Thinking about Alternatives to Psychiatric Diagnosis

Lucy Johnstone, PsyD
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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.
 

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33 COMMENTS

  1. Lucy-
    I appreciate your posts and share your critical view of the limitations of the current diagnostic system.
    What your are proposing seems awfully close to psychodynamic formulation. This is how I was trained and was the prevailing approach in American psychiatry up through the 1980’s (and in my experience continues along side DSM labels to this day).
    What I value in Open Dialogue (and I do not want to present myself as an expert, but as a student and observer) is that the explanation arises from the dialogue and is not imposed from the clinician. My experience with dynamic formulation is that is derives from the clinician and there can be as much labeling, albeit of a different nature, as with the categorical labeling of the DSM.
    With some of the people I meet, even stating that one is hearing voices is a form of labeling. What if Jane came to you complaining that her neighbors and people on the street are always critical of her?
    I suppose this is what you mean by your phrase, “It all depends on how you do it”, so perhaps I am anticipating future posts. In that case, I look forward to reading more!
    Thank you for your writing,
    Sandy

    • I agree with Dr. Steingard, your example seems like a pretty typical psychodynamic formulation and doesn’t seem like something that would early on in a treatment relationship be co-created. It seems a clinician had very quickly made dynamically informed hypotheses about the the etiology of symptoms/experiences and very quickly made interpretations about the meaning of someone else’s experience. What if Jane didn’t share this view of the meaning of her difficulties/voices? This might feel kind of like an assault early on, let alone keep someone from seeking support again. Perhaps if Jane does have “self-awareness,” “intelligence,” and “motivation” to talk about her past, she may be amenable to a psychodynamic approach, but not necessarily. But I always kind of resent the often dichotomy I see in psychotherapy communities (particularly psychiatrist led circles), that push for as much exploratory therapy as possible, see patients who possess traits that they think make people do better in dynamic therapies as somehow ideal/better, regardless of what the patient feels about such a treatment plan or lack of evidence to back it up.

      I’m not sure this formulation also suggests particular paths forward for recovery. I can see many clinicians have this formulation and still recommend narcoleptic medication. I bet a lot of clinicians/patients could also come to the conclusion of: “you have experienced a great deal of trauma for a long time, so at this point, you are likely to have to be on medications for the rest of your life. Your intelligence and self-awareness of your illness are assets in this treatment because you know that you have to comply to medication use to feel well and avoid relapse.” Either treatment recommendation can come from the formulation, and again, they seem more clinician developed and not co-developed, and a little coercive/depend on the explanatory power of a professional.

      I’m not really convinced yet that this process has any more validity or reliability in terms of describing the issues people face and the helpfulness of intervention (ex. relationship with therapist/worker) than the research of application of treatments to reduce particular symptoms and increase well-being based on diagnostic criteria. I don’t want to sound like a stick in the mud, but this all just seems neo-neo-analytic and I’m not yet convinced how accessible and helpful such an approach will be.

  2. Thank you, this is an excellent post. A thought that I would like to raise is that a big part of “Jane’s” therapy and recovery lies outside the clinical relationship. It’s the family. A Jane (or even a James) is not living in a vaccuum. Most twenty year olds go home every night to parents who also need to find meaning in what is happening to their relative. It would be most helpful if they were in synch with “Jane’s” meaning. How “Jane” is treated by her family often makes all the difference and in the best case scenario, positively reinforces what she is learning about herself. The family needs to figure out a way forward, too. I wonder, like Sandy does in her comment, if therapeutic help is too clinician centered. Help is needed beyond just concentrating on the identified patient.

  3. My God, she does it again!

    Quotes I shall treasure:

    1 “…so-called theories about biochemical imbalances and so on hardly deserve the name; a better phrase might be ‘wild and desperate guesses”

    2 “…it doesn’t really make sense to talk about the ‘wrong’ psychiatric diagnosis, because in psychiatry every diagnosis is a misdiagnosis.”

    Now the statement, “many have argued that mystifying individuals about the origins of their emotional pain while…. is not just the effect but the purpose of psychiatry,” is worrying and something I’d like to hear more of. It is certainly the effect, and I can see how drug companies collude for the profit motive,that it is the purpose, if it is true, is rather worrying.

    I’d have to stop saying to the psychiatric industry “look you guys, you’re just deluded,” and start saying, “Look everyone, these people are just being deliberately nasty!”

