Moving Beyond Psychiatric Diagnosis: Lucy Johnstone, PsyD

August 14, 2020

In this interview, Dr Aftab and Dr Johnstone discuss her criticisms of psychiatric diagnosis and her approach to psychological formulation as a conceptual alternative to diagnosis.

CONVERSATIONS IN CRITICAL PSYCHIATRY

Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

Dr Lucy Johnstone is a consultant clinical psychologist in the UK. She is the former director of the Bristol Clinical Psychology Doctorate and was the lead author of “Good Practice Guidelines on the Use of Psychological Formulation” (Division of Clinical Psychology, 2011.) She has worked in adult mental health settings for many years, most recently in a service in South Wales. She is the author of Users and Abusers of Psychiatry (2nd edition, Routledge; 2000) and A Straight-Talking Guide to Psychiatric Diagnosis (PCCS Books; 2014), and co-editor of Formulation in Psychology and Psychotherapy: Making Sense of People's Problems (, 2nd edition, Routledge; 2013), along with a number of other chapters and articles taking a critical perspective on mental health theory and practice. She was lead author, along with Professor Mary Boyle, for the “Power Threat Meaning Framework” (PTMF), a Division of Clinical Psychology-funded project to outline a conceptual alternative to psychiatric diagnosis. Dr Johnstone currently works as an independent trainer. Her particular interest and expertise is in the use of psychological formulation, in both its individual and team versions, and in promoting trauma-informed practice.

Dr Johnstone’s views on psychiatric diagnosis have attracted a great deal of attention and controversy over recent years, especially online on platforms such as Twitter. Such forums are not always ideal for debates that can arouse strong feelings, so I appreciate Dr Johnstone’s willingness to participate in this interview series, where we have a better opportunity for productive dissent, to chart the extent of disagreements, and to explore potential for common ground. For an interview series that is devoted to critical and philosophical perspectives, it would be an egregious omission if I did not engage with Dr Johnstone, given the emerging prominence of hers and similar views, particularly in the UK, and the support she and her colleagues have received from the Division of Clinical Psychology of the British Psychological Society. While the series has not shied away from engaging with controversy, featuring criticisms which might provoke substantial antipathy among some psychiatric readers is not without its challenges. As the interview makes clear, I am not a neutral participant here, and I come to the discussion with my own disagreements.

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.

Aftab: I don’t agree with you that a diagnosis is a causal hypothesis over and above a formulation, but I think this issue is indirectly related to some of the other questions I have to ask you. So, let’s carry on. A common refrain among critics seems to be that what we call mental disorders are understandable and normal responses to adverse psychosocial experiences. From your perspective, when it comes to the realm of the mind and behavior, is there such a thing as a “disordered” response to adversity at all? Is everything—no matter how bizarre, distressing, impairing, or irrational—“normal”?

Johnstone: A better word than “normal”—which has various different meanings—is “understandable.” For example, it is not statistically “normal” to believe that men in red cars are planning to kill you, and this belief may lead to levels of distress that are not “normal” as compared to most people’s, and to many difficulties in leading what we might call a “normal” life. However, a formulation-based approach starts from the belief that, as clinical psychologist Gillian Butler puts it, “. . . at some level it all makes sense.”4(p2) The so-called paranoid belief about men in red cars stands for something, and it is meaningful in terms of the person’s past and present circumstances and the sense they have made of them. It is our primary task as mental health professionals to join service users in “a process of ongoing collaborative sense-making”5(p8) which can usefully be summarized in a formulation. So yes, I agree that assuming we have excluded the rare organic causes of “bizarre, distressing, impairing, or irrational” responses, then the guiding principle of “At some level it all makes sense” applies. In fact, I can’t immediately think of anyone I’ve worked with for whom it did not, in the end, turn out to be true.

