Psychological formulation as a way forward? Lucy Johnstone Consultant Clinical Psychologist

The arguments so far……. Mental distress cannot be understood as analogous to bodily dysfunction – but it is hard to escape the ‘DSM mindset’ Injustice and distress are perpetuated by obscuring, minimising and denying the powerful links between trauma and psychosis Medical language plays a key role in nullifying context and meaning and undermining people’s innate wisdom and resources

Question: Could we replace psychiatric diagnosis with psychological formulation? Answer: It depends what you mean by formulation… and it depends how you do it…. …..and there are different issues at an individual versus a wider clustering level

1. It depends what you mean by formulation Psychiatric formulation: 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). Psychological formulation: ‘Is not premised on a functional psychiatric diagnosis (eg schizophrenia, personality disorder)’ ( DCP 2011 ‘Good Practice Guidelines on the use of psychological formulation’ p.29 )

In other words, psychological formulation is replacement for, not an addition to, a psychiatric diagnosis ‘Once these complaints have been explained, there is no ghostly disease remaining that also requires an explanation. Complaints are all there is’ ( Bentall, 2003 ) ‘There is the abuse, and there are the effects of the abuse. There is no additional “psychosis” that needs explaining’ ( Johnstone, 2007 )

Contrast: Psychiatric formulation (eg ‘schizophrenia triggered by the stress of exams’) vs psychological formulation (eg ‘hearing the voice of your abuser as a response to the trauma you experienced’)

2. It depends how you do it Psychological formulations can, like psychiatric diagnosis, obscure social contexts; be individualising; undermine agency; pathologise; and be constructed in an expert- derived, unreflective and disempowering way…. …and because the term ‘formulation’ is itself based in a Western psychological model, it has the potential to marginalise other cultural explanations (spirit possession, voices of ancestors, etc) …unlike the Hearing Voices concept of a ‘construct.’

Best practice principles (DCP Guidelines 2011) Integrative Reflective Collaborative Include social and societal contexts Culturally sensitive Include strengths Centrally concerned with personal meaning… ‘…a process of ongoing collaborative sense-making’ ( Harper and Moss, 2003 )

Psychiatric diagnosis Obscures meaning Removes agency (‘sick role’) Removes social contexts Individualises Keeps relationships stuck Disempowering Stigmatising Culture blind Deficit-based Medical consequences Social consequences Psychological formulation Explores meaning Promotes agency Can include social circumstances Includes relationships Looks at relationship change Collaborative Non-stigmatising Culture sensitive Includes strengths Non-medical No social consequences

3. But do we also need broader formulation-based clustering terms to replace DSM? To reduce complexity by grouping similar experiences together To inform individual formulations by linking to bodies of evidence To provide a basis for research …plus administrative purposes: aid communication, plan services, allocate benefits etc

Attempts to define new subdivisions of existing categories, eg: ‘Complex post traumatic stress disorder’ (Herman, 2001) ‘Dissociative schizophrenia’ (Ross, 2006) ‘Traumatic psychosis’ ( Callcott and Turkington, 2006) NB These imply psychosocial causal factors but do NOT avoid the ‘DSM mindset’. Nevertheless, they are signs of a paradigm under serious threat

Oddly enough, DSM already contains some categories that are perhaps better understood as broad-level formulations than as diagnoses…if you remove the term ‘disorder’ ‘Adjustment disorder’ Bereavement reaction’ ‘PTSD’

‘Trauma reaction in the context of attachment difficulties’ ….but this covers just about all presentations! ….and doesn’t help with the ‘everything causes everything’ problem ‘……researchers have recently established that a broad range of adverse childhood events are significant risk factors for most mental health problems, including psychosis….’ (Read and Bentall, BJ Psychiatry, Feb 2012)

Tentative conclusion Psychological formulation does have the potential to replace psychiatric diagnosis at an individual/family level, and to perform more effectively the claimed functions of diagnosis (suggest how the problems arose, indicate interventions, predict outcomes)…. Along with other benefits (enhancing the therapeutic alliance, normalising, thinking about lack of progress, providing containment) ….although research is lacking (and much needed)

…but we have a long way to go, and a great many conceptual and political challenges, in developing a broader system that avoids the ‘DSM mindset’, and informs the co-construction of individual narratives in a way that puts back what diagnosis takes out: Restores context Restores meaning Restores agency Restores hope We are open to your suggestions!

Bentall, R (2003) Madness explained: psychosis and human nature. London, New York: Penguin Callcott. P and Turkington, D (2006) CBT for traumatic psychosis. In W. Larkin and AP Morrison (eds) Trauma and psychosis. Hove, New York: Routledge Harper, D and Moss, D (2003) A different kind of chemistry? Reformulating ‘formulation.’ Clinical Psychology, 25, Herman, J (2001) Trauma and recovery. London: Pandora Johnstone, L (2007) Can trauma cause ‘psychosis’? Openmind, 150, 6-9. Ross, CA (2006) Dissociation and psychosis. In J Johannessen, B Martindale and J Cullberg (eds) Evolving psychosis. London, New York: ISPS for Routledge