Despite integrative case formulation being referred to as the core skill of a trained psychiatrist (1, 2), and despite published attempts to explain what it is and how to do it, in practice, trainees have difficulty developing these skills and have high degrees of uncertainty as to what is required (2–4). The challenge is not so much ascertaining what should be included in a formulation (according to the American Board of Psychiatry and Neurology’s Psychiatry Core Competencies, the items comprise neurobiological, phenomenological, psychological, and sociocultural issues ) but rather linking it to the development of a comprehensive and individualized treatment plan.
Our trainees, from medical students to trainee psychiatrists, have found the explanation and diagram listed below to be helpful (Figure 1). Hence, we submit it to more public scrutiny. It should be noted that we are not proposing yet another competing model for integrative case formulation but putting forward a didactic strategy for effectively teaching it.
Consumers or patients come to psychiatric services seeking (or their relatives hope) some intervention(s) which would improve the way they feel and/or the way they function. The key to this, and the whole point of the psychiatrist/patient interaction, is to jointly develop a management or recovery plan.
To gather the assessment information is a skill taught at various depths to medical students, nurses, psychologists, trainee psychiatrists, and students of other disciplines. Despite the fact that it is treated, at times, with ponderous formality in some training schemes, collecting the information is not a skill so difficult to learn that its attainment separates students from practitioners. Rather, it is how they put that assessment information together. The process of the clinical logic of the clinician/consumer interaction that we are advocating is displayed diagrammatically below. The link between the assessment and the management plan is provided by the diagnosis and formulation.
The teaching process commences with the students indicating they lack confidence in their ability to write patient formulations. The point is then made that the real function of the clinician/patient contact is to produce a patient recovery plan. The diagnosis and formulation should drive the patient recovery plan, and it should be possible to trace back to the diagnosis and formulation a reason for everything that appears in the management plan.
Students are then asked to go through all of their assessment information, underlining or otherwise extracting everything that, in their clinical thinking, will make a difference to their proposed management plan. That material comprises the content of the formulation. This ensures that the formulation content is driven above all by the needs of the patient recovery plan rather than being conceptualized in this development as a summary of the assessment. Since the information gained in the assessment should have the same logical link to the diagnosis and formulation as we described between the latter and the patient recovery plan, the formulation to be derived by our technique is largely the same as that driven by standard teaching practices of summarizing, explaining, and understanding the assessment. The difference largely lies in how the student arrives at his or her opinion on what to include. In the teaching sessions, students are encouraged to justify everything they include.
This simple diagram of the flow of clinical logic appears to us to be a very helpful aid in developing the skills and the confidence in making formulations. Probably, we suspect, because it gives focused meaning to the task of formulating, and direction to the process. Knowing where one wants to go has always been of great assistance to getting there! It gives a conceptual logic to menu approaches such as the seven P’s of Nurcombe and Fitzhenry-Coor (2) and the comprehensive diagnostic system envisaged by Williams et al. (5) or the mechanistic approach to a biopsychosocial-cultural formulation as explored by Guerrero et al. (6).