Formulation: the radical

alternative to psychiatric
diagnosis
Lucy Johnstone
Consultant clinical psychologist
Lucyjohnstone16@blueyonder.co.uk
Why is this important?
From a theoretical perspective:

The critique of diagnosis is the critique of psychiatry
(Brown 1990)

Diagnosis is the Holy Grail of psychiatry and the key to
its legitimation (Kovel 1981)

Without schizophrenia there would be no psychiatry
(Holmes 2011)




A reliable and valid classification system is the
foundation of any science. Without this, psychiatrys
claim to be a legitimate branch of medicine is fatally
undermined.
Psychiatry would become ..something very hard to
justify or defend a medical specialty that does not treat
medical illnesses.
(Breggin, 1993)

Diagnosis provides the foundation for the
biomedical language we use.

illness, patient, treatment, prognosis, remission, symptom,
etc

.which in turn shapes our assumptions about
mental distress and how we deal with it

doctors, nurses, wards, clinics, hospitals, medication etc



From a service user perspective:

The act of diagnosis is the crucial first step in the career of
any psychiatric patient

It turns people with problems into patients with illnesses

Meaning is first and greatest casualty of diagnosis and
biomedical psychiatry (cf Karl Jaspers)

In the final analysis, power is the right to have your definition of
reality prevail over all other peoples definition of reality
(Rowe 1990)



I got a diagnosis of schizophrenia. With this I got the
message that I was a passive victim of pathology. I
wasnt encouraged to do anything to actively help
myself. Therapy meant drug therapy. It was hugely
disempowering and undermining, exacerbating all my
doubts about myself. And the impact was devastating
because it just served to make the voices stronger and
more aggressive because I became so frightened of
them. What started off as experience became a
symptom This all happened in a shockingly short
space of time. I went into that hospital a troubled,
confused, unhappy 18-year-old and I came out a
schizophrenic. And I was a good one. I came to embody
how psychosis should look and feel.
Eleanor Longden (2011)


Clients and the general public are negatively affected by the
continued and continuous medicalisation of their natural and
normal responses to their experiences; responses which
undoubtedly have distressing consequences which demand
helping responses, but which do not reflect illnesses so much
as normal individual variation.
..The putative diagnoses presented in DSM-V are clearly
based largely on social norms, with 'symptoms' that all rely on
subjective judgments, with few confirmatory physical 'signs'
or evidence of biological causation. The criteria are not value-
free, but rather reflect current normative social
expectations..
[taxonomic] systems such as this are based on
identifying problems as located within individuals. This misses
the relational context of problems and the undeniable social
causation of many such problems.(DCP/BPS consultation response)


The DSM controversy

Society for Humanistic Psychology open letter and petition

www.ipetitions.com/petition/dsm5

Follow the story at:

www.dxrevisionwatch.wordpress.com


Worldwide coverage on Feb 10
th
2012
Lonely? Shy? Sad? Well now youre mentally ill too (The
Independent, 10.2.12).

The proposals in DSM-5 are likely to shrink the pool of normality to a
puddle with more and more people being given a diagnosis of
mental illness (Til Wykes, The Guardian, 10.2.12)

It is hard to avoid the conclusion that DSM-5 will help the interests of
the drug companies and the wrong-headed belief of some mental
health professionals (David Pilgrim, The Financial Times 10.2.12).

Many people who are shy, bereaved, eccentric or have unconventional
romantic lives will suddenly find themselves labelled as mentally ill.
This isnt valid, isnt true, isnt humane (Peter Kinderman, The
Independent, 10.2.12).




DSM 5 will radically and recklessly expand the boundaries
of psychiatry.

Professor Allen Frances, Chair of DSM IV Task Force

The petition is about specific revisions rather than the
whole system.. But have we reached a tipping point?

Schizophrenia Commission

www.schizophreniacommission.org.uk


Inquiry into the schizophrenia label

(schizophreniainquiry.org)
Could we replace psychiatric diagnosis with
formulation..?
All formulations..

