Clinical Formulation: Where It Came ARTICLE From, What It Is and Why It Matters John Baird, Alan Hyslop, Marjorie Macfie, Ruth Stocks & Tessa Van Der Kleij
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BJPsych Advances (2017), vol. 23, 95–103 doi: 10.1192/apt.bp.115.014670 Clinical formulation: where it came ARTICLE from, what it is and why it matters John Baird, Alan Hyslop, Marjorie Macfie, Ruth Stocks & Tessa Van der Kleij Although written only 40 years ago, this last John A. Baird is a retired SUMMARY sentence in particular sounds to be from a very consultant forensic psychiatrist, formerly in the Directorate of Clinical formulation was introduced in its present different age. The Concise Oxford Textbook of form a little over 30 years ago and is, in essence, Forensic Mental Health in Glasgow Psychiatry (Gelder 1994) describes the process in and at the State Hospital, Carstairs. a concise summary of the origins and nature similar terms and defines a formulation as: He is accredited by the Risk of a person’s problems, together with opinion Management Authority as a risk on what may go wrong in the future and what ‘concise assessments of diagnosis, aetiology, assessor and is a member of the steps should be taken to improve matters. In our treatment and prognosis […] it is not merely a Parole Board of England and Wales article we discuss how, in recent times, the task summary in another form but an exercise in clinical and the Mental Health Tribunal reasoning’. of preparing a clinical formulation has rightly for Scotland. Alan Hyslop was become a multidisciplinary exercise involving the Head of eHealth with the Scottish In this article we discuss how the concept of Government until his retirement. whole clinical team and, even more important, that formulation has evolved since those times. In Since retirement he has continued nowadays the patient – the subject of the clinical particular, explicit multidisciplinary contributions to work part time in eHealth with formulation – together with their carers should to the preparation of a formulation have become the Scottish Government. Marjorie also be actively involved in the process and feel Macfie is a consultant in the expected and, even more recently, it has been some ownership of the conclusions and decisions. psychiatry of learning disability with realised that patients themselves, the subjects In addition, we compare these developments in NHS Greater Glasgow and Clyde. Ruth Stocks is a chartered clinical clinical formulation with similar developments, of the formulation, should be actively involved through being able to question and contribute, and chartered forensic psychologist arising for the same reasons, in clinical teaching specialising in the assessment and and education. should they wish to do so. The therapeutic treatment of mentally disordered benefits of this active participation cannot be offenders and is professional LEARNING OBJECTIVES overestimated. Indeed, it is expected under the lead for psychology in forensic • Understand the core principles of formulation terms of current General Medical Council (2013) mental health with the Directorate of Forensic Mental Health, NHS • Know how to prepare a formulation within a guidelines on good medical practice and is required Greater Glasgow and Clyde. She clinical team following the recent judgment by the UK Supreme is also a part-time Mental Welfare • Understand the role that formulation plays in the Court in Montgomery v Lanarkshire Health Board Commission visitor. Tessa Van der Kleij is a psychiatric registrar effective management of patients [2015], the implications of which are discussed by in the Adult Acute Mental Health DECLARATION OF INTEREST Badenoch (2016). Unit, Auckland City Hospital, New None Zealand. The Montgomery judgment Correspondence Dr John A. Baird, Leverndale Hospital, 510 Crookston The case that led to the Montgomery judgment Road, Glasgow G53 7TU, UK. Email: Formulation has an important place in modern concerned a young woman who was allowed to go [email protected] clinical practice, but the term only came into into labour despite risks that vaginal delivery would Copyright and usage regular use in relatively recent times. The be harmful to the baby.