B-4 Formulation competency
Formulation sounds challenging. It is not. You are frequently formulating, many times a day, as you attempt to understand something, such as why the person across the road is pointing to the sky. You run through possible reasons (he has seen a plane), test your hypothesis (look up, no plane in sight), think he may be waving to a friend, test again (look for someone responding) and so on. Eventually, you reach a satisfactory explanation, such as he was putting on his coat. A formulation explains a situation within a theory (or hypothesis) that you consider appropriate. In rehabilitation, formulations are commonly framed within the biopsychosocial theory of illness, but other theories may be added or used instead.
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The competency is that the expert is “Able to set out, verbally and in writing, an analysis of a patient’s clinical situation focused on main problems and the factors that are important in its aetiology or management.”. The expected behaviours, knowledge and skills are detailed on a sheet for download. It also gives relevant references.
Healthcare solves problems. The initial healthcare approach is based on the biomedical theory that symptoms arise from a disease within the body, so the formulation is usually framed as, for example, “this person has autoimmune inflammation affecting joints and small blood vessels and treatment with methotrexate should reduce the problems”. The formulation can be more detailed, for example, considering the influence of genes and precipitating viral infections or how inflamed small hand joints affect function, such as turning a key in a lock.
A biomedical approach may lead to complex formulations, considering the influence of many genes and how they interact, taking into account other independent diseases, for example, the influence of external agents such as chemicals. Sometimes the formulation can extend to include a host of different influences. Still, the formulation is generally restricted to biological factors or factors such as radiation that have a direct biological effect.
Rehabilitation is primarily concerned with disability, which can be considered as altered behaviour, and although the disease may influence behaviour, the most significant influences on behaviour are quite different. For example, disability is influenced by culture, expectations, the physical environment, a person’s goals etc. It is impossible to construct a formulation for observed disability (limitation of activities) using the biomedical model. A complete understanding leading to specific interventions requires a broader theory.
The biopsychosocial model of illness provides a general theory which can help formulation in most cases. However, it cannot be the only model, and incorporating other ideas will often improve the formulation. For example, an understanding of functional illness can be helped by psychological, neurophysiological, and sociological theories, which leads to a more effective management strategy.
I have already discussed rehabilitation formulation on this site where you can find a MindMap showing five areas to consider. This page discusses formulating a rehabilitation problem and learning and improving this essential skill. I am unaware of research into rehabilitation formulation. Therefore, this page draws on published research into formulation within psychiatry, where formulation is also considered an essential skill.
“The psychiatric formulation is the clinician’s compass guiding treatment. It should accurately reflect the patient and their pattern of functioning as well as the precipitants, predisposing and perpetuating factors, and prognosis, while being clear, concise and clinically useful.”
“The psychiatric formulation is an important and necessary skill for all psychiatry residents. Thorough understanding of the formulation helps residents understand a patient’s unique psychopathology, organize a differential diagnosis, and prepare a useful treatment plan.”
The biopsychosocial theory of illness is an excellent general-purpose theory suitable for most situations met in rehabilitation. Every rehabilitation expert should be able to formulate a case using it.
Rob Selzer and Steven Ellen have provided a simple learning aid for biopsychosocial formulation for psychiatric trainees, an assistance that applies equally well to rehabilitation. The basis is a simple table with three columns covering biological, psychological, and social factors, with prompts about likely items.
It introduces the idea of predisposing, precipitating, perpetuating, and protective factors. Although these may appear less relevant in rehabilitation at first glance, they draw attention to vital aspects of any patient’s situation. They focus on how the past influences the present and the need to identify positive strengths the person has; too often, we only consider impairment and limitations.
Ahmed Fayad and colleagues refer to identifying these additional factors as the ‘three Ps approach’; they, unfortunately, omit protective factors. They found that constructing a formulation took about four to seven minutes using written case vignettes. I suspect that in clinical practice, constructing the formulation may take longer.
Based on the biopsychosocial model of illness, the Oxford Case Complexity Assessment Measure (OCCAM) provides an aide memoire tailored to rehabilitation and might be a better framework. First, it explicitly includes context, especially the physical context, which is often a vital component of a formulation and treatment plan. The physical environment is less relevant in many people with psychiatric illnesses. Second, it covers a range of impairments commonly seen in rehabilitation but not often so applicable in psychiatric practice.
Several papers discuss the potential benefits of using other, more detailed theories in psychiatric practice. These are not in place of the biopsychosocial formulation; they add detail to particular aspects, just as increasing understanding of neurophysiological or neuropathological factors may improve a formulation in patients with functional disorders or multiple sclerosis.
Adam Brenner considers how increasing awareness and understanding of the many factors influencing behaviour and experience may influence formulation. He discusses the neurobiological aspects of social stress, the influence of stigma, and the need for doctors to know some sociology and anthropology to understand their patients better. This broader range of knowledge is likely to improve management and outcome. It is one reason I emphasise humanities on this site.
Irosh Fernando and colleagues discuss how formulations may differ depending on the theory used. In a psychiatric context where many psychological theories may explain psychologically based illness. The intervention is often determined by the theoretical approach used by the clinician, and they suggest having a series of templates based on different theories so that the psychiatrist or psychologist can recognise which template is most appropriate for a patient.
Their article emphasises how the theory may influence treatment choice, highlighting the importance of using a good (relevant, appropriate) approach. Rehabilitation is based on the biopsychosocial model and does not have other competing theories. It remains reasonable to use additional ideas when appropriate, for example, when considering cognitive behavioural therapy. It is inappropriate to have completely different alternative approaches to choose from.
There is no published teaching material for rehabilitation formulation. David Ross and colleagues report their experience with a training programme for psychiatric rehabilitation. The programme is based on a book. They use written materials and feedback to trainees; their standard is the formulation given by an experienced senior psychiatrist. Sullivan et al. report using seminar and group activities, sharing experiences from clinical practice. They do not provide specific details.
Organising clinical information formally within the biopsychosocial model framework after each new assessment and then writing out a formulation is likely the best approach. The information should be collected without imposing structure and then reformatted using a form such as this one based on the OCCAM. The accompanying MindMap could be used as a visual reminder during the interview.
Thus, as with all other training, the best approach is likely to be:
- Read about the formulation and discuss it with a trainer or other experienced colleague
- Start writing formulations using a template if preferred, reviewing each one
- Discuss some formulations with others 1:1 or in small groups, gaining and giving feedback and learning how to improve
- Write out a formulation for all complex cases and a proportion of less complicated cases
- Start teaching others; always a good way to learn!
Formulation of complex situations is essential for developing an effective management strategy. Many rehabilitation problems are complex and benefit from formulation, yet it is a skill rarely taught or practised in rehabilitation. Here I have reviewed publications from psychiatry to show what it is and how it may be undertaken. The skill can be taught, However, teaching may not be available, and the information here should enable a group of trainees to learn from each other collectively.