In recent years, a variety of medical professionals who often identify as ‘critical’ psychologists, psychiatrists, and psychotherapists seem to have reached a consensus. This holds that psychiatric diagnosis is scientifically invalid and harmful, and that person-centred psychological formulation should take the place of diagnosis. This has become especially influential in the UK, where large, mainstream professional bodies such as the British Psychological Society and the Critical Psychiatry Network now promote psychological formulation as a superior alternative to the use of diagnostic classifications.
The critical psych argument begins with a critique of psychiatric diagnosis. In contrast to bodily medicine’s scientifically grounded constructs, they argue, psychiatric classifications are made by committee decision, and are based on normative assumptions rather than scientific discovery. To add insult to injury, these scientifically invalid medicalised constructs are used to control those who dissent from the norms and requirements of neoliberal economies. Diagnosis is thus analysed as part of the neoliberal privatisation of mental distress that depoliticizes in order to reinforce social control.
Based on this analysis, critical psychs increasingly suggest using psychological formulation as an alternative. Formulation, which is already routinely used alongside diagnosis, focuses on attempting to understand the individual and their emotional problems in context, co-constructing a narrative about the individual’s psychological distress. This is touted by criticals as providing a scientifically rigorous and epistemically liberatory way of evaluating individual problems that avoids the epistemic harms of imposing diagnosis. Indeed, leading formulation proponent Dr Lucy Johnstone writes, it may be that “formulation has the potential to be not just an alternative, but an antidote, to psychiatric diagnosis and its potentially damaging effects” (p. 13). For many proponents, formulation will be part of the basis for a ‘paradigm shift’ away from individualistic medical models, towards a more humane, contextualised understanding of mental distress.
There is much that is at least partly right in this critique of psychiatry. Unfortunately, however, the critical psych argument runs into problems of its own. We begin to see these problems when we consider the framing of all psychiatric diagnoses as uniquely problematic because they are determined by committees, in a bit more detail.
The first thing to note is that this narrative presents a misleading picture of medical knowledge production. In fact, all medical diagnoses, from viruses to cognitive disabilities, are normative constructs voted for by committees. While it is true that committee members often have vested interests or biases, this is not unique to psychiatry. Moreover, despite its significant problems, committee decision is still seemingly the best way scientists have so far developed for classifying things, whether in astronomy, biology, or psychology. So while there are many problems with psychiatric diagnoses, the mere fact that they are decided by committees is not one of them.
More importantly, diagnostic categories are not made solely by psychiatrists through the act of voting. Rather, prior to and following any given committee vote, they are continually co-created in a broader context of power and resistance from those who are classified. The influence of such activist influence is most clearly seen in the many instances where self-advocates have successfully lobbied to include, exclude, or change diagnoses. This happens with every revision of the major diagnostic manuals, and can clearly be seen, for instance, in this recent account written by prominent neurodivergent self-advocates who managed to significantly influence over how they were classified in the DSM-5.
Beyond these more obvious and direct cases of co-construction, the philosopher Ian Hacking has detailed how such classifications are constantly subject to ‘looping effects’, whereby both classifiers and those classified continually negotiate the nature and boundaries of the classifications. Here Hacking follows Foucault, who argued that wherever there is power there is also resistance. From this Foucauldian perspective, psychiatric constructs are in part expressions of dominant ideologies, but they are also in part expressions those who continually interact with and change them through acts of neurodivergent subversion and agency.
Once we bear these factors in mind, not only are the agency and history of disabled self-advocates erased on the critical narrative regarding diagnosis, it also becomes clear that psychiatric classifications have a lot more in common with formulation than the criticals acknowledge. Both are co-constructed between medical professionals in positions of power, and those who are being described, and both continually change in response to inputs from both sides. Of course, it is true that there is room for ideological bias and coercion to corrupt such processes. But both diagnosis and formulation are equally open to these problems, and the idea that psychologists can somehow transcend such risks is a dangerous illusion.
If anything, there are reasons to think that completely rejecting all diagnoses in favour of formulation could itself be epistemically harmful. One of the main differences is that formulation puts more power in either one medical professional or a small team of professionals, whereas diagnostic categories are developed in the public sphere and draw on a much larger, more diverse pool of voices to attempt (with mixed results) to minimise bias. While this leaves plenty of problems in our diagnostic categories, there is some reason to think that comparatively private teams with direct power over individuals may be less accountable than the much more public revision processes of the diagnostic manuals. So similar problems will surely emerge.
It is also vital to note that disability classifications are often necessary to recognise groups of people who share similar forms of marginalisation and oppression. For instance, while it is true that autism is a shifting construct that has little direct medical utility, it does help us recognise an important aspect of social reality, and the shared forms of disablement that autistic people face. For this reason, such classifications can be epistemically emancipatory as political categories used for shared organisation and resistance. In fact, the autism classification has precisely been much more successfully used as an emancipatory political construct than it has as a medical construct, much as is typical of many disability classifications.
This is important to consider because it shows where the critical position goes from helpful to epistemically harmful. They are right to helpfully point out that psychiatric classifications can sometimes be epistemically harmful, especially when they are presented as brain diseases. But by wholly denying the viability of things like ‘autism’ or ‘ADHD’ as valid disability constructs that grant recognition to certain ways of functioning outside the norm, criticals end up holding a position not unlike those who purport to be ‘colour blind’ with regard to race. That is, they end up seeing only individuals with problems, but will fail to understand these problems because they erase the broader context of the marginalised groups they are part of and the shared forms of discrimination specific to members of these groups.
Consider a partial analogy with the politics of autism and neurodiversity. People who claim to be ‘colour blind’ about race tend to see the acknowledgement of race constructs as divisive, and argue that we should just accept individuals as they are regardless of race; but in doing this they end up reinforcing epistemic violence that erases the reality of racism and the experiences, voices, and cultures, of people racialised as black or brown. Similarly, as one leading anti-diagnosis critical psych, Dr Sami Timimi, says of autistics who reclaim the autism classification: doing this only “perpetuates the “us” and “them” dynamics and further solidifies the individualisation that feeds neoliberal politics. [In fact we] are all, each one of us, unique and therefore we are all neurodiverse.” Yet Timimi’s position – that ‘we are all neurodiverse’, only serves to erase autistic voice, culture and solidarity, and reduces disabled groups to suffering individuals.
Because of this, I do not think that there is much radical or emancipatory potential in wholly moving to psychological formulation over diagnosis. Both run into much the same problems, and can also have similar benefits, in different contexts and for different people. Still, the distinct utility of disability classifications largely resides in their providing the grounds for solidarity, culture, and community understood in the context of the minority disabled group; by contrast the formulation approach seeks to elucidate individual suffering precisely in the absence of this minority group context. Given this, any move to completely erase broader diagnostic categories in favour of default formulation, rather than being the solution to the privatisation of stress, is better understood as neoliberal individualism’s latest and fullest expression.