Lucy Johnstone, PhD is a marvelous British psychologist on the cutting edge of what’s good in the field. She promotes”psychological formulation,” including the patient’s input, to replace psychiatric diagnosis. Yes, replace it!

The Dr. Peter Breggin Hour - 01/15/14 | PRN.fm

Formulation is the process of making sense of a person’s difficulties in the context of their relationships, social circumstances, life events, and the sense that they have made of them. It is a bit like a personal story or narrative that a psychologist or other professional draws up with an individual and, in some cases, their family and carers.

Formulation ? The Psychological alternative to Diagnosis | Clinical Psychology and People

[Chopin99]

I didn't listen to the audio file, but I did read the article. I think the idea of formulation rather than diagnosis could revolutionize the field of psychology, psychiatry, and counseling. As a budding counselor, this fascinates me. I have worked with individuals with intellectual and developmental disabilities and the field is slowly moving toward person-centered planning for their lives. I recently researched wellness models for a paper I am writing and counseling seems to be making the move, but because the counseling field is still so fragmented and disparate, the move is very slow.

Another serious issue is that here in the US, despite the Affordable Care Act, insurance companies still run the show and they do not want to move from a medical model. Treatment of symptomology rather than prevention and wellness. Until the insurance companies change their point of view, counselors remain stuck with diagnoses so that individuals can have their treatments paid for (although sometimes only partially).

[dumburn]

Thanks for this, i'm on the waiting list for something called Guided Formulation and this sounds exactly like it, but I haven't been given much information or been able to to find out much by myself. I certainly like the sound of it.

[Nightlight]

I found that really interesting and very relevant to what I'm studying as well. I've always found mental illness diagnoses to be extremely imperfect, so I'm really interested to learn more about the concept of formulation as an alternative to diagnosis. Interesting! It makes me feel glad that I'm studying psychology (and will be focusing on the DSM-5 this year).

I love the idea. Psychoanalysts have been doing formulations for years, including consideration of the patient's capacity and strengths.

In fact, psychoanalysts created their own "DSM" years ago to reconceptualize treatment, but it doesn't parallel insurance reimbursements and can create gaps in care continuity. Unless all institutions/practitioners/payors adopt the same thing, it won't fit in the system. Maybe that is why it didn't catch on?

"The Psychodynamic Diagnostic Manual (PDM) is a diagnostic framework that attempts to characterize the whole person--the depth as well as the surface of emotional, cognitive, and social functioning. It emphasizes individual variations as well as commonalities. We hope that this framework will bring about improvements in the diagnosis and treatment of mental disorders and will permit a fuller understanding of the functioning of the mind and brain and their development. The goal of the PDM is to complement the DSM and ICD efforts of the past 30 years in cataloguing symptoms by explicating the full range of mental functioning.

The PDM is based on current neuroscience, treatment outcome research, and other empirical investigations. Research on brain development and the maturation of mental processes suggests that patterns of emotional, social, and behavioral functioning involve many areas working together rather than in isolation."

Thanks for passing this along. I'm always interested in modeling/reconceptualizing, and it seems like mental healthcare can be so much better. As most of us probably know, there are just so many influences to the current model of care (e.g.-pharma).

edit: wrong link; this one is right from the source and more detailed:

http://www.pdm1.org/intro.htm

[Perna]

There's a lot of good stuff on it: http://www.canterbury.ac.uk/social-a...lation2011.pdf

Not a fan of the man . . .

[Lauliza]

I agree, I'm not a fan either.

[jacq10]

I understand why some people aren't a fan of "labels" but they are just a way to summarize and operationalize symptom presentation to facilitate communication between health care professionals.

[Lauliza]

In the US a diagnosis is necessary in order to receive any insurance coverage for psychiatry and psychotherapy. Without one, most insurance companies will only pay for about 12 sessions a year. And then clients are forced to pay out of pocket, most of whom can't afford to, and therefore end up with nothing.

I don't see why a diagnosis is a negative though. Yes it is based on the medical model, so a personality disorder diagnosis won;t get you the best coverage, but since MDD usually accompanies a PD, then the addition of this to your diagnosis means access to comprehensive care. A psychiatrist will usually recommend therapy with counselor or social worker. A good one will assess the whole picture - health, social factors, work and education, financial needs, etc when devising a treatment plan. All this is essentially what you're describing as a formulation. The diagnosis is a necessary part of the picture, but used my most clinicians as means to an end - as a way to ensure their clients get insurance coverage.

[Nightlight]

Although I don't think labels are perfect, I'm not strongly against them either. I do think it's important to be aware of all of the other things that labels do as well. They aren't neutral and do carry quite a lot of meaning to patients and practitioners, (as well as employers, insurance companies, drug companies and so on). I think that the labels can and often do lead to many negative as well as positive outcomes.

[Favorite Jeans]

Originally Posted by amee200

In the US a diagnosis is necessary in order to receive any insurance coverage for psychiatry and psychotherapy. Without one, most insurance companies will only pay for about 12 sessions a year. And then clients are forced to pay out of pocket, most of whom can't afford to, and therefore end up with nothing.

I don't see why a diagnosis is a negative though. Yes it is based on the medical model, so a personality disorder diagnosis won;t get you the best coverage, but since MDD usually accompanies a PD, then the addition of this to your diagnosis means access to comprehensive care. A psychiatrist will usually recommend therapy with counselor or social worker. A good one will assess the whole picture - health, social factors, work and education, financial needs, etc when devising a treatment plan. All this is essentially what you're describing as a formulation. The diagnosis is a necessary part of the picture, but used my most clinicians as means to an end - as a way to ensure their clients get insurance coverage.

