Formulating Formulation

This month I have a review in Clinical Psychology Forum of Lucy Johnstone and Rudi Dallos' standard text "Formulation in Psychology and Psychotherapy" (thanks to the editors at CPF for the invitation!). Doing the piece was an opportunity to spend more time than usual thinking about formulation; what it is and how it is supposed to be helpful. However, the resulting article is just 400 words; space enough only to develop a few ideas, and not in much depth. This post is a more extended reflection on the book and the ideas it prompted.

My review is principally positive. I praise the book for being practical (the new chapters especially deal with issues that can only have been identified my psychologists in multi-disciplinary teams in the NHS); for being ambitious (psychologists are given excellent advice on what to expect when formulating in teams) and unique (there is no other book that meets the needs of NHS psychologists in this way). Here's an overview and elaboration of conceptual points in the CPF Review I wished I could extend:

The Validity of Formulation:

The book is not afraid to address concerns about formulation's validity. Formulation is not "evidence-based", (partly because it is difficult to know what that would look like) and although there have been attempts to hold it to an external standard (coding formulations' content for quality), that simply raises the question of how to empirically validate the standard. I wonder if formulation-enhanced therapies would be amenable to validation by RCTs (therapies that are vs. therapies that are not guided by a formulation), but that may be unworkable.

However, as is pointed out, any given formulation is less an entity, diagnosis or instrument (which can be easily tested for reliability etc.) than a process for making inferences and predictions. Inferences are more or less valid, depending on their premises and how they are drawn. Predictions can be more or less valid/useful depending on how testable they are. This brings us to an important role formulation could have in a "local clinical scientist" model of clinical psychology.

Gillian Butler’s statement that a formulation is a set of “hypotheses to be tested” is often cited in the literature on formulation, and this text is no exception. A hypothesis can be tested if it can theoretically be falsified, so in the review I wonder whether formulation based on the principles of “risky prediction and refutation” could play a role in yielding valid psychological knowledge.

"Usefulness vs. Truth"

Another key issue running through the text is the distinction between “usefulness” and “truth”. The implication seems to be that formulation is about the former while diagnosis aspires to the latter. This seems to reflect a leaning toward a "constructivist" theory of knowledge (a respectable enough position) but I don't think we need a strong commitment to that position. On the contrary, I suspect “truth” tends to bring “usefulness” along with it, such that the more we know about a particular individual (and they about themselves) the more able we are to help them.

However, I assume the "usefulness vs. truth" distinction is made because psychologists want to avoid "imposing" their felt certainty on their clients. One way to do this is to say (quite correctly) that there are no basic, easy-to-articulate "truths" about human experience. We make our own meanings for ourselves, and any health professional should have respect for this project. So far I agree. However, things get tricky when we want to extend this way of thinking beyond existential-phenomenological "truths" and into the realm of aetiology. If formulation were just a meaning-making process, a constructivist theory of truth would go most of the distance, but it is not. Formulation also purports to be a description of a person's problems with an inbuilt theory about how they came about. Some stories will be closer to than others to reality, and we shouldn't be afraid of that.

If this sounds like I am advocating an authoritarian view of how to do therapy, I am not. While there is probably something like "the truth" about causes, it is vital that practitioners stay in touch with the tremendous uncertainty we have to face in knowing, for any given person, what that is. Such knowledge as we do have is based on the proportions of variance derived from large N samples. It does not generalise straightforwardly to an individual, whom we have to take with all the idiosyncrasy, and uncertainty, they deserve. This uncertainty is characteristic of science, not inimical to it, so for me the spirit of much of this book is perfectly compatible with a "scientist-practitioner" model.

We can then, believe in the value of multiple constructions AND in a basic underlying reality. The text itself makes a similar point. In the discussion in Chapter 10, "Using Formulation in Teams", the point is made that clinicians can be insufficiently-aware of the prevalence of sexual abuse, leading to the failure to consider this as a factor. Here is a stark fact about reality we are encouraged to face; abuse happens, it has often has devastating consequences and formulation should acknowledge it wherever appropriate. There are obviously limits upon how constructivist to be about abuse (no-one seriously advocates the construction of a truth in which we pretend it hasn't happened), and the same is presumably true for other aetiological factors. The reason all the chapters in this gloriously eclectic text can be helpful is that they can help the clinician formulate different aspects of social and psychic reality in different ways that need not be mutually exclusive.

