Rehabilitation is a problem-solving process. The first stage in any problem-solving process is to understand the problem in detail: what is the fundamental difficulty, which may or may not be the same as the initially identified problem; what are the critical factors related to the genesis and/or maintenance of the problem; what will happen if we take no action; what factors if any might help identify measures that could improve the situation; and what factors help decide which actions should be undertaken and/or should not be undertaken? This analysis is the process of formulating a detailed analysis of a situation that includes both a description and an explanation. The formulation also consists of a bridge to the next section, rehabilitation planning and interventions, and therefore uses information about prognosis and information that will decide between options.
“Ask not what disease the person has, but rather what person the disease has.”William Osler (1849-1919)
The psychiatric formulation is the clinician’s compass guiding treatment. It should accurately reflect the patient and his or her pattern of functioning as well as the precipitants, predisposing and perpetuating factors, and prognosis, while also being clear, concise and clinically useful.Len Sperry 1992 (here).
These two quotations emphasise the need for the formulation, not only in psychiatry and rehabilitation. The second one refers to the formulation as a ‘compass‘.
A more accurate description of a formulation is as a ‘map of the journey’, showing where the person is, how the person arrived at their current location and some possible routes for moving on. A map also provides information on obstacles, places to pick up help, eat or refuel, etc. The compass is a direction or goal provided by the patient in the form of long-term objectives. I have shown an outline of the process needed in this drawing. (here)
What is a formulation?
A full understanding of a patient’s situation is the end product of the assessment and analysis. It is the explicit, formal exposition of the patient’s situation, setting out:
- what the presenting problem is, and
- what other problems there are;
- what the present position is in terms of:
- pathology, impairments, activities, social roles
- contextual factors, including the history (temporal context)
- analysing the causes of these problems and
- the factors exacerbating or maintaining the problems;
- what the prognosis is and
- what actions might help in resolving the problem.
- what the patient’s over-arching goal and interests are, and
- the availability of resources to help.
Developing a full analysis of a patient’s situation plays a critical role in rehabilitation because it determines all subsequent plans and actions. To achieve a dependable understanding, you must collect all data needed, and you must use the data to analyse and understand the patient’s situation fully.
Despite its importance, the formulation is rarely mentioned in the rehabilitation literature. On searching Medline (rehabilitation, formulation, case), I only identified 28 papers, of which 2-3 referred to case formulation. These papers came from psychiatry or psychology and related to individual cases. I cannot recall reading about it in the context of rehabilitation, nor can I remember any teaching or academic or clinical discussion.
The process is necessary within psychiatry. (e.g. see here) Psychiatric practice is based on the biopsychosocial model of illness, and the analysis is usually set in that framework. The biopsychosocial model of illness is also the framework used in rehabilitation, and rehabilitation also requires a complete, holistic understanding of the patient’s situation. Therefore it seems sensible to use the system widely used for decades in psychiatry.
A formulation is a concise synthesis of all the available information that should give the recipient a good understanding of the clinical situation: the nature of the problems, their genesis and causation; their prognosis; and the alleviating actions possible. It is based on the biopsychosocial model of illness
How to make a formulation.
There are many articles and websites on undertaking formulation within psychiatry, and within most, there is a reference to “The X Ps” where X is any number between 3 and seven. (for example, here or here). The letter ‘p’ may stand for:
- presenting problem
- pattern (of symptoms I assume)
- predisposing factors
- precipitating factors
- perpetuating (maintaining) factors
- protective factors
The meanings attached to the letter p have grown like Topsy, just as the meaning attached to each letter of SMART, the widely used acronym in goal setting, has grown. (Over 113 different words for SMART; see here)
One approach (e.g. here) is to construct a table with the chosen ‘p’ words on the left-hand side, identifying the rows, and (in psychiatry) three columns for biological, psychological, and social factors. Some tables also include prompts or items that you can circle or highlight if present. In my view, this devalues the process because it removes most thinking and analysis.
There are many other approaches used in clinical reasoning (see here). From the perspective of a formulation, the most crucial consideration is that the clinician ends up with a comprehensive description that does not omit any important information. Whatever method you use, it is unlikely to be helped by trying to fill in a table while engaged in the diagnostic process of reaching a formulation.