    As for Formulation, I of course want to hear more detail, especially in answer to the people commenting above as well as how it could be used to help get money from health care providers. However I also want to comment that it seems bloody obvious. It is an extension of those common sense questions:

    1 Tell me how you’re feeling dear?
    2 What do you think caused you to feel so bad lovey?
    3 What do you think might help dear?

    It may have a little dressing up so it can be used in a repeatable way by professionals but refreshingly little as far as I can see. Lets here more!

    • You don’t necessarily have to change what you think and say about psychiatry. Even if “mystifying individuals (and everybody else, I’d add) about the origin of their emotional pain” is the actual purpose of psychiatry — and I for one am convinced it is — that doesn’t mean it’s done consciously, on purpose, by the individual practitioner. And only if it’s done consciously, it makes for “deliberately nasty”.

      IMO, psychiatry is the logic consequence of modern western civilization’s ongoing efforts to have its — warning, label ahead! — narcissistic needs met. Modern western civilization is the culture, or cultivation, of “toxic mimicry”, with Derrick Jensen. And in perfect alignment with what we can see this culture do in all other areas of life, also in the area of help for people in emotional distress it has turned the meaning of the word “help” upside down, creating a huge discrepancy between the word, what is said on the one hand, and the actions, what actually is done on the other. Whenever you have a discrepancy between what is said on the one hand, and what is done on the other, which counts is what is done. However, that which is said serves to turn that which is done into its opposite, in your own mind, and in that of others. It serves to delude both yourself and others about what actually is done. The narcissism that creates these delusions is always unconscious. Once narcissism becomes conscious of itself, it’s gone, together with the needs that come along with it: no more need for an institution that labels certain people as “lesser than”, so that the rest of us can feel “better than”, because deep down we feel absolutely miserable about ourselves. Many of the mh professionals I’ve met were people with zero self-love, self-respect, and self-esteem.

  4. while I share your views about the lack of scientific basis for psychiatric diagnoses,one thing that seems missing from this discussion is that the primary use of psychiatric diagnosis is billing. Until insurance companies and government programs stop requiring DSM diagnoses for payment, their use will continue, no matter how useless they are.

  5. Lucy, Thank you for this post. I agree that people suffering from mental illness need to have someone listen to their distress. My son was hospitalized three years ago for psychosis and all they did was medicate him. He told me that noone in that hospital where he spent three weeks ever asked him WHY he wanted to kill himself.

    However, my son was eating very poorly at the time (soda, candy, Pastries, very little protein or fruits and vegetables) and the psychiatrist told me that diet had nothing to do with becoming mentally ill. “Eating poorly was a symptom not a cause” was how he put it.

    Well I don’t want to make my story too long but my son refused medications so we encouraged him to talk. He talked a lot, to professionals, friends and family, on and on and on. The same stuff again and again and again. Everytime we thought he was OK and moving forward and then a few days later the craziness would start again.

    I started to notice that when he was crazy and screaming at me if I gave him water or fruit he would calm down after about twenty minutes. If he consumed soda, juice or ice cream he would get worse and we would end up throwing him out or calling the police. This went on about once a week for about two years. The last eight months have been much better (only called us up to scream at us five times in the last eight months and hasn’t come to our house.)

    I have a really hard time convincing him of the importance of eating properly when all the doctors and professional seem to be in two camps. The first camp says psychosis is biological and he must be medicated or he will continue to relapse. The second group of professionals whom I found here and on Dr. Peter Breggin’s website seems to believe that psychosis is caused by distress and he needs more counseling.

    Do you know if there is any interest among professionals in doing research on diet as a possible cause and cure of psychosis? I know they used to do research on sugar and ADHD but concluded no link. I think it is probably the lack of fibre rather than the sugar in the diet that is the problem. My son would become psychotic when drinking orange juice but improve if given a whole orange.