All White and Predominately Female: Clinical Psychologists

So much for the points in my CPF review. In addition to these ideas, I have some other broad thoughts on the place of formulation within clinical psychology, which I will get to below, but before I do, here are two problems I had with aspects of the book:

1. "Primitive" Defences:

To my mind formulation is at least partly about re-imagining what is going on when people approach mental health services. Whatever you think about diagnosis, it is a fact that it represents an extremely limited way of describing people, and one which alienates many of its recipients. Formulation affords the luxury of a more open and inclusive language; a way to aid the clinician in their understanding of subjective experience. For this reason I am surprised at the continued use, in Rob Leiper's chapter on Psychodynamic formulation, of the term "primitive defences". Sure enough this terminology reflects a longstanding tradition in psychoanalytic discourse, but it seems clearly pejorative, at least as much so as any DSM-diagnosis. What is more, it is increasingly outmoded. In her book on psychoanalytic diagnosis, Nancy McWilliams adopts "primary" defences rather than "primitive", a preferable option to simply placing ironic quote marks around the latter word, as though that were enough to mitigate its influence on the clinician's thinking. Even then the implied developmental trajectory ("primitive" is supposed to mean "developmentally primitive") is probably bogus, as Drew Westen pointed out 25 years ago.

2. "Medical" vs. non-medical:

One of the difficulties in thinking about "psychiatric diagnosis" is to know what we are and are not talking about. DSM-diagnoses obviously fit the bill, but what about other categorisations? Is Judith Herman's "Complex PTSD" a psychiatric diagnosis? What about neologisms that might arise from the patterns which formulations reveal? In Johnstone's final chapter, "trauma reaction" is approvingly suggested as a useful linguistic shortening-but how do we recognise one of those when we see it? If there are criteria for "trauma reactions", and if an aetiology is strongly endorsed, in what way is this different from psychiatric diagnosis? We might say that psychiatric diagnoses are those which posit an "underlying" disease mechanism, except this is false. Psychiatry is plainly interested in entities which are not considered "diseases" by any metric. Perhaps then psychiatric diagnosis is anything which is done by a psychiatrist, but if psychiatric diagnosis is undesirable by definition this seems a little unfair on that profession, whose practitioners are damned whatever they do.

The distinction persists in Johnstone's chapter, which contains a discouragement against using the shortened formulations of psychoanalytic character diagnosis (Obsessional personality; Narcissistic personality etc.). These terms closely resemble formulations in that they put an emphasis on the ways that life events train someone to become the character they are, so why are they ruled out? Because they are "medical" Johnstone claims. Given the extent to which psychoanalytic clinicians lament the rise of the medical model as a challenge to their own approach, calling their system of diagnosis "medical" strikes me as contestable. True enough their descendants, the personality disorders, have found their way into the DSM, but that tells us more about the powerful influence psychoanalysis still had in 1980s American psychiatry than it does about the impact of the "medical model". There are good reasons to be wary of character diagnosis (alongside the usual questions of validity are very real concerns that the terminology is rather insulting) but its putative "medicalness" is not one of them.

Those two issues both get to the heart of why I started this blog, but perhaps they are marginal when it comes to the business of really understanding and articulating the role of formulation. Here is my final section, containing a reflection on the book and the thoughts it prompted about why psychologists should "formulate", and why this book can help them:

Generative Thinking and Eliminative Thinking: In Defence of Formulation:

There is a distinction to be made between the generation of ideas, and their validation. It is a distinction that Herbert Feigl talks about in his 1949 paper Philosophical Embarrassments of Psychology:

The clearest way I can think of to articulate the value of formulation is in terms of how it helps the clinician to generate ideas. When we do therapy with people we would like to know when our pet theories are right and when they are wrong. The standard caricature of Freud is that he believed everything came down to sex. If you took seriously his ideas about the dynamic unconscious (that an idea could stand for its opposite and denial by an analysand can really represent confirmation), you could accommodate virtually any evidence into his scheme. Hence Karl Popper's famous idea about theories needing to be refutable in order to be testable.

