The shape of formulation



Below is a collection of wonderings, hypotheses and ideas. It draws on my clinical experience, research, training, knowledge and conversations I have had with clinicians and people who use services, with activists and academics. There is an attempt to make sense of some of the dilemmas, divisions and difficulties with the concept of formulation. It is driven by reflective processes, is situated in a given context and is open to change. It is not a completely comprehensive or finished piece; it’s the start of a conversation, not the last word.

As such, this blog is not dissimilar from formulation as I see it. The word, divorced from its connection with mental health services, means the putting together of components in appropriate relationships or structures. A way of making sense of ourselves and others. It’s about understanding how different aspects of experiences develop, are maintained and could be changed- how they link together. It draws together personal events and meaning-making, scientific/psychological understanding, theory and evidence. The format can be narrative (words), images, metaphors, diagrams, even objects.

Formulation can sometimes framed as a ‘thing’ that is ‘given’ but I disagree with that meaning. I view it more as a process that can occur in different ways, with different formats and functions, in different contexts. In 1:1 work, it can help make sense of a confusing history or current experiences, normalise and validate responses and seek exits from stuck patterns. In the context of team working, it can be used to enable staff to make sense of their own responses, understand the things that maintain difficulties and thus engender more compassionate and effective support.  I have been part of formulations that have been incredibly helpful for both teams and individuals.

This is formulation (own reflections):

I am struggling to start this; feeling anxious and frustrated. In the past, I have tended towards procrastinating due to a bit of perfectionism; wanting things to be done ‘the right way’; I guess I get that from my past. I remember once being asked by a teacher why I got a B rather than an A on a test and I guess that perceived criticism stuck with me. Today is especially difficult as it’s Friday and I am eager to do other things, so concentration is tricky. I am worrying and that’s adding to the anxiety and my avoidance of writing- I’ve put it off for a few days now and so it seems even harder to get started! My enthusiasm for the topic helps me to persevere though, and that’s what has enabled me to put pen to paper; telling myself it’s ok if it’s not great first time and I can come back to it- just to get something down. I’ve put some good music on to work with and I am rewarding myself with a brew while writing

This is formulation (staff room kitchen on inpatient ward):

Nurse: “I’m really struggling to work with X because every time I offer a 1:1, he tells me to go away. I feel really frustrated”
Me: Did you know what happened with all the care coordinator changes before admission?
Nurse: No
Me: He had three leave really close together, so I wonder if that’s affected things.
Nurse: Yeah, I guess he might not trust staff that much if they keep leaving- he might be pretty pissed off too.   I’ll keep trying. Maybe we could go for a walk rather than a 1:1.

This is formulation (developed in 1:1 session with someone):


Team formulation is often a kind of a mash up of these. Bringing together what’s already known about a person’s history, observations, staff members’ own emotional responses and how they are managing these to try and make sense of what might be happening and why. Understand how the staff can step back from urges to act in ways that maintain cycles and move to more helpful responses; hopefully mitigating iatrogenic harm. It also helps to organise information from multiple sources - e.g. referral, notes, observations - and look for potential links between these that could indicate avenues for support or change (either individual or systemic), informing care planning. Alongside this, one to one work is building relationships with an individual to develop their personal formulation - collaboratively, in whatever way they find helpful (written/ drawn/ discussions). Any hypotheses developed in the team discussions are presented as such (i.e. we can never know if the links we are suggesting are helpful/ make sense or not unless they are developed and shared collaboratively with the person involved). So team formulation is a Venn diagram of traditional formulation and clinical supervision. Because (I believe) we can never support staff to act in helpful ways unless we know what is helpful (and not damaging) for that individual person, given their specific circumstances.

Formulation is a dynamic process. It seeks to make sense of complex information and catalyse change. It is not a panacea and it is not without difficulties, capacity for damage and the need for change itself. If we frame formulation as an alternative to diagnosis, we might get stuck. Diagnosis is a way of categorising a group of experiences. It is a thing that is given. For some people, it also describes the ‘cause and the cure’; for others, it’s a loose, short-hand description. We certainly need alternatives or additions to diagnosis. Alternatives to fixed care pathways that limit care to those who fall in neat boxes. Support that is based on needs and preferences, not archaic and arbitrary groupings. But to suggest formulation as that alternative risks seeing it as equivalent. It risks seeking formulations that are ‘reliable’ and ‘valid’, rather than ‘useful’. For how can something that is truly collaboratively created, informed by the subjective experiences of the particular individuals present in a specific context and time, ever be (or seek to be) the same as another? Moreover, this equivalence positions formulation in the same doing-to, giving-of power structures in which diagnosis finds itself.

And therein lays another of the challenges. Consent. Formulation, when a process in teams, might occur without the person to whom it relates being present. If the person declines involvement, if the need for team sense-making and care planning occurs at such an early stage in the relationship that to be part of that might feel too difficult or exposing, if the process occurs in an individual staff member’s supervision.  I believe team formulation can’t be helpful unless it includes information specific to that person alongside general understanding of what is helpful and what is not. That might include observations of interactions, it might include an understanding of history from previously-gathered information. Formulation is personal, otherwise it’s not useful. But this means people are talked about when they are not present – I feel uncomfortable about this, and it can be experienced as re-traumatising. Team formulation also has to be a safe space for staff to voice their own emotional reactions because these might be driving unhelpful staff responses. In the context of 1:1 therapy, you can navigate these issues much more easily; working together, in the context of a dyadic alliance, to engender collaboration and develop a truly shared understanding. But in teams it becomes more complicated. There are important conversations to be had about how we talk about, implement, utilise and share the space of formulation and the products of it.

It might be an uncomfortable truth for some (it has been for me), that despite its aim of compassionate understanding and supportive, collaborative change, formulation still operates within the power imbalance inherent in mental health services and as such is  saturated with it. Anything can be weaponised if we are at war. Even if I believe (which I do) that supporting staff to acknowledge a person’s history, the impact of this and their current part in unhelpful cycles, can thus develop empathic understanding and compassionate responses, this is still care that is ‘done to’ rather than ‘done with’. Sometimes offering paternalistic care is all we feel we can do or have access to. But we have got to seek to move away from that, within the progress of our clinical care but also by dismantling the structures, and our part in them, that maintain the power imbalance and paternalism on which mental health services often rest. Formulation with the person fully involved, sharing control, actively participating, is the heart of formulation, and yet - even when this is the format that the process occupies- can true collaboration ever be achieved in a system that rests on responsibility and power being held by clinicians? (and can we dismantle power while still expecting responsibility? That’s probably another conversation…..).

Thus, I come back to the title. Etymologically, formula is the diminutive of the Latin forma, meaning shape. The shape of our understanding is formed by the meaning and experiences we bring to it and derive from it. Formulation is shaped by and shapes the people involved in it. It is bound by the system it occupies and yet can also influence the system. Each shape moulds and is moulded by the other. I think if we can learn from this; be open to formulation as a process to be shaped by those involved in it, alongside carving out more collaborative structures and systems in which it sits, then we can continue to evolve. Formulation might help us understand our own difficulties as a health system and signify exits from that. Within this change- as with any other- we have got to empathise with and validate the good intentions and current predicaments, while challenging the status quo to effect real change, otherwise we might find ourselves stuck. My hope is that we can find safe spaces to explore this together – clinicians, activists, survivors, academics; people – collaborating to find meaning and change.


[I am grateful to Beth @beth_1day and Donna @MyNewMummyLife for prompting some of my reflections on this.] 



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