Alternatives to Psychiatric Diagnosis: Psychological Formulation
I am pleased to have the opportunity to follow up some of the themes that have already appeared on this site, and to offer an outline of one possible alternative to psychiatric diagnosis: psychological formulation. First, I will supply some context from the UK.
Background to the UK Division of Clinical Psychology’s call for a paradigm shift away from psychiatric diagnosis
The Division of Clinical Psychology is the largest sub-division of the British Psychological Society, and has been promoting psychosocial models as alternatives to the biomedical one in a series of documents over the last 15 years or so. In 2000, the DCP published an influential report ‘Recent advances in understanding mental illness and psychotic experiences’ which concluded that ‘Given the problems of diagnosis… clinical psychologists have suggested alternative approaches’ (p.19) and recommended that ‘One important implication is that professionals and other mental health workers should not insist that all service users accept any one particular framework of understanding…. such as (that) hearing voices and holding unusual beliefs are always symptoms of an underlying “illness”…. (They) should respect and work collaboratively with the service user’s frame of reference’ (p.59.) This report is currently being updated.
In 2010, another report, ‘Understanding bipolar disorder’, noted that ‘Not all mental health professionals accept the idea that these experiences are caused by an underlying illness’( p.4) and argued that ‘Services should not insist that all service users see their problems as an “illness” and take medication’ (p.8.)
As described below, the Good Practice Guidelines on psychological formulation (2011) state that ‘best practice formulations…are not premised on psychiatric diagnosis. Rather, the experiences that may have led to a psychiatric diagnosis (low mood, unusual beliefs, etc) are themselves formulated’ (p.17) – in other words, explained in psychological terms.
The DCP, via the BPS, also made a robust response to the consultation on DSM-5: ‘Clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences which demand helping responses, but which do not reflect illnesses so much as normal individual variation….The putative diagnoses presented in DSM-V are clearly based largely on social norms, with ‘symptoms’ that all rely on subjective judgments, with few confirmatory physical ‘signs’ or evidence of biological causation. The criteria are not value-free, but rather reflect current normative social expectations…..’ As many readers will know, this led directly to the Society of Humanistic Psychology’s online petition and open letter about the proposed revisions to DSM.
The Division of Clinical Psychology’s position statement on ‘Classification of behaviour and experience in relation to functional psychiatric diagnosis: Time for a paradigm shift’ was therefore a logical progression in this series of official reports. The key paragraph states:
The DCP is of the view that it is timely and appropriate to affirm publicly that the current classification system as outlined in DSM and ICD, in respect of the functional psychiatric diagnoses, has significant conceptual and empirical limitations. Consequently, there is a need for a paradigm shift in relation to the experiences that these diagnoses refer to, towards a conceptual system not based on a ‘disease’ model.
This led to a great deal of national media coverage and debate (see The Observer May 12th 2013), with strong feelings expressed in all quarters. It is not a view that is accepted by all clinical psychologists, but nevertheless a letter with 210 signatories in the July edition of ‘The Psychologist’, saying that ‘This is a very important step for the profession and one that is long overdue’, tends to confirm my personal impression that there is widespread grassroots support for this position.
Among the DCP’s recommendations are:
To support work, in conjunction with service users, on developing a multi-factorial and contextual approach, which incorporates social, psychological and biological factors.
In support of this recommendation, the DCP is currently funding a project, led by myself and Mary Boyle, which aims to ‘develop a psychosocial framework for identifying patterns in mental health problems, as an alternative to functional psychiatric diagnosis.’ Several of the members, who include two survivor/activists, will be familiar to you: clinical psychologists Peter Kinderman and David Pilgrim have already posted on this site. We’ve been meeting for about a year, and it is turning out to be an extraordinarily challenging task, even for a group with so much collective clinical, research and service user experiences. We are working towards identifying the principles of an over-arching framework that could indicate alternative ways of serving some of the broader functions that psychiatric diagnosis currently fulfils, or claims to fulfil, such as clustering similar problems together, providing a basis for research, planning services, and meeting various other administrative purposes. However, to avoid raising expectations, I will hasten to add that we are not anticipating being able to produce anything more ambitious than a very initial conceptual outline which might serve as the basis for a series of future projects.
