Basic Concept

DEFINING ABNORMALITY

Like many concepts that form a part of our everyday discourse, the notions of "normality"
and "abnormality" are evoked in a wide range of contexts that bear on our everyday lives. In
general, when characterizing and categorizing behaviour, actions, a body, a person, a life-
style or a community, the normal is usually associated with what occurs, conventionally,
naturally or originally; the abnormal with what is unusual, exceptional, unconventional or
unnatural. While our varying conceptions of normality and abnormality, may or may not have
severe implications in the context of something as simple as a person’s style of clothing or
food choices, such conceptions are bound to have far- reaching consequences when taken in
the context of something as sensitive as ‘mental health’. Thus, the perception of what is
normal and what isn’t, is heavily laden with one’s presuppositions, making the apparently
simplistic binary, quite vague and contentious.

Despite the fact that there is no universal agreement regarding the precise definition of
‘normality’ and ‘abnormality’, there have been attempts to come to a concise understanding
of normal and abnormal, when speaking of mental health. ‘Mental disorder’ or abnormality,
in this context, has been defined as groups of emotional, cognitive or behavioural symptoms
within an individual that cause significant distress or impairment in functioning and that is
not typical or culturally expected. Three major approaches to abnormality that can be derived
from this definition are as follows:

1. Deviance from Norms:

An objective, statistical method of defining abnormality involves determining the probability

of a behaviour for a population. Any behaviour that is less frequent or less probable in a
population of individuals is considered to be statistically deviant or abnormal. This translates
to the fact that any behaviour that is atypical or culturally unexpected and thus deviates from
the ‘average’ may be categorised as abnormal. Such a conceptualisation of abnormality
brings in the role of ‘culture’ in governing what is considered normal and what is considered
abnormal.
 2. Difficulties in Adapting to Life Demands

Any behaviour that interferes with a person’s ability to function effectively may be labelled
as abnormal. This mal adaptiveness of behaviour may hamper one's ability to care for
oneself, have good relationships with others and function well at school or at work. Such a
psychological dysfunctionality may lead to a breakdown in cognitive, emotional, or
behavioural functioning and make it difficult for individuals to adjust to life demands.

3. Experience of Personal Distress

If people suffer or experience psychological pain, it might be considered as indicative of

abnormality. Any situation causes personal distress in an individual if it leads to impairment
in an individual’s day to day functioning. Thus, if an individual is not able to sufficiently
meet his/her life demands and this in turn causes an individual distress, it may be considered
as an essential indicator of abnormality.

4. Danger-Individuals who are psychologically abnormal pose a danger to him/ herself

or to another person around them. They often required to be hospitalized in case such
individuals show any suicidal tendencies or display explicit threats to harm oneself or
others (homicidal or violence etc.). However, dangerousness as a criteria for
categorizing an individual as abnormal does not provide a correct understanding of
abnormality. For example, an extremely bad driver poses a danger to himself and to
others, but the general notions of abnormality wouldn't consider such an individual as
mentally ill.

5. Duration - Duration refers to the persistence of the various behavioral or

psychological signs and symptoms. Thus the time period is considered to be an
important criteria in the Diagnostic world. Symptoms have to be occurring for a
particular duration for it to be considered a disorder, for example , persistent and
chronic sadness seen for a period of two weeks qualifies one for a diagnosis of major
depressive episode; similarly for schizophrenia, symptoms must be present for a span
of 6 months , including one month of active symptoms of delusions.
6. Irrationality and unpredictability- It is generally believed that those who are
normal behave rationally and their behaviours are predictable while abnormal
individuals are irrational and unpredictable. Their behaviours are considered to be
fluctuating, conventional and inconsistent. For example, individuals who are suffering
 from psychopathology he's like phobias, schizophrenia, OCD are seen as irrational
and their fears and observations are seen as unjustified and without an explanation.

7. Absence of Mental Health- Abnormality is often seen as an absence of mental health

in an individual. While it is in itself difficult to define the concept of "mental health",
it is in general believed that any absence of illness constitutes mental health. Thus,
any deviation from a psychologically healthy person is seen as abnormal.

None of these approaches by themselves are either necessary or sufficient for one to consider
a particular pattern of behaviour as abnormal. An extremely talented individual or an
eccentric performance by a person in any specific area, is something that is not average i.e. it
deviates from the norms and yet such behaviour would not be considered disordered. Further,
the very lines of adaptive and maladaptive behaviour are often blurred. There are no clear-cut
criteria specifying at what level an individual is effectively adapting to life demands and at
what point the person isn’t. Thus, for a con artist or a contract killer, both of whom have
antisocial personality disorder, their behaviour might not be maladaptive, because in fact it is
such a behaviour that is helping them earn a living and in turn ensure their survival. At such
points, experience of personal distress is considered to be an important indicator of a
disordered lifestyle. However, even the domains of distress are vaguely defined. One
wouldn’t consider it abnormal, if a person is extremely distressed after a great loss such as
death of a loved one. Also, there are certain times when an individual might be having a
disorder but doesn’t experience any distress on account of that, for example in the case of
mania, whereby a person is in a state of extreme elation. Thus, defining psychological
disorder by either of the three domains or even the three domains taken together doesn’t
contribute to “the” definition of abnormality.

