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• To understand the role of individual formulation in mental health practice
• To recognise how formulation can be used to understand, plan and implement service user care
• To learn about two transdiagnostic models of formulation that you could use in your practice
Formulation is a collaborative process that promotes shared understanding of a service user’s narrative to ensure their care is meaningful. This article provides an overview of individual formulation in mental health practice. It explores the interaction between formulation and interventions, and how mental health practitioners can work with service users by using formulation to plan and implement care. The article also presents two models of formulation – the five-area and 5Ps models – and explains how these can be used across a wide range of clinical presentations to understand a service user’s immediate problems and longer-term challenges, thus supporting the selection of appropriate evidence-based interventions.
Mental Health Practice. doi: 10.7748/mhp.2020.e1515
Peer reviewThis article has been subject to external double-blind peer review and has been checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Cox LA (2020) Use of individual formulation in mental health practice. Mental Health Practice. doi: 10.7748/mhp.2020.e1515
Published online: 01 December 2020
The aim of this article is to enhance nurses’ understanding of individual formulation and how it may be used to effect positive change in mental health practice. After reading this article and completing the time out activities you should be able to:
• Understand the role, value and purpose of formulation in clinical practice.
• Identify important aspects of formulation and how they interact, using the five-area and 5Ps models.
• Explain how formulation can contribute towards shared understanding and care planning.
• Practise using the models outlined in this article as the basis for planning care and interventions.
• Formulation is an individualised process that seeks to understand the idiosyncratic nature and development of an individual’s problems, including the psychological, biological and systemic factors that may maintain and alleviate these problems
• Formulation is a core clinical function for mental health practitioners and is central to care planning, risk assessment and the care programme approach processes, since formulation may result in interventions that produce beneficial behaviour change and subsequently affect these aspects of care
• Two models of formulation – the five-area model and the 5Ps model – aim to develop a shared understanding of the service user’s problems, defining the main areas for intervention and support
• Further research is required to explore formulation and its applications in mental health nursing, and further support is necessary for practitioners using formulation
The process of formulation aims to support service users and practitioners to reach a collaborative understanding of problems through the development of a shared narrative (Harper and Spellman 2006), which then guides the use of evidence-based interventions to address these problems by linking psychological theory with practice (Kuyken et al 2009, The British Psychological Society (BPS) 2011).
Formulation is an individualised, often experimental, process that seeks to understand the idiosyncratic nature and development of an individual’s problems, including the psychological, biological and systemic factors that may maintain and alleviate these problems (Eells 2007). It attends to each person’s past and current situation, focusing on the functions of emotion, behaviour and thought (Cullen and Combes 2006, Turkat 2014). While the use of formulation can vary in clinical practice (Rainforth and Laurenson 2014), literature cited regarding outcomes is usually in the context of cognitive behavioural therapy (CBT). However, shorter-term, non-therapy-based approaches – for example brief psychosocial case formulation – have also proven effective (Ingham 2011).
While there is no universally agreed definition of formulation (Corrie and Lane 2010), the following essential features of all formulations have been identified (BPS 2011):
• Summarise the service user’s core problems.
• Suggest how the service user’s problems may relate to and maintain one another, by drawing on psychological theories and principles.
• Indicate a collaborative plan of intervention that is based on the psychological processes and principles identified.
Formulation is a fluid and dynamic process. Its quality often depends on the quality of the assessment and development of a positive therapeutic relationship between the practitioner and the service user (Crowe et al 2008), founded on empathy, respect and attention to subjective experience (Gallop and Reynolds 2004). The formulation is developed from the summation and integration of knowledge acquired through assessment and is interpreted according to an explanatory framework to elicit meanings. Because this interpretation is dependent on the service user’s and the practitioner’s explanatory frameworks, there are multiple ways of formulating.
Formulation is also flexible in how it is used and depicted, rather than the person and their experiences ‘fitting into’ discrete domains. This may mean the formulation is couched fully in the person’s own terms using their own language, diagrams or images. This will depend on the depth of formulation and how it is being used to inform care, for example, whether this is in a care or risk management plan or used during each clinical contact. Therefore, multiple models and frameworks for formulation exist that often depend on particular psychological modalities and the service user’s needs.