    • There certainly are people looking at the role of nutrition and environmental toxins in relation to psychaitric problems, including psychosis. There are even psychiatrists that primarily practice in this area, although they are very few and far between. It is usually called Orthomolecular Psychiatry. They will do full tests, not just blood tests, but hair samples, and many other things as well to see what is happening in the body. This is the Wikepedia piece about it: http://en.wikipedia.org/wiki/Orthomolecular_psychiatry

      It certainly works well for some people, generally about 50% show massive improvements. That others don’t means psychiatrists as a whole reject it. Problem is there own treatments cannot do as much as this group does. At a minimum thsese tests should be done on everyone before they consider any drugs or anything else.
      http://www.hriptc.org/index.php

      It would also be very very true that no one asked him why he wanted to die. The same thing happened to me and everyone I know. I do not personally know of anyone who has attempted or contemplated sucide and who has ever been asked why. They believe it is a brain disease that makes us think such things, and that nothing else is of any relevance. Everyone I know of had very valid reasons for wanting to die, and pretending that those things do not exist is not going to change anything.

      Mindfreedom could also possibly link you in with some alternative resources.

    • Just wanted to let you know the work of William J Walsh PhD in Napperville Illinios . He has written a book called “Nutrient Power” and has trained over 140 doctors in Australia – see http://www.biobalance.org.au for more information.
      He uses science to measure a person’s biochemistry by taking blood/urine tests then prescribes vitamins and minerals to rebalance back to normal. Doctors here say it has profoundly changed they way they practise medicine and many people have found it has helped them very much. I think most psychiatry uses the Look, See , Guess method of diagnosis and treatment.

  6. Lucy,

    You complete your first sentence of this follow-up blog, with the straightforward advice, “stop diagnosing people.” Such an emphasis makes for a genuinely great start, in my view.

    From all you say (now, in this second post, as well as in your first), I now surmise that you’re strictly opposed to pysch-labeling, of any kind. Psychiatric labels must go; and, no less, psychological labels must go. If I’m right that such is your position, then you have my sincere commendations, and I cannot help but conclude, you’re far more wise, in your work, than the majority of those working in most realms, similarly aiming to provide ‘mental health’ services.

    Now, please, forgive me if I seem somewhat repetitive, as I don’t know who may or may not be aware of my story. (Frequent readers of MiA may have been more or less well aware, of that Emergency Room scene, to which I alluded, in response to your first blog post, of January 1.)

    In response to other bloggers here, at MiA, I’ve posted the following link, to my blog, which explains, that: When I was in that crisis (now nearly 27 years ago), all involved, “tacitly condoned a ‘treatment’ of stuffing me with grossly debilitating meds and tagging me with indelible psych-labels.”

    http://beyondlabeling.posterous.com/none-cared-to-listen-to-my-reasons-for-how-i

    I’m feeling confident of your strict opposition to any and all “diagnosing” (of whatever may seem, in the eyes of conventional observers, to be ‘mental health’ issues); so, now, I ask you, sincerely (as I’d ask anyone who is, likewise, thoughtful and proposing alternatives to the current, typical way of providing “mental health” services): Would your approach do anything (and, if it would do something, then what would it do) to prevent the *forced* (and/or, *coerced*) “medication” of persons who are in crisis, such as I was, at age 21?

    Surely, you’re aware, that: throughout most of the “developed world,” the officially declared existence of a “mental disorder” comes to legally ‘justify’ *forced* and/or *coerced* “medication” of anyone who is deemed (by a psychiatrist or other similarly “qualified” psych-pro) “a danger” – supposedly – “to others and/or to himself/herself”.

    Would someone who has your strict ‘no-diagnosis’ orientation even be allowed to work, in an E.R., without agreeing to appease the psychiatrists and others who are trained to insist, that it’s their duty to declare the existence of “mental disorders,” I wonder?

    Would a professional such as yourself wind up deciding who is or is not supposedly “a danger” – whist the psychiatrists and psych-techs readied their hypodermic needles?

    I ask you these questions, with all humility (and with admiration of your obviously excellent scholarship).

    Respectfully,

    Jonah

    • P.S. – Lucy, something in your first post (January 1), I questioned silently, and – happily – found it answered, by the following lines, in your second post (above):

      “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.”

      You say you, “do not personally believe that people in distress are possessed by spirits,” yet you’re apparently *much* more open-minded than most pros who work in the ‘Mental Health Care System’ – as psychiatry has come to dominate, and few psychiatrists have any tolerance for ‘spirit possession’; of course, it is more common for psychologists (such as yourself) to have tolerance, of that kind; but, it is not entirely common.

