‘We are engaged in something much more complex than a debate about the evidence’

Assistant Psychologist Fauzia Khan talks to Clinical Psychologist Dr Lucy Johnstone about her journey as a psychologist. Lucy discusses her interest in formulation, trauma-informed practice and her contribution to the Power Threat Meaning Framework. She also addresses campaigns, conflict and critics.

You've been a qualified psychologist for many years. Can you tell me about your journey, and what drives your work?

Like many people who are drawn to this line of work, I've had my own struggles, and this is mainly what led me to an interest in psychology and psychotherapy. I have always believed that distress arises out of people's life contexts, and that mental health services are based on a fundamentally mistaken analogy with physical illness. My suspicion that this causes more harm than good was borne out right from my earliest days of training, when I worked on wards in the now closed asylums. We have more modern facilities now, but the guiding ideas haven't changed, and nor are current interventions achieving the recovery rates we would hope for. In fact, levels of distress are rising, and it appears that many standard interventions – such as anti-depressants – have limited benefits and can cause substantial harms. It is all too common for people to spend years in the psychiatric system without anyone addressing the life problems that brought them there in the first place. I see this as a largely unrecognised scandal, and have always been driven by a desire to change how we understand and heal emotional distress.

You have a keen interest in formulation; what spurred this interest and how has it informed your work?

Formulation is the process of co-constructing a summary, hypothesis or 'best guess' about the origins of a person's distress. It consists of synthesising two equally important forms of evidence; the professional's clinical experience and knowledge of the research, and the service user's expertise in their life struggles and the sense they have made of them. Together, this forms the foundation of an evidence-based personal summary, which evolves over time.

The widespread role of formulation in mental health and related services is, as far as I can tell, unique to the UK. The extent and acceptability of formulation-based practice is met with a mixture of envy and astonishment in other countries I have visited. Lecturing on the Bristol Clinical Psychology Doctorate showed me that we needed clearer definitions and descriptions of this core skill, and this resulted in my 2006/2013 co-edited book with Rudi Dallos, Formulation in Psychology and Psychotherapy. Subsequently I was lead author for the first professional guidelines on formulation, published by the British Psychological Society's Division of Clinical Psychology in 2011, which took the bold step of defining it as an alternative to, not just an addition to, psychiatric diagnosis. With colleagues, I have also done a lot of training across the UK in team formulation, a form of supervision or consultation to teams, which supports staff to develop a shared, psychosocially-based understanding of service users' problems. Finally, I did a top-up doctorate on the subject of formulation (2011, Psychological formulation: A radical perspective), which helped to develop and refine my ideas.  

We now have the research to justify what many clinicians have always known – that services need to be based not on 'What is wrong with you?' but 'What has happened to you?'

I hope that as clinical psychologists, our whole approach is formulation-based. A formulation isn't just something written up for the notes; it is our starting point when we first meet users of our services, our guide as we work with them, and the means through which we support them to make sense of their difficulties and find ways forward. Essentially, I see it as process of putting back what psychiatric diagnosis takes out: personal meaning, and a sense of empowerment and agency which, as many have testified, can be undermined if you are essentially seen as suffering a medical condition that arose out of the blue.

Critics have said that formulation lacks reliability and validity, and that there is no evidence of its effectiveness. I have always thought this is a misunderstanding. Formulations are hypotheses. It doesn't make sense to demand evidence that it is a good idea to have a hypothesis about the reasons for someone's difficulties; that is what evidence-based practice is about. Nor can we sensibly argue about whether formulations in general are reliable or valid. Like any other hypothesis, each one is tested out in practice, and modified accordingly.

Of course, this is a separate question from how formulations should be developed,  tested out, communicated and so on in the most helpful and collaborative way. Like anything else, this can be done badly or unhelpfully; hence the need for professional guidelines.

Your work has heavily focused on trauma informed practice. Where does your motivation for this stem from, and how has it shaped your practice?

I was incredibly excited to be introduced to these ideas at a workshop run by survivors Jacqui Dillon and Eleanor Longden in 2010.  Anyone who has worked in front line services knows it is not a coincidence that the people who end up there very often have histories of severe trauma and abuse. The trauma-informed approach (TIA) shows us how this happens. It reframes 'symptoms' as 'survival strategies' and suggests ways in which we can start to heal our minds and our bodies. I and colleagues were able to translate some of this into practice in a mental health service in the Valleys in South Wales. We developed stabilisation resources, offered MDT staff training, ran sexual abuse survivor groups, and supported the whole process through trauma-informed team formulation meetings.

