9 Mixed messages from psychotherapies

If we look at the range of therapies on offer in the marketplace, ambivalence of non-medical therapists towards diagnosis remains. Pentony (1981) notes that broad affiliations exist within three separate rationales for personal change:

1. There are those that explicitly focus on faith in the interpersonal therapeutic alliance. This position is strongest in humanistic counselling.
2. There are those that have a rationale about resocialisation: habits and inner events are dismantled and new learning takes place. This approach is evident in psychoanalytical therapy and in cognitive–behavioural therapies.
3. There are those that emphasise contextual factors in maintaining and changing mental health problems. The latter has been largely derived from general systems theory and more recently constructivism in philosophy and social science. It has been associated far more with family than with individual therapy, although existential therapy shares its more critical stance.

This long but still partial list of forms of therapy reminds us that the therapeutic understanding of mental health problems is not a monolith. Each therapy brings with it separate and sometimes quite discrepant versions of formulation. These subsume different assertions about relevant antecedents of problems (which may or may not retain the notion of ‘aetiology’) and different explanations. Given this picture, what potentially opposes psychiatric diagnosis is not formulation but formulations. Vigilance is required by advocates of each therapeutic approach to construct and reproduce a particular and distinctive rationale because tribal membership, hierarchical status and salaries rely upon it.

Thus, a formulation is both a rationale for counsellors and psychotherapists within a school (about antecedent and maintaining factors relevant to particular problems and their resolution) and a rhetorical device to claim particular expertise about mental abnormality. Therefore, the ideological battle that ensues within the mental health professions is not merely between those who are biologically minded with their diagnoses and those who are psychotherapeutically minded with their formulations.