Inpatient mental health settings are traditionally guided by the medical model, with treatment focusing primarily on psychiatric diagnosis and pharmacological interventions. A drawback of this approach is that people may feel labelled and not fully understood as individuals. To address this, the author advocates greater use of psychological formulation on inpatient mental health units.
A psychological formulation may include:
Present Problems - Focusing on individual symptoms that are problematic for the person, as well as life stressors that are exacerbating distress. Drawing these out in a CBT based vicious cycle can help people to see how problems are linked and promote ideas for recovery using the metaphor of “breaking the cycle”.
Vulnerability Factors - For example, traumatic events, invalidating family environments, developmental problems, as well biological predispositions if a strong family history of psychological problems exists.
Moving Forward - Focusing on a person’s goals, values, dreams and aspirations, and the strengths and supports that will help them to achieve this. Here, the importance of resilience should be acknowledged. People who present to inpatient units often possess great resilience that can facilitate their recovery.
Different methods can be used to construct a formulation. If a person is relatively stable and able to engage, the preferred approach of the author is to construct the formulation with the person collaboratively in sessions in the form of a “shared understanding” or “psychological jigsaw puzzle”. Whilst some people are clearly not well enough to engage, a basic formulation may still be constructed using information from file reviews and collateral information.
The benefits of psychological formulation are widely reported (Clark & Wilson, 2009; Padesky, Dudley & Kuyken, 2008). A good individualised psychological formulation helps people attach meaning to their problems, enhancing their understanding of why they experience mental health problems. This helps people to feel validated and empowered which is crucial in recovery. Psychological formulation can also benefit and support the MDT, for example in case reviews, risk management and treatment planning.
Whilst further research is needed, anecdotal evidence has shown that there is a place for using psychological formulation alongside psychiatric diagnosis in inpatient settings.
Submitted by Dr Mark Franks, Senior Clinical Psychologist
Mental Health, Justice Alcohol & Drug Services