However, much as we need a system for eliminating possibilities, we also need a system for generating them. This is what struck me about the variety of this book, which references multiple psychological frameworks, including one (Personal Construct Psychology) that I hadn't heard from since it was referenced in an undergraduate social psychology class. As people who work with people, we need to be able to think our way into the experiences of others, and to be imaginative in understanding why they have the problems they have. Minds are weird and elusive, experiences often half digested or unformulated. Out of this confusion, a therapist seeks to draw some order.

However, our personal frame of reference, our own system of metaphor and interpretation will almost certainly be entirely inadequate to this task. What we need is to listen to people with the utmost respect for their own "construction" of their lives, and with a willingness to jointly forge sense. Where people struggle to make sense of their own experiences, we need to have the flexibility and imagination to frame things in ways that can help. We need to be open to being wrong, and we need to be open to putting things differently. This sort of task is something this book is superbly set up to encourage, and is surely its great strength.

In Favour of Objectivism about Psychotherapy Outcomes

A lot of people in my field dislike the use of quantitative measures to determine the value of what they are doing. Some of the emotional intensity of this view can be seen in the conversation I had on Twitter after posting a link to an article by Richard Gipp. The idea seems to be that objective measures "miss" something that can only be framed in language. People's psyches are fragile and complicated, and using a numerical scale is somehow riding roughshod over this, or doing to violence to the subjectivity of the other. This post is a response to (though not straightforwardly an argument against) Gipps' piece, which contained many fascinating points I don't really speak to here. My aim is to persuade you that "objectivist" approaches to measuring psychotherapy outcome are a good thing.

I am not making a rational argument (though I hope it's not irrational); that has been done consistently over the past 60 to 70 years and it is fairly widely acknowledged that numerical information has its own self-contained logic. This is an attempt at polemic. I want to convince you at a gut level that the use of numbers works for people who use services, that it can actually be quite noble in all the ways that certain forms of clinical writing claim to be. Furthermore, I want to suggest that, for all its value, the most poetic and optimistic clinical writing can act to conceal reality in important ways, potentially giving a veneer of respectability to processes which have little meaningful impact. Conversely, just because there is something rather prosaic about the notion of an "evidence-based-therapy", it is in fact perfectly compatible with all the beauty and subtlety we see in more "subjectivist" approaches.

In regard to the first point, the promise of insight, self knowledge or a deep connection with someone else does not necessarily carry along with it the promise of "feeling better" in important ways. I have learned a lot about myself through experiences of psychodynamic therapy or supervision, but to some degree one can separate the process of self-understanding (itself, in my view, an extremely valuable thing) and the process of feeling substantially less rotten about one's life. Although I find it invaluable to have the head-space to wonder about my relationship to my desires and my personal history; to think about the way they rebound in the minutiae of my social interactions in the present, I am not always sure how essential these are for my capacity to continue getting out of bed in the morning or avoid feeling like I want to kill myself.

Getting somehow "better" (and better is necessarily a vague word, in psychotherapy outcome research. It has ended up meaning whatever is indicated in the questionnaire you choose: "less anxious"; "less depressed" by a certain number of points on a scale) is not always a beautiful process. Something could be good for you psychologically without necessarily reaching your subtlest places. Some of the times I have made the most important changes in my well-being or happiness have been of the "crass" variety; events I could re-describe as "behavioural activation" or "cognitive restructuring". These are not Orwellian portents of a psychotherapy devoid of the human factor, they are clumsy attempts to describe ways we can change ourselves (in the right context) rapidly and  effectively .

More importantly, there is simply no incompatibility between a blunt (but objective) measure of psychotherapy outcome and a fine-grained "appreciation" of the unique and subjective aspects of the experience. Something could be useful in the crass numerical sense (indexed by a clinically interesting drop in an Anxiety measure) while also being moving, poignant, invigorating, thought-provoking, inspiring and so on.