      Along these lines, you may or may not be aware of a frequent commenter, on this site, “mjk”; if you click on the following link, you’ll find one of mjk’s comments, which I find interesting and informative, referring to the work of a Dr. Wilson Van Dusen, “…a university professor who has served as chief psychologist at Mendocino State Hospital in California.”

      https://www.madinamerica.com/2012/11/the-madness-of-psychiatry/#comment-17382

      If, perhaps, you have a moment to read that comment, by mjk, you’ll notice another commenter (Richard D. Lewis) replies by purely dismissing, “The theories of Dr. Van Dusen”; he insists they, “are just the flip side of the same coin stamped with the theories of Biological Psychiatry.”

      I know Mr. Lewis is perfectly well-meaning; and, almost certainly, I’d *disagree* with certain practices of Dr Van Dusen (considering his resume, I presume he has been involved with the forced ‘treatment’ of so-called “patients”); but, from what mjk offers, in that comment, I’m inclined to be interested in Dr Van Dusen’s theories, on ‘spirit possession’.

      After all, I do believe in spirit possession, of a certain kind; that people in distress may be possessed by spirits seems a perfectly reasonable possibility. E.g., long ago, I worked as an administrative assistant, in a small stock brokerage, where at least one broker was *clearly* possessed by the spirit of greed. In Buddhist terms, it could well have been said, that he was, *possessed* by the world of ‘Hungry Ghosts’; anyone who speaks that way makes perfect sense to myself, being that I’m one who appreciates many Buddhist teachings. (I.e., whether or not I believe in ‘ghosts’ all depends upon what one means, by “ghosts”.)

      By the way, I must add, that, generally speaking, I quite appreciate Mr. Lewis’s skepticism, when it comes to matters of psychiatry, but I think his views might possibly lean towards what many call “scientism” http://en.wikipedia.org/wiki/Scientism . Or, at least, in his response to mjk, he may have been momentarily possessed by the spirit of scientism…

      🙂

      • Jonah

        Why does an excessively greedy person have to be “possessed” with the spirit of greed? We live in a capitalist society where greed is taught and encouraged throughout our culture; this is a much better explanation than ascribing this quality to some supernatural force which cannot be proven to exist.

        I stand by my previous comments on this subject.Superstition throughout history has caused great harm to people. To view people in an extreme state of psychological distress (with a “schizophenic” label) as possessed by the Devil or some other demon is just as bad as the brain disease theories of Biological Psychiatry. Both label and marginalize people and subject them to enormous amounts of prejudice along with various oppressive forms of treatment (drugging and forced incarceration). Both obscure and misdirect people’s attention away from the various forms of abuse, trauma, and stress in our society that creates conditions for these extreme states of psychological distress.

        This same type of superstition has historically caused people with epilepsy and other neurological disorders to be treated as outcasts and in some cases killed. And what about the women burned at the stake in Salem Mass for being “witches” and possessed by demonic forces.

        Jonah, your postings on MIA I usually agree with; on this topic you are way off the mark. If you are accusing me of “scientism” then I plead quilty. For me there is no such thing as being too scientific. Science is the search for the truth using the scientific method. We need to do more of this not less and it needs to be developed and presented in an exciting and living way. I am opposed to the empiricism and reductionism that are the hallmarks of Biological Psychiatry’s phony attempts at real science. Is there phenomona in this world we do not yet understand? Yes, of course, but we can search for the answers without resorting to superstition.

        Richard

        • Richard,

          You begin by asking me, ‘Why does an excessively greedy person have to be “possessed” with the spirit of greed?’ In that way, you are responding to my comment, wherein I’d referred to a particular man (a stock broker) with whom I had worked, long ago. (I wrote that he: “was *clearly* possessed by the spirit of greed. In Buddhist terms, it could well have been said, that he was, *possessed* by the world of ‘Hungry Ghosts’.”)

          Your question includes these words, “have to,” which seems possibly suggesting, that you think I believe ‘spirit possession’ is the *necessary* (as in, ‘the one-and-only, best’) explanation for excessive greed; but, I certainly don’t believe that…

          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:

          http://beyondlabeling.posterous.com/an-open-letter-to-richard-d-lewis-psych-psych

          Respectfully,

          ~Jonah

  7. “I’m not sure this formulation also suggests particular paths forward for recovery.”

    In my mind, just having the opportunity for honest and dynamic understanding of one’s experience can help to make clear a recovery paths. You have to know what you are recovering from and what you are recovering.

