4 Classification and assessment in psychiatry4.3 Clinical assessment
4.3.5.3 Systemic and other therapeutic formulations
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Written by Resident Doctor Committee · Published
New in the 2027 syllabus
The College added this topic for exams from January 2027.
The person in relationships
A systemic formulation looks at a person within their relationships and the wider social systems around them, such as services, school or work. It focuses on reciprocal patterns. What one person does affects the others, and their responses feed back to the first person.
Circular causality means that people's responses influence one another. You do not need to find a single person who caused the problem.
Context is wider than family interaction. It includes culture, power, resources, discrimination and developmental transitions.
Concept | Meaning | Clinical use |
|---|---|---|
Feedback | A response changes the behaviour that came before it | Spot a cycle that is escalating |
Boundaries | How involved with, or separate from, each other people are | Explore autonomy, support and intrusion |
Roles | What each person is expected to do | Look at burdens and competing expectations |
Multiple perspectives | People may describe the same event differently | Understand what the event means to each person without picking a culprit |
A reciprocal pattern
Here is an invented example. A parent keeps checking where their anxious adolescent is. The adolescent holds back information to avoid being questioned. The parent then worries more and checks more often.
Map the sequence. Work out what each person does, how the other person reads it and what happens next.
Use circular questions. These explore each person's view. For example, ask one person how they think another responds when worry rises.
Agree a change. This might combine predictable contact with more privacy. Then review its effect on both the anxiety and the conflict.
Other explanatory frameworks
Other therapeutic models explain the same difficulties in different ways.
Framework | Main focus |
|---|---|
Psychodynamic | Unconscious conflict, defences and relationship patterns that keep recurring |
Interpersonal | Current grief, disputes, role transitions and interpersonal difficulties |
Cognitive behavioural | Appraisals (how the person interprets events), learning and the behaviour that keeps the problem going |
Attachment-informed | Expectations about safety and closeness, and how the person responds to separation |
A formulation is a hypothesis. Do not present a framework's concepts as proven causes in an individual case.
Integrate with care. Choose the explanations that are useful, fit the evidence and match the person's goals. Avoid simply collecting labels that do not fit together.
Safety and power
Ask directly about abuse and coercion. Reciprocal interaction does not mean equal responsibility for violence or exploitation.
Joint work may be wrong where disclosure would expose someone to harm. See people separately when needed.
Review the formulation. Check whether it explains change and whether it supports a treatment plan that is workable and acceptable.