To assume otherwise is to place a peculiar store in one narrative version of events as though "the truth" about someone's subjectivity resides in one place and one place only. Truth is trickier than that. What is "the truth" about a person's experience of a depressive breakdown; their narrative of events? The narrative of the people they love? A measure of their moods on a series of psychological questionnaires? Or does the truth lie somewhere beyond all these, in an inarticulate mesh which can only be variously approximated by different representations?

One critical response to the varieties of a treatment like CBT is to regard them as a form of authoritarian "training" or "brainwashing". This is to take the language of CBT too seriously, to imagine that your experience of that language is identical with the experience of the therapeutic relationship in which its techniques are deployed. "Cognitive restructuring" sounds quite mechanistic, but depending on how it is conducted it can mean something closer to "helping someone consider alternative readings of their situation" or "expanding a person's psychic possibilities". One could experience cognitive restructuring and find the experience elevating and beautiful. One could experience it as an intrusion by an idiot who has no appreciation for how difficult your life is. Or your reaction could lie somewhere between those extremes.

Precisely the same is true for any modality of therapy. Psychoanalysis (for some reason the most poetically described form of therapy) can be constructed as a disintegration and reconstruction of the ego through a profound subjective attunement between analyst and patient. It can be beautiful (it can certainly be written about beautifully by clinicians). It can also be experienced as sadistic, or as pointless (For some reason this perspective is more frequently seen in the narratives of patients like Susanna Kaysen in "Girl Interrupted", or Jenni Diski than in the writing of psychoanalysts themselves).

These disconnects are why I like numbers and think you should too. Efforts to represent the truth are all around us. Although patient narratives ought to be taken very seriously, in clinical professional circles the narratives of practitioners (every clinical psychologist has a copy of Irving Yalom somewhere at home) are generally given more credence. Given this fact, it is nothing short of wonderful if a healthcare system can be organised around a system of aggregating numerical indices of individual experience. We can, if we want, say that quantitative measures are an impossible attempt to objectify the subjective, but their value doesn't rely on this vaunted ambition. Numbers are a simple and systematic language. You indicate how you feel at time 1, and when time 2 comes along, any observable difference can easily be registered. It is much harder for clinicians to deny the fact that more people report feeling worse at time 2 than it is for them to re-construct the whole encounter so as to undermine any testimony that doesn't fit with their own.

None of this is to say that quantitative measures should "trump" patient narratives, but the way that different decisions are made will mean that different sorts of information are prioritised. When a healthcare organisation decides to fund a treatment, it has to know whether said treatment represents a meaningful improvement over something cheaper. Numbers are easier in making this determination. However, when deciding if mistreatment is occurring in a care setting, a single person's narrative ought to all that is needed for substantive concerns to be raised. In the quotidian process of navigating psychotherapy, a clinician cannot hope to proceed without attending, to almost everything done or said by the person with whom they are working.

When it comes to statistical data, it is hoped that we can learn to love the numbers which many people find so alienating. Behind each number lies a person, so used correctly they are an excellent way of finding out important information about real lives and real experiences. Ideally we would be able to think in two registers at once; deploying the skills of the most technically competent statistician and the empathy and interpretative nous of a novelist or poet.

Five Halloween Costumes to REALLY be Scared of

This time of year has come to be marked by a familiar woe as various costume companies and theme parks market a peculiar brand of offensive mental health paraphernalia in the name of Halloween entertainment. From experiential tours of a "scary Asylum" to "mental patient" fancy-dress, if you want to spend a surprising amount of money buying into stereotypes that are deeply hurtful to a large number of people, then there is a company which can help you do it. I won't catalogue examples here as Sectioned has a good page detailing comprehensively the various offenders. Instead, I am going to do my bit for mental health stigma by offering some alternative fancy dress options for anyone seeking to truly terrify their friends this Halloween. All of these are far scarier than any imagined "mental patient" and are made more so by their ubiquity and relative invisibility. Here are 5 Costumes to REALLY be scared of this Halloween:

1. The Pharmaceutical Sales Rep:

Aaaarrrggghhh!!!!

The Pharmaceutical Sales Rep's only job is to flog medicines to healthcare organisations Although a science background can "boost your credibility", it is by no means a requirement in a field which principally requires that you "sell sell sell" and raise the profile of your brand. The pharmaceutical sales rep is the perfect example of the shady figure tacitly manipulating the minds of others to see that his ends are met. He is especially scary because although his knowledge might be low, his influence can be high. Some doctors may be unable to resist his creepy powers of mind control!