And how has this work been received?

I have observed a strong backlash to these ideas as they gain more prominence. TIA is absolutely not about assuming, let alone insisting, that everyone in services has experienced a trauma of some kind, or that if they have, they must be pressurised to disclose or talk about it. In fact, as research shows, hardly anyone is even asked about abuse, let alone offered appropriate support with it. Judith Herman (1992/2001) had a lot to say about our need to deny the prevalence and emotional pain of trauma, and I think this goes some way towards explaining attempts to distort and discredit the approach.

We now have the research to justify what many clinicians have always known – that services need to be based not on 'What is wrong with you?' but 'What has happened to you?' The addition of this very large and well-established body of evidence, which at its best integrates the role of mind and body, relationships and wider social contexts, is one of the most important developments since the inception of psychiatry.

How have your books and writing reflected these interests?

I've always loved writing. My first book, Users and Abusers of Psychiatry, was written in 1989 in my twenties, in longhand. The recent 'Classic' edition includes a new introductory chapter which allowed me to look back on how things have changed – or not – over the intervening period. One of my convictions certainly still stands… as I phrased it in the first edition: 'The time is long overdue for a new metaphor, a new way of understanding distress'. I think we are a lot closer to achieving that goal than in 1989 – which partly accounts for the heat in the debate, since it poses a challenge to many vested interests.

My other books, chapters and articles have all been elaborations of these core themes. This year saw the second edition of A Straight Talking Introduction to Psychiatric Diagnosis. I wrote it as an accessible guide for the vast majority of people who are never offered alternative, non-medical understandings, despite the fact that even members of the committees which draw up the diagnostic manuals are describing them as scientifically unsound. There have been some remarkable new trends since the first edition. No longer do we have to see a doctor to acquire a label which may be experienced as unwelcome and stigmatising. Instead, huge numbers of us – especially young people – are eagerly self-diagnosing via social media. In fact, we are rapidly approaching the point at which every one of us will qualify for at least one diagnosis, and a prescription to match. We cannot possibly explain all this in terms of better recognition of 'disorders'. Rather, as I've discussed in the book, we need to think about the ways in which life is more difficult, difference is less tolerated, and all kinds of forces are promoting – and profiting from – the individualisation and pathologisation of the consequences.

Can you tell us a bit about some of the campaigns that you're involved with?

I will highlight two. First of all, there is the 'A disorder 4 everyone' (AD4E) movement which, like almost everything in my career, happened by accident. I met psychotherapist Jo Watson through Twitter, and our first event in Birmingham in 2016 followed the same pattern as subsequent ones all over the UK – inviting clinicians, service users, voluntary workers, campaigners, researchers and performance artists to offer their perspectives and experiences on challenging the diagnostic model of distress. There is no substitute for the extraordinary power of such stories told in person, but Covid has encouraged us to branch out into online festivals, debates and poetry events.   

Secondly, colleagues and ECT survivors have recently stepped up our long-running campaign to recognise the harms that can be caused by ECT. Most lay people don't even know it is still used, let alone that it is optional for clinics to be accredited in the minimal Royal College of Psychiatrists safety standards. Our research has found that there is a 47-fold difference between the highest and lowest-using Trusts, which suggests a complete absence of agreed practice standards. We know that seizures are potentially damaging to the brain. The typical signs of concussion, post-ECT, are in other circumstances seen as needing close medical monitoring. ECT is a form of head injury. It may induce effects – through temporary euphoria, memory loss, or placebo – that bring temporary relief. However, no study has ever demonstrated longer-term benefits. And I know from my fellow campaigners that in some cases it causes permanent, life-changing brain damage, denied by clinicians, with no rehabilitation available. This is simply not an ethical way to proceed. We have the support of 25 MPs, including the shadow minister for mental health, Dr Rosena Allin-Khan, for an independent review of this controversial practice.

You're one of the lead authors of the Power Threat Meaning Framework. Can you tell us a bit about how all your work comes together in the framework?

