I want to follow up my first post by outlining the principles of possible alternatives to psychiatric diagnosis – that is, alternatives in addition to the most obvious one, which is simply to stop diagnosing people.
Oddly, in some ways it would be easier to do that than you might think. Despite psychiatry’s theoretical reliance on diagnosis to justify its status as a branch of medicine, numerous studies have testified to the fact that the label does not actually perform any of the functions that it is meant to do. It doesn’t suggest any particular treatment, for example. Anyone who hangs around in psychiatric hospital long enough will get every type of drug that is available, often at the same time. It doesn’t indicate biological aetiology.
As we know, none has been established, and the so-called theories about biochemical imbalances and so on hardly deserve the name; a better phrase might be ‘wild and desperate guesses.’ (‘To say that an unknown number of biochemical substances may interact in an unknown way to produce schizophrenia is a tortuous way of admitting that we have no clue as to what the hell is going on’: Skrabanek, 1984.) Lacking reliability and validity, diagnosis doesn’t provide a sound basis for research: if you investigate a meaningless category, it really isn’t surprising that you come up with confused and meaningless results, although this ‘massive flaw in every single study undertaken’ (Hill, 1993) is rarely admitted.
Quite the contrary: treatment guidelines such as the UK ones which are issued by NICE (National Institute of Clinical Excellence) completely fail to acknowledge that the diagnoses on which the recommendations are based are themselves unevidenced. Nor does a psychiatric diagnosis indicate prognosis (except in the self-fulfilling sense that anyone who is diagnosed has been coerced into the first stage of a potentially lifelong psychiatric career.)
In summary, although some psychiatric diagnoses are more stigmatising than others, it doesn’t actually make much difference on a day-to-day basis exactly which diagnosis you have – which is convenient in a way, because anyone who is unfortunate enough to spend any length of time in the system is bound to collect at least half a dozen of them. And it doesn’t really make sense to talk about the ‘wrong’ psychiatric diagnosis, because in psychiatry every diagnosis is a misdiagnosis.
Some psychiatrists do recognise this by practising with a focus on ‘symptoms’ and a certain amount of scepticism for the wider classification system. However, and this is an important caveat, it does matter that you have been given a psychiatric diagnosis of some sort, because this conveys the general message, heavily reinforced by all the other aspects of the system, that you are ‘mentally ill.’ And the single most damaging aspect of the diagnosis that assigns you this status is the loss of personal meaning that it implies.
I want to elaborate on this point (which, of course, has been made by many others as well.) Emil Kraepelin is known as the founding father of the biomedical model of psychiatry because of his assertion that the various manifestations of distress were indicative of an underlying brain disease – a claim that has been vigorously contested by a distinguished series of critics ever since (see comment above by Seth Farber.) In this view, the presenting distress is not understandable in the context of the person’s life and the sense they have made of it.
If hearing voices, or believing you are being poisoned by your relatives, or feeling so low that you can’t get out of bed, or so frightened that you are trapped in your house, or so overwhelmed that you can only find relief in self-harm, are ‘symptoms’ of a ‘disease’, it makes no more sense to enquire further into them than into the meaning of a rash, or the content of delirious speech in a fever. Factors such as past abuse, neglect and trauma will be noted in the psychiatric history and probably never mentioned again, while your role as patient is to take the medication and follow the experts’ advice.
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, not ruthlessly divesting it of its personal, social and cultural significance.
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.) But setting that aside for the moment, it seems to me that any alternative to psychiatric diagnosis has to have at its heart the restoration of personal meaning within its relational and social contexts.
There are many different ways of doing this. The Open Dialogue model in Finland is one current example. In fact, the history of psychiatry shows that such approaches have always been a marginalised presence alongside the dominant one (see the excellent summary in Foudraine, 1974.) Each culture probably needs to develop its own appropriate ways of exploring the meaning of distress, and some of them may look quite strange to Western eyes. To return to an example from my first post, I do not personally believe that people in distress are possessed by spirits, but if this makes sense within a particular culture or sub-culture, and if it leads to rituals that are healing and helpful, it is not my business to interfere. After all, as I pointed out, the current Western conceptions of mental distress are no more scientific (if that is the criterion we are using) and certainly they are not effective.
This is a rather lengthy preamble to the topic I now want to introduce: psychological formulation – something that has absorbed me for some years now, and is the subject of a growing number of books and articles in the UK, including my own (Johnstone and Dallos, 2006.) In 2011 I led a 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 )
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. (Implications to be discussed in due course!) It is only one of many ways of restoring meaning, but in the UK it does at least have the advantage of a degree of acceptability and credibility within existing psychiatric settings, and several groups of professionals 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 draws on psychological theory and evidence in order to suggest the best path to recovery. Unlike diagnosis, it 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 talents 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 process of ongoing collaborative sense-making’ (Harper and Moss, 2003) or ‘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, 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.
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 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 voice-hearing. It suggests an individual pathway forward, which will probably include developing a trusting relationship with a worker or therapist, learning ways to manage and cope with her voices, perhaps gaining support from others with similar experiences, and talking through her past. 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.
In short, formulation has the potential to restore meaning, agency and hope, for staff and service users. But – a very important but – it all depends how you do it.
So, anticipating the questions that may arise from this post, these are the issues that I hope to discuss in the near future:
Can formulation and diagnosis be used alongside each other?
What is best practice in formulation?
What are the limitations of formulation?
How can we use formulation beyond individual therapy?
What evidence is there for the effectiveness of formulation?
How can we promote formulation as a possible alternative to psychiatric diagnosis?
In the meantime I welcome comments on this website or via Twitter @clinpsychLucy
Butler, G (1998) Clinical formulation. In AS Bellack and M Hersen (eds) Comprehensive clinical psychology. Oxford: Pergamon 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.
Hill, D (1993) ‘Psychiatry’s lost cause.’ Openmind 61, 16-17.
Ingleby, D (1981) ‘Understanding mental illness’ in D. Ingleby (ed) Critical psychiatry: the politics of mental health. Penguin
Johnstone, L and Dallos, R (2006) Formulation in psychology and psychotherapy: making sense of people’s problems. London, New York: Routledge
Skrabanek, P (1984) ‘Biochemistry of schizophrenia: a pseudoscientific model.’ Integrative Psychiatry, 2 (6), 224-8.