Clinical Psychology- Anti or Ante-Science?

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Burning Down the House (Talking Heads)

Have some clinical psychologists developed a bad case of ...anti-science?

Burning down the House, Pull up the Roots and I Get Wild

Although scientists thought this disabling disorder had been eradicated in the previous century, we are seeing increasing numbers of clinical psychologists presenting with a variety of anti-science symptoms. I start here with the symptom of formulation (recently also accompanied by paradigma shiftitis ) - other symptoms will follow in later posts

I understand the reservations that psychologists have routinely and historically expressed about psychiatric diagnoses. Indeed, questions can be always be raised about the reliability and validity of any diagnosis -psychiatric or otherwise. Often these questions about diagnosis are framed in a low evidence, high hyperbole manner - for example saying they are "...hardly more meaningful than star signs". One thing is sure, much research has attempted to assess the reliability and validity of diagnoses like schizophrenia - whether people decide the evidence is sufficiently impressive is then at least a matter of empirical - rather than simply ideological - debate.

Making Flippy Floppy and Slippery People

Given the recent 'position statement' by the British Psychological Society's (BPS) Division of Clinical Psychology (DCP) - Time for a Paradigm Shift in Psychiatric Diagnosis (link to full document at foot of that page) - it is worth taking a closer look at the alternative to diagnosis proposed by the DCP -so-called Formulation

Pere Ubu (Non-Alignment Pact: 1977)

In their Good Practice Guidelines on the use of Psychological Formulation, the DCP states "there is no universally agreed definition of formulation", but do rather nebulously state that:

"Psychological formulation is the summation and integration of the knowledge that is acquired by this assessment process that may involve psychological, biological and systemic factors and procedures"

In the same document, they reference Clinical psychologist Gillian Butler (1998) who says

"A formulation is the tool used by clinicians to relate theory to practice… It is the lynchpin that holds theory and practice together… Formulations can best be understood as hypotheses to be tested.”
 

and later Kuyken (2006) is quoted as saying

'...formulation is ‘a balanced synthesis of the intuitive and rational cognitive systems’

So, Formulation is a hypothesis that links (any specific?)theory and (any specific?) practice that balances intuitive and rational cognitive systems?


and then later still, what formulation is not?

"A formulation is not an expert pronouncement, like a medical diagnosis, but a ‘plausible account’ (Butler, 1998, p.1), and as such best assessed in terms of usefulness than ‘truth’  (Johnstone, 2006)"

Plausible to whom? How do we assess usefulness as opposed to truth? It seems from the way that some clinical psychologists speak that formulation is viewed as orthogonal to veracity - indeed, it is implicit that multiple formulations of the same case are not only possible but possibly desirable(?)

This Heat: 24 Track loop (1978)

Girlfriend is Better

In this context, it is worth unpacking this very recent post - So... What happens next? by the clinical psychologist Peter Kinderman in the light of the DCP paradigm shift document:

Of course, traditional psychiatrists, and many members of the public, say that they find a diagnosis helpful and even comforting. But the truth is that this comfort comes from knowing that your problems are recognised (in both senses of the word), understood, validated, explained (and explicable) and that the person you’re speaking to has a decent plan to help you. A problems list and a formulation can do that. Paradoxically, better than a diagnosis – since, for example, two people with a diagnosis of ‘schizophrenia’ or ‘personality disorder’ might have absolutely nothing in common, not even the same ‘symptoms’, any comfort from a diagnosis is likely to be illusory.

Doesn't Peter Kinderman seem to speak about diagnosis as meeting just those criteria set out by Lucy Johnstone for assessing formulation? As Kinderman says, psychiatrists and patients often view diagnosis as a ‘plausible account’ and presumably diagnosis may also be assessed in terms of usefulness rather than ‘truth’?  It does sometimes seem as though clinical psychologists want to use different criteria for assessing diagnoses and formulations (Science and anti-science).  Further, don't these claims sound somewhat modest and mundane for a paradigm shift? On the basis of saying that no two people with a schizophrenia diagnosis have anything in common, he leaps to the conclusion that "any comfort from a diagnosis is likely to be illusory" - presumably we do return to 'truth' as opposed to ill-usion. Indeed, it would be interesting to hear how Professor Kinderman delineates illusory comfort from real comfort in his patients - that would take some expertise!

Moon Rocks

What about the evidence on formulation?
Bieling & Kuyken (2003) state in their paper Is Cognitive Case Formulation Science or Science Fiction?

