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Making sense of mental health problems
Making sense of mental health problems

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3.1 Psychological formulation

Figure 5 Lilly from the interactive ‘A Support Net [Tip: hold Ctrl and click a link to open it in a new tab. (Hide tip)] ’ which is associated with this OpenLearn course

Although practitioners such as clinical psychologists, psychotherapists and counsellors may use terms such as ‘anxious’, ‘depressed’ or ‘psychotic’ to describe the experiences of their clients or service users, they tend not to use the formal diagnostic categories developed within psychiatry (or from the medical perspective).

By contrast, a psychological formulation would attach greater meaning to the nature of the problems faced by the individual. According to guidance provided by the National Institute for Health and Care Excellence (NICE – the organisation which provides national guidance and advice to improve health and social care, particularly within the National Health Service [NHS]):

Assessments are carried out for a number of reasons primarily to establish a diagnosis, as a means of screening (for example, for risk), to measure severity and change and as the basis for a psychological formulation. Psychological formulations provide an explanation of why a problem has occurred and what is maintaining it; they also guide the intervention and predict potential difficulties that might arise. The significant factors within the formulation will be underpinned by the theoretical persuasion of the practitioner, including cognitive behavioural, systemic or psychodynamic. A formulation is a hypothesis, based on the information that is available at the time and will often be developed or change during the course of the intervention. Although set in the context of a theoretical model, the formulation is individualised based on the unique life experiences of each person. The individual with psychosis or schizophrenia may not share professionals’ view of what the main problem is. Seeking out and assisting with what the individual regards as the main problem can provide a route towards establishing common ground, which may help to establish trust and collaboration and allow collaborative care planning over time.

(NICE, 2014, p. 26)

Activity 6 Psychological formulation

Timing: Allow about 45 minutes

Using an internet search engine (e.g. Google), find a description of ‘psychological formulation’ in relation to mental health and note down the key features of the process. This will help you understand a key feature in psychological practice and will be useful in completing the activities that follow.

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The Clinical Psychology Division of the British Psychological Society (2011) has produced Good Practice Guidelines on the Use of Psychological Formulation. Section 9 of the document provides a useful overview of what is involved; part of this section is reproduced below.

‘The following principles of psychological formulation in clinical psychology are widely accepted: 

  • it is grounded in psychological theory and evidence; 
  • it is constructed collaboratively, using accessible language; 
  • it is constructed reflectively; 
  • it is centrally concerned with personal meaning; 
  • it is best understood in terms of usefulness than ‘truth’. 

In addition, it will be argued that best practice clinical psychology formulation and formulating has the following characteristics: 

  • it is person-specific not problem-specific; 
  • it draws from a range of models and causal factors; 
  • it integrates, not just lists, the various possible causal factors through an understanding of their personal meaning to the service user; 
  • it is not premised on functional psychiatric diagnoses such as schizophrenia or personality disorder. Rather, the experiences that may have led to a psychiatric diagnosis (e.g. low mood, hearing voices) are themselves formulated; 
  • it includes a cultural perspective and understanding of the service user’s presentation and distress;
  • it is clear about who is the service user and who are the stakeholders in any given situation; 
  • it starts from a critical awareness of the wider societal context of formulation, even if these factors are not explicitly included in every formulation.’

(BPS, 2011, p. 12)

Psychological formulation can address the same concerns about an individual’s mental state, for instance anxiety, depression, unusual thoughts and perceptions, as psychiatric diagnosis. However, the way it goes about investigating these issues can be quite different. You’ll find out more about this in the next section.