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Use of individual formulation in mental health practice

December 2020
DOI:10.7748/mhp.2020.e1515
Authors:

Lauren Cox
The University of Manchester

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Use of individual formulation with service users; theory and practical

applications

Lauren Ashton Cox

North West Boroughs Healthcare Foundation Trust

Correspondence: lauren.cox@NWBH.nhs.uk

Accepted for publication in Mental Health Practice on 08/07/2020

Accepted for publication in Mental Health Practice on 08/07/2020

This is the author accepted version; please cite in full in any use.

Abstract
This article offers an understanding of individual formulation in mental health practice. Formulation is a
collaborative process that promotes shared understanding of a client’s narrative to ensure care is meaningful.
The interaction between formulation and intervention is explored, as is how mental health professionals might
work with clients using formulation to plan and implement care. A maintenance and a broader developmental
model are presented to give readers an understanding of how both may be used to understand immediate issues
and longer-term challenges across a multitude of clinical presentations to support choice of evidence-based
interventions.

Author details
Lauren Ashton Cox, cognitive behaviour therapy specialist in psychosis, Halton and Warrington Early
Intervention in Psychosis Service, St John’s Unit, North West Boroughs Healthcare NHS Foundation
Trust, Cheshire, England
Keywords
mental health, mental health service users, mental health therapies, psychological
interventions

Aims and intended learning outcomes

The aim of this article is to offer an understanding of individual formulation and how it may be used to effect positive
change in mental health practice. After reading the 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.
• Review how formulation can contribute towards shared understanding and care planning.
• Practise using the models in this article as the basis for planning care and intervention.

Formulation
Developing a formulation aims to support clients and practitioners reach a collaborative understanding of issues through
cultivation of a shared narrative (Harper and Spellman 2006). This then guides the use of evidence-based interventions to
target problems through linking psychological theory with practice (Kuyken et al 2009, British Psychological Society (BPS)
2011). It is an individualised, often experimental, process that seeks to understand the idiosyncratic nature and development,
maintaining and alleviating factors for difficulties, including psychological, biological and systemic factors (Eells 2007).
Formulation attends to each person’s past and current situation, focusing on the functions of emotion, behaviour and thought
(Cullen and Combes 2006, Turkat 2014). Clinical formulation improves outcomes (Berry and Lobban 2016), however, its
uses can vary in practice (Rainforth and Laurenson 2014). Evidence regarding outcomes is usually in the context of
cognitive behavioural therapy (CBT), however, shorter-term, non-therapy-based approaches have proven effective (Ingham
2011).
There is no universally agreed definition of formulation (Corrie and Lane 2010) however there are some shared
characteristics (BPS 2011):
Summarise the core problems.
Suggest how difficulties may relate to and/or maintain one another.
Ensure shared understanding and collaborative working.
Indicate a plan of intervention(s).
Formulation is fluid and dynamic and might best be considered a process rather than a product. Its quality often depends
on the quality of the assessment and cultivation of a positive therapeutic relationship (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 interpreted according to an explanatory
framework to elicit meanings. Because this interpretation is dependent on the client’s and the practitioner’s frameworks,
multiple ways of formulating exist.
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 is dependent on the depth of formulation and how this is being used to inform care (i.e. discharge,
within a care or risk management plan or during each clinical contact).
Multiple models and frameworks exist that often depend on particular psychological modalities and the client’s needs.

Formulation in clinical practice

Each person we work with is unique with a distinct set of needs, preferences and goals. While two people may have the
same diagnosis, how they came to encounter challenges, their appraisals of these and their wishes about how they might be
supported are individual (Department of Health 2003). Recovery literature and guidance on care planning have espoused

