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Visualizing psychiatric formulation

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research-article2015
APY0010.1177/1039856215593024Australasian PsychiatryAlyami et al.

Australasian
Teaching and training Psychiatry
Australasian Psychiatry

Visualizing psychiatric formulation 2015, Vol 23(5) 575­–580

© The Royal Australian and
New Zealand College of Psychiatrists 2015
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DOI: 10.1177/1039856215593024
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Hussain Alyami Psychiatric Registrar, Mental Health Services of Older People, Auckland
District Health Board, Auckland, and; Clinical Fellow, Centre of Health System Innovation
and Improvement (Ko Awatea), Manukau District Health Board, Auckland, New Zealand
Frederick Sundram Senior Lecturer, Department of Psychological Medicine, University of Auckland,
Auckland, and; Consultant Psychiatrist, North Shore Hospital, Auckland, New Zealand
Andrew G Hill Head, South Auckland Clinical School, University of Auckland, New Zealand
Mohsen Alyami School of Psychology, Massey University, Auckland, New Zealand
Gary Cheung Senior Lecturer, Department of Psychological Medicine, University of Auckland,
Auckland, and; Consultant Psychiatrist, Auckland City Hospital, Auckland, New Zealand

Abstract
Objective: Despite the importance of psychiatric formulation, it remains one of the most challenging tasks for medi-
cal students and trainees. To facilitate teaching and learning this essential skill, we propose a visual metaphor in
order to conceptualise psychiatric formulation.
Conclusions: It is expected that this paper will assist educators and learners to better conceptualise psychiatric
formulation through activating prior knowledge through this visual metaphor. Future educational research will
determine the effectiveness of this proposed learning tool.

Keywords: learning tool, psychiatric formulation, psychological formulation, visual metaphor

‘Tell me and I forget. Show me and I remember.
Involve me, and I understand.’
(Traditional Chinese proverb)
Although formulation is considered as the cornerstone of
psychiatric clinical practice,1 it remains sub-optimally
taught and learnt2–8 and is reported to be a declining clin-
ical skill.9 It is also considered by some psychiatric train-
ees and medical students as one of the most daunting
clinical tasks6; however, when performed well, formula-
tion is associated with improved treatment outcomes.1,10
This may be related to theoretically-supported assess-
ment, clear hypotheses of the etiologies of the patient’s
presentation and that it informs management.2
According to Sperry et al.,1 psychiatric formulation is
‘a process of linking a group of data and information to
define a coherent pattern and it helps to establish diag-
nosis, provides for explanation and prepares the clinician
for therapeutic work and prediction’. Similarly, Sim et al.2
defined it as ‘…a succinct description of the chief features
of the case as well as an encapsulation of the diagnosis,
aetiology, treatment options, and prognosis of patients’
problem’ (p. 290). Therefore, formulation goes beyond
making a diagnosis, to developing a conceptualisation of
the patient’s current and future clinical picture, etiology
and management in the context of multi-dimensional
bio-psycho-sociocultural domains.11 Moreover, it ‘can fill
this gap between diagnosis and treatment and can be
seen to lie at the intersection of etiology and description,
theory and practice and science and art’ (p. 289).2 To fur-
ther highlight its importance and place in clinical prac-
tice, international psychiatric training programs, such as
the Royal Australian and New Zealand College of
Psychiatry (RANZCP) and the American Board of
Psychiatry and Neurology (ABPN) include it as a core
competency for psychiatric trainees.12,13
The traditional teaching and learning methods of psy-
chiatric formulation include didactic teaching, distribu-
tion of reading material and group discussions about
formulating case vignettes.9 Selzer and Ellen14 have
recently described a framework and a step-by-step guide
Corresponding author:
Hussain Alyami, South Auckland Clinical School, University of
Auckland, Middlemore Hospital, Private Bag 93311, Otahuhu,
Auckland 1640, New Zealand.
Email: haly282@aucklanduni.ac.nz

