Rather than reliance upon broad diagnostic categories, this constitutes an understanding of the main factors responsible for a clinical presentation, and their interplay. Formulation can drive treatment planning if there is an understanding of the salience of each factor. Not just from understanding how influential each is (which could be anywhere from a distant influence through to an immediate influence), but also how it is salient, i.e. whether for example, it
- contributed to the underlying vulnerability of the individual or family (i.e. was a predisposing factor)
- had provoked the emergence of a problem (i.e. was a precipitating factor)
- or is currently perpetuating the problem, or hindering its resolution (i.e. as a maintaining factor).
This long-established framework provides a means of making sense of what uniquely brought the family to the clinic. Drawing upon these multiple perspectives, a formulation can be developed with the family as participants, reaching some shared understanding as the assessment concludes (an example of how that is shared is provided elsewhere).
A clinical case-example is reviewed below to ‘unpack’ the main elements of a formulation, not presented in the way it might be summarised toward the end of a consultation but in order to deconstruct the concept. We have chosen anorexia nervosa as the example (since this provides a particularly straightforward example of the influence of ‘bio’ in a biopsychosocial formulation).
Introduced by Engel, the term ‘biopsychosocial’ is best considered as a perspective on mental health, rather than a model in its own right, an appreciation that ‘bio’ and social-cognitive factors often co-relate. Applying that to formulation in systemic work, we prefer Bebe Speed’s term ‘thickening the description’, since it implies a disposition on the part of the therapist rather than a formula defining what has taken place. Other examples of ‘thickening the description’ can be found within case material throughout Integrated Family Therapy.
A clinical case-example: anorexia nervosa
Absolute weight and BMI occupy a central role in the diagnosis, but have little or no place at all in a systemic formulation. Unless the patient’s ‘at Death’s door’, each contribute little or nothing to understanding the dilemma the patient had been facing on their journey from untroubled development into ‘patienthood’. Either, if strongly introduced into discussion on newly meeting a family, tend to prompt a youngster and frightened carers to work in renewed opposition to one-another, re-enacting their dominant discourse.
The ‘bio’ in biopsychosocial lies in understanding ‘starvation syndrome’, because it is a powerful proximal maintaining factor, due to its adverse effect upon thinking and mood, kicking in however the pathway into restricted eating began. Acute calorific starvation (persistent calorific intake <800-1000cal daily) reduces mood and frustration-tolerance, narrows personal horizons, reduces short-term memory concentration and decision-making capacity, and promotes rigid perseverative thinking; the hormonal responses induced to ‘survive’ these effects may produce an empty euphoria.
Starvation syndrome may thus strongly contribute to ‘why now?’ – the 4th layer of 1985 ‘integrated framework’, i.e. why the family is currently presenting with a problem that requires the help of others. As Goldrick, Haley and many others have described, ‘why now’ is most often considered to relate to family life cycle issues (developing empty nest syndrome, etc.), which the case-example will illustrate too. ‘Why now?’ may also apply to similar issues of relevance to interpersonal psychotherapy (e.g. significant or sudden loss events, not always spontaneously acknowledged by families), which Rolland and others expanded to describe the impact of chronic illness (as a new event or as a continuing adversity), acting to either splinter the family apart centrifugally, or to impede natural family life cycle separations.
We explore the factors salient to the formulation from the most influential or ‘why now?’ (which indicate early intervention) to the more distant, indirect or predisposing (which can be addressed, or better addressed, over a longer period).
Laura: was the 14-year-old elder child of Mary, an elegant ex-ballet dancer who seemed at ill-at-ease for much of the consultation, and her husband Donald, an accountant, who placed himself beside his daughter opposite his wife. Outwardly more composed than Mary, his responses to his wife’s concerns seemed more acquiescence than agreement. That included the decision to not bring Cameron, Laura’s 10-year-old brother, described as distressed by what was happening to his sister; on the way to the appointment he was dropped off to remain with Donald’s parents.