You Will Need : A grey suit and a bland tie. 

2. The Healthcare Administrator:

Nooooooo!!!!!!

The Healthcare Administrator makes life and death decisions about whether to fund particular treatments and services. Poised between the world of political decision making and healthcare provision, he is aptly positioned to draw on the worst of both. Although the healthcare administrator is capable of using his powers for good, he is also capable of much evil. Last seen in a helicopter over Connecticut, deciding whether to pay for a 9 year old's cancer treatment.

You Will Need : A grey suit and a bland tie. 

3. The Public Relations Expert:

UUUuuuUUuuUuurGHhhhhh!!!!

The Public Relations Expert's job is to present something as good, even if the thing itself is not that good; even if it is actually rather bad. While there's nothing scary about doing the promo material for, say, a poorly written book, the work this guy will do to help people cover up fairly egregious errors (and get wealthy in the process) is a little more sinister. 

You Will Need : A grey suit and a bland tie. 

4. The Arms Dealer:

Urryhhhhlllghhllgg!!

Let's ramp things up a notch. If you are insufficiently scared by the murky antics of the Sales Rep, the Administrator and the PR Expert, you can't fail to be terrified by the downright horror of the Arms Dealer. Utterly unconcerned by anything other than turning a profit, the Arms Dealer will happily sell weapons to anyone willing to pay. The ideal scenario for the Arms Dealer is a protracted and bloody war in which he can offer his wares to both sides over the longest possible period, getting rich as his customers shoot one another indefinitely. As a major player in most western economies, the Arms Dealer is seriously scary! 

You Will Need : A grey suit and a bland tie. 

5. David Cameron:

AaaAAAAAARRRRGGGGHHH!!!!!

He's real, he's the Prime Minister, and he's coming for YOU!

You Will Need : A grey suit and a bland tie. 

From "Diagnosis" to "Characterisation"

What a lot of difficulty there is in trying to talk about psychiatric diagnosis. We try to say one thing but can easily end up meaning something else.

I have often taken a position that defends the value of diagnosis in mental health. People have often refuted that position by citing the failings of the DSM project, as though diagnosis and the DSM were the same thing. For a while I tried to resist this by pointing out (over and again) that I was not necessarily referring to that complex and troubled manual but to something like "classification plus a probable explanatory story". The point has never stuck, and I have to face the possibility that some of the fault is mine.

Why persist in talking about diagnosis? Why not seek a word that doesn't alienate people? Diagnosis seems to suggest "knowing", which it isn't if we're honest.

Perhaps instead of diagnosis, we could talk of "characterisation". When someone understands a problem in a particular way they characterise it, describe it as having a particular nature. "Your avoidance of parties is a social phobia, exacerbated by your ongoing avoidance and we can expect forms of exposure therapy might help." or "Your mood changes are like those that have been called "Bipolar", and when people have taken this or that drug they have found them easier to live with."

This way of talking can resemble formulation (the first example) or it can resemble diagnosing (the second), but it isn't supposed to be more like one or the other. Formulation tends, in this debate, to mean the idiosyncratic and "intelligible"; the formation of "meaningful narratives" (Boyle and Johnstone, 2014). Diagnosis tends to emphasise the regularities across cases, with "intelligible" referring to explanation in terms of medical as well as psychological processes (Hayes and Bell, 2014).

The idea of characterisation is consistent with either of these approaches. You can characterise a problem as psychosocial, as medical, or as a combination of both. If what we are doing is characterising, then we can take seriously the idea that someone is unwell when their mood consigns them to their bed for a fortnight. We can benefit from pattern recognition (Characterising the problem as a depression), without appearing to commit ourselves to belief in an entity that we can't yet describe (the "underlying" illness).

Characterising is more than classifying (because it speaks to how you view the classification), but less than diagnosing. It is a bit like formulating, but without the assumption that the explicable processes take place at the level of meaning. It's a clunky term, and not one that can be expected to "catch on", but when I talk about the value of diagnosis, it is this I am trying to describe.

