More Thinking about Alternatives to Psychiatric Diagnosis


In my last post, I argued that 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.

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 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 (see my first post.) 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

•Expert-derived                                            Collaborative

•Stigmatising                                                 Normalising

•Culture-blind                                               Culture-sensitive

•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.

In my next post I will describe an area of growing interest in the UK: the use of formulation in multi-disciplinary teamwork as a way of supporting staff to develop shared, consistent, empathic and psychosocially-informed intervention plans for service users. Meanwhile I welcome comments and feedback.


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 Escher Psychosis as a personal crisis: an experience-based approach.ISPS series: Routledge 

Royal College of Psychiatrists (2010) A competency-based curriculum for specialist core training.






  1. Hi Lucy great to see you have become a fellow blogger here! 🙂

    As I was also commenting on facebook a friend of mine whose ‘step-son’ is in the sectioned ward is in belts for the 8th(!) yes 8th day, he has been force medicated and is to be subjected to forced electroshock. He has been given a diagnosis of paranoid schizophrenia. Not only has he been removed from any kind of context but even his reaction to this dreadful treatment is viewed as a sign of illness and indicative of paranoia. As you write so eloquently these horrors are sealed off behind pseudo-medical labels and abusive treatment is allowed to be performed behind closed doors.

    Few people would argue that what they do and think in their everyday pursuits has no meaning yet psychiatry has managed to persuade the public and governments that madness is meaningless. I would venture to say that it is the profits in ensuring madness remains meaningless combined with fact that allowing for meaning is also psychiatry’s Achilles heel which is perhaps why there is a meaning in keeping things meaningless!

    Cheers Olga

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    • Thanks for your comments. Yes, there are many reasons for keeping madness meaningless, with drug company profits being one of the most powerful drivers – see Ethan Watters’ post for a horrifying example of how the medical model was exported to Japan. The huge vested interests in supporting the status quo mean that any attempt to change things has to be sophisticated and multi-level. Formulation can perhaps be a useful strategy at one of those levels.

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  2. Excellent, Lucy.

    I deeply appreciate your writing. the addition of your blogging, to this site (now, especially, as you’re gifting readers, with this declaratory post) is precisely the kind of message, that has been most sorely missing from MIA, to now. Your vision is clear and unequivocal.

    I would just point out, to you (and, to your MIA readers, many of whom may be won over by your views, already, as am I, in many ways), that: quite naturally, as you are, in every sense of the word, a true-believer in psychological formulation, it’s understandable, that you conclude: “In summary – best practice psychological formulation is, if I may put it like this, the antidote to the poison that is psychiatric diagnosis.”

    To say, “best practice psychological formulation,” is, “the antidote”…is a very strong assertion (maybe a bit too strong for my taste).

    I wonder if psychological formulation is, perhaps, “one antidote” amongst various possible antidotes.

    And/or, we could agree: so long as it’s advanced with tried-and-true best-practice guidelines, psychological formulation shall (hopefully) become the leading antidote to psychiatric diagnosis, within the ‘mental health care’ *system*; to speak that way (and, to find that happening, at anytime, anywhere in the world) would be great, I feel.

    But, many will choose to avoid that *system* altogether – in which case, they can find other antidotes (perhaps, peer driven – perhaps, faith based – maybe 12-Step, etc.) wherein individuals are encouraged to come to terms, with their own lives (indeed, to fathom the sources, of their own sufferings), in ways free of State-regulated, professional guidance.

    Personally, I recommend that, anyone who can avoid State regulated ‘mental health care,’ should avoid it. After all, as Jack Carney and other MIA bloggers and commenters have mentioned, we are threatened – here in the U.S. – with ever-growing calls for more court ordered, ‘Assisted Outpatient Treatment’ (AOT – which is also sometimes called “IOT” for “involuntary…”; where you live, this is, “Community Treatment Orders” — COT).

    In a comment under his excellent blog, of December 4, titled, “Big Brother Is Watching: A Strategy to End Kendra’s Law in New York State, Part II”), Jack explains, that the, “NYS Supreme Court … [has been] citing parens patriae, the power of the state to protect its residents from doing harm consequent to poor judgment.” And, that post, of Jack’s, came *prior* to the Newtown shooting.