Classifying abnormal behaviour

The process of classification of disorders provide with a nomenclature (naming system) and
enables to structure information in a more helpful manner. It helps in organising information
within a classification system that allows to study different disorders and learn about causes
and how to treat them the best. It furthermore, delineates which types of psychological
difficulties warrant insurance imbursement and to what extent. There are currently three basic
approaches to classifying abnormal behaviour: the categorical, the dimensional and the
prototypical approach (Widiger&Boyd,2009).
 1. The categorical approach is similar to what the diagnostic system of general medical

diseases. It assumes that:

a) All human behaviour can be divided into the categories of “healthy” and “disordered”.

b) Within the “disordered” there exist discrete, non-overlapping classes/types of disorder that
have a high degree of within class homogeneity in both symptoms displayed and underlying
organization of the disorder identified.

2. Dimensional approach-It is assumed that a person’s typical behaviour is the product

of differing strengths or intensities of behaviour along several definable dimensions-
mood, emotional stability, aggressiveness, anxiousness, social introversion and so on.
A dimensionally based diagnosis has the incidental benefit of directly addressing
treatment options.
3. Prototypal approach- Is a conceptual entity depicting an idealized combination of

characteristics that more or less regularly occur together in a less than perfect or standard way
at the level of actual observation.

Age related common psychological difficulties

The common psychological difficulties experienced by people differs with different age
groups. The following section describes some of these difficulties with respect to four periods
of lifespan:

1. Childhood (Birth-11 years of age)

Disturbances in children often consists of a lack of developmental progress in one or more

domains, rather than a presence of specific symptoms that are pathognomonic of adult
disorders. For example, a nursery school child's failure to develop useful social language or
interactions or a school aged child's inability to meet the developmental expectations of
separating from parents and settling into the school, maybe indicative of childhood
psychopathology.

Common referral problems for children are:

  Developmental delays- Specific delays such as delayed, absent or deviant motor or
speech development or General delays in multiple areas of development.
 Psychophysiological dysregulation- behaviour disturbances, disturbances in sleep or
feeding, rumination, eczema, self -stimulatory behaviour (head-banging, rocking).
failure to thrive.
 Behavioural disturbances - hyperactivity, excessive tantrums, negativism, aggression.
 Disturbed social development - lack of Apparent Awareness of or interest in others,
response to abuse, neglect or multiple placements or repeated or prolonged
separations
 Medical and genetic problems- prematurity, genetic syndrome
 Exposure to domestic or urban violence, exposure to trauma, any form of abuse
physical, verbal or sexual.

2. Psychopathology in adolescence (11- 18 years)

Adolescence is a period of transition from childhood to adulthood that involves a number of

changes in terms of one's behaviour, ways of relating to others, peers, academic challenges
and problems. As a result, most mental disorders first appear in adolescence or early
adulthood, making this particular group of individuals quite vulnerable. Children are most
likely to be diagnosed with anxiety, disruptive, mood and substance use problems (Costello,
Egger&Angold,2005;,U.S. Department of Health and Human Services,1999).

Anxiety disorders are characterized by unrealistic, irrational fears or anxieties of disabling

intensity. They generally begin at age 19 to 31 years. The median age of onset for one of the
anxiety disorders i.e. Social phobia, is early (13 years)(Kessler et al.,2005,2007). Obsessive
compulsive disorders, panic disorders also trace their beginnings to adolescence. Further, the
onset of personality disorders can also often be traced to early adolescence.

Another common disorder of adolescence are mood disorders.(unipolar depression, bipolar I ,

bipolar II). The prevalence of major depression is as high as 14%(Hammen&Rudolph,2003)
and of bipolar I disorder is around 0.6% in adolescents (Geller & DelBello,2003).

Because of varied social influences on adolescence, eating disorders become quite common
during this age. While bulimia nervosa and binge eating disorders are most likely to occur in
adulthood, peak age of onset for anorexia nervosa is 15-19 years. Adolescents live under an
intense fear of gaining weight or becoming 'fat' coupled with refusal to maintain adequate
nutrition and with severe loss of body weight. Such disorders are more prevalent among
females than in males.

Substance related disorders in adolescents involves patterns of maladaptive behaviour centred

on the regular use of a substance , such as a drug or alcohol. While these disorders may begin
at any age, research has identified factors that puts in adolescence at greater risk for these
disorders. For example, having a mother of father who smokes is associated with double the
risk of smoking among adolescence (Schepis& Rao,2005). Thus, this population of
individuals are vulnerable to substance related disorders.

Further, disruptive disorders such as conduct disorder may begin in childhood or early
adolescence and may develop more among Boys as compared to girls, with the symptoms
causing mild to moderate to severe disruptions in their day to day life.