In mental health services, each service user is unique with a distinct set of needs, preferences and goals. While two people may have the same diagnosis, how they came to encounter their problems, their appraisals of these and their wishes about how they could be supported are individual (Department of Health 2003). Recovery literature and guidance on care planning have emphasised the importance of this since their inception (Barker et al 1999, Repper and Perkins 2003). However, service users do not always feel they are sufficiently involved in decisions about their care (Cree et al 2015, Grundy et al 2016, Simpson et al 2016).
Priority areas for improvement include ensuring care decisions are appropriate for individuals’ needs, and for jointly agreed care and crisis plans to achieve their goals and preferred outcomes (National Institute for Health and Care Excellence (NICE) 2019a). Despite calls for improvements, mental health care planning may not always adequately address service users’ holistic needs, with the process often unable to respond to complexity, thus reducing their experience to simplistic frameworks (Brooks et al 2018). Other barriers to care planning include ritualised practice and ineffective information exchange (Bee et al 2015), service users’ inhibitions based on experience of coercion, and time frames between reviews (Brooks et al 2018). Service users and carers have also reported not being involved with or seeing their care plan and not finding this useful for managing their mental health and recovery (Brooks et al 2018).
Care planning and risk assessment can be formulaic and often paternalistic tools that may prioritise organisational agendas, for example performance management and quality indicators, thus distancing them from service users’ everyday lives and solutions (Lester et al 2011, Slemon et al 2017). This can prevent meaningful activity and the relational aspects of care that service users value (Rogers et al 2014). It has been suggested that these barriers can be overcome by separating risk management from holistic needs assessments (Brooks et al 2018). However, service users acknowledge the need to talk about risk (Coffey et al 2017), and a holistic approach should consider all aspects of a person’s experience. Care planning and risk assessments require updating to ensure they are personalised and meaningful, which may be achieved through formulation.
Formulation is a core clinical function for mental health practitioners and is central to care planning, risk assessment and the care programme approach processes, since formulation may result in interventions that produce beneficial behaviour change and subsequently affect these aspects of care (Phull and Hall 2015, Sturmey and Lindsay 2017). Comprehensive mental health assessment includes consideration of the patient’s psychosocial and psychological needs, strengths and areas for development (Royal College of Psychiatrists 2019). Here, formulation can assist in moving beyond the description and categorisation of risk behaviours towards attending to broader holistic aspects of an individual’s experience in developing a personalised narrative (Hart et al 2011). This process can facilitate evidence-based care based on the current problems a service user is experiencing, rather than solely focusing on diagnosis, which may give a descriptive overview but can fail to explain personal meanings (Rainforth and Laurenson 2014).
A shared understanding is developed by identifying links between an individual’s experiences and the situational, psychological and social processes maintaining their distress. This involves placing the person’s behaviours and feelings in the context of why these coping methods have emerged and persisted, and discussing their effects (Crowe et al 2008). Drawing on the person’s identified strengths and needs enables the collaborative selection of appropriate interventions (Macneil et al 2012), which can be used to test hypotheses contained in the formulation (Kuyken 2006), for example whether incrementally increasing the service user’s physical activity levels improves their thoughts about their self-image and emotional state when depressed. This shifts from a didactic approach to treatment in which the mental health practitioner is considered the expert, to a curious and collaborative approach where the service user can be supported to take ownership of their care.
If interventions do not result in the anticipated changes, barriers can also be formulated and made sense of, providing further information on how to change the approach used to ensure it is effective. Formulation can also be used to navigate issues encountered in the therapeutic relationship (Katzow and Safran 2007).
Nurses are expected to coordinate and evaluate complex care and take action to improve its quality. Formulation skills are inherent in mental healthcare; the Nursing and Midwifery Council (NMC) (2018a) standards of proficiency for registered nurses correlate with formulation skills across a range of areas, including:
• Planning person-centred, evidence-based care in partnership based on mental, physical, cognitive, behavioural, social and spiritual needs, goals and preferences that reflect the service user’s values, beliefs and cultural characteristics.
• Drawing on strengths and choice to encourage change.
• Using opportunities to discuss the effects of lifestyle on well-being in the context of personal circumstances.
