The key purpose of a formulation is to share with a young person in a non-critical and non-threatening way how you have come to understand their experience and situation. Sharing formulations can seem a rather daunting process. In AMBIT, this is much more a process than a single event. It is part of the on-going process of making sense of another person as they make sense of you. Occasionally, it may be useful to really focus on this in a planned way.

Externalizing a formulation

A key part of the process is to create a context in which the therapist and the young person look at things together so that literally building a picture for both to observe and comment can be extremely useful. The more this can be co-constructed on a blank piece of paper together the better. Simple diagrams, images can be more effective than complex sentences or paragraphs of text.

Not too much information at once

For many young people, these types of conversations can be a completely new experience and can easily be quite overwhelming. It is important to check back with the young person throughout the conversation and take responsibility for pacing the process as you go along. Sometimes there conversations may just be a few minutes and then it may be good to pull back and come back to it later.

Monitoring affect

It is very easy for there to be significant shifts in affect during these conversations, as issues may evoke anger, anxiety which may be indicated by agitation, restlessness or withdrawal. when this occurs, the therapist should attend to the change of affect rather than pursue the content of what may have been spoken about.

The MBT-A approach to formulation

In MBT-A there is more emphasis on presenting an overall formulation as part of the initial phase of treatment. The following part of this page is a summary of MBT-A ideas about formulation. We are grateful to Trudie Rossouw for sharing her manual with us.The formulation describes the young person’s problems in the context of mentalizing breakdowns. These breakdowns are explained in the context of interpersonal relationships and perceived threats to the continuity and safety of the self and attachment. Mentalizing failures often give rise to coercive patterns of behavior which can undermine effective use of treatment. The notion of coercive cycles, driven by emotional arousal and mentalizing breakdown, helps parents appreciate the interpersonal nature or the youngster’s, and their own, problems. Discussing the formulation with the family plays a crucial goal: it enlists the parents as partners and it helps to shift from discussing behaviors that need to be controlled or eliminated – the “dialogue of the deaf” between caregivers who bemoan their child’s “out of control” behavior while the young person bristle and reject their parents efforts to control them – to a mentalizing conversation that enables family members to grasp each other’s point of view and convey their own perspective.
Framing the goals of treatment along these lines focuses the therapeutic process on first assisting the parents in achieving or maintaining mentalizing in the face of the very pressures that have prompted their own retreat from mentalizing, so they can, in turn support their children’s mentalizing. Such an approach involves inviting parents to collaborate in identifying what experiences and interactions lead to their feeling buffeted by emotional turmoil and unable to adopt a mentalizing position in respect to themselves, the other parent and their children. A major focus of the work with the parents, therefore, is to identify stressors impinging on the parents that affect their mentalizing and parenting capacity and help them access support and/or treatment for themselves.

Example of a MBT-A formulation.

Background Information.When you were referred to this service you reported a two year history of feeling depressed and harming yourself. At times you have felt so depressed that life did not feel worth living. You thought your parent’s divorce three years ago, your mother’s subsequent depression, your father's drinking and his recent violent relationship with his girlfriend all played a role to make you depressed. You spoke about feeling guilty as if it was all your fault. Before you came to us for help you entered into a relationship in which you allowed someone to treat you in a disrespectful manner, almost as if you were being punished. All of this made you feel terrible about yourself.
Personality Style:From what you told us and based on the tests you completed, it seems as if you tend to be an introverted person and that you value time on your own as it helps you to feel calm. When you are with friends you can feel very worried that you will be hurt or that you will not be liked. When you feel like that, you hold yourself back but in doing so you do not give people a chance to like you which in turn reinforces for you that they do not like you. It also seems that at times you are able to form passionate attachments to others, but then you can become suspicious and anxious that you may be rejected. It seems that relationships can at times make you feel a rollercoaster of different feelings, from love to anger. Sometimes your mood can also swing from sad to happy. Sometimes you can feel so overwhelmed emotionally that your mind goes blank and then you can feel numb. The problem with this coping strategy is that it then makes you feel disconnected from what you or other people feel and then it is sometimes difficult to understand what is going on and then action feels the only thing available to you - it is at these times that you have a tendency to harm yourself. You often relate to others in a self sacrificing manner and at times even allow others to take advantage of you. You also at times tend to present yourself in a negative light to others. You can feel deep pain as your mind often dwells on past pain and misfortunes. This is very sad, because then you are not able to see your own good qualities.
Treatment Plan. We propose to offer you a treatment in which we suggest a combination of individual therapy once a week and family therapy once or twice a month delivered by the community team.
Crisis Plan. Trigger factors that you and I identified are times when you feel rejected, humiliated or bad about yourself. As we have discussed , these feelings do not just arrive out of the blue, they are likely to have been triggered in a close relationship. When you have those feelings you tend to rush into an action to take the feelings away. When you feel like that again, I would like you to try and stop the action by trying to delay it for 10 minutes. Then use the 10 minutes to try and reflect on what was happening a few moments before you had the bad feeling. That might help you to understand more clearly what it is that you feel as well as what might have happened in a close relationship which may have contributed to the feeling. Once you have this understanding more clearly it may be easier to think about a solution or to see things from a different perspective. Once that has happened you may not feel as if you need to rush into action anymore. If that fails and you still feel at risk to harm yourself, try to explore alternatives to self harm. Do something physical and strenuous like going for a run, try and distract yourself or talk to a friend or someone you trust or try and think about a person you know who loves you and imagine what that person would feel and say to you if you were to talk to them Sometimes you harm yourself when you numb yourself emotionally. When you get into such a state of mind, try to remember that it is not a good state of mind for you to be in and it is harmful to you. Try and bring yourself back to reality – do something to occupy you, like talking to someone, playing a game, writing a poem, painting or watching something that can hold your attention on TV. Don’t just sit and stare into space with your mind full of negative thoughts about yourself.
If all else fails, call the clinic and ask to speak to me and I will call you back when I can.