Those of us who do not believe in the pseudo-medical model of mental health service provision want all of the following to happen:
1. We want to help deconstruct and rid society of the “mental illness” model and “mental illness thinking.”
2. We want specifically to dispute the DSM, its paradigm, and the medicalization of society that flows from that paradigm (including wanton chemical dispensing).
3. We want to provide folks in distress with a different vision from the pseudo-medical one and a different road back from suffering than “just meds.” We want this to include “talk,” but we want this to be talk about everything that matters to the person, including talk about things that are not strictly “psychological.”
4. Ultimately we want to produce a replacement paradigm to the DSM/pseudo-medical model that is intellectually more honest, genuinely more helpful, practical enough that it can be “communicated easily” (whether for insurance purposes or just so that two human beings can have a conversation), and that will find favor with practitioners.
5. We want that paradigm to include “more of life” than most current models do (whether that current model is a pseudo-medical sort of model or a psychological sort of model): we want socioeconomic realities included, we want life circumstances included, we want existential realities included, and so on. We want to create a paradigm that “includes psychology” but that also moves “beyond psychology” to include everything pertinent to an understanding of human distress and human helping.
6. We want to make it clear that it makes no sense to “buy” any particular psychological theory, model, or paradigm as the be-all and end-all, whether that model is a CBT one, a Jungian one, and so on; and that while we are ecumenical enough to suppose that any particular psychological theory, model, or paradigm might have interesting things to say and useful practices to aid a service provider, we want to make it clear that there is no existing paradigm that can be considered a winner. Each, because of the nature of the task at hand—fully understanding human beings—only deals with the trunk or the tail of the elephant (or only deals with one version of the elephant).
Taking all of the above into consideration, I think that the following makes sense as an alternative to the current models and paradigms. I am calling it a “life formulation model.” It nicely disputes the current DSM paradigm and also frees us from the tyranny of acting as if we are talking only about “psychology” when we talk about mental health, when in fact we are talking about all of life.
In this life formulation model, a practitioner would describe her relationship with the person she is seeing in six ways: 1) the person’s expressed concerns; 2) the person’s circumstances of note; 3) the person’s behavioral and emotional considerations; 4) the person’s challenges as inferred by the provider; 5) the provider’s concerns; and 6) the provider’s recommendations. There would be no DSM or pseudo-medical language used in this model, no new diagnostic language introduced, and everything would be described in “plain English” (or plain French or plain German).
How might this work? Let’s consider a fifteen-year-old girl named Jane who is “brought in” to a service provider by her parents. They believe that Jane is “depressed.” They are also worried about her drinking, her insomnia, her school difficulties, her thinness, and the fact that she is cutting herself.
First the service provider would check in with Jane about Jane’s expressed concerns. These might turn out to be that Mary likes Elizabeth better than she likes Jane; that the clique that includes Mary and Elizabeth will not let Jane in; that Billy prefers Elizabeth to Jane; that Mrs. Williams in English may well be giving Jane a C, ruining Jane’s chances of getting into the college she is dreaming of attending; and that her parents are driving her crazy by always scrutinizing her and criticizing her.
There is absolutely no reason why these concerns can’t also come with some sort of number, if that were deemed useful: it would not be hard to create a huge list of concerns and attach a number to each one, if that was wanted. So let’s say that in addition to the words describing Jane’s concerns, there were also numbers: let’s say 1104, 1931, 2242, 4482 and 5561. It would be child’s play to list those five numbers in a “summary report,” if a service provider needed to do such a thing. This would look like: Expressed Concerns (1104, 1931, 2242, 4482, 5561). (I think there is a better way to do this summarizing, which I will describe later.)