3. Psychopathology in adults (18 years – 65 years):

Biologically, an adult is a human or other organism that has reached sexual maturity. In
human context, the term adult also has meanings associated with social and legal concepts.
Human adulthood encompasses a range of psychological and social adult development. In
different cultures, there are often events that relate passing from being a child to becoming an
adult or coming of age. While most modern societies accept a certain age bar that separates a
minor from an adult, in psychological assessment, we tend to demarcate that age based on the
formation of enduring emotional , psychological and behavioural patterns that contribute to
the formation of a ‘personality’ as opposed to inherent temperament as a benchmark.

 General unhappiness and stress accompanied or compounded by anxiety, worry, and

sleep disturbances, marital and interpersonal distress.

 Sexual dysfunctions, career dissatisfaction, interpersonal isolation, compulsive

behaviours, self-defeating behaviours, grief, loss, ageing, caring for ones parents and

children, often culminating into caregiver burden in a few cases.

 Menopause, medical conditions that may require life-long commitment and enduring
changes in lifestyle like diabetes, hypertension etc.
 Additionally, personality disorders, mood disorders, somatoform disorders are mostly
diagnosed during this age frame.
4. Old age (65 and above)

 Old age may bring with it, biological illnesses that cause distress and discomfort like

arthritis, symptoms of dementia: poor memory, intolerance to change, insomnia,

disorientation, severe mental clouding in which the individual becomes restless,

combative and incoherent.

 Depression and substance abuse may also take control of the individual.
 Psychosocial isolation and feeling of guilt, a general feeling of sadness may also take

over.

Clinical assessment versus diagnosis

The processes of clinical assessment and diagnosis are central to the study of
psychopathology and, ultimately, to the treatment of psychological disorders.
Clinical assessment or psychological assessment is the systematic evaluation and
measurement of psychological, biological, and social factors in an individual presenting with
a possible psychological disorder. It refers to a procedure by which clinicians, using
psychological tests, observation, and interviews, develop a summary of the client’s symptoms
and problems. Clinical assessment is one of the oldest and most widely developed branches
of contemporary psychology, dating back to the work of Galton (1879) in the nineteenth
century (Butcher, 2010; Weiner&Greene,2008).

On the other hand, Clinical diagnosis is the process through which a clinician arrives at a
general “summary classification” of the patient’s symptoms by following a clearly defined
system such as DSM-IV-TR or ICD-10 (International Classification of Diseases). It is the
process of determining whether the particular problem afflicting the individual meets all
criteria for a psychological disorder, as set forth in the standardised classification systems.

Assessment could employ methods of medical evaluation aimed at assessing the structural
and functional integrity of the brain as a behaviourally significant physical system (Fatemi
and Clayton, 2008). These could include General physical examination, eg EEG, MRI, fMRI,
PET Scan, CAT Scan, etc. Assessment can also include neuropsychological examination,
which involves the use of various testing devices to measure a person’s cognitive, perceptual
and motor performance, as clues to the extent and location of brain damage (Snyder,
Nussbom and Robins, 2016) such as finger oscillation task, Halstead category task, etc.
Finally, assessment can also be psychological in nature using methods such as:

a) Assessment Interviews: An assessment interview, often considered the central element of

the assessment process, usually involves a face-to- face interaction in which a clinician
obtains information about various aspects of a client’s situation, behaviour, and personality
(Craig, 2009; Berthold & Ellinger, 2009; Meers, 2009). The interview may vary from a
simple set of questions or prompts to a more extended and detailed format (Kici & Westhoff,
2004). It may be structured, semi-structured or unstructured.

b) Psychological Tests: Psychological tests are standardized sets of procedures or tasks for
obtaining samples of behaviour. A subject’s responses to the standardized stimuli are
compared with those of other people who have comparable demographic characteristics,
usually through established test norms or test score distributions. From these comparisons, a
clinician can then draw inferences about how much the person’s psychological qualities
(intelligence, personality, creativity etc) differ from those of a reference group, typically a
psychologically normal one. Examples include MMPI, NEO-PI R, WAIS-IV.

c) Clinical Observation: Clinical observation is the clinician’s objective description of the

person’s appearance and behavior—her or his personal hygiene and emotional responses and
any depression, anxiety, aggression, hallucinations, or delusions she or he may manifest.
Ideally, clinical observation takes place in a natural environment (such as observing a child’s
behavior in a classroom or at home), but it is more likely to take place upon admission to a
clinic or hospital (Leichtman, 2009).

Assessment is an ongoing process and may be important at various points during treatment,
not just at the beginning— for example, to examine the client’s progress in treatment or to
evaluate outcome. In the initial clinical assessment, an attempt is usually made to identify the
main dimensions of a client’s problem and to predict the probable course of events under
various conditions. It is at this initial stage that crucial decisions have to be made about what
treatment approach is to be offered, whether the problem will require hospitalization, to what
extent family members will need to be included as co-clients, and so on. Another important
function of pre-treatment assessment is establishing baselines for various psychological
functions so that the effects of treatment can be measured. Criteria based on these
measurements may be established as part of the treatment plan such that the therapy is
considered successful and is terminated only when the client’s behavior meets these
predetermined criteria. Also, comparison of post-treatment with pre-treatment assessment
results is a essential to evaluate the effectiveness of various therapies.
Once the clinician is equipped with sufficient knowledge about the client’s presenting
problem, an effort is made to diagnose the client and classify him/her into a psychological
disorder category based on the DSM or ICD systems of classification. This classification
process is termed as diagnosis.
Classification is a fundamental human activity that people use to understand their world. In
psychopathology, the general goal of classification is an attempt to use similarities and
differences among people who behave in deviant and socially abnormal ways in order to
understand their behaviours.
More specifically, there are five purposes to the classification of mental disorders:
(i) forming a nomenclature so that mental health professionals have a common language;
(ii) serving as a basis of information retrieval;
(iii) providing a short-hand description of the clinical picture of the patient;
(iv) stimulating useful predictions about what treatment approach will be best; and
(v) serving as a concept formation system for a theory (or theories) of psychopathology.