The NMC (2018a) proficiencies also state that nurses should be able to demonstrate skills in talking therapies appropriate to their level and field of practice. Formulation can guide the selection of interventions, reduce risk incidents and increase the psychological skills of the service user and mental health nursing teams in understanding complexity (Boschen and Oei 2008, Houghton and Jones 2016), while improving therapeutic relationships and staff attitudes towards service users (Summers 2006, Berry et al 2009). This can improve outcomes for service users and reduce their distress (Berry et al 2012), promoting the holistic, person-centred, participatory care advocated in policy and the literature (Joint Commissioning Panel for Mental Health).
In Gray et al’s (2019) study, mental health nurses reported that using a formulation approach to assess and manage risk increased their clinical skills and confidence, improved communication across agencies and increased service users’ safety. There are often practical issues in achieving goals within the time frames adopted in care programme approach frameworks. Such issues may also be overcome through use of a formulation approach that is flexible and reviewed regularly in collaboration with the service user to ensure understanding and resulting actions are in line with their needs and preferences (Johnstone and Dallos 2014).
The five-area model (Williams and Chellingsworth 2010) can be used to support understanding of a service user’s current problems. This model provides a whole-person biopsychosocial assessment, summarising the service user’s problems into five areas, detailed in Box 1. It provides clear targets for change (Wright et al 2002) and facilitates problem-solving using CBT principles to understand what is maintaining an individual’s problem. This can assist the person to change unhelpful thinking and behaviours to improve how they feel (Brewin 2006, Wills 2015).
• Area 1 – event or situation. Situations experienced, people and events
• Area 2 – thoughts and images. Altered thinking that can become extreme and unhelpful when a person is in distress
• Area 3 – feelings and emotions. Altered feelings, moods and emotions
• Area 4 – physical. Altered physical symptoms, for example low energy, tension or co-morbidities
• Area 5 – behaviour. Altered behaviour – helpful and unhelpful responses to feel better
Figure 1 illustrates how the five-area model may be mapped out using the example of Steve, who is experiencing depression due to adverse life circumstances. It offers some suggestions about how a practitioner could facilitate a dialogue with Steve to elicit relevant information.
Depression can arise from a specific event or series of events, which may be influenced by past events and the formation of associated core beliefs and assumptions, resulting in heightened sensitivity to negative stimuli and negative thinking. This can maintain a person’s feelings of hopelessness and may affect their behaviour, motivation, affect and physiology, thus compounding their low mood and beliefs concerning negative outcomes (Clark et al 1999).
In Steve’s case, recent situational factors had contributed towards his negative thoughts about himself, which meant he felt deflated and hopeless about the future. Due to his insecurities about what others might think of him, Steve had withdrawn from others, thus avoiding potentially pleasurable situations. Experiencing these situations may have disconfirmed his beliefs about being alone and that the situation could not improve, but instead his fears continued. Steve was also overspending in local convenience stores because he did not want to venture further out, which meant his debt increased and his confidence that this could be addressed subsequently diminished. Furthermore, drinking alcohol to induce sleep caused Steve to feel worse the next day, which compounded his concerns.
Practitioners can use a diagrammatic formulation, such as that shown in Figure 1, to check they have the necessary information, whether it makes sense and how the different aspects may reinforce one another. Once this information has been collated, the practitioner and service user can then attempt to break cycles using various strategies and interventions (Blackburn et al 2006).
Review Figure 1 and the problems identified in Steve’s case. What interventions do you think may be beneficial for him? To support intervention planning and delivery, you may wish to consult Bennett-Levy et al’s (2010) guide to low-intensity cognitive behavioural therapy interventions
Steve and his care coordinator generated a shared understanding of his current problems and how his thinking, physiology, mood and behaviour were interacting, maintaining and intensifying his distress. This enabled them to understand how Steve’s thoughts and behaviour were affecting his energy and motivation, leading to further inactivity and fuelling his negative thoughts about himself and his position in the world. Steve could see how catastrophising (thinking of the worst possible outcome rather than the likely outcome) about the challenges he was experiencing and his reactions had reinforced these problems. Together, Steve and his care coordinator generated ideas to address the challenges he was experiencing (Box 2).
