Talking about ‘the gap’

In a previous post, I described the thoughts Clinical Psychology Forum 261 – a special about the gap between clinical psychology and psychiatry.  A letter summarising those thoughts was published along with other responses to CPF 261 in this month’s Forum, which is somewhat poignantly a special about ‘Remembering the bio in biopsychosocial’.

I was struck by the variety of responses in the other letters, showing the breadth of opinions held by psychologists in relation to this issue. Matthew Fish described how the issue was useful to an outsider to the profession as it gave a sense of what differentiates (clinical) psychology from psychiatry. Huw Green talks about how the range of ways in which issues are described using diagnoses and formulations could be seen as metaphors for our inability to fully  understand our ‘complex psychic system’. Simon Stuart described how the issue highlighted how often we tend not to pay attention to the views of service users. Certainly, I believe these should be at the heart of our clinical practice, and I hope that things are gradually moving that way, with the potential for increased use of community psychology approaches to future interventions. Isabel Clarke describes the point as being that ‘psychiatry has lost its way and landed up a blind alley’. She describes hopes for the future in the form of the Psychosis and Complex Mental Health Faculty and the New Paradigm Alliance. Dr Peter Scragg goes so ar as to suggest that the CPF might be renamed ‘Anti-Psychiatry Forum‘, and challenges clinical psychologists to produce empirical proof of the clinical value of formulation as opposed to diagnosis.

How can we take this forward? It sounds like there might be places for different approaches in different situations and with different people. Perhaps if we keep service users’ perspectives in mind and welcome service users’ opinions more, we might gain more insight into what work for whom, beyond analyses of different dyadic and systemic approaches to working with people. We might look at what constitutes something working for someone: how outcomes can be measured in meaningful ways, and hopefully fed back to clinicians and clients alike. I look forward to hearing more about The New Paradigm Alliance.

Perhaps diagnoses could be framed more as potentially useful heuristic tools that convey a concepts, but not an irreversible labelling of someone’s mental state, temperament or character. At the risk of sounding facetious, all words effectively function as metaphorical heuristics or symbols for something else, and by moving away from diagnosis, might people not simply come up with new ways to describe conditions that they see recurrently? How might diagnoses be effectively eradicated from common parlance? Would they be diluted out of existence, or somehow banned from use? Might psychologists risk alienating themselves further by refusing to use diagnostic terms and replace them with descriptions that other professionals might see as unnecessarily circumlocutory? Might this provoke anger towards psychologists from other professionals who might not have as much time to think as psychologists are afforded?

I think the formulation-based approach that seems to be at the core of most of the clinical psychology work I have witnessed and taken part in is the most humane and inclusive way of conceptualising most of the problems that the  people clinical psychologists work with in NHS settings. It takes time, but qualitatively at least, it seems to be more helpful than simply telling someone that they might have a certain diagnostic label. Formulation done properly is an intrinsic part of the therapeutic process. Perhaps, to paraphrase Winston Churchill, formulation is the worst form of conceptualisation of people’s difficulties, except for all those other forms that have been tried from time to time.