    Just yesterday, it was reported, by the New York Times, that, in New York, the governor and state legislators are moving to enact, “legislation [that] would extend and expand Kendra’s Law, which empowers judges to order mentally ill patients to receive outpatient treatment,” in response to that tragedy, which took place, in neighboring Connecticut.

    One places oneself in considerable peril, by subjecting oneself to the ‘mental health care’ system, in this country. (And, of course, likewise, one places ones loved ones in peril, by urging them into the system.) It is a system designed to ‘medically’ control people. Indeed, I expect it will be *many* (MANY) years before the system allows psychological formulation to trump psychiatric diagnosis.

    So, I urge people to beware of that system.

    But, that’s not to say I feel we should abandon our hopes, of helping those who are caught up, in the system, nor do I feel it’s pointless to try to change the system; truly, with all my heart, I wish more power to you and your colleagues – in your collective attempts, to do what you can, to clean it up the ‘mental health care’ system, wresting it from the grip of coercive-medical psychiatry…

    Very Respectfully,


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    • 🙂 P.S. — I should have said “CTO” to abbreviate “Community Treatment Orders”!

      Surely, that would be understood, by readers, regardless of my explaining here (no need to have offered the correction, it was so minor).

      But, I wanted an excuse to log back in and post the following link, to an exceptionally brilliant short film (just 9 minutes long).

      Titled, “Wordfood,” it conveys how verbal abuse may affect children, such that they’ll be virtually destined for ‘mental health care’ – and, thus, tragically, wind up tagged with psychiatric labels, which simply heap further abuse upon them.

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    • Thanks – and I agree with your caveat that formulation is probably most useful WITHIN the psychiatric system. If people manage to stay out of the system altogether and create their own meanings and narratives out of distress (as most of us do most of the time), then so much the better. There is an interesting contrast with the Hearing Voices Movement idea of a ‘construct’ here. A construct is a way of making sense of your voices in the context of your life experiences and their significance to you, BUT there is no implication that it has to be facilitated by a professional. Friends, allies or other voice-hearers might do as well or better. Developing a construct is thus a more radical alternative to diagnosis than formulation is. However, I believe that formulation may have more credibility and power as an alternative strategy WITHIN the psychiatric system. In order to change psychiatry we need to use the most effective weapons at every level of a multi-faceted campaign.

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  3. Another thought provoking post Lucy, although I can’t help thinking that it sounds like “re-inventing” the wheel? Surely “formulation” in its best practice approach is about how to BE with another human being along the lines of Rogers “person centered,” approach. Haven’t we been down this track before and are simply re-visting it with a different “cognitive construct?”

    Yet is the “meaning of madness,” a cognitive construct or narrative, or is the “existential crisis” of emotional/mental anguish deeper than the mind’s conscious awareness, allows access to? You rightly point out the issues of “truama” and its effects on social relationships, yet I feel this formulation approach will be too shallow to provide real healing. Please consider Peter Levine’s thoughts on trauma and its resolution;

    “Trauma resolution is about the conjoined twin sisters of embodiment and awareness. This asset, even beyond its crucial role in regulating stress and healing trauma, is a master tool for personal enrichment and self-discovery.

    Take your body seriously enough to learn a bit more about its promptings, yet hold it lightly enough to engage it as a powerful ally in transforming intense” negative” or uncomfortable emotions, and so to experience what its like to truly embody goodness and joy. (p, 271)

    “Embodiment” is a personal-evolutionary solution to the tyranny of the yapping “monkey mind.” It paradoxically allows instinct and reason to be held together, fused in joyful participation and flow. Embodiment is about gaining, through the vehicle of sensate awareness, the capacity to feel the ambient physical sensations of unfettered energy and aliveness as they pulse through our bodies. It is here that mind and body, thought and feeling, psyche and spirit, are held together, welded in an undifferentiated unity of experience. (p, 279)

    Through embodiment we gain a unique way to touch into our darkest primitive instincts and to experience them as they play into the daylight dance of consciousness; and in so doing to know ourselves as though for the first time – in a way that imparts vitality, flow, color, hue and creativity to our lives.

