Formulation is considered a fundamental process of cognitive behavioural therapy for psychosis (CBTp). However, an exploration into the personal impact of different levels of case formulation (CF) from a service user (SU) perspective is lacking, particularly for those experiencing a first episode of psychosis.
This Big Q qualitative design used semi-structured interviews.
Reflexive thematic analysis (TA) was used to analyse 10 participant interviews. NVivo 12 computer-assisted qualitative data analysis software aided data organisation and analysis.
One overarching theme ‘CF – A vehicle for change?’ was developed as a pattern of shared meaning across the data set. Three main themes related to the overarching theme: (1) Vicious cycles: ‘I never really thought about it being me maintaining the problems’ (including one subtheme – Self-empowerment: ‘Only you can make the changes for yourself’); (2) Early life experiences: ‘My experiences have shaped the person that I am, therefore, it's not my fault’ (including one subtheme – Disempowerment: ‘[My] core beliefs have been damaged’); and (3) Keep it simple: ‘Don't push it too far over the top in case it becomes like spaghetti’.
Maintenance formulations may be experienced as self-blaming, but also self-empowering, which may help to facilitate change. Longitudinal formulations may be experienced as non-blaming, but also disempowering, which may inhibit change. Simple CF diagrams may also facilitate change, whereas overly complex CFs may inhibit change. How CBTp therapists might look to improve the impact of different levels of CF for service users (SUs) in first episode psychosis (FEP) are described.
- Maintenance formulations are particularly valued by SUs as they increase understanding and outline a route for change.
- Maintenance formulations may increase self-agency and internal locus of control (LoC), potentially leading to self-empowerment, but also self-blame. Longitudinal formulations may decrease self-agency, potentially leading to external LoC and disempowerment, but also non-self-blame.
- Simple and parsimonious formulation diagrams (ideally drawn by the SU) are likely to facilitate a clearer understanding for change.
- Redrawing maintenance formulations mid, and end of therapy, may provide an indication of progress, change, and recovery.
Early intervention in psychosis (EIP) services are committed to ensuring that those experiencing a first episode of psychosis have rapid access to evidence-based interventions for early treatment and prevention (National Institute for Health and Care Excellence, [NICE], 2020; NHS England, 2019).
Cognitive behavioural therapy for psychosis (CBTp) is one such treatment (NICE, 2014), and a case formulation (CF) that synthesises personal experiences with a psychological theory or model, is viewed as the fundamental process in CBT that drives the whole treatment approach (Kuyken et al., 2009). Moreover, case formulations (CFs) take centre stage as a daily feature of clinical practice within EIP services, despite being under-researched.
In EIP, the early phase of psychosis is a period where the onset of symptoms is relatively recent, with service users (SUs) often feeling confused or puzzled by the nature of their experiences. A key function of formulation is to help create understanding of these experiences, and direct treatment, with CFs attempting to make sense of the meaning and mechanisms of psychosis. Consequently, service user (SU) reactions to the experience of CF in first episode psychosis (FEP), seems particularly important/timely to understand. This represents a shift away from viewing individuals with psychosis as ‘un-understandable’ (Jaspers, 1963/1997), towards listening to the voices of SUs via the use of qualitative enquiry (Hodgetts & Wright, 2007). Nevertheless, the impact of CF from a SU perspective is lacking, especially in relation to psychosis, and this question has not yet been explored in relation to FEP.
SUs have been asked about their experiences of CF in CBT for depression (Kahlon et al., 2014; Thew & Krohnert, 2015), depression/anxiety (Redhead et al., 2015) and other mental health difficulties (Kannis-Dymand et al., 2021). Broadly speaking, CFs were found to be ‘a helpful experience overall’ (Thew & Krohnert, 2015), leading to an increase in ‘understanding and/or acceptance’ of their difficulties (Kannis-Dymand et al., 2021), whilst helping them to ‘move forward’ (Redhead et al., 2015). Nevertheless, the authors recommended that CFs be undertaken sensitively and collaboratively, to help mitigate potential adverse reactions (Kahlon et al., 2014; Kannis-Dymand et al., 2021; Redhead et al., 2015).
In EIP, studies found that SUs value psychosocial formulations as a way of making sense of the factors that contributed to the onset of their psychosis (Cairns et al., 2015; Dudley et al., 2009; Harris et al., 2012). However, only two qualitative studies have explored the experiences of CF in CBTp (Chadwick et al., 2003; Pain et al., 2008). An additional study explored SU experiences of ‘CBT-oriented’ formulations in psychosis (although the therapy itself was described as integrative; Gibbs et al., 2020). All three studies noted that SUs had ambivalent emotional reactions to the CF process.
