Friday, 31 May 2013

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"


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 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


  1. It is interesting and useful to see this analysis. Whilst the detail is subject specific some of the broad problems are not. Recent discussions in evolutionary biology have had a similar pattern - over definition and calls for a new paradigm or even claims that one has occurred (check out arguments around the Extended Evolutionary Synthesis).

    We would expect this as this is a philosophy of science issue, so if that discipline has any utility it should be generalizable across sciences. In other words, philosophy of science is, in a sense, a profoundly psychological or cognitive discipline in that it excoriates thinking patterns and behaviours in the domain of science. One of its own major issues has been demarcating science in order to aid this focus, which is more than a little resonant.

    I have recently wondered about how psychologists are trained in research methods and I have claimed a reintroduction of formal logic as a possible cure:

    But I also have an anxiety about exposure to philosophy of science. It strikes me that modern scientists (perhaps of a certain sort) have a passing awareness of demarcation, paradigms, research programmes, Popper, Kuhn, and possibly Lakatos and Feyeraband. But these names and terms are latched onto quickly and used somewhat cheaply - or rather inexpertly, a bit like only having a hacksaw to hand to cut paper. My general rule of thumb is that a paradigm shift is something for future historians of science to judge, and philosophers to examine. We will all be long dead, so if one has happened we won't know about it.

    Of course, that won't always be true but it takes the heat out of such discussions and allows a focus on conceptual structure of each argument and the associated data. Talk of paradigm shifts is pure hubris, and perhaps a symptom of our metrics based system these days (a paradigm shift must count as impact for REF).

    Scientists are but a small part of one Great Curve.

    1. Thanks Tom
      Interesting to hear that similar stuff goes on in other areas - I wonder why it aflicts some areas more than others - why are clinical psychologists so poor at assessing fundamental aspects of their work?

      Re philosophy of science and formal logic - I agree that psychologists (indeed...all scientists) should be required to study both. I also think that the conjunction of second-hand knowledge of philosophy of science (especially Kuhn) and no knowledge of formal logic is a fatal combination for clear thinking!

    2. "I wonder why it aflicts some areas more than others - why are clinical psychologists so poor at assessing fundamental aspects of their work?"

      It seems to me that there could be a few important things that may relate to this (purely from a reasoning perspective):

      1. standards (e.g. what should a clinical psychologist do and/or know)

      2. rules, regulations and continuous monitoring of them (e.g. how do we know if a clinical psychologist does and knows what he/she should)

      3. education (e.g. why, how, and what should clinical psychologists learn to subsequently do and know)

      I wonder if a) different countries, and even institutions within countries hold different views on all of these. I also wonder if b) all these things (should they make any sense) are even made explicit enough in order to subsequently guide education & practice. I also wonder if c) clinical psychology attracts certain types of people who want to be a clinical psychologist (who think/don't think about all these things, select similar types as their co-workers, educational advisors, etc.)

      If you take 1, 2, and 3 and a, b and c (and maybe even mix them up) then perhaps you got a few possible answers to your question.

  2. So a 'formulation' is a diagnosis that makes no claim to be true...?

  3. For me, whatever my rather junior opinion is worth, the DCP do seem to have wandered into a bit of a double bind.

    If they deny nomothetic knowledge, like a classification, they end up allowing any old relativistic opinion to be used to describe a patient. Like pre-Rosenhan. As useful as that might be to an individual, it's difficult/impossible to further research in many areas, and leaves sheer quackery open.

    The alternative of accepting nomothetics, like a "symptom list", really isn't any different in any meaningful way to a diagnosis; certainly not evidenced to be so.

    Most of this stems from on abysmal misunderstanding of what a diagnosis is anyway, that familiar straw man. It's not a biological entity; that image of it is perpetuated by the DCP. Take PTSD for example. The clue is in the name, people.

  4. Thanks for this post. As a service user, I find this paragraph in the BPS Good Practice Guidelines chilling:

    "Formulation can be used in insensitive or disempowering ways (Johnstone, 2006). There is evidence that as well as finding formulations helpful, encouraging and reassuring, service users can also (sometimes at the same time) experience them as saddening, upsetting, frightening, overwhelming and worrying (Chadwick et al., 2003; Evans & Parry, 1996; Morberg Pain et al., 2008). While it is possible that the longer-term impact is beneficial overall, much more research is needed into service user and carer reactions to formulation."

    So, formulation could be distressing in multiple ways but it's okay because "it is possible" formulation is beneficial?

  5. You said no clinical psychologists had commented yet Keith, so here's some thoughts from a trainee.

    Formulation's problems begin once it sets itself up as an alternative to diagnosis. The DCP is conflating the epistemological problems that can arise from diagnosis (Eleanor Longden's anecdote about being told by her doctor that a diagnosis of Schizophrenia was "worse than cancer" is an oft cited and informative example) with the fact of diagnosis per se.

    If formulation is not set up as a sort of humane panacea in this way it doesn't seem so problematic. Is it scientific? On the one hand it doesn't get much scientific validation from the studies cited here. However, does it count in formulation's favour that it is an integral part of the process of most psychotherapy? Such empirical validation as exists for these therapies also presumably supports the formulations that they rely on.

    Even without validation by research, if formulation is conducted with a greater degree of humility (not seen as a great humane panacea) then it is nothing more than a process of finding out more information about a person; additional to that which is provided by meeting diagnostic criteria in a manual. The skeptical accrual of information about a person seems to be a scientific enough stance to me. It becomes un-scientific if overly grand claims are made for the significance of the things it reveals.

    1. Thanks Huw
      Your point about the DCP setting-up formulation as an alternative to diagnosis is interesting. That's not quite how I perceive it ...

      I see the DCP position as simply being 'anti-diagnosis' .
      This may be why the 'paradigm shift' document mentions 'diagnosis' over 25 times and 'formulation' only 3 times
      The DCP are not presenting an argument 'for' formulation, but a position 'against' psychiatric diagnosis

      This may also explain why clinical psychologists so infrequently assess 'formulation' empirically

      By the way, I recommend readers to look at your post on formulation as 'narrative fallacy'

  6. Thanks for this ... I think the danger with responding to this type of post is that it very easy to get into the attacking to attacked positions:

    - Psychology versus psychiatry
    - Diagnosis versus formulation
    - Nature versus nurture
    - Academic versus clinician
    - Laws versus Bentall?!

    These positions feel unhelpful at times, as the more attacked people feel, the harder it is for people to appreciate the opposite fact my understand has always been that such arguments tends to shut off people's thinking about challenges/alternatives ... the very opposite of what is trying to be done...

    Indeed when I look at some of Laws, Johnstones, Bentalls, APAs, CPNs, points... This seems to be happening in a really unhelpful way..

    People read these helpful and valid critiques and end up making ridiculous conclusions, perhaps because they are feeling attacked or criticised. For example, things I have heard recently...

    - You just ask what's happened to someone and all will be revealed
    - Clinical Psychologists need to be got rid of and replaced with Befrienders as there is no evidence at all for their work
    - Psychiatrists are labelling people with no awareness at all and are a force for evil
    - All Clinical Psychologists in psychosis use CBT therefore need to be shot
    -All clinical psychologists who don't use CBT for psychosis don't have any evidence for their work- so what the hell are they doing?
    - If there is no EVIDENCE - what's the point ? Get rid of such unscientific (therefore unethical/dangerous and expensive ?!) work... So in the case of psychosis, get rid of cbt for psychosis (poor evidence), diagnosis (little reliability and validity), formulation (no reliability and validity), anti-psychotic medication (have you see the Cochrane review for resperidone?!), and if you dare think about Psychodynamic, CAT, PIT, DBT, Counselling, EMDR, Narrative, Community approaches... God come down on you with hell and fire....

  7. My argument is that no one at present can provide us with evidence that tells us (SHOW ME THE PAPERS if you think otherwise):

    - Formulation helps everyone
    - Formulation harms everyone
    - Diagnosis helps everyone
    - Diagnosis harms everyone
    - Medication helps everyone
    - Medication harms everyone
    - There is a gene/set of genes for each identified diagnosis
    - There is a clear psychological basis for each identified diagnosis
    - Diagnoses have full scientific validity/reliability
    - Formulations have full scientific validity/reliability
    - Mental health is a science

    Laws can write as many blogs as he wants and critique as many papers as he likes...
    Morrison can publish as many RCTs as he wants
    The DCP can make as many position statements as they like
    The DSM can have an infinite number of diagnoses ...

    But at this moment, and I'm sure for some time to come..we are forced to work with what little we have...

    Clinical psychology has got it right on one level in that we do need to move away from a position of categorising people as one size DOES NOT fit all....however, it has tripped up, by saying formulation is the alternative for everyone ...

    I know academics and researchers and professionals and society are DESPERATE to find an overall answer ...But until we can let go of that and truly appreciate that it is ok that people are individual and that different methods and combinations of methods work for some people (and are less helpful for others) we will be stuck in discourses which are about trading one approach against another.

    Research doesn't really get on well with conclusions that end up with "for some people, some of the time" , unfortunately this is often the best we have...

    The critiques about formulation that Laws gives are correct ... it is NOT well evidenced , it is NOT a standardised approach and it is NOT helpful for everyone ... there is NO evidence that it is better than diagnosis...

    I think it is to the DCPs credit that it is citing evidence to show that formulation can be distressing and unhelpful to some people - it immediately allows us to look at addressing these areas - new research is possible... The approach can be developed , it can be made more scientific, more individual, more helpful ... I genuinely believe that by owning such critiques that Laws makes we can improve and improve our approach....

    1. "Clinical psychology has got it right on one level in that we do need to move away from a position of categorising people as one size DOES NOT fit all....however, it has tripped up, by saying formulation is the alternative for everyone "

      It seems a given that "one size does not fit all" (with regard to all available options), but is that the question at hand/ what would be most helpful to talk about ?

