Diagnosis vs Formulation in Mental Health
"Should psychological formulation replace diagnosis?"
When Brian Hodges created the model the original purposes (c. 1983-84) were to facilitate:
- Reflection and reflective practice;
- Integrated - person-centred care;
- Holistic care (mental, physical, social, political and spiritual) and;
- Bridge the Theory - Practice gap.
After learning and applying the model in 1987-88 I quickly recognised the multi-fold purposes and functions to which Hodges' model can be applied. One of these is clinical assessment which are encapsulated in 1-4 above. Importantly this includes assessment across all fields of health and social care; and more specifically case formulation as applied within various psychological therapies and interventions.
Noting a tweet (see below) I knew straight away that here is a blog post, even before being pointed to an associated blog post,
In 1998-9 I started a course on the use of psychosocial intervention and cognitive behaviour therapy in psychoses. From the outset as a student mental health nurse, you are constantly made aware of the politics in psychiatry and mental health nursing:
Clare, A.W. (1976) Psychiatry in Dissent: Controversial Issues in Thought and Practice. London: Tavistock
Even on twitter (and I don't wish to denote surprise) there is often marked debate, critique, even sniping between psychology, psychiatrists and users of mental health services, patients, or survivors whichever nomenclature you prefer.
I have always tried to draw student's attention to coding and classification. Key to this is purpose: clinical diagnosis, epidemiology, research, demographics, national and international reporting and statistics (plus of course - pandemic management). Being a health care professional demands an awareness of diagnosis, the tools available, how they change and their limitations. Even if it is 'not your job' to 'diagnose', that understanding is important to your effectiveness and ability to empathise with patients, carers and families.
Implicit in Hodges' Health Career - Care Domains - Model is time and potential or otherwise for change in and throughout someone's life.
Students will and should become embroiled in the debate of mental illness as a social construct. Although world events at present heighten the view of things being polarised and now in its starkest form - people too and Yes - #BlackLivesMatter. The continuum model of mental health affords another viewpoint. It suggests the gradual way a person's beliefs can become more bizarre over time. Substance harmful use is not some necessary (essential) precipitating factor, but it can accelerate a negative transformation of a person's view of themselves, others, the world and future.
A diagnosis can be constructive, providing renewed certainty and direction. A diagnosis can also be destructive in terms of how a patient, their loved ones, friends and society receive it. There are nursing diagnoses also; and as such Hodges' model provides a means
for a nursing, psychological and clinical case formulation.
In response to reference to the 'medical model', I have tweeted many times how the biopsychosocial model, of which the medical model is a part, is incomplete.
Beyond diagnosis and formulation, there is a need to see the model that really does the work,
for the real elephant in the room to reveal itself.
I am of course referring to the bio-psycho-socio-political model.
Appeal to the medical model, without reference to the political is ingenuous. It is the political after all that permits institutions to award degrees and the granting of licensing and registers to 'practice', prescribe drugs and other treatments. Ready incorporation of the political should be acknowledged by the extent of change through the past 40 years of mental health service provision (and more recent stasis?).
Or, perhaps legislation passed in that time does not yet speak volumes?
The role of community mental health nursing has changed profoundly in this time and the accent (as evinced three days a week Nov-Mar 2020) is upon assisting individuals to manage their substance harmful use, financial affairs, strained therapeutic relationships and emotional dysregulation. Very often it is statutory agencies who 'rely' on diagnoses. A psychological formulation would probably have little 'leverage' as part of a Personal Independence Payment (PIP) assessment or appeal. It is here that a medical diagnosis - has currency. Consultant Psychiatrists have little enough time so the CPN/CMHN acts as the go-between. Reaching across from the intra- interpersonal domain to the political.
The narrative written on the assessment/appeal form will include content that would no doubt contribute to a psychological formulation (and even psychodynamic) were this is relevant purely for the purpose of the assessment. As such it is the dialogues and narratives that are engendered that can increase self and mutual understanding and awareness. This can in turn provide the opportunity to progress more positively a person's situation within which diagnoses and formulations play a part. There is still a great 'gap' between the formulaic and diagnostic outputs and the therapies that are available.
individual
|
INTERPERSONAL : SCIENCES
humanistic ----------------------------------------------- mechanistic
SOCIOLOGY : POLITICAL
|
group - population
| Diagnostic and Statistical Manual of Mental Disorders (DSM–5) multiaxial? Psychological formulation Psychodynamic formulation Psychiatric diagnosis TI:ME Health career - life chances | Medical diagnosis multiaxial? International Classification of Diseases SNOMED CT TI:ME Health career - life chances |
[Recruitment agencies seek mental health nurses as 'disability assessors'. I am a realist. I know some people are beyond the pale, but that doesn't mean we should not try. These assessments can be opportunities to engage anew, but of course that is not what is required?]
My prompt:
Samei Huda - Twitter
orcid.org/0000-0002-0192-8965