Australasian Psychiatry
2014, Vol 22(4) 397 –401

© The Royal Australian and
New Zealand College of Psychiatrists 2014

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DOI: 10.1177/1039856214536240
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397

AustrAlAsiAn
Psychiatry

A common misconception of students and psychia-
try trainees is that the formulation process is dif-
ficult; that to write a formulation you must know

all the psychological, biological and social theories. It’s
not surprising, then, that many are put off the formula-
tion process or avoid it altogether. However, the sooner
you start thinking in terms of formulation, even if not
overly sophisticated to begin with, the sooner you will
think like a psychiatrist. This paper is aimed at beginners
to formulation, and their teachers.

Formulation need not be onerous or difficult. Essentially
a formulation is a written attempt at understanding a
patient. Over the decades it has adopted differing struc-
tures, styles and theoretical underpinnings, but at its
core the formulation remains the author’s best effort at
understanding the person in their care. Or, as the Royal
Australian and New Zealand College of Psychiatrists puts
it: ‘Why does this patient suffer from (these) problem(s)
at this point in time?’.1

Understanding necessarily includes aetiology, so much of
the formulation is about identifying postulated reasons/
factors/causes/mediators for a patient’s presentation.

The formulation provides an understanding that
becomes the foundation upon which treatment is based.
In addition, the formulation provides the written record
for communication with others.

The common misconceptions of formulation have been
well characterized by Perry et al.2 in that a formulation:

•• is useful only for psychotherapy patients

•• is only for trainees and not experienced psychiatrists

•• will make treatment inflexible

•• doesn’t need to be written

•• needs to be overly inclusive, elaborate and time
consuming

Another misconception is that you have to know a lot
about psychodynamics to write a good formulation. You
have to know enough about a couple of psychological theo-
ries – even a basic understanding is a good start. You should
know some of the key ideas in psychodynamic theory; we
find Gabbard3 as well as Mitchell and Black4 very readable.
Beginners, as they progress, will also need to learn about
other psychological, biological and social theories too.
Dedicated texts on formulation such as The Biopsychosocial
Formulation Manual,5 Psychiatric Case Formulations,6 and
Multiperspective Case Formulation7 can be useful for the
beginner and seasoned formulator alike.

The idea of the formulation is to be broad, and to use theo-
ries that are useful in understanding the patient. Sometimes
biological reasons will predominate in a formulation, in

Formulation for beginners

Rob Selzer Director Clinical Teaching MBBS, Central Clinical School,
Monash University and Alfred Health; Consultant Psychiatrist at Alfred Health;
Monash Alfred Psychiatry Research Centre, Central Clinical School, Monash University, Melbourne, VIC, Australia

Steven Ellen Head of Consultation, Liaison and Emergency Psychiatry at Alfred Health;
Monash Alfred Psychiatry Research Centre, Central Clinical School, Monash University, Melbourne, VIC, Australia

Abstract
Objective: Developing a formulation is an important method of understanding the people we treat. Writing a for-
mulation need not be seen as burdensome or difficult. Our objective is to provide a framework for the formulation
process to make it more accessible for beginners.
Conclusion: We describe a method that beginners can adopt easily and then build upon as their experience and
knowledge broadens.

Keywords: formulation, training, psychiatry, assessment

Corresponding author:
Associate Professor Rob Selzer, Monash University, Level 5
Alfred Centre, 99 Commercial Road, Melbourne, VIC 3004,
Australia.
Email: [email protected]

536240 APY0010.1177/1039856214536240Australasian PsychiatrySelzer and Ellen
research-article2014

Teaching and training

Australasian Psychiatry 22(4)

398

another psychodynamic factors may have emphasis, and
in another behavioural factors, and so on. Sometimes no
one thing predominates and it’s a mix of all. As Gabbard3
points out, a formulation is not about either/or, rather both/
and. In a similar vein, we’ve moved away from arguments
about nature versus nurture and now think more in terms
of how nature and nurture interact.

Writing the formulation

There are many ways to write a formulation; below is
just one approach. It is a simplified, step-by-step method.
As the user gains more experience and theoretical knowl-
edge it can be built upon, varied (or even jettisoned in
favour of a better way).

It is also worth noting the RANZCP also provides a for-
mulation framework in their Formulation Guidelines for
Candidates.1

Step 1. Write a summary paragraph

This introduction is a brief description contextualizing
the patient and their issues. It may include relevant key
mental state findings.

Step 2. Identify obvious aetiological data

The formulation uses data (from the past and present) to
develop a hypothesis about the patient’s current presen-
tation. The first basic task then is to identify the relevant
data. What stands out in the history? Let’s call these the
obvious data. You’ll identify these easily. For example,
drug use and non-adherence to medications are usually
fairly obvious pieces of data.

Step 3. Use the formulation matrix to
a. Structure the data and
b. Prompt identification of other data/theories

Table 1 is an example of a standard 12-box formulation
matrix (with some helpful prompts). The arrows indicate
that factors in one matrix may be active in another. Use
the formulation matrix to structure the obvious data,
putting them into the appropriate matrix box.