The Power Threat Meaning Framework is the end result of a five-year, co-produced, DCP-funded project to outline a conceptual alternative to the diagnostic model of distress. The core author group, including co-lead author Professor Mary Boyle, have all known each other for many years, and the PTMF represents the culmination of our collective clinical, research and lived experience work. It turned out to be a daunting project; there were times when we were very unsure what we were doing and how it would turn out.

The great majority of mental health professionals want the very best for their patients.

In brief, the PTMF argues for the replacement of diagnostic models with narrative-based ones. This includes but goes beyond formulation, such that the PTMF respects culturally-appropriate meaning-making of all kinds, rather than seeking to impose Western views. The PTMF centres the role of power in all its guises, and suggests a narrative structure which can be used to make links between personal, family or community distress, and social inequality and injustice at all levels. This means that it has implications well beyond services. Although it draws on TIA, the discussion of ideological power, as transmitted through our social norms, expectations, and language uses, shows how distress can arise in the absence of anything we might typically recognise as abuse or trauma. 

The PTMF does not accept the division between those who are said to be 'mentally ill' and the rest of us. All of us are faced with the negative impact of power at times. All of us have periods of distress. All of us use whatever strategies are available to us – in PTMF terms, threat responses – to survive as best we can. The main documents, along with podcasts, practice examples and other resources can be found on the BPS website, and in 2020, Mary and I wrote a 'straight-talking introduction' to using the PTMF in practice.   

How has the framework been received?

We had no plans for dissemination, and have been led entirely by the responses we have received, which have been more enthusiastic than we could ever have hoped. We have been invited to do talks and workshops across the UK and in Denmark, Spain, Greece, Brazil, New Zealand, Australia and the US, and several translations are in progress. On the other hand, we have been subjected to a great deal of social media harassment, which is all the more extraordinary given that the PTMF – unlike the diagnostic model – is completely optional. But the enthusiastic reactions suggest to me that there is widespread recognition of the need for fundamental change.   

The PTMF is not designed for professional use only, and the website hosts the accounts of two different peer groups whose members decided to work through the PTMF core questions collectively, in order to construct non-medical narratives about their distress. They made comments such as 'We began to develop a new perspective rather than see ourselves as abnormal and disordered… This was a very therapeutic process as we felt our experiences were recognised, validated and understood and we began to feel more hopeful about the future… this may be the first time that the narrative and pain have truly been heard…. This takes us from being isolated and lonely individuals to being part of a wider community of equals.' We are delighted that one of the facilitators has joined the PTMF Committee, and now offers training in the Framework.

One service currently drawing on and developing the PTMF ideas is the Irish national charity for young people's mental health, Jigsaw. They have co-produced adapted versions of the core PTMF questions with their clients, and integrated the PTMF into their training, language, interventions and community work. Non-diagnostic understandings are thus routinely offered from first contact, although never imposed. Ongoing evaluations suggest that the approach is well-received by the young people, and people are using the ideas within mental health and criminal justice services, in small scale and larger projects.

Many other examples are appearing on the website. They are all very different, since the PTMF is a set of ideas, not a 'how to' manual. Collectively, these practice-based projects are feeding back into the further evaluation and development of the PTMF. 

You're no stranger to conflict. Many individual psychiatrists seem more comfortable accepting the 'psychosocial' as an inevitable part of the bio-psycho-social approach to mental health than do psychologists in accepting the 'bio'. Would you say that is a fair comment?

I would say we need to be clear what we mean here. No one, whatever their profession or perspective, denies that there are biological aspects of our experiences. All our human experiences are mediated and enabled by our bodies, as we have discussed at length in the PTMF. In that broad sense, a 'biopsychosocial' approach applies to everything, whether or not it falls under the remit of 'mental health'. 

But it all depends what role you see for the 'bio'. TIA is very solidly based on a growing amount of evidence about this aspect – in other words, how our bodies are impacted by overwhelming experiences and as a consequence, how healing can be promoted through working with our bodies not just our minds. This explains the increasing popularity of body-oriented therapies. 

It is true that there are now fewer hard-line medical model psychiatrists of the kind I met when I first qualified – convinced that 'schizophrenia', for example, was a genetically-determined brain disease and that it was actually harmful to explore people's unusual beliefs. But including the 'psychosocial' aspects merely as precipitants of a medical illness – as the 'biopsychosocial' or 'vulnerability-stress' models often mean in practice – simply preserves the biomedical approach with minor modifications. It relegates the horrific abuses in many people's lives to 'triggers' which they would have coped with had they not been biologically 'vulnerable.' This is both insulting and untrue. To put it at its simplest: All human experiences involve the body, but not all forms of suffering are best understood as medical illnesses.

