8 Psychotherapy8.7 Psychotherapeutic psychiatry
8.7.7 Formulation as a therapeutic intervention
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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.
What a formulation is
A biopsychosocial formulation explains how biological, psychological and social factors may interact to cause and maintain this person's difficulties at this time.
Diagnosis and formulation do different jobs. A diagnosis names a syndrome. A formulation links the person's own experiences, and the mechanisms behind their problems, to a plan of action.
Make the formulation collaborative. Use the patient's own words and invite them to correct you. Do not present your professional interpretation as settled fact.
Organising the information
Domain | Question |
|---|---|
Presenting problems | What is troubling the person and limiting their daily life? |
Predisposing factors | Which vulnerabilities and earlier experiences may have contributed? |
Precipitating factors | What changed around the time the problem started or got worse? |
Perpetuating factors | What keeps the difficulty going now? |
Protective factors | Which strengths, relationships and resources support recovery? |
Relational factors: what the person expects of others, how they have experienced trust and authority, how they respond to separation, and patterns they repeat with clinicians.
The clinical encounter: this shows these patterns in action. Treat staff reactions as hypotheses to reflect on, not direct proof of what the patient intends.
Social context: this includes real deprivation, discrimination and danger. Do not automatically reframe these as distorted beliefs.
Using the formulation to guide treatment
Validation: showing how a response makes sense in the person's circumstances can reduce shame, while leaving room to change the harm it causes.
Planning: link each proposed intervention to a maintaining process that can be changed, or to an unmet need.
Prioritising: balance immediate safety, the patient's own goals and changes likely to make further treatment possible.
Uncertainty: record it openly. Keep clear what you observed, what the patient told you and what is only a tentative explanation.
Revision: update the formulation after new information or a poor response to treatment. It stays a working account, not a label that stops further enquiry.