How to Critique the DSM

I've just finished reading Rachel Cooper's excellent, and remarkably unsung new book "Diagnosing The Diagnostic And Statistical Manual of Mental Disorders". It came out in May and it's hard to believe I hadn't run across it until now. In a debate that becomes polarised and heated with alarming speed, Rachel Cooper is a calm and insightful voice. Her book (replete with a brilliantly irreverent cover, which makes you wonder at first if it's part of the "official" series of companion texts published by APA) is only 60 pages, but it packs more substance into that space than many of the books on psychiatry I have read recently.

Given the book's relatively low profile (at least, apparently, in clinical circles), here is a summary of the its arguments:

- Cooper is unsure about what to call those protagonists in her story who receive diagnoses. She finds "survivor" "too angry" (something I like about a certain strain of philosopher is that they openly admit the role of personal temperament in their thought) and makes the point that "client" can be disingenuous. The nature of mental health care is such that, in many instances, it simply isn't the case that an individual is paying, in the manner of client, for a service that they straightforwardly want to receive. She opts for "patient".

-Cooper is skeptical about the APA's own attempts to manage the financial relationship between the DSM and the pharmaceutical industry. Limiting the present pharmaceutical interests of clinicians involved in the DSM is simply inadequate when the relationship between doctors and drugs companies is ongoing over the course of a career. Such relationships are more like what anthropologists call a gift relationship where "gifts are given and received over time, and thereby create real but non-explicit obligations for reciprocation in the future" (p. 15). Cooper suggests that only complete independence from the pharmaceutical industry can save the DSM from this sort of malign influence, but that this sort of step would require "nothing less than a revolution" in the way research is funded.

-The APA invited patient involvement for the creation of DSM-5, but this was, in Cooper's view, largely tokenistic. How informative can it really be for the working groups to hear information in the random, bitty way invited by the online-comment feedback structure it provided? Drawing on the sociology of science Cooper points out that the questions that get researched, and the conclusions that are drawn are partly a function of who does the asking. She advocates for the presence of "patient researchers" who are trained to do research but also happen to be patients. This seems a sound proposal, though it is hard to imagine some critical mass of patient-researchers being reached without an extraordinary recruitment drive. Perhaps the best model is Hearing The Voice, which tries to amalgamate the tools of researchers with the priorities and subjective experience of people with first hand encounters. Charles Fernyhough describes the project in this Lancet article.

-It is not just big pharma that drives the inclusion of new diagnoses. Hoarding Disorder is new in DSM-5 and was, Cooper argues, the result of a combination of public awareness (Hoarding has become quite popular on Channel 4 in recent years) and of the development, by Randy Frost, of a specific CBT protocol, replete with inclusion criteria. Cooper suspects Hoarding Disorder is a bad thing, and suggests that it is more analogous to an "unwise" habit like eating unhealthily than a psychiatric disorder. As such, it might be better suited to interventions which bear a resemblance to Weight Watchers than to the ministrations of health professionals.

-Fascinatingly, the standards for reliability seem to have shifted quite a lot between DSM-III and DSM-5. In 1980, Spitzer and his colleagues set a kappa (a metric for estimating reliability) of 0.7 as the "acceptable" threshold. In the field trials for the latest edition, the goalposts have shifted and kappas in the order of 0.5 and 0.6 are now regarded as acceptable (the issue is handled more extensively in this post by 1 Boring Old Man, which Cooper herself cites). Cooper suggests this may be the result of greater attempted precision in the latest manual, but her main concern is how to make sense of the question of reliability. In her survey of the changes in the definition of "acceptable" reliability, Cooper brings out the sense of how little agreement there is over how to use this metric. More work is needed on what, for a psychiatric diagnosis, constitutes reliable enough.

-Ultimately Cooper concludes that the DSM's days are numbered; not because an anti-psychiatric tide will wash away psychiatric diagnosis for good (Cooper explicitly distances herself from anti-psychiatric positions), but because of the likely rise of other classification systems in research (like the RDoC) and of other psychiatric jurisdictions in which mental health care is expanding (such as in China). She advocates not the abolition of diagnosis, but a more flexible thinking along the lines of philosopher John Dupre's "promiscuous realism". Interestingly Richard Bentall has recently advocated this in the case of psychosis.

