Psychological Formulation, a Critical Viewpoint: Illness Ideology in Disguise

Recent years have seen a surge of interest by clinical psychologists in the idea of psychological formulation. Interest in this idea has also been shown by humanistic psychologists as evidenced by a recent issue of this journal, in which formulation is offered as a possible antidote to diagnosis. In this article, I examine the idea of formulation from the viewpoint of client-centered therapy, offering a critical perspective and concluding that as formulation is ultimately about identifying a specific pathway for a specific problem, it continues to subtly promote a medical ideology, incompatible with client-centered therapy.

Team psychological formulation to create a shared understanding of distress: a qualitative study in an older people’s mental health inpatient setting

Purpose Team psychological formulation is an organisational intervention aimed at developing a shared understanding of a person’s mental health difficulties. There is a lack of evidence regarding the therapeutic value of this approach for older people. The purpose of this paper is to explore how older people and their carers experience a cognitive-behavioural approach to team psychological formulation, within a mental health inpatient service in the UK. Design/methodology/approach A qualitative study using interpretative phenomenological analysis was undertaken. In total, 13 participants were interviewed: five older people/carer dyads, two lone older people and one lone carer. Findings Three overarching themes emerged: “Emotional impact of formulation” captured the mixed emotions that the process evoked in participants. “Making sense?” reflected the therapeutic value that participants experienced and what held them back from making gains in their recovery. “Disempowered people trapped in a biomedical world” illustrated the negative aspects of ward care, which hindered recovery. Research limitations/implications The findings provide insights into the therapeutic value of team psychological formulation and the difficulties in facilitating the process effectively. More consistency is required to ensure that team formulation is standardised. Further research into the outcomes of the approach for older people is recommended. Practical implications Recommendations are proposed for how team psychological formulation can be conducted effectively, using the mnemonic “SETUP”. Originality/value This study focussed on older people’s and their carers’ own perspectives regarding the team psychological formulation approach.

Reliability of diagnosis

Reliability of a diagnosis can be measured as either agreement with a reference criterion or agreement between clinicians as to a diagnosis. Most psychiatric and some general medical diagnostic constructs are identified on the basis of a clinical picture, not using a reference criterion such as laboratory tests. Most psychiatric diagnostic constructs have moderate to substantial reliability in research studies. They are likely to be less reliable in clinical practice. Measures such as standardizing interviews can improve reliability. General medical diagnostic constructs have similar reliability to psychiatric diagnostic constructs in research studies and are also likely to be less reliable in clinical practice. Even with laboratory tests, some medical conditions are hard to distinguish due to similarities in their clinical pictures. For alternative mental health classifications, psychological formulation—except psychodynamic formulation—is less reliable than psychiatric diagnosis. Symptom-based classification has at least equal reliability to psychiatric diagnosis. Dimension-based classification has equivalent reliability to psychiatric diagnosis. These may be combined with diagnosis but may have less usefulness on their own for other functions, e.g. administrative.

Variability of clinical picture

Psychiatric diagnostic constructs produce highly variable clinical pictures in patients. Amongst the reasons for this are high rates of co-occurrence of different diagnostic constructs, which themselves are often polythetic in nature. People who meet criteria for a diagnostic construct may have little or even no clinical features in common. These diagnostic constructs rely on people meeting the diagnostic criteria having similar qualities to their condition such as similar likelihoods of outcomes/responses to treatments. These highly variable clinical pictures are seen even when clear disease is involved, such as the dementias. General medical diagnostic constructs can also display highly variable clinical pictures even when clear disease processes have been identified. Polythetic diagnostic criteria decided upon by expert committees are also used for general medical diagnostic constructs which can also result in people meeting the same diagnostic criteria having little in common in their clinical pictures. Co-occurrence is also common in general medicine. Psychological formulation does not have to address the issue of variable clinical pictures. Both symptom-based and dimensional classifications can depict variable clinical pictures more accurately than diagnostic constructs but there are pragmatic issues such as suitability for brief appointments or emergency work.

Clinical utility of diagnosis

There is evidence of overlap between psychiatric and general medical constructs for clinical utility particularly for variability of outcomes; use of diagnostic criteria decided by committees of experts and use of clinical information apart from the diagnosis. For psychiatric diagnostic constructs there is evidence of some differences in outcomes and responses to treatments between different diagnostic constructs. On the other hand, it is easier to directly measure variables relevant for clinical purposes in general medicine. Therefore, for all the questions the conclusion of some (not near total overlap) seems fairest. Psychiatric diagnostic constructs can have clinical utility if there is useful information attached e.g. on likely range of outcomes or likely responses to treatments. Psychological formulation has utility but is unlikely to be helpful in all clinical scenarios or ways of working. Dimension or symptom based classification may have greater validity, still involve categorical choices and have limitations in clinical utility. Alternative classifications have compatibility problems with the healthcare system for collective administrative data, statistics or for other social functions such as access to benefits.

Variations in how Students describe ‘Friendship’ An Application of Appraisal Theory

This study explores the link between cognition and emotion using concepts from functional linguistics. Appraisal Theory argues that all emotions are first articulated (actively or passively) before they are experienced. As with many essentially constructionist approaches, this process is influenced both by circumstances and previous experience. This study specifically tests if positive and negative framings of the concept of friendship use different linguistic formulations. If so, this provides some evidence both for the underlying theoretical assumption and the value of functional linguistics as a tool to understand the process. Appraisal Theory has roots in both Psychology and Functional Linguistics and this study aims to bring these two strands together so as to link the analytic framework from Functional Linguistics to the conceptual framework in the Psychological formulation. In conclusion, it was found that negative formulations used more complex language, offered alternative formulations and used words to indicate both the focus and to modulate the force of any statement. In the context of the study, it was suggested that positive images of friendship reflected their expectations of the behaviour of close family members.