575
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Figure 1. Psychiatric formulation visual metaphor.
on formulation for beginners in psychiatry, using a
12-step matrix of predisposing, precipitating, perpetuat-
ing and protective factors vertically; and biological, psy-
chological and social factors horizontally. The purpose
of this was to improve learners’ formulation through the
providence of a framework, which they could expand as
clinical experience broadens. This hopefully will enable
the learner to overcome having the need to fill in the
12-step matrix. For example, we included three rocks
representing precipitating bio-psycho-social factors, but
not all of them need to be present together as triggers.
The current paper describes the use of an innovative
visual metaphor (Figure 1) developed by author HA, and
based on Selzer and Ellen’s14 framework, as a teaching
and learning method to enhance the conceptualization
of formulation. It attempts to conceptualise the vertical
and horizontal elements of the framework visually,
using familiar visual metaphors. At each stage, there are
three visual elements representing the internal bio-psy-
cho-social factors influencing clinical presentations,
while the overall metaphor represents the vertical four
Ps. In addition, this visual metaphor also incorporates
the treatment, recovery process and prognostic factors,
which are often neglected in formulation.
Methods
Visual metaphor
Visual metaphors are used in our everyday lives, for
example, with computer and smart phone user inter-
faces. Most of us recognize instantaneously the com-
puter desktop and trash can icons, which are visual
representations of certain computing functions. In the
era of digital natives, it would be hard to imagine what a
desktop would look like without such visual metaphors.
A visual metaphor is defined by Eppler15 as:
‘A graphic structure that uses the shape and elements
of a familiar natural or man-made artefact or of an
easily recognizable activity or story to organize
content meaningfully and use the associations with
576
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Australasian Psychiatry 23(5)
the metaphor to convey additional meaning about
the content’.
(M. J. Eppler, 2006)
For example, the tip of the iceberg is a commonly used
verbal metaphor referring to the proportion of explicit
to implicit knowledge and a visual representation of that
is the visual metaphor equivalent.
The use of metaphor in medicine dates back to Aristotle:
he used vases to compare the heart and blood vessels.16 In
psychiatry, Sigmund Freud used metaphor commonly in
his writings, especially when describing abstract concepts
to the extent that some authors considered metaphor as a
source of Freud’s thoughts.17 For example, he explained
the relationship between the Ego and Id as the horse and
its rider. In his paper, The Ego and the Id,18 he stated that,
‘…the Ego… in its relation to the Id it is like a man on
horseback, who has to hold in check the superior strength
of the horse’ (Freud, 1923).
Metaphor was considered until recently a mere decora-
tive component of speech which limited research to
mainly verbal metaphors,19 partly because of the print
culture that relies heavily on text;20 however, visual met-
aphors have been used successfully to teach some of the
more complicated and abstract scientific principles (e.g.
Emil Fischer’s21 Lock and Key Model of enzyme-substrate
interaction, in physiology). It has been shown that vis-
ual metaphor is an essential cognitive process and a
product of thought, independent of language.19,22
Results
Use of visual metaphor in practice
We illustrate below the use of visual metaphor, as applied
to the formulation of mental illness, while integrating a
variety of clinical factors.
Sarah is a 14-year-old skateboarder. She is an individual
with a unique set of biological, psychological and social
factors; such as genetics, brain structure and circuitry,
Alyami et al.
Figure 2. Protective factors: the protective gear.
Figure 3. Predisposing bio-psycho-social factors: the skateboard wheels with cracks.
personality, relationships, and experience in her past
and current environment.
Sarah wears protective gear to help her skate safely
(Figure 2). Her leg protectors represent the biological
protective factors, hand protectors represent social pro-
tective factors, while the helmet represents protective
psychological factors.
Sarah travels on her three-wheeled skateboard (Figure 3).
Each wheel represents one of the bio-psycho-social
­factors, while cracks in the wheels represent predispos-
ing factors that could make her more vulnerable to fall-
ing off the skateboard and into the hole of mental
illness; however, she skates reasonably well on her life
journey.
The three stones represent the bio-psycho-social precipi-
tating factors (Figure 4). As Sarah skates over one or more
of these stones, the chips on the wheels become bigger,
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thus precipitating a fall into the hole of mental illness.
The consequence of the fall and the grazes she suffers are
dependent on the interaction between her protective
gear, the sizes of the cracks in the wheels and the stones
encountered.
Once Sarah is in the hole of mental illness, she hangs
onto the tree branches on the side of it. The tree branches
represent the perpetuating bio-psycho-social factors
(Figure 5). The greater the severity of the perpetuating
factor, the more likely it is for the branch to break.
Consequently, if one or more break, she falls further into
the hole and experiences a worsening of her symptoms.
The severity of her grazes and functional impairment
corresponds to the severity of her mental illness.
The ladder provides a way for Sarah to get out of the hole
of mental illness (Figure 6). A mental health clinician
assesses Sarah’s grazes (severity of mental illness), along
577