    Also, I appreciated the question about so-called extreme states and diet. The link between our nutrition and our mood states and modes of processing and cognition is really strong. I have to be sure that I get enough of a particular vitamin to avoid depression…or, as mjk by proxy of Jonah noted, evil spirits…low points in a wave pattern, the ancient metaphysical forces of radio…who knows?

    (by the way, madincanada, if you’re not familiar with it, check out http://www.beyondmeds.com for interesting articles, links about diet and ‘mental health’, plus a lot more.)

    Which brings us back to the question Mike Cornwall asks again and again: If we all agree that madness is not a brain disease, what is it?

    I’d hazard a guess that our approach to madness must be as myriad as madness itself often is?

    Viewed from a biopsychiatric perspective, it is a brain disease.

    From a psychodynamic perspective, it can be a culminate of trauma.

    From a Jungian stance, it is the waking dream of the subconscious in the universe.

    To Campbell it was the hero, coming home.

    How many different views of the many forms of human distress are there and have there been. How many different words have tried to name them?

    As John H. up yonder noted, it is fairly simple to give people a chance to express what, in their mind is happening and to meet that expression with kindness and acceptance.

    However it is not in the narcissistic minds (thanks, Marian) of many practitioners to be inclined to sit with, listen to, etc. – nor do they have the time and nor could many systems even operate without diagnostic codes. The logistical prospects of a transition to a system without codes is almost comically nightmarish. There is a lot invested in those words, those codes.

    Which is why community-based and off-grid mutual aid networks and spaces like Hearing Voices and Icarus are so, so important.

    I diagnose the mental health system as having Diagnoses. I can’t begin to think about how one would go about trying to advocate for a shift to no diagnoses in formal systems that are built on diagnosing people.

    I think in some alternative settings, respites and education centers, if diagnosis must be given, a “temporary” diagnosis is given…meaning that one has a “brief reactive psychosis” as opposed to “chronic paranoid schizophrenia” or some “adjustment disorder” as opposed to “major depressive disorder.”

    I’d prefer it all just be called livin’ and learnin’ – but I don’t think that’d fly with SAMHSA.

  8. “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.”

    Personal meaning within its relational and social contexts in Western world tends to to take the “mind” as the foundation of our personal reality? A “who am I?” Not “what am I,” approach? Yet is the West with its urge to dominate other cultures, confused about the very nature of subjective experience and reality? And is our preference for diagnosisng others, stimulated by our instinct based intelligence and an innate need to judge otherness?

    Consider a non-western approach to the mind & reality;

    “Presence in Reality

    Presence in reality is not possible if your mind is overwhelmed by thoughts. When the mind is emptied, it is possible to turn your attention spontaneously to reality.

    But what is reality?
    Reality is the environment that surrounds us.

    In fact, for each of us, the environment that surrounds us is our reality.
    This isn’t such a trivial fact, which we unknowingly or unconsciously take for granted .

    Try this little test.
    We are in New York, sitting on the terrace of the Times Square Brewery.
    I ask you, ‘Do you think the Place Pigalle in Paris is real?’
    You probably answer, ‘Yes.’
    But it isn’t.
    If you are in New York, in Times Square, the environment that surrounds you is Times Square in New York, not The Place Pigalle in Paris.
    Therefore “your reality” is Times square New York.
    Paris and The place Pigalle are not the environment that surrounds you.
    They aren’t your reality/

    They are only in your mind, in your memory, not in your reality.
    Herald Square in New York isn’t real to you either, if your in Times Square.
    Because Herald Square isn’t the environment that surrounds you. Herald square isn’t real to you.

    Do you understand what I’m saying?

    Your reality is the environment that surrounds you, and which you percieve with your senses.
    In other words, your reality is your surrounding, wherever you are.
    Nothing else.

    Paris and the Place Pigalle may be the reality of someone in Paris, but this is not your reality.
    Your reality is only the surrounding environment of wherever you are right now.
    If you behaved as if you where in Paris, you would not be intune with reality.
    You would not be present in your reality.

    There are two worlds:

    1. The world of the mind.
    2. The world of reality.

    The world of reality is real, the world of the mind isn’t real.