Chadwick et al.'s (2003) study (which used an unspecified qualitative method), explored SUs' experiences in relation to a CF diagram and an accompanying letter. They found that some SUs felt ‘reassured’ and ‘encouraged’ by their CF, whilst simultaneously finding it ‘saddening’, ‘upsetting’ and ‘worrying’. Similarly, Pain et al. (2008), used content analysis to explore SUs' reactions to CF in the form of a written diagram. They reported that the meaning, emotions and behaviour evoked by individual CFs were found to be complex and multifarious. Using grounded theory, Gibbs et al. (2020) found that CF helped make sense of past events, and their impact on the present, whilst providing a route to change. However, SUs also described ‘an array of emotions’ in relation to seeing their formulation written down, with some feeling ‘understood’ and ‘relieved’, whilst others felt ‘vulnerable’ and ‘confused’.
Overall, research investigating the impact of CF has highlighted that sharing a CF with a SU is powerful and may be experienced as helpful and/or distressing. One reason to account for these mixed reactions may be that CFs have not been enquired about as a process where evolving levels build progressively over the course of therapy, moving from descriptive, to maintenance, then longitudinal (where clinically indicated; Kinderman & Lobban, 2000; Kuyken et al., 2009). Descriptive formulations in CBTp (such as those devised from an A-B-C model (Ellis, 1957) – see Spencer (2019) for examples), offer a basic explanation of how thoughts, feelings and behaviours are linked together. Maintenance formulations focus on the individual in the ‘here and now’, identifying perpetuating factors that are maintaining the problem(s) to generate a hypothesis for change (Dudley & Kuyken, 2014). In contrast, longitudinal formulations ‘look back’ over the individuals' timeline, to develop a shared understanding about the origins and development of the psychosis, through identification of precipitating and predisposing factors (Dudley & Kuyken, 2014). These distinct levels of CF therefore raise several important questions concerning their impact on SUs.
Indeed, CFs outlined in studies by Chadwick et al. (2003), and Pain et al. (2008) were described as ‘developmental’ (longitudinal), which also included the use of maintenance cycles. Enquiring about CF as if it is one and the same, makes it harder for researchers and clinicians to pin-point (and differentiate between) which aspects of the CF evoke adverse emotional reactions, versus which aspects of the CF are experienced positively.
In contrast to previous study samples (Chadwick et al., 2003; Gibbs et al., 2020; Pain et al., 2008), the principle aim of this study was to explore the personal impact of CF for SUs that engaged with CBT for the treatment of FEP. A secondary aim was to explore the impact of different formulations (maintenance and longitudinal), in-keeping with the literature which proposes that CF should be researched as evolving levels (Kinderman & Lobban, 2000; Kuyken et al., 2009).
The primary research question is:
What is the personal impact of CF for SUs that engaged with CBT for the treatment of FEP?
A secondary research question is:
What is the personal impact of different levels of formulation for SUs that engaged with CBT for the treatment of FEP?
A Big Q qualitative design was adopted (Kidder & Fine, 1987), alongside the use of semi-structured interviews. Big Q qualitative research recognises the strength and value of researcher subjectivity to ‘sculpt’, ‘shape’ and ‘co-create’ meaning (Clarke, 2021a).
This study was approved by the NHS Health Research Authority (HRA) Newcastle and North Tyneside 1 Research Ethics Committee (reference: 12/NE/0219).
The interview topic guide (see Appendix S1) was developed in relation to the research questions, existing literature, the researchers' clinical/research expertise in the area and SU consultation. The topic guide was exploratory, whilst being centred around participants' written formulation diagram(s) to help anchor the interview to the CF process. For example, ‘Can you talk me through the content of this formulation?’; ‘Can you explain to me how your formulation diagram(s) were drawn up and put together?’. Questions were also spontaneous and responsive to the participants developing account, combined with prompts to drill down to richer, deeper levels of meaning (Braun & Clarke, 2013). For example, ‘Tell me more about that’; ‘In what way(s)?’
The topic guide was piloted with a user-researcher who had personal experience of CF in CBT for an At-Risk Mental State (ARMS). Feedback led to minor amendments (such as the sequencing and wording of some of the questions). Participant information sheets, and consent forms were reviewed by the Manchester Psychosis Research Unit (PRU), SU Reference Group (SURG) and revised in response to their feedback.