Aftab: I have 2 concerns with this. One is that “disorder” and “understandable” are not necessarily contradictory notions. For instance, what we call “PTSD” is certainly an “understandable” reaction to trauma, yet to say that PTSD is not a disorder because it is understandable would be to talk past the intended meaning of disorder. My second concern is related to falsifiability. Let’s say a person presents to you with obsessions and compulsions. You approach the person with the assumption that the obsessions and compulsions are meaningful in terms of the person’s past and present circumstances. How would you know if you are wrong? I think humans are very good at creative story-telling. We can come up with narratives where none may exist. So, what makes this process of sense-making scientific?

Johnstone: Firstly, I would reject the “disorder” part of the label of PTSD. As we know, post-traumatic stress reactions are included in one of the two chapters of DSM5 now explicitly devoted to responses to psychosocial events and circumstances; indeed, biological causes are exclusion criteria. They do not, then, describe “disorders” in a medical sense, but natural responses to overwhelming circumstances. Echoing earlier editions of DSM, I would prefer the term “reaction” as in “post-traumatic stress reaction,” if we are to use this label at all.

The answer to your second question is, in principle, simple. As you say, a psychologist would work with such a person over a period of weeks or months to develop a shared formulation, or hypothesis, about the function and meaning of their intrusive thoughts or ritualising. Together you would plan an intervention based on that hypothesis. In other words, you would test the ideas out in practice, and amend them as necessary. That is what a hypothesis is for, and that is the heart of scientific practice. For example, if we both make a guess that the compulsion to check electrical plugs arose in the context of wanting to feel safe because an abusive ex-partner threatened to burn down the house (I am thinking of an actual client here), then we would hope that making those links, working through some of the traumatic memories, and finding other ways to feel safe, might reduce the need for checking, as well as addressing the core problem for which the checking was an attempted solution. If it didn’t, then we would need to revisit and revise our formulation.

I would add that therapeutic work is art as much as science. Such a formulation would be drawn from intuition, clinical experience, and empathy with the client’s story, as well as more formal evidence, and part of testing it out would be the client’s feeling that it “fits” at a gut level, and makes sense to them. But the process is also entirely defensible as scientific practice. Indeed, the reason we need formulation in mental health work is because diagnosis—which serves pretty well as the hypothesis in general medicine—does not do so in psychiatry. Thus, teams are essentially left floundering, switching from one non valid label to another, and trying out every drug in every combination available. This can continue for a lifetime.

Aftab: Do you advocate for a complete and total abolition of psychiatric diagnoses? Do you think formulation can perform all the pragmatic functions of diagnosis in clinical practice, in research, and for demonstrating efficacy of medications for purposes of regulatory approval?

Johnstone: Firstly, I’m not sure “abolition” is the right word. I believe we should use concepts that are evidence-based and jettison those that are not. I would hope this is not a controversial point. I follow your distinguished fellow countrymen such as Dr Allen Frances6 in agreeing that “there is no reason to believe that DSM-5 is safe or scientifically sound” and Dr Thomas Insel,7 who wrote that the weakness of the DSM is its lack of validity, and that patients deserve better.

Frances and Insel are optimists who think we will come up with a new, valid diagnostic system in the next decade or so, but meanwhile no responsible clinician should be uncritically using, or imposing, constructs that are known to have the same scientific status as “dropsy” or “railway spine” or “wandering womb” and that can have such devastating effects on people’s lives and identities. This is, I believe, a scandal. It is why I wrote, “A straight talking introduction to psychiatric diagnosis”8 so that people can make an informed choice about whether they wish to take on these labels and identities.

Secondly—formulation is obviously not suitable for all the purposes currently served by diagnosis, but nor is diagnosis. Again, this follows logically from the admitted fact that psychiatric diagnoses are not valid scientific categories—which is why, for example, the National Institute of Mental Health (NIMH) announced it would be “re-orienting its research away from DSM categories”7 and using what they call transdiagnostic constructs instead. That is 1 alternative. Simple descriptive terms, such as hearing voices or experiencing panic/low mood, can often serve clinical and administrative purposes. There are many other possible ways forward that do not rely on diagnostic categories, some of which we have discussed in Chapter 8 of the PTMF Main Document.9