    Sensation is the connecting point between the mind and the body, the point at which physical and mental phenomena are spoken in the same language, where the boundaries between these two realms disappear and one can actually perceive what is true for the whole being.” _Rajan Sankaran. (p, 281)

    Intuition is an example of bottom-up processing. This is in contrast to the top-down processing reflected in Descartes “I think therefore I am.” Bottom-up processing is more potent than top-dowm processing in altering our basic perceptions of the world. This potency derives from the fact that we are first and foremost “motor creatures.” “Secondarily,” we employ and engage our observing/perceiving/thinking minds.

    We think because we are, rather than existing because we think. When asked in a pub if he wanted another beer, Descartes responded, “I think not.” But did he disappear? (p, 281)

    Transformation occurs in the mutual relationship between top-down and bottom-up processing. As sentient beings we own the latent capacity for a vital balance between instinct and reason. From this confluence, aliveness, flow, connection and self-determination come to pass. (p, 282)

    Traumatized individuals are disembodied and “disemboweled.” They are either overwhelmed by their bodily sensations or massively shut down against them. In either case, they are unable to differentiate between various sensations, as well as unable to determine appropriate actions. Sensations are constricted and disorganized. When overwhelmed, they cannot discern nuances and generally overreact. When shut down, they are numb and become mired in inertia. In addition, they may actually harm themselves in order to feel something. (p, 282)

    The constriction of sensation obliterates shades and textures in our feelings. It is the unspoken hell of traumatization. In order to intimately relate to others and to feel that we are vital, alive beings, these subtleties are essential. And sadly, it is not just acutely traumatized individuals who are disembodied; most Westerners share a less dramatic, but still impairing disconnection from their inner sensate compass. In contrast, various eastern spiritual traditions have acknowledged the “baser instincts“ not as something to be eliminated, but rather as a force available for transformation.

    The essence of embodiment is not in repudiation, but in living the instincts fully, while at the same time harnessing their primordial raw energies to promote increasingly subtle qualities of experience. (p, 283)

    As a society, we have largely abandoned our living, sensing, knowing bodies in the search for rationality and stories about ourselves. Much of what we do in our lives is based on this preoccupation. Like Narcissus, who fell in love with his own reflection, we have become enamored by our own thoughts, self-importance and idealized self-images. ( p, 285)

    Have we fallen in love with a pale reflection of ourselves? In gazing at his own reflection, Narcissus lost his place in nature. Without access to the sentient body, nature becomes something “out there” to be controlled and dominated. Disembodied, we are not part of nature, graciously finding our humble place within its embrace. (p, 286) (we are still in the cave, looking out?)

    “Deepening awareness is a challenge. It isn’t a challenge because my parents didn’t love me enough. It’s a challenge because it’s a challenge. I don’t need to take it personally. I’ve spent years excavating my past, sorting and cataloguing the wreckage. But who I really am, the essential truth of my being, can’t be grasped by the mind, no matter how acute my insights. I’ve confused introspection with awareness, but they’re not the same. Becoming the worlds leading expert on myself has nothing to do with being fully present.”

    Selected Excerpts from: “In an Unspoken Voice.” by Peter Levine, PhD.

    Of coarse those who love the mind’s cognitive constructs and make their living from creating appropriate narritives, would have to accept an instinctual underpinning of our intellect to adopt Levine’s approach, and even question as he does, why such words as animal and instinct are generally absent from the cognitive constructs of psychology?

    You mention history in the context of madness and meaning, and perhaps excerpts Michel Foucault’s “Madness and Civilization,” may enlighten your readers further;

    Too many historical books about psychic disorders look at the past in the light of the present; they single out only what has positive and direct relevance to present-day psychiatry. This book belongs to the few which demonstrate how skillful, sensitive scholarship uses history to enrich, deepen, and reveal new avenues for thought and investigation. No oversimplifications, no black-and-white statements, no sweeping generalizations are ever allowed in this book; folly is brought back to life as a complex social phenomenon, part and parcel of the human condition.

    The French Revolution, Pinel, and Tuke emphasized political, legal, medical, or religious aspects of madness; and today, our so-called objective medical approach, in spite of the benefits that it has brought to the mentally ill, continues to look at only one side of the picture. Folly is so human that it has common roots with poetry and tragedy; it is revealed as much in the insane asylum as in the writings of a Cervantes or a Shakespeare, or in the deep psychological insights and cries of revolt of a Nietzsche. Correctly or incorrectly, the author feels that Freud’s death instinct also stems from the tragic elements which led men of all epochs to worship, laugh at, and dread folly simultaneously.

