[T]he single most damaging effect of psychiatric diagnosis is loss of meaning. By ruthlessly divesting experiences of their personal, social and cultural significance, diagnosis turns ‘people with problems’ into ‘patients with illnesses.’ Horrifying stories of trauma, abuse, discrimination and deprivation are sealed off behind a pseudo-medical label as the individual is launched on what is often a lifelong journey of disability, exclusion and despair.
It follows from this that the most important function of any alternative system is to restore the meaning in madness. There is a whole history of attempts to do this, dating right back to the inception of psychiatry and re-surfacing at various points such as the so-called ‘anti-psychiatry’ movement of the 1960s. The same message is given by contributors to this website. For example, Phil Thomas has advocated what he calls a ‘narrative view of psychiatry’ in which ‘the most important task for the psychiatrist is to engage with (service users’) stories respectfully and empathically’ (25th Sept 2012.) On Jan 10th Jacqui Dillon described how the Hearing Voices Movement supports people to ‘look for the meaning in their madness…..However crazy someone appears, we believe that they are making a meaningful attempt to survive maddening experiences.’ The HVM uses the term ‘construct’ to describe the creation of personal stories about these meanings (Johnstone 2011). This has a lot in common with the concept of formulation.
I am proposing that one way of restoring meaning is through the use of psychological formulation. But of course, as several people have pointed out in their comments, it depends how it is done. This is always the danger with challenges to biomedical psychiatry: they are stripped of their potentially radical aspects and assimilated into the status quo. Hearing Voices groups in psychiatric settings too often consist of a set of techniques to manage the ‘symptoms’ of your ‘illness.’ Powerful evidence about the causal role of trauma in psychosis is re-defined as the ‘trigger’ of a pre-existing ‘biological vulnerability.’ And so on, and so on.
I have already mentioned the development of the first set of professional guidelines on the use of formulation (which can be downloaded from www.bpsshop.org.uk for a small fee.) One of the working party’s main aims was to establish best practice criteria so that UK clinical psychologists (and others) will use formulation in the most empowering and sensitive way, and certainly not as a kind of additional expert pronouncement about a service user’s deficits.
As a result, the Guidelines specify that the formulation practice of clinical psychologists in the UK should be collaborative; respectful of service users’ views about accuracy and helpfulness; expressed in ordinary and accessible language; culturally sensitive; aware of the possible role of trauma; non-blaming; and inclusive of strengths and achievements. Psychologists are expected to take a reflective stance which reduces the risk of using formulation in insensitive, non-consenting or disempowering ways, especially with more vulnerable groups. There is also a strong emphasis on the wider context of formulation. This includes ‘the possible role of services in compounding the difficulties’ (Division of Clinical Psychology 2011, p.29); and ‘a critical awareness of the wider societal context within which formulation takes place’ (p.20.)
The most important and controversial issue is whether formulation is used as an addition to, or an alternative to, psychiatric diagnosis. It may not be a coincidence that the controversy about DSM has been paralleled by a small but growing number of articles by psychiatrists calling for the greater use of formulation. Indeed, an internet discussion group recently received the following comments from various psychiatrists: ‘It is formulation that is really important. Diagnoses are just to keep the records dept happy’. ‘Developmental formulations, especially agreed with the service user, are probably much more valuable (than diagnosis)’. ‘Formulations, agreed with the client, are better than diagnostic categories’.
At one level this is to be welcomed – any attempt at widening the gaze of diagnosis is likely to be an improvement. However, there is a potential problem which threatens to assimilate this newly-popular approach back into traditional psychiatric practice. The term ‘formulation’ appears in several places in the UK training curriculum for psychiatrists, who are required to ‘demonstrate the ability to construct formulations of patients’ problems that include appropriate differential diagnoses’ (Royal College of Psychiatrists 2010, p. 25).
While this does suggest a greater willingness to acknowledge psychosocial causal factors, the overall result is simply to put new icing on the cake of the basic biomedical model, rather like adding in the DSM axes along with the primary diagnosis. A psychiatrist who followed these training guidelines might thus produce a formulation for Jane (see previous post) which looked something like this: ‘Schizophrenia/psychosis triggered by the stress of job loss.’ I don’t think I am being too cynical or paranoid when I say that there is a risk of the psychiatric profession responding to criticisms of diagnosis by saying, ‘But we don’t just diagnose. We formulate as well. We do BOTH. Other professions only can only do ONE!’