Aftab: I think it serves a rhetorical purpose to compare the scientific status of contemporary psychiatric diagnoses to "wandering womb" but bears little resemblance to reality. An analogy would be if I said that psychological explanations have the same scientific status as the notion of "schizophrenogenic mother." Neither examples are very charitable. You bring up Dr Insel, but perhaps you don't appreciate that the notion of validity that Insel is referring to is such that nothing in the “psy” professions has achieved that. The sort of validity that he talks about, psychological formulations are likely to be even worse than psychiatric diagnoses in capturing that. Allen Frances has had concerns about DSM-5 which he has articulated very well, but he is certainly not a skeptic about diagnoses. He sees them as immensely useful constructs. And by Dr Frances’ standards, even British Psychological Society (BPS) has not fared well, as he has described BPS's approach to psychosis as, “All very pie-in-the sky stuff with no real-world foundation.”10

There is a distinction between the praxis-centrism of medicine and the episteme-centrism of science. John Sadler11 has discussed it very well in his work—and most clinicians, including psychologists, intuitively understand that clinical work and scientific work differ in important ways. I think its disingenuous to argue that psychiatric diagnoses are not valid with respect to a certain scientific standard but then not apply that same standard to psychological formulations. Are you aware of any scientific evidence that demonstrates that psychological formulations have greater validity based on the scientific standards by which we judge psychiatric diagnoses?

Johnstone: We might have to disagree about my analogies. Whether or not they are “charitable” (and by the way I don’t accept the construct of “schizophrenogenic mothers” either), they are accurate. We have talked about the scientific method. In science, it is understood that constructs routinely have to be revised and abandoned in favor of more accurate ones. As one of the UK’s most senior psychiatrists, Robin Murray12, puts it, “I expect to see the end of the concept of schizophrenia soon . . . The term schizophrenia will be confined to history, like ‘dropsy.’” In Biblical times, people believed that madness was caused by evil spirits. No one could actually see them, but everyone was sure they were there. Diagnoses like “wandering womb” or more currently “schizophrenia” are based on exactly the same logic. There are no bodily signs to confirm or disconfirm their presence, but we are convinced we’ll find them someday. This is purely a matter of faith, and it flies in the face of the mountain of evidence for psychosocial causal factors in all forms of mental distress.

As I said above, I am aware that Allen Frances is not a skeptic about diagnoses in general. His position seems to be: The ones we have are entirely wrong, but they are better than nothing, and new, valid systems will be along in a decade or so. In the meantime, we have an entire branch of medicine based on the unproven theory that what are called “functional psychiatric disorders” are best understood as medical illnesses. I don’t think that is a defensible position, especially when these labels are presented to patients as facts. Nor do I agree with Dr Frances’ determination to dismiss the BPS document “Understanding Psychosis,” to which I contributed, as “psychosocial reductionism.” It isn’t, and nor has he been able to produce an example of anyone who takes such a position; the document contains a very careful, inclusive consideration of the biological aspects of what we might call “psychosis.” Far from being “pie in the sky,” it is solidly based in the best clinical practice of leading UK clinicians, supported by recovered service users themselves. I’ve had these debates with him.13 “Understanding psychosis” was welcomed by the 2 most senior UK psychiatrists, one of whom said he wished his own profession had written it. There seems to be a real trans-Atlantic difference here. I can’t quite account for it, but it is an interesting topic in its own right.

I am familiar with these criticisms of psychological formulation. As I said above, a psychological formulation is a hypothesis. The statement that “psychological formulations are not valid” makes no sense. It is like saying “Hypotheses about the origins and meanings of people’s distress are not valid.” Hypotheses cannot be declared globally “not valid.” A particular formulation, or hypothesis, might turn out to be mistaken, of course, and that is why we test it out in practice and modify it accordingly, as I described above. Having said that, psychological formulation is not in a head-to-head competition with diagnosis for scientific status. It is based on a completely different paradigm—one that is meaning and narrative-based, as opposed to a natural science one. This was our starting point for the Power Threat Meaning Framework.

