Formulation avoids mental health labels and helps you to understand your own individual story instead. Here, we explore how it works.
'Essentially, we need to acknowledge that we are not dealing with patients with illnesses, but people with problems.’ Dr Lucy Johnstone
Joseph, a 39-year-old Finance Manager, hasn’t been feeling like himself for a while. From the outside looking in, his life is going really well — he has a good marriage, two lovely kids, a nice house and a stable job. But he is low in mood, lacking in energy and feels as if he is stuck inside his head. It’s like he can’t connect with his family or be fully present. He’s even noticed thinking ‘what’s the point’, which concerns him.
Joseph decides to see his GP about how he is feeling. His GP is a kind and empathic person, but she isn’t a specialist in mental health and can only offer very brief appointments. She has been trained to see things from a medical perspective so goes through a checklist and finds that Joseph meets many of the criteria for depression. She diagnoses Joseph with depression and prescribes some antidepressants, while also recommending exercise.
Joseph leaves the GP surgery hoping that the medication will work and decides to go to the gym more regularly, but otherwise, he is at a loss about what to do. He has been labelled as ‘depressed’ but he still doesn’t know what has caused him to feel this way and what this means for him going forward.
After speaking to a close friend about it, Joseph decides to see a psychotherapist to help make sense of things and to get extra support. Together, they explore what is going on in his life at the moment. Has anything changed? How is he feeling about himself? What is happening in his relationships? Is there anything he’s worried about? Are there any pressures at work?
Over the course of their weekly sessions, they also explore the role Joseph takes in relationships, both now and in the past. Joseph reveals that his dad wasn’t around much and his mum was often low in mood, meaning that he didn’t want to be a burden and always felt he had to be the ‘strong one’ in the family. He learned from a young age to bottle up his feelings as he didn’t want to make his mum more sad. This role continued into his marriage, where he again felt the need to be the strong one. And when his mum passed away over a year ago, he bottled up a lot of his grief so that he could remain on top of things as the main earner in the family. Trying to keep on top of these emotions has been exhausting and has resulted in Joseph feeling switched off, as well as unable to feel the more pleasant emotions that connect him with his family.
Through these conversations, Joseph becomes aware of patterns that he hadn’t noticed before and emotions that he hadn’t been expressing. And in the safe space of the therapist’s office, he is finally able to process his feelings of grief, anger and frustration. Together, Joseph and his therapist work on different ways of coping with these emotions so that he no longer feels the need to bottle them up.
Joseph’s psychotherapy journey has helped to take him beyond the label of ‘depressed’ and into a deeper understanding of himself, his feelings and how his past has shaped him. In other words, he had created a ‘formulation’ with his therapist that explains his current struggles.
And once his course of therapy comes to a close, Joseph leaves with a huge sense of relief and greater energy. His mood has improved and he finally feels understood and now knows what he needs to do to maintain his mental health. He is also more open to feeling his feelings and is more resilient to life’s ups and downs.
In essence, through the process of formulation, Joseph experienced a ‘what happened to you?’, trauma-informed approach to mental health. This was in contrast to the more traditional, medicalised ‘what’s wrong with you?’ approach that resulted in a diagnosis of depression.
Many of us have grown to believe (perhaps due to our own personal experiences) that there is only one way of understanding mental illness — the medical diagnostic model.
In essence, the process of being professionally diagnosed with a mental health condition or ‘illness’ that needs treating, whether that is depression, anxiety, borderline personality disorder, bipolar disorder, PTSD or schizophrenia.
It is important to acknowledge that some people find this very helpful — suddenly, you have a label and a context for feelings, thoughts and behaviours that might have not made sense to you before. And once you have that diagnosis, it might help you to access other support mechanisms, such as medication, therapy or sickness benefit. A diagnosis also provides a way of communicating your struggles and may help you to feel less alone, as well as providing options to reach out to others with this label via support groups. So if the medical model has worked well for you, then that is wonderful and you may wish to keep using it.