On the other hand, the ideas or implicit questions that lead to the construction of a table may help in two ways. They may suggest hypotheses that you had not already thought of. They will also help organise and record the information collected.
Each clinician will develop and use their approach to collecting and analysing data, and other methods are discussed elsewhere on this website (here and here). The clinician must consider each domain of the biopsychosocial model during assessment and when constructing the completed analysis. Everyone should develop this central skill. The flow of information is illustrated in this drawing (here).
Recording the formulation
The formulation is the bedrock on which all plans are built. Team members need to understand the reasoning behind their planned activities because no one should act simply on the orders of another person, however senior or experienced. Therefore, it is essential to have a public record of it. The need to provide a good justification for actions extends to the patient and family; they must have a precise description given to them to understand their roles.
Many vital consequences flow from the proper formal recording, written and accessible.
It forces commitment.
In rehabilitation, coming to a diagnostic conclusion and making a firm decision is difficult because there are many unknowns and uncertainties. One common way to handle this is to speak in relatively vague generalities without committing to any specific formulation. The clinician can then adapt their understanding later without having to acknowledge that the original analysis was incorrect.
Unfortunately, this lack of commitment means that the clinician learns less because they never have to acknowledge that a formulation was incorrect. Failures are often associated with good learning and improved quality of practice.
Conversely, committing to something in writing will generally make the clinician (or the clinical team) more careful and thoughtful. For example, the clinician may well double-check the quality of a piece of important information that is crucial or ensure that information from all domains of the biopsychosocial model has been considered.
It documents facts and reasoning.
One significant difficulty faced when reviewing rehabilitation records is knowing what the situation was. The nature of the goals gives clues – if a goal is to walk further, it implies that the patient is walking – and incidental comments may provide other clues, but base facts are often not recorded. The reason is simple. Everyone involved at the time knows the situation and considers it unnecessary to record this information.
A second difficulty is understanding why someone undertook specific actions or set certain goals while other activities or goals are not mentioned. There is rarely any explicit justification for interventions, even interventions that carry significant risk or use substantial resources.
It improves continuity.
Most patients have long-term problems, and over a few months, there will often be many changes in team composition. Responsibility will pass not only from person to person but also from team to team and organisation to organisation. A well-written formulation will reduce the risk of harm to the patient and make it more likely that a consistent approach is taken across settings and over time.
It improves patient and family understanding and trust.
When patients and families have a situation explained, they will usually forget most of it and misinterpret the remainder. That is entirely normal. Furthermore, clinicians giving information tend always to err on the side of optimism or omission, not being completely straightforward. Probably mistakenly, clinicians feel that patients do not want to have the whole truth.
However, by giving the patient the written formulation used by the team, the team will reassure the patient that they have the same information and reasoning as everyone else. They will have much greater confidence in the information given to them.
Thirdly, sometimes the patient or family will point out errors in the formulation, perhaps disclosing new information or reminding the clinical team about the information given.
The format of the formulation is a matter for the team to decide. Nonetheless, it is unlikely to be helpful if it is just a table, it will be much less helpful if it uses jargon or abbreviations, and if it is handwritten, it may not be legible.
Therefore it should be well-written, using plain English (translated if necessary in equally straightforward terms), with a clear, logical structure. It also needs to be succinct. A more than one page formulation is probably too long, and many suitable formulations will be much less. Seeking feedback from patients and others will improve the recording of formulations.
Everyone will have an initial impression of the patient’s situation as soon as they meet. It is their understanding of the case. However, internal, explanatory beliefs are often incomplete, sometimes wrong, and are not subject to any critical evaluation.
Sound rehabilitation plans depend totally on a complete understanding of the situation; the term used here is a formulation. This formulation, in turn, depends upon an appropriate assessment and data-collection process. Having a consistent way to develop a formulation and then present and record the formulation will improve the quality of rehabilitation.
This page has outlined some of the characteristics of a suitable formulation. One analogy is to consider a formulation as a map. The map shows how and why a patient arrived at his current location, including places (events) passed through and difficulties overcome. In this analogy, the the patient’s route is determined by the disabilities, which will limit the routes available. But the map will show some possible routes the patient could take to move on. Which course is taken will depend upon the patient’s preferred reachable destination.