This is a refreshing and constructive book. One approach to the DSM is to reject diagnosis altogether, but this sets up a seemingly unbridgeable divide between those who do and those who don't reject diagnosis. Cooper's approach is more painstaking. There is plenty wrong with the DSM and Cooper has thought hard about it. Not content with critique, she also tries to envision remedies.

Putting the "C" into "CBT": What is a "Cognition" Anyway?

CBT will be familiar to almost all readers of this blog. It is a model for therapy that has spread with immense success since its inception in the early 1960s. The theory is clear, and fairly intuitive. When I first came across it as an undergraduate I was impressed; its basic premise seemed to accurately describe a surprising degree of variation in my own mood. Here is an overview of that basic premise, taken from Judith Beck's standard text:

"Automatic thoughts" are a key concept in this approach; rising like bubbles from our underlying beliefs, and interfering adversely with our emotional lives. Note the proposed order of events: I have an automatic thought and then I feel a certain way. This is not uncontroversial; surely it is sometimes the case that we think something because of how we feel. However, I'm not concerned with that argument here. Classic CBT seeks to intervene at the level of thoughts (although more recent "3rd wave" approaches get interested in affect too). Whether that process has a downstream effect on feelings (as per this model), or whether it manages to work backwards (a modified thought changing the mood from which it was derived), if it helps it helps. There is a more interesting problem for CBT, not necessarily a barrier to its use, but a conceptual tangle which is hard to resolve: what is a thought?

We all have thoughts, and all of us will have had them automatically "popping into our heads". Often they are verbal (these linguistically articulated inner experiences are what CBT trades in), but often they are not, and here lies a problem that reveals the messiness of reality when compared to the simplicity of a treatment manual. We all know a propositional statement when we see one, but when it comes to defining a thought things get very tricky indeed. 

CBT instructional texts often rely on the neatly articulated automatic thoughts of straightforward seeming cases: "I'm no good"; "I will never get a job" and so on. These can form hypotheses which we test (and inevitably fail to confirm) in the process of "collaborative empiricism". However, in reality, when we ask ourselves (or the people we are working with) the central question--"what just went through your mind?"-- we need to be prepared for the answer "nothing in particular", or more commonly to hear that, whatever it was can't really be articulated.

What then are we asking people to do? Thoughts don't straightforwardly exist. You can't see them, and often when you try to write them down they are entirely elusive. What do we mean when we say "thought"? It looks like there is a philosophical tangle at the heart of CBT that isn't being addressed*. This conceptual difficulty is not (as far as I can see) a deep practical flaw in CBT, though it is a superficially unnerving question in the context of a task that takes linguistic content so seriously. Thinking about its implications carefully might have positive ramifications for practice.

To help think this one out, here is a list (not comprehensive and not in any particular order) of things that can reasonably be said to exist (stolen entirely from Paul Meehl's ontology, about 70 minutes and 15 seconds into video #4 here):

1. Substances
2. Structures
3. Events
4. States
5. Dispositions
6. Fields

Minds are abstract entities, but to the extent that we have them, they must arise out of things in the world like this. Which of them corresponds to a thought? A "thought" doesn't seem as though it can be mapped onto a specific substance or structure. Equally it doesn't seem quite plausible that a thought is the result of a specific brain-state either; thoughts seem dynamic in a way that states are not. It might then be reasonable to say that any given thought could be re-described as something like an event (meanwhile, another of CBT's concepts, "attitudes", sound like they could be re-described as dispositions).

The Numbskulls: Thoughts as Instructions

We have the experience of a verbal, or pictorial (or whatever) "thought", and what is going on at that moment is an event in our mind. So when we ask a person "what went through your mind just then", perhaps we are asking them a version of "how would you describe your subjective experience of the event which just took place?". This helps us around the potential objection that there was no obvious automatic-linguistic-proposition ("I will fail the exam") to report.