Potential participants were invited to take part in the study via their cognitive therapist at the end of therapy (excluding any scheduled booster sessions). Written consent was obtained, and all participants consented to the use of anonymised quotes in the write-up of this study.
Semi-structured interviews were conducted by the lead researcher (H.M.S.) at the participants' home or mental health service. Interviews were audio-recorded using an encrypted Dictaphone and conducted in one session that lasted an average of 42 min (range 23–55 min).
A criterion-based purposeful sampling strategy was used, to identify participants who had experience of the topic under investigation (Palinkas et al., 2015). The following inclusion criteria provided some level of homogeneity and focus, whilst also being flexible so that heterogeneity could be explored to capture a wide range of experiences: (a) aged 16–65 years; (b) had engaged with CBTp (delivered on a 1:1 basis by a cognitive therapist) for a first episode of psychosis, where therapy was formulation driven and psychosis was addressed on the problem list; (c) had received (or had been offered) a written copy of their CF diagram, and were willing to discuss it; (d) were willing to have their interview audio-recorded; (e) able to provide informed consent; and (f) had sufficient command of the English language.
Exclusion criteria included: (a) moderate-to-severe learning difficulties; (b) organic impairment; (c) primary diagnosis of substance misuse (as the above factors may have impeded understanding of the formulation, and/or the ability to have engaged with the CF process); (d) had dropped out of therapy, prior to experiencing the formulation process.
Reflexive thematic analysis
A reflexive form of thematic analysis (TA) was adopted, which uses qualitative techniques underpinned by qualitative research values within a Big Q qualitative paradigm (Kidder & Fine, 1987). An experiential framework was also adopted, underpinned by critical realist ontology (Bhaskar, 2020; Pilgrim, 2020) and contextualist epistemology (focusing on the person-in-context; Clarke, 2021b; Ushioda, 2009). These positions are compatible with one another and with reflexive TA (Braun & Clarke, 2021a; Clarke, 2021c).
Critical realism posits that there is a ‘true’ reality, but we can only partially access this ‘truth’ because it is obscured by social context, language, culture, etc. (Clarke, 2021d; Danermark et al., 2019). Therefore, in reflexive TA there is no assumption that ‘truth’ (in its purest form) resides within the data, owing to researcher subjectivity and interpretation (Clarke, 2021e). Indeed, themes are reported as having been ‘generated’ or ‘developed’, to acknowledge the active role of the researcher in theme development (Braun et al., 2022). Consequently, critical realism posits that all knowledge is ‘fallible and open to adjustment’ (Danermark et al., 2019, p. 19).
Contextualism argues that whilst no single method can ever get to the ‘truth’ (in its purest form), some knowledge will be valid in certain contexts (so is context-specific; Clarke, 2021d). Using reflexivity, researchers can share some of the contexts that have shaped their research, and the knowledge that has been produced (Clarke, 2021d).
Braun and Clarke's (2006) six-phases were flexibly used, owing to the recursive nature of the method. This involved H.M.S. immersing herself in the data by transcribing the interviews verbatim. Identifiable information was removed from the interview transcripts, and pseudonyms were assigned.
Semantic and latent coding of the transcripts was a fluid process, which involved assigning pithy labels with linked memos to excerpts, to capture what was of relevance in the data (Clarke, 2021f). Coding was primarily inductive—grounded in participants' accounts; however, it was also deductive—informed by theory and existing literature. Deduction provided an ‘interpretative lens’ for making sense of (and orientating H.M.S. to) the data (Braun & Clarke, 2006; SAGE Publishing, 2022).
NVivo 12 (QSR International Pty Ltd, 2018) ensured a systematic approach to the analysis via: defining, memoing, searching, visualising and the collation (clustering) of codes (nodes), across the data items. Nodes were organised hierarchically into tree structures to maximise the analysis process. The interactive modelling tool within NVivo was then used to identify patterns and relationships in the data (Bazeley & Jackson, 2013).
