Psychological formulation as a
way forward?
Lucy Johnstone
Consultant Clinical Psychologist
The arguments so far…….
Mental distress cannot be understood as analogous to
bodily dysfunction – but it is hard to escape the ‘DSM
Injustice and distress are perpetuated by obscuring,
minimising and denying the powerful links between
trauma and psychosis
Medical language plays a key role in nullifying context and
meaning and undermining people’s innate wisdom and
Question: Could we replace psychiatric diagnosis with
psychological formulation?
Answer: It depends what you mean by formulation… and it
depends how you do it….
…..and there are different issues at an individual versus a
wider clustering level
1. It depends what you mean by formulation
Psychiatric formulation: The Specialist Core Training in
Psychiatry (Royal College of Psychiatrists, 2010)
requires trainee psychiatrists to ‘demonstrate the ability
to construct formulations of patients’ problems that
include appropriate differential diagnoses’ (p25).
Psychological formulation: ‘Is not premised on a functional
psychiatric diagnosis (eg schizophrenia, personality
(DCP 2011 ‘Good Practice Guidelines on the use of psychological
formulation’ p.29)
In other words, psychological formulation is replacement
for, not an addition to, a psychiatric diagnosis
‘Once these complaints have been explained, there is no
ghostly disease remaining that also requires an
explanation. Complaints are all there is’ (Bentall, 2003)
‘There is the abuse, and there are the effects of the
abuse. There is no additional “psychosis” that needs
explaining’ (Johnstone, 2007)
Psychiatric formulation (eg ‘schizophrenia triggered by
the stress of exams’) vs psychological formulation (eg
‘hearing the voice of your abuser as a response to the
trauma you experienced’)
2. It depends how you do it
Psychological formulations can, like psychiatric diagnosis,
obscure social contexts; be individualising; undermine
agency; pathologise; and be constructed in an expertderived, unreflective and disempowering way….
…and because the term ‘formulation’ is itself based in a
Western psychological model, it has the potential to
marginalise other cultural explanations (spirit possession,
voices of ancestors, etc) …unlike the Hearing Voices
concept of a ‘construct.’
Best practice principles (DCP Guidelines 2011)
Include social and societal contexts
Culturally sensitive
Include strengths
• Centrally concerned with personal meaning…
‘…a process of ongoing collaborative sense-making’
(Harper and Moss, 2003)
Psychiatric diagnosis
• Obscures meaning
• Removes agency
(‘sick role’)
• Removes social contexts
• Individualises
• Keeps relationships stuck
• Disempowering
• Stigmatising
• Culture blind
• Deficit-based
• Medical consequences
• Social consequences
Psychological formulation
• Explores meaning
• Promotes agency
• Can include social
• Includes relationships
• Looks at relationship
• Collaborative
• Non-stigmatising
• Culture sensitive
• Includes strengths
• Non-medical
• No social consequences
3. But do we also need broader formulation-based clustering
terms to replace DSM?
• To reduce complexity by grouping similar experiences
• To inform individual formulations by linking to bodies of
• To provide a basis for research
…plus administrative purposes: aid communication, plan
services, allocate benefits etc
Attempts to define new subdivisions of existing
categories, eg:
• ‘Complex post traumatic stress disorder’ (Herman, 2001)
• ‘Dissociative schizophrenia’ (Ross, 2006)
• ‘Traumatic psychosis’ (Callcott and Turkington, 2006)
NB These imply psychosocial causal factors but do NOT
avoid the ‘DSM mindset’. Nevertheless, they are signs of
a paradigm under serious threat
Oddly enough, DSM already contains some categories
that are perhaps better understood as broad-level
formulations than as diagnoses…if you remove the term
• ‘Adjustment disorder’
• Bereavement reaction’
• ‘PTSD’
‘Trauma reaction in the context of attachment difficulties’
….but this covers just about all presentations!
….and doesn’t help with the ‘everything causes everything’
‘……researchers have recently established that a broad
range of adverse childhood events are significant risk
factors for most mental health problems, including
(Read and Bentall, BJ Psychiatry, Feb 2012)
Tentative conclusion
Psychological formulation does have the potential to
replace psychiatric diagnosis at an individual/family level,
and to perform more effectively the claimed functions of
diagnosis (suggest how the problems arose, indicate
interventions, predict outcomes)….
Along with other benefits (enhancing the therapeutic
alliance, normalising, thinking about lack of progress,
providing containment)
….although research is lacking (and much needed)
…but we have a long way to go, and a great many
conceptual and political challenges, in developing a
broader system that avoids the ‘DSM mindset’, and
informs the co-construction of individual narratives in a
way that puts back what diagnosis takes out:
Restores context
Restores meaning
Restores agency
Restores hope
We are open to your suggestions!
Bentall, R (2003) Madness explained: psychosis and human nature.
London, New York: Penguin
Callcott. P and Turkington, D (2006) CBT for traumatic psychosis. In W.
Larkin and AP Morrison (eds) Trauma and psychosis. Hove, New
York: Routledge
Harper, D and Moss, D (2003) A different kind of chemistry?
Reformulating ‘formulation.’ Clinical Psychology, 25, 6-10.
Herman, J (2001) Trauma and recovery. London: Pandora
Johnstone, L (2007) Can trauma cause ‘psychosis’? Openmind, 150,
Ross, CA (2006) Dissociation and psychosis. In J Johannessen, B
Martindale and J Cullberg (eds) Evolving psychosis. London, New
York: ISPS for Routledge