Aftab: Your understanding of psychiatric diagnosis seems to be restricted to a rather specific biomedical understanding of diagnosis, in which the diagnosis is incompatible with meaning and agency and ignores personal and social context. That is certainly one way of understanding psychiatric diagnosis, but not the only way. Many in the psychiatric field have criticized such understanding of psychiatric diagnosis and have articulated versions of psychiatric diagnosis which are compatible with meaning and agency, and with psychosocial context. You can find such philosophical accounts in the works of Paul McHugh, John Sadler, and Derek Bolton, to name a few. I can see why you are against the stereotypical biomedical understanding of diagnosis, but have you had any engagement with some of the more philosophically sophisticated accounts?

Johnstone: I think much of this writing misses the point. We may be able to come up with all kinds of cleverly nuanced perspectives on how we, as professionals and philosophers, understand psychiatric diagnosis, but the fact remains that people are being told they have mental illnesses and disorders, with all the usual connotations of those terms in Western societies. Moreover, they are heavily encouraged to take on the particular narrow understanding that you refer to—we are all bombarded with messages about “mental illness” being “as real as a broken arm”, and needing to be managed by drugs “just like diabetes.” Even the dubious compromise that is the “biopsychosocial” model—a way of acknowledging some role for psychosocial factors while at the same time instantly relegating them to “triggers” of a disease process—is not much in evidence on the ground. And furthermore, the biomedical message is reinforced by the fact that these labels are applied by doctors and nurses, working in hospitals and clinics, who use not just the labels themselves but the whole medicalized discourse of symptom, patient, prognosis, treatment, relapse, and so. The “stereotypical biomedical understanding of diagnosis” as you put it, is absolutely everywhere. In the PTMF, we argue that this leads to epistemic injustice14—in other words, people are systematically denied the knowledge that they need in order to create their own meanings about their experiences.

I do get a bit impatient with these abstract debates. I have yet to hear any real life service user say, “Although the doctor told me I have schizophrenia I’m not too worried, because ‘illness’ is really being used as a metaphor for suffering in this case and it doesn’t exclude personal meaning.” I am sure readers are aware that the consequences of being diagnosed—such as being sectioned, forcibly injected, and so on—are not just metaphorical. Some of these learned articles strike me as a form of defense against admitting to the fundamental inadequacy and devastating damage of the current diagnostic system. Essentially, we need to acknowledge that we are not dealing with patients with illnesses, but people with problems. We cannot make the necessary shift to a more appropriate and humane system unless we are prepared to drop the whole biomedical discourse altogether.

Aftab: I don’t think these are abstract debates. Clearly there is a lot wrong with the popular perception of what a diagnosis entails, and I believe we need tremendous effort to counter that. Yet, if all you’ve criticized is a widespread stereotype, then you have been engaging in a certain sense with a strawman. Sure, your arguments work well if you are trying to convince the public or convince professionals who don’t have a nuanced understanding of these things, but if your goal is to engage with thoughtful psychiatrists and psychologists, then this is not sufficient by any means. I’ve already mentioned Allen Frances. Kenneth Kendler, who is the vice chair of the American Psychiatric Association DSM Steering Committee, has done excellent work over the past 2 decades in outlining what our best understanding of psychiatric diagnoses should be. You don’t seem to consider the possibility that popular understanding of psychiatric diagnoses may simply be caricatures—caricatures that you may be inadvertently reinforcing yourself by presenting them as the “real thing.”

Johnstone: My primary goal—and that of other colleagues and allies, both professional and service user—is to work towards a non-medical understanding of emotional suffering, which is actually what we mean by “mental illness.” We do this on the basis that there is not, and never has been, any hard evidence that the experiences we call “mental illness/disorder” are best understood in this way, while there is an overwhelming amount of evidence that they arise within, and can be understood as a response to, psychosocial adversities of all kinds. The dominance of the diagnostic viewpoint blinds us to the extent to which non-medical alternatives are already flourishing. We have described some of them in the Appendices of the PTMF Overview. For example, we have Open Dialogue, the Hearing Voices Network, and many courageous survivor campaigners—including Jacqui Dillon and Eleanor Longden, co-authors of the PTMF—who recovered only by leaving psychiatry behind.