In terms of the scientific status of the cognitive case formulation process, current evidence for the reliability of the cognitive case formulation method is modest, at best. There is a striking paucity of research examining the validity of cognitive case formulations or the impact of cognitive case formulation on therapy outcome.
 

One problem, of course, is that all humans are prone to biases and influence of short-cut heuristics that include halo effects, illusory correlations, framing biases, recency effects, confirmatory biases, and failure to consider normative standards. Bieling states that

"Clinicians may make these errors so habitually that in cognitive case formulations of identical cases using identical formulation methods it is not possible to accurately establish consensus."

Of course, some clinical psychologist essentially argue for a science of the individual. In their review of case formulation in mental health, Rainforth & Laurenson 2013 state

… there are difficulties in promoting commonality due to the individual nature of the formulation, based on the service user presentation, traits, personality experiences and needs, and issues relating to practitioner skills and experience...The complex nature of formulation-based approaches to treatment planning contains vulnerability due to judgemental and inferential bias. Benefits for standardizing treatments were noted; however, this also highlights a dilemma in whether to use standardized or individualized approaches to CF.

In other words, it sounds awfully like no two formulations would be the same

Who benefits from formulation?
As noted by Kinderman above, those who use formulation do, of course value it believing it benefits their patients ….but this remains unsubstantiated by any acceptable notions of empirical scientific evidence.

Some evidence suggests that formulation benefits staff rather than the patients or the outcomes for patients

"care planning, staff-patient relationships, staff satisfaction and teamworking, through increasing understanding of patients, bringing together staff with different views and encouraging more creative thinking" Summers 2006.

 

Kuyken et al (2005) in their paper 'The reliability and quality of cognitive case formulation' say:

Our review suggests that, contrary to the claimed benefits of cognitive case formulation, it is not a panacea, and its evidence base is weak at best. Our review suggests instead that it is a promising but currently limited approach to describing and understanding patients’ presenting problems

They suggest "the quality of formulations ranged from very poor to good, with only 44% rated as being at least good enough." and among mental health practitioners in training this fell to 24.1%. Formulations were distributed across the range from very poor to good (‘‘very poor’’ 22.1%; ‘‘poor’’ 33.6%; ‘‘good enough’’ 34.5%; ‘‘good’’ 9.7%). In other words, only a minority of formulations are rated as "good enough"

Swamp

Perhaps reliability and validity are irrelevant to the anti-science of formulation?

"Formulations may be reliable and valid but have no impact on treatment outcome. In contrast, they may be unreliable and invalid but lead through some alternative mechanism (e.g., increasing therapist self-confidence or enhanced alliance) to improved outcome." Bieling & Kuyken (2003) - see also p34 Good Practice Document Johnstone et al 2011

What this highlights most is the view that, while evidence for reliability and validity for formulation is lacking, it just doesn’t matter! The implication is that the lack of evidence for formulation is irrelevant, as it may still improve outcome. - Actually, no empirical scientific evidence exists to show that formulation improves outcome. Moreover no evidence at all exists to support the bold claim that formulation is in fact orthogonal to reliability and validity.


Finally, clinical psychologists may see formulation as an art rather than a science. Indeed, the BPS Good Practice Guidelines on Psychological Formulation states

"the subject matter of our discipline [clinical psychology], human beings and human distress, is not best served by the narrow ‘technical-rational’ application of research to practice. Rather, it requires a kind of artistry that also involves intuition, flexibility and critical evaluation of one’s experience. In other words, formulation is ‘a balanced synthesis of the intuitive and rational cognitive systems’ (Kuyken, 2006, p.30)."

Again, it seems little interest in the science rather than the artistry of formulation

Formulation is a treatment in itself?
Interestingly the BPS document on psychological formulation states "It should also be noted that developing a formulation can be a powerful intervention in itself" - this is an interesting notion insofar as it has no typical 'science' oriented evidence-base whatsoever - and if it is an intervention in itself then it ought to be evidence-based

This Must be the Place (naive melody)

So, formulation cannot be defined, it is a hypothesis, a theory-practice link. It has no basis in truth, it is based in usefulness (though possibly not usefulness to the patient it seems) . It may be an intervention in itself, and also not imply an intervention. It is unreliable and lacks validity. It has no evidential link to outcome. It is artistry linked to intuition...in short, it is anti-science....

An ironic conclusion, that the touted Kuhnian paradigm shift appears to be one going backwards into pre-science or perhaps....formulation its better described as ante-science