Psychiatric diagnosis is deeply embedded in practice, research and clinical governance, as well as in other areas of public life such as the criminal justice system and the benefits system. This is likely to remain true for the foreseeable future. For example, Trusts are required to return Mental Health Minimum Data Sets based on psychiatric diagnoses. The IAPT initiative is based on diagnostic criteria for depression and anxiety disorders (with others to be included soon. NICE recommendations and most outcome measures are diagnostically-based, and a diagnosable mental illness is a prerequisite for access to mental health services. Court reports and risk assessments are based on psychiatric diagnoses. Most evidence-based practice is based on classification by psychiatric diagnosis, despite the fact that these terms are not evidence-based themselves that is, they have poor reliability and validity (Boyle, 2002; Bentall, 2003). Although it could be argued that formulation is a viable alternative to some psychiatric diagnoses at an individual level, there is no agreed system of non-medical terms to replace psychiatric diagnosis for broader, clustering purposes. Some clinical psychologists and psychiatrists have suggested new categories that incorporate recent evidence about the causal role of trauma, and can perhaps be seen as occupying a place halfway between functional psychiatric diagnoses and formulation. For example, it has been proposed that in many cases personality disorder is better understood as complex PTSD’ (Herman, 2001). Similarly, Callcott & Turkington (have suggested traumatic psychosis as an alternative to some diagnoses of ‘schizophrenia’. 24 Division of Clinical Psychology
of brevity. They do not necessarily imply wholesale rejection of existing psychiatric diagnoses. They do, however, represent initial attempts to develop coherent, credible alternative forms of categorisation which are based on psychological theory and which have direct implications for both aetiology and intervention. In fact it could be argued that some current psychiatric diagnoses, for example, bereavement reaction, adjustment disorder and dissociative disorder, are better understood as broad-level formulations, implying primarily psychosocial rather than medical/biological causes. Among a number of new developments is the concept of ‘trauma-informed’ services in the USA (Harris & Fallot, 2001). These are based on the recognition that violence, trauma and abuse are causal factors across the whole range of psychiatric presentations and need a common, trans-diagnostic approach grounded in a different model of service delivery. Although the model has yet to make an impact in the UK, it implies a much greater role for formulation-based categorisation of mental distress. Good Practice Guidelines on the use of psychological formulation 25
Division of Clinical Psychology 1.
Best practice psychological formulation is a highly skilled process that combines scientific principles with intuition and reflectiveness. It serves a range of purposes in psychological work with individuals, carers, teams and organisations, and has the potential to enhance core aspects of clinical work across roles and specialties. It helps to ensure that our interventions are evidence-based by linking theory with practice. It can be seen as a prime example of level 3 skills inaction. A distinguishing characteristic of psychological formulation is its sophisticated,
multiple-model perspective which integrates theory and evidence from psychological, biological, social/societal, and cultural domains through a shared understanding of their personal meaning to the service user. Clinical psychologists receive the most in-depth training in formulation, and are well-placed to promote its use through practice, teaching, supervision, consultancy and research. 4. Emerging evidence suggests that formulation is highly valued by other MDT members. Further research into the impact of formulation on team functioning and on the quality of care is needed. 5. Formulation also has the potential to promote collaborative work with service users by enhancing the therapeutic relationship and increasing their sense of meaning, agency and hope. More research is needed into service user and carer experiences of formulation in order to ensure that it is used sensitively, respectfully and productively. Formulation can facilitate culture change by promoting a more psychosocial perspective in services as a whole. New evidence about common psychosocial causal factors across psychiatric diagnostic categories suggests the potential for formulation to take a more central role in mental health settings, including the development of formulation-based categorisation systems. Although much of the theory and research on which formulation draws is firmly established, to date there is only limited evidence to support it as a specific intervention in its own right. This is a significant gap that needs to be filled. 8.
Culturally-sensitive formulation is another underdeveloped area which is ripe for research. This, along with other aspects of formulation, is recommended for clinical psychology trainees doctoral projects. Clinical psychologists need to ensure that formulation has a central place in electronic records so that it can be integrated into care packages and pathways. The checklists in this document are recommended as a means of enhancing good practice in clinical work, training, supervision, consultancy, audit and research in the field of formulation.