex associations attached to it. For example, Laura described how probation is often thought of as “dirty work”, and for one participant her decision to become a probation officer was highly disruptive to family dynamics. This raises the question of why people train to become probation officers in the first place. 

In order to investigate and capture the journeys to this profession, Laura introduced us to the life map exercise where participants would trace their journey to becoming probation officers. The maps themselves were constructed in diverse ways, reflecting a diversity of narratives.

The third talk of the day was given by Valeria Motta (University of Birmingham) and titled “From participant to co-researcher: Navigating different levels of knowledge production with young people”. Valeria described her work within the ASP Belong Project, which focuses on using augmented reality through smartphones to help young people strengthen their sense of belonging. 

In conducting this research, she noted that the way we conceptualise ‘vulnerability’ has important consequences for framing research questions, as it can imply that an individual is inherently vulnerable regardless of policy change. 

However, Valeria argues that this obscures the role of systems, institutions and elites in effecting someone’s vulnerability, and, ultimately, their health. From this, Valeria aims, in her first study, to investigate experiences of belonging in young people with an integrative and functional account of vulnerability. 

Valeria then plans to undertake a co-researched study with young people to find the best arts-based methods for eliciting, expressing, and communicating vulnerable experiences. Both of these studies, she notes, involve different ways of working with young people.

Jess Webster (Aston University) led the fourth talk, titled “From Lego-balancing to Information Sharing – how do you make the jump?” Jess notes that early intervention for mental health is sorely needed, especially in the case of young people and children. 

To this end, a series of protective factors were introduced to pupils in schools to investigate which were the most important and effective, and therefore which ones could be implemented. Pupils were given Lego, a set of scales, ‘daily stressors’ and ‘protective factors’. 

Pupils then used these to represent how they felt a particular protective factor would mitigate (or balance) the stressors. For example, “self-kindness” and “school connectedness” where two such factors said to be effective by pupils. This information could then, Jess says, be turned into a PSHE lesson with a take-away tool kit. Conference delegates where then invited to participate in an activity practicing self-kindness, which involved decorating a hand with affirmations.

Ainhoa Rodriguez-Muguruza (University of the Basque Country) then presented on her research in collaboration with Arantza Etxeberria-Agiriano (University of the Basque Country) on “The Concept of “Relational Health”: How menstruating bodies are key for understanding health”. Ainhoa argues that women’s health is been neglected in medicine, in part, due to structural gender biases in science at large. 

Moreover, as medicine has become more specialised, the body has increasingly been conceptually carved up by function; menstruation is then relegated to the ‘reproductive function’, which is seen as just a woman’s problem. This then treats menstruation in isolation of other functions of the body. 

However, as Ainhoa highlights, the body cannot be understood in a a static and isolated way; menstruating bodies not only get sick differently, but they also react differently to drugs and treatments. In their work, Ainhoa and Arantza argue that a concept of health is needed to capture the dynamic nature of menstruating bodies, i.e. how bodies can change over the cycle of month and a lifetime. They refer to this notion of health as “dynamic, differential and relational”.

Jo Billington (Reading University) and Shioma-Lei Craythorne (Aston University) followed up a second zine-making session over lunch with their talk “Adapting IPA to work inclusively with diverse ways of being”. Jo led the delegates in a discussion on what “diverse ways of being” could mean, noting that while diversity exists in abundance in nature, academia itself lacks diversity. 

This discussion was based on the speakers’ recently submitted paper “Toward epistemic justice: using a multimodal Interpretative Phenomenological Analysis methodological approach in research with autistic children”. 

Jo and Shioma-Lei note in this paper that the double empathy problem – the idea that autistic and non-autistic individuals experience with world in very different ways – can be a useful lens for approaching research with autistic people. 

They note a resonance with the concept of the ‘double hermeneutic’ in IPA, where the investigator is trying to make sense of the participant’s account, which is itself the participant trying to make sense of their own experience. 

Following this, Jo led us to reflect on what adaptations we might need to make to facilitate this investigation and described to us her own experience of an interview with one of her participants which was able to continue successfully over email after problems communicating in person.

Joanna Farr (Birbeck University) introduced us to her research which explored the everyday experiences of adolescent girls in her talk, “Understanding young people’s everyday experiences using mobile phone video diaries, film and IPA”. Joanna asked participants to report their daily reflections using video diaries captured on their mobile phones. She noted that that this captured spontaneous, familiar and temporal experiences for rich data, but, importantly, it also gave participants a greater sense of choice and control as to what they shared. 

