Trying to navigate the world of mental health can be really difficult and confusing. There are so many terms from Cognitive Behaviour Therapy to Psychotherapy and from Schema therapy to DBT and we understand that this can make it really challenging to understand what the right approach is for you. On our ‘Therapies’ page we try and explain some of the therapeutic approaches we offer so today I want to explain the difference between a diagnosis and a formulation.
Diagnosis and formulation
Most people are familiar with the term diagnosis from health diagnoses such as flu or diabetes to mental health diagnoses such as Major Depressive Disorder and Generalised Anxiety Disorder. Typically if people are looking for a mental health diagnosis we suggest they have a psychiatric assessment with a Psychiatrist and we are pleased to say we have a Psychiatrist who is affiliated with our practice. For some people a diagnosis can be very validating as it can help make sense of difficulties, can lead to the most appropriate medication being prescribed and can also some people access services.
Most people are less familiar with the term formulation. A formulation is something that Psychologists are trained in and we use formulations to guide our plan for therapy-a bit like creating a road map that we use to navigate to where we want to get to rather than aimlessly trying different roads in the hope we will arrive at our chosen destination! A Psychologists formulation will look slightly different depending on what therapeutic approaches they are trained in but most will include the following elements. Firstly it will seek to clarify the presenting problems a client wants to address in therapy. This might be one thing like feelings of emptiness or Panic Attacks or might be several things like low self esteem, feelings of irritability, problematic eating and difficulties in relationships. When a psychologist is exploring the presenting problems that a client wants to address in therapy they will usually consider mental health diagnoses but the intention of a formulation isn’t to diagnose people it is to understand in an individualised and nuanced way what might be making someone suffer.
Secondly a formulation considers predisposing factors, which is our genes, temperament as well as events and relationships from our past that may have led to a vulnerability to us experiencing difficulties in our adult life. For example, some of us temperamentally may be very sensitive and empathic so growing up in a family where there were lots of big personalities and perhaps lots of arguing might have felt overwhelming, especially to our nervous system. Aside from our temperament a psychologist will also explore during a formulation what life was like for us growing up. Where as some people feel a diagnostic label implies there is something ‘wrong’ with them, the predisposing factors helps us to understand that is the the things that happen to us (like being bullied or our parents always fighting or trauma) and the things that haven’t happened that should have happened (like feeling safe and loved by our family or accepted by people around us or the freedom to explore our own identity rather than conform to expectations and the need for fun and spontaneity) that often lead to our struggles. So a more helpful question to ‘whats wrong with me’ is to ask ‘what happened to me’ and what a psychologist will help you explore is what the unmet needs for me growing up (and we usually all have a few even when we were raised in very loving supportive families) that created a vulnerability to experiencing the difficulties I am now grappling with.
Thirdly, we look at key precipitating factors which are things in our current life that may have triggered our particular struggles. For example someone who was bullied may have developed a belief that they aren’t worthy of connection but it’s not until their partner leaves them that this belief gets re-triggered in their adult life. Or perhaps a sudden loss such as loss of a job or loss of a loved one may trigger memories of loss from their childhood such as a parent leaving. Or the restrictions placed on us during the pandemic and the isolation that many of us have experienced may trigger memories of isolation and loneliness from childhood. Sometimes we aren’t consciously aware that our current struggles are related to anything from our past and therapy can help us to explore this. However sometimes our difficulties don’t have routes to our early developmental years, for example perhaps life has just suddenly become very stressful and this has precipitated feelings of anxiety. Either way therapy can help us understand what might have triggered our struggles.
Fourthly a formulation looks at perpetuating factors, these are things we do that inadvertently might maintain our difficulties for example perhaps I avoiding taking the bus for fear of a panic attack but my avoidance actually maintains my anxiety as I never learn that it is safe for me to take the bus and moreover makes me life smaller and smaller which also robs me of my confidence and sense of freedom. Or perhaps I get angry at others and push them away and this perpetuates my feelings of loneliness and disconnection. Another example is my perfectionism which drives my unrelenting standards and feelings of pressure and exhaustion or my self criticism which drives my feelings of inferiority and inadequacy. Typically perpetuating factors are coping strategies – attempts we make to try and cope as best we can for example using food to soothe ourselves when we are feeling hurt, but often they have negative unintended consequences in the form of maintaining our struggles. Perpetuating factors can also be more cognitive in nature including the inner voice in our head that for too many of us is demanding and/or critical.
Finally a formulation will look at protective factors-these are the things we have in our life that give rise to positive emotions and/or create a degree of resilience such as friendships, self compassion, exercise, meditation, a sense of meaning, hobbies, a fulfilling job or doing things that give us a sense of mastery and accomplishment, participating in activities in an engaged way that helps create a state of flow, self soothing skills or ability to distance ourself from our thoughts.
One we have established a formulation which is your individual map for how you came to seek therapy we then use this to create a plan for change. Each section of the formulation can be used to guide the change process, for example a therapist might help you process some of the predisposing factors, or help reduce the perpetuating factors or support you in building more protective factors.
By seeing a psychologist you can build your own formulation or road map to help you on your journey to where you want to be.