As the biomedical model of psychiatry is increasingly criticized for its narrow focus and lack of acknowledging the social and systemic causes of psychological suffering, clinicians, academics, and service users have developed new person-centered alternatives that move beyond diagnosis and the disease model of psychological distress. A new UK based study published in PLOS Mental Health details the development of the Personal Narrative Model (PNM), an alternative to biomedical diagnostic approaches developed with lived experience experts that emphasizes past experiences, systemic and political factors, patient and service user meaning-making around their distress, strengths, and available resources. This research, led by Aneita Pringle from Anglia Ruskin University in the UK, finds that while patients and mental health staff generally liked the PNM, there are significant barriers to implementing this model into current mental healthcare systems. The authors write:
“The PNM, one of the few known formulation models to incorporate service users in its development phase, was acceptable to participants and provided practical utility in helping them structure and understand service users’ experiences. It also supported meaning-making around service users’ experiences and enhanced the perceived coherence of the care model. Overall, the PNM was viewed favourably by participants … interestingly at the time of the focus group no participants indicated they had adopted the PNM in their practice … This may reflect an important implementation gap; several such implementation barriers were identified, including concerns about discussing past experiences and staff resistance to adopting new practices.”
Problems With the Biomedical Model of Psychiatry and Diagnosis
Past research has detailed validity problems with DSM-style diagnosis, meaning that experts have questioned whether these diagnostic categories actually line up with reality. For a diagnostic system to be valid, it must detail a pathological process or disease that causes specific symptoms. However, “a causal mechanism of mental disorders upon which validity depends is absent.” Research has failed to identify a single biomarker or neurobiological marker that can diagnose mental “illness.” One study found that diagnostic labels can persist even when service users no longer meet diagnostic criteria or require support.
Numerous studies have also identified significant problems with the reliability of DSM-style diagnosis, meaning that two clincians often give a different diagnosis when presented with identical sets of symptoms. As a result of problems with both validity and reliability, some experts have called DSM-style diagnosis “scientifically meaningless.”
Research has linked the biomedical model of psychiatry to social rejection, stigma, and discrimination. Psychiatric diagnoses based on the biomedical model are associated with hopelessness, disempowerment, exacerbation of symptoms, disengagement from mental health services, worse quality of life, and significantly increased risk of medical errors. Studies have found that psychiatric labels can change the way patients and service users view themselves, as well as how they are viewed by others.
Diagnosis can result in “epistemic injustice” in which the statements and concerns of patients and service users are not taken seriously, or in some cases completely ignored. These labels can also lead to “diagnostic overshadowing,” with doctors often contributing physical ailments to existing psychiatric diagnoses. This can result in delayed treatment of physical illnesses, improper treatment with psychotropic drugs, and worse outcomes.
Psychological formulations such as the PNM, and the Power, Threat, Meaning Framework on which it is based, offer an alternative to the biomedical model of psychological suffering and psychiatric diagnosis. These formulations emphasize applying psychological theory to develop a collaborative understanding of patients’ and service users’ unique experiences and distress that can inform care and treatment planning.
Study Details
The goals of this research were to report on the development of the PNM and to examine whether mental health staff, patients, and service users viewed the PNM as useful and acceptable, what might hinder its implementation in inpatient settings, and how this model could be integrated into care planning.
In addition to detailing the development of PNM, the current work investigated mental health staff and service user views of this model in two phases. The first phase involved PNM staff training followed one month later by a focus group with seven mental health staff participants. The second phase included an online survey around the PNM with 26 mental health staff and service user participants, followed by semi-structured interviews with eight participants. The authors analyzed the focus group and interview data for recurring themes related to the acceptability and implementation of the PNM.
The PNM is a psychological formulation model that was developed by a service user advisory board, clinicians, and academics. According to the authors, the involvement of lived experience experts during the development stage was unique, as other formulation models were developed by clinicians and academics first and only later involved service users and patients in evaluation. During the development of this model, service users pushed for more accessible language, greater attention to the realities of psychiatric inpatient wards, and the inclusion of strengths-based practices.