This method made the experiences of adolescent girls more accessible but were coupled with qualitative interviews in order to further explore the participant’s emotional experiences. Participants were also invited to a workshop where they were given their diaries back and taught to edit complications of them into longer videos.

Michael Larkin's "monster manual" for challenges in qualitative research

In the last block of afternoon sessions, Michael Larkin (Aston University) set to outline a unifying set of key challenges we face as qualitative researchers in his talk, “Attunement and Perspective through Collaboration: finding an ethical and just way forward for phenomenologically-informed qualitative research in psychology”. 

Drawing on the tropes of table-top roleplaying games like Dungeons & Dragons, Michael argues that we can understand these challenges to be like tests as we undertake the quest of our research, like gateways to other realms of knowledge, or like side quests that distract us from our main objective. 

Michael then reframes these challenges as classic D&D monsters; for example, the Rigour Zombie represents those individuals who police discourse about what counts as science. Rigour zombies are dangerous in that they can push the quest off course, and as adventurers we can become unhelpfully preoccupied with monsters that ultimately can’t do much harm. 

To keep on the right path, however, we need only rely on the equipment we already have in our trusty bag-of-holding, i.e., our skills in attunement, collaboration, and perspective taking.

Sally Latham (Open University) followed with a discussion of the problem of self-deception in her talk, “Narrative therapy and the falsehood objection”. Sally notes that Narrative Therapy is built on the premise that stories influence identity and life opportunities, and so to combat a self-narrative about the individual’s deficiencies and problems Narrative Therapy seeks to identify unique events that challenge that narrative. 

However, Sally argues that there is a risk of self-deception; the individual receiving the therapeutic treatment might develop false memories or the therapeutic process might misleadingly (or falsely) imply that the event they are pointing to generalises to the rest of someone’s life. Sally argues this is unethical because it violates autonomy; you cannot fully consent to being deceived. Because of this, it wouldn’t be sufficient to merely disclose that false memories and false implied generalisations are possible with Narrative Therapy. A different solution is needed.

Lastly, Jodie Russell (University of Birmingham), postdoc in project EPIC, closed the day with her talk, “Intersectional invisibility and its impact on belongingness and being understood”. Her goal was to give a phenomenological account of “intersectional invisibility” and discuss its implications for qualitative research. Intersectional invisibility refers to when a person has multiple group identities and belonging to one group renders them ‘invisible’ with respect to some of the social structures that affect other groups. 

For example, men who experience mental disorder may be rendered invisible because of patriarchal expectations about what constitutes the group ‘men’; this may not include men who show vulnerability or emotion, which might be typical for people with mental disorder. 

These men may then be invisible with respect to the group ‘men’, but they might not be seen as fully fledged members of the group ‘people with mental disorder’ either as they may still hold some patriarchal norms and values not typically shared by the rest of the group. 

Intersectionally invisible groups, like men with mental disorder, might not then be able to participate in group activities, like generating and sharing knowledge for self-understanding, simply because the norms of one group may conflict with the norms of another.

Workshop report: Feeling and Being Understood (Day 1)

Last week, EPIC project members Lisa Bortolotti and Jodie Russell spoke at the conference "Feeling and Being Understood" which was organised by the Phenomenology of Health and Relationships (PHaR) group at Aston University and took place over two days. 

The first day was filled with a number of inspiring workshops to introduce attendees to new methodologies in health research, new ways of working and new ideas to consider in our projects. Here is a brief summary of each talk, including links to further information.

Workshop 1, titled “Dialogical Co-analysis: a new methodology for conducting qualitative analysis with young people as co-researchers” was presented by Michael Larkin (Aston University), Rachel Temple (McPin Foundation), and the Agency-in-Practice team, including members of the Young People Advisory Group (YPAG). The speakers described their experience as part of the Agency-in-Practice Project, which is made up of an interdisciplinary team of researchers as well as young people with lived experience of mental disorder. 

This project started as a collaboration between young people and researchers to analyse transcripts and videos of interview participants that blossomed into a methodology for co-analysing research. Members of the YPAG described their input into the methodology, for example, by calling out unhelpful jargon, and the creation of a space where everyone can be heard. Rachel Temple also emphasised the importance of agency, which inspired the project, and the necessity to balance this with safety by, for example, signposting, debriefing and taking breaks. Rachel also notes that this is important for both the young people involved and for the academics too. You can read more about the project here.