these sentiments since their inception (Barker et al 1999, Repper and Perkins 2003). However, clients do not always feel
they are as involved as they would like to be in decisions about their care (Cree et al 2015, Grundy et al 2016, Simpson et al
2016). Priority improvement areas are support to make care decisions appropriate to individual need, and the role for jointly
agreed care and crisis plans to achieve preferred outcomes (National Institute for Health and Clinical Excellence (NICE)
2011a). Despite calls for improvements, mental healthcare planning does not always adequately respond to users’ holistic
needs, with the process often unable to meet complexity, often reducing experience to simplistic frameworks (Brooks et al
2018). Other care planning barriers are ritualised practice and ineffective information exchange (Bee et al 2015), clients’
inhibitions based on experience of coercion and timeframes between reviews (Brooks et al 2018). Clients and carers have
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 often paternalistic tools that can prioritise organisational agendas, for
example performance management and quality indicators, distancing the process from clients’ everyday lives and solutions
(Lester et al 2011, Slemon et al 2017); getting in the way of meaningful activity, expectations and the relational aspects of
care which clients value (Rogers et al 2014).
It has been suggested these barriers are overcome by separating risk from holistic needs assessments, and managing risk
through formulaic less engaging processes (Brooks et al 2018). However, clients acknowledge the need to talk about risk
(Coffey et al 2017), and a holistic approach should consider all aspects of a person’s experience; indeed a formulaic
approach may increase negative connotations. These tools require updating to make them personalised and meaningful,
which may be achieved through formulation.
 Case formulation is a core clinical function for mental health professionals and is central to care planning, risk assessment
and the care programme approach (CPA) processes that are interdependent clinical activities, that is case formulation may
result in interventions which produce beneficial behaviour change and subsequently affect the risk assessment (Phull and
Hall 2015, Sturmey and Lindsay 2017). This moves beyond description and categorisation of risk behaviours towards
attending to broader holistic aspects of experience in developing a personalised narrative (Hart et al 2011).
A shared understanding is developed through identifying links between experiences and the situational, psychological and
social processes maintaining distress; placing behaviours and feelings in the context of why ways of coping have emerged
and persisted to discuss their effects (Crowe et al 2008). Drawing on identified strengths and needs allows for collaborative
selection of appropriate intervention(s) (Macneil et al 2012), which can be used to test hypotheses contained in the
formulation (Kuyken 2006), for example, whether incrementally increasing activity affects thoughts about self and
emotional state when depressed. This shifts from a didactic approach to treatment and professional as expert, to a curious
and collaborative approach where the client can be supported to own their care.
If interventions do not make anticipated changes, barriers may too be formulated and made sense of, providing further
information about how to change tack. Formulation does not stop at making sense of one challenge and can also be used to
navigate issues encountered in the therapeutic relationship (Katzow and Safran 2007).
Use of the 5Ps model is supported in the literature (Macneil et al 2012, Phull and Hall 2015); and is expected to be
undertaken during admission to inpatient mental health settings alongside diagnosis (Royal College of Psychiatrists
(RCPsych) 2017). Formulation facilitates evidence-based care based on current issues rather than a sole focus on diagnosis
which may give a descriptive overview but can fail to explain personal meanings (Rainforth and Laurenson 2014).
Varying diagnostic clinical guidelines indicate the complexity of care provision which is important for nurses who are
expected to coordinate and evaluate complex care and take action to improve its quality (Nursing and Midwifery Council
(NMC) 2018a). Formulation can guide intervention choice, reduce risk incidents and increase the psychological skills of the
client and mental health nursing teams in understanding complexity (Boschen and Oei 2008, Houghton and Jones 2016),
while improving therapeutic relationships and feelings towards clients (Summers 2006, Berry et al 2009). This can improve
outcomes and reduce distress (Berry et al 2012), promoting the holistic, person-centred participatory care advocated in
policy and literature (Joint Commissioning Panel for Mental Health 2013). Mental health nurses have cited formulation
approaches to assess and manage risk as instrumental in increasing clinical skills and confidence, improving communication
across agencies and, most importantly, increasing clients’ safety (Gray et al 2019). Practical issues regarding timeframes
adopted with CPA frameworks may also be overcome through use of a formulation approach which is flexible and fluid;
updated regularly in collaboration with the client to ensure understanding and resulting actions are in line with needs and
preferences (Johnstone and Dallos 2014).

Formulation models and application

Five-area model
The five-area formulation is a useful maintenance model to support understanding of a ‘here and now’ issue during
clinical contact. This summarises issues into areas that provide clear targets for change (Wright et al 2002) and facilitates the
problem-solving process via use of CBT principles to understand problem maintenance (links between the five areas),
helping change unhelpful thinking and behaviour to improve how the person feels (Brewin 2006, Wills 2015). The five-area
assessment provides a whole-person biopsychosocial assessment, summarising the issues in five areas (Williams and
Chellingsworth 2010) (see Table 1).

Table 1. The five-area assessment

Area 1 (event or situation) Situations experienced, people and events
Area 2 (thoughts and images) Altered thinking that can become extreme and unhelpful when in
distress
Area 3 (feelings/emotions) Altered feelings (moods, emotions)

Area 4 (physical) Altered physical symptoms (low energy, tension or co-morbid

illness)
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 (a pseudonym) who is
experiencing depression due to adverse life circumstances and gives some hints about how a dialogue may be facilitated to
elicit relevant information.