    Of the objects which present themselves to our consciuosness, in fact, some belong to the reality that surrounds us , while others belong to our mind – that is, to our memory. (the body/brain and its nervous stimulation).
    We tend to falsly believe that “both” kinds of mental objects are real, yet this is a false assumption based on our past, not the present reality, by which we are surrounded and unknowingly immersed in.
    Only the mental objects which belong to the surrounding environment are real, not those which belong to our memory ( the body/brain nervous energy of the past)

    Your probably thinking that this is a very debatable point?
    Especially, if your still strongly anchored to the world of your mind, here’s proof though.
    A relitive of yours who has died is undoubtedly still present in your memory, yet it is obvious that they are NOT present in the environment which surrounds you, (or even in the environment which doesn’t surround you), which means that they are no longer real.

    The attribution of reality to the mental objects of our mind, is the cause of mental suffering.
    We suffer because of the “fantasies” in our mind.

    “The fantasies of your thought are not real.
    They are generated by your attachment, and therefore by your desire, your hate, your anger, your fear.
    The fantasies of your thought, are generated by yourself” _Buddha.

    We suffer because we mistake the fantasies of our mind for reality.

    It is fundamental, therefore, that we learn to distinguish between reality and the fantasies of our mind.

    A state of “Buddha-ness – truly awake” involves awareness of the distinction between the world of the mind and the world of reality.

    Deprive your fantasies of your approval and they will vanish” _Buddha.

    Most people in the Western world, love the mind and the power of its creations, and rightly so, yet true presence in reality does not negate the power of the mind, it simply offers a way out of suffering.
    Suffering generated by our own mind, due to confusion about the distinct difference between objects of reality and the mental objects of the mind, as NOT real?

    Buddhism has one essential purpose: liberation from suffering.
    All it is saying is, you cannot defeat the fantasies of your mind, by staying within your mind.
    You need to come out of your mind and enter reality.

    This is why “attenuating” thought allows us , quite naturally and without effort – in other words, spontaneously – to implement the second power of Buddha-ness (truly awake): presence in reality.

    In true reality, there is no suffering!

    This is a simple truth, which is difficult for us to accept.
    Again, using an extreme example:
    You have just lost a loved one.
    You think that reality is the cause of your suffering, because in reality the person you have lost is no longer there for you.
    But this is precisely the Buddha’s point?
    In reality that person is no longer there, but that’s ALL.
    In acceptance of true reality, there is no suffering.

    The sun continues to rise, the clouds continue to sail across the sky and the birds continue to sing.
    Your suffering, is only “inside” you.
    Yet you think that reality is the cause of your suffering, and you mistakenly, unknowingly, attribute your suffering to “reality” itself.

    But “suffering” is not an object which can be found anywhere in true reality.
    Suffering, is a “mental state.”
    In other words, suffering is “inside” your mind, not in reality.
    A famous Zen koan says:

    “Show me the hand which is holding your suffering.”

    You can’t do it, because “mental suffering” belongs to the world of the mind and not the world of reality.

    True presence in reality, is not a question of “intellectual knowledge,” but of “experience.”

    EXERCISE:

    1. Calm your breathing, relax your body, observe with a “felt sense,” your thoughts.

    2. Come out of your thoughts and observe (sense) the environment around you.

    3. Perform common actions, (interactions with reality). Do the dishes using your senses to interact with your surrounding reality, to discover true presence. To Be in Reality.”

    Excerpts from “HOW TO BECOME A BUDDHA IN 5 WEEKS: The Simple way to SELF-REALIZATION” by Giulio Cesare Giacobbe.

    Perhaps we need to let-go of our “I think therefore I am” mind & come to our senses, to discover why we diagnose, why we judge and find the presence to be with each other, without “acting-out” an instinctive need?

    Best wishes,

    David Bates.

      • Hi Stephen:))

        It is a very good articulation of Buddha-ness, as Giulio puts it.

        Its interesting to contemplate how we tend to objectify or mystify the human experience in our mind’s interpretation of reality? Buddha, literally meaning Awake, mystified into the name of its originator Siddhārtha Gautama who developed “the way,” transformed hundreds of years later into Christ’s “I am the way?”

        It seems the great theme’s of existential reality never change, in which respect this “now” is of coarse eternal, and Tolle explores this reality in his “The Power of Now.” Is the practice any different to Siddartha’s Way? The great prince of Sense-Abilty, as I’ve come to know him.