In the meantime, I think it is of crucial importance in the campaign to emphasise that we already have alternatives to psychiatric diagnosis. We always have done. A parallel discourse to do with understanding people’s distress within their life contexts has always existed, right back to the inception of biomedical model psychiatry, and has re-surfaced at various points – most notoriously in the so-called ‘anti-psychiatry’ movement of the 1960s. The Moral Treatment of the 19th century, therapeutic communities, some psychotherapeutic approaches, the work of Jung, Stack Sullivan, Foudraine (1974) and many others are examples from the past, and the tradition continues today in the work of Soteria, The Open Dialogue model in Finland, and survivor movements like the Hearing Voices Network. Insisting that we need ‘alternatives’ before diagnosis can be discarded is not a legitimate position but a strategy used to maintain the status quo. The simplest response to the question ‘What do we do instead of diagnosing people?’ is: ‘Stop diagnosing people.’ Ask people what their problems are and what they want help with instead, and proceed on that basis. This is essentially Peter Kinderman’s suggestion. Like many clinical psychologists, and like the best psychiatrists, I have never used diagnosis in my whole career. At a day-to-day clinical level, it is neither necessary nor helpful.
(I acknowledge that we enjoy a degree of freedom from the requirements of insurance companies in the UK, although it is not clear how long that will last. Nevertheless, I maintain that in terms of actual clinical practice, diagnosis adds absolutely nothing – and nor does it provide a sound basis for any other research, administrative or legal purpose.)
However, given the intensity of the debate, I think is also necessary and useful to be able to point to specific examples of more structured alternatives. This is where Recommendation 5 from the DCP Statement on Classification comes in:
For the DCP to continue to promote the use of psychological formulation as one response to the concerns identified in this statement.
Please note that formulation is recommended as ONE alternative. We need to avoid falling into the trap of proposing some kind of monolithic, all-purpose replacement for DSM and ICD. I am in favour of many different solutions, according to the needs of specific settings and cultures. However, there are certain general principles that must underlie any proposals that are to function as a genuine alternative. In summary they must have at their heart the restoration of personal meaning within its relational and social contexts. This is because the 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. This isn’t accidental – the biomedical approach is there for a reason, and many have argued that mystifying individuals about the origins of their emotional pain while at the same time concealing the true extent of the damage that Western cultures inflict on individuals is not just the effect but the purpose of psychiatry (see Ingleby, 1981.)
This extraordinarily narrow way of conceptualising emotional distress is, as far as I am aware (but please correct me if I am wrong) unique to the last 100 years of Western societies. In contrast, other cultures and sub-cultures (before they are colonised by the Western worldview that is codified in DSM, as documented by Ethan Watters in ‘Crazy like us’, 2010) seem to have ways of making meaning out of distress. Each culture, or subculture within dominant cultures, develops its own ways of exploring the meaning of distress, and some of them may look quite strange to Western eyes. We need to respect and work alongside these explanations; once again, it is important to emphasise that many peoples of the world already have their alternatives to diagnosis, which do not need replacing in an act of psychiatric or psychological colonisation.
Within Western cultures, as I have suggested, one alternative is psychological formulation, which I will now discuss in more detail.
Psychological formulation is a topic that has absorbed me for some years now, as a clinician, lecturer, trainer and author, and is the subject of a growing number of books and articles in the UK (see Johnstone and Dallos, 2013.) In 2011 I chaired the working party which developed the first set of professional guidelines for formulation (‘Good practice guidelines on the use of psychological formulation’ which can be downloaded for a small fee from http://www.bpsshop.org.uk/Good-Practice-Guidelines-on-the-use-of-psychological-formulation-P1653.aspx ) These form the basis of training and practice in formulation in UK clinical psychology but are open to wider adoption.
I’m not sure how familiar the concept of formulation is to visitors to this website. In Britain, formulation is considered to be the core skill of the profession of clinical psychology, although also it also appears in the regulatory requirements for counselling, health and forensic psychologists, as well as in psychiatrists’ training curriculum. Thus, in the UK it has the advantage of a degree of familiarity, acceptability and credibility within existing psychiatric settings, and several professions who claim it as a skill.