Hence, clinical assessment and diagnosis are quite different from each other and are both
indispensable in psychopathology and treatment.

Clinical interview

A clinical interview, often considered the central element of the assessment process, usually

involves a face-to face interaction in which a clinician obtains information about various

aspects of a client’s situation, behaviour, and personality.

The interview may vary from a simple set of questions or prompts to a more extended and

detailed format. It may be relatively open in character, with an interviewer making moment-
to-moment decisions about his or her next question on the basis of responses to previous

ones, or it may be more tightly controlled and structured so as to ensure that a particular set
of questions is covered. In the latter case, the interviewer may choose from a number of

highly structured, standardized interview formats whose reliability has been established in

prior research.

There are three types of clinical interview:

 Structured interviews

Structured interviews follow rigid rules. The clinician asks specific questions that

follow an exact sequence and that include well-defined rules for recording and

judging responses. This practice minimizes interview biases and unreliable

judgments, hence providing more objective information. Although structured

interviews generally have better psychometric properties than do unstructured ones,

structured interviews may overlook idiosyncrasies that add to the richness of

personality, artificially restraining the topics covered within the interview. They also

may not create much rapport between client and clinician. Also, structured interviews

typically take longer to administer than unstructured interviews and may include some

seemingly tangential questions. Clients can sometimes be frustrated by the overly

detailed questions in areas that are of no concern to them.

 Semi-structured interviews

Semi-structured interviews are more flexible and provide guidelines rather than rules.

There are neither prepared questions nor introductory probes. These types of

interviews may elicit more information than would emerge from a structured

interview because the clinician is allowed more judgment in determining what

specific questions to ask. The interviewer also may ascertain more detailed

information about specific topics.

  Unstructured Interviews

Unstructured assessment interviews are typically subjective and do not follow a

predetermined set of questions. The beginning statements in the interview are usually

general, and follow-up questions are tailored for each client. The content of the

interview questions is influenced by the habits or theoretical views of the interviewer.

The interviewer subjectively decides what to ask based on the client’s response to

previous questions. Because the questions are asked in an unplanned way, important

criteria needed for a DSM-IV diagnosis might be skipped. Responses based on

unstructured interviews are difficult to quantify or compare with responses of clients

from other interviews. On the positive side, unstructured interviews can be viewed by

clients as being more sensitive to their needs or problems than more structured

procedures. Moreover, the spontaneous follow-up questions that emerge in an

unstructured interview can, at times, provide valuable information that would not

emerge in a structured interview.

Case history and clinical work

The clinical case history method originated with Freud, and his early case studies continue to
be taught as models of psychoanalytic thinking. It was Freud’s extensive reliance on this
method and the insights it yielded that leads us to emphasize his key role in the development
of the case formulation approach. According to Freud the case histories provide “an intimate
connection between the story of the patient’s suffering and the symptoms of his illness”. The
psychiatric case history is the record of the patient's life; it allows a psychiatrist to understand
who the patient is, where the patient has come from, and where the patient is likely to go in
the future. The history is the patient's life story told to the psychiatrist in the patient's own
words from his or her own point of view. Many times, the history also includes information
about the patient obtained from other sources, such as a parent or spouse. Obtaining a
comprehensive history from a patient and, if necessary, from informed sources is essential to
making a correct diagnosis and formulating a specific and effective treatment plan. A
psychiatric history differs slightly from histories taken in medicine or surgery. In addition to
gathering the concrete and factual data related to the chronology of symptom formation and
to the psychiatric and medical history, a psychiatrist strives to derive from the history the
elusive picture of a patient's individual personality characteristics, including both strengths
and weaknesses. The psychiatric history provides insight into the nature of relationships with
those closest to the patient and includes all the important persons in his or her life. Usually, a
reasonably comprehensive picture can be elicited of the patient's development from the
earliest formative years until the present.