    Fascinating as Renaissance men found it—they painted it, praised it, sang about it—it also heralded for them death of the body by picturing death of the mind. Nothing is more illuminating than to follow with M. Foucault the many threads which are woven in this complex book, whether it
    speaks of changing symptoms, commitment procedures, or treatment. For example: he sees a definite connection between some of the attitudes toward madness and the disappearance, between 1200 and 1400, of leprosy. In the middle of the twelfth century, France had more than 2,000 leprosariums, and England and Scotland 220 for a population of a million and a half people. As leprosy vanished, in part because of segregation, a void was created and the moral values attached to the leper had to find another scapegoat.

    Mental illness and unreason attracted that stigma to themselves, but even this was neither complete, simple, nor immediate. Renaissance men developed a delightful, yet horrible way of
    dealing with their mad denizens: they were put on a ship and entrusted to mariners because folly, water, and sea, as everyone then “knew,” had an affinity for each other. Thus, “Ships of Fools” crisscrossed the seas and canals of Europe with their comic and pathetic cargo of souls.

    Some of them found pleasure and even a cure in the changing surroundings, in the isolation of being cast off, while others withdrew further, became worse, or died alone and away from their families. The cities and villages which had thus rid themselves of their crazed and crazy, could now take pleasure in watching the exciting sideshow when a ship full of foreign lunatics would dock at their harbors. The seventeenth and eighteenth centuries saw much social unrest and economic depression, which they tried to solve by imprisoning the indigents with the criminals and forcing them to work. The demented fitted quite naturally between those two extremes of social maladjustment and iniquity.

    A nice and hallowed tradition has labeled Tuke and Pinel as the saviors of the mentally ill, but the truth of the matter is not so simple. Many others had treated them with kindness, pleading that they belonged first and foremost with their families, and for at least two hundred years before the 1780’s, legislation had been considered or passed to segregate criminals and indigents from fools. But this legislation was prompted, as often as not, by a desire to protect the poor, the criminal, the man imprisoned for debts, and the juvenile delinquent from the frightening bestiality of the madman. As the madman had replaced the leper, the mentally ill person was now a subhuman and beastly scapegoat; hence the need to protect others.

    While the Quaker Tuke applied his religious principles, first to demented “friends” and later to foes also, partly to convert them, the great Pinel was not sure at times that he was dealing with sick people; he often marveled at their unbelievable endurance of physical hardship, and often cited the ability of schizophrenic women to sleep naked in subfreezing temperatures without suffering any ill effects. Were not these people more healthy, more resistant than ordinary human beings?

    Didn’t they have too much animal spirit in them?

    Madness is really a manifestation of the “soul,” a variable concept which from antiquity to the twentieth century covered approximately what came to be known, after Freud, as the unconscious part of the human mind. Only time will tell how much better students of the psyche can look at the future, after reading this sobering re-creation of yesteryear’s madness and the ineffective attempts of humanity to treat it by amputation, projections, prejudices, and segregation.” _JOSE BARCHILON, M.D.

    And from the great man himself;

    PASCAL: “Men are so necessarily mad, that not to be mad would amount to another form of madness.” And Dostoievsky, in his DIARY OF A WRITER: “It is not by confining one’s neighbor that one is convinced of one’s own sanity.”

    We have yet to write the history of that other form of madness, by which men, in an act of sovereign reason, confine their neighbors, and communicate and recognize each other through the merciless language of non-madness; to define the moment of this conspiracy before it was permanently established in the realm of truth, before it was revived by the lyricism of protest. We must try to return, in history, to that zero point in the course of madness at which madness is an undifferentiated experience, a not yet divided experience of division itself. We must describe, from the start of its trajectory, that “other form” which relegates Reason and Madness to one side or the other of its action as things henceforth external, deaf to all exchange, and as though dead to one another.

