Moving Beyond Psychiatric Diagnosis: Lucy Johnstone, PsyD

In this interview, published in the Psychiatric Times , Dr Awais Aftab and Dr Lucy Johnstone discuss her criticisms of psychiatric diagnosis and her approach to psychological formulation as a conceptual alternative to diagnosis:

Aftab: Formulation has a long history in psychiatry and psychology. It is an integral part of psychiatric training, both in the UK and the United States. It is intriguing to me that you envision formulation as an alternative to diagnosis, as a way of replacing it. I think most folks in psychiatry and psychology don’t see diagnosis and formulation as mutually exclusive, but rather as complementary and synergistic. In fact, many would argue good diagnostic practice requires diagnosis to be made in the context of a formulation. Why should we see diagnosis and formulation as competitors rather than allies?

Johnstone: I have spent much of my career practicing, writing about and offering training in formulation. In the UK, formulation is the central plank of clinical psychologists’ training and subsequent work, whatever our specialty or general perspective. This is much less true of other professions in the UK, although it seems to be changing, as formulation is added to the core competencies of other professions as well.1

There is a lively debate in the UK about whether formulation is an addition, or an alternative, to psychiatric diagnosis. (This debate does not apply in fields such as health psychology where clearly a medical diagnosis must form the basis of the formulation.) A significant number of clinical psychologists take the latter position. The Division of Clinical Psychology (DCP)’s ‘Good practice guidelines on the use of psychological formulation’2(p12) state that a best practice formulation ‘. . . is not premised on a functional psychiatric diagnosis (eg, schizophrenia, personality disorder),’ whereas the Royal College of Psychiatrists3(p24) requires trainees to ‘. . . demonstrate the ability to construct formulations of patients’ problems that include appropriate differential diagnoses.’ Individual members of each profession may take a different view, but we can see that there is a crucial difference between what the DCP Guidelines define as ‘psychiatric formulation’ as opposed to ‘psychological formulation.’ The first might look something like “schizophrenia triggered by life stresses and bereavement,” whereas the second might be summarized as ‘hearing hostile voices as a result of childhood sexual abuse.’

The argument for psychological formulation—or formulation as an alternative to diagnosis—is simple. A formulation is a hypothesis, drawing on the best evidence, and tailored for the particular client. If you have a reasonably complete hypothesis, based on someone’s life experiences and the sense they have made of them, about why they are having mood swings or feeling suicidal or self-injuring, then you don’t need another, competing hypothesis that says, ‘And it is also because you have bipolar disorder/clinical depression/borderline personality disorder.’ Even if we think these are valid categories, the diagnosis is now redundant. In science, you test 1 hypothesis at a time, not a combination of 2. Moreover, these hypotheses are based on contradictory core messages: ‘You are experiencing an understandable reaction to your life circumstances’ and ‘Your problems are the symptoms of a medical illness.’ This is not just theoretically confused—in practice, it gives mixed messages to the client about causality, responsibility, and so on. As a psychologist working for many years with people in various extreme forms of distress, I have never drawn on diagnostic assumptions, and I have also been privileged to see how diagnostic language fades away when teams are offered alternative, formulation-based perspectives. The diagnostic way of thinking simply becomes irrelevant …”

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