In recent years have you found ways to share common ground with even your most strident critics, or is the debate becoming increasingly polarised?

Firstly, this question doesn't apply just to me: I am one of a large and growing number of people of all backgrounds, including many service users, who are challenging the dominant model. A common rhetorical strategy is to talk about this in terms of individual 'extremists' who can be discredited at a personal level. Another strategy is to frame it as a 'battle' or 'war' between professions – which is untrue, and distracts from the main points. Challenging the core assumptions underpinning our mental health system was always going to arouse strong feelings, and critics are often told that their views are 'polarising'. Actually, I don't think the debate is any more polarised than it always has been. What is new is that the arguments are reaching a much wider audience, and that previously marginalised voices are demanding a platform.

Conflict is certainly not comfortable, but every important societal debate is conflictual.

I think the truth is that not all positions are compatible. We can find common ground in some areas but not in others. The great majority of mental health professionals want the very best for their patients. As a practitioner, my role depended on working respectfully and constructively alongside people who often held different views. We spent quite a bit of time on the Bristol course discussing how to work within systems whose core assumptions you may disagree with. For me, that has been both a challenge and an opportunity; both the most frustrating and the most rewarding part of working within services. I think I managed that pretty successfully overall. Now that I am no longer working clinically, I am freer to express myself through talks, workshops and writing – and of course, as I always say at the start of every event, people are equally free to disagree with me. But we do need to have these debates. What worries me is when responses essentially consist of 'These views should not be held, expressed or disseminated'. That is a sign that we are engaged in something much more complex than a debate about the evidence.  

Do you think that to a certain extent conflict is inevitable, and even desirable in terms of driving real change?

Conflict is certainly not comfortable, but every important societal debate is conflictual. We can see this in relation to abortion, racial discrimination, women's suffrage, homosexuality, and so on. Critics of the mental health system are arguing that we need a complete change in our basic assumptions. Modifications don't take us far enough. Extreme distress can't be both a medical illness 'just like diabetes', as we are often told, and at the same time, an understandable emotional reaction to life circumstances.

In PTMF terms, the current debate poses a challenge to power, and as we know, few people or institutions will give up power voluntarily. That includes my own profession, of course. And it includes me. We all need to reflect on the forms of power and privilege we enjoy, and how they can best be used to create a fairer world.

How does it feel when the criticism and conflict comes from service users, rather than professionals?

Working as a clinician, my job – in the spirit of formulation itself – was to offer, not impose, formulation-based understandings to my clients. If someone prefers to see their difficulties in diagnostic terms, that is entirely up to them. No conflict is necessary! My only concern was to ensure that it was an informed choice – that people knew there are other options. This is very rarely the case. As the powerful testimonies at our AD4E events show, people commonly endure years and decades within the mental health system without access to these forms of knowledge, and with diagnostic views and their consequences often imposed.

In my other life, as a trainer, writer and speaker, I am well aware that some service users find the medical perspective helpful. The PTMF authors, the AD4E group, and all my other colleagues strongly believe that people have the right to their own views, and acknowledge that diagnosis may still be necessary for some purposes. The PTM Framework spells this out very clearly, as we do at the start of every AD4E event, and as I do in my book on diagnosis. Diagnostic understandings are, for most people, the dominant and only approach on offer. If that is what you want, you will certainly be able to get it, and if it is helpful to you, then again, there is no problem. Formulation-based, trauma-informed alternatives, on the other hand, are rarely available. If you do come across them, they are optional, and there will be no problem refusing them – unlike, say, disagreeing with your diagnosis. Conflict sometimes seems to be based on a misunderstanding of these points. 

I believe there is a bigger question, which is whether professionals should be offering – let alone imposing – diagnostic understandings in the first place, given the official admissions that they are no longer fit for purpose. As a recent UN report puts it: 'We have been sold a myth that the best solutions for addressing mental health challenges are medications and other biomedical interventions.' The very least we can do, as professionals committed to evidence-based and ethical practice, is inform people about the debates, and refrain from imposing life-changing labels on them without their informed consent. That is my position, and in my view, it should not be a controversial one.