I realize this places me in the second of the 2 camps, under the so-called heading of “antipsychiatry,” as described by Ronald Pies in your recent interview.15 This is not a label I accept. It is legitimate to question whether the medical lens offers the best way of understanding emotional distress, unusual experiences and troubled or troubling behavior, and I and colleagues have moved well beyond an “anti” position, towards being “pro” the more effective and humane alternatives. That is where the Power Threat Meaning Framework comes in.

I found this statement of Dr Pies interesting: “To be sure: not all instances of prolonged or severe suffering and incapacity are instantiations of ‘disease.’ For example, someone might be tied to a chair by kidnappers or terrorists, then beaten and starved, and thereby experience profound suffering and incapacity—but we would not ordinarily attribute this to ‘disease.’”Dr Pies’s problem, and that of psychiatry in general, is where and how to draw the line between emotional distress and “disease.” One way of stating my position is that I would draw it very much further down the line than he would. A hypothetical person might, like many service users, have been neglected as a child. Do we call their distress “disease”? Then perhaps they were bullied at school. Do we call their fear “disease”? Then they may be assaulted in the street, and at that point start to hear voices telling them they are evil and people are out to kill them. Has this suddenly become a “disease”? Or is this, too, a logical and understandable, if unusual, consequence of what has happened to them?

In summary, it doesn’t matter whether you think I am putting forward a caricature of diagnosis. Diagnosis—however we choose to understand it—has no place in this field, and nor does the diagnostic thinking that it supports and perpetuates. All human experience has biological aspects, but not all forms of suffering are medical illnesses. We are dealing with people with problems, not patients with illnesses, and the whole paradigm—the “DSM mindset” as clinical psychologist Mary Boyle9 puts it—needs to change.

Aftab: Tell us about the Power Threat Meaning Framework? Why do you think it is important to focus on power, threat, and meaning specifically?

Johnstone: ThePTMF was published in January by the Division of Clinical Psychology of the British Psychological Society.9 Co-produced by a core team of psychologists and service users over a period of 5 years, it offers an alternative to more traditional models of mental health based on psychiatric diagnosis. It illustrates the strong links between wider social factors such as poverty, discrimination, and inequality, along with traumas such as abuse and violence, and the resulting emotional distress, whether it shows itself through fear, despair, mood swings,unusual experiences or troubled or troubling behavior. The Framework can be used as a way of helping people to create more hopeful narratives or stories about their lives and their difficulties, instead of seeing themselves as blameworthy, weak, deficient, or “mentally ill.” It also shows why those of us who do not have an obvious history of trauma or adversity can still struggle to find a sense of self-worth, meaning, and identity.

The main PTMF documents are quite long and dense, but the essence of the PTMF is captured in the core questions which can be used flexibly to help create a non-diagnostic story or narrative (see Table).

We started with a consideration of Power in all its forms, including ideological power, because it is the aspect that is excluded by definition from psychiatric diagnosis, although it is also missing from much of psychology and psychotherapy as well. Responses to this question inevitably imply the others—how you have reacted, what it meant to you, and how you are managing all this—in other words, Threats, Meanings and finally the Threat Responses which include the experiences that psychiatry calls “symptoms.” The PTMF does not recognize a separate group of people who are “mentally ill”—we are all subject to the negative impact of Power at times and we all have to find ways of surviving it. You can read more, and find resources and practice examples, here.

Not surprisingly, the PTMF has proved controversial but has also attracted a great deal of interest, nationally and internationally, within and beyond services. We see the documents as the first stage of an ongoing project, and we will be using practice examples and evaluations to develop the Framework further.