It was for this reason that we wanted the Guidelines to draw a clear distinction between psychiatric formulation and psychological formulation – the former being an addition to diagnosis, and the latter being an alternative. After a certain amount of intra-professional debate, the following best practice criterion was agreed: psychological formulation as practised by UK clinical psychologists ‘is not premised on a functional psychiatric diagnosis (eg schizophrenia, personality disorder)’ (Division of Clinical Psychology 2011, p.29.)
This is a remarkable position for a professional body to take – although entirely consistent with the Division of Clinical Psychology’s response to the DSM consultation. The argument is that if a psychosocial formulation can provide a reasonably complete explanation for the experiences that have led to a psychiatric diagnosis – low mood, hearing voices, unusual beliefs and so on – then there is no place or need for a competing hypothesis that says ‘…and by the way, she has schizophrenia as well.’ The diagnosis becomes redundant. In the words of clinical psychologist Richard Bentall: ‘Once these complaints have been explained, there is no ghostly disease remaining that also requires an explanation’ (Division of Clinical Psychology 2011, p.17.)
Best practice psychological formulation is, therefore, based on fundamentally different principles from psychiatric diagnosis. It is the difference between the message: ‘You have a medical illness with primarily biological causes’ and ‘Your problems are an understandable emotional response to your life circumstances’ (Johnstone 2006.) Clearly, these explanations cannot both be true. And they are not only different: they are contradictory. People who are offered both models simultaneously, as happens when we try to dilute biomedical approaches with psychosocial ones, or add formulations to diagnoses, become deeply entangled in this confusion. The overall message to service users comes across as:
‘You have an illness which is not your fault BUT you retain responsibility for it and must make an effort to get better BUT you must do it our way because we are the experts in your illness.’
Given this mixed message about personal responsibility, it is almost impossible for service users to get things right. Either they are ‘non-compliant’ – not taking their meds as prescribed – or they are ‘too dependent’ – wanting more support than we are prepared to offer. Either they reject their diagnosis through ‘lack of insight’ or they become too attached to it and hang around on the ward smoking and not making an effort to get better. Either they are too demanding of services, in which case they will probably be told they have borderline personality disorder and get sent away, or they refuse to engage with services, in which case an Assertive Outreach team will arrive on their doorstop and try to coerce them into some unwanted form of activity or treatment. These confusions are the inevitable result of combining models with fundamentally incompatible core assumptions. Muddled thinking leads to muddled practice, and both staff and service users become stuck, frustrated and demoralised in the resulting mess.
The damaging effects of psychiatric diagnosis are summarised below, and contrasted with the principles of best practice formulation:
Psychiatric diagnosis Psychological formulation
•Removes meaning Creates meaning
•Removes agency (‘sick role’) Promotes agency
•Removes social contexts Includes social contexts
•Individualises Includes relationships
•Keeps relationships stuck Looks at relationship change
•Deficit-based Includes strengths and achievements
•Medical consequences Non- medical
•Social consequences No social consequences
In summary – best practice psychological formulation is, if I may put it like this, the antidote to the poison that is psychiatric diagnosis. To formulate in this way is a radical act which restores agency, meaning and hope. If diagnosis is about silencing service users, formulation is about giving them a voice.
Division of Clinical Psychology (2011) Good Practice Guidelines on the use of psychological formulation. Leicester: British Psychological Society.
Johnstone, L (2006) Controversies and debates about formulation. In L.Johnstone and R.Dallos (eds) Formulation in psychology and psychotherapy: making sense of people’s problems. London, New York: Routledge
Johnstone, L (2011) People with problems, not patients with illnesses. In (eds) M Romme and S EscherPsychosis as a personal crisis: an experience-based approach.ISPS series: Routledge
Royal College of Psychiatrists (2010) A competency-based curriculum for specialist core training. http://www.rcpsych.ac.uk/training/curriculum2010.aspx