      It seems to me that it would be helpful to investigate what would be MOST helpful (and/or least harmfull) as a therapy/ therapeutic method (i.c. it is a matter of comparing A with B/ it is a relative matter), if only to provide a default approach with the highest probability of being helpful (and/ or least harmfull).

  8. The problem or perhaps what is freeing about formulation is that apart from in CBT it does not tend to be standardised ... they are far more individual ...

    CBT is perhaps more realist in its approach. It tends to be diagnostically driven - which means it is coming from a certain epistemological stance - there is one truth (like diagnosis) - this raises many questions...

    Other formulations (e.g., CAT, narrative, systemic approaches) take a more constructionist stance - they focus on the understanding created between the client and therapist - there is an acknowledgement that the understanding created is co- constructed between therapist and client - that it is subject to bias and that it is one truth that is being favoured in order to allow someone to gain an understanding that makes sense to them to allow for change.... Many questions could be said about this too...

    In ending I would just encourage readers to keep questioning ... Both evidence, clinical experience and personal viewpoints:

    Why might keith laws be critiquing clinical psychology, formulation and cbt for psychosis?

    Why might Bentall be critiquing keith laws and psychiatry?

    Why might Morrison, kuipers, chadwick, garety etc be so dedicated to producing so much research in cbt for psychosis?

    Why is there a lack of other research for psychosis?

    Why does the DCP oppose diagnosis?

    Why does psychiatry diagnose?

    Why has the science v non-science, nature v nurture debate never been resolved?

    Why is does this post have certain biases?

    These questions, critiques, arguments, discussions must be looked at holistically to avoid shutting down perspectives.... rather allowing us to further advance our thinking ...

  9. As a trainee clinical psychologist, I'm surprised and slightly saddened when arguments such as this become polarised (although maybe that's a function of my own naivety). I don't think we do anyone -- least of all service users -- any favours if we start sketching professional battle-lines, or if we resort to arguing about right/wrong, truth/falsehood, psychology/psychiatry, etc.

    Psychodiagnosticator, above, is way more eloquent than I could be about formulation and diagnosis, and I think his is an excellent summary. However, I think it's also worth reminding ourselves that formulation is proposed as a collaborative process (e.g. DCP, 2011): not something presented *to* the service user as fact or immutable explanation, but an attempt to work *with* each person to explore their problems and generate a treatment plan. This, for me, is where the idea of "usefulness" rather than "truth" is at its most important -- not telling the service user "this is what's wrong with you, this is how we'll fix it" but working together towards agreed goals, reflecting and reformulating as necessary over time. I'd hope this suggests how we might begin to avoid the problems highlighted by Chasing Data, above; also, I see no reason why diagnostic terminology can't be part of a formulation should the service user find it useful.

    This doesn't mean that formulation can't be researched: quite the opposite. It can be and it absolutely should be -- and I wonder if this is something the DCP might usefully drive forward.

  10. As a trainee Clinical Psychologist, I also share Huw's understanding about the function of formulation as a process not as a 'truth'. I also see where Huw is coming from in the criticism of the DCP's stance as 'conflating the epistemological problems that can arise from diagnosis...with the fact of diagnosis', however it does pose the question: can these two concepts be separated out?

    I think the problem is that wherever we continue to hold on firmly to a diagnostic system, the more it reinforces an idea that mental illness is something you either have or you don't have. In my view, formulation offers a way of thinking about how we can make changes in our lives to help us cope differently with our distress. It's often used as a map for therapy and intervention. My understanding of the DCP document is that by raising the awareness of a formulation-driven approach to mental distress, it empowers people and gives people hope that things can change.

    There's two caveats I want to make here: Firstly, we need a lot of research to test to see if this is the case - and i recognise the minefield in trying to break down this research into testable hypotheses. Secondly, I know that mental health systems working with diagnosis are not saying there is no hope for change; I am merely saying that I wonder if the popular opinion of 'mental illness' is that there is less hope for change (again, this needs testing but I am aware of some work done by Weiner and colleagues on the way people attribute the cause, level of control, level of stability etc in 'mental illness').

    My hope for formulation comes down to language. Formulation gives us language which I see as being a more useful alternative when it comes to considering ways we can make changes to reduce/manage/understand our distress.

  11. Thanks for posting this - it's a thought provoking and timely debate to have. I'm a trainee Clinical Psychologist myself so grappling with the issues presented above is very useful and certainly food for thought.

    For what my two pence is worth, it seems that there are two ways of conceptualising "formulation" - as a noun or a verb. I'd argue that separating them out is helpful. One strand of the concept appears to relate to formulation as something that is "done to" or "offered" to the client. For example, a comprehensive, theory-based account of their presenting difficulties. Formulation (noun) in this sense of the word can be compared to diagnosis, in that it is attempting to categorise a set of problems in order to make a coherent meaning out of them, that will drive an intervention forward. When formulation is defined in this sense, as an "object", I would concede that we are not at a stage where we can say formulation confers any additional benefits (or any benefits at all for that matter) over diagnosis, to either service users or clinicians. The evidence base, as the above blog post highlights, is simply not there yet and there is a clear gap that needs filling. I would add that this is recognised by the Division of Clinical Psychology in their document entitled "Good practice guidelines on the use of psychological formulation" (BPS, 2011). Additionally, in July's edition of Clinical Psychology Forum (BPS, 2013), a short article regarding the recent DSM position statement has stated that the DCP working group that are taking the lead on this have identified a "...range of further work streams" (p.12). Whilst there is clearly a need for an evidence base to substantiate the use of psychological formulation as a replacement to diagnosis, it appears that there are at least whisperings of the profession putting our money where our mouth is and devising a plan to investigate alternatives to diagnosis.

    From a different angle, I would argue that formulation does have an evidence base if it is considered as a process, rather than an object. When I say process, I mean that formulation (verb) is used as 1) a way of structuring assessment and collating gathered data, 2) a way of making sense of a client's presenting problems alongside them. 3) a road map for intervention, 4) an integral part of the intervention. For example, psychological literature has a great deal to say about the role of threat in a person's life (I'd refer anyone interested to any of the works of Paul Gilbert or Patricia M. Crittenden). A concept I find myself returning to with many clients is the notion that early threat has a profound effect on the development of the limbic system, which makes that person very sensitive to threat, such that even innocuous stimuli outside of a threat-context may activate a safety-seeking response. Such a concept is key to Compassion-Focussed Therapy and may form an crucial part of a person's formulation. Therapeutic work may focus on self-soothing and ways of coping with this threat sensitivity. The concept of limbic hypersensitivity is quite well researched from what I have seen (recent neuroimaging evidence from Garrett et al. (2012) for example, supports this concept. A comprehensive review has also been published by van Der Kolk).

    My point is, if treated as simply an alternative to diagnosis, the evidence to support its superiority is just not there at the present time (although it will be interesting to see how the research unfolds in coming years). However, formulation is a lot more than that, and the content of a formulation can and has been tested empirically in a lot of cases.

    Frustratingly for me as a trainee, who is still learning about formulation, there is a clear need to tighten up definitions of the concept, and the fact that I've had to outline to different definitions in my post stands as testimony to this.

  12. As someone with a (dare I say it?) diagnosis, I have been very attracted by the DCP's idea that I have never been ill: that all the extreme states I have experienced have merely been a commensurate response to my life and environment. So I've searched to find the DCP's explanation of intense, off-the-wall mania and how they would deal with it at its height. So far, I haven't found the answer, but I have discovered from the DCP folk that my psychiatric teams think of me as a label, drug me to my eye-balls and write me off - all the while making a fortune in cahoots with big pharma. How could I not have seen it! How was I taken in? When my evil doctor helped me with finding healthy housing or referred me to gym, he was merely distracting me from his abusive drug regime? And when my CPN helped me find voluntary work, that was her keeping me sweet and keeping me on meds: and the Crisis Team, when they came round, they were only pretending to want to keep me at home and out of the hospital. I can't take the DCP people seriously if their starting point is that those in mainstream psychiatry are not just wrong, but corrupt and abusive. The currnt system is a long way from perfect, but there are a lot of good people in it. I want the DCP to win me over, to let me genuinely feel I've never been ill and that answering the apparently never asked question "what happened to you" will open the gates of perpetual well-being. The funny thing is, I have a non-identical twin, and what happened to me is almost the same as what happened to him in the 21 years before I "got ill". The notion that the 50% difference in his genes might have some part to play in the difference in our lives is a formulation worth considering. We can't always reformulate if that's not useful.

  13. The previous post is amongst the best I've ever read.

  14. Thanks for saying that! Was hesitant to wade in on the debate. My last line was meant to be a slightly sardonic "we CAN always reformulate" ..... (predictive text can be a pain). Best wishes, Someone With a Diagnosis (otherwise labelled by those who know him as Jonathan)

  15. Lucy Johnstone4 June 2013 at 12:52

    I welcome this debate and am adding my thoughts - which, to be clear, are not identical to the DCP position or to all other psychologists. Incidentally I've discussed many of the issues Keith raises, including truth vs usefulness, who benefits, etc, in the final chapter of 'Formulation in psychology and psychotherapy', 2nd edn due out very soon.

    Some general points. Firstly, I am not myself proposing some kind of one-to-one swop of formulation for diagnosis. Formulation is one of a number of possible alternatives - all of which are based on the general principle of CO-CONSTRUCTING MEANING OUT OF PEOPLE'S DISTRESS. Many of these alternatives exist (and there have always been such projects, right back to the dawn of psychiatry as we know it): eg Soteria, Open Dialogue, therapeutic communities, constructs (the HVN version of formulation), various therapies, etc etc. Formulation is simply a particular and more structured way of framing these kinds of narratives, conversations and understandings. I think it has some specific advantages - eg it has some credibility in services and professional training (eg it is part of the core training competencies for psychiatrists as well as psychologists.) But it also has some limitations. I will mention one that doesn't seem to have occurred to Keith - more ammunition for you, Keith - it is a culturally specific concept that does not (I suspect) apply in non-Western settings... although the more general practice of making meaning out of distress certainly does. To be continued.....