However, for others, the effects of being diagnosed with a mental illness are not always as positive. They may feel shamed or stigmatised by the label that they have been given (such as ‘personality disorder’), feeling that it somehow ‘reduces’ them to an illness rather than a whole person, as well as affecting their identity and how they’re perceived by themselves and others. They may also find themselves prescribed with medications that they become dependent on for life — and which could include side effects or complications. And more than this, they may feel that while their mental health label offers a description of their symptoms, it doesn’t really help them to make sense of their story — in other words, how they reached such a point of distress in the first place. Being given a diagnosis can also make some people feel powerless, for instance, ‘there’s nothing I can do about this, it’s just something that I have’. This may affect their beliefs about their ability to heal, change or take constructive action.
This is where the concept of formulation comes into play as an alternative way of understanding mental health. For instance, instead of someone being labelled as ‘schizophrenic’, you may simply describe their symptoms as ‘hearing voices’ — a much more accessible and less medicalised description that describes what they are experiencing, rather than labelling them. And the process can go deeper than that, for a formulation-based approach is also about understanding the background, history and context of a person’s mental health issues — the entire life narrative leading up to their symptoms.
This is crucial, as if we're not careful, the very normal responses we have to life's ups and downs — such as job loss, relationships ending — can be pathologised as something unhealthy. So instead of being seen as an appropriate and natural response to something difficult, they can be labelled as an illness or condition like an ‘anxiety disorder’. In the same way, it is also possible to feel sad about the loss of something, or flat in mood or just uninterested in things, without having 'depression'.
The truth is that we all experience all of these emotions and responses on a continuum. However, when they are experienced more intensely and frequently, or coupled with unhealthy ways of managing them, then of course this will be more challenging and have a greater impact on someone's mental health. But this still doesn’t mean that the person needs to be labelled — unless this would be useful for them. Instead, the sense-making process of formulation – ‘Why am I feeling this way? How did I get here?’ — can sometimes be a lot more helpful.
Let’s look more deeply at the example of schizophrenia. According to Dr Lucy Johnstone, author of Formulation in Psychology and Psychotherapy: Making Sense of People's Problems, this condition can often be understood as someone reacting to severe trauma by dissociating from their reality. Describing it in this way takes away the stigma of the label and focuses on creating a sense-making process instead, one that can explore the trauma and its effects. In an interview with Psychiatric Times, she states that ‘My primary goal…is to work towards a non-medical understanding of emotional suffering, which is actually what we mean by “mental illness.”’
In fact, many of the ‘conditions' that people are diagnosed with can actually be understood as responses to trauma and seen through a trauma-informed lens. They can be the person’s attempt to cope, particularly when trauma happens early in life. For instance, trying to feel more in control when everything feels unpredictable or dangerous can lead to someone developing rigid rules for themselves, rituals or other compulsive behaviours. This can result in a diagnosis of Obsessive Compulsive Disorder (OCD). And while some people might find this diagnosis helpful, it also doesn’t explain the painful childhood roots of their obsessive behaviours or thoughts, or put another way, the original problem that they developed to solve.
Likewise, repeatedly finding yourself in an upsetting situation that you feel powerless to change — for instance, being stuck in a toxic workplace — can lead to a feeling of giving up, a lack of motivation, passivity, flatness and a belief that you are inadequate. This in turn can result in a diagnosis of depression.
Finally, if you have experienced bullying or exclusion, then you might naturally want to protect yourself from similar experiences. So you might develop patterns of avoidance, social withdrawal and hypervigilance about how you are coming across to others socially. In turn, this can lead to a diagnosis of social anxiety disorder.
These are the reasons why Dr Johnstone feels that formulation offers a better perspective on mental and emotional struggles. She is critical of the medicalised model of mental health, as she feels that the view it offers is far too limited. ‘To put it briefly, Western psychiatry is based on the idea that the various forms of distress that people can suffer from, such as very low mood, extreme anxiety, hearing voices, unusual beliefs, suicidal impulses, self-starvation and so on — are best understood as medical illnesses with mainly biological causes in our genes and biochemistry.’ Yet she argues that there is no real evidence for the idea of mental illness being purely biomedical.