Development of the PNM drew on several approaches, including the Power Threat Meaning Framework, power-mapping, strength-based approaches, the Consumer-Centered Assessment of Strengths, Interests, and Goals, and the Comprehend, Cope, and Connect model. The PNM was designed to help service users and patients to develop a shared, contextual explanation of their distress with clinicians.
While this approach does not necessarily exclude biological explanations for suffering and psychiatric diagnosis, these factors are secondary to the service user’s own narrative. This model is unique among psychological formulations in that it explicitly incorporates considerations of service user strengths and available resources as well as linking the past, present, and future together by asking service users to consider past experiences, the meaning they have assigned to those experiences and their distress, perceived threats, responses to those perceived threats, their current situation, and possible next steps.
While prompts for all of these elements are included in the PNM, the authors note that this approach is flexible and not all service users will use every factor in building and understanding their personal narrative. For example, some patients and service users may prefer not to incorporate past experiences into their understanding of their current distress.
The authors identified three main themes in the survey, focus group, and interview data. (1) “Value of collaborative formulation” dealt with participants positive views of the PNM. Participants valued the emphasis on individual’s own experiences, meanings, history, and strengths, as well as the whole-person approach which focused on developing a complete portrait of each service user rather than reducing them to a supposed disease and various deficits as is common in biomedical psychiatric practices. Participants believed that the PNM could improve understanding between service users and clinicians and make care-planning more meaningful. They also reported that this model could replace or significantly improve current care-planning. One clinician said:
“The main strength is that it is based on the individual person as a whole, and from their own personal narrative instead of being based on a medical model which is based on numbers on a paper resulting from laboratory tests, exam results, etc.” A lived experience participant reported that “it [the PNM] also looks at how they are feeling about current treatment which is something that is not often talked about in therapy sessions.”
(2) “Selling and embedding change” involved how participants believed the PNM could be integrated into current mental health systems. Participants reported that staff would need to be convinced this model was useful rather than just another task for them to complete. Some participants believed this could be achieved by connecting this approach to existing practices, demonstrating concrete benefits, and making training accessible for staff with varying levels of psychological training and experience. Leadership and institutional support were also identified as important for implementing the PNM.
(3) “Implementation barriers” involved problems identified by participants with implementing the PNM in current mental health systems. These systems are often risk-focused, prioritizing risk management over recovery. The influence of biomedical models, which the PNM directly challenges, is deeply embedded in mental healthcare systems. Participants also cited time constraints, additional training requirements, and increased workload as problems with implementing the PNM. Some participants questioned whether patients and service users would want an active role in collaborative formulations, noting that patients and service users sometimes just want the professionals to solve their problems. One practitioner said:
“In a community team, I think it’s much easier than on an inpatient ward. Whereas a lot of the staff I’ve come across it’s more, ‘well, they just need – we just need to check with the meds and they’ll be fine.” Another practitioner with lived experience of mental health struggles reported that “sometimes you come across clients that basically say I don’t wanna get involved in this; just cure me. Just problem solve my stuff for me.” Remarking on the strained nature of current mental health systems, another practitioner said “staff are busy putting out fires, they don’t have time to look for the source.”
This study had five main limitations. The small sample size and recruitment exclusively from the UK limits generalizability. The lead researcher was involved in developing the PNM, potentially introducing bias into the current work. A single researcher conducted most of the qualitative analysis. Some of the survey questions may have primed participants to think about the benefits of the PNM, possible biasing the data. This study examined acceptability of the PNM, but did not evaluate its actual effectiveness in clinical settings.
****
Pringle, A., Totman, J., Van Bortel, T., & Kaminskiy, E. (2026). An exploration of acceptability of a collaboratively developed model of formulation. PLOS Mental Health, 3(9). (Link)