    This is doubtless an uncomfortable region. To explore it we must renounce the convenience of terminal truths, and never let ourselves be guided by what we may know of madness. None of the concepts of psychopathology, even and especially in the implicit process of retrospections, can play an organizing role. What is constitutive is the action that divides madness, and not the science elaborated once this division is made and calm restored. What is originative is the caesura that establishes the distance between reason and non-reason; reason’s subjugation of non-reason, wresting from it its truth as madness, crime, or disease, derives explicitly from this point.” _M Foucault.

    Is it our “unreasoned,” denial of our evolved nature, our reaction to madness, which keeps us at arms-length from its reality and the addmission of its causation?

    There is so much science research out there which casts serious doubts on an assumed brain disease process in mental illness, science which is curiously absent from mainstream media and psychology’s cognitive constructs? As Jaak Panksepp points out, the intellectual zeitgeist is not ready to really explore the some of the gains of neuroscience research, becuase to do so would bring in question the very nature of our subjective experience?

    Best wishes,

    David Bates.

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    • I can’t see anything to disagree with here. In answer to your first point: Yes, we certainly have been here before. As I hope I made clear at the start of my post, formulation is just one of the most recent expressions of the long-standing controversy about whether madness is meaningful or not. It is a battle that we have to fight again and again, in numerous different forms and arenas. Many many people, Carl Rogers among them, have argued that the essence of healing is to be found by exploring meaning within a trusting relationship. At this juncture, we have a vitally important opportunity to take the fight to the foundation of psychiatry, ie the diagnostic system, and for this purpose we do, I think, need to strengthen our arguments by demonstrating that there are workable and effective alternatives to the current classification system. This is where formulation comes in – an old idea in new clothing, but in one that is, I believe, well-suited to this particular challenge. (Depending how you do it!!!)

      And yes, I do agree about the need to acknowledge the embodied nature of trauma and indeed of all our experiences, and this should also be apparent in our formulating.

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  4. I’m still trying to challenge the notion, taking off from Jonah, about the value of formulation to people who are wary of mental health system. It still requires an engagement, and one seemingly with a professional, in which to me leans towards having a coercive element and lack of authenticity/mutuality but attempting to have the illusion of it.

    It still feels like you’re paying someone to tell you what’s wrong and they know how to fix it, and if you disagree/disengage/feel off, well, that sucks, or, maybe you would still be diagnosed with something as to cover the professional’s reputation.

    I kind of feel this is similar to John Hopkins Psychiatry’s theoretical export, “The Perspectives,” a way of doing psychiatric evaluation through the lens of four perspectives, disease (or biological lens), dimension (personality/intelligence), motivation, and life story. It bills itself as somewhat at odds with DSM/diagnosing but not mutually exclusive.

    Perhaps, I guess as someone who has lost interest (and increased fear) in engaging with mental health professionals and pushing for a severe reduction of the mental health care apparatus in our lives/societies, I’m trying to see why we would try to maintain it for what I still feel is like psyhological diagnosing.

    I guess it still comes down to “how it’s done,” but I think that can be said about most anything. I also disagree with the binary distinctions you made with DSM diagnosing and formulation, particularly in the extent that they both require engaging with mental health professionals which is not necessarily normalizing, often stigmatizing, assumes expertise differences (otherwise, why seek a professional), and is certainly not culture-blind.

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  5. Interesting I certainly agree with Lucy’s eloquent argument, that “ 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.’ “
    I agree also that too often an effort is made from either side
    to have it both ways–which I think only reinforces the dominant model. I’m not very enthusiastic about those who want to make room for an agency-exception for their group within the DSM.

    However Jonah’s qualification is valid. And there are other problems with the mental health system. In the US it is impossible to imagine ANY professional body even taking the position Lucy’s did. So I would posit that the value of promoting Lucy’s alternative would be more in the UK than in the US.

    Here in the US I agree more emphasis should be placed upon creating non-hierarchical alternatives outside the system. Re what Nathan says I’m reminded of the numerous studies (see Robyn Dawes) showing that trained professionals are no more successful in helping depressed people than non-professionals. While that finding does not challenge the value of counseling per se, it certain challenge the value of a system based on the mystification of professional expertise. Robert McKnight described the professional credo: “You the client will be better because I the professional know better”—and of course the system as is requires years of education and certification.

    But every interaction requires interpretation. Is not Lucy psychological formulation of universal value? I would agree it WOULD be a universally useful guideline for understanding the Other—it need not be restricted to professional-client relationships. It is still only one language game–—one that has appeal in literate modern cultures.