Why now!: in addition to the effects of starvation syndrome, Laura felt she was floundering in S1 and S2, as she believed she didn’t share the perceived self-confidence nor interests of her peer group but now had little in common with her brother, and she felt awkward with her father. She also felt short of her mother’s perfectionism, whose irritable responding made her feel at fault, lowering her mood and self-confidence further. This in turn diminished her appetite and concealment of food; as her academic grades became more difficult to attain, listening to music in her bedroom and a private diary in which she described her confused thoughts became her main means of support.
Links with the past: Without sisters or peer-group experience of young women as a teenager, her father mistook his own diffidence toward Laura as Laura’s withdrawal from him, and didn’t pick up on Laura’s silent hope that he’d remain on in her bedroom after he called in to wish her goodnight. Any conflict in his own family was never openly expressed, so Mary’s brittleness – which, combined with her young glamour made her seem like a starlet – had at first intrigued him, he now found increasingly difficult. During their children’s growing up he had left much of the emotional side of parenting to Mary, feeling in broad agreement with her approach to discipline and standard-setting, but now found himself in silent disagreement with her irritable cajoling manner.
Mary found her own father “useless” (by which she meant ineffectual), and her independently-wealthy mother disinterested (Mary’s interpretation of being sent to boarding school at 10 years old). ‘Struggling alone’ was a script familiar to her, which was resolved by one of her teachers (a firm but kind disciplinarian) taking an interest in her. She had offered strong encouragement for Mary’s dance performances in school shows, which exceeded her scholastic achievements. Mary’s successful entry to dance school was not followed by success as a solo dancer.
Donald’s proposal of marriage took her out of an ensemble role as a dancer that she felt uncomfortable with; making a success of herself as Donald’s wife and mother to their two children became the new way to express herself. She was dismayed about Laura’s unconfident social skills (which reminded her of her own) and by Laura’s later low mood and withdrawal (which reminded her of her father’s, then reputed to be depression due to his family firm’s bankruptcy after he had joined it as a young man).
Interventions based on these: links with the past threw some light upon the responses of Laura’s parents to her plight i.e. parents’ past experiences that predisposed them to not managing the difficulties well. These experiences, previously unspoken of, became enacted through conscious and unconscious identification with aspects of each other and of their daughter. A non-judgmental exploration of the background to these helped them reality-test (called ‘taking back the projections’ in psychodynamic speak!), where each came to feel better understood and cared-for, helped into new responding rather than being silently condemned by the other.
Once greater adaptive flexibility was established, listening to Laura’s account of her journey into difficulty becomes easier to listen to i.e. parental curiosity and reflection became more sustainable (an earlier absence of parental defensiveness would have allowed that journey to be shared far earlier in the consultation).
For example, parents more fully appreciating their daughter’s social lack of confidence, which had been less exposed in the local small primary school class than at the High School. Such issues sometimes pre-date school entry; in Laura’s case it reflected an anxious-attachment style rather than social-communication problems.
Donald recalled his wife’s irritation with Laura’s fussy eating as a child, but had not associated it with Mary’s own strict dietary choices. He was aware, more than Mary had been, that Laura ate less when she was worried; when she first began to pick at her food again he had wondered what she might be worrying about.
He had taken this to be about the onset of menstruation, which Mary had just told him about, but during the family consultation Laura’s parents learnt that – after over-hearing a telephone conversation about “cancer” between her father and his parents – Laura had begun to worry about the death of her grandmother, with whom she had always had a warm relationship, often staying with her before, and after, her brother was born.
Rather than a diagnosis, Laura’s experience (and the dynamic of predisposing, precipitating and maintaining factors) lay at the heart of the formulation. As the assessment had been embedded within a family session, her parents were enabled to recognise that Laura (like any anorexic teenager, by repute insightless), was actually more than capable of collaborating in the development of a detailed formulation that made sense of her predicament.
Her parents saw how family-based perceptions and behaviours which had inadvertently maintained the problem could be changed, and how Laura – now newly more in charge of herself – could reverse the effects of starvation syndrome by herself (rather than they having to inevitably to take control of Laura’s diet, which the well-known Maudsley approach advocates).