In the write-up phase, latent, rich and multifaceted interpretations of meaning and experience were generated, defined and then refined, to capture the ‘essence’ of each theme (Braun & Clarke, 2006). In reflexive TA, ‘overarching themes’ tend not to contain codes or data (Braun & Clarke, 2013; Clarke, 2021g). Their purpose is to provide organisation and thematic structure, tying several themes together to form the overall analysis (Braun & Clarke, 2013; Clarke, 2021g). In contrast, individual ‘themes’ are defined as patterns of shared meaning across the data set, underpinned by a ‘central organising concept’ (Braun & Clarke, 2019a). However, qualitative research produces many ‘stories’ in relation to the data, and so reflexive TA requires researchers to make active and deliberate choices, such as reporting the themes of most interest, including those that best answer the research question(s) (Clarke, 2021f). Finally, ‘subthemes’ may be used to capture (and develop) an important facet of a theme, but this is not a requirement (Clarke, 2021g).
Reflexivity and other indicators of quality
Reflexivity is one indicator of ‘quality assurance’, defined as the rigorous self-reflection, questioning and interrogation of one's role as a researcher (Braun & Clarke, 2021a). As such, Braun and Clarke (2021a) advocate for ‘knowing practice’—that researchers should strive to ‘own their perspectives’ (Elliott et al., 1999). Therefore, H.M.S. kept a reflexive journal, and her positioning, assumptions, and values are stated below in the first person, as recommended in the write up of reflexive TA research (Braun & Clarke, 2019b; SAGE Publishing, 2021).
Myself and my co-authors, acknowledge that we think favourably about the use of CF in CBTp. We all work (or have worked) as CBT clinicians and/or researchers in the NHS. Several of us have also worked within EIP services, and so we are positioned as clinicians and researchers that recognise the value that CBTp can bring to individuals experiencing a FEP. Our familiarity with the wider literature leads us to understand that SUs report mixed feelings about the CF process. Therefore, these prior assumptions will have likely permeated the current analysis (Braun & Clarke, 2021a; e.g. we remained open to hearing, both positive and negative experiences).
However, as stated above, researcher subjectivity is embraced as an inevitable part of the analytic process, and a resource that drives the research (Braun & Clarke, 2021a). Indeed, ‘accuracy’ of interpretation is viewed as a futile process in reflexive TA (Clarke, 2021f), whereas depth of interpretation is viewed as a skill that resides within the researcher (Braun & Clarke, 2021b). As such, two interview transcripts were independently coded by one of the supervisors (S.T.) for the purposes of ‘analytic enhancement’ (see SAGE Publishing, 2021, 2022). This brought different insights/interpretations into the analytic process (e.g. to question some of the assumptions I was making and to highlight data I may have overlooked; Braun & Clarke, 2020).
Contextualising the data
In total, 10 participants (gender, n = 5, 50% male; n = 5, 50% female; age, M = 28 years; range 16–41 years) were recruited from EIP services in the North-East of England. Collectively, they were treated by five cognitive therapists—all accredited by the British Association for Behavioural and Cognitive Psychotherapies (BABCP). The CBTp (number of therapy sessions completed, M = 25 sessions; range 3–40 sessions) was delivered face-to face. Timing of the CFs was naturalistic, with therapists formulating as and when it felt clinically appropriate to do so. The formulations themselves were based on maintenance focused cognitive models of depression (Beck et al., 1979) and/or longitudinal models of psychosis (Morrison, 2017). All participants were White British. Table 1 outlines the participant characteristics.
|Pseudonym||Age||Gender||Clinical presentation||Type of formulation discussed in interview||Hard copy of their written formulation diagram (s) physically referred to in the interview||Presenting issues described in the formulation||Number of therapy sessions received at the time of interview||When did therapy end|
|Tia||17||Female||First episode of psychosis||Maintenance (pre-, mid- and post-therapy)||Yes||Voices, obsessive–compulsive thoughts/behaviours||40||Receiving 1 booster session every 2 months|
|Ciara||34||Female||First episode of psychosis||Maintenance (pre- and post-therapy), and longitudinal||Yes||Rumination, frustration, persecutory beliefs||39||3 weeks previously|
|Katelyn||31||Female||First episode of psychosis||Maintenance and longitudinal||Yes||Auditory hallucinations, childhood trauma, self-criticism, perfectionism, low mood||14||3 months previously|
|Michael||16||Male||First episode of psychosis||Maintenance and longitudinal||Noa||Paranoid ‘irrational thoughts’, anxiety, anger||20||4 months previously|
|Gary||24||Male||First episode of psychosis||Maintenance and longitudinal||Yes||Persecutory beliefs||16||Due 1 final booster session|
|Dominic||26||Male||First episode of psychosis||Longitudinal||Yes||Flashbacks, childhood trauma, auditory, visual and olfactory hallucinations, persecutory beliefs, anxiety, depression||38||Due 1 final booster session|
|Neil||41||Male||First episode of psychosis||Maintenance||Nob||Persecutory beliefs||3 (drop-out)||1 month previously|
|Chris||26||Male||First episode of psychosis||Maintenance||Yes||Persecutory beliefs, social anxiety||36||1 week previously|
|Julie||33||Female||First episode of psychosis||Longitudinal||Yes||Sexual/physical/emotional abuse, auditory hallucinations, persecutory beliefs, panic||17||Due 1 final booster session|
|Lucy||35||Female||First episode of psychosis||Maintenance and longitudinal||Yes||Auditory and visual hallucinations, persecutory beliefs, anxiety||28||2 weeks previously|
- a Did not wish to keep a copy of the diagram (owing to concerns about what his formulation diagram contained, and whether his family might discover it at home).