The most important technique for obtaining a psychiatric history is to allow patients to tell
their stories in their own words in the order that they consider most important. As patients
relate their stories, skilful interviewers recognize the points at which they can introduce
relevant questions about the areas described in the outline of the history and mental status
examination.
The broad topics to be covered in the case history schedule are given below-
1. Identifying data
2. Chief complaints
3. History of present illness
4. Past illnesses
5. Family history
6. Prenatal history
7. Occupational history
8. Marital and relationship history
9. Current living situation

Use of Case studies in clinical work

Clinical case studies are designed to represent actual patient encounters or a series of patient
encounters. By presenting clinical issues in the context of a patient's situation, case studies
are an effective tool for demonstrating clinical decision-making. Case studies are widely used
in teaching diagnostic and management skills to medical students and in CME activities.
Case-based teaching is a valuable strategy in all areas of clinical education, and it is
particularly valuable for educating practitioners about HIV disease. It is essential for
practitioners to be able to individualize care given the complexity and chronic nature of HIV
disease, the number of opportunistic infections and related conditions, the range of treatment
options for each, and the high pill burden and consistent adherence required for effective anti-
HIV therapy. The case example used throughout this guide follows a man with active heroin
addiction who has been hospitalized with Pneumocystis carinii pneumonia (PCP; also known
as Pneumocystis jiroveci pneumonia). This patient's drug addiction and unstable social and
economic circumstances influence the direction of treatment, as often happens in a real
clinical setting. Immediate feedback on a treatment decision made in the context of a case
study prepares practitioners to work more effectively with patients.

Clinical diagnosis versus clinical formulation

According to Kendell and Jablensky, while diagnosis may serve as 'helpful working concepts
for clinicians', many are not 'valid', in the sense that they are not ' discrete entities with
natural boundaries that separate them from other disorders'. A formulation, on the other hand,
can be best understood as co- constructing the personal meaning of the client's life story. It is
' a process of ongoing collaborative sense-making' (Harper and Moss,2003) which
summarises the client's core problems in the context of psychological theory and evidence
and those indicates the best path to recovery. Unlike diagnosis, it is not about making an
expert judgement, but about working closely with the client to develop a shared
understanding which is likely to evolve over the cause of the therapeutic work. Further,
unlike diagnosis, it is not based on deficits, but draws attention to talents and strengths in
surviving what are newly always very challenging life situations.

Understanding and incorporating these into an individual eyes treatment plan is an essential
part of quality care, with failure to do so, not only risking an ineffective outcome, but
potentially impacting negatively on the therapeutic relationship and resulting in exacerbation
of the person's symptoms. At least in part due to recognition of the limitations of diagnosis
and mental health, the concept of formulation or case conceptualization has attracted
increasing interest in recent years. Formulation has been defined as,' synthesizing the patients
experience with relevant clinical theory and research, as the bridge between assessment and
treatment' and has been utilised for multiple disorders in children, adults and older adults. A
Psychiatrist formulation for schizophrenia would look something like this,' schizophrenia/
psychosis triggered by the stress of job loss'. This, thus retains all the disadvantages of
diagnosis in a slightly modified form. Psychology guidelines,on the other hand, state that the
psychological formulations ' are not premised on psychiatric diagnosis'. From this
perspective, if a combination can provide a reasonably complete hypothesis or ' best guess'
about why a person has developed their difficulties, one which leads to effective intervention,
then there is no need to add in an extra layer of explanation for the same. Psychiatric
diagnosis have long been under criticism for Poor reliability and validity, as well as the lack
of evidence for the supposed biological causes of these conditions. Arguably, a formulation,
specially one which is firmly based in recent psychological evidence, makes psychiatric
diagnosis redundant.

Purpose of clinical formulation

According to Butler (1998) in the clinical domain, the process of formulation is what makes
us accountable for our work, separating responsible, effective practice from informal,
supportive conversations. A formulation can be understood as an explanatory account of the
issues with which a client is presenting. As a psychological explanation of a client’s needs, a
formulation can reasonably be expected to draw upon a wide range of data, including
psychological theory, general scientific principles (such as how to test hypotheses), research
findings from the wider literature (the latter becoming particularly influential since the
political and professional endorsement of empirically-supported interventions and evidence-
based practice), supervision, and prior professional experience.

A clinical formulation can serve a diverse range of functions. These include;

 clarifying key hypotheses and identifying relevant questions;

 facilitating understanding of the client’s needs as a whole;
 prioritizing client issues and concerns;
 planning and selecting appropriate intervention strategies;
 determining criteria for a successful outcome, including organizing practitioner and
client around the same goals;
 predicting client reactions to specific interventions;
 predicting obstacles to progress;
 thinking systematically and productively about lack of progress;
 identifying patterns in a client’s actions and responses that can be examined
conjointly and impartially;
 identifying missing information;
 helping refine the search for relevant theoretical constructs or processes;
  deriving a coherent understanding of the links between past and present;
 forming judgements about the extent to which a case is typical (and how any
intervention plan may need to be adjusted in the light of atypical features).

From these criteria, a number of essential themes can be identified. First, and most obviously,
a formulation equips the practitioner with a systematic means of applying psychological
knowledge to a client’s story, problem, or dilemma for the benefit of the client and others
involved. The formulation functions as a framework for clarifying those questions which are
likely to drive the enquiry forward. It creates thematic links between past events, present
circumstances, and future aspirations, and refines the search for any additional information
that is needed.