Figure 1. The five-area model

 Depression can arise from a specific event or set of events, which may be influenced by historical events and associated
core belief and assumption formation, resulting in heightened sensitivity to negative stimuli and negative thinking . This can
maintain hopelessness and affect behaviour, motivation, affect and physiology which serve to compound low mood and
beliefs concerning negative outcomes (Clark and Beck 1999).
In Steve’s case, recent situational factors had contributed towards negative self-referential thoughts which meant he felt
deflated and hopeless about the future. Due to insecurities about what others might think of him, Steve had withdrawn and
avoided potentially pleasurable situations. If he had experienced these situations it may have disconfirmed his beliefs about
being alone and that the situation could not improve. Instead his fears continued. He was also overspending in local
convenience stores due to not wanting to venture further afoot which meant his debt increased and his confidence that this
could be tackled diminished. Drinking alcohol to induce sleep backfired, causing Steve to feel worse the next day which
further compounded his concerns.
Using the diagrammatic formulation can help practitioners check they have the right information, whether it makes sense,
and illustrates how aspects reinforce one another. Once the information is collated, practitioner and client may then try to
break cycles using various strategies (Blackburn et al 2006).
Steve and his care coordinator generated a shared understanding of his current issues and how his thinking, physiology,
mood state and behaviour were interacting, maintaining and intensifying distress. This helped both 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, understandably, about life
challenges and his reactions had reinforced problems, rather than these stemming from issues found in himself. Together
Steve and his care coordinator generated ideas to tackle challenges (Box 1).
Box 1. Intervention plan
Thinking strategies: keep diary noticing ‘hot’ thoughts
Cognitive restructuring: using thoughts elicited from the diary, spot common ‘thinking traps’, challenge these using thought records and
prompts

Behavioural strategies: graded activity scheduling; incorporating one pleasure and one mastery task per week into schedule noting effects
on mood
Budgeting: income and expenditure form, monies allocated for each expense, contact made with debtors to pay back monies
Alcohol consumption: psychoeducation about recommended units and effects of alcohol on the body, motivational interviewing approach
to check motivations for change. Plan agreed to reduce units incrementally, reward self for abstinence with favourite box set or snack
Behavioural experiment to tackle avoidance: test belief ‘I have no one’ – refuse an invitation, monitor feelings/thoughts. Accept an
invitation and do the same
Physical: sleep hygiene, low-level exercise (couch to 5k) to increase energy, combat aches and pains, improve mood
To support intervention planning and delivery, consult Bennett-Levy et al’s (2010) guide to low-intensity CBT
interventions.
5Ps model
The 5Ps model seeks to understand the client’s experience in a broader context, considering the effect of historical
experiences. It is popular due to its accessibility to a wide range of modalities and professions and is used to integrate
information from multiple sources to formulate the case across five factors (Macneil et al 2012, Dudley and Kuyken 2014,
Butler et al 2018) (Table 2):

The framework lends itself to therapeutic intervention through its ability to demark short, medium- and long-term goals,
develops the relationship and confidence in this and provides a focus for interventions.

Table 2. The 5Ps model

5Ps
Predisposing factors What factors increased the client’s vulnerability? Factors that
may contribute to risk (trauma, biological, genetic, environmental
 and social factors)
Precipitating factors What made the issue worsen recently? Events or situations
(internal or external) preceding issues (money concerns, physical
health issues, relationship changes, drug use)
Presenting issue(s) What are the person’s current concerns or complaints? Usually
outlined as thoughts, emotions and behaviours, consequences
and effect.
Perpetuating factors What is keeping the issue going or from being solved?
Behavioural (avoidance, escape), biological (insomnia), cognitive
patterns (paranoia, worry), systemic factors (how others behave
towards the person, lack of resources)
Protective factors What are the person’s strengths and resources? What might
mitigate effect of difficulties i.e. character, social support,
interests, motivations

TIME OUT 1
Read case study 1 and using Table 2, think about how you might organise the information into the relevant
factors. Then consider Figure 2 which depicts the formulation. How did your attempt marry up?

Case study 1
John grew up in a loving family, an only child. Parents were teachers and wanted John to achieve. He had friends at school but was
bullied in English because he often mixed up words, with a memory of reading a book and saying the wrong word and everyone laughing.
Reading age was well below other skills, for example maths. Dyslexia diagnosed but not until high school. Enjoyed football and made the
school team. Now in Year 11 and has mock exams coming up. Worried about these and has started having panic attacks. So scared has
stopped going to school some days, especially when has English lessons so is missing main content and staff support. Worrying a lot and
making plans for revision but does not stick to these as too scared to begin. Has told parents that he is scared he will fail English, be
unable to go to college and never get a job. Parents have said he needs to revise every night for 3 hours to make up missed work
It is also important to draw on our clinical knowledge and skills to inform hypotheses about what might be happening and
to consider interventions. Consider the following knowledge about anxiety:
Worry can increase anxiety and includes catastrophic misinterpretations; thinking of the worst possible rather than likely
outcome. Avoidance maintains anxiety and belief in the danger of the avoided activity.

Figure 2. The 5Ps formulation

Citations (3) References (57)

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person-(not symptom-) focused psychological formulations and treatment plans [64][65] [66] . Clinically, patients who
report sudden tinnitus onset or loudness fluctuations may particularly benefit from clinicians' awareness and
consideration of psychological influences beyond tinnitus as the presenting index symptom, as well as their own
emotional reactions to respective patient presentations [67][68][69][70]. Ideographic associations between patients'
psychological distress levels and experienced characteristics of the tinnitus sound remain uninvestigated. ...

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