Summarise the clients core problems
Show how the clients difficulties relate to
one another, by drawing on psychological
knowledge
Explain, on the basis of psychological theory,
why the client has developed these
difficulties, at this time and in these situations
Give rise to a plan of intervention
Are drawn up collaboratively with the client
Are open to revision and re-formulation

A formulation is the tool used by clinicians to relate theory
to practiceFormulations can best be understood as
hypotheses to be tested...

..The lynchpin that holds theory and practice together

..at some level it all makes sense (Butler 1998)

Formulation as a different type of explanation from
diagnosis
a process of ongoing collaborative sense-making
(Harper & Moss, 2003)
.a way of summarising meanings, and of negotiating for
shared ways of understanding and communicating about
them (Butler, 1998)
- with no clear boundaries or end-point
broad snapshot summaries of complex evolving
stories (Cole, 2008)
- and for this reason perhaps best understood as a
process not an event
- and best evaluated in terms of usefulness or fit, not truth.


Formulation in psychology and psychotherapy: Making
sense of peoples problems

eds L Johnstone and R Dallos, Routledge 2006
Partly because of your early experience of trauma, you
were a quiet and hard-working child without a great deal
of self-confidence. The transition to university was a
shock to you. Unable to work out who you were or how
you wanted to live your life, you felt very unhappy and
confused. The appearance of your first voice seemed to
be triggered by these worries, and many unresolved
feelings came to the surface. Unfortunately, psychiatric
treatment reinforced all your doubts and lack of
confidence by giving you the message that you were
defective, helpless and hopeless in the face of a serious
mental illness. The more afraid you were of your voices,
the more frightening they became. As you became
further entangled in the identity of a mental patient, and
felt increasingly powerless, the voices grew in power and
dominance. Taunts and rejection from other people
increased your sense of alienation and rejection. The
dominant voice took over, and you felt completely in his
control.
We have talked about how you need to start believing in
yourself and taking some control back from the voice,
and questioning other peoples definition of you as a
hopeless schizophrenic. We have begun to understand
that the voice represents the insecure and rejected parts
of yourself, and calls attention to unresolved issues from
the past. There may be things that you can learn from
the voice which will help you on your path to recovery.
You are an intelligent, determined and resourceful
person, and these strengths will help you to find a way
forward.


It was the first time that I had been given the
chance to see myself as a person with a life
story, not as a genetically-determined
schizophrenic with aberrant brain chemicals and
biological flaws and deficiencies that were
beyond my power to heal.. Pat Bracken was
so much more humane than that. And he didnt
talk about auditory hallucinations he talked
about hearing voices and unusual beliefs rather
than delusions, anxiety rather than paranoia. He
didnt use this terrible mechanistic, clinical
language, he just couched it in normal language
and normal experience.

Trauma and psychosis
Childhood abuse and neglect is at least as strongly linked to
psychosis as to other psychiatric conditions, and the link appears to
be a causal one

Evidence of a dose-dependent relationship between the severity,
number, and number of types of traumatic episodes, and the
likelihood of psychosis (People abused as children are 9.3 times
more likely to develop psychosis; risk rises to 48 times for the
severest abuse (Janssen et al 2004); people who have experienced 3
kinds of abuse were 18 times more likely to be psychotic; 5 types of
abuse = 193 times more likely (Shevlin et al 2007.)

The link appears to be a causal one; there is a dose-dependent
relationship between the severity, number, and number of types of
abuse and later symptoms. The relationship holds in prospective
studies and after controlling for gender, ethnicity, education,
substance abuse, etc.

The content of delusions is often closely related to actual
experiences of abuse (Read et al 2005)


People who have survived atrocities often tell their
stories in a highly emotional, contradictory, and
fragmented manner which undermines their credibility
and thereby serves the twin imperatives of truth-telling
and secrecy..Witnesses as well as victims are subject
to the dialectic of trauma. It is difficult for an observer to
remain clearheaded and calm, to see more than a few
fragments of the picture at one time, to retain all the
pieces, and to fit them together. It is even more difficult
to find a language that conveys fully and persuasively
what one has seen(Herman 2001)