A second component of formulation is to identify which areas of a client’s experience or

behavior will be prioritized. Informed decisions must be made about which concerns will be
addressed, the most appropriate goals of the enquiry (based on a psychologically-informed
understanding of what is amenable to change) and what interventions might be used in the
service of those goals.

A third function of formulation is to aid empathic understanding. Difficulties in terms of

insufficient progress, apparent “resistance”, or obstacles to collaboration that might otherwise
contribute to problems in working together can be reflected upon in an impartial manner in
order to identify ways forward.

In a similar vein, formulation can help protect against decision-making biases that could
impede effective working. By ensuring that practice-based choices are underpinned by a
systematic, psychologically informed account of the relationship between different aspects of
a client’s experience, it becomes possible to articulate and, where necessary, challenge the
thinking that underpins the approach taken. Formulation, then, permits a degree of
transparency in the decision-making process. It has the potential to protect a client and
contribute to the enhanced effectiveness of psychological interventions.

A further function of formulation—and one that is often overlooked—is its use as a form of
professional communication. In its most straightforward form, this can mean the development
of a shared understanding that benefits the client through ensuring a consistency of approach.
If a client’s journey through services entails contact with a number of professionals, for
example, there is the potential for the client to be subjected to conflicting opinions that
hamper effective service provision. A formulation can, therefore, unite the many
professionals who may be involved in a client’s care around the same issues, priorities, and
goals.

Thus, the act of formulation can serve many purposes, some of which will be more explicit
than others. At the most obvious and official level, it supports decisions about the content of a
psychological enquiry (e.g., knowing what to prioritize, which hypotheses to test, and which
interventions might be useful). It also supports understanding of process (e.g., by allowing
the practitioner to predict and interpret clients’ reactions to the work undertaken). However,
formulation may also serve a more political function, enabling the practitioner to demonstrate
their epistemic authority in the understanding of client concerns and the stories they can
construct about those concerns.

Approaches to clinical formulation

 Psychodynamic
The earliest psychotherapy formulation originates from Freud's case studies and
draws on the psychoanalytic concept of the unconscious, the transference, defense
mechanisms and the ID Ego and superego (Bateman and Holmes,1995). Although
Freud did not use the term formulation, this was a way of explaining symptoms in
psychological terms and having both meaning(often symbolic) and a function
(classically, meeting instinctual needs).
'Psychodynamic' is a General term for approaches that draw on psychoanalytic ideas
and assumptions, but the field is a very wide one, and include significant later
developments such as object relations theory, self psychology and attachment theory.
Each of this brings its own characteristics, emphasis, which is reflected in the process
of formation.
During the initial assessment interview, the psychodynamic therapist will be gathering
information and looking for the client's ability to form a good working alliance, to
make use of interpretation, and to be in touch with their feelings (Bateman and
Holmes,1995). The therapist will be looking for important factors in the past, for
patterns in relationships, and for the key Defense mechanisms used by the client.
Elements of the formulation formed by the therapist may be shared with the client at
the end of the first meeting in order to assess the response and hence the ability to
work psychodynamically.
 The scientific status of psychoanalysis and its derivatives has been a subject of heated
debate for many years, and was a part of the impetus for the emergence of the more
experimentally verifiable Behavioural School of therapy.

 Cognitive- Behaviour
Most current rating and research on formulation comes from the cognitive- behavioral
tradition. Bruch and Bond(1998) describe how the approach was pioneered at the
Mudslay Hospital from the 1950s onward by clinical psychologist such as Hans
Eysenck, Victor Meyer, Monte Shapiro and Ira Turkat (who coined the term' case
formulation', key figures in the development of the then new approach to behaviour
therapy. In its earlier form of functional analysis, aimed to describe problem
behaviour in terms of environmental stimuli and response contingencies (Hayes and
Follette,1992). For example- agoraphobia might serve the purpose, or function, of
helping someone to avoid anxiety - provoking situations etc. This kind of analysis was
said to provide a much more useful guide to treatment then psychiatric diagnosis.
Cognitive therapist such as Aaron Beck(1976), have from the 1970s, made significant
additions to early behavioral analysis by including the role of thought process in the
development and maintenance of mental distress.
Today, in the most widely used approach of Cognitive Behavioral Analysis (CBT),
the formulation is located firmly within a scientific, experimental framework as a '
central process in the role of the scientific practitioner' (tarrier and Calam,2002). It is
considered to be' an elegant application of science' (Kinderman, 2001).
 Systemic
The concept of working hypothesis has been central to the practice of family therapy
from late 1970s (Pallazzoli et al,1980). In the early years of family therapy, there was
an emphasis on making objective and scientific assessments and formulation of a
family 'out there', and mapping their dysfunctions(Dallos and Draper, 2000). The
'symptoms', displayed by one member was seen as a part of the attempted solution
that was serving a function for the whole family. More recently, they have been a
recognition that a therapist's assumptions are inevitable part of the process of
formulating, and that there is not such thing as' the truth' about a given family. This
 represented a shift from the position of certain, families were assessed in terms of
their 'dysfunctions', to one it is recognized that there are multiple realities in any given
situation- there is no one way of viewing of family and thus the therapist holds
working hypothesis, not ' truths'.
Systemic formulations, are working hypothesis, must therefore be constantly open to
revision (progressive hypothesizing). Their worth is not best judged in terms of the
ability to find 'the truth' but by their usefulness in helping to bring about a change. A
social constructionist perspective is influential in current systemic thinking, leading to
an increasing awareness of the wider socio-cultural context in which therapists and
clients exist, and the variety of assumptions that shape our understanding of what the
problem is.