Laura’s ‘newly in charge’ position was aided by her understanding that an increased calorific intake could, without significant weight gain, begin to reverse many of its most troubling signs and symptoms. The speed and effect-size of that reversal strengthened the therapeutic alliance: it set Laura on a journey of recovery, and self-discovery, which addressed the vulnerabilities which the fears about her grandmother had exposed, and promoting her parents’ early confidence in the treatment plan.
Postscript: referral from the community is most often prompted by fears for the individual’s safety, but by far the greatest risk for adolescent patients is chronicity, not death (most of the perceived ‘risk’ is socially constructed, not a medical certainty – not even an immediate possibility). Once that is understood and accepted, an understanding of their family member’s predicament, and how it came about, is welcomed by families – rather than parents insisting upon the involvement of a distant specialist.
This may be best achieved by asking the anorexic patient, very early in the conjoint family session, what ideas they themselves have had about the problem. If their response is suffused by their current concerns about how others are responding to their difficulties, these should be noted but the question persisted, now directed at ‘how do you think this all began?’, ‘what was happening then?’.
If the patient goes back to the early symptoms of the disorder (i.e. so their response still remains problem-saturated), the question can be re-stated by asking ‘how were things before that?’ – since the purpose of the enquiry at this early stage is less concerned with problem-description; the primary intention is to establish the informant as an individual within their family, able to reflect upon their developmental experiences, rather than remaining exclusively in a patient role.
This facilitates the dual task of assessment: family members reflecting upon their experiences, and the gradual development of a formulation. Without the anorexic patient being included, their own ideas about the early pathway into difficulty remains undiscovered, and the emerging story becomes instead that of the disorder that resulted. If no beginning becomes apparent, a useful rule-of-thumb is to take the patient back to ‘how were things before then?’, allowing a back-history of at least as many months or years as the duration of the anorexic symptoms.
The affordances and constraints of a Formulation
These are explored by a further case-example. A formulation does not negate a diagnosis any more than the other way round; schizophrenia is an awful illness and, like any chronic illness, the vicissitudes of life, relationships, and service-delivery have an important bearing upon a family’s experience of it.
The case-example below is taken from the first consultation of a young man where ADHD had been already diagnosed elsewhere; certainty of opinion was contested during the family meeting and each assertion of it was found unsafe by others.
The case-illustration demonstrates that however good a history of the presenting problem is provided, and of associated family matters, a ‘told’ story often isn’t as illuminating (for formulation-building) as a ‘lived’ one i.e. how stuff gets talked about. The case also demonstrates how similar in some respects a narrative/social constructionist approach to systemic work is to psychoanalysis – the interest in both lies with how the person/s involved position themselves in the story.
The family of Tony, an 11-year-old young man already on ADHD medication, had moved from near London to a remote Scottish island, and sought a renewed prescription for Ritalin. He was brought by his parents to the clinic, a thick file of past expert opinion (including from the Maudsley) under their arm; each parent walked with a stick or crutch, the young man wore a scowl. His parents said that the files described an additional reported diagnosis of ASD.
Within very few minutes, a persistent verbal sparring between the young man and his parents became established: the young man held his ground – in a quite witty sometimes scathing way – as his parents attempted to maintain their dominant position as experts on him. He seized words they used in a literal sense; or – more unexpectedly – played with their words, bettering a metaphor they had used.
It gradually became clear that – each time he did it – had been to demonstrate the absurdity of their statements about him. Their attempts at an authoritative account of his difficulties were weakened by the world-weary way they exercised their authority. They were unable to ignore his constant interruptions which – to the therapists – seemed designed to challenge their view of him in order to maintain his dignity, a dynamic that his parents seemed unaware of.
Tony finally stated he didn’t want the medication anymore! He then declared – with a bold smirk, “If I wasn’t taking them, I’d have to be adopted!”
The therapists were initially confused by this statement, but then understood it as a contemptuous dismissal of his parents – who agreed. They had already used such words to us, or to him, as not being able to cope, if he wasn’t on medication. And, in similarly expressive way, talked of what we worry about, their whole body posture mirroring their sighs. Later on, rather sadly, what they felt so guilty about.