For example, a depressed patient with cognitive impair-
ment describes multiple head injuries and periods of
unconsciousness several years back – you would note
these injuries in the predisposing biological box next to
brain injury.

Table 1. Formulation matrix

Biological Psychological Social

Predisposing •  Genetic •  Personality •  Socio-economic status
  •  Birth trauma •  Modelling •  Trauma
  •  Brain injury •  Defences (unconscious)  
  •  Illness – psychiatric, physical •  Coping strategies (conscious)  
  •  Medication •  Self-esteem  
  •  Drugs/alcohol •  Body image  
  •  Pain •  Cognition  

Precipitating •  Medication •  Stage of life •  Work
  •  Trauma •  Loss/grief •  Finances
  •  Drugs/alcohol •  Treatment •  Connections
  •  Acute illness •  Stressors •  Relationships
  •  Pain  

Perpetuating  

Protective •  Physical Health •  Engagement  
  •  Insight  
  •  Adherence  
  •  Coping strategies  
  •  Intelligence  

(reproduced from Psych-Lite: Psychiatry that’s easy to read. Selzer and Ellen, 2010, Sydney, page 22, table 4.1 with permission 
from McGraw-Hill Australia).

Selzer and Ellen

399

Once you have inserted the obvious data, it’s time to
check through the matrix prompts to see if there is any-
thing else you can add in any other of the boxes. The
prompts act to jog your thinking. Notice that some of
the prompts are data based (e.g. medication) whereas
others are more theoretical (e.g. defences).

Start filling out the boxes vertically – first all the biologi-
cal boxes, then all psychological boxes then the social –
using the prompts in each box to stimulate your
thinking. Ask yourself, ‘is it possible that this [prompt]
has relevance in this case?’ Not all prompts will. No mat-
ter if you don’t know all the prompt theories, later in
your training you’ll be able to see how the facts and the-
ories relate.

For the patient example above, on glancing at the medi-
cation prompt you recall he was started on a beta blocker
just prior to his presentation. This can then be noted
under precipitating biological box next to medication.

If you have identified data for which there is not a
prompt then just place it the box that seems like the best
fit. The prompts are by no means comprehensive! We’ve
tried to keep the table as simple as possible, so there will
undoubtedly be many occasions when you’ll have data
that we have not included as prompts.

Mostly, figuring out which row the historical data fits
into is not too difficult. A distant event is predisposing
and a very recent one is precipitating. Protective is usually
fairly obvious. Sometimes precipitating factors are ongo-
ing and act to perpetuate the symptoms as well. In this
case you can put it in both places, or make a choice as to
which is most prominent.

If it’s difficult deciding into which box data should go,
ask yourself, ‘What theory (think prompt) would make
sense of this data to explain the current presentation?’.

For example, a young man has lost his job. Recent job
loss might play a prominent role in the presenting pic-
ture through precipitating psychological losses in a man
who was invested in his job as a reflection of his sense of
self. But in a person who wasn’t attached to the job per
se, the key effect of job loss might be via financial strain.
In which case precipitating social finances is the relevant
prompt. You have to decide on the significance of the
job loss to this man. Then you put job loss next to the
appropriate prompt(s).

Another example: a young man presents with poly-sub-
stance abuse on a background of a father dependent on
alcohol. You would have no trouble identifying that
there may be a genetic component so you write ‘father
dependent on alcohol’ next to the genetic prompt in the
predisposing biological box. If the son witnessed his father
drinking often (say, in response to stress) you might
include ‘father dependent on alcohol’ under predisposing
psychological modelling as well.

Social factors may be so pervasive that they may have a
role in predisposing, precipitating, or perpetuating the

presentation. Nonetheless, you can make an educated
guess as to when you think they had the most impact, or
you can highlight them in multiple boxes. In the case of
social protective factors, these include all of the factors
within the social domain that can serve to buoy and pro-
tect the individual.

In reality it doesn’t matter too much if you don’t put
some of the data into the ‘right’ box or next to the right
prompt. Often there is no one ‘right’ box or prompt. But
try to note the important data and how it contributes to
the presentation so it is clear in your mind. Over time
and with experience you’ll develop your own matrix
prompts.

Step 4. Connect data to the present via
the theory

In other words, describe how this data explains the pre-
sent circumstances for this patient. A theory will connect
data to presentation.

We have done some of this already in the above exam-
ples. The young man who witnessed his father’s drink-
ing – the theories that may help explain his presentation
are modelling and genetics. Another example: a 29-year-
old depressed man has several close, married friends, but
he has not had a prolonged intimate relationship; a the-
ory that may aid in understanding his presentation is
Erikson’s Developmental theory (Intimacy vs. Isolation).8

Not every piece of data in the table needs to be used in
the written formulation – the table is used for brain-
storming, the formulation is the more considered end
product.