    One of my favorite lines by R D Laing is the following, “The well-adjusted bomber pilot is a greater threat to species survival than the schizophrenic who thinks the Bomb is inside him.” This of course was in the 1960s when US pilots were dropping bombs in Vietnam and the greatest threat was not global warming but the nuclear arms race. Many things could be said about Laing’s brilliant analyses in The Politic of Experience but one of Laing’s points was that the schizophrenic was often making an implicit critique of society. Laing interprets the perception of the Bomb- inside- her as a statement about society—whereas usually even progressive therapists don’t assume a referent more general than the family. So Laing’s language game goes beyond the typical “psychological formulation”-and was very enlightening to his readers. I think this add another dimension to Lucy’s list of features. Laing was a radical who frequently translated the “symptoms” of the mad man into the left-brain language of social critique. But what about going beyond that”?

    What about translating the language of social critique into the poetic right-brained language of the schizophrenic? Not just as a therapeutic ploy. But as another language game— of equal or greater value, of equal or greater authenticity.

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    • Good points Seth, and we recall what happens to authentic radicals in our consensus reality of “psychological formulation?” Laing’s son has written a very good and honest biography of his father with excerpts from his books;

      “From the moment of birth, when the stone age baby confronts the twentieth century mother, the baby is subject to forces of outrageous violence, called love, as its mother and father have been, and their parents and their parents etc, mainly concerned with destroying most of its potentials. This enterprise is on the whole successful. By the time the new human being is 15 or so, we are left with a being like ourselves. A half-crazed creature, more or less adjusted to a mad world. This is normality in our present age. (p, 94)

      I do not myself believe that there is any such “condition” as “schizophrenia.” Yet the label as social fact, is a political event. This political event, occurring in the civic order of society, imposes definitions and consequences on the labeled person. It is a social prescription that “rationalizes” a set of social actions whereby the labelled person is annexed by others, who are legally sanctioned, medically empowered, and morally obliged, to become responsible for the person labelled.

      The person labelled is inaugurated not only into a role, but the career of patient, by the concerted actions of numerous others who for some considerable time become the only ones with whom a sustained relationship is permitted. The “committed” person labelled as patient, and specifically as “schizophrenic,” is degraded from full existential status as human agent and responsible person, no longer in possession of his own definition of himself, unable to retain his own possessions, precluded from the exercise of his discretion as to whom he meets, what he does. His time is no longer his own and the space he occupies no longer of his choosing.

      After being subjected to a degradation ceremonial known as psychiatric examination he is bereft of his civil liberties in being imprisoned in a total institution known as a “mental hospital.” More completely, more radically than anywhere else in our society he is invalidated as a human being. (p, 95)”

      Excerpts from “R. D. Laing,” by Adrian Laing

      In our efforts to be responsible to others, to care for their welfare, do we use a “psychological-formulation” to deny the survival-reality involved? Can those in the “professional” ranks of the “knowledge econonomy,” the mental health experts, face-up to the paradox of their chosen mode of self-preservation? Consider;

      ” Perception, PhD’s & other MisConceptions?

      Knowlede Economy?
      Is PhD research into mental health about the livelihood of reseachers, more so, than the mental health of other people?

      In a hiearchically structured society, which group of people does the knowledge economy serve?
      Like the money markets of the worlds stock exchanges, can knowledge be the basis of a real economy?

      “We’re in a knowledge economy and it is about being able to demonstrate that the most capable staff are on the books to give the best possible experience to students,”

      Professor Marshall added. But such capabilities could equally come from expertise gained outside the research degree track, she said. “I would argue it is about what’s fit for purpose.

      Different discipline areas will require different skill sets to deliver the best outcomes for students.” New universities are just as likely as those in the Russell Group of large research-intensive institutions to require academic staff to have PhDs or the equivalent relevant experience.

      UK universities are increasingly pushing for academic staff to hold PhDs, an investigation has revealed. Almost 30 per cent of the 113 universities that responded to a Freedom of Information request by Times Higher Education say they have aims or commitments to increase their proportion of academics with doctorates, whether by hiring new staff or by providing training for existing employees. See: Doctoral-level thinking: non-PhDs need not apply By Elizabeth Gibney.