  16. Lucy Johnstone4 June 2013 at 13:25

    ...continued. Secondly - yes the term 'paradigm shift' is over-used but one of its hallmarks is that people are so embedded in previous ways of thinking that they fail to grasp what is being proposed. I think this is partly what is happening here. Yes ,I mean you, Keith! When you suggest the (apparently outrageous to you) notion that 'perhaps reliability and validity are irrelevant to... formulation' - spot on! That is exactly what I believe (and have written about.) If we are talking about shared narratives that find meaning and patterns in people's distress then rel'ty and val'ty are simply not relevant ways of assessing them - (I disagree with Bieling and Kuyken on this issue.) The whole point is to get away from taxonomy as in the natural sciences. We are not dealing with the same kind of issue in psychiatry. Human emotional distress does not come in neat parcels. Let me take an analogy. We will all, at some point, suffer the trauma of bereavement. It can be seen as a kind of temporary madness... if we came across someone so distraught, upset, perhaps reporting hearing the voice of their dead husband etc without knowing the circumstances we might well be tempted to call it 'mental illness' and reach for a diagnosis. But bereavement is not an illness. By extension, research tells us that (nearly all?) the experiences that are currently diagnosed as 'schizophrenia' 'bipolar disorder' etc are, if you look close enough (if you formulate....) understandable responses to life traumas and events. Bereavement is not an 'illness' and nor are these other manifestations of distress. But.... saying this does not mean that we are proposing some kind of 'anti or ante science.' What bizarre logic! I am simply pointing out that our subject matter is not understandable within the framework of medicine and the natural sciences. Nor are lots of other things. It doesn't mean we can't use scientific methodology to investigate them , of course - hence the various projects I am engaged in to look at the impact of formulation. But get your head round this 'paradigm shift' - yes there could be a number of different formulations of the same problem. Of course. As there could be a number of different interpretations of a painting, or a piece of music, etc etc - none of which leads us to dismiss them as 'anti-science.' I hope!


  17. Lucy Johnstone4 June 2013 at 13:26

    ...continued.....Thirdly, I am puzzled by this apparent quote from me:

    "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."

    I don't actually recognise it - are you sure it isn't a misquote? But if it comes from where I think it does, the point I am making, in context, is that - as above - rel'ty and val'ty are not relevant criteria in assessing formulation.

    Fourthly - I am not an uncritical advocate of ANY theory, framework, approach etc and thus I endeavour to present an honest appraisal of the limitations as well as the strengths of formulation. So yes, like anything (and certainly like diagnosis) it can be used in disempowering etc ways. The DCP guidelines were drawn up for exactly that reason - to maximise benefits and minimise disadvantages - and they contain a checklist of good practice to help achieve this. And yes we need more evidence. (Although let's not forget that lack of evidence has not prevented us using diagnosis for many years... and even the verdict by one of the US's top psychiatrists that DSM is 'an absolute scientific nightmare' probably won't stop it either). But the Guidelines do point out that there IS strong evidence for all the theories that formulation draws on - eg attachment, developmental, effects of trauma etc etc. And there is also evidence for the healing effects of narratives - again, from attachment theory and other places. So I think we can feel some confidence in our formulation-based work.

    That's enough for now! Pleased for the chance to debate, Lucy

    1. Someone With A Diagnosis4 June 2013 at 16:13

      This description of the psychologist's role sounds distinctly like a call for secular hospital chaplains. As it happens, I'm all for hospital chaplains, but not in lieu of a doctor. I still struggle to understand how a psychologist can help a patient in the grip of mania or psychosis to recover their equilibrium. Once sufficiently restored, therapy may well be of benefit. But I don't think the search for meaning is dependent on a psychologist - that is an instinctive human response that can be private and personal, shared with friends and family - or indeed co-constructed with a therapist. It would be wonderful for everyone who felt so inclined to be able to talk with a trained and sympathetic clinical psychologist, but in the meantime people will carry on trying to make sense of their experiences and trying to avoid repeat of some of the nastier ones. Regards, Someone With A Diagnosis

    2. Thanks Lucy - good to hear from a key author & the chief spokesperson regarding the two DCP documents (paradigm shift and formulation) that I question in my post

      Here are my responses:
      1) You say " the term 'paradigm shift' is over-used, but one of its hallmarks is that people are so embedded in previous ways of thinking that they fail to grasp what is being proposed I think this is partly what is happening here. Yes, I mean you, Keith!"

      Inability to understand your (& the DCP position) is not evidence of a ‘paradigm shift’ any more than my inability to comprehend Creationists or homeopaths. Ironically, your choice of Kuhnian 'paradigm shift' language is illuminating - like Kuhn, who has over 20 definitions of paradigm in his short book, 'formulation' is equally opaque. In the classic Kuhnian Gestalt duck and rabbit illusion example- I suspect this rabbit … quacks

      2) you say " When you suggest the (apparently outrageous to you) notion that 'perhaps reliability and validity are irrelevant to... formulation' - spot on! That is exactly what I believe (and have written about.) If we are talking about shared narratives that find meaning and patterns in people's distress then rel'ty and val'ty are simply not relevant ways of assessing them - (I disagree with Bieling and Kuyken on this issue.)"

      I fully grasp what you are saying and that's what worries me! Formulation has little or no reliability and validity (cf psychiatric diagnosis), but you try to bypass this by now arguing that reliability and validity are "not relevant ways of assessing them [formulations]".
      As you say, many of your colleagues do not view reliability and validity as irrelevant. But you don’t elaborate...what is your reason for saying that they are not relevant to formulation? Is it not possible for two clinicians to 'formulate' the same client and arrive at the same formulation? Why does that not matter? How is it science?

      I assume your rejection of reliability and validity is a personal view. The Good Practice Guide Formulation document (where you are first author) devotes a lot of space to reliability and Validity... and how formulation lacks in these regards. P.34 is generally quite illuminating as it also states that: formulation is no better than non-formulation approaches " …the results do not support claims that formulation improves outcomes" and also that " Qualitative data from structured interviews suggest that clients are ambivalent about formulation"

      You and your co-authors say on p.34 of the document that " ...formulation could be reliable and valid but have no impact in terms of helping the client; conversely, it could be unreliable and invalid but lead to improved outcomes" - Why is this not also possible for psychiatric diagnoses?

      To me, your view implies that the client is at the mercy of the capricious (biased) interpretations of the therapist regarding the 'cause' of their client’s ‘problems’ and what should be done – as no evidence links formulation to intervention. How can this inspire confidence in service-users? How would they feel secure about the specific formulation they receive? If they saw another therapist for a second opinion, how could they ‘choose the formulation they like best? Especially if formulation is unrelated to veracity?

      Finally, I note how often you say ‘not’ in your posts above – your position often looks like one based in negation (of diagnosis) – not about offering an evidence-based alternative in formulation

  18. Lung cancer is an understandable reaction to smoking.

    It's 'normal'

    Doesn't make it less shitty for someone who has it and doesn't mean there's no meaning behind it

    When will you realise that it's how people feel that's important, not what's on or not on tests? Mental illnesses are more 'real' than any other.

  19. Reflecting on Epistemology and Ontology in the Diagnostic Debate (Part I)
    Hi Keith a key issue missing from this debate on diagnosis and so forth is epistemology and ontology, much psychiatric and psychological research (the human sciences) make claims to "science" but are often in fact "scientism" - which tends to place emphasis on methodological empiricism. Such empirical rigour is assumed to lead to unproblematic claims to truth. Such a stance often assumes reality can be measured in an unproblematic manner. Such a naive realism is often inadequately critical / reflective on the concepts measured in empirical research - observations / concepts of reality (knowledge) are often confused with reality. As Pilgrim (2008) notes such ontic and epistemic fallacies mean "naively trusting our perceptions too readily" and "naively assuming reality is what we call it" (see also Irwin, 1997). Naive realism therefore leads to assumption that we can derive truth claims with-out critical reflection on the concepts we are researching. Critical realism whilst having a place for empiricism, also has space for critical reflection on the concepts under empirical investigation - including historical analysis and reflection on the interests (such as professional groups) in the formation of concepts and their use, including why certain subjects are under empirical investigation and others not. Critical realism also has greater reflection on the meaning and context of any empirical data. The human sciences will always be more highly contested than the natural sciences because the those observing and their ability to observe (development of scientific skills) are part of system under scrutiny - therefore observation of ourselves will always be far more problematic.

    The problem with psychiatric diagnosis is that it often falls into naive realism, so vast amounts of empirical research is done on "people with schizophrenia" with-out critical reflection that "schizophrenia" is a concept and not a thing - therefore falling into the fallacies of confusing reality with our observations / concepts of reality - scientism, not science. Such research is lacking the appropriate critical reflection on the pre-empirical concepts under scrutiny - such scrutiny to my mind is necessary to being a good scientist.

    Psychiatry and psychology have too often jumped too quickly to inadequate concepts, categorisations and classifications, then performed empirical research and made truth claims (based on empirical rigour) whilst not noticing the concepts put into such research undermine the whole empirical enterprise. To my mind psychiatry and psychology both need to show far more modesty in its claims to truth and science - this includes those claiming empirical rigour. Psychology and psychiatry need to be more modest, transparent and honest in the status of our knowledge.

    To be Continued...