Workshop 2, titled “Photovoice, with and without the voice: combining collaging, phenomenology and photographs”, was led by Will Day (Aston University). In this workshop, Will introduced delegates to the photovoice methodology, showing us how he used such a method himself in the development of his PhD project which focused on the lived experience of those with invisible chronic illnesses. He noted that, in the context of welfare reforms, these individuals faced significant stigma and were not often discussed in the psychological literature. 

Will sought to capture the day-to-day lived experience of this group during the pandemic by asking participants to take and submit photos that represent their days. Each photo was then analysed using Boden & Eatough’s (2014) framework for analysing drawings, generating an individual analysis for every photo. The photos were also cut up and collaged to group them by mood, generating group experiential themes. It is in this way that photo voice is embedded into Interpretative Phenomenological Analysis (a qualitative research method) for a rich discussion of the participants lives.

Our thematised statements from workshop 3

Workshop 3 developed and expanded on the use of the photograph in qualitative research. In their talk, “Polyphonic Photo Analysis in phenomenological research”, speakers ‪Mikołaj Zarzycki (Liverpool Hope University), Shioma-Lei Craythorne (Aston University) and Kisane Prutton (Derby University) walked us through their new methodology for analysing photographs. The speakers note that photos are usually used to elicit verbal data but with Polyphonic Photo Analysis it becomes possible to analyse the photos themselves. Inspired by Dostoevsky, the method involves being open to multiple perspectives at the same time. Using photos collected for Kisane’s PhD project on experience of peacebuilding for women in Northern Ireland, the conference delegates were split into roughly 3 groups, each attempting a stage at the analysis. 

Group 1 focused on the first stage: observing the visual features of the photo, including its composition, colour, and framing. Group 2 focused on the next stage, which involved interpreting the photo from the research perspective (i.e. an outsider perspective) to look for possible meanings in the photo without the context of the participant. Group 3 then took on the analysis state which involved interpreting the photo alongside the participant’s narrative to explore further features of the participant’s lifeworld. The last stage, completed by the speakers themselves, involved taking the statements we made in the analysis process and synthesising them (see photo above).

During the lunchbreak, Julie Kane (Aston University) lead a pop-up workshop on “Exploring sense of belonging through zine making” where Julie talked us through some of the history of zines, introduced to some beautiful examples and gave us free rein to create our own!

A range of colourful zines from which to draw inspiration!

Workshop 5 was delivered by Lisa Bortolotti on her work with the Agency Project and EPIC, co-authored with Rose McCabe. In her talk “Epistemic injustice, agency, and youth mental health”, Lisa argued that when responsibility is associated with blame, blame can damage the relationship between the patient and their healthcare provider, undermining knowledge exchange and mutual trust. As agency can be threatened by a number of environmental factors and factors outside our control, we never have full responsibility for an event .

Drawing on the work of Brandenburg (2018), Lisa argues that in the therapeutic context responsibility should be replaced by the affirmation of the person's capacity to contribute to change. This is important because it reduces the risk of burdening young people experiencing a mental health crisis with responsibility for past events and implying that they are to be blamed. For more information on enhancing the agency of young people in mental health, see the post on the McPin blog here.

Workshop 6 introduced us to a narrative development of Interpretative Phenomenological Analysis (IPA). Nathan Thomas (University College London) led this talk, titled “Understanding Experience using a Narrative Variation of Interpretative Phenomenological Analysis (NIPA)”, which took us through the adapted steps to generate a narrative analysis of a qualitative interview. Nathan’s account draws on both narrative and hermeneutic phenomenology (as developed from Paul Ricœur) which looks at experience as it presents itself in a narrative text (in this case, an interview transcript). 

Narrative gives our experience a kind of order, and so when we analyse narrative we also analyse an aspect of experience itself. So in Nathan’s narrative variant of IPA, the narrative structure needs to be maintained. To do this, instead of breaking down the order of a participant’s account to group statements into themes (as is done in IPA), Nathan suggests developing a narrative description of the account. This should read as if the participant were telling their story, capturing the essence of the interview and amplifying key information. Participants can also be involved in the process to give them the chance to craft their story. The resulting narrative replaces the transcript in the rest of the analysis, informing the themes which are compared and contrasted with other participants.