 Integrative
Psychological formulation is bedevilled by divisions and splits even with the so-called
'single model perspective' such as cognitive - behavioral therapy , psychodynamic or
systemic. These include differences about technique versus non specific factors, about
an open ended versus time limited focus and about emphasizing the individual versus
the social context. There is a general tendency to ignore these divisions, or to adhere
to one side, or profess non- aligned eclecticism where multiple models are used in the
service of clinical necessity. While such solutions have pragmatic advantages, they
lack technical and epistemological coherence. One way of looking at integration is in
terms of the complexity and uniqueness of the formulations that are developed.
The main types of integrative formulations are:
1. Off the shelf - These are approaches that use standardized integrative formulations
combining a number of models. An Example of this is- cognitive analytic therapy
(CAT) where there has been an attempt to develop a coherent new model which
integrates a number of other models such as personal construct theory and object
relations theory. The same formulation process and format is applied to all clients,
although it is acknowledged that the approach may be less suitable for some, for
example, those who are actively ' psychotic'.

2. Aptitude treatment mix (A-T)- In these approaches, there is a greater emphasis on

matching ' diagnosis' or' symptoms' to the type of therapy. The integrative
 formulation can involve considering, for example, the clinical utility of exploratory
(brief psychodynamic) versus prescriptive (CBT) therapies for a given problem such
as depression.
3. Idiosyncratic formulation - Here, the integration consists of a multifaceted, high- level
formulation that aims to encompass the complexity of an individual client, their
family and their context. This can incorporate a 'functional' approach which considers
a client's behaviour in terms of what it solves, what is conceals or avoids, and what
the costs and benefits are, both for the individual and his social context. Integration at
this level, also requires the therapist to drawn on personal qualities such as intuition,
capacity to listen and ability to synthesise disparate information, and to hold a
tentative position which tries to integrate different perspectives. This is sometimes
described as a 'both/and' position.

One of the most influential models of integrative formulation is Weerasekera's integrative

formulation. The 1996 model of formulation offers a structure which helps us to be
systematic about what information we seek and also generates some ideas about how it
might all be woven together. Within the two dimensions idiosyncratic/ off the shelf and
synthesis/ eclectic described above, this model can be broadly described as idiosyncratic
and eclectic.

Similarities and differences between formulations

Formulations from the various therapeutic traditions can differ in terms of:

1. The factors that are seen as the most relevant like thoughts, feelings, behaviours,

social circumstances etc.

2.       The explanatory concepts they draw on like schemas, unconscious, discourses etc.

3.       The emphasis they place on reflexivity.

4.       The degree to which they adopt an expert as opposed to a collaborative stance

5.       Their position in relation to psychiatric diagnosis

6.       Their position about the ‘truth’ versus ‘usefulness’ of the formulation

7.       The way the formulation is developed, shared and used within therapy.
However, all formulations have the following features in common, in that they:

1.       Summarise the core problems of the client.

2.        Indicate how the client’s difficulties relate to one another, by drawing on
psychological theories and principles,

3.       Suggest on the basis psychological theory why the client has developed a certain

difficulty at a particular time in the current situations

4.       Give rise to a plan of intervention that is based on psychological processes

principles already identified.