† These were not discussed © The Royal College of Psychiatrists Companion to Psychiatric Studies (Forrest 1973) with the woman in advance and in the event vaginal 2017. does not have the word in the index, but Clinical delivery became very problematic and the infant Psychiatry (Slater 1977: p. 35) does, and there it suffered serious and irreversible birth trauma. The †The Montgomery case is discussed is defined as: basis of the appeal was that the woman believed in more detail in Rix K. J. B. (2017) After a prolonged gestation and ‘A detailed statement of the diagnosis in multi- that the risks and the options should have been difficult labour, informed consent dimensional terms. It will contain a classification discussed fully with her so that she could make an is safely delivered into English and of the disorder and a specification of the factors, informed decision, and the judgment was entirely Scots law. BJPsych Advances, 23: physical, constitutional and psychogenic, which 63–72. Ed. have contributed to its appearance. It will also in her favour. The Court reached the conclusion contain a short plan for further investigation and that it was the patient’s right in law to decide for treatment’. herself what should happen. To allow the doctor to decide on the patient’s behalf was not considered The definition concludes: to be acceptable in today’s society. The doctor’s ‘It is a more difficult matter than the description of responsibility was to provide the patient with past and present in extended form and will test all the psychiatrist’s powers of judgement and wealth sufficient information to make the decision. In this of experience.’ case, the woman would have chosen an elective 95 Downloaded from https://www.cambridge.org/core. 02 Oct 2021 at 03:22:39, subject to the Cambridge Core terms of use. Baird et al caesarean section, which would almost certainly BOX 1 Formulation in the MRCPsych Exami- have avoided all the problems. The implications nations: specialist core training for patient participation in formulation are clear. Their participation must be active and meaningful ‘Intended learning outcome 2: Demonstrate the to the level of their abilities, and most certainly ability to construct formulations of patients’ problems not merely tokenistic. Just because a patient’s that include appropriate differential diagnoses problem is mental health related, or even forensic By the end of CT1 the trainee should demonstrate the in nature, does not change the obligation to at least ability to construct a formulation on an adult patient who make every effort to confer with them and promote has any of the common psychiatric disorders, including their understanding. affective disorders; anxiety disorders; psychotic disorders; and personality disorders The place of formulation in current practice By the end of CT2, the trainee should demonstrate the Clinical formulation is widely accepted as a core ability to independently construct a formulation on adult patients who present with a full range of psychiatric component of clinical education in psychiatric disorders including disorders of cognitive impairment; training in the UK and, indeed, across the world substance misuse disorders; and organic disorders (Royal College of Psychiatrists 2010, 2013; By the end of CT3, the trainee should demonstrate Royal Australian and New Zealand College the ability to construct a formulation of patients with of Psychiatrists 2014). The skills required to psychiatric disorders who have a learning disability or are construct a formulation include the ability to children’ (p. 116) integrate the synthesis of the data and highlight the relevant predisposing, precipitating, perpetu- ‘Skills: Integrate information from multiple sources to ating and protective factors (Royal College of formulate the case into which relevant predisposing, precipitating, perpetuating and protective factors are Psychiatrists 2013). highlighted’ (p. 45) Early surveys reported a lack of consensus (Royal College of Psychiatrists 2013) among psychiatrists about what should be included in clinical formulation (Hollyman 1983a,b). A more recent study examining how psychiatrists understand and use formulation found its utilisation The curricula for the Royal College of Psychia- to be dependent on both psychiatric training and trists’ MRCPsych Examinations include clinical clinical practice (Mohtashemi 2016). Participants formulation (Boxes 1 & 2), and formulation is a reported multiple barriers to constructing formal requirement in the Royal Australian and formulations, such as limitations of resources, New Zealand College of Psychiatrists’ (2014) insufficient time available and pressures to use a more ‘medical’ model. Some felt that a professional rivalry between psychologists and psychiatrists, BOX 2 Formulation in the MRCPsych Exami- or between the psychological and the medical nations: specialist (higher) training model, was a barrier to collaborative formulation, ‘Intended learning outcome 2: Demonstrate the and most professed this rivalry to be unhelpful. ability to construct formulations of patients’ Our view is that, although the preparation of problems that include appropriate differential a clinical formulation is most certainly not the diagnoses, liaising with other specialists and sole responsibility of the team psychologist, making appropriate referrals’ (p. 23) formulation does require psychological knowledge ‘By the end of ST4 the trainee will be able to and familiarity with psychological