Aftab: I myself in my residency training was taught biopsychosocial formulation, psychodynamic formulation, and cognitive behavioral formulation. How does your framework stand in relationship with these other styles of formulation? Do you advocate a pluralistic approach to formulation, or do you think PTMF is the only valid way of conceptualizing mental disorders?

Johnstone: My co-edited book, Formulation in Psychology and Psychotherapy: Making Sense of People’s Problems, consists of an overview of many different models of formulation. Personally, I would advocate an integrative approach. The PTMF is, in many ways, a step beyond formulation as such—in fact, it contains very little about formulation—in favor of narrative in general. It takes the view that human beings are, and always have been, meaning-makers and storytellers, and that narratives of all kind, whether written or verbal or expressed through legend, art, song or community ritual, can be healing. This allows us to be much more inclusive of culturally specific ways of expressing and healing distress. For example, I was privileged to share the PTMF in a workshop attended by Maori people in New Zealand, and to find that there were commonalities and compatibilities with their creation legends, as described in this blog.

The PTMF is thus a very broad, over-arching framework which builds on and supports many existing non-diagnostic approaches. Formulations from various models are a subset of narratives in general, and they have strengths in service contexts. But while the PTMF can be used to ensure that we include social contexts in our formulating, it also offers tools for people to construct their own stories without professional support. We have been encouraged by the way some peer groups have taken this on.16,17 The PTMF also acknowledges and respects non-Western perspectives and narratives, rather than seeking to export the diagnostic model across the globe.

Aftab: What would you say to psychiatrists like me who welcome the focus on social factors, adversity, trauma, power, individual narratives, and sense-making offered by PTMF, but are “put off” by the contextual narrative around PTMF, a narrative which is actively hostile to psychiatric diagnosis and which we would argue—and you can reserve the right to disagree—mischaracterizes psychiatric diagnostic framework? I’m sure many psychiatrists who are reading this interview would have similar reactions. Do you welcome efforts by psychiatrists to integrate PTMF within psychiatric practice? Or is your attitude more along the lines of “East is East, and West is West, and never the twain shall meet”?

Johnstone: The PTMF summarizes the huge amount of evidence that psychiatric diagnoses are not valid scientific categories. This is not about being “actively hostile to psychiatric diagnosis,” which sounds as if though we are primarily motivated by an ideological vendetta of some sort—it is about putting forward a rigorous, evidence-based critique (with which people may disagree). I suspect there are some cultural differences here—a number of UK psychiatrists (and Spanish and Danish ones) have welcomed the PTMF (Joanna Moncrieff, whom you interviewed, is one). And in general, the ideas I have expressed in this interview would not be seen as be particularly unusual in the UK, although they are not the dominant ones. Finally, the PTMF is not about psychiatrists as such. Many psychologists and other professionals work within a diagnostic model, and some psychiatrists do not. It is about ways of thinking, which cut across professional groups.

The PTMF is a conceptual resource, a set of ideas, not a plan for services or for anything else, and it is entirely up to individuals whether and how they use it. The authors have no wish, and no power, to impose it on anyone. In practice, it is likely that it will run alongside existing biomedical models. However, a bit like psychological formulation, it is conceived of as a replacement for, not a supplement to, diagnostic approaches. As a practitioner, of course I engaged respectfully and collaboratively with colleagues of all backgrounds who had different views. As a trainer and campaigner, I’m much more interested in the growing grassroots movement of people who, like me, are arguing for fundamental change. So yes, of course we welcome use of the PTMF by psychiatrists or anyone else. Ultimately, though, the change we need is not going to come from within services or within the profession of psychiatry—or psychology, for that matter. It needs to be a much wider social movement. I am confident that we are seeing the crumbling of the current diagnostic paradigm, with or without the PTMF. But we hope we have made a contribution to envisaging a better future.

Aftab: Thank you!

To ensure that references to writings by Sir Robin Murray and Dr Allen Francis did not misrepresent their intended context, they were asked to comment on the representation of their views in this interview.