      Is there a MisConception about the true nature of Mental Illness & Civil Society?
      Do we all collude in this Perception of Civilization? We don’t have instincts and there is no predator/prey axis in human relationships? Well, maybe in “them?”
      The bad things in life are about others, not “I?”

      Consider the thoughts of a now famous PhD, Ram Dass;
      “In 1969, the beginning of March, I was at perhaps the highest point of my academic career. I had just returned from being a visiting professor at the University of California at Berkeley: I had been assured of a post that was being held for me at Harvard, if I got my publications in order. I held appointments in four departments at Harvard–the Social Relations Department, the Psychology department, the Graduate School of Education, and the Health Service (where I was a therapist); I had research contracts with Yale and Stanford. In a worldly sense, I was making great income and I was a collector of possessions.
      I had an apartment in Cambridge that was filled with antiques and I gave very charming dinner parties. I had a Mercedes-Benz sedan and a Triumph 500CC motorcycle and a Cessna 172 airplane and an MG sports car and a sailboat and a bicycle. I vacationed in the Caribbean where I did scuba-diving. I was living the way a successful bachelor professor is supposed to live in the American world of “he who makes it.”

      I wasn’t a genuine scholar, but I had gone through the whole academic trip. I had gotten my Ph.D.; I was writing books. I had research contracts. I taught courses in Human Motivation, Freudian Theory, Child Development. But what all this boils down to is that I was really a very good game player.
      My lecture notes were the ideas of other men, subtly presented, and my research was all within the Zeitgeist–all that which one was supposed to research about.

      In 1955 I had started doing therapy and my first therapy patient had turned me onto pot. I had not smoked regularly after that, but only sporadically, and I was quiet a heavy drinker. But this first patient had friends and they had friends and all of them became my patients. I became a “hip” therapist, for the hip community at Stanford. When I’d go to the parties, they’d all say “here comes the shrink” and I would sit in the corner looking superior. In addition, I had spent five years in psychoanalysis at a cool investment of something like $26,000.

      Before March 6th, which was the day I took Psylocybin, one of the psychedelics, I felt that the theories I was teaching in psychology didn’t make it, that the psychologists didn’t really have a grasp of the human condition, and that the theories I was teaching , which were theories of achievement and anxiety and defense mechanisms and so on, weren’t getting to the crux of the matter.”
      Excerpt from “Remember, Be Here Now” by Ram Dass.

      * * *

      For those interested in “identified patients,” the family and the parental nature of society;

      “Societal problems from an emotional systems view:

      All of the people who were, or are members of families replicate the same emotional patterns in society. Family and societal emotional forces function in a reciprocal equilibrium to each other, each influencing the other and being influenced by the other. These observations are based on the same criteria used to estimate family functioning, which is the amount of principle determined “self” in comparison to the “feeling-orientation” which strives for an immediate short term feeling solution to the anxiety of the moment.”

      The reality of survival, has a rather harsh edge to it, do we soften it with “psychological-formulations?”

      Are we just doing the same old “tango” here? Dancing around the edge of core emotions and the hard core reality of life’s survival needs?

      Tough questions, I don’t expect anyone to respond to. Survival has a physiological foundation, the “innate” reaction will be “ignore-it,” no relevence to me? Yet is the psychological-formulation of relevence underpinned by “unconscious” emotional “valence?” Our presumption of reason, a physiological reaction?

      Best wishes,

      David Bates.

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  6. Seth, you ask (January 16, 2013 at 8:12 am): “Is not […] psychological formulation of universal value?” And, you add, “I would agree it WOULD be a universally useful guideline for understanding the Other—it need not be restricted to professional-client relationships. It is still only one language game—one that has appeal in literate modern cultures.” …I, too, feel psychological formulation is of universal value, and it is just one language game, amongst many.

    And, David, I value your contribution (January 16, 2013 at 10:03 pm) which states: “I do not myself believe that there is any such ‘condition’ as ‘schizophrenia…’” (Likewise, I value your emphasis on *family systems* and the *physiological* aspects of emotional trauma.)