    Warm wishes Steven Coles

  20. ...Continued Reflecting on Epistemology and Ontology in the Diagnostic Debate (Part II)
    On a secondary point (which I won't go into as I wish to have a cup of tea) we should also not assume the only useful knowledge is that which pops out of empirical studies. To be human is a complex interaction with others, culture and the world, which is imbued with meaning - meaning does not exist inside a head but is co-created between people historically and currently - such meaning (including the meaning of experiences such as voices) cannot be simply be understood by IV / DV experiments (though I do not dismiss empirical investigation as having no rolw in understanding the world, as long as it is critically done). In this regard, formulation has some advantages over diagnosis as it sees the person in context and as meaning existing in-between people - such creation should be done with modesty, transparency and sharing - not the imposition associated with psychiatric diagnosis. Diagnosis is poor at co-creation of meaning as it confusing reality with a concept of reality. Service users currently have one option when understanding their experiences - diagnosis, and if they disagree they are seen as lacking insight, whilst diagnosticians fail in their reflection and "insight" into their epistemological and ontological fallacies. It should be noted that I do not believe the act of meaning making should not just be the preserve of professionals, psychology or psychiatry through endeavours such as formulation.

    So my questions to you Keith are (which I'd kindly ask you to reflect upon - over a hot beverage of your choice) what is your epistemological position? What epistemological positions do your research projects fall into? If you critically reflect on your empirical research, how often does it slip into epistemological and ontological fallacy? My impression is that you make claims to truth and science (though I apologise if my small sampling of your tweets / blogs is incorrect),...Keith are you a scientist or a scientismist?

    Warm wishes

    Steven Coles

  21. I wondered the following when reading this text:

    "In this regard, formulation has some advantages over diagnosis as it sees the person in context and as meaning existing in-between people - such creation should be done with modesty, transparency and sharing - not the imposition associated with psychiatric diagnosis"

    If I were to be feeling down (i.c. "depressed") and go the see a psychologist, am I not also part of "existing in-between people meaning" ? Apparently, I consider myself to have a sub-optimal mental state and I think this psychologist to hold certain knowledge about, and/or possible solutions for, what I consider to be my sub-optimal mental state and I prefer to go there for help (instead of for instance a fortune teller or a paranormal medium).

    What I wonder is, whether "diagnosis" is in fact also (be it maybe a more implicit form) of this "in-between people meaning".

    If this makes any sense, then I don't understand why "(...) formulation has some advantages over diagnosis as it sees the person in context and as meaning existing in-between people "

  22. Keith, a good read.
    1. To the anonymous person who has felt that psychiatry services have treated them well, and with high regard, that is gratifying, and reflects my experience of high quality psychiatric care and care from my nursing colleagues (and other professionals, including clinical psychologists and OTs -though I am biased,as a Consultant psychiatrist.
    2. At a pragnatic level all the grief given to diagnosis does not wash. Worldwide, govenrnments do not invest a great deal in mental health. Classification is necessary. I would be interested to see how health services could be set up (and maintained) by what the DCP has advocated (a tad too vociferously for my liking).
    Of course there are problems with classification systems, but it is usually the implementation of them that is erroneous: any sensible psychiatrist understands the shortcomings, and I would like to think most doctors treat people as opposed to diseases (we were taught that mantra at medical school).
    3. Ms Johnstone, I hope I am not being rude in commenting on your post directly, but when you say "By extension, research tells us that (nearly all?) the experiences that are currently diagnosed as 'schizophrenia' 'bipolar disorder' etc are, if you look close enough (if you formulate....) understandable responses to life traumas and events." you do a disservice to the use of epidemiology in research. Can you please reflect on the data you are putting forward for this statement, and make clear comment in regard to basic principles of epidemiology, such as confounding, bias, causality and association?
    I just was not aware that a relative risk was necessarily causal, especially given the relative risks claimed in regard to the causes you mention.
    My reasoning is that, when someone in a position such as yourself makes these comments, people do tend to pay attention. People with significant mental illness (and their families (mothers, fathers and siblings) will make assumptions based on your comments, and blamed may be laid at people and families' doors.
    To be honest, as a professional, I would hope that you would have a significant degree of evidence before you (at the level of Doll and Hill, with regard to lung cancer and smoking) before making these pronouncements.

    1. I'm not sure why you chose to address Lucy Johnstone by a title, when you do not do so to Keith. I could be wrong, but I read this as a slightly sexist attempt to belittle her position, whether it was or not. Furthermore, I'm sure Lucy is above correcting you, but if you are going to address her by title, it is Dr Johnstone, not "Ms".

  23. Lucy Johnstone8 June 2013 at 00:53

    Hallo Keith,

    This is getting to be a bad habit…but I can’t resist replying. You know I love a debate!

    To rectify Friday’s misinterpretation - your tweet said ‘proposal by clin psychs in their document is to replace dx with formulation asap.’ This is not accurate. My earlier post here made it absolutely clear that from my perspective it is not about replacing one monolithic system wholesale with another one. It is about starting from different PRINCIPLES – which might or might not be translated into action via formulation. Ditto, the DCP statement calls for a joint effort to develop ‘a multi-factorial and contextual approach…… as an alternative to diagnosis’ (Rec 3.) Clearly not an overnight swap, and clearly not specifically about formulation, although formulation is promoted as ONE RESPONSE (Rec 5, my emphasis). Not sure how you could possibly have translated this as you did…but anyway I am, as you said, a stickler for language and this is a subtle - well actually not that subtle - but certainly a vitally important distinction.

    In responses to your reply to me - firstly I want to make some comments about the context in which you are raising this debate on your blog. Let’s remind ourselves what some of the world’s most eminent psychiatrists have recently said. Former NIMH director Dr Steven Hyman described DSM-5 as 'totally wrong, an absolute scientific nightmare.' Dr Thomas Insel, current director of NIMH, commented: ' The weakness is its lack of validity.’ Dr David Kupfer, chair of the DSM-5 committee, admitted: ‘We've been telling patients for several decades that we are waiting for biomarkers. We're still waiting.’

    So - defenders of the diagnostic status quo (if that is how you see yourself) are at the very least on somewhat shaky ground… and I think it is legitimate to turn your questions back on psychiatric diagnosis. How is this science? What about the complete absence of reliability and validity in psychiatric diagnosis? And perhaps….why aren’t you writing an equally vociferous (one of your favourite words) blog critiquing psychiatric diagnosis?

    Secondly, of course it’s true that your failure to grasp my position isn’t in itself evidence of a paradigm shift - and in fact I didn’t say it was; merely made the point that a similar process happens in paradigm shifts - but avoiding the disputed PS term, I still think you are too deeply embedded in your own assumptions to understand what I am saying (which is a separate matter from whether you AGREE with it. I’m pretty sure you won’t!) So - I am puzzled by your question to me, ’How is this science?’ I thought I had made it clear that formulation - and indeed the whole process of working with people in extreme emotional distress - ISN’T a branch of science, as in the natural sciences. And it certainly isn’t medicine. That is where our fundamental difference lies..... continued.....

  24. Lucy Johnstone8 June 2013 at 00:54

    Clinical psychologists like to describe themselves as reflective scientist-practitioners, which to me means that we evaluate, draw on and quite often generate scientific evidence – but the ‘practitioner’ bit - the actual face to face work with people in extreme states of distress, and with the systems around them, often via formulation - that is not analogous to the work of scientists in biology, chemistry, or (specifically) medicine. It is primarily about working with HUMAN EMOTIONAL DISTRESS and HUMAN RELATIONSHIPS. That is why the charge of lack of reliability and validity (in the senses applied to medical diagnosis) is not fatal or even relevant to formulation. Yes, we discuss these issues in the appendix of the Formulation Guidelines as part of summarising (not necessarily agreeing with the assumptions of) the research that has been carried out, and yes there have been some (deeply misguided, in my view) psychologists who have researched these issues, but I am sure you noted that a key message in the main body of the document is that formulation is ‘not an expert pronouncement like a medical diagnosis but a “plausible account” and as such best assessed in terms of usefulness not truth’ p.7.

    Perhaps I can use an analogy. Is parenting, the process of bringing up our children, a ‘science’? It can be informed by science and research, of course - about developmental stages, biological aspects, the impact of attachment on the developing brain etc, in fact much of the same kind of evidence that informs a formulation - and it can be scientifically investigated - what kind of childcare practices work best, etc - but is the actual day to day process of nurturing our children to adulthood a ‘science’? I don’t think so. And no one thinks it’s a branch of medicine. It is about RELATIONSHIPS. And when our kids have problems – if my daughter comes back from school crying and I sit down with her and work out that it is because she is being bullied – do we feel we have to establish some kind of reliable and valid categorisation of exactly what kind of ‘bullying reaction’ this is, as a precursor to resolving (‘treating’) it? (Is it Bullying Reaction Disorder Type 1 with 4-6 episodes of tearfulness a day, or perhaps the more serious Bullying Reaction Disorder Type 2 accompanied by tantrums?) Of course not. Ditto in psychiatry. The problems might be more complex, the presentations (‘symptoms’ or as I prefer it, ‘survival strategies’) more unusual, but the principle is exactly the same. If we are dealing with people with problems not patients with illnesses – if we are asking not ‘What is wrong with you?’ but ‘What has happened to you?’ then we are in a completely different kind of business. It is the business of human emotional suffering, which is healed (ultimately) through human relationships (and all the therapy research confirms this as the central healing factor – although please note I am not recommending therapy as a solution for all problems.)... continued....

  25. Lucy Johnstone8 June 2013 at 00:55

    Finally, your comment about ‘Couldn’t someone get a different formulation from different therapists?’ - again I have to turn the question back on you and ask, isn’t this exactly what happens with psychiatric diagnosis? People simply collect a whole range of diagnoses throughout their mental health careers. Are you equally concerned about that, and if not, why not?