Sir Robin Murray (Professor of Psychiatric Research; Institute of Psychiatry, Psychology and Neuroscience; Kings College, London): “Dr Johnstone is correct that I do not believe that schizophrenia exists as a discrete clinical entity. In my practice I find it more useful, like many psychologists, to use the term psychosis. Of course, psychosis still is a diagnostic category—just a broader one! I anticipate that as we learn more we will be able to refine it into those psychoses which are mainly psychosocial in origin (eg, following trauma), those which result from a mixture of biological and social causes (eg, cannabis-associated psychosis), and a few which will be predominantly biological, due for example to copy number variants or receptor auto-antibodies. Sadly, within society relatively few care about people who suffer from serious psychological/psychiatric conditions. In my view, those of us who do care have a duty to treat our colleagues from different disciplines with respect and not denigrate their views. Most British psychologists and psychiatrists work in this way, happily collaborating to help their patients/clients. Sadly, a few psychologists appear to have been stranded in a Jurassic world where they spend their energies railing against a type of psychiatry which became extinct years ago.”

Dr Allen Francis (Professor Emeritus and former Chair, Department of Psychiatry, Duke University): “Thanks for this opportunity to correct Lucy Johnstone's misrepresentation of my critiques of the DSM system. I take a commonsense position regarding psychiatric diagnosis—equally distrusting of clinicians who worship DSM as a bible and those who don't use it all. Similarly, I equally oppose those psychiatrists who are narrowly mindless, and those psychologists who are narrowly brainless, in their understanding of human distress. And I equally dislike the biological reductionism of NIMH's RDoC project and the psycho/social reductionism of "Understanding Psychosis" published by the British Psychological Society. To me, a 4-dimensional bio/psycho/social/spiritual model is the only way to understand the full complexity of human behavior and to guide our work with patients.

I have been one of the fiercest critics of DSM-5 and urge clinicians to always use DSM with great caution; preferring to err on the side of under-diagnosis; weighing the risks vs benefits of making any diagnosis; never jumping quickly to conclusions; and mentally "writing their diagnoses in pencil. But despite all its many limitations, DSM is absolutely essential to safe clinical practice; neglecting it inevitably leads to careless and idiosyncratic treatment decisions. The symptoms of all the mental disorders can be mimicked by medical illness; by medication side effects or withdrawal; and by substance intoxication or withdrawal. Systematically ruling these out is the very first step in every careful DSM differential diagnosis—ensuring that these quite common causes of psychiatric distress are not missed via a quick and careless assumption that all symptoms reflect psychological or social causation. You can't possibly be a good clinician without understanding the proper use of diagnosis in guiding specific treatment interventions—both the choice of which psychotherapy techniques and the choice of which medication. It is Hippocratic wisdom to know the patient but knowing the patient also means knowing the disorder. No evaluation is ever close to complete if it focuses only on DSM diagnosis; but no evaluation is ever complete if it carelessly ignores it.

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of Psychiatric Times.

Dr Aftab is a psychiatrist in Cleveland, Ohio, and clinical assistant professor of psychiatry at Case Western Reserve University. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the Psychiatric Times Advisory Board. He can be reached at awaisaftab@gmail.com or on Twitter @awaisaftab. Dr Aftab and Dr Johnstone report no conflicts of interest concerning the subject matter of this article.

Previously in Conversations in Critical Psychiatry

Relentless Warrior for Mental Health: Allen Frances, MD

The Structure of Psychiatric Revolutions: Anne Harrington, DPhil

Skepticism of the Gentle Variety: Derek Bolton, PhD

Explanatory Methods in Psychiatry: The Importance of Perspectives: Paul R. McHugh, MD

Chaos Theory with a Human Face: Niall McLaren, MBBS, FRANZCP

The Rise and Fall of Pragmatism in Psychiatry: S. Nassir Ghaemi, MD, MPH

Integrating Academic Inquiry and Reformist Activism in Psychiatry: Sandra Steingard, MD, and G. Scott Waterman, MD