Lucys all-purpose formulation for long term service users
Service user X has unmet attachment needs and unresolved
trauma from their early life. X tries to meet these through the
psychiatric services, but fails, since services are not set up to
do this. Still needy, but unable to achieve enough emotional
security to move on, X ends up trading symptoms for
whatever psychiatric care is on offer. Staff are initially
sympathetic but become increasingly frustrated at Xs lack of
progress. The resulting dynamic may end up repeating Xs
early experiences of neglect, rejection or abuse. Both parties
become stuck, frustrated and demoralised in this vicious circle.
Service user X has unmet attachment needs and unresolved
trauma from their early life. X tries to meet these through the
psychiatric services




Diagnosis versus formulation
Diagnosis
Removes meaning
Removes agency
(sick role)
Removes social contexts
Individualises
Keeps relationships stuck
Culture blind
Disempowering
Stigmatising
Medical consequences
Social consequences


Formulation
Creates meaning
Promotes agency
Can include social
circumstances
Includes relationships
Looks at relationship
change
Culture sensitive
Collaborative
Non-stigmatising
Non-medical
No social consequences
Some pitfalls on the horizon..
Simply replacing one nonsensical term
with another
Cf dopamine dysregulation disorder

Re-drawing the boundaries of the
increasingly discredited diagnosis of
schizophrenia
Borderline personality disorder and bipolar disorder

Using psychosis as a woolly, more user-
friendly substitute
Cf Read et al; Hammersley et al on trauma in psychosis;
Romme on postraumatic psychosis; Ross on dissociative
psychosis
Using formulation alongside diagnosis
RCP curriculum
The Specialist Core Training in Psychiatry (Royal
College of Psychiatrists, 2010) requires trainee
psychiatrists to demonstrate the ability to construct
formulations of patients problems that include
appropriate differential diagnoses (p25).

Contrast DCP guidelines
Psychological formulation is not premised on a
functional psychiatric diagnosis (eg schizophrenia,
personality disorder)
Mixed models (diagnosis plus formulation, or biopsychosocial
or vulnerability-stress models) are problematic

Weak sense obviously true in a general sense, but by
explaining everything they explain nothing in particular
(Skrabanek 1984)

Strong sense the bio or vulnerability bit (for which there is
no evidence) seen as primary causal factor

This preserves medical assumptions by reducing
psychological and social factors to the trigger of an
underlying illness
Divests them of their personal meaning

You have a medical illness with primarily biological causes
vs
Your problems are a meaningful and understandable response to
your life circumstances

This is a mixed message about personal responsibility

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.


.which leads to all the familiar contradictions of
everyday psychiatric practice

Not compliant vs Too dependent

Wont accept theyre ill vs Sick role behaviour

Too demanding of services vs Not engaging with services


These contradictions are inherent in the combining of
two models with fundamentally incompatible core
assumptions


A more convincing version of a biopsychosocial model
would look at how these various factors interact

Cf recent research looking at the effects of trauma and
deprivation on the developing brain (Gerhardt 2004)

Note: this is NOT an illness model, but a genuinely
integrative one which prioritises social and psychological
causal factors. It does not justify the use of medical
diagnostic terms.

Formulation is not perfectdepends how it is done
Can obscure social contexts; be individualising; remove
responsibility; be pathologising and non-collaborative;
overlook the role of relationships

Dangers of psychological diagnosis eg challenging
behaviour. (Problem is not an objectively identifiable
natural category, and it is often not possible to see any
particular behaviour or experience as inherently
problematic Boyle 2001)
Future directions
There is a need for a revision of the way mental distress
is thought about, starting with recognition of the
overwhelming evidence that it is on a spectrum with
'normal' experience and the fact that strongly evidenced
causal factors include psychosocial factors such as
poverty, unemployment and trauma.

An ideal empirical system for classification would not be
based on past theory but rather would begin from the
bottom up starting with specific experiences, problems
or symptoms or complaints. DCP statement 2011

Eg Hearing Voices research


Formulation-based clustering terms to replace
schizophrenia, bipolar disorder etc
DSM already contains some of these! Adjustment
disorder, PTSD, bereavement reaction, attachment
disorder

For example, Trauma reaction in the context of insecure
attachment

Formulation as a radical act
Where diagnosis is about silencing people, formulation is
about giving them a voice

RESTORES MEANING
RESTORES AGENCY
RESTORES HOPE

.for service users and staff
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