The presenting problem was prompted by the need for renewed medication, for a confirmed diagnosis. The family’s narrative was forcefully provided, but which one to privilege? A great deal of material and observations had already been obtained by systematic enquiry down south. And what was experienced in the room seemed compelling: in Hannah Segal’s language, it was that which seemed the point of greatest emotional urgency, not what lay in the reports.
What was happening in the room: the least explored or tested in a scientific way, and particularly prone to confirmatory-bias, but a manic defence was clearly going on. Working in silos (choosing them in fact!), the psychoanalytical term ‘manic defence’ has used in ‘psychotherapy talk’ for half a century but is dropped whenever psychotherapists talk to other colleagues. Needlessly, as the empirical basis of that behavioural pattern has been well-established, by and within many different professional domains (e.g. animal behavioural studies, whenever mammals become distressed; from psychology, where mood lifts as gross motor activity increases; as well as from human brain-imaging and from developmental studies of temperament and maternal depression).
None of these later findings negate psychoanalysts’ original observations, they instead simply – to borrow Bebe Speed’s phrase “thicken the description”, an example of a concept that’s been well triangulated by evidence. Allowing a fuller formulation of the problems can drive treatment-planning.
By directly addressing the process, and understanding the fears that drove it, produced the turning point of the session: allowing the family to re-consider their unwise intention to home-school Tony and (for the first time in his education) to enter him into mainstream school. Although this was only available on an adjacent island, the single consultation helped this once fearful young man and his parents overcome their misgivings and, accepting both Ritalin and the fully informed support of his teachers, Tony has used ferries each day to gradually find his place in education; three years later he is still completing it, among his peers.
In summary, the young man’s ASD and ADHD were salient issues, but plainly developmental concerns and anxieties of his own as well as those of his parents were very important to understand, including his sense of self and need to protect his self-esteem.
Is psychoanalytic terminology useful for a formulation? This question is perhaps less pressing for manic defence, which has high construct-validity, than for ‘projective identification’ – which may be seen to drive emotional over-involvement but neither Minuchin nor the Milan group (frequently preoccupied with enmeshed family relationships) acknowledged the term. Peter Rober, writing from a contemporary perspective on the unspoken thoughts and feelings in a family consultation, might argue that the term ‘projective identification’ has become redundant, as it involves needless conceptual elaboration.
Such arguments reflect the imposition of ‘Occam’s razor’ i.e. seeking parsimony of language and theory, and the fewest assumptions to explain an event. That principle could extend to systemic work, albeit particularly challenging where complexity presents – but then perhaps all the more necessary! In other words, useful as a conceptual tool for formulation-building, psychoanalytic terminology probably has little place in the language of formulation.
Occam’s razor: this principle stands as a helpful guardian at the door into formulation-building, because it forces one to think of how to make sense of what an assessment process has produced, rather than just providing a long detailed descriptive summary of findings, which might simply reflect how diligent or arduous the process had been (which Einstein may have experienced on his way to e=mc2 !).
The dangers of ontological commitment: a formulation is a proposition, not an immutable set of facts. Writing about the history of nations, the novelist Colm Toibin warned “while historians may go on attempting grand, sweeping and defining narratives, they work in a time when readers know that another narrative always lies in wait, and that the more intelligent an historian is, the more tentative and self-scrutinising the tone” (Guardian 10th August 2013). Any clinical formulation is similarly prone to confirmatory-bias: committing therapists to preferred ways of thinking however varied the families encountered.
It is therefore important that all the evidence from which a formulation has been derived is made explicit (including the search method employed, as in any literature review), any important gaps in knowledge that remain acknowledged, and being open about why other possible propositions have, for the moment, been discounted.
Stopping rules: Edmund Sonuga-Barke’s description of “stopping rules” in science (what drives science) applies to therapeutic practice: such ‘rules’ “allow one to recognise when a paradigm has outlived its usefulness”, when “a change of paradigm underpinned by different assumptions would be more fruitful”. Examples of Minuchin doing just that can be seen in the videotapes available of him at work. Healthy scepticism is therefore a second guardian, standing at the exit door to remind therapists that any formulation reached is ‘safer’ where it has not sought refuge in certainties.