8 The politics of diagnosis and formulation

Both diagnosis and types of formulation are forms of sense making about distress in our midst. Because a diagnostic view has been linked to the history of medicine, one explanation for its domination in our culture is simply about medical dominance: it is the highest status profession responsible for understanding distress. Accordingly, we find this sort of conclusion: ‘Ownership of the DSM trademark has guaranteed psychiatry’s reign over psychopathology because psychiatry controls how mental disorders will be named, determined, described, and diagnosed’ (Blashfield and Burgess, 2007, p. 104).

Whilst medical dominance explains the retention of a diagnosis to an extent, it is not the full story. I have argued elsewhere that the survival of psychiatric diagnosis is only partially about medical dominance (Pilgrim, 2007). Many psychiatrists themselves are ambivalent about diagnosis. Also, some non-medical counsellors and psychotherapists retain a faith in the validity, or at least utility, of diagnosis and they may be required to submit diagnostic codes for payment in insurance-based health systems (such as Australia and the USA), or if they work within the NHS. Patients and their relatives at times find diagnosis helpful, though this depends on the label in question. ‘Depression’ might be a badge of honour for celebrities and politicians but ‘schizophrenia’ is rarely the basis of a positive career move. For relatives, a psychiatric diagnosis may reduce confusion and even alleviate a sense of personal guilt, if what Szasz (1961) called ‘problems of living’ are deemed to be specifiable illnesses like any other.

Thus, a social negotiation to maintain diagnosis implicates more than the medical professional alone, when a person with difficulties in their life world becomes a patient with a medical label. As de Swaan (1991) puts it, ‘troubles become problems’ when professionals begin to talk of ‘presenting problems’ or ‘symptoms’. In this way, for example, misery is reframed as ‘common mental health problems’, ‘anxiety states’ or ‘mild to moderate clinical depression’; recurrent nuisance or incorrigible offensive conduct is reframed as ‘personality disorders’; and madness is reframed as ‘schizophrenia’ or ‘bipolar disorder’. This reframing can suit a number of interest groups beyond the psychiatric profession.

There is disagreement in the literature regarding the conceptual distinction between diagnosis and formulation. At one extreme, diagnosis and formulation are viewed dichotomously. For example, Johnstone (2006) maintains that a formulation focuses on the personal meaning of psychological distress, whereas personal meaning is irrelevant to diagnosis. Accordingly, if diagnosis is correct, then formulation is redundant and vice versa. Carr and McNulty (2006) also point out that the diagnostic categories of the DSM IV (APA, 1994) are atheoretical, whereas formulation is fundamentally concerned with theory.

Other authors, however, see diagnosis and formulation as part of the same process. Scott and Sembi (2006), for example, claim that there is no inherent reason why diagnosis and formulation need to be mutually exclusive. Since the current classification (or nosology) of mental disorders is descriptive rather than aetiological, the purpose of formulation could be to fill the gap between diagnosis and treatment (Eells, 2002), echoing the logic of Carr and McNulty noted above.