Formulation can be defined as the process of co-constructing a hypothesis or ‘best guess’ about the origins of a person’s difficulties in the context of their relationships, social circumstances, life events, and the sense that they have made of them. It is the next step after the ‘problem list’ described by Peter Kinderman on this site. Once you have established what the problems are, the immediate next question is, ‘How do we jointly understand these experiences, why they arose, and how we might be able to move forward?’ Formulation draws on psychological theory and evidence, combined with the service user’s expertise in their own life, in order to suggest the best path to recovery.
Unlike diagnosis, formulation is not about making an expert judgement, but about working closely with the individual to develop a shared understanding which will evolve over time. And, again unlike diagnosis, it is not based on deficits, but draws attention to the service user’s resources and strengths in surviving what are nearly always very challenging life situations. The development of this personal story or narrative has been described by clinical psychologists as ‘a way of summarising meanings, and of negotiating for shared ways of understanding and communicating about them’ (Butler, 1998).
In summary, formulation approaches all forms of distress with the assumption that ‘at some level it all makes sense’ (Butler, 1998.) In my view, the work of every professional, whatever their training, should be based on this principle: that however unusual, confusing, risky, destructive, overwhelming or frightening someone’s thoughts, feelings and behaviours are, there is a way of making sense of them. The central task of all mental health professionals is to work alongside service users to create meaning out of chaos and despair. As already argued, this is the opposite of a diagnostic approach. Formulation is, in my experience, a powerful and effective way of doing this.
Here is a hypothetical example:
Jane is 20 and has started to hear critical and hostile voices. The diagnosis is likely to be ‘psychosis’ or ‘schizophrenia.’ In contrast, a written formulation shared and developed with Jane over a few weeks or months might look something like this:
You had a happy childhood until your father died when you were aged 8. As a child, you felt very responsible for your mother’s happiness, and pushed your own grief away. Later your mother re-married and when your stepfather started to abuse you, you did not feel able to confide in anyone or risk the break-up of the marriage. You left home as soon as you could, and got a job in a shop. However, you found it increasingly hard to deal with your boss, whose bullying ways reminded you of your stepfather. You gave up the job, but long days at home in your flat made it hard to push your buried feelings aside any more. One day you started to hear a male voice telling you that you were dirty and evil. This seemed to express how the abuse made you feel, and it also reminded you of things that your stepfather said to you. You found day-to-day life increasingly difficult as past events caught up with you and many feelings came to the surface. Despite this you have many strengths, including intelligence, determination and self-awareness, and you recognise the need to re-visit some of the unprocessed feelings from the past.
We can see that the formulation is personal to Jane, and helps to make sense of her experiences in terms of recent evidence about trauma and voice-hearing. It suggests an individual pathway forward, which will probably include developing a trusting relationship with a worker or therapist, information about the impact of trauma, learning practical ways of managing and coping with her voices, perhaps gaining support from others with similar experiences, and processing the feelings from the past. We hope that the formulation conveys the message to Jane that her experiences are understandable, that she has many strengths, and that she can take steps, with support, to overcome her difficulties. All of this is in stark contrast to the messages of shame, damage, hopelessness and despair that are conveyed by a diagnosis, and that too often lead with tragic inevitability to medication, admission and a lifetime career as a psychiatric patient.
This example shows that although training courses and some textbooks tend to describe formulation as if it is an event or ‘thing’, it is perhaps more accurate to see it as a process, an aspect of a shared exploration that has no definite end point. This is captured in the definition ‘a process of ongoing collaborative sense-making’ (Harper and Moss, 2003). However, there are times and purposes for which a summary – a formulation-as-an-event – may be useful, such as at the start and end of contact with mental health services. Appropriately adapted versions can be used for communication with other professionals, in letters to referrers and so on.
In short, formulation has the potential to restore meaning, agency and hope, for staff and service users. But – an important caveat which applies to all interventions – it all depends how you do it. One of the main aims of the Formulation Guidelines was to establish best practice criteria so that UK clinical psychologists (and others) will use formulation in the most empowering and sensitive way (DCP 2011.)
