Monday, 22 April 2013

Diagnosis vs. Formulation: A False Opposition?

In British Clinical Psychology, "diagnosis" has itself become a dirty word, regarded as a simile for "labelling" "over-simplifying" and "pigeonholing". It has been spoken about as a malign process of linguistic colonisation, in which an individual's account of their distress is completely effaced. Psychological Formulation, a core competency of the profession is seen as the answer, a process of encapsulating service users' rich descriptions of their own psychological distress. It has been proposed as an alternative not only by the expected team of UK and New Zealand psychologists and psychiatrists but also on philosophical grounds by Belgian psychoanalyst Stijn Vanheule (though it has been noted by David Pilgrim and Timothy Carey that it can be read as an attempt by Clinical Psychology to further affirm its professional status).

A naive observer would be forgiven for feeling puzzled. Surely a diagnostic classification and an explanatory story are not incompatible? Indeed, even Lucy Johnstone, a vociferous opponent of diagnosis and author of a leading text on formulation, has pointed out on Twitter that Formulations can, for the purposes of medical record keeping, be shortened to a version agreed with service user such as "Reaction to severe early trauma, compounded by recent bereavement". She has also said that "Schizophrenia' can often (not always) be replaced by 'dissociative reaction to severe trauma'"; a statement which seems to imply that one construct can be more or less replaced by another.

The real problem with "Diagnosis", in the context of "Diagnostic and Statistical Manual" is that it is not really a diagnosis at all. When you type the word into Google, the first result is the Wikipedia page, which says that "Diagnosis is the identification of the nature and cause of anything". DSM is a text largely devoid of causes and certainly doesn't get into the nitty gritty question of the nature of the phenomena it claims to codify. This is a point that proponents of Formulation have made, and I suspect they would agree that what they are proposing is much closer in spirit than is the DSM to an actual diagnosis.

This suggests that the distinction between "Diagnosis" and "Formulation" is a false one. Evidently the two practices should, in an ideal world, bleed into one another. There is nothing wrong with Diagnosis per se, it is just that the manual we currently use to do it is actually doing something else entirely (namely, bland and often unworkable classification). Formulation does a better job, but, from what I know about it, has no systematic way of incorporating information about the psychology and biology of the person to whom the life events has happened. A third alternative is the PDM, a psychoanalytic, American competitor which manages to integrate psychodynamic information about the person (their chosen style for coping with strong affect, their manner of relating) with an openness to a consideration of environmental factors and life events (their parenting, trauma etc).

Is this a dialectic that can be successfully resolved, or is the debate so bound up in territorial warfare that mental health professionals will always revert to the position dictated by their ideological prejudices?


  1. Good post. I wonder, though, if you’re missing an important difference between a formulation and a diagnosis (in the “medical” sense), to do with truth claims. A medical diagnosis purports to be *true* in the sense that it is based on a realist epistemology. It assumes that there is a real, actual, existing-independently-in-the-world causal story about the aetiology of someone’s symptoms and that it’s possible to know what this is.

    I don’t think many proponents of formulation would claim to be making that kind of statement. Rather, a formulation is a *way of thinking* about someone’s problems, that is valid insofar as it helps the clinician AND the client make sense of them. It is not meant to be a claim about truth in the direct realist sense. That’s not to say that all proponents of formulation are relativists (although I know that some are), simply that a formulation isn’t understood as a statement of fact in the way that a medical diagnosis is usually intended to be. This means that there are at least as many possible formulations of a given person’s difficulties as there are models of therapy, or even as there are therapists. And that’s not, per se, a problem.

    For me, this was the take-home point from the Johnstone and Dallos book, in which a range of clinicians from different orientations offer formulations of the same two cases. There’s no attempt to establish which formulation is best, most correct, most accurate or whatever. In the absence of a real interaction with the client there would be no basis on which to do that, since the validity of a formulation is in its clinical utility not its truthiness.

    1. Hi uilleannair, nice point, and it is well taken. Psychiatric diagnosis is taken, by many professionals and service users, to be *true* in some deep ontological sense.

      However, whatever the common practice of diagnosis, this implication isn't inherent to it. I am being taught to use the DSM at the moment because in the US one needs a diagnosis for insurance purposes. Believe me it's very jarring, not only to me but to all my colleagues. However, we are being specifically taught to regard the label not as some ontological category, but as a "snapshot" of the person's problems at a particular point in time.

      It is not clear to me how much this goes against the officially stated purpose/vision of the DSM, but the APA openly acknowledges the consensual manner in which it devises its categories. This seems to suggest that even many of the DSM's designers are able to view it as an imperfect work in progress.

      My main point however, is not necessarily that the DSM is compatible with formulation, but that the concept of diagnosis per se need not be thought of as separate and opposed to formulation . If a nominal diagnosis can be derived from the distillation of a longer formulation (as in the examples I use in the post) then there is no reason why these two things can't be considered to have the same ontological status as one another.

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