    But this, again, highlights the huge gap between us. You are an academic, I am a clinician. You have based your whole career on researching entities (‘schizophrenia’ etc) that have now been admitted by senior psychiatrists to have no known correspondence to the real world - I have never believed in them in the first place. You have never used formulation in practice – I do so every day. And from my position, I would say that your question just doesn’t relate to how formulation is used in practice. Ask your wife! Yes of course there will be different perspectives on the same problem. How could it be otherwise? But re-read those excellent Guidelines and you will see that formulation is a COLLABORATIVE process. It isn’t like visiting different therapists and collecting a different expert verdict that each has prepared independently (as happens with psychiatric diagnosis.) It is about sitting down over a period of time and working out, together, what makes sense to you as an individual. And if you are lucky enough to have two therapists with whom to do that, then you will benefit from two different takes on the issues, and you will be able to choose which seems the best fit for you - but given that both are based on YOUR story and YOUR personal meanings, they are bound to be pretty similar.

    Anyway, that is more than enough from me. This is my final word - I have other things to do (writing up formulations, for one thing.) If I haven’t made myself clear - well, that’s a pity but I have done the best I can. If you or others disagree... that’s fine by me. I would rather you didn’t misrepresent me but I don’t have a lot of control over that. Once again I am genuinely grateful for the opportunity to have the debate.

    1. My response to the latest comments from Lucy Johnstone are here:

    2. By the way Lucy , please be 'specific' about where you think I may have misrepresented you? This has just not happened - everything I have written is sourced and referenced and folk can check for themselves - so if you have a claim, please post it rather than insinuate

      I also note that when you posted your comments, you also 'twice' asked me not to *censor* you and here

      I do think that the way you (and the DCP) express these views is worrying...But why on Earth would you think I (or anyone) would censor or misrepresent you? To alter or misreperesent anything you say would only deter from the natural incoherence of what you say

  26. There is an interesting angle to all of this (well one I find interesting). For many years Dynamic Psychotherapy has been squeezed by the "research" and "science" of Psychology. It is increasingly seen as having less validity because the scientific base to it is less immediately impressive, compared to Psychology. Clinical Psychology has become more and more mainstream on the basis of it's evidence base, which in turn is, of course, founded on treatment of patient with symptoms fitting diagnostic criteria ....

    So, perhaps, say the Dynamic Psychotherapists .... we don't need these fly-by-night Psychology folk with their unscientific formulations. We can give you robust Psychodynamic formulations based on well over 100 years of discourse, debate and argument.

    Perhaps the DCP should be careful which icons they clast?

    Gordon Lehany
    Consultant Forensic Psychiatrist

  27. And on another point. Psychologists will sometimes talk about how medication could be useful, but in the absence of diagnosis. Of course, the evidence of treatment outcomes of medication are based on diagnosis and without diagnosis we would have virtually no evidence of what medications will be of benefit to an individual patient. Diagnosis is imperfect, but is often the best basis we have for prescribing and predicting which medication is likely to be of benefit.

    A world without diagnosis may have superficial appeal, but would leave us without an evidence base for prescribing.

    Of course, formulation is invaluable as part of a thorough clinical assessment, and diagnosis (or the absence of a diagnosis) is a key component of a Psychiatric formulation.

    Gordon Lehany
    Consultant Forensic Psychiatris

  28. I like this post and it raises some really core issues about what clinical psychology is all about. I remember the first day of my training when my course director - a now deceased, scientifically robust Maudsley graduate, told us 'Clinical Psychology is a craft. A blend of science and art'. And so it is. It's the mechanics of the relationship between these two, and the relative emphases that different psychologists place on them, that can cause observers to wonder if things hang together, and as Steven Coles says above, both psychology and psychiatry can get themselves into an epistemological and ontological tangle - I think because of this issue.

    This is why operationalising formulation is so tricky. Ref Wittgenstein - "The meaning of a word lies in its use" and so formulation is a word that means what clinicians do when they try to give an explanatory account of someone's distress. This process involves (sometimes) the use of tools whose utility is measured against 'laws' of reliability and validity, sometimes involves consideration of deeply human subjectivities - "meaning", "purpose", "values" et. seq., and often a combination of both of these. As such it is hard to talk about 'formulation' as a thing so when you use the term 'orthogonal to veracity' this implies that formulation yields itself to a metric which allows it to be compared orthogonally to a metric of 'truth' (which I'm assuming for our purposes here means 'a refutation of the null hypothesis when empirical quantitative data is collected, measured and subjected to an experimental design). I think that this treats formulation as a thing which it is not and implies that it is weak because it does not in itself yield to the yardsticks of 'truthfulness' that its components do (e.g. psychometric tests can be reliable / valid and they are often used as an information input into formulation). Specifically I think this is a composition error, (lapsing into the terminology of logic, I know).

  29. Continued...

    I’m sure you could justifiably accuse me of being a little pedantic here in that I'm pretty sure that you didn't use orthogonal in a technical sense, but I do think it's important because it raises a problem for formulation, as you rightly say - how do we measure its utility? This in turn comes down to the relationship between technology and values, and as our understanding of our 'humanness' as viewed through the necessary lens of neuroscience and information theory increases, so do those questions of how we link this technical knowledge with the other language of mind - personhood and what that means. Psychiatry / psychology is where these questions become acutely real and pressing as we are dealing simultaneously both with complex bio-informational systems (under one gaze) and persons (under another). And both link back to the same container, so to speak. At one level I'm aware this may sound obvious and it's hardly a revelation, but as clinicians we should be considering this all the time when we use language, because reducing someone's distress to technical language can increase it as well as, in some cases, help it. A good formulation puts the technical in the context of the human.

    But this is not an answer to the question - how do we make justifiable utility claims about formulation? How can we evaluate a process? What is a good formulation? Technically speaking, the stochastics that would impact on this are huge and probably unmeasurable- clinician personality, clinician training, the accuracy of self report, previous experience, biological status at time of evaluation. These factors affect the assessment outcome of any mental health evaluation, regardless of the epistemological framework of the clinician. Qualitative evaluation seems inevitable, but this is not scientific as traditional empiricism defines it. I don't know the answer, but talking to people receiving our services and asking them what is helpful is critical, and this in my mind should be our main yardstick of utility. It is hugely problematic for psychologists to provide an explanation of distress to people in that distress who may be vulnerable to suggestion (e.g. 'false memory' syndrome) and it is naive of us to think that because we are co-creating a narrative, we are not beholden to scientifically defensible accounts of what might be going on to cause the distress. We know very little about the mind/brain, but we know more now than we did, and we will know much more in the future.. This is the truth, even if, again, pretty obvious. We try to help, and certainly to not make people worse. This is why critical discussions about the claims of psychologists are so helpful, and why we need to be careful that we present our activities as defensible using reasoned arguments, and not lapse into proselytisation or certainty, which I'd like to think we don't often do. However, it is a mistake to think in my view that because clinical psychology is an applied science if all of its processes are not exactly concordant with empiricism, it is anti or antescientific in sum. So conversations need to keep happening and, more importantly, people who receive clinical services need to feel understood and helped.

    1. Thanks Andrew, I think you raise some interesting issues

      1) I dont regard my description of formulation as a 'composition error'. Indeed, I have no problem with formulation - or even clinical psychology itself - being outside of the remit of 'science' (viz the rejection of assessing reliability, validity and even client outcome or 'truth').

      I do find it striking that clinical psychologists 'shy away' from the measurement of reliability and validity, but claim it is possible to (personally) evaluate ‘outcome’ as a thing or ‘usefulness’ as a thing…

      2) Like others, you argue that formulation cannot be compared to 'a metric of truth' - which you assume to be "...a refutation of the null hypothesis when empirical quantitative data is collected, measured and subjected to an experimental design). I think that this treats formulation as a thing"

      This, however, is *precisely* how many 'use' formulation e.g. Kuyken (in my post) says this, as does Gillian Butler (also quoted above) who says "Formulations can best be understood as hypotheses to be tested"
      It is even a feature of the Core Policy Document of the BPS DCP in 2010 which says "formulation may comprise a number of provisional hypotheses"
      And crucially, the DCP Good Practice Formulation Guide (referenced above) says "This document *defines* psychological formulation as a hypothesis about a person’s difficulties, which links theory with practice and guides the intervention"
      Though it is clearly not an hypothesis in any conventional ‘scientific’ sense...and it is imporatnt to recognise this distinction

      Again I dont have an issue with formulation *not* being an hypothesis either - if it is untestable, unfalsifiable ...or even unexpressable, then for some it might again fit my question viz clinical psychology and anti-ante science.

      3) Re Wittgenstein and the "meaning of a word lies in its use" - a Freudian error? Perhaps it should be 'is' its use rather than 'lies' with its use?
      Wittgenstein is (for me) the philosophical embodiment of a Rorscach test...

      He also says " If the meaning of a word is to be whatever the word suggests to me ("means to me"), then a word "may have all sorts of meanings, and I don't wish to say anything about them"
      and "What does it mean to know what a game is? What does it mean, to know it and not be able to say it? Is this knowledge somehow equivalent to an unformulated definition? So that if it were formulated I should be able to recognize it as the expression of my knowledge?"

      4) You say "reducing someone's distress to technical language can increase it as well as, in some cases, help it. A good formulation puts the technical in the context of the human"
      But what is a 'good formulation' and how do we know that formulation does not itself increase distress? (without empirical evidence?)

      I agree totally when you say “it is naive of us to think that because we are co-creating a narrative, we are not beholden to scientifically defensible accounts of what might be going on to cause the distress” - unfortunately, your voice may be drowned by the louder agenda-setting voices saying otherwise

  30. "It is hugely problematic for psychologists to provide an explanation of distress to people in that distress who may be vulnerable to suggestion (e.g. 'false memory' syndrome) and it is naive of us to think that because we are co-creating a narrative, we are not beholden to scientifically defensible accounts of what might be going on to cause the distress. "

    Thank you for this comment. I sometimes wonder if clinicians or proponents of the "we are collaborating" (how could such a thing ever be anything but good) are fully aware of this.