Instead, she points out that there is substantial research pointing to other factors as being more significant causes of mental distress. These can include Adverse Childhood Experiences (ACES), relationship issues, abuse, discrimination, poverty, unemployment, bullying and social exclusion.
She feels that all of these factors in a person’s life — both past and present — add up to what we can think of as their ‘story’. And for proponents of the formulation approach, this story is crucial in understanding mental illness. As she explains, ‘The process of labelling someone's problems as an illness, or in other words, diagnosing them, is the cornerstone of psychiatric practice. We urgently need alternatives, and in essence, all alternatives consist of ways of listening to people's life stories. Psychological Formulation is one way of doing this…’
So by understanding your experience as a whole rather than as a diagnostic category, you can get a clearer view of any struggles you are having. It is also worth noting that there is a lot of overlap between categories, meaning that some people might be given multiple diagnoses throughout their life, which can be unhelpful and confusing.
Overall, formulation is a whole different way of thinking about emotional and mental distress. The core assumption is that, on some level, everyone’s experiences make sense — that there’s a valid and important reason that they learned to be and act in a certain way. So if someone is having delusions that they are being followed everywhere, then this might not make sense on the surface. It could seem easier to label it as a form of ‘psychosis’ caused by a ‘chemical imbalance’. Yet very often, this delusion could be rooted in a previous trauma, such as being frequently criticised and shamed growing up, or actually physically harmed.
Perhaps because it offers a much wider lens and a normalising approach to understanding our mental health, formulation is an increasingly popular approach, even in global organisations such as the UN. All MTA psychotherapists and psychologists use formulation to guide their work. It’s also used by other types of professionals including social workers and some psychiatrists. As mentioned, in some cases it’s used as an alternative to the medical model and at other times, as a complementary process to it.
But how does formulation work, exactly? And how might it help you to make sense of any issues that you are going through right now?
In essence, developing a formulation is a process of ongoing, collaborative sense-making between an individual and a mental health professional, such as a psychologist or psychotherapist.
With the combination of the therapist’s expertise and the individual’s knowledge of their own life, a narrative will begin to take shape. This is a collaborative process which draws upon the person’s strengths and intuitive abilities, rather than just focusing on their struggles and suffering. It can help to make sense of how a person’s difficulties have developed as well as looking at what might be maintaining them in the present. And by understanding how current issues might have been born out of difficult circumstances, the person can break free of self-criticism and experience greater self-acceptance, as well as having a route towards recovery.
For instance, if you feel labelled or stigmatised by a previous diagnosis (or you aren’t even sure if that diagnosis is accurate), then a formulation of what’s feeling difficult can be a more holistic, less medicalised way of understanding any issues.
And if you are having doubts about whether pharmaceutical intervention is right for you, then a formulation might help you to explore other solutions (however, it is very important to only stop taking medication under medical advice).
Or maybe you are struggling right now, but reluctant to see someone because you are afraid of being permanently labelled with a medical diagnosis? Again, a psychological formulation uses everyday language and practical descriptions rather than medical labels. It is about treating you as an individual and viewing mental health as something we all have that fluctuates according to life and experiences.
And remember, formulation is not an either / or option — it’s possible to think about both the development of your own unique mental health landscape and which diagnostic category any struggles you’re experiencing could fit into. The important thing is what works best for you and supports you to overcome any obstacles in your life. Many mental health professionals use this approach alongside the medical one and you might find that this combination works best for you.
Whatever you decide, a personalised formulation can offer a way for you to understand the story of you — not just as someone who might be going through distress right now, but as someone with strengths, life skills and valuable knowledge as well.
Overall, formulation challenges the idea that there is just one lens for understanding mental health issues. And with this approach, we can find a fresh perspective on our struggles that help us towards a deeper understanding of ourselves.
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