Good practice guidelines on the use of psychological formulation



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Formulation and diagnosis

Medical conditions such as cancer, Down’s syndrome, Alzheimer’s disease, head injury and various kinds of physical disability frequently play an important causal role in presentations in Clinical Health, Learning Disability, Older Adults and Neuropsychology specialties, and to a lesser extent in Child and Adolescent and Adult Mental Health. Clinicians may also have to take account of the psychological effects of alcohol, street drugs, stroke, starvation,
and soon, depending on specialty. These medical/organic/developmental factors are an essential part of a holistic biopsychosocial formulation. The clinical psychologist will aim to construct a formulation that explores the personal meaning and impact of the condition,
and that also includes the service user’s wider interpersonal and environmental context.
This is consistent with Kinderman et al.’s (2008) model of psychological processes as a mediating factor and final common pathway in all cases of mental distress, whatever the particular combination of biological, psychological and social factors in any given situation. The use of so-called functional psychiatric diagnoses such as schizophrenia, bipolar disorder and personality disorder is more contentious (Boyle, 2002; Bentall, 2003). There is no space within these guidelines to repeat the longstanding debates about the validity of such diagnoses (but see forthcoming Division of Clinical Psychology position statement on classification. However, psychological formulation starts from the assumption that at some level it all makes sense (Butler, 1998, p. From this perspective, mood swings,

hearing voices, having unusual beliefs and soon can all be understood as psychological reactions to current and past life experiences and events, in the same way as more common difficulties such as anxiety and low mood. They can be rendered understandable in the context of an individual’s particular life history and the personal meaning that he or she has constructed about it. They may also be understandable within a cultural context for example, beliefs about supernatural possession or witchcraft. Describing these experiences within an illness model is based on the very different assumption that the primary causal factor is biological dysfunction. This obscures the personal meaning of difficult events by framing them as triggers of an underlying biological vulnerability, which lead to symptoms rather than understandable responses to overwhelming life circumstances. It also reduces agency, or the service user’s belief in their ability to work towards their own recovery, rather than simply waiting for medical treatment to take effect. Psychological formulation’s meta-messages about personal meaning, agency and hope can act as a helpful corrective to some of the well-documented negative consequences of receiving a psychiatric diagnosis, such as increasing a service user’s sense of powerlessness and worthlessness (Rogers et al., 1993; Barham & Hayward, Mehta & Farina, 1997; Honos-Webb & Leitner, 2001). A label of learning disability can also have a profound impact on a service user’s sense of identity. Division of Clinical Psychology


This does not imply that biological factors should be excluded from formulations in mental health settings. Clearly we have bodies and brains as well as minds, and there is an increasing amount of evidence about how they shape each other (e.g. the effect of trauma and attachment styles on the developing brain Schore, 2009). This growing area of research contributes to a genuinely integrated version of a biopsychosocial model that is not based on unwarranted prioritisation of biological factors but which recognises, in the words of biologist Steven Rose, that every aspect of our human existence is simultaneously biological, personal, social and historical (2001).
Psychiatric formulation and psychological formulation
A psychiatric formulation, in other words a formulation that is partially based on a psychiatric diagnosis such as schizophrenia or personality disorder, differs in several important ways from a psychological formulation. The curriculum for Specialist Core
Training in Psychiatry (Royal College of Psychiatrists, 2010) requires trainee psychiatrists to
‘demonstrate the ability to construct formulations of patients problems that include appropriate differential diagnoses (p. Psychiatric formulation as described in the curriculum is based on the description of the various biological, psychological and social factors involved in the predisposition to, the onset of and the maintenance of common psychiatric disorders (p. Thus, it may take the form of bipolar disorder triggered by the stress of bereavement or similar.
Psychiatric diagnoses are sometimes included in the types of formulation discussed above:

problem-specific protocols, ‘list-of-factor’ frameworks, and some diathesis-stress and biopsychosocial formulations. However, with the exception of conditions of clearly organic origin such as dementia, it is recommended that best practice psychological formulations in mental health settings are not premised on psychiatric diagnosis. Rather, the experiences that may have led to a psychiatric diagnosis (low mood, unusual beliefs, etc.)

are themselves formulated. If this is carried out successfully, the addition of a psychiatric diagnosis becomes redundant. In Bentall’s words (2003, p Once these complaints have been explained, there is no ghostly disease remaining that also requires an explanation. Complaints are all there is Since some service users and carers find psychiatric diagnoses helpful, it is in keeping with the spirit of respectful and collaborative work to include this perspective. In such a case,
the formulation might recognise their views by, for example, noting that You find the diagnosis of bipolar disorder a useful way of explaining your difficulties to family and friends For others, the meaning maybe less positive, and this too needs to be acknowledged for example, The diagnosis of personality disorder seemed to confirm your feelings of being unacceptable, and soon. What is important is that enough common ground can be agreed between psychologist and service user to provide a basis for the intervention, if one is required. The process of formulating provides an opportunity to discuss and negotiate a shared psychological perspective with the service user (and his/her family and carers if appropriate) – one that may not have been offered before. One of the advantages of psychological formulation over diagnosis is that it allows for this kind of negotiation. Good Practice Guidelines on the use of psychological formulation
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