Step 5. Write out the formulation reading
the matrix horizontally

Next, whilst you filled out the matrix vertically, now you
write out your formulation reading from the matrix hor-
izontally. You do this as it makes more narrative sense to
move from the past (predisposing) to the present (pre-
cipitating) to the future (perpetuating) and ending on
the protective. You’re trying to tell a story of someone’s
life, namely, how they arrived at this point and what fac-
tors have been important.

Always remember a formulation is a hypothesis based on
data to explain the present. It will change as more is
learnt about the patient and their circumstances.

For example, after completing the matrix as shown in
Figure 1 we can write out the formulation below:

Jenny is a 30-year-old temp-agency worker, living
with her de-facto partner in a tenuous relationship.
She was admitted 12 days ago following a manic
relapse on the background of a decade-long history of
relapsing, severe bipolar disorder and alcohol abuse.

Australasian Psychiatry 22(4)

400

Her symptoms on admission (e.g. believing she was
a Hollywood actress) appear to have ameliorated and
she is due for discharge soon.

Jenny has a genetic vulnerability to bipolar disorder,
having two maternal aunts diagnosed with the con-
dition. There may also be a genetic component to
her alcohol abuse as her father was a heavy drinker.
Several untreated relapses into depression and mania
have further primed her for this current relapse.

The seeds of future emotional distress were sown
early. She describes her father drinking excessively
when under stress – perhaps modelling a cop-
ing style Jenny was to use as an adult. His drink-
ing binges were followed by long absences from
the family, perhaps contributing to Jenny’s sense
that relationships are unstable. Jenny describes her
mother’s persistent smouldering fury and distance
– potentially leaving her unavailable to care for
Jenny.

Figure 1. Formulation matrix for Jenny.
(original table reproduced from Psych-Lite: Psychiatry that’s easy to read. Selzer and Ellen, 2010, Sydney, page 22, table 4.1 with 
permission from McGraw-Hill Australia).

Selzer and Ellen

401

Jenny’s current frantic efforts at maintaining unsat-
isfying relationships might be seen as a reflection of
an anxious attachment style. Her low self-esteem and
reliance on others to make decisions leave her prone
to exploitation, further eroding her self-esteem or
sense of mastery.

The trigger for the current relapse appears to be non-
adherence with prescribed medication preceded by an
alcohol binge. This occurred in the context of Jenny’s
partner threatening to leave her – bringing into sharp
relief their tenuous relationship and absence of chil-
dren, in contrast to her married peers with families.

Jenny has worked a series of different jobs, most of
which were foreshortened by relapses of her bipolar
disorder and subsequent hospitalizations. Financial
stress is ever present, rekindling noxious childhood
memories and threatening her sense of security. Binge
drinking to escape her predicament compounds non-
adherence to medication thereby furthering her
relapses in mania, which becomes a viscous cycle.

Jenny does, however, have a series of kind, caring
friends. Her desire to re-establish involvement in
her local church is positive, as is her willingness to
engage with her case manager and psychiatrist. She
is thankfully physically well despite many years of
binge drinking. Whilst not academically minded,
Jenny conveys a desire to learn new skills and find
meaningful work.

Conclusion

Formulation is a skill, and as such it requires practice. It is
akin to cooking. One must identify the right ingredients
(the data), mix them in the right amounts (the emphasis
placed on the data) and then cook at the right tempera-
ture (write the explanation in a coherent, logical way).

Above we have described just one way of writing a for-
mulation. There are many styles of cooking; so too with
formulation. We hope this simple method starts begin-
ners on a long career of thinking and writing in terms of
formulation, in time developing their own style and
sophistication.

Formulation should be seen as assisting good practice
and the development of good habits, and not as some-
thing that is only useful in passing exams.

Acknowledgements
We wish to thank Drs Jack Kirszenblat and Bob Adler for their helpful comments.

Disclosure
RS and SE are co-authors of  the book: Psych-Lite: Psychiatry that’s easy to read  for which 
royalties are received.

References
  1.  Royal Australian and New Zealand College of Psychiatrists. Formulation Guidelines for

Candidates. Trainee Clinical Examination.  RANZCP,  2004,  www.ranzcp.org  (accessed 
2/3/2012).

  2.  Perry S, Cooper AM and Michels R. The psychodynamic formulation: its purpose, struc-
ture, and clinical application. Am J Psychiatry. 1987; 144: 543–550.

  3.  Gabbard GO. Psychodynamic psychiatry in clinical practice. Washington, DC: American 
Psychiatric Pub., 2005.

  4.  Mitchell  SA  and  Black  MJ.  Freud and beyond: a history of modern psychoanalytic
thought. New York: BasicBooks, 1995.

  5.  Campbell WH and Rohrbaugh RM. The biopsychosocial formulation manual: a guide for
mental health professionals. New York: Routledge, 2006.

  6.  Sperry  L. Psychiatric case formulations. Washington, DC: American Psychiatric Press, 
1992.

  7.  Weerasekera P. Multiperspective case formulation: a step towards treatment integra-
tion. Original ed. Malabar, Fla.: Krieger Pub. Co., 1996.

  8.  Erikson EH. Childhood and society. 2d ed. New York: Norton, 1964.