Formulation and Treatment Aims

13th September 2015

What is a formulation?

A formulation is a mentalized summary of your Assessment that offers:

a coherent story of What's the problem?
rational avenues for therapeutic work, by making sense of your Treatment Aims.

Formulations will change over time, reflecting learning on the part of the worker and young person, or changing circumstances.
Formulations are built in COLLABORATION with the client.
Formulations are subtly, but importantly different from Diagnoses as they include this mentalizing, "making sense" function, and attempt to address specific experiences rather than to categorise symptoms and signs in relation to populations.

What do you do with it?

Critically, a formulation must be:

(a) RECORDED - this is an important piece of work.

The act of writing it down, or representing it as a diagram, etc, helps in the process of making sense of it.
From the point of view of the young person, it also ensures that the worker "shows their cards" (we might describe this as Broadcasting Intentions).

(b) SHARED tentatively but DIRECTLY with the young person.

This is a personal message to the young person
It might take the form of a written letter, a diagram, a piece of video, etc, (Examples of Mentalizing Formulations).
This is a separate job from record taking; it is an intervention - the introduction of NEW INFORMATION to the system (i.e. "How my difficulties are seen and understood").

(c) Built up as a WORK IN PROGRESS

Formulations should always be labelled as "our THOUGHTS about you", rather than "This IS YOU!")

What does a formulation look like?

There are many ways to present a tentative formulation, but there are some common features.
There are some Examples of Mentalizing Formulations.

General pointers:

The formulation is like the map, helping client and worker come to agreement on "where we are", "how we got here", and "where we should start heading".

The process of arriving at this is Assessment (we often refer to it as Taking Aim.)
To aim accurately, I need to know where I am as well as where I want to go.
A structured assessment supports this; in the AMBIT manual we provide the AIM assessment, which is 'built in and ready to go', but other local teams may have their own assessment schedule that they would want to replace it with.

A good formulation will include the following:

Accurate reporting of DETAILS that the young person has shared - quoting them verbatim in particularly key areas. This emphasises the continuity between what is in their mind, and what appears in yours, and helps to foster Epistemic Trust.
Careful attention to LANGUAGE - using phrases like "I wonder if..." or "As I write this, it seems to me...".
There is a BALANCE between rephrasing/quoting what you have heard from the young person, and your own response to their account.

Depending on how much Epistemic Trust there is, you may need to err more towards accurate representation of the young person's position, rather than a full explanation of your own.
This is because presenting a "story" that appears too different from the young person's own account of themselves risks giving them the experience of not being understood, or of being overlooked.