Journal of Psychiatric and Mental Health Nursing, 2008, 15, 800807

Clinical formulation for mental health nursing practice

M. Crowe1 rn phd, D. Carlyle2 rn phd (candidature) &
R. Farmar3 rn psychotherapist
1
Associate Professor, Centre for Postgraduate Nursing Studies, and 2Senior Lecturer, Department of Psychological
Medicine, University of Otago, and 3Registered Nurse, Psychiatric Emergency Service, Mental Health Services,
Canterbury District Health Board, Christchurch, New Zealand

Correspondence: CROWE M., CARLYLE D. & FARMAR R. (2008) Journal of Psychiatric and Mental
M. Crowe Health Nursing 15, 800807
University of Otago Clinical formulation for mental health nursing practice
PO Box 4345
Christchurch There are problems for mental health nurses in using psychiatric diagnoses as outcomes of
New Zealand
their nursing assessments and nursing diagnoses present similar issues. However, there is a
E-mail: [Link]@[Link]
need in practice to link the assessment to nursing interventions in a meaningful way. This
paper proposes that the clinical formulation can be regarded as central to providing this
cohesion. The formulation does not merely organize the assessment findings but is also an
interpretation or explanation, made in consultation with the client, of what meaning can be
attributed to the issues explored in the assessment process. Because this interpretation is
dependent on both the clients and the nurses explanatory frameworks, there are multiple
ways of developing the formulation. It is also an evolving and dynamic statement of under-
standing. A case example is provided in the paper to illustrate how the same case can be inter-
preted in different ways and the implications this has for the nursing interventions provided.

Keywords: nursing, nursing role, psychotherapy, therapeutic relationships

Accepted for publication: 03 June 2008

This paper explores the characteristics of clinical formu-

Introduction
lations, differentiates them from diagnoses, draws on the
A defining feature of mental health expertise is its hetero- psychotherapeutic nature of mental health nursing care to
geneity and lack of consensus (Morant 2006). The field of make the case for the use of clinical formulations and
mental health care is one of competing paradigms and provides an example of its use in practice. A clinical for-
understandings about what constitutes mental health and mulation can be understood as an interpretation of what
illness. Expert knowledge is partial and provisional with is happening for the client based on the clients and the
as yet no definitive proof to support one perspective over nurses explanatory frameworks what she or he under-
another (Morant 2006). Psychiatric discourse implies an stands to be the precipitant and nature of mental distress
identified biological aetiology but there is as little evidence and how best it can be alleviated.
for this as there is for other theories. Despite this psychiatry
has staked its claim to being the most authoritative and
The differences between diagnosis
legitimate paradigm. However, it could be argued that one
and formulation
of the most positive attributes of contemporary mental
health care is the coexistence of multiple paradigms bio- The main differences between diagnoses and formulations
logical, cognitive, interpersonal and psychodynamic. This have been summarized by Mace & Binyon (2005). Because
coexistence provides the opportunity for working along- diagnoses serve a statistical function there are only a
side the person experiencing mental distress to establish a limited range of standardized terms to choose from, e.g.
meaning that best fits her/his experience. Major Depressive Episode, Bipolar Disorder NOS. The