I think one problem with diagnosis is that doctors often try hard to squeeze a patient into a diagnosis rather than use appropriate descriptors to try to capture what is going on for the patient. As many have mentioned, they are often forced to do this for documentation and billing purposes but maybe we should question that too. Often diagsoses take that form of checklist (eg "at least four of the following eight symptoms") and it can be hard to figure out where someone's symptoms truly fit. What if they only have three symptoms? It reduces a person's entire life to a quick label.

I enjoyed the article for the most part but thought that the idea (last few sentences) that one can subscribe either to a psychosocial model or to a medical/biological one to be simplistic, misleading and really not rooted in evidence. The best evidence out there suggests that of course all of it (genes, in utero environment, parenting, schooling etc.), makes up who we are and how we feel, that medication can be a lifesaver and that babies are not simply blank slates but people with personalities.

Originally Posted by Favorite Jeans

I enjoyed the article for the most part but thought that the idea (last few sentences) that one can subscribe either to a psychosocial model or to a medical/biological one to be simplistic, misleading and really not rooted in evidence. The best evidence out there suggests that of course all of it (genes, in utero environment, parenting, schooling etc.), makes up who we are and how we feel, that medication can be a lifesaver and that babies are not simply blank slates but people with personalities.

Breggin is the king of black and white thinking. If others like this model, they need to get a different spokesperson. It won't get anywhere with him at the wheel.

Originally Posted by amee200

I don't see why a diagnosis is a negative though. Yes it is based on the medical model, so a personality disorder diagnosis won;t get you the best coverage, but since MDD usually accompanies a PD, then the addition of this to your diagnosis means access to comprehensive care. A psychiatrist will usually recommend therapy with counselor or social worker. A good one will assess the whole picture - health, social factors, work and education, financial needs, etc when devising a treatment plan. All this is essentially what you're describing as a formulation. The diagnosis is a necessary part of the picture, but used my most clinicians as means to an end - as a way to ensure their clients get insurance coverage.

I agree with you that diagnosis facilitates insurance reimbursement, and I am not thinking of diagnosis as a negative concept, although I think the system has room for much improvement.

Maybe my thoughts are tangential to the conversation because I am looking at the big picture implications, but these diagnoses are used for research also and so they are used in formulating evidence based treatments and research funding and policy making, to name a few. The stakes are high, so in my opinion, this diagnostic system can't afford the extremely low inter-rater reliability that exists with the current system.

The DSM is based on descriptive symptoms, which doesn't align with psychodynamic thinking. For example, the behavioral symptoms often point to extraversion, rather than the internal world of someone suffering from BPD, so introverts are often excluded from the diagnosis (often given the Bipolar II diagnosis). People with BPD can express their symptoms in many different ways, but the nature of a descriptive diagnosis limits the diagnosis to only people who express the disorder through the narrow list of symptoms listed. But despite that, DBT was created. If Linehan was not suffering from BPD herself, this treatment may have not been conceptualized. Who really knows.

It just doesn't match with psychodynamic conceptualization, but then the CBT promoters complain that psychodynamic therapy is not "evidence-based". Well this is one major reason why. Of course CBT can be researched to show more evidence because the symptoms align with the diagnosis system in the first place. There are other problems with the research....but what happened is that people in the UK and elsewhere are extremely limited in the treatments they can receive as an indirect result of this diagnostic system.

So it can be damaging and so some of us might like to discuss or promote awareness and trends for potential improvements to the overall system.

[Lauliza]

Originally Posted by Favorite Jeans

I think one problem with diagnosis is that doctors often try hard to squeeze a patient into a diagnosis rather than use appropriate descriptors to try to capture what is going on for the patient. As many have mentioned, they are often forced to do this for documentation and billing purposes but maybe we should question that too. Often diagsoses take that form of checklist (eg "at least four of the following eight symptoms") and it can be hard to figure out where someone's symptoms truly fit. What if they only have three symptoms? It reduces a person's entire life to a quick label.

I enjoyed the article for the most part but thought that the idea (last few sentences) that one can subscribe either to a psychosocial model or to a medical/biological one to be simplistic, misleading and really not rooted in evidence. The best evidence out there suggests that of course all of it (genes, in utero environment, parenting, schooling etc.), makes up who we are and how we feel, that medication can be a lifesaver and that babies are not simply blank slates but people with personalities.

I think we should question the power insurance companies have in this field also. I bet most practitioners would rather have more flexibility in the way they run their practice. If they didnt need to worry about their patients losing coverage I think the mental health system in this country would be run much differently. I don't see any kind of change happening here anytime soon. My psychiatrist said that to me recently when I mentioned a professor of mine said they are thinking of doing away with the DSM altogether. He said "No way. It makes a lot of money for the APA, drug and insurance companies..."

[archipelago]

While I like the idea of formulation and will use it when I'm a therapist, the problem with it is that each approach will formulate the set of issues in ways particular to that approach. So there is in this thread the example of the psychodynamic approach. It resists the DSM to some extent and helps psychodynamic therapists work within their own framework. That makes sense to me because I lean that way, but what would a CBT therapist say about the very same client?

I think in terms of becoming a working therapist I've decided to do parallel work. To have notes that are more specific to my approach and others that use the medical model, trying not to have them be too far apart. We are trained to do formulations in many modes according to different approaches. I think flexibility is key. Being able to see things in multiple ways helps as long as it's not confusing. Taking in the whole person and the person's context is way better than just assigning a label. I agree with that. And a strength based approach to the treatment plan can be really helpful.