    Nathan, you say (January 15, 2013 at 11:04 pm), that: To you, psychological formulation, “leans towards having a coercive element and lack of authenticity/mutuality but attempting to have the illusion of it.” I believe you’re right about that, most certainly – so long as the professional who’s made responsible for developing the formulation is *State* certified and licensed, in that capacity.

    With your comments in mind, I offer these further musing…

    *Coercion* is part and parcel of any and all perceived threats of forced/unwanted ‘care’ aimed at restricting and/or changing behavior; and, effects of forced/unwanted ‘mental health care’ are, necessarily, severe (to say the least); meanwhile, as far as I can tell, this is true, almost everywhere: the State seeks to regulate anyone’s aims to do business as a ‘mental health’ practitioner – and threatens to undermine the practices of those practitioners who may seemingly flaunt those regulations. In that way, to some extent, it codifies ‘mental health’ practitioners’ standards of ‘care’ (somewhat like it does for practitioners in the field of medicine); in the course of so doing, the State maintains a supposed ‘responsibility’ to *dictate* the administration, of certain detentions – called “holds” – by ordering *forced* impositions of ‘treatment’ (if not necessarily recommending specific ‘therapies’ for the ‘held’ person). The State orders a “hold” when a so-called “patient” (or, even more euphemistically: a “client” or “consumer”) has been deemed “a danger to himself/herself” or “a danger to others,” by family members and/or by ‘mental health’ professionals ostensibly ‘qualified’ to make that call. Thus, licensed ‘mental health’ practitioners wind up working – to varying extents – at the behest of the State, and/or (at the very least) they intend to remain in good stead with the State’s licensing board, by appeasing (if not always openly or enthusiastically condoning) forced ‘therapeutic’ practices, which are initiated, in order to *hopefully* prevent the enactment of would be ‘dangerous’ behaviors (including suicide).

    So, really, *coercion* is employed whenever and wherever a State licensed ‘mental health care’ worker goes to work — and, most especially, when s/he’s addressing any particularly troubling interpersonal and/or personal crises…

    To read my full response (which became too long, to post, as a comment), you can find it in my blog, by clicking on the following link:



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  7. I see Formulation, as proposed by the British Psychological Society includes,‘the possible role of services in compounding the difficulties. Marvellous!

    I agree, if it is an idea that becomes popular amongst a significant group of professionals it can be used to undermine the idea of psychiatric diagnosis, and that is something that underpins the medical validity of psychiatry.

    I like the way you explain that the psycho-social explanations of mental distress are incompatible with biological, or even bio-social,explanations. Something that is very prevalent round here. It’s all, “Recovery Star,” a life coaching tool for service users, and calls to the crisis team if you have a bit of wobbly and encouragement to attend meetings with psychiatrists, who then ask if you are hearing voices that tell you to do violent things and ask if you want a few more drugs? And don’t mention any trauma, because we’re not qualified to deal with it, despite half the members of the day centre talking to each other about horrific things they have experienced. Most confusing and not very useful.

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  8. David, Yes thanks I read thebook by Adrian Laing. And Politics of Experience is the book I cite that most on this topic. I had forgotten how decadent Richard Alpert was.
    Jonah I agree with you. In your letter on the last page you mention that the mental health sytem has become n extension of the criminal justice system, only medicalized. I read Obama recent proposal–he even speaks of cops and shrinks working together in the schools.It’s the realization of Foucault;s Panopticon. Did you read Laura Delano piece posted yesterday–she escaped. Think of all the others who are destroyed. I don’t think Lucy knows how bad it is in America.Except for Vermont. In fact things are so bad I think it forces us to become more radical. I read Jonah’s piece yesterday but I think you speak Jonah of a long time–a century. But we don’t have a long time because everythinbg is collapsing. Global warming is reaching a tipping point. We are forced here to take the most radical path, which is the thesis of my recent book THe Spiritual Gift of Madness… sf

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  9. I passed this article onto a friend who was looking for a psychiatric evaluation to help with his bid for social housing. He wrote various formulations, with some coaching from me, and then took them to the assessment interview and then to other interviews with other professionals.

    It helped my friend keep an eye on what he wanted and avoid the agendas of the proffessionals, especially the demeaning ones. He made full notes of how services had damaged him in the past and got that acknowledged in the report from the assessing psychiatrist. He also got what he wanted acknowledged.

    So overall this essay has been very useful to my friend.


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