800 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd
 Clinical formulation

diagnosis does not identify and explain what is unique peutic theories to practice in a clinical environment domi-
about a particular clients presentation. Diagnoses are pri- nated by a theoretical psychiatric discourse. It may also be
marily descriptive in format while formulations provide an because of a lack of knowledge regarding different theo-
explanatory summary of what is happening for a particular retical approaches as a consequence of nursing education
client. Formulations provide more than a description of a programmes that fail to provide a broad approach to
particular category of mental disorder and this requires the understanding mental distress but favour a medical model
nurse to seek additional information such as a sense of how approach.
the client feels and responds in a variety of situations, the If mental health nurses choose to support this pursuit of
sequence of significant events in the clients life and the a diagnosis at the expense of developing an understanding
meaning of these events for the client. Although psychiatric of the client it leaves them with a very constrained role
diagnoses identify a recognized cluster of symptoms they observing for behaviours to fit a diagnosis, administering
fail to refer to a presumed cause or aetiology. There is also medications and supporting the role of the psychiatrist.
presumed to be a predictive function in diagnoses; they The formulation can be regarded as a more effective client-
suggest a prognosis. Formulations strive to take sufficient centred alternative to psychiatric diagnosis that makes
factors into account to identify the likely pathway for that sense of assessment data and indicates an approach to
particular person. The current influence of the evidence- treatment.
based practice movement has resulted in the course of
treatment being dictated by the diagnosis. It can be
Clinical formulation
argued that formulations provide a sounder basis upon
which to identify and choose treatments (Mace & Binyon Most of the literature on clinical formulation relates to its
2005). use in psychotherapy, specifically cognitive behavioural
Clinical formulation is not concerned with what cat- therapy and psychodynamic therapy (Persons et al. 1995,
egory the problem fits into, but what situational, psycho- Tarrier & Calam 2002, Eells & Lombart 2003). In this
logical and social processes are maintaining this particular literature it is often referred to as case formulation. The
clients mental distress and how these could be addressed. development of case formulation began in the 1960s which
Psychiatric diagnosis claims to be a theoretical (American marked the beginning of an era within which psychological
Psychiatric Association 1994) in that it is not interested in formulations to account for mental health difficulties
the underlying causes of the clients problems but there are was offered as an alternative to psychiatric diagnosis and
implicit assumptions that the problem is biochemical in medical models of conceptualizing emotional distress
nature. Psychiatric problems are therefore regarded as (Tarrier & Calam 2002). Over the past few years there has
medical problems with a biological basis. The diagnostic been increasing interest in researching the effectiveness
process works by attempting to fit the clients presenting and clinical outcomes of case formulations (Kukyen et al.
symptoms into a diagnostic category which often means 2005). This research has focused on the reliability of case
only information pertinent to categorization is elicited formulations, the quality of the formulations in relation to
during psychiatric assessment. A very narrow understand- accurately representing the clients distress, the usefulness
ing of the client and her/his issues is the consequence of this of formulations in treatment and whether the frameworks
approach which may contribute to the multiple diagnoses for formulations can be readily used by clinicians.
clients receive, the attribution to personality attributes that While there is no agreed definition of case formulation
occurs when clients do not respond to pharmacological Sim et al. (2005) found that most definitions include the
treatment and the polypharmacy that occurs in evermore descriptive, prescriptive and predictive aspects of the case.
desperate attempts to find a drug that will fix the problem A good formulation captures the essence of the case and
(Crowe 2000). includes a theoretical basis, sensitivity to the client and
Because of the centrality of medication prescribed by a specificity to the client. The formulation is therefore a way
psychiatrist as the treatment outcome of the diagnostic of understanding the client rather than judging their behav-
process, it has limited utility to mental health nursing prac- iour and feelings as it places these behaviours and feelings
tice. However, mental health nurses often seem to be reluc- in the context of why the client needs to use them and why
tant to develop clinical formulations as a basis of their care. they may have been helpful to the clients coping in the
They seem more comfortable to go along with the descrip- past.
tive approach of the DSMIVTR (American Psychiatric There is no literature available on the use of clinical
Association 1994) rather than employing the interpretive formulation in mental health nursing practice despite the
approach necessary for clinical formulation. This may be opportunities it provides for developing more effective psy-
because of a lack of confidence in applying psychothera- chotherapeutic nursing interventions.

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd 801
M. Crowe et al.

