What do we mean by formulation? It is a word that is increasingly used in mental health, learning difficulty and forensic settings, although in fact it has been around for a while – usually described as a core skill in clinical psychology training and practice. Formulation is both simple and complex, common sense and controversial, depending on how it is defined and used (for more detailed discussion, see the recent guidelines developed for the Division of Clinical Psychology http://www.bpsshop.org.uk/Good-Practice-Guidelines-on-the-use-of-psychological-formulation-P1653.aspx). Perhaps this can serve as a starting point:

Formulation is the process of making sense of a person’s difficulties in the context of their relationships, social circumstances, life events, and the sense that they have made of them. It is a bit like a personal story or narrative that a psychologist or other professional draws up with an individual and, in some cases, their family and carers.

Everyone who comes into contact with mental health services will have had a rocky and often extremely traumatic road leading up to that point. They will almost certainly be given a diagnosis – anything from ‘depression’ to ‘ADHD’ or ‘schizophrenia.’ But that tells us very little about the individual, and nothing at all about the context and impact of their difficulties. A formulation, on the other hand, can be best understood as co-constructing the personal meaning of the client’s life story. It is ‘.a process of ongoing collaborative sense-making’ (Harper and Moss 2003) which summarises the client’s core problems in the context of psychological theory and evidence and thus indicates the best path to recovery. Unlike diagnosis, it is not about making an expert judgement, but about working closely with the client to develop a shared understanding which is likely to evolve over the course of the therapeutic work. And, again unlike diagnosis, it is not based on deficits, but draws attention to talents and strengths in surviving what are nearly always very challenging life situations.

Here is an example:

Jane is 19 and has started to hear critical and hostile voices. The diagnosis is likely to be ‘psychosis’ or ‘schizophrenia.’ However, a formulation might look something like this:

You had a happy childhood until your father died when you were aged 8. As a child, you felt very responsible for your mother’s happiness, and pushed your own grief away. Later your mother re-married and when your stepfather started to abuse you, you did not feel able to confide in anyone or risk the breakup of the marriage. You left home as soon as you could, and got a job in a shop. However, you found it increasingly hard to deal with your boss, whose bullying ways reminded you of your stepfather. You gave up the job, but long days at home in your flat made it hard to push your buried feelings aside any more. One day you started to hear a male voice telling you that you were dirty and evil. This seemed to express how the abuse made you feel, and it also reminded you of things that your stepfather said to you. You found day to day life increasingly difficult, as past events caught up with you and many feelings came to the surface. Despite this, you have many strengths, including intelligence, determination and self-awareness, and you recognise the need to re-visit some of the unprocessed feelings from the past.

We can see that the formulation is personal to Jane, and helps to make sense of her experiences in terms of recent psychological theory about voices. Most importantly, and this is the main purpose of a formulation, it indicates a way forward, which will probably include developing a trusting relationship with a counsellor, learning ways to understand and cope with her voices, perhaps gaining support from others with similar experiences, and talking through her past. Formulations are often experienced as enormously reassuring to clients, since they can convey a sense of hope about the future. In contrast, a possibly frightening diagnosis such as ‘psychosis’ gives the message that the ‘symptoms’ have somehow emerged out of the blue, unconnected to actual life experiences. The implication is that the client needs to rely on expert direction, including medication, rather than having the capacity to re-build their lives after understandably traumatic events.

The issue of diagnosis in relation to formulation is controversial. Psychiatrists see formulation as an addition to, not an alternative to, diagnosis. A psychiatric formulation for Jane would thus look something like ‘Schizophrenia/psychosis triggered by the stress of job loss.’ This retains all the disadvantages of diagnosis in a slightly modified form. Psychology guidelines, on the other hand, state that psychological formulations ‘are not premised on psychiatric diagnosis.’ From this perspective, if a formulation can provide a reasonably complete hypothesis or ‘best guess’ about why a person has developed their difficulties, one which leads to effective intervention, then there is no need to add in an extra layer of explanation that says ‘…and by the way, she has schizophrenia as well.’ Psychiatric diagnoses have long been under criticism for poor reliability and validity, as well as lack of evidence for the supposed biological causes of these conditions. Arguably a formulation, especially one which is firmly based in recent psychological evidence, makes psychiatric diagnosis redundant.

These are controversial issues which are not likely to be resolved in the near future. They raise fundamental questions about the nature of mental health problems. Are they best understood as ‘illnesses’ with biological causes, or as understandable responses to, and attempts to survive and cope with, traumatic life events? The latter view, for which there is an increasing amount of support, is very threatening to some professionals, not to mention the many vested interests (drug companies and so on) in what is sometimes called the ‘biomedical model ‘ of mental distress. In the meantime, mental health workers can support the growing use of formulation, and clients should feel free to ask for formulation as a way of working towards recovery.

Lucy Johnstone
Consultant clinical psychologist

Co-editor: Formulation in psychology and psychotherapy: making sense of people’s problems. Routledge 2006.