Figure 4. Precipitating factors: the three stones.
Figure 5. Perpetuating factors: the three tree branches in the hole of mental illness.
with her protective gear (protective factors), the cracks in
the skateboard wheels (predisposing factors) and the
stones (precipitating factors). The clinician uses an evi-
dence-based instruction manual to build a reliable ladder
made out of three main steps, which represent the bio-
psycho-social rungs as part of the multidisciplinary team.
The recovery principles emphasize self-responsibility and
management, along with instilling therapeutic hope.
The multidisciplinary team assembles the 3-step ladder,
but Sarah has to accept it and climb up the first step,
emphasizing the importance of self-responsibility.
If she refuses to accept the ladder or climb, and there is
risk involved (for example, she is starving at the bottom
of the hole, or the hole is filling up with rain water and
she is at imminent risk of drowning), then the multidis-
ciplinary team will rescue her and might start the Mental
Health Act.
Now that Sarah has successfully climbed out of the hole
and is back riding her skateboard (Figure 7), a number of
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Australasian Psychiatry 23(5)
bio-psycho-social factors will determine her progress
ahead. Initially, the treatment team monitors her closely,
making sure she is not falling off the skateboard, by rein-
forcing her previous abilities in riding and eliminating
stones (stressors) on the road. The treatment team will
gradually withdraw, as she becomes more confident in
riding her skateboard. Prior to the treatment team
departing (discharge), she will be equipped with the
skills to build her own ladder if she falls into a hole again
(early warning signs and relapse management).
Discussion
Benefits and limitations of visual metaphor
A number of benefits are reported for use of visual meta-
phor as a learning and knowledge-sharing tool, including:
improved audience engagement, attention, memory and
comprehension.23 Visual metaphor can provide a means
of transferring a complex concept by using simple visual
Alyami et al.
Figure 6. Treatment and recovery: the ladder.
Figure 7. Prognostic factors: the journey ahead.
symbols, which facilitates the connection between
thoughts and feelings.24 Visual metaphors, when created
and presented well, have high levels of memorability and
understandability. In addition, they have low-to-moder-
ate levels of difficulty, in comparison to mind maps.15
They also assist learners to incorporate newly-learnt mate-
rial to prior knowledge.25 This feature fits particularly well
with one of the main teaching principles of psychiatric
formulation, which is activating previous knowledge.26
This activation of prior knowledge is seen as one of the
main characteristics of problem-based learning princi-
ples.27 Visual metaphor, as one type of visual representa-
tion, has been associated with enhanced problem-solving,
as well as linking of new to prior knowledge.28 The rela-
tional structure of the metaphorical components of visual
metaphor allows for optimal information organization.29
This could be due to activation of semantic memory.30
A number of limitations have been reported, when using
visual metaphor for teaching and learning. For example,
novel metaphors are prone to be misinterpreted and are
likely to lead to perceptual error; but when they are
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clearly explained, the associated misperception can be
resolved.31 Therefore, it is essential that the visual meta-
phor be interpreted according to the textual or verbal
explanation accompanying it. When developed inap-
propriately, a visual metaphor could misdirect attention
from its content, resulting in false associations.15,32 On a
practical level, visual metaphors are difficult to develop,
and once drawn, it is difficult to make amendments.15
Finally, some learners are not able to comprehend meta-
phors, especially the novel ones. For example, people
with autistic spectrum disorder may struggle to under-
stand the implicit association of metaphors.33
Conclusion
We have presented a novel approach using visual meta-
phor, for teaching and learning psychiatric formulation.
The proposed metaphor aims to simplify the psychiatric
formulation process, by activating learners’ prior knowl-
edge while organizing the various factors in a format
that can aid future recall. The metaphor developed also
579

informs on diagnosis, treatment, recovery and progno-
sis. Though the current paper utilized aspects of the bio-
psycho-social model, the benefits and disadvantages of
this approach are beyond the scope of this paper and are
discussed elsewhere .34 Future medical education research
will be required to test the effectiveness of this visual
metaphor against the more traditional method of teach-
ing and learning psychiatric formulation. In the mean-
time, medical students and psychiatric trainees may
want to use this visual metaphor to augment their learn-
ing. It may help them to have a better understanding of
the various components involved in formulation, which
is a fundamental skill required of a psychiatrist.
Disclosure
The authors report no conflict of interest. The authors alone are responsible for the content
and writing of the paper.
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