chological strategies for helping the client establish some

The psychotherapeutic nature of care
meaning and control over their experiences. Peplau
Mental health nursing is a specialist area of nursing prac- (1999) has described the psychotherapeutic nature of
tice. Its specialty is the assessment, treatment and long-term nursing care as strategies or approaches that impact on
management of people with complex mental health prob- the pathology or an asset of the patient. She suggests the
lems. The skills required to practice in this area can best tactic for which that there is anticipated a beneficial effect
be described as psychotherapeutic. Mental health nursing on the patient must be sustained over time; there are no
literature has long been concerned with the therapeutic magical tactics which if used once or twice will produce
nature of this relationship dating back to its origins in the substantial, constructive and lasting effects. Nursing strat-
work of Peplau (1952) who emphasized the importance of egies which are considered psychotherapeutic must be
interpersonal relations in nursing. Most of the subsequent used persistently, many times in situations in which a spe-
mental health nursing literature on the nurseclient rela- cific pathological item is presented by a patient and
tionship draws on Peplaus conceptualization (Thelander observed by the nurse. Therefore the alertness of the
1997, Chambers 1998, Lego 1998, OBrien 2001). An nurse in immediately noticing, assigning meaning to and
understanding of psychotherapeutic processes is a core then responding specifically to the item of behaviour pre-
component and distinguishing feature of mental health sented by the patient is crucial to psychotherapeutic
nursing. It is insufficient for mental health nurses to merely outcome (Peplau 1999).
adhere to a medical model of practice or engage in basic Therapeutic engagement is essential to develop a for-
therapeutic relationships. mulation as its purpose should be to facilitate a psycho-
This relationship is based upon the nurses assessment of therapeutic relationship. Listening to clients actively and
the clients psychological and emotional needs, the devel- communicating an understanding of the clients words, in
opment of a clinical formulation that interprets those needs order that they can comment on the accuracy of the cli-
from a psychotherapeutic perspective and a plan of psy- nicians understanding, form the empathic basis of the
chotherapeutic care that is derived from this formulation. relationship (Gallop & Reynolds 2004). An important
Mental health nursing is a specialty area of nursing practice characteristic of the formulation should be its malleability
that requires an expansion of the therapeutic relationship and flexibility to change. It should be a negotiated
to become a psychotherapeutic relationship. It is the psy- description of the context to the clients current situation.
chotherapeutic nature of this relationship that distinguishes
mental health nursing expertise. This relationship is
The process of formulation
founded upon understandings of the psychotherapeutic use
of self, principles of empathy, respect and attention to the The formulation is developed from the summation and
subjective experience of the client (Gallop & Reynolds integration of the knowledge that is acquired by this assess-
2004). ment process and interpreted according to an explanatory
Forchuk & Reynolds (2001) explored what clients con- framework. The interpretation requires a theoretical basis
sidered to be therapeutic in their relationships with nurses. that may reflect one particular psychotherapeutic approach
Having a sense of connectedness with nurses emerged when or a theoretically coherent blending of approaches. The
nurses were perceived as friendly, trusting, genuine inter- explanatory framework is the assumptions, values and
ested and understanding. Clients found it helpful when beliefs upon which the nurse bases her/his care. The for-
nurses were able to help them explore and clarify their mulation that evolves from the explanatory framework
feelings, to anchor their accounts of their problems by involves a negotiation of the meaning of the distress for the
sorting out what needed attention, and to focus on solu- client. The validity of the formulation is not determined by
tions to problems. Coatsworth-Puspoky et al. (2006) its rightness as there are multiple ways of interpreting any
described what they called the client test where the nurse situation, but rather by the theory upon which it is drawn
client relationship moved forward if the client perceived the and the research into the clinical relevance of that theory.
nurse as client and trying to understand their feelings and Kaye (1999) suggests that it is important to avoid taking
behaviours. on the persons frame of reference as the sole explanation
The term psychotherapeutic can be defined as strate- of experiences but rather take what he describes as a super-
gies that facilitate the alleviation and healing of mental ordinate framework. This involves responding to the per-
distress through the thoughtful and purposeful use of psy- sons narrative and re-contextualizing it to help facilitate
chological interactional strategies. This requires the nurse new meanings and new possibilities through the process of
to have a framework of understanding for creating clinical formulation. The re-contextualization provides the
meaning in the clients distress and have a range of psy- opportunity for making new connections between how the