5.       Are open to revision and re-formulation.

Controversies and debates

One of the most heated debates in formulation concerns the very definition of the term itself.
The British Psychological Society (2005) outlined the basis of different forms of applied
psychology in which five areas of psychology are presented: clinical, forensic, counselling,
educational, and health. While for clinical, forensic, and counselling psychology, formulation
is identified as a key competence, the extent to which formulation has a scientific basis and is
drawn directly from psychological theory varies between disciplines. Despite its popular use
in all major disciplines within psychological professions, the act of formulation cannot be
seen as consisting of one enterprise, uniformly defined and undertaken in the same way by all
disciplines. While there exists a fairly broad agreement about the wide ranging functions of
formulation, there is less agreement on the specific components and tasks that constitute a
formulation. Some describe it as a hypothesis while others describe it as an entity or tool that
helps in organising assessment data. This differential description of the term substantiates
Ingram’s (2006) point that formulation can be interpreted as both a product of enquiry as well
as a process that underpins the enquiry that unfolds.
Moreover, formulation will also be reflected in the way in which the enquiry has been
attempted. For instance, a psychodynamic formulation will, for example, aim to identify the
pervasive themes that are central to the client’s concern, that can be traced back through the
individual’s personal history and used to explain how their attempt to resolve these central
conflicts have been unhelpful as well as helpful. In contrast, cognitive approaches tend to
focus on more specific components of experience (often derived from information processing
theory), which can be operationalised and measured. Thus, this goes onto show that there lies
some difference between case formulating and formulation of a case respectively.
Another classic debate of formulation caters to what factors need to be tapped into in order
for psychological enquiry. Butler (1998) highlighted how, traditionally, formulations have
focused on predisposing, precipitating, and perpetuating factors that relate closely to
individual, internal, or intrapsychic events, tending to neglect social, cultural, and historical
factors, including socially and culturally shared assumptions about gender roles and the
behaviours it is appropriate for each gender to display. In this context, she emphasised that
the practitioner would need to be mindful that the perceived options for change available to
female clients raised in the 1980s may be very different from those raised in the 1940s,
meaning that social factors such as gender roles need to be taken into careful consideration
while formulation. This tendency to focus on internal events at the expense of wider
interpersonal and social influences has led to the development of trans-theoretical models that
require the practitioner to embrace a more holistic and inclusive approach. One of the best
known of these is Lazarus’s multi-modal model (1973, 1981), typically known by the
acronym “BASIC ID”. He argued that traditional forms of therapy focuses on the client’s
concerns from the perspective of cognition, affect and behaviour. Rather, he suggested that, it
is necessary to adopt a holistic perspective in order to achieve a more comprehensive
approach to data collection. Wilkinson (2004), too, expressed her concern with the issue of
how to be sufficiently inclusive in thinking about the areas of a client’s life that might be
relevant to explore. Viewing formulation through this lens renders it less of a tool that holds
together theory and practice and more of a pantheoretical framework, underpinned by
knowledge of broad psychological principles, that enables practitioner and client to organize
information from myriad sources.
A different aspect of the debates caters to the accuracy and effectiveness of formulation.
Despite the long held belief that individualized case formulation drawn from specific
experimental tests provided the most accurate representation of the client’s issues held sway
over clinical practice, it has been questioned whether formulation has any substantive and
beneficial impact on outcome. Wilson (1996, 1997), among others (e.g., Meehl, 1954), has
expressed doubts about the relative merits of individualized case formulation on the grounds
of accuracy, arguing in favour of manual-based, empirically-validated interventions over
individually tailored approaches on the basis that formulations always rely upon potentially
flawed professional judgement. It is argued that practitioners should restrict their work to
actuarial data rather than poorly validated technical procedures based on clinical reasoning.
Based on research into one theoretically-driven approach (cognitive–behavioural), Bieling
and Kuyken (2003) argue that accuracy is too varied to provide confidence in any
formulation achieved.
Finding ways to bridge the tension between what science tells and what practice demands of
practitioners is an ongoing issue. Butler (1998) highlighted how practitioners bring to their
enquiries theoretical knowledge that shape how they listen, respond to, and understand their
clients’ concerns. Significantly, Butler (1998) also proposed that formulations do not have to
be “100% accurate or complete”. The reason being that the formulation is not concerned with
providing answers but rather, with generating a rich source of questions and ideas that
potentially add value to the work.
A critical and often neglected issue underpinning the different definitions is the question of
who owns the formulation and, thus, who is entitled to change, refine, or discard it. Use of
formulations brings in labels that, in turn, bring assumptions that are not always to the
advantage of the person to whom they are applied. Another aspect of formulations was
questioned by Crellin (1998) who expressed that reservations about the idea that we can
frame clients’ problems as testable hypotheses. Translating clients’ experiences into
empirical constructs may make them manageable, but can fall prey to a reductionism that
prevents the quality of understanding that is required for a meaningful encounter between
practitioner and client.
From the few debates cited above, it can be seen that there can be no single, correct way to go
about formulation. It is not a neutral, impartial, non-political statement of fact based on
evidence leading to the best possible intervention for the client. Rather, it is a story told to
meet specific needs—an account agreed between the stakeholders to access whatever change
process seems to them to be appropriate at that time.

Best practices in formulation

Any therapeutic procedure can be harmful as well as helpful depending on how it is used, &
formulation is no exception. It is also addressed in DCP Guidelines (2011), which includes
checklists of best practice for formulation  (as well as event) & formulating (as a process).
The former list specifies that formulation should, along with serving the purposes listed by
Butler (1998), meet the following criteria :
Formulation must meet the following criteria for best practices. The formulation must:

1. Be grounded in an appropriate level and breadth of assessment

2. Be culturally sensitive
3. Be expressed in accessible language
4. Considers the possible role of trauma and abuse
5. Include the impact and personal meaning of medical and other health care interventions
6. Consider possible role of services in compounding the difficulties
7.Be informed by awareness of social factors
8.Be informed by a range if models and causal factor
9. Not be premised on a functional psychiatric diagnosis

Furthermore, the checklist of best practices in formulation specifies that the clinician:
1. Is clear about who the formulation is for (individual, family, team etc.)
2. Is clear about who has the problem
3. Is clear about who are the stakeholders and their interests
4. Is respectful of the service users or teams view about what is accurate or helpful
5. Constructs the formulation collaboratively with the service user or team
6. Paces the development and sharing of the formulation appropriately
7. can provide a rationale for choices within the formulation
8. Is reflective about their own values and assumptions