• Thinking strategies – Steve to keep a diary noting his ‘hot’ thoughts (negatively skewed beliefs which people have when they are experiencing strong and unpleasant moods. An example might be ‘I am always screwing up’)
• Cognitive restructuring – using thoughts elicited from the diary, identify common ‘thinking traps’, and challenge these using thought records and prompts
• Behavioural strategies – graded activity scheduling; incorporating one pleasurable activity and one mastery task per week into his schedule, then noting their effects on his mood
• Budgeting – complete an income and expenditure form, with monies allocated for each expense. Contact debtors to pay back monies owed
• Alcohol consumption – psychoeducation about recommended weekly alcohol intake and the effects of alcohol on the body, using a motivational interviewing approach to check his motivations for change. Plan agreed for Steve to reduce his alcohol units incrementally, and to reward himself for abstinence with his favourite television series or snack
• Behavioural experiment to address avoidance – to test the belief ‘I have no one’, refuse an invitation, then monitor his feelings and thoughts. Accept an invitation and do the same
• Physical health – promote sleep hygiene and low-level exercise to increase his energy, manage his aches and pains and improve his mood
The 5Ps model (Box 3) (Macneil et al 2012) seeks to understand the service user’s experience in a broader context, considering the effects of their past experiences. It is commonly used across a wide range of modalities and professions and can integrate information from multiple sources to formulate a case across five groups of factors (Dudley and Kuyken 2014, Butler et al 2018).
• Presenting problem(s) – what are the person’s current concerns? These are usually outlined as thoughts, emotions and behaviours, consequences and effects
• Predisposing factors – what has increased the service user’s vulnerability? Factors that may contribute to risk, such as trauma or biological, genetic, environmental and social factors
• Precipitating factors – what has made the problem(s) worse recently? Events or situations (internal or external) preceding the problem(s), for example money concerns, physical health issues, relationship changes or drug misuse
• Perpetuating factors – what is keeping the problem(s) going or preventing it from being resolved? These factors may be: behavioural, for example avoidance or escape; biological, for example insomnia; cognitive patterns, for example paranoia or worry; or systemic factors, for example how others behave towards the person or a lack of resources
• Protective factors – what are the person’s strengths and resources? What factors might mitigate the effects of the person’s problem(s)? These may include their character, social support, interests and motivations
The 5Ps model lends itself to therapeutic intervention through its ability to identify short-term, medium-term and long-term goals, develop the relationship between the practitioner and the service user, and provide a focus for interventions.
Read the case study and, using Box 3, think about how you might organise the information into the relevant factors. Then compare your attempt with Figure 2, which depicts the formulation. What similarities and differences can you identify?
John (a pseudonym) grew up in a loving family as an only child. His parents were teachers and wanted John to achieve. He had friends at school, but was bullied during English lessons because he often mixed up words; he has a memory of reading a book and saying the wrong word and everyone laughing. John’s reading age was well below his other skills, such as maths. He was diagnosed with dyslexia, but not until high school. He enjoys football and made the school team.
John is now in Year 11 and has mock exams coming up. He is worried about these and has started having panic attacks. He is so scared that he has stopped going to school some days, especially when he has English lessons, so he is missing the main content and staff support. John is worrying a lot and making plans to revise but he does not stick to these because he is too scared to begin doing so. He has told his parents that he is scared he will fail English, be unable to go to college and never get a job. His parents have said he needs to revise every night for three hours to make up for the work he has missed.
It is important for the practitioner to draw on their clinical knowledge and skills to inform hypotheses about what might be happening and to consider interventions. For example, it is known that worry can increase anxiety and may lead to catastrophising, and that avoidance maintains anxiety and belief in the danger of the avoided activity.
Using the information in Figure 2, consider how you might work with John to tailor your support, then read how practitioners and John developed a collaborative intervention plan (Box 4). What did you think of the intervention plan? Was there anything you would have done differently?
