Formulation: A potential way forward together?

Formulation: the radical
alternative to psychiatric
Lucy Johnstone
Consultant clinical psychologist
[email protected]
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, psychiatry’s
claim to be a legitimate branch of medicine is fatally
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,
….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 people’s 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
wasn’t 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 valuefree, but rather reflect current normative social
… [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
Follow the story at:
Worldwide coverage on Feb 10th 2012
‘Lonely? Shy? Sad? Well now you’re “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 isn’t valid, isn’t true, isn’t 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’
Inquiry into the ‘schizophrenia’ label
Could we replace psychiatric diagnosis with
All formulations……..
•Summarise the client’s core problems
•Show how the client’s difficulties relate to
one another, by drawing on psychological
•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 practice…Formulations can best be understood as
hypotheses to be tested…...
…..The lynchpin that holds theory and practice together
… some level it all makes sense’ (Butler 1998)
Formulation as a different type of explanation from
‘……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 people’s 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
We have talked about how you need to start believing in
yourself and taking some control back from the voice,
and questioning other people’s 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
‘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 didn’t
talk about auditory hallucinations he talked
about hearing voices and unusual beliefs rather
than delusions, anxiety rather than paranoia. He
didn’t 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)
Lucy’s 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 X’s lack of
progress. The resulting dynamic may end up repeating X’s
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
• Removes meaning
• Removes agency
(‘sick role’)
• Removes social contexts
• Individualises
• Keeps relationships stuck
• Culture blind
• Disempowering
• Stigmatising
• Medical consequences
• Social consequences
• Creates meaning
• Promotes agency
• Can include social
• Includes relationships
• Looks at relationship
• 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
Borderline personality disorder and bipolar disorder
Using ‘psychosis’ as a woolly, more userfriendly substitute
Cf Read et al; Hammersley et al on trauma in ‘psychosis’;
Romme on ‘postraumatic psychosis’; Ross on ‘dissociative
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’
‘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
…….which leads to all the familiar contradictions of
everyday psychiatric practice
Not compliant vs Too dependent
Won’t accept they’re 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
• 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 perfect…depends 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
• For example, ‘Trauma reaction in the context of insecure
Formulation as a radical act
Where diagnosis is about silencing people, formulation is
about giving them a voice
….for service users and staff
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