        Lucy mentions other culture’s and the white man’s need for dominance above, and I must admit I went to Thailand with a typical Western sense of superiority. Yet I found recovery in mixture of Western objective science (The Polyvagal Theory) and Peter Levine’s adaptation of Eastern practices of sensate awareness, and of coarse a culture which takes non-attachment to the objects of the mind, for granted, a daily practiced, way of life.

        Lucy suggests we think about a regurgitated model of Carl Rogers “person centered” approach in her articulation of “Formulation” yet of coarse an Eastern approach would regurgitate a need to center the person in the realty of the body and its sensory nature.

        The existential theme of being, remains the same? Perhaps its all about the body, and its its need of approach or avoidance? Consider;

        “HOW CAN WE STUDY INTERNAL PROCESSES, WE CANNOT SEE:

        Imagine an archetypal interaction: A cat is cornered by a dog. The cat hisses, its body tensely arched, hairs on end, ears pulled back. If the dog gets to close, the cat lashes out, claws unsheathed. If we could see the cat’s heart, it would be pounding “a mile a minute.” The dog barks loudly, bounding forward and backward, but coming only so close, as not to get slashed by the cat. What is motivating their behavior? “Fear” and “anger” might be a satisfactory answer in everyday terms.

        A slightly more sophisticated explanation might be that the dog’s initial attack was produced by anticipation of a good chase, but the cat’s affective defenses successfully thwarted the dog’s intentions and provoked frustration. That really aroused the dog’s ire and got emotional volleys of anger and fear bouncing back and forth. (p, 10)

        At the simplest level, world events can produce approach or avoidance, but careful analysis of the evidence now suggests that both these broad categories contain a variety of separable, albeit interactive, processes that must be distinguished to reveal a proper taxonomy of affective processes within the brain. (p, 14)

        I will assume that recent evolutionary diversification has more vigorously elaborated surface details of behavior and cognitive abilities, than it has altered the deep functional architecture of the ancient brain systems that help make us the emotional creatures we are. Thus, fear is still fear, whether in a dog or an angry human. At deeper levels, very similar emotional systems guide many of the spontaneous behavioral tendencies of all mammals, (p, 15)

        Even though our unique higher cortical abilities, especially when filtered through contemporary thoughts, may encourage us to pretend that we lack instincts–that we have no basic emotions–such opinions are not consistent with the available facts, Those illusions are created by our strangely human need to aspire to be more than we are–to feel closer to the angels than to other animals. But when our basic emotions are fully expressed, we have no doubt that powerful animal forces survive beneath our cultural veneer. It is this ancient animal heritage that makes us the intense, feeling creatures we are. (p, 21)

        The most primal affective-cognitive interaction in humans, and presumably other animals as well, is encapsulated in the phrases “I want” and “I don’t want.” These assertions are reflected in basic tendencies to approach or avoid various real-life phenomena. When these affective systems are overtaxed or operate outside the normal range, we call the end results “psychiatric disorders.” Under-activity of certain systems may cause depression and variants of personality disorders. Over-activity can contribute to mania, paranoid schizophrenia, and anxiety, obsessive-compulsive, and post-traumatic-stress disorders (PTSDs).

        The extent to which the emotional operating systems exhibit neural plasticity–changes in the efficiency of synaptic connections and dendritic arborization as a function of experience–is becoming an increasingly important avenue of empirical enquiry. Practically every brain system changes with use and disuse. For instance the “archetypal situations” described earlier are the types of experiences that lead to PTSD, and its presently believed that persistent neural traces of emotional traumas reflect the development of long-term sensitization in areas of the brain such as the amygdala, which are known to mediate fearfulness.

        Indeed, newly emerging disorders such as “multiple chemical sensitivities,” which may have contributed to that mysterious recent outbreak known as the “Gulf War Syndrome,” may be due to a change in the sensitivity of emotional circuits that can be induced, especially in temperamentally predisposed individuals, by exposure to environmental toxins. Although our knowledge of chronic changes that can occur in emotional circuits remains rudimentary, it is likely that all emotional systems exhibit forms of plasticity, which eventually will help us understand much about the underlying neuronal nature of psychiatric disorders.

