Day 13: Lucy Johnstone on Psychological Formulation
The future of mental health interview series, day 13
Posted Jan 30, 2016
The following interview is part of a “future of mental health” interview series that will be running for 100+ days. This series presents different points of view about what helps a person in distress. I’ve aimed to be ecumenical and included many points of view different from my own. I hope you enjoy it. As with every service and resource in the mental health field, please do your due diligence. If you’d like to learn more about these philosophies, services, and organizations mentioned, follow the links provided.
Interview with Lucy Johnstone
Lucy Johnstone is a leading light among British mental health advocates who are actively disputing the current, dominant paradigm of “diagnosing and treating mental disorders” and who, going the next step, are endeavoring to provide alternative methods and paradigms, in Lucy’s case the paradigm of “psychological formulation.”
Interview with Lucy Johnstone
EM: You are in the forefront of what is variously called the anti-psychiatry movement, the critical psychiatry movement, and the critical psychology movement. Can you tell us a little bit about what concerns you about our contemporary paradigm of “diagnosing and treating mental disorders”?
LJ: To put it briefly, Western psychiatry is based on the idea that the various forms of distress that people can suffer from, such as very low mood, extreme anxiety, hearing voices, unusual beliefs, suicidal impulses, self-starvation and so on—are best understood as medical illnesses with mainly biological causes in our genes and biochemistry. As a result, we expect such people to receive a diagnosis, and to be treated with medication, prescribed by doctors and administered by nurses.
This idea has taken hold so strongly that it can seem bizarre to question it. But in fact there has never been any evidence for the so-called biomedical model of mental distress. Obviously all human experience has biological aspects, but despite what you may have read or been told, no one has ever been able to identify the genes or chemicals that are said to cause 'mental illness.’ On the other hand, we do have a mountain of research to confirm that all kinds of social and relationship adversities massively increase the likelihood of experiencing mental distress. This includes poverty, unemployment, emotional neglect, physical and sexual abuse, domestic violence, bullying, and so on, as well as more subtle difficulties such as feeling criticized, undermined, invalidated and excluded. These are the causal factors we should be tackling.
EM: More specifically, what are your objections to biomedical model psychiatry?
LJ: One of the worst consequences of traditional psychiatric models is the growing amount of research showing that psychiatric drugs tend to increase, not reduce, disability in the long term. Medication does have its uses—for example, its short-term use can help people survive a crisis. I must also warn that it is dangerous to come off medication without taking professional advice. However, it is not true to describe these drugs as 'treating illnesses.' Combine over-prescription of drugs with the stigmatizing effect of receiving a psychiatric diagnosis, and the end result is often to introduce someone to a lifelong career as a psychiatric patient.
In other words, the biomedical model of mental distress is not only untrue, but is often actively damaging. Many former patients/service users have testified to this, and say that they only started to recover when they rejected the messages of psychiatry. In fact, even the senior professionals who draw up the lists of psychiatric diagnoses are now admitting that they need to start again from first principles. That's not to deny that some people are indeed helped by mental health staff, but this tends to be despite, not because of, the medical approach. It is a scandal—but one which the general public is largely oblivious to. However, I am hopeful that we are on the brink of fundamental change.
EM: You are involved in efforts to help practitioners better understand and better employ “psychological formulation.” Can you tell us a little bit about what psychological formulation is and why you consider it useful?
LJ: The process of labeling someone's problems as an illness, or in other words diagnosing them, is the cornerstone of psychiatric practice. We urgently need alternatives, and in essence, all alternatives consist of ways of listening to people's life stories. Psychological formulation is one way of doing this, although not the only way. However, it has a firm foothold in UK mental health practice.
Briefly, it 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 narrative that a psychologist or other professional draws up with an individual and, in some cases, their family and the people who care for them. The professional contributes their clinical experience and their knowledge of the evidence—for example, about the impact of trauma. The client or service user brings their personal experience and the sense they have made of it. The end result of putting these two essential aspects together, in written or diagrammatic form, is called a formulation. Unlike diagnosis, this is not about making an expert judgment. It is a shared, evolving, collaborative process which also includes the person's strengths, and which suggests the best route towards recovery.
EM: How do you personally work with individuals in distress? What is your approach and what are your methods?
It goes without saying that formulation is at the heart of my clinical practice. This is true both at a one-to-one level and in the form of consultation known as Team Formulation, in which I facilitate meetings to enable a group or team of mental health professionals to develop a shared psychosocial understanding of a client's difficulties.
Since formulation is a kind of over-arching structure for tailoring our knowledge and evidence to the individual, it is compatible with a number of different therapeutic approaches. I believe that all formulations should be 'trauma-informed'—in other words, be based on an awareness of the prevalence of all varieties of trauma and adversity and the impact they can have on people's mental health. Therapy isn't the only way forward, though, and team formulation plans often highlight the need to work with practical issues about employment, benefits and so on as the main priority.
EM: If you had a loved one in emotional or mental distress, what would you suggest that he or she do or try?
LJ: All of us go through emotional distress at times—it’s part of life—and generally we get through it with the support of partners, friends and family. We are often much too quick to think that professional help must be involved, and hard-pressed doctors are also much too inclined to hand out medication for ordinary life problems. But at times those resources aren't available, or can't offer all the help we need, or are actually part of the problem.
People who have enough money can pay for therapy, or take a holiday, or change their job, or move away from an abusive relationship, and so on. Those who don't have these choices—and they are the very people who are most likely to experience severe forms of distress—may have no alternative but to turn to psychiatry. They may be lucky enough to find professionals who offer more than narrow medical understandings and remedies, but they may not.
I think people need to be as well informed about critiques of the mental health system as they can be, so that they don't get directed down the path of long-term psychiatric patient. Both your and my books would be a good start! I would particularly like to mention my recent short book 'A straight-talking introduction to psychiatric diagnosis' (PCCS Books 2014) which aims to enable people to make an informed choice about whether or not to take on a diagnostic label, and points them to alternatives if they wish to pursue them. I also have a blog at the Mad in America site www.madinamerica.com, which hosts a wealth of information about critical perspectives on psychiatry.
Dr. Lucy Johnstone is a consultant clinical psychologist, author, lecturer and trainer who has worked in Adult Mental Health settings for many years. She was lead author for the Division of Clinical Psychology 'Good practice guidelines on the use of psychological formulation' (2011), author of 'Users and abusers of psychiatry' (Routledge 2000), and co-editor of 'Formulation in psychology and psychotherapy' (Routledge 2013). Her most recent book is 'A straight talking guide to psychiatric diagnosis' (PCCS Books, 2015) http://www.amazon.com/s/ref=nb_sb_noss?url=search-alias%3Daps&field-keywords=johnstone+diagnosis+straight+talking. She blogs at http://www.madinamerica.com/author/ljohnstone/
Eric Maisel, Ph.D., is the author of 40+ books, among them The Future of Mental Health, Rethinking Depression, Mastering Creative Anxiety, Life Purpose Boot Camp and The Van Gogh Blues. Write Dr. Maisel at email@example.com, visit him at http://www.ericmaisel.com, and learn more about the future of mental health movement at http://www.thefutureofmentalhealth.com
To learn more about and/or to purchase The Future of Mental Health visit here.
To see the complete roster of interview guests, please visit here: