Working with Clinical Case Formulations: Methodological Considerations
Mapping Mental Health Problems
In Chaps. 2 and 3 we focused on classificatory diagnosis, and looked critically at what kind of appraisal of mental health problems the DSM manual leads to. Reliability and validity were our core concepts. With these concepts we evaluated how solid the DSM is in assessing psychopathology in clinical practice. This brought us to the conclusion that the evidence supporting the DSM approach to mental symptoms is limited. The DSM does not enhance solid and straightforward clinical decisionmaking, and by decontextualizing symptoms through its mere focus on psychiatric syndromes crucial information on the meaning and function of the symptom gets lost. In Chaps. 3 and 4 we made a plea for studying the quality and the context of mental suffering. Assuming that in making a diagnosis “thorough knowledge” concerning an individual’s symptoms, disability, and suffering needs to be collected, we suggested that case formulations provide us with a useful format. In case formulations symptoms are framed within the context of a person’s broader functioning, such that the damaging impact of symptom and context, the logic of functioning, as well as strengths and aspects of resilience are mapped.
© The Author(s) 2017
S. Vanheule, Psychiatric Diagnosis Revisited,
This chapter returns to the concepts of reliability and validity, examining how they apply to case formulations.
It is generally accepted that a measurement instrument is reliable if it allows us to draw conclusions in a consistent way. Studies show that the reliability of psychiatric decision-making is far from obvious. This applies both to the recent versions of the DSM and to older diagnostic systems. Many idiosyncratic factors seem to have a great impact, such that in a large number of cases professionals assess the same patient differently to their colleagues. Some will be annoyed when reading that idiosyncratic factors play such an important role in psychiatric diagnosis. Nevertheless, we argue that these factors are not arbitrary and that professionals must do everything in their power to assess patients’ symptoms and suffering as accurately as possible. However, if we accept the proposal of Markova and Berrios (2009), or our Triangular Model of Symptom Formation, which suggest that psychological symptoms are not natural objects that we can observe, but constructed phenomena, we cannot but bring subjectivity into account. Not only are patients’ experiences of symptoms constructed in an interplay between physical, psychological, social, and cultural factors, but professionals also grant meaning to the actions and words of the patient. Herewith they too are influenced by many factors, such as their socio-cultural background, professional training, and life experiences (Did you ever hear voices? Have you ever lost a friend through suicide?).
Validity relates to the correctness of measurements. A measuring instrument is valid if it really assesses what one wishes to know. In Chap. 3 we suggested that forms of psychopathology come to be through a subjective construction process. We emphasized that psychological configuration processes and context factors play an important role in the creation of psychological symptoms. Whoever experiences symptoms not only endures them passively, but also experiences them qua self-reflexive transcendental subject. The DSM does not bring these configuration processes and the self-reflexive relationship of people to their symptoms into account, and therefore does not provide a valid appreciation of psychopathology. Moreover, the DSM-5 starts from the idea that mental disorders are biologically founded. Meanwhile research largely contradicts this and points to a complex interplay between biological, social, and psychological factors, which implies that in accordance with its own biological aspirations, the validity of the DSM-5 leaves much to be desired.
That there are major issues concerning the clinical value and the scientific quality of the DSM will have become clear. It is therefore not wise to organize scientific research, clinical work, or the organization of mental health care too strongly on the basis of this psychiatric manual.
A simple alternative to the DSM, however, does not exist. Switching to a different classification system cannot solve crucial problems with this form of diagnosis. In accordance with our contextualizing ideas about psychological symptoms, diagnosis should not primarily focus on the detection of disorders, but on a clarification of the role and function of a symptom within someone’s functioning. Diagnosis in the field of mental health should be function-oriented rather than disorder-oriented. In this chapter I further discuss what function-oriented diagnosis by means of case formulations implies, and discuss how the validity and the reliability of this narrative form of diagnosis can be optimized. Just as my criticism of the DSM in Chaps. 2 and 3 is especially methodological in nature, I focus my discussion of function-oriented diagnosis especially on methodological aspects of clinical case formulation. A methodological framework for the work with case formulations is essential to give shape to a theory-based function-oriented appraisal of mental symptoms, disability, and suffering.