802 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd
 Clinical formulation

person is feeling and their experiences and beliefs. The in childhood may no longer be effective for adapting to
shift in perspective serves to highlight previously unnoticed the world as an adult. Through interventions the adult
connections between behaviour events, beliefs and feelings becomes aware of present ways of coping that are ineffec-
as well as to disrupt previously automatic behaviour tive and how they served a purpose in childhood that is
sequences (Kaye 1999, p. 23). no longer relevant. The person learns that he or she now
The explanatory framework provides a template for has a range of new options for solving problems, and for
describing and explaining a clients problem both to the living in general that are now based on his or her maturity
client and the clinical team. This explanation would iden- and independence (Gallop & OBrien 2003, Crowe
tify the clients main problems in the context of their 2004).
predisposing, precipitating and perpetuating factors. The The different approaches have different components to
formulation identifies the pattern inherent in the clients their formulations; however, a basic structure upon which
distress. It helps the nurse to experience greater empathy to consider the factors that different approaches regard as
for the client beyond the presenting symptoms. significant is what is commonly called the 4Ps predispos-
Nursing interventions based on the clinical formulation ing factors, precipitating events, perpetuating factors and
provide meaning and direction for nursing care. These protective factors. The content of this structure should
interventions may be psychotherapeutic or psychotropic in provide an explanatory account of the clients mental dis-
nature but are designed to facilitate change. The interven- tress and provides a direction for interventions. Its focus is
tions test the provisional hypotheses contained in the for- the consideration of what is happening for this client and
mulation and are subject to modification in the light of why it is happening at this point in time.
experience and new information. They would focus on the
reduction of symptoms, improvement of functioning, pre-
Formulations in practice
vention of relapse, increased self-awareness and mobiliza-
tion of strengths and resources. To illustrate how different formulations can be generated
The most common explanatory frameworks in the from the same data, a clients situation is described and
contemporary mental healthcare environment are: cogni- then followed by four formulations from different clinical
tive behavioural therapy (CBT), interpersonal therapy perspectives.
(IPT) and psychodynamic. Emma is a 28-year-old Maori woman who lives with her
A cognitive behavioural formulation addresses a central 18-month-old daughter and her partner, John. She was
underlying mechanism that influences the clients behav- initially diagnosed with depression in her early twenties but
iour. This mechanism is regarded as a core belief or schema following a period of hypomania following the birth of her
that underlies all of the emotional, behavioural and cogni- daughter she was re-diagnosed as having a bipolar disorder.
tive difficulties that can be observed at an overt level She has taken lithium and sodium valproate in the past
(Bergner 1998). The formulation focuses upon the schemas but she does not want to take them again because of side
and thoughts that drive the persons behaviour and treat- effects. Emma currently takes quetiapine as a regular dose
ment is directed at rectifying these unhelpful thoughts and of 200 mg nocte and 25100 mg pro re nata. She also takes
schemas. citalopram 20 mg per day. Her mood has been generally
An interpersonal explanatory framework would focus stable but low.
on repeated patterns in relationships that serve to maintain She continues to have sleep problems, low energy and
the clients current distress (Klerman et al. 1994). These motivation and irritability which is particularly directed
patterns are defined as being interpersonal disputes, role towards her partner. Both her and her partner drink
transitions, interpersonal deficits or grief. An interpersonal alcohol regularly and smoke marijuana socially. On occa-
approach to nursing interventions would focus on identi- sions when her mood begins to elevate she tends to spend
fying interpersonal patterns, how they affect the person and to excess, becomes intolerant and irritable, and finds
exploring different ways of engaging at an interpersonal herself in a range of interpersonal conflicts. She utilizes the
level. quetiapine to good effect at these times.
A psychodynamic explanatory framework has its basis Emma was adopted by a Pakeha (New Zealander of
in psychoanalytic theory and attributes emotional prob- European ancestry) family when she was about 8 months
lems to the clients unconscious motives and conflicts. It is old after her birth mother was found by Child Youth and
based on the rationale that difficulties experienced in adult Family Services (a government child welfare service) to be
life originate in childhood, that children do not possess the incapable of looking after her competently. She was the
maturity for making effective choices nor the independence youngest in her adoptive family and had two older broth-
to do so, and that methods of adapting that were developed ers. She is very close to her adoptive mother but has some

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd 803
M. Crowe et al.