    Perhaps, on a technical note, this is only relevant if clinicians aim, or imply, to have a scientific base upon which they base their help (and credibility?). If they do not think that's important, then they could perhaps still offer what help they want to offer, but it would seem to me that it should at least be made clear to the people asking for help that there is no scientific evidence to support the help they are getting. I think this might be important because a)I think that people asking clinician's help could (should?)expect that this help is based on scientific evidence and/or b)clinicians are expected to base their help on scientific evidence (?).

    Regardless of this, this whole "collaborating to tell a story and find meaning" also got me thinking about the following:

    What if I were "collaborating with a clinician to tell my story and find my meaning" and if I were to think that purple dragons exist, and that they were the ones responsible for making me feel depressed, would that become part of "my story" then? What I wonder is, are there any restrictions on what would/could become part of "my story", and/or to what point clinicians should "collaborate" to find my story and my meaning?

  31. Reliability and Validity in Formulation

    There are a multitude of issues that make discussing these concepts and meaningfully achieving them difficult. My argument falls across the following points:

    1) Applying positivist notions of reliability and validity onto formulation is unhelpful
    2) The 'problem' of contrasting/differing therapeutic modalities
    3) Research evidence on formulation
    4) Therapy is integrative

    1) Ok, so firstly, there is an issue in terms of how we define validity and reliability, and secondly how we apply these concepts to formulation.

    Whilst the arguments about whether formulation stands up to many of the same criticisms posed by psychologists to diagnosis feels like a separate debate, it is important to consider. In my humble opinion diagnosis can be meaningfully assessed in terms of whether it is a valid and reliable concept because of the epistemological and ontological positions on which the biomedical tradition is predicated. A diagnosis is an identification of a disease from its symptoms, therefore it should map onto distinct and identifiable biological markers (i.e. so hepatitis could be indicated by raised bilirubin in the blood). Consequently if we are talking about a definite concept then there should be a consistency in how it is identified by clinicians and according to what symptoms and markers - however mental health diagnoses (especially schizophrenia) can be disjunctive concepts. So in contrast to purely medical problems such as diabetes mental health diagnoses are challenging because a) symptoms that occur together within a diagnostic category but not in other diagnoses rarely exist b) illness onset, development and outcome do not have predictable outcomes c) there is no identifiable biological cause of many mental health diagnoses and d) responsiveness to medical treatments/pharmacotherapy is inconsistent and often has limited outcome.
    So my point is this - formulation is not a diagnosis, nor is it a cover word for a psychological diagnosis whereby the theory is merely predicated on psychological theory rather than medical! Therefore applying the same criteria used for assessing diagnosis to formulation doesn't work and is unhelpful. If we are going to be truly scientific about this then we need to recognise that all formulations will be derived from an interpretivist or subjectivist epistemology and also that we need to assess formulation for reliability and validity according to its aims (see DCP 2011). So in this regard I perhaps differ to Keith as I don't think he made what would constitute reliability and validity in the context of formulation clear, but I do agree that there needs to be greater assessment and refinement about the criteria through which we assess the function and utility of formulation.

  32. Cont...When I have evaluated my own practice this is often based upon a) the predictive validity of the formulation - i.e. can we use the formulation to make accurate predictions about the client's difficulties, experience and outcome, experiments and exposure work are good tests/refinements of a formulation b) the validity and rigour of the theory I use to inform the formulation - formulation is an understanding based upon psychological theory, some theories are more robust/better supported than others (purely constructionist therapists might have something to say about this but this is just based upon my practice!!) c) the involvement of the client in the formulation - how much of this is truly collaborative? How much is their language and interpretation used and represented? Are they able to meaningfully use this and own it? d) use of the formulation to use and understand transference and countertransference - again just based on my practice, but I would expect psychological problems to be brought into and enacted in our relationship in therapy, a good formulation would include this and its relationship to the target problem e) the utility of the formulation for care planning/other professionals. I’m sure there are many other dimensions we could add, but essentially what I’m saying is we need to assess formulations against their initial aims, purposes and theories that underpin them, which will not be applicable to all formulations. To move forward I think psychologists need to think about these criteria further, and research needs to value this – I don’t think the research Keith mentioned by Kuyken is a particularly good example of this.

    2) This has already been identified by a previous psychodynamic contributor. Not only do differing therapeutic approaches have different definitions, standards and practices regarding formulation, but this makes assessing formulation per se extremely challenging. This isn't to say we shouldn't do it, but that we need to be mindful of this. Also some psychologists (i.e. solution-focused) do not formulate! A further challenge is that most psychologists including myself tend to integrate theories, and not only is there no one way or agreed way of doing this, but assessing then the qualities of these formulations can become extremely subjective. Theoretical diversity is not a weakness and should not be seen as one. However it does complicate the achievement of an accepted definition of a formulation and its aims. This raises a challenge to clinical psychology and also the various traditions within it; should we have one global general definition? Should each tradition move to define and refine a set of practices relevant to formulation?

  33. 3) The research evidence on formulation is both problematic and interesting. Arguably the CBT paradigm and evidence referenced by Keith offers the most structured and uniform way to put together a formulation, and on many training courses the classic 5 P's model is the very first they learn. Perhaps one could argue that this makes CBT formulations the most clear, theoretically rooted, comparable and therefore testable? Perhaps this is also why research exploring formulations from other psychological approaches is severely lacking and under-represented? Similarly to point 1) I think if we are to begin to conduct necessary research into formulation better consideration needs to be given to its aims and scope and on what criteria it can be appropriately assessed.

    Moreover, ‘formulation’ or the construction of a collaborative understanding is a fundamental aspect of very many psychotherapeutic traditions - CBT, CAT, ACT, systemic/family therapy, and even some psychodynamic schools. Therefore the utility of these processes will be contained in research that already exists. CAT may be a good example of this, as often research focuses upon distinct phases of the therapy - reformulation, recognition and revision. Just as you wouldn’t assess the impact of a diagnosis on the initial consultation research needs to explore the use of formulation across the process of therapy.

    4) To quote Gilbert and Orlans (2011) the idea that "any one theoretical perspective as a potential 'truth' within the psychotherapies becomes impossible", and I think this is important to recognise. There is no one psychological therapy for any one person or presenting issue. Although at times evidenced-based guidelines may lead us to believe this, as Darian Leader puts it - we are offered a 'quick fix for the soul'. There are truths within a formulation but is it not a truth. Yes different formulations can be conducted for the same problems or presentation, and indeed in Lucy Johnstone's book two case studies are subsequently formulated and approached from different perspectives. But this is a strength of formulation and not a weakness. We are meaning making individuals. We are rationalising but not always rational. Take the example of diagnosis - for one person a diagnosis of bipolar disorder means they have a brain disease, they are defective, something is wrong with them; for another a diagnosis brings an acceptable explanation for puzzling and scary phenomena, it brings control, it doesn't blame them for their behaviour but explains it. Being able to bring psychological explanations and formulations to both these individuals may be important, therefore it is important to me to have a range of ways and options of doing that.

  34. I hope Keith that this provokes thought and discussion, and I hope you are able to offer suggestions as to how formulation can work better, or how it can work alongside diagnosis rather than set up a straw man for the purposes of slamming the profession, as you become guilty of much of what you accuse psychologists of doing in regard to psychiatry. I’d also be really interested in your experiences of formulations that have been shared with you. Both diagnosis and formulation have strengths and weaknesses, and as professionals it is our duty to think objectively about each and the challenge of how we can work most effectively together. At the heart of these debates are the millions of people who use mental health services and we should not forget that, as it seems to have been replaced by one-up-man-ship and the academic equivalent of “na na na na na!” To criticise the professions of either clinical psychology or psychiatry globally is a ridiculous and poorly thought out argument regardless of who you are. There are many things about psychiatry I thoroughly dislike. Every time I walk by the ECT suite off an adjacent inpatient ward I shudder and actively try to avoid looking at the directions on the hospital wall. But conversely I wouldn't have got into psychology if it wasn't for the brilliance of psychiatrists like Viktor Frankl, or Rex Haigh. Nearly all of us have entered these professions to better the lives of others and we need to recognise that in a context where health services and jobs are under threat and many people have profoundly negative experiences of care, this can make us feel anxious and threatened, so we become overly defensive or attacking of other out groups.

    Anyway, if Keith or anyone else would like to continue this healthy debate I'll do my best to get involved, I hope at the very least this has been thought provoking whoever you are. Thanks.