        Each emotional system is hierarchically arranged throughout much of the brain, interacting with more evolved cognitive structures in the higher reaches, and specific physiological and motor outputs at lower levels. The emotional systems are centrally placed to coordinate many higher and lower brain activities, and each emotional system also interacts with many other nearby emotional systems. Because of the ascending interactions with higher brain areas, there is no emotion without a thought, and many thoughts can evoke emotions. Because of the lower interactions, there is no emotion without a physiological or behavioral consequence, and many of the resulting bodily changes can also regulate the tone of the emotional systems in a “feedback” manner. (p, 27)

        Taxonomies of emotions are bound to differ depending on an investigator’s preferred level of analysis. For instance, subtle social emotions like shame, guilt, and embarrassment may emerge from separation-distress systems interacting with higher brain functions. In any event , at the present time, the lower command level provide the best organizational principles for scientific inquires. We can now be confident that a limited number of executive structures for emotionality were created in our brains by our genetic heritage, but we cannot yet be certain how many exist and how widespread they are in the nervous system.”

        Selected excerpts from, “Affective Neuroscience: The Foundations of Human and Animal Emotions.” by Jaak Panksepp.

        Are most “intellectuals,” here on MIA, too firmly “attached” to those wonderful cognitive constructs, and the life of the mind? Will we continue to regurgitate cognitive constructs here, as we wind on down the road, our shadows taller than our Souls?

        We’re not animals and we don’t have instincts? There is no predator/prey axis in the emotional life of human beings?

        Best wishes,

        David Bates.

  9. I definitely can support the idea of “formulation,” IF it is a formulation that is created by the CLIENT in collaboration with a supportive professional, who is not invested in their own explanation of their client’s reality. I would stay away from clinical language altogether, and put it in the client’s words (i.e. “The client says he hears people talking to him that others don’t appear to be able to hear, one of whom is rather rude and scary, and he would like this voice to be quiet or at least be nicer. He says the voice reminds him of his mother’s and he wonders if it may be related to how he used to treat her as a child.”), and I would require that the clinician check back at every juncture with the client to make sure their version of reality continued to reflect the client’s formulation of the problem.

    Unfortunately, it would be way too easy to take “formulation” and make it into a disguise for “diagnosis” if the clinician decides to substitute his/her voice for the client’s, whom the clinician may easily decide “lacks the insight” to be able to do his/her own formulation. The element of the clinician’s humility is the critical factor, regardless of what you call the final product.

    I really appreciate your efforts to create an alternative view. I do agree also with the concerns raised regarding reimbursement – it’s hard to see how insurance companies will pay for something without their little diagnostic codes to make them feel secure. Perhaps the idea of subsuming mental/spiritual/emotional well being under the rubric of medical care/insurance has to change before we see real progress.

    —- Steve

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  11. Lucy,
    When you say that 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”, this describes what the French have long called “la clinique”,(long before “formulation” came about), i.e. the therapeutic relationship and collaboration between person and therapist to work towards recovery.

    The problem with that is that it can and often leads the psychiatric system to take a so-called humane way to still put their bio-medical stamp on your story, i.e. pathologising it.

    As you quite rightly say, there is a need to acknowledge different cultures.
    I can tell you that the French system still thinks that there is nothing better than the diagnostic system but they also cling on to certain diagnostics no matter what, e.g. BDP or schizophrenia. The French psychiatric culture also intellectualises “psychiatric disorders” in a way that does not exist in Anglo-Saxon culture. French descriptions of the BPD, for instnace, are quite extraordinary in that respect.

    Actually I am going to present at a psy seminar in Paris in May (to coincide with the publication of the DSM) and I already know that I am going to have a fight on my hands. The French users are not educated politically about psychiatry as they can be in the UK where I am based or in other Anglo-Saxon countries. Besides the French, and others, would argue that they do not use the DSM but the WHO’s ICD-10. It does not matter that the DSM and ICD are currently harmonising their codes and desciptions, they point to the prestige of the WHO, as an organisation said to produce quality tools, to legitimise the use of diagnoses. It is self-serving and hyprocritical of course, but also extremely powerful lobbying.

  12. Hi Licinia
    I don’t know but I can tell you that it very much depends on which perspective you are coming from. Indeed, there are still practitioners who have trained in psychoanalysis who would offer a different presentation, looking at the relationship between “language, unconscious and symptom”. Then there are practitioners whose approach follows the medical model. Even then there are perspectives which look at causality between psychological experiences and physical explanations (different explanations).
    I will see what I can find out from a psychoanalyst I am in contact with about your particular question.
    cheers
    Anne-Laure