Next would come an acknowledgment and understanding of Jane’s circumstances as gleaned from Jane and maybe from the reports of others. This might sound like:
Circumstances of Note:
In Jane’s family, a college education and a professional career are required
In Jane’s family, it is not permitted to date someone from a different cultural or religious background
Jane is not permitted to lock her door or any door, including the bathroom door
Jane surprised herself by doing much more poorly in freshman year that she had expected
Jane’s older sisters were the stars of her high school
Are these all the circumstances one might include? Of course they aren’t. Are these the most pertinent circumstances to include? Who knows? But each is suggestive and each helps a service provider understand Jane’s reality. They may not be exactly the correct circumstances to note or a sufficient number of circumstances to note, but they are important and they matter.
Next would come behavioral and emotional considerations. In Jane’s case, this might look like the following:
Jane is cutting herself (confirmed by Jane)
Jane is drinking excessively (disputed by Jane)
Jane is quite sad (confirmed by Jane)
Jane is starving herself (disputed by Jane)
Jane is sleeping very little (confirmed by Jane)
Next would come inferred challenges, that is, the provider’s ideas about what is going on. This might sound like the following:
Predictable challenges of adolescent girls in Jane’s cultural and socioeconomic situation
Special challenges of living in a strict, punitive family
Emotional challenges of intense sadness and constant worry
Cognitive challenges of self-denigrating and punitive self-talk
Behavioral challenges of cutting, drinking, starvation and sleeplessness
These inferred challenges would be described in the service provider’s preferred language: the language of psychological formulation, the language of narrative psychology, the language of CBT, the language of Jung, the language of Freud or contemporary psychoanalysis, the language of existential psychotherapy, in “ordinary” or “everyday” language, and so on.
You could use any language, indicating where the language came from: that is, in addition to a long list of everyday inferences (like “the predictable challenges of adolescence”) there might be also long lists of Jungian inferences, existential inferences, etc. If a code was needed, coded items might appear as J462 for “Jungian mid-life crisis” or F993 for “Freudian arrested development in the anal stage” and so on. Naturally (and hopefully) these taxonomical niceties would not be needed or wanted. But if they were, they could be accommodated.
Next would come the provider’s concerns. These would be expressed in ordinary language in the following sort of way:
Concerned that Jane has no one to talk to, given that she’s on the outs with her successful siblings and that she has no confidante in either of her parents
Wondering if Jane was born a little sad and, if so, if sadness will constitute a lifelong challenge for her
Some suspicions of childhood sexual abuse given Jane’s particular presentation
Want to really focus on the sleeplessness and its causes, as sleeplessness can drive “mania” and “psychosis”
Must tackle the cutting, the drinking, and the self-starvation
Next would come the provider’s recommendations. This might sound like:
Cognitive work around self-esteem
Depth work around possible trauma
Behavioral work around eating, cutting, and drinking
Behavioral work around sleeping
Family work around expectations
Personally I would want a seventh category that communicates the sufferer’s life purposes, dreams, goals, aspirations, and other existential and motivational factors. These could be reported in ordinary language and might sound like the following:
Jane remembers her camp counseling experiences as particularly meaningful
Jane considers that one of her life purposes is to marry and raise a family although she believes that she would be a “bad parent”
Jane would like to leave her small town and live in London or Paris
Jane sees herself as both “secular” and “spiritual” and would like to find a “spiritual outlet”
Jane does not believe that she has a real chance at success
This represents the life formulation model in a nutshell. Let’s take a closer look at some of its pluses.
Some virtues of this life formulation model (and its accompanying Life Formulation Guide, which might eventually replace the DSM) include the following:
It not only avoids the word “diagnosis” and the very idea of “diagnosis” (and essentially ends diagnosing), but it also avoids the word “psychological” and announces that a service provider is helping people in distress with their problems with living and not exclusively with their “psyche.” Thus, for example, both “getting a job” and the “psychological consequences of not having a job” become legitimate areas of exploration. A helper could as legitimately work on “job skills” or “social skills” as work on any traditional “psychological” or “psychotherapeutic” issue.
It doesn’t conflate or confuse the person’s concerns with the provider’s concerns. Jane may not be concerned about her lack of sleep, her drinking, her cutting, or her eating habits, but her service provider may well be. This model allows both sorts of concerns to find a place in the conversation and a way to get both sorts of concerns communicated to third parties.
It allows for conversations about, and reporting on, both “causes” (like suspected sexual abuse) and “treatment recommendations” (like, for example, cognitive work on self-esteem or behavioral work on stopping the cutting). No two providers might look at “causes” or “treatment recommendations” in the same way, but the life formulation model at least has built-in places for both to appear. “Causes” can appear in both “inferred challenges” and “provider’s concerns,” and “treatment” has a dedicated home in “provider’s recommendations” (with the pseudo-medical word “treatment” studiously avoided).
Some items could “auto-fill.” If, for example, it is generally accepted that everyone should have a complete medical workup to see if the concerns presented are organic or biological in nature—to see, that is, if any “real” disease or medical condition is present—then one “standard recommendation” that could “auto-fill” would be “It is suggested that Jane have a complete medical workup.”
Likewise, if it is generally accepted that it is good to have someone to talk to about things, then the recommendation that “Jane should have the chance to talk in an ongoing way with a service provider” might auto-fill. This latter point might seem obvious and go without saying, yet in the pseudo-medical model that we are disputing, it is not at all clear that “talking to someone” is seen as valuable, not when chemicals can be dispensed in a minute and save psychiatrists so much time and idle chit-chat. If we believe that “talking to someone” matters, it should be regularly included in our recommendations.
It allows for an interesting “tag” system of reporting. This is an important point. When you search for something on the Internet you introduce certain words or “tags” that help you find what you are looking for, say “solar system,” “planet,” and “rings” if you are looking for a planet with rings. This gets you to “Saturn.”
Tags are not labels but instead are our attempts to partially describe an entity. You can partially describe a thing in a “list sort of way” by identifying its parts: legs, head, tail, and so on (this is “defining by denotation”). You can also partially describe a thing in an “idea sort of way” through the use of concepts: a horse is a carbon-based living creature descended from some now extinct other carbon-based living creatures (this is “defining by connotation”).
Such describing and defining is always incomplete, imperfect, and more arbitrary than we would like to admit. We know from philosophers of language like Wittgenstein that every abstract word (say “war” or “love”) has no real definition but rather a huge range of meanings and colorations. Maybe World War II is the exemplary or paradigmatic instance of “war,” but it is not meaningless or inappropriate to talk about “the war between the sexes” or “corporate warfare.” The same is true of words like ego, dysfunction, abuse, or any other abstract word that can be used to describe human beings, human behaviors, and human situations.
Tags merely help describe: they do not amount to a “diagnosis,” and they do not pretend to present an exhaustive, complete, or even adequate picture of a life. That is a good thing, because we should be tired by now of all that pretension. In Jane’s case, you could report on Jane by providing some number of items in the six categories—say five items per category—and produce a one-page report that is thirty lines in length. That is one kind of “description of Jane’s situation.” But you could also choose from among those various items and select some number of tags—let’s say seven—that together provide a kind of snapshot of Jane’s current reality.
For example, one provider might choose as her seven tags for Jane and her situation “strict and punitive family dynamics,” “low self-esteem coupled with high expectations,” “adolescence,” “self-starvation,” “sadness,” “excessive drinking,” and “cutting.” Naturally, each of these tags could come as a number rather than as words, if that was wanted. This snapshot would in no way provide a complete picture of Jane’s current reality, but it would do a more sensible and humane job than labeling Jane with a pseudo-medical “clinical depression” diagnosis and some additional “adjustment disorder” or “personality disorder” diagnosis.