- b Reported that the staff on the hospital ward disposed of it whilst cleaning his room.
Overview of analysis
One overarching theme entitled: ‘CF – A vehicle for change?’ was developed as a shared pattern of meaning across the data set. Three key themes relating to the overarching theme were generated and reported here. Themes 1 and 2 were associated with the content of the CF, and theme 3 was associated with the CF process.
The first theme related to maintenance formulations and aligned with the concept of why now? This theme was entitled: ‘vicious circles’, which had one subtheme: ‘self-empowerment’. The second theme related to longitudinal formulations and aligned with the concept of why me? This theme was entitled: ‘early life experiences’, which had one subtheme: ‘disempowerment’. The third theme related to both maintenance and longitudinal formulations and aligned with the concept of how to? This theme was entitled: ‘keep it simple’. All three themes are outlined below and presented in Figure 1.
Overarching theme – CF – A vehicle for change?
One overarching theme was developed to provide organisation and thematic structure. The title of the overarching theme captures the analysis overall, by suggesting that certain levels of a CF in CBTp led SUs to experience the process as ‘a vehicle for change’, whereas other levels of the CF did not.
Theme 1 – Vicious circles: ‘I never really thought about it being me maintaining the problems’ (Gary)
This theme was developed to capture the personal impact of the maintenance formulation which involved taking ownership, affirming self-agency (Etelämäki et al., 2021) and having an internal locus of control (LoC; Rotter, 1966).
I'll tell myself things [voices/visual hallucinations] are not real, but I would still run away from them, hyperventilate, have panic attacks, and it [maintenance formulation] was showing how it's all just a vicious circle. Everything I do then makes [embarrassed laugh] more things happen (Lucy).
‘Vicious circle’ was a CBT phrase often used by participants. It evoked a sense of being caught/trapped in an endless negative feedback loop, with safety behaviours creating new problems that aggravated the original problem. The person-centred language also helps us to contextualise Lucy's embarrassed laugh, in that participants were guided by the maintenance formulation to position themselves at the centre of the problem.
This was often alluded to as an ‘aha!’ moment of sudden insight or discovery, an understanding which the maintenance formulation afforded. For example, learning ‘to be more polite, more sociable’, instead of ‘avoiding people’ (which perpetuated his suspiciousness), led Michael to state: ‘I don't think I would've been able to come to that sort of epiphany by myself’.
However, for the most part, the impact of this revelation reflected an appraisal of self-blame; a sense that the maintenance of their psychosis was their fault. This evoked feelings of shame, frustration and sadness in relation to the coping strategies participants had been using: ‘I made things distressing for myself (…) I was giving her [female voice] all the power and all the control’ (Lucy); ‘I know that it is, it's all me (…) what I do [rumination about persecutors] it frustrates me. I know it makes me worse!’ (Ciara).
Checking up there [the loft] every time I walk past [to check for intruders], just makes things worse (…). You know, cos you check once and you hear another noise, and you check again. And then that becomes a bad habit, doesn't it? (Ciara).
Despite this, recognising one's own maintenance factors, was the first step towards implementing change.
Subtheme – Self-empowerment: ‘Only you can make the changes for yourself’ (Ciara).
This subtheme was generated in response to participants experiencing a cognitive shift from self-blame, towards a re-appraisal of self-empowerment.
I'm in control, and I need to be in control of my own life, and the only way I can do that, is if I stop these [safety] behaviours that I've got myself into…(Lucy).
It gave me direction, and then I used that to change how things were (…) one example was feeling like people were looking at me. By staying with my head down that was never really challenged, so when I stopped doing that, I realised people weren't looking at me (Gary).