conflict with her adoptive father usually over lifestyle

A cognitive-behavioural formulation
choices. In her late teens Emma made contact with her birth
mother and half-sisters. She found this very stressful and Emma thinks she is a failure and that she is unlovable. She
developed a strong dislike for her birth mother whom she thinks she will be rejected by people to whom she becomes
describes as a junkie and a user. She describes having a close. These thoughts have developed through her percep-
reasonable relationship with one of her step-sisters but feels tion of her birth mother neglecting her because she was not
she has to always bail this sister out of trouble. good enough to be cared for. Her personal schema is that
Emma feels that she has lost her confidence and that she is in some way faulty and defective and her schema
whatever she attempts she will fail. Because of her anger about others is that they will abandon her.
with her birth mother she does not want to be identified as These thoughts influence her behaviour when her mood
Maori and at times expresses quite strong racist attitudes. is both elevated and depressed. When Emmas mood is
There has been some ongoing conflict with her partner as elevated she spends considerable amounts of money on
she feels she cannot really trust him although there is no items she thinks will improve how people see her and
evidence that he has behaved in an untrustworthy way in pushes people away from her with her grandiosity and
their relationship. At times she becomes very fearful that he irritability. When her mood is depressed she ruminates
will leave her despite his reassurance and this places con- about being worthless and a failure and feels guilty about
siderable strain on the relationship as it leads to arguments. her behaviour when she is elevated. She has difficulty in
Emma describes finding it very hard to believe that he loves allowing her partner becoming too close to her at an emo-
her. tional level because she thinks if he finds out what she is
Her relationship with her daughter can become stressful really like he will reject her. The consequences of these
at times because Emma has strong perfectionist tendencies behaviours serve to reinforce her thoughts about herself as
and finds it difficult when her daughter hinders her unlovable and defective. She believes that if she pleases
attempts to maintain the perfect household. others and tries to meet all her partners needs he will not
Emma is keen to receive help to manage her mood and leave her. Emma finds it difficult to be anything other than
receive support in organizing her daily routines as she tends accommodating to others and has difficulty identifying or
to spend a lot of time doing housework and has little time asserting her own needs.
with her baby or for herself. She would also like to enrol in Mental health nursing interventions based on the CBT
a university course but she lacks confidence to do this approach to treat would link mood to thoughts and behav-
because of her past failures. iour addressing Emmas faulty thoughts about being unlov-
able and defective.

A psychiatric formulation
An interpersonal formulation
Emma was first diagnosed with depression in her early
twenties. Within the postpartum period of the birth of her Emma interpersonal relationships are influenced by her
daughter 18 months ago she experienced her first onset of feelings of potential abandonment and a sense of herself
hypomania. At this point a diagnosis of bipolar I disorder as not being good enough. These feelings stem from her
was able to be made. Since that time Emma has experienced early neglect as an infant, the involvement of welfare
abnormal variations in her mood including mood eleva- authorities and her subsequent adoption. Despite being
tion, but most often remaining depressed. much loved in her adoptive family Emily felt different
DSMIV Multiaxial evaluation: from her siblings (all brothers) and experienced this as
Axis I: 296.52 Bipolar I disorder, most recent episode feelings of inferiority. She has strong feelings related to
depressed, moderate. mothering and has high expectations of herself as a
Axis II: V71.09 No diagnosis. Current defences/coping mother. Emma also experiences isolation from her Maori
style: acting out. culture and is fearful of involvement in this culture or
Axis III: No diagnosis. being identified as Maori.
Axis IV: Conflict with partner and adoptive father. In her current relationship with her partner Emma feels
Axis V: Global Assessment of Functioning = 50 (current) a need to constantly test the relationship and finds it diffi-
Mental health nursing interventions are directed at sup- cult to trust him. She describes this as getting into a cycle of
porting psychiatric treatment which focuses on finding the pushing him away just to see if he really does love her and
right mood stabilizing medication for Emmas Bipolar Dis- that he will stay with her. She is very reliant on her adoptive
order and providing psycho-education related to manage- mother for emotional support and providing child care
ment of the disorder. when she finds it difficult to manage her baby.