What might this tag system sound like in practice? For one person, and according to one service provider, the seven tags might be “sad,” “unemployed,” “mid-life crisis,” “recently divorced, ““health issues,” “‘addicted’ to porn,” “no goals or aspirations.” For another person, and according to another service provider, the seven tags might be, “traumatic childhood,” “issues with food,” “dramatic relationships,” “spiritual seeker,” “creatively unfulfilled,” “uninspiring day job,” “lives in ‘chaos and confusion.’” These snapshots could be created around any agreed-upon number of tags. The more tags, the more cumbersome the system but also the more complete the snapshot.
If you decide to set the bar as, “We need one word like ‘depression’ to capture everything that we need to know about a person’s distress and his or her current situation,” a tag system does not reach that absurd height. But if you decide to set the bar differently as, “We need a way of communicating a snapshot of a person’s reality that includes some important features of a person’s life and aims a helper in the direction of helping,” a tag system would meet that threshold beautifully.
This model would “force” a service provider to inquire about Jane’s actual concerns; learn about Jane’s actual circumstances; acquire a picture of Jane’s behaviors, thoughts, and feelings; come to some conclusions about Jane’s situation; and offer up some recommendations as to what might help. This would naturally improve service. Service providers would become smarter about human nature and about human challenges by virtue of having to think about how “cause and effect” operates in the lives of real people and having to consider what actually works to reduce distress. This model stretches and tests the practitioner in a useful way.
To be clear, as we are not always so clear about this, this life formulation model is not an alternative system of diagnosis but an alternative system to diagnosis. It allows providers to chat with one another, either through summary reports or the tag system, and if it were widely accepted, it would force those entities that believe they need diagnoses (like, for example, the courts) to begin to change their mind. The courts and other institutions would be forced to accept that “hearing voices,” for example, is a reportable thing but does not lead to some made-up diagnostic label like “schizophrenia.” It would serve our vital communications needs and at the same time it would act as an agent of change.
No doubt other alternative systems to diagnosis can be dreamed up and one or another of them might provide even more pluses than this life formulation model. But this is a good start, I think; it could be enacted right now; and were it enacted, it would revolutionize how helpers think about and care for the people who come to them in difficulty and distress.
Imagine that a sophisticated software program were available to aid a practitioner using the life formulation model. Let’s call this software “life formulation software” and imagine what it might do and how it might help.
To begin with, you would be able to pick one category or any number of categories called “orientations.” One might be your personal orientation, which would be a customized orientation that you create. You could also pick any number of the many orientations that currently exist: a DSM orientation, an ICD orientation, a psychoanalytic orientation, a Jungian orientation, a systems orientation, an existential orientation, a psychological formulation orientation, a biological orientation, etc.
As you worked with a person in distress and entered information, that information would automatically be “digested” by the software in each of your chosen orientations, so that, for example, you would get a message (that of course you might choose to entirely ignore) that the threshold had been reached for a DSM or ICD diagnosis. In this way, you could be kept up-to-date about the labels being generated as you added information, and you would have at hand a Jungian vision of your client’s presentation, or a DSM vision, an ICD vision, a psychoanalytic vision, and so on.
You would enter running information in the seven categories: 1) the person’s expressed concerns; 2) the person’s circumstances of note; 3) the person’s behavioral and emotional considerations; 4) the person’s goals and life purposes (a category I would like to see included); 5) the person’s challenges as inferred by the provider; 6) the provider’s concerns; and 7) the provider’s recommendations. As you entered information, not only proposed “diagnoses” would appear, but also proposed tactics and strategies. For example, an alert might appear with the message “psychological formulation alert: check in on the possibility of childhood trauma,” “Jungian alert: archetype of the gambler present,” or “CBT alert: systematic desensitization suggested for fear of flying phobia.”
For example, if you input “Marcia lost her sister to breast cancer when her sister was thirty-five and Marcia was thirty-nine,” the DSM orientation would take in that information and likely consider it irrelevant; the existential orientation would take it in and “wonder aloud” if perhaps that event had provoked a meaning crisis; the CBT orientation would “wonder aloud” if any new language around mortality had entered Marcia’s internal vocabulary and, as a result, produced new anxiety in her; and so on. This would be done effortlessly, at the speed of computing, and the practitioner would either get that information as running commentary, in the margins, as it were, or get it when requested (for example, “Please tell me where we are now, existentially speaking”).