• To manage worry – set a ‘worry time’ from 5pm to 6pm each day. At other times, use mindfulness techniques to notice and let go of worries. Challenge worst-case scenario beliefs with more realistic predictions
• To manage physical sensations of anxiety – provide psychoeducation about the role of anxiety and normalise experiences. Practise deep, slow breathing to reduce the adrenaline response
• To manage avoidance – provide education about the role of avoidance in maintaining fear. Develop a graded plan to reintegrate John into his English lessons. Ensure that John has time to see his friends and play sports during the school day
• To enhance family support – support John’s family to acknowledge his worry, while giving him positive reinforcement when he attempts to revise. Encourage his family to spend positive time together playing sports
In this case, the therapist combined the information from John’s history with their knowledge about the maintenance of anxiety and potential solutions to develop a bespoke intervention plan.
John and the therapist worked to understand how his previous experience of bullying and his parents’ high expectations had led him to worry about his exam performance. John had predicted the worst-case scenario and often felt anxious, particularly during English lessons, since this was where the previous bullying had occurred, so he had stopped attending these lessons. This made him less anxious in the short term, but his concerns persisted and each time it became increasingly challenging for him to return. He was also missing important work that reduced his chances of success. John’s parents wanted to support him so often talked about his revision plans, but this made him even more worried and they argued.
Together, John and the therapist shared this understanding and started to generate ideas, based on evidence, for what could assist with each of the factors maintaining his problem. The therapist wrote a letter to John summarising the understanding they had developed.
It can often be unclear who takes responsibility for formulation, since it is traditionally seen as a job for psychologists, rather than for mental health nurses. Training and research on formulation in mental health nursing is limited. Practitioners using formulation skills should be supervised appropriately, and processes to support them to apply these skills in their practice are required. It has been identified that training in formulation positively affects its quality (Eells et al 2011) and it has been proposed that formulation can meet NICE (2009, 2019b) guidelines for managing mental health in secondary care; however, research is often conducted with established therapists rather than mental health nurses.
Research indicates that ‘psychological mindedness’ – the ability to draw together thoughts, feelings and behaviours to understand meanings and causal factors – is a strong predictor of formulation skills among mental health staff (Hartley et al 2016), with formal training being proposed to develop such skills. Kendjelic and Eells (2007) identified that brief formulation training for trainee clinicians has produced formulations rated as higher in overall quality, although further research is necessary. Nurses are required to promote practice improvements and to develop quality and safety improvement strategies (NMC 2018a); efforts to develop supportive structures to train, implement and review formulation strategies could take the form of local in-house training and clinical supervision to encourage reflective practice (Cookson et al 2014), focusing on knowledge sharing, use of case vignettes and presentations (Page et al 2008), which may all enhance its application.
Team formulation may also augment skills and practitioner confidence, whereby shared understandings from the multidisciplinary team develop hypotheses about causal and maintenance factors to inform treatment plans (Christofides et al 2012, Johnstone and Dallos 2014). This can ensure that resources are streamlined by defining ‘who is doing what’ in relation to each need, rather than silo working. A forthcoming CPD article in Mental Health Practice provides further information about team formulation.
In England, there is a drive for psychological approaches to be adopted in routine mental healthcare to support models that advocate greater choice, control and support for individuals to lead fulfilling lives (NHS England 2019a). Formal training for the mental health workforce to support delivery of NICE-recommended psychological therapies (NHS England 2019b) may also benefit team members through the practise and dissemination of psychological skills such as formulation.
Mumma (2011) suggested the complexities of formulation are more vulnerable to inferential bias (that is, issues with measuring validity, accuracy and variability in quality) than standardised treatments, suggesting leadership during formulation training for practitioners would improve clinical judgement through clarifying performance.
Care must be captured in a meaningful way (Robert and Cornwell 2011), and tools measuring care should be standardised to ensure a unified approach, common language and consistency (Gray et al 2019). Further research is required to explore formulation and its applications in mental health nursing, and further support is necessary for practitioners using formulation. The research base concerning reliability, validity, uses with service users and training also requires review (Sturmey and Lindsay 2017), and consideration needs to be given to how formulation may enhance current models used in mental health practice.
Formulation is a collaborative and fluid process that promotes shared understanding of a service user’s narrative. It may enhance ways of working to ensure care is meaningful and can be a catalyst for positive change. There are multiple ways to undertake formulation, depending on the person’s needs, and various models, tools and frameworks may be used, such as the five-area and 5Ps models. The use of these models can enhance mental health practice by gathering information about the service user and using this to provide insights that support the selection of appropriate evidence-based interventions.
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