    1. Thanks for these detailed comments. I will try to briefly respond to what I see as the key points:

      1) You say "Applying positivist notions of reliability and validity onto formulation is unhelpful" - I am not quite sure why you consider reliability and validity to be 'positivist notions'. per se or why it is 'unhelpful'
      You can have, for example, simple empirical evaluation of inter-rater reliability for formulation - as noted in my post, where this has been examined, formulation is found seriously wanting.
      I think it would be helpful to service users to know if the formulation they receive is reliable...why would anyone not want to answer a service user on this question?
      Or at least, tell them that - we clinical psychologists have a different epistemology and regard such things as irrelevant
      Beyond this, simply saying reliability or validity "isnt helpful" or it "doesnt work" for formulation - is not an answer at any level (in science or to clients)
      3) as you say formulation is subjectivist and that is fine - as long as service users know it is subjective (and they would almost certainly get a different formulation from your colleague in the next office)
      4) I agree, it is important to define what you mean by 'function' and 'utility' of formulation and how you measure these (if they are preferred to reliability and validity)
      5) You say "When I have evaluated my own practice this is often based upon a) the predictive validity of the formulation - i.e. can we use the formulation to make accurate predictions about the client's difficulties, experience and outcome"
      Yes, again it is subjectivist and prone to the biases I mention in my post. And as I note on my post, formulation has anyway....not been shown to have predictive validity or any positive impact on outcome for clients
      6) You say "validity and rigour of the theory I use to inform the formulation" - these are not transferable qualities! Even if the model is well-validated, it has no consequences at all for the validity or rigor of your particular formulation.
      7) You say to me "I hope you are able to offer suggestions as to how formulation can work better" - well, as you don’t regard reliability and validity as relevant, we will have to differ - so really the obligation is on you to produce an answer - within [what is for me] a model of science that I don’t recognize or work

  35. As a BSc psych student - these debates are becoming really interesting! But I must sit on the fence and be objective! But thank you all - this is more educating than the degree
    Best regards

  36. I've been discussing this on twitter with St Domingo, who I think is the Anonymous who posted a three part response earlier. If it's OK with Keith, I'd like to continue the debate here, because it's difficult to keep track of multiple threads on twitter. I'd like to comment on the points St Domingo raised about positivism, reliability and qualitative research.

    I'm not a philosopher, as will be apparent from the rest of this post, but I think I've understood what St Domingo is saying. I think s/he would describe me as a positivist - in an epistemological sense - because I work from the assumption that we live in a real reality. I know we can't *know* that for sure; the reason I assume it is because I can't see that it makes much difference, for most intents and purposes, whether our reality is really out there, whether it's solely co-constructed, or a combination of the two. For example, if someone jumps out of an aircraft at 30,000ft without a parachute, their experience of the outcome is likely to be the same whether or not the aircraft and the earth below it are real, or are part of their co-constructed reality.

    However, when it comes to scientific methodology, if I've understood the terminology correctly, I'm not a positivist because I don't think our knowledge of reality is either certain or verifiable but is subject to varying degrees of uncertainty. So, there's a high degree of certainty that the period of daylight I'm currently experiencing will be followed by a period of darkness; there's less certainty about whether or not it will rain during the night; and even less certainty about whether or not the postman will deliver mail to me tomorrow.

    St Domingo says "you can't use concepts of reliability and rigour in qualitative research". I disagree. Questionnaires, structured interviews, anumerical Likert scales, repertory grids, card sorts and laddering are all rigorous, reliable, qualitative research methods. If they're well designed they can have high validity too. I'm not clear how research low in rigour and reliability would be useful to anybody.

    Incidentally, (as an aside, but it might clarify the issues) there was a lengthy debate in the letters pages of The Psychologist magazine in the late 90s about qualitative vs quantitative methods. The participants tended to fall into one of four groups;

    1. People doing quantitative research who were positivists and didn't know what qualitative methods proponents were talking about.

    2. People doing mainly quantitative research who weren't positivists, and who objected to being accused of being so.

    3. People doing quantitative and/or qualitative research who weren't positivists and didn't understand what qualitative methods proponents were making a fuss about.

    4. Qualitative methods proponents who had a rather narrow view of both quantitative and qualitative methods.


  37. Part 1 from @SameiHuda
    I know we are supposed to be talking about formulation and people keep posting about diagnosis instead. I just wanted to clear up some misconceptions some psychologists seem to have about general medical diagnosis in comparison to specifically psychiatric diagnosis. I will comment about formulation first so if people are bored by the talk about diagnosis they can stop after my comments about formulation. I will put a reminder in to people to stop reading after a certain point.

    Formulation and problem lists etc are already used by doctors in all branches of medicine and surgery already in conjunction with diagnosis, if formulation is conceived as a brief statement summarising the relevant clinical facts. Specifically psychological formulation however would seem to be an important technique in many forms of psychotherapy. If formulation is viewed as a technique rather than as a classification system then concerns about inter-rater reliability are less relevant. Now diagnosis is used for other purposes apart from a clinician choosing which treatment to give. It is used for service planning (e.g. we expect roughly x number of cases of y so we need to provide z level of services for this), as well as used for eligibility for services (often as part of a criteria), for recording service levels of activity (e.g. Hospital Episode Length of Stay is based on diagnostic categories), for pricing purposes and so forth. In short, diagnosis categories are used for administrative and managerial purposes of the health service. Now we could use a generic “distressed” category with a dimensional level of “very” to “mildly” but this would not really fit the administrative or managerial needs as it wouldn’t have sufficient detail (which diagnosis provides more of, though not perfectly). Also there would be the reluctance of a health service to have a completely separate administrative/ managerial system for one branch of health care if they can avoid it.

    Diagnosis is also used for research. Research needs to split people into categories so that when clinicians see patients, they can assign them to a category that has been researched on and there is evidence from past research that shows people in the same category found a certain treatment beneficial (sorry if I’ve explained this badly).

  38. Part 2
    Given the highly individual nature of psychological formulation (although similar patterns e.g. histories of abuse etc may be found) it can’t be used to produce categories of enough individuals to be used for these other purposes of diagnosis. Now it may be in the future that certain similarities between formulations mean you can class them together to form large enough categories, (particularly if you include biological information) that can be used for health service administration and treatment research but then you have produced essentially an aetiological diagnosis (a group of people whose cause of distress/ illness is due to a similar set of biopsychosocial factors). There is also the issue of reliability, not to mention validity for all patients of a purely psychosocial model as a basis for using formulation to make categories. The inter-rater reliability of formulation seems worse than diagnosis again compounding the difficulties of using it for research categories or administrative/ managerial processes. It is interesting that this individualised formulation seen as part of a clinician-patient interaction having face validity to explain the current problem is similar to pre-DSMIII diagnostic codes, a thesis to which DSMIII was the anti-thesis. Johnstone’s musings on the Art side of clinical practise again suggest an Ante-Science viewpoint.

    So psychological formulation can be used to supplement diagnosis for certain psychotherapies as well as for other purposes e.g. group supervision, advising teams how to manage difficult case and so forth. It should not be used to force other clinicians to drop diagnosis if they find it helpful, as well as not being able to replace diagnosis for administrative/ managerial/ research purpose.

    Now comes the medical diagnosis discussion, which you can skip if you are tired of it.

    I’ve noticed some psychologists don’t quite understand diagnosis, and seem to hold up general medical diagnosis as some paragon of virtue with which to beat up psychiatric diagnosis in comparison. I can’t blame them for this as they aren’t medically trained so try to understand it as a scientific construct. By which I mean they expect it to have very high standards of separating different types of illnesses (‘carving nature at the joints’), each case being similar, perfectly predicting outcomes, perfectly predicting unique treatment choices and almost guaranteeing treatment response. (I say this because they criticise psychiatric diagnosis for NOT doing this). Again this is also because some psychiatry theorists on diagnosis have proposed these as properties of diagnosis so I can’t blame the psychologists for this. (I would regard it as an honest mistake). Critical psychiatrists tend to forget or disregard their medical knowledge in favour of their alternative ideology or philosophy.

  39. Part 3
    Now medicine is an Art that uses Science to help people (again a familiar theme). Diagnosis is a human abstract construct that all doctors use to help them understand the interaction between people and biopsychosocial factors to produce states that culture labels as illness. (Forgive me if my language isn’t watertight). This construct summarises and groups people together on the basis of similarities between states. It does not actually exist as a real thing. The purpose of this is to allow doctors to recognise and name states of illness and to improve (but not perfectly) their knowledge of the range of likely outcomes and to give them a clue as to what they should do, based on previous research.

    Diagnosis 1.0 groups people by symptoms or signs that seem to go together (cohere) in syndromes but without a confirmed pathological basis: this is often the case with psychiatric diagnosis but also with e.g. migraine.
    Diagnosis 2.0 further groups people by an understanding of the pathological basis of the illness e.g. pneumoccoal pneumonia or dementia of the Alzheimer’s type.

    Obviously most general medical diagnosis are of type 2.0 and psychiatric diagnosis are 1.0 level.

    However the idea that general medical diagnosis have high inter-rater reliability in contrast to psychiatric diagnosis just isn’t true. Up to 40% (probably average 20%) of diagnosed appendicitis have a normal appendix. Some psychiatric diagnosis like the supercategory schizophrenia in ICD-10 has high inter-rater reliability, as good as medical diagnosis. At post-mortem (a skewed sample admittedly) a significant proportion of medical diagnosis are wrong. So reliability of diagnosis is often not much different between psychiatric and medical diagnosis. Pies in his riposte to Kinderman gave several examples.

    There is also an idea that because people with the same psychiatric diagnosis can have very different symptoms invalidates the diagnosis. In general medicine however this often happens. A common game in medical school is where your tutor tries to get you to identify the diagnosis from the most atypical picture. This is a game with a serious purpose. The father of a friend of mine at medical school died because the hospital sent him home because the doctors failed to realise that heart attacks in South Asian people can present very differently from heart attacks in White people. So this idea that people with the same diagnosis can’t present differently isn’t borne out in general medicine.

  40. Part 4
    On separating different illnesses perfectly, well again this is not borne out in general medicine either. This because complex biopsychosocial stressors on complex systems like humans often don’t provide single pathological responses. We use the term chronic obstructive airways disease as sufferers often have combinations of bronchitis and emphysema rather than pure diseases (cf anxiety and depression). Nature is not a giant turkey with thighs waiting to be disjointed. People with the same illness in medicine often have different outcomes, everyone with a heart attack isn’t guaranteed to have heart attack and die at the same time. In the same way people with the same diagnosis don’t necessarily need the same treatment or will invariably respond to the same treatment. My general pharmacology textbook has lots of treatment algorithms for heart failure, blood pressure, asthma and so forth due to this unpredictable treatment response.