804 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd
 Clinical formulation

An interpersonal explanatory framework would link

The clients response
mood to interpersonal situations and focus on exploring
Emmas needs in her relationship with her partner, what Emma initially found meaning with an interpersonal for-
her expectations of the relationship are and how her behav- mulation of her issues. It gave her a platform from which
iour might be perceived by her partner. to understand some of her experiences but over time she
engaged with a formulation that encompassed psychiatric,
cognitive, interpersonal and psychodynamic components.
A psychodynamic formulation
From a psychiatric perspective a diagnosis of Bipolar
(self-psychology)
Affective Disorder enabled Emma to understand and name
Emma has experienced a disruption in the development of her experiences of mood fluctuations. She had previously
self in the first few months of her life. The early lack of understood that she experienced depressive episodes but
adequate mothering has resulted in a lack of trust in others had no way to understand her elevated behaviour and
in intimate relationships and an inability to hold onto her assumed that the behaviours were associated with her
fears of both feeling intruded on or abandoned. She has being fundamentally a bad person who was unlovable.
developed some ability to relate to others during her place- It also helped Emma to be able to challenge the cogni-
ment within a caring adoptive family but she still feels like tions she had around being a failure and being unlovable.
she does not fit (cannot be her authentic self) anywhere. She From an interpersonal perspective Emma acknowledged
has also been displaced from her own Maori culture and in that her expectations of her relationships were often not
rejecting her birthmother and culture rejects a part of reciprocal and she acknowledged that her partner may not
herself, further alienating her from a sense of belonging be able to meet all her interpersonal needs. She was also
somewhere. A lack of mirroring has resulted in her low able to recognize and acknowledge the problems that her
self-confidence and feeling a failure. interpersonal sensitivity caused in relationships.
Emma attempts to compensate for this by being a per- Emma also found it useful to understand that her inter-
fectionist and presents a false self to others to ensure they personal insensitivity could be related to her experiences of
do not see how flawed she is and reject her. Keeping busy neglect and rejection. Providing her with psychodynamic
and task oriented stops her focusing on the anxiety she feels understandings of the possible causes for her sensitivity
about her inadequacies and keeps the relationship with her helped her understand her feelings of displacement and her
daughter superficial and non-threatening. Her difficulty need to present a false self to others. Over time her drive
providing a holding relationship with her daughter to present herself as perfect diminished and she was able
increases the chances of her daughter becoming distressed to engage in more authentic relationships with her
and acting out which will challenge her need to be the partner.
perfect mother and activate her sense of failure. Emmas process of recovery has had its ups and downs
Emma accommodates the needs of others above her own and over the past 3 years she learned to manage her mood
in an attempt to feel some sense of self-worth and in doing fluctuations with medications and to identify some of the
so diminishes her own experience. This leads to an internal triggers associated with this. She also had two separations
feeling of deadness and her inability to self-regulate emo- from her partner but they are currently engaged in couple
tionally will lead her to use alcohol and cannabis to provide counselling. Emma feels considerably more comfortable
this for her. When she is elevated she is unable to repress and competent in her parenting role and has also taken on
her own needs as easily and her anger causes problems a part-time job which she finds very worthwhile. The
with her family and friends who may reject her in a similar dynamic and inclusive nature of the formulation evolved
manner to early experiences. This ongoing lack of stability over time to meet Emmas needs and understandings.
within her relationships and inability to hold herself emo-
tionally steady will impact on her Bipolar disorder and her
Discussion
quality of life.
A self-psychological framework would focus on the Although mental health nursing practice is concerned with
development of a sense of reflective consciousness within a the psychotherapeutic nature of care there is surprisingly
therapeutic relationship. By elaborating and validating her little research into what psychotherapeutic strategies are
experience within an atmosphere of warmth and trust her effective. There is some mental health nursing literature
sense of self could begin to emerge and develop. Over time that explores the role of cognitive/behavioural therapy
she would learn to tolerate the level of intimacy within (Beech 2000, Donoghue et al. 2004, Puentes 2004),
such a relationship and replicate it within her own with solution-focused therapy (Hillyer 1996, Sandeman 1997),
others. interpersonal psychotherapy (Crowe & Luty 2005) and

2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd 805
M. Crowe et al.

psychodynamic therapy (Gallop & Reynolds 2004).

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