A floorplan of where medication is kept in the home

The last workshop of the day was a powerful discussion lead by Zoë Boden-Stuart (Open University) titled “Medications and care: a reflexive workshop exploring embodiment, spatiality and meaning”. In this workshop, delegates were invited to participate in three creative exercises. For the first, we drew floorplans of our living spaces, noting where in our homes we kept medications and the factors that have led to them being there. In discussion, we noted many similarities and differences in locations as well as the implicit reasons that go behind choosing these places. In the second exercise, we chose a medication box from a selection, reflected on some of the phenomenal features of the box (e.g. its texture, weight, size) as well as its meanings to us. This culminated in the third exercise where we reflected on a situation in which we were to give these medications to someone else.

Psychiatry as mind-shaping

 In this post, project EPIC postdoc Jodie Russell summarises her recent paper “Psychiatry as Mind-shaping”, published in Erkenntnis:

I make the case that researchers in mental health, clinicians and the wider public participate in a process called mind-shaping. By highlighting the involvement of these individuals in shaping the minds of people with disordered experiences, we can better understand phenomena like looping effects (when the behaviour of the person being labelled changes in response to that label, which in turn changes the meaning of the label). Moreover, characterising psychiatry as mind-shaping also helps us understand harms like epistemic injustice in a new light. But, first, let me unpack what I mean by psychiatry as mind-shaping.

Mind-shaping is a particular theory of social cognition – the study of how we understand each other. In contrast to traditional theories of social cognition, where we try to ‘read’ the minds of other people, the mind-shaping thesis proposes that understanding occurs through trying to get another person to conform to some set of shared rules. For example, I understand that my partner is hungry because their behaviour conforms to certain norms of being a ‘hungry person’, i.e., they rub their stomach, look wistfully at the kitchen, or graze on near-by biscuits. In this example, I try to understand what ‘type’ of person my partner is trying to be, assuming their behaviour conforms to some norms of that ‘type’ that I also adhere to.

In this way, I argue that researchers and clinicians are trying to understand what kinds of people individuals with disordered experiences are. In other words, clinicians and researchers might try and understand whether someone is a ‘well’ or ‘unwell’ person, a person with schizophrenia, or a person with a brain disease etc.

However, under the mind-shaping view, this process of categorizing people comes with certain expectations; in order for social understanding to be successful, it may be necessary to conform to certain norms. For example, for my partner and I to successfully coordinate over our shared task of making food for dinner, I really need to know that my partner is hungry. If they act hungry when they aren’t, we’ll make food for no reason. If they don’t act hungry when they are, my partner starves (if they are feeling melodramatic). Either way, if my partner is unreliable in conforming to norms, it makes working together to make dinner more difficult, and communication in general might struggle if they are not in some way reliable. There are therefore certain expectations at play in social understanding; if you are a hungry person, you should act like it. This is what it means to be mind-shaped.

This has, however, some unintended consequences when it comes to mental health research, namely, that individuals with mental disorder who are labelled may be prone to particular “expectancy effects”. In other words, by being labelled or studied in a particular way, as a particular kind of person, people with mental disorder may be obligated to act in certain ways. One such case study of this can be seen in a study conducted by Örmonet al. (2014). They noticed that the women in their study who had experienced abuse did not often have their experiences validated by clinicians, with their history of abuse considered irrelevant to diagnosis, and thus the women did not receive what they felt was the appropriate care. As such, the women responded to this treatment by changing their behaviour to conform to particular disorder categories that were seen as worthy of care (such as bipolar disorder). In this case, I argue that the women conformed to norms of being mentally unwell that clinicians typically expected to find; by understanding their patients as unwell, the clinicians were then able to provide some kind of care for these women. In this way, both the patients and clinicians were mind-shaped in order to coordinate on some goal (getting care for the women).

The consequences of this particular case study, however, was that the struggle of the women to have their abuse acknowledged was then interpreted by clinical staff through the lens of mental illness. This struggle was then either a mental health problem or secondary to the mental health problem. It is in this way that I think we should pay closer attention to the effects of mind-shaping, and how it may perpetuate epistemic injustices. Given that a core part of social understanding is the expectation we conform to shared norms, we may not only present very narrow options to individuals with mental disorder if they want to be understood by others (e.g. through the lens of specific disorder categories that may or may not fit their experiences), we may also exclude as irrelevant, or un-understandable, those behaviours, thoughts and feelings, which don’t fit our expectations but that are nevertheless important to the individual in question. The solution, I would want to propose, is giving people with mental disorder more agency to determine what norms are in play so that they might be better understood on their own terms.