Why is formulation daunting? A response to Bagster et al.’s ‘instructions’ for developing skills in formulation

Abstract

Objective: To explore the theme identified by Bagster et al.1 in their selective psychiatric literature review that formulation can appear daunting. Conclusion: Formulation is understandably daunting, even though it occurs in all human encounters. The plural nature of mental symptoms is such that anxiety-provoking intuitive judgement is required at all points in both the process and explication of formulation, a type of instinctive guessing. There are no rules for this, because the laws of vertical integration of systems are not established. Guidelines are more appropriate than ‘instructions’. Much of the wider mental health and clinical reasoning literature addresses intuitive judgement, but the current psychiatric literature tends to focus on pattern recognition as a deliberative cognitive act of Type 2 processes. Arguably this reductionism adds to the dauntingness. Anxiety detected about the intuitive judgement involved can be addressed in supervision, taking into account the psychological mindedness of the trainee.

Addressing the dauntingness of formulation: The value of considering empathy as “grasping”

“…The concept of grasping appears in literature familiar to trainees, that of Clinical Reasoning, where it is described as Type 1 processing. 11,12,2…”

“…The search for a fully conscious understanding of such mental processes is unresolved, 7 arguably contributing to the dauntingness experienced by clinicians otherwise sympathetic to the importance of subjective phenomena. 8,1,2 The divergent emphasis on affective and cognitive aspects of empathy reflects its conceptual history. 9 The cognitive focus comes from 19th century German philosophers' concept of Einfühlung; grasping automatically, with little mental effort, the liveliness of texts and minds, particularly in social interaction.…”

“…The search for a fully conscious understanding of such mental processes is unresolved, 7 arguably contributing to the dauntingness experienced by clinicians otherwise sympathetic to the importance of subjective phenomena. 8,1,2…”

“…T he need for formulation, answering the question, 'Why is this person presenting in this way at this time? ', 1,2 emerged as a corollary of the application of modernist humanist concepts to Psychiatry by Karl Jaspers and others at the turn of the 19th century. 3 Promoting the subjective concepts of empathy and understanding challenged Emil Kraepelin's promissory materialist paradigm, firmly establishing the ongoing debate about the ontology of Psychiatry; that of empiricism versus interpretation and explanation versus understanding.…”

“…The concept of grasping appears in literature familiar to trainees, that of Clinical Reasoning, where it is described as Type 1 processing. 11,12,2 An Oxford English Dictionary (OED) definition of 'grasp'; 'To lay hold of with the mind; to become completely cognizant of or acquainted with; to comprehend' 13 conveys the certainty of a comprehensive grasping. The epistemology of grasping is dealt with under the rubric of empathy and intuition in the extensive literature on those topics.…”