    It’s well know the impact of psychosocial factors in medicine, at Medical School we got taught about the Black Report (1980) which emphasised this. There are also cultural factors in what is regarded as illness in general medicine. In Germany they treat idiopathic low blood pressure as a medical problem, whereas in the UK we don’t tend to.

    The main criteria for a diagnosis is utility, i.e. does it help the doctor help the patient by identifying a problem and knowing how to treat it based on research. Psychiatric diagnosis do have this utility, you can argue about how much I find them useful rather than groping in the dark.

    It is factually incorrect to state that psychiatric diagnosis have no reliability, predictive value, no utility, no ability to predict treatment response etc. For these qualities there is often little or no difference with general medical diagnosis (and in any cases the differences are one of degree rather than absolute qualitative differences). You can state they are insufficient in this regard so long as you state you’re a priori criteria for this and justification including for dropping diagnosis in general medicine because they don’t meet this criteria either in many cases. You also have to have a viable alternative.

  41. Someone With A Diagnosis20 June 2013 at 08:43

    As someone with a diagnosis, I wrote a couple of posts earlier in the discussion countering the caricature of psychiatric care put forward by advocates of formulation. I should perhaps have made clear that mine aren't the facile comments of someone who's had an easy ride: I have endured the extremes of the bipolar spectrum (suicidal depression, euphoric mania and dysphoric mania); been sectioned six times; been injected and medicated; contended with all the consequences on confidence, on career prospects, on finances, on family life and unintentionally put my loved ones through hell. It is precisely because it has been so tough to stabilize my health that I can't accept simplistic rhetoric or crass caricatures of current mental healthcare and those working in it. Mercifully, I have not been in hospital for 10 years now and have enjoyed almost unbroken good health. In that time I have been on lithium and sodium valproate (for the last six months just lithium), but I would attribute a fair chunk of my improvement to a range of psycho-social initiatives put in place by my psychiatrist (CPN, housing, physical health referrals,voluntary work referral etc). The Manichean rhetoric of so many opponents of current psychiatric care simply does not describe reality - not just mine, but that of the many people I know who have been diagnosed with mental illnesses; medication isn't the only model and people are treated as people, not labels. Of course, the system's imperfect, but then people's problems are far from straightforward either. It should go without saying that the views of self-styled "survivors" need to be taken seriously, but theirs is not the only lived experience. For me, the biggest problem is not the diagnosis, or the system, or the stigma of diagnosis - it's the problem itself and the disturbance and disruption it causes in the business of living. I really hate having a mental illness; but there are many other illnesses I would hate to have too. Having a diagnosis of Bipolar 1 is the least of my worries. Of course, I would rather not have a diagnosis and I have looked at a lot of pro-formulation/anti-diagnosis blogs, but I have found them unconvincing. One thing I object to is that many of these anti-diagnosis blogs and twitter accounts, including Dr. Lucy Johnstone's, infer that people like me have been "brainwashed" and need their "consciousness raised". However imperfect, I do have a mind of my own! It's just that my experiences and my consideration of the case put by the DCP tell me that formulation is not the great panacea.

  42. In reply to 'logicalincrementalism' I appreciate your point but I'm not sure if you have understood the premise of my argument. To reiterate, it is implausible to evaluate knowledge that is interpretivist/constructionist from a positivist perspective. And this is what seems to happen when people evaluate/critique formulation. Concepts of reliability and validity cannot be successfully applied to formulation in the same ways as diagnosis. You argue for formulation to stand up to these concepts but like Keith you cannot give me tangiable examples of what this means - either in a practical sense or a case example. At least I have attempted to do this with examples/reflections from my own practice - which I notice neither of you have responded to! Are the suggestions for evaluating the validity and rigour of formulations I have given not valid?!

    1. Hi
      I am not sure why you say "it is implausible to evaluate knowledge that is interpretivist/constructionist from a positivist perspective."
      I am simply asking about reliability and validity and as I said above, these are not exclusively 'positivist' notions - it's a red herring to suggest otherwise.

      Or if you want to argue that it 'impossible' to determine even the basic reliability of a formulation, then that is also fine (again as I have said above) - just make it clear to clients that your formulation has no known reliability! And that they would get a different interpretation from any other clinician - I dont have a problem with that solution

      You go on to say "You argue for formulation to stand up to these concepts but like Keith you cannot give me tangiable examples of what this means - either in a practical sense or a case example." -

      I gave several examples in my post of how reliability/validity have been examined by, for example, Kuyken and colleagues - seems fairly straightforward to me (though you may disagree in principle...which as I said, is also fine)

      In my opinion - Your *personal* examples are the problem!

  43. Also - briefly in response to @SameiHuda (who I thought made some excellent points re: distinction between diagnosis and formulation) I would like to offer my two pence worth:

    Firstly, the examples they give re: some medical conditions not having high IR reliability akin to some psyc diagnoses I felt was a bit of an unhelpful comparison - in that we know diabetes exists and maps onto distinct biological processes and markers, whereas schizophrenia does not, therefore diabetes as a diagnosis is high in validity but perhaps not in reliability whereas schizophrenia and most psyc diagnoses are low in both...

    I also think his/her experiences of diagnosis are important to acknowledge, that diagnosis is not in itself a negative thing. However within western medical paternalism the imposition of a diagnosis can also be a gateway to a lifetime of control, stigma and subjugation in the name of treatment (see the work of Mark Cresswell and others), and we should not forget the perspectives of these people either.

    I agree we need a diagnostic classification system, but we need one that is based on evidence, that empowers people, and that is ethical. And I think things still have a long way to go.

  44. @ Anonymous/St Domingo

    I'm sorry I haven't yet picked up the points you made about your own practice. I got drawn into this discussion via Twitter and was specifically replying to points you'd raised there.

    Before responding further, could you clarify something? You say under your first point about reliability and validity (on 15 June)"Applying positivist notions of reliability and validity onto formulation is unhelpful" then "...diagnosis can be meaningfully assessed in terms of whether it is a valid and reliable concept because of the epistemological and ontological positions on which the biomedical tradition is predicated" and later in the same post "If we are going to be truly scientific about this then we need to recognise that all formulations will be derived from an interpretivist or subjectivist epistemology and also that we need to assess formulation for reliability and validity according to its aims..."

    If I've understood you correctly, you're saying diagnosis can be assessed only in relation to its own epistemological framework and formulation can only be assessed in relation to its own epistemological framework - is that correct?

    I'm pretty sure I understand your terminology; what I'm not sure about is:-

    1) What you mean by 'positivist notions of reliability and validity' and

    2) what you mean by reliability and validity within an 'interpretivist or subjectivist epistemology'? How would you, or anyone else, know whether formulations were reliable and/or valid?

    Thanks, Sue

  45. From @SameiHuda

    Seen a couple of responses to my comments on your blog and appreciate the compliments.

    Someone with a diagnosis’ comments I think point to the nub that is the goal is to help someone with their illness/ difficulties and that inter professional bickering diverts energies.

    I apologise to Anonymous for explaining my points badly.

    I described two levels of diagnosis 1.0, based on syndromes recognised by clinicians, and diagnosis 2.0 with pathological basis worked out. Many general medical diagnosis are at level of Diagnosis 1.0 such as fibromyalgia, migraine. Poorly understood conditions like Chronic Fatigue Syndrome (also known as ME) are also Diagnosis 1.0 but try telling people with this condition they aren’t ill and you will get a well-deserved flea in your ear. I apologise for not explaining that most diagnosis began at level 1.0 but progressed to level 2.0 with the advance of medical science. If you want to exclude all diagnosis of 1.0 type be prepared to tell people with fibromyalgia, headache, CFS etc sorry mate you’re not ill. You are basically assuming that medical scientific knowledge has advanced sufficiently that if you haven’t reach Diagnosis 2.0 yet, sorry you ain’t met the cut and discard them Simon Cowell style. Do you really feel that confident? Of course it doesn’t mean that it’s guaranteed that all Diagnosis 1.0 will reach the giddy heights of Diagnosis 2.0 or that a better Diagnosis (1.0 or 2.0) will supplant it as better describing the phenomena of interest.

    Now these syndromes of Diagnosis 1.0 or 2.0 are often “archetypes” or pictures of a “typical” case.

    The diagnosis in itself is a clinical shorthand describing an interaction between the human and nature and so forth…They don’t actually exist in the concrete sense. So diabetes is not a thing but an umbrella term for similar conditions found in a number of people. In fact there is a continuum between people without diabetes diagnosis glucose tolerance and people with diabetes glucose tolerance.

    Anonymous states that schizophrenia has low reliability, but in fact ICD-10 schizophrenia super category had a kappa >0.7 so that’s fairly good. Also said no mapping onto biological process for schizophrenia despite the wealth of evidence about this. I suggest reading Prof. Murrays’ Festschrift for a good summary on this evidence.

    As for validity, well this is something that can be hard to properly operationalize. Certainly I do see quite a lot of patients who fit the archetype of schizophrenia quite closely, as well as patients who don’t fit it as well. However I hope the example I gave of heart attacks shows this happens in general medicine. So to me, it has validity and utility as I have a better idea of what to do to help than if I DIDN’T make the diagnosis.

    As to the question of stigma, well this is a problem with how society views the diagnosis and treats people with the diagnosis. This happens in general medicine too with diagnoses like HIV and epilepsy which can carry a lot of stigma. However this doesn’t mean we shouldn’t make the diagnosis and deny the patient the benefit of help. The answer is to improve how society as a whole and the health service in particular treats people with that diagnosis. For example, people with HIV are still treated badly but I suspect treated better now than 20 years ago. People can make the point about the biomedical view justifies the stigma, but this also applies to HIV, epilepsy and so forth.

    I am sorry I have been poor at getting across the point that psychiatric diagnosis are not categorically different from general medical diagnosis in terms of reliability, utility, predictive value, utility etc. but that they often overlap in these qualities.