The program could pop up all sorts of important notifications. For example, as you input the information that the person you are seeing is a male originally from the Caribbean living in London, it could pop up the announcement that males from the Caribbean living in London are x times more likely than the general population to receive a label of schizophrenia or y times more likely than the general population to be diagnosed with clinical depression. If you didn’t want information of this sort to pop up, you could shut off this function; and you could also program the system so that it only popped up certain kinds of notifications.
Pop-up boxes might also appear that contrasted the views of the various orientations. For example, if you were to input the information that John “hears voices,” a “compare and contrast” box might pop up with the following sort of information: “In the biological model, auditory hallucinations are considered possible symptoms of the following conditions and diseases; in the DSM model, auditory hallucinations are considered ‘symptoms’ of ‘schizophrenia’; and in the psychological formulation model, hearing voices is considered one predictable response to stress, especially if the service user has a history of significant trauma.”
Using software of this sort would also allow for regular updating of the different orientations. If the programmers of the psychoanalytic track or the CBT track wanted to make some changes based on new empirical evidence—wanted to include a new tactic to help with fear of flying or stopping smoking or “sadness reduction”—they could update “their portion of the program” and provide the practitioner with the most up-to-date information in their domain. In this way the practitioner would possess the best (or at least the latest) tactics, strategies, and methods from each domain, including the medical domains of brain diseases and neurological problems.
This “software support” beautifully serves the life formulation model and enhances its benefits. Its running commentary paints a clear picture that there is no agreement as to how to conceptualize these matters; it honors disagreement rather than fumbling us towards unjustified, artificial agreement; it reminds us that human beings can and must be viewed through multiple lenses. A human experience specialist using a life formulation model and its adjunctive, supportive software would be helped to understand and describe the reality of the person sitting across from her in multiple ways—in ways that might not interest her, like a DSM or ICD way, but also in ways that might interest her tremendously, including according to her own idiosyncratic orientation.
This idea of software support may prove fanciful: for one thing, most of the orientations in question probably aren’t coherent or consistent enough to be programmed. Is there any such thing as a coherent, consistent Jungian, Freudian, cognitive-behavioral, or existential orientation? How could one program in a “psychological formulation” orientation or a “problems in living” orientation? On the other hand, some useful software support might indeed prove possible. There is no reason to suppose that we can’t create a program that pops up an anxiety management tactic, a community resource, a cognitive-behavioral strategy, or an emotional healing technique right at the appropriate moment when a human experience specialist might want it, maybe before, during, or after a session.
This life formulation model, whether software supported or not, would go a long way toward providing a human experience specialist, or any practitioner looking to free herself from the DSM model or some other model, both with a conceptual framework that honors the richness of life and the naturalness of distress and an organizational scheme that allows her to report in an honest way on a sufferer’s experience. In one sense, no such model is needed: the essence of our task is to lean forward and collaborate, not to report on our efforts. But a model that by its very nature disputes the DSM, that helps a practitioner ask the right questions, and that distinguishes her concerns from her client’s concerns might well prove extremely valuable.
Some practitioners who are unhappy with the DSM model are nevertheless still looking for alternate methods of diagnosing: they are still attached to the idea of “diagnostic categories” that make reporting (and payment) easy and that allow them to continue to appear like “experts who diagnose and treat.” That is a mistaken idea and a mistaken ideal for all the reasons we’ve been discussing. What are needed aren’t alternative methods of diagnosing but excellent alternatives to diagnosis. We must stop “diagnosing” nonexistent “mental disorders” and instead find ways of talking sensibly about the problems of living that human beings experience. The life formulation model is one such sensible model.