Best practice formulation
The Guidelines include two checklists. One covers best practice formulating (formulation-as- a-process) and includes the need to be collaborative and respectful of service users’ views; be clear about who has the ‘problem’; and be reflective about one’s own values and assumptions. The checklist of best practice formulation (formulation-as-an-event) specifies, among other things, the need to use accessible language; to be culturally sensitive; and to include strengths and achievements (pages 29-30).
Four of the best practice criteria deserve particular attention. The first is that formulation should ‘Consider the possible role of trauma and abuse.’ This acknowledges the large and growing body of research that indicates a causal role for these events in all mental health presentations (Read and Bentall, 2012.) A trauma-informed formulation can be a powerful way of integrating this knowledge into our interventions. The second is ‘Considers possible role of services in compounding the difficulties.’ Using formulation in teamwork (the topic of my next post) can be a way of raising this sensitive topic and helping to ensure that we don’t simply re-traumatise people, as is so often the experience of service users. The third is the requirement to include ‘a critical awareness of the wider societal context within which formulation takes place’ (p.20.) The intention is to minimise the individualising tendency of both medical and (some) psychotherapeutic models, which, by locating the difficulty within a person, implicitly convey a message of blame and deficit.
The most important and controversial issue is raised in the criterion ‘Is not premised on a functional psychiatric diagnosis’ (p. 29.) In other words, the Guidelines anticipate the DCP Statement on Classification by stating that clinical psychologists use formulation as an alternative to, not an addition to, psychiatric diagnosis.
This distinction is an increasingly lively area of debate in mental health circles in the UK. It is not a coincidence that the controversy about DSM has been paralleled by a small but growing number of articles by UK psychiatrists calling for a higher profile for formulation, while claiming that they have always used it anyway. At one level this is to be welcomed – any attempt at widening the gaze of diagnosis is likely to be an improvement. However, it also threatens to assimilate this newly-popular approach back into traditional psychiatric practice – as too often happens with any challenge to the status quo.
The term ‘formulation’ as described in the UK training curriculum for psychiatrists requires them to ‘demonstrate the ability to construct formulations of patients’ problems that include appropriate differential diagnoses’ (Royal College of Psychiatrists 2010, p. 25, my italics).
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 which looked something like this: ‘Schizophrenia/psychosis triggered by the stress of job loss.’ 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!’ Indeed, I am told that at this year’s Annual Conference of the Royal College of Psychiatrists in Edinburgh, one of the keynote speakers emphasised that ‘We always need a formulation – but we always need a diagnosis as well.’
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. 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’ (DCP 2011, p.17.)
Impact and effects of formulation
To date there is only a limited amount of research into formulation. This topic deserves a post on its own. At this point I will simply note that in my view it is a mistake to try and compete with diagnosis on its own terms; in other words, to get entangled with questions about reliability, validity and so on, which are appropriate in the natural sciences but which simply do not apply in the same way to formulation. Human emotional suffering does not come in neatly delineated categories. We do need to look at issues such as acceptability to service users, and to date there is some evidence that some can feel overwhelmed or upset when they first read a formulation (Chadwick et al, 2003). It is not clear whether this is, in the longer-term, succeeded by a sense of relief and increased understanding, but it highlights the need for sensitive working according to best practice principles.