My re-description is a bit over-the top, and won't usually be necessary in practice (despite the conceptual complexities, most of us have a working definition of "thought"), but I wonder if it helps us to get around the apparently perplexing challenge raised by the question guiding this post. The failure to locate neatly verbalised "thoughts" could be unsettling for someone new to CBT, therapist or client, raising the spectre that the process won't "work" because it's not proceeding as it does in the book. Having a more flexible sense of what is meant opens up the space for productive questions within the therapy about just what both parties are trying to get at.

-Richard Gipps has posted a fascinating and beautifully written whole book chapter offering a philosophical critique of CBT on his Clinical Philosophy blog. 

*I have heard it suggested that CBT is more generally silent on these broad conceptual questions, and that it only appropriated the moniker "cognitive" as a way of trading on the enormous success of the "cognitive science" framework that came to dominate psychology after the late 1950s. 

Schizophrenia as a "Disjunctive Category": Does it Matter?

Among the commonly articulated criticisms of the concept of Schizophrenia is Don Bannister's claim from the late 1960s that the diagnosis is unfit for scientific research because it is a "disjunctive category". This point recently raised its head again in the comments section of an article about the findings of the Schizophrenia Genetics Consortium (see David Pilgrim's third comment). What does it mean for us to say that Schizophrenia is "disjunctive"? Here is a quote taken from a Schizophrenia Bulletin paper by Bannister (published a few years after the BJPsych piece Pilgrim mentions):

Essentially Bannister is concerned about the fact that any given pair of people with a diagnosis of Schizophrenia can have entirely different behavioural presentations. On the face of it this looks very problematic; Schizophrenia is behaviourally defined, so it seems a little counter-intuitive that the definition can-in theory- capture radically different sorts of behaviour without any overlap among them. Bannister's "disjunctive" point therefore seems to land a blow on those who do research into Schizophrenia, and it provides critics with a nifty sounding slogan for their claims ("Schizophrenia is a disjunctive concept, so there!"), but to what extent should the "disjunctive" argument actually be a worry?

Although Schizophrenia is defined behaviourally, it has been a key assumption throughout the term's history that there is something behind that behaviour that requires explaining. Psychoanalytic theories have put more emphasis on a loss of ego boundaries and self-integration while biological theories traditionally focus on the action of neurotransmitters. Modern trauma theories put more stock in the notion that dissociation may play a role. What all these explanatory ideas have in common is that they attempt to explain the diverse range of behaviours that lead to a diagnosis.

Without any prejudice as to aetiology or mechanism therefore, we can say that the behaviour of a person with a diagnosis of Schizophrenia is not meant to be the main fact about them that determines the presence of Schizophrenia. Instead, the diagnosis is conferred when the behaviour of the patient gives the clinician some reason to hypothesise that the underlying process (aberrant dopamine signalling; disintegration of the self/other boundary) is taking place in the mind or body of the person being assessed.

We can of course argue that the diverse presentations of Schizophrenia are not in fact caused by a single underlying process, but that is an empirical matter.  If there is a single underlying process (or family of interconnected underlying processes), then the fact of Schizophrenia's being behaviourally "disjunctive" is no more interesting than the fact the fact that the same virus can lead to both diahorrea and vomiting. If there is no underlying process (or family of interconnected underlying processes) then that speaks against a single "Schizophrenia" whether or not it is "disjunctive" in Bannister's sense.

Now, just because the "disjunctive" argument may be a red herring, it does not follow that the concept of Schizophrenia can have a free pass in the clinical and scientific lexicon. There are many reasons to be dissatisfied with Schizophrenia-talk, both from a scientific perspective and from a political/social care perspective. My point is not to defend all the ideas associated with one limited reading of "Schizophrenia", nor is it to seek necessarily to preserve its use as a term. Rather it seems we should focus our attention on thinking about what sort of thing or things we really believe "Schizophrenia" refers to.

Many researchers are well aware of the contested nature of Schizophrenia and their work is about understanding how viable a category it is and what is actually going on with people who get the diagnosis. They know that the Schizophrenia of the 1960s is radically different to the Schizophrenia of the 1980s, which has in turn evolved between then and the present day. The fact that a research programme is oriented around the broad family of issues that goes under this name should not be taken the a sign of institutional myopia that many believe it to be.