Social Constructionism Meets Aging and Dementia: Peter Whitehouse, MD, PhD

50 Shades of Misdiagnosis: Susannah Cahalan

Institutional Corruption and Social Justice in Psychiatry: Lisa Cosgrove, PhD

The Impoverishment of Psychiatric Knowledge: Giovanni Fava, MD

Psychiatry and the Human Condition: Joanna Moncrieff, MD

Psychiatric Disorders as Imperfect Community: Peter Zachar, PhD

Weaving Conceptual and Empirical Work in Psychiatry: Kenneth S. Kendler, MD

The Battle for the Soul of Psychiatry: Ronald W. Pies, MD

Psychoanalysis and the Re-Enchantment of Psychiatry: Jonathan Shedler, PhD

References

1. Skills for Health, Health Education England and Skills for Care. Mental Health Core Skills Education and Training Framework. 2016. Accessed August 13, 2020. https://www.skillsforhealth.org.uk/services/item/525-mental-health-download

2. Division of Clinical Psychology. Good practice guidelines on the use of psychological formulation. Leicester: British Psychological Society. 2011. Accessed August 13, 2020. https://shop.bps.org.uk/good-practice-guidelines-on-the-use-of-psychological-formulation

3. Royal College of Psychiatrists. A competency-based curriculum for specialist core training in psychiatry. 2010. Accessed August 13, 2020. https://www.rcpsych.ac.uk/docs/default-source/training/curricula-and-guidance/general_psychiatry_curriculum_march_2019.pdf

4. Butler G. Clinical formulation. In: Bellack AS, Hersen M, Eds. Comprehensive Clinical Psychology. Oxford: Pergamon; 1998.

5. Harper D, Moss D. A different kind of chemistry? Reformulating ‘formulation.’ Clin Psychol. 2003;25:6-10.

6. Frances A. One Manual Shouldn’t Dictate Mental Health Research. 2014. New Scientist. Accessed August 13, 2020. http://www.newscientist.com/article/dn23490-one-manual-shouldnt-dictate-us-mental-health-research.html#.U0_jR3JeF1s

7. Insel T. Director’s Blog: Transforming diagnosis. National Institute of Mental Health. April 29, 2013. Accessed August 13, 2020. http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml

8. Johnstone L. A Straight-Talking Guide to Psychiatric Diagnosis. Monmouth, UK: PCCS Books; 2014.

9. Johnstone L, Boyle M, Cromby J, et al. The Power Threat Meaning Framework: Overview. Leicester: British Psychological Society. 2018. Accessed August 13, 2020. https://www.bps.org.uk/power-threat-meaning-framework

10. Frances A. The British Psychological Society Enters the Silly Season. Education Update Online. May 16, 2013. Accessed August 13, 2020. http://educationupdate.com/allenfrances/2013/05/the-british-psychological-society-enters-the-silly-season.html

11. Sadler JZ. Values and Psychiatric Diagnosis. Oxford University Press; 2005.

12. Murray RM. (Mistakes I have made in my research career. Schiz Bull. 2017;43(2):253-256.

13. Frances A. Does it make sense to scrap psychiatric diagnosis? A debate on shifting paradigms. Psychology Today. October 28, 2018. Accessed August 13, 2020. https://www.psychologytoday.com/gb/blog/saving-normal/201310/does-it-make-sense-scrap-psychiatric-diagnosis-0

14. Fricker M. Epistemic Injustice: Power and the Ethics of Knowing. Oxford: Oxford University Press; 2007.

15. Aftab A. The Battle for the Soul of Psychiatry: Ronald W. Pies, MD. Psychiatric Times. Accessed August 13, 2020. https://www.psychiatrictimes.com/view/battle-soul-psychiatry-ronald-w-pies-md

16. Griffiths A. Reflections on using the Power Threat Meaning Framework in peer-led systems. Clinical Psychology Forum. 2019;313:9–14.

17. SHIFT Recovery Community. Using the Power Threat Meaning Framework in a Self-Help Group of People with Experience of Mental and Emotional Distress. J Constr Psychol. 2020. DOI: 10.1080/10720537.2020.1773361