Initial audits and evaluations also suggest a great many benefits, summarised in the Formulation Guidelines as:
- Clarifying hypotheses and questions
- Providing an overall picture or map
- Noticing what is missing
- Prioritising issues and problems
- Selecting and planning interventions
- Minimising bias by making choices and decisions explicit
- Framing medical interventions
- Predicting responses to interventions; predicting difficulties
- Thinking about lack of progress; troubleshooting
- Determining criteria for successful outcome
- Ensuring that a cultural perspective in incorporated
- Helping the service user to feel understood and contained
- Strengthening the therapeutic alliance
- Encouraging collaborative work with the service user/carer
- Emphasising strengths as well as needs
- Normalising problems and reducing self-blame
The potentially damaging effects of psychiatric diagnosis are listed 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
Best practice psychological formulation is, therefore, based on fundamentally different principles from psychiatric diagnosis. It is not surprising that there are many similarities between formulation and the alternatives suggested by other critics of psychiatry. For example, Phil Thomas, a founding member of the UK Critical Psychiatry Network, 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, www.madinamerica.com.) The Critical Psychiatry Network has likewise argued for a narrative-based approach based on human relationships not narrow technological paradigms (Bracken et al, 2012.) The Hearing Voices Network uses the term ‘construct’ to describe the creation of stories about the personal meanings of voice-hearing (Johnstone, 2011). There is the potential to link these various ideas via their common commitment to listening to service users’ stories and co-creating personal meaning out of distress.
At one level, formulation is simply a more formal and structured way of making explicit what we all do already, as professionals, as service users, and indeed as human beings – we develop theories to explain what is happening to us. For this reason, I have found that mental health staff ‘get it’ very quickly – they can see the point of the process, and are usually eager to learn more and use it in their practice. At another level, it is a fairly sophisticated skill to integrate, sensitively and collaboratively, a large amount of theory and evidence with a service user’s lived experience in a way that is accessible and helpful.
In this post I have mainly described the use of formulation as part of one-to-one work (or perhaps couple or family work.) Not all service users are ready or able to engage in this way, and certainly not all will want, need or benefit from therapy as such. However, formulation has just as much to offer for service users who are in the most intense states of distress and have the most complex difficulties. This growing area of practice in the UK is referred to as ‘Using formulation in teams’. It is a powerful way of changing team cultures as well as offering better support to individuals (Johnstone, 2013). I will describe this in my next post.
In summary: Best practice psychological formulation is not just an alternative, but an antidote, to psychiatric diagnosis and its damaging effects. 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.
Bracken, P, Thomas, P, Timimi, S, Asen, E, Behr, G et al (2012) Psychiatry beyond the current paradigm. British Journal of Psychiatry, 201, 430-434.
Butler, G (1998) Clinical formulation. In AS Bellack and M Hersen (eds) Comprehensive clinical psychology. Oxford: Pergamon
Chadwick P, Williams C and Mackenzie J (2003) Impact of case formulation in cognitive behaviour therapy for psychosis. Behaviour Research and Therapy, 14 (6), 671-680
Division of Clinical Psychology (2000) Recent advances in understanding mental illness and psychotic experiences. Leicester: British Psychological Society
Division of Clinical Psychology (2010) Understanding bipolar disorder. Leicester: British Psychological Society
Division of Clinical Psychology (2011) Good practice guidelines for the use of psychological formulation. Leicester: British Psychological Society
Foudraine, J (1974) Not made of wood: a psychiatrist discovers his own profession. London: Macmillan
Harper, D and Moss, D (2003) A different chemistry? Re-formulating formulation. Clinical Psychology, 25, 6-10.
Ingleby, D (1981) ‘Understanding mental illness’ in D. Ingleby (ed) Critical psychiatry: the politics of mental health. Penguin
Johnstone, L (2011) People with problems, not patients with illnesses. In (eds) M Romme and S Escher Psychosis as a personal crisis: an experience-based approach. ISPS series: Routledge
Johnstone, L (2013) Using formulation in teams. In Johnstone, L and Dallos, R (2013, 2nd edn) Formulation in psychology and psychotherapy: making sense of people’s problems. London, New York: Routledge
Johnstone, L and Dallos, R (2013, 2nd edn) Formulation in psychology and psychotherapy: making sense of people’s problems. London, New York: Routledge
Read, J. and Bentall, R.B. (2012) Negative childhood experiences and mental health: theoretical, clinical and primary prevention implications. British Journal of Psychiatry, 200: 89-91.
Royal College of Psychiatrists (2010) A competency-based curriculum for specialist core training. www.rcpsych.ac.uk/training/curriculum2010.aspx
Lucy Johnstone, consultant clinical psychologist @clinpsychLucy
Acknowledgment: Parts of this article originally appeared on www.madinamerica.com, and are reproduced here with thanks.