I've learnt (…) what I can do, which is - get myself out or talk to friends. You know, do things. Practical things…I know what I have to do, to put it into practice. Stop it [maintenance cycle] before I get into, you know, going round and round all day (Ciara).
I started trying to actually sort of help myself, instead of trying to get other people to help me (…) and when I did, it worked! (Michael).
It's like a two-way thing, isn't it? You've got to both have your involvement in it to actually make it work (…). You've got to want to get involved, and you've got to want to understand…(Ciara).
Theme 2 – Early life experiences: ‘My experiences have shaped the person that I am, therefore, it's not my fault’ (Katelyn)
This theme was generated to capture the personal impact of the longitudinal formulation, specifically the realisation that participants' earlier life experiences had contributed to the development of their psychosis.
…how my past had been, and how that had shaped my future (…) I understand where you get from your early experiences to how you feel now (Katelyn).
I thought there was people in the walls in the house, cameras watching me, people in the loft (…) we'd had a burglary and I still hadn't kind of recovered from that and that's I think part of it - having people in my house taking things, was maybe a bit related… (Ciara).
…things that I feel guilt and shame about from being a child, have affected the way perhaps my voices speak to me (Lucy).
Furthermore, the impact of the CF enabled participants to understand that an accumulation of predisposing and precipitating factors, had contributed to the development of their psychosis. Such ascriptions brought about perceptions of an external LoC, with the longitudinal formulation often affirming that participants had been victims of external forces. As such, there was a shared narrative of non-blame—a sense that the development of their psychosis was not their fault. Nevertheless, these aspects of the CF did not appear to facilitate change.
Subtheme – Disempowerment: ‘[My] core beliefs have been damaged’ (Dominic).
This subtheme was developed in response to the personal impact of the longitudinal formulation, specifically the realisation that historic (often traumatic) life experiences, had shaped, moulded or harmed the individual in some way.
…all the [traumatic] experiences I've went under (…) and then a kid like me is programmed, and that's locked in, and then it affects everything I will become, or what I am (Dominic).
As the extract above shows, the statement ‘I've went under’ appeared to have negative connotations. Dominic didn't describe going ‘through’ these experiences, or ‘rising above’ them. Instead, he ‘went under’.
a normal person – my husband, doesn't have all of this going on in his head. He doesn't have bad experiences from childhood (…) he doesn't have rules [for living] like what I have (Katelyn).
It's [longitudinal formulation] making me understand that the way other people have treated me like say when they hit me, or I was sexually abused, or drowned (…) that's so bad and that's upset me so much, and damaged me so much. Someone like me, all your history's bad (Dominic).
…it's more of a long-term thing, it takes a bit longer to work that out and work out how you can learn to feel differently about the past (Gary).
Theme 3 – Keep it simple: ‘Don't push it too far over the top in case it becomes like spaghetti’ (Dominic)
This theme applied to both longitudinal and maintenance formulations. It was developed to highlight the personal impact of participants engaging in (and seeing) their CF written down in a simple, parsimonious diagram, which inadvertently facilitated change. In contrast, complex formulations, too inclusive of detail/information were seen as inhibiting change.
Change primarily occurred in the context of maintenance diagrams. However, it was also described in the context of longitudinal diagrams if the CF incorporated a small number of perpetuating factors (or a simple maintenance cycle); for example, as seen in the longitudinal model provided by Morrison (2017).
- You said that it helped, seeing it [written] down on paper?
- Knowing that I wasn't crazy.
- And how did writing it on paper help you to see that you weren't crazy?
- Like, it all came together…why I'm hearing the voices.
So, I would say at first start with simple, but making sure you know the individual, and then go up to a level what you think is understandable for them (Dominic).
Seeing it on paper…it makes me feel more norm [shy laugh] normal (…). Just not feel like the only one who has this problem (…) because you can design a formulation that people have similar…cos he [therapist] gave me the titles, which means that other people must have had the same sort of titles (Tia).
[they gave] me a little confidence boost to not let me give up…cos sometimes you can't really tell the difference between whether the voice is getting better or not, but seeing it [formulation diagram] on paper makes you think “oh actually I have made progress” and you want to keep doing it [therapy] to get better, so you don't give up (Tia).
As such, this theme appeared to have a tentative relationship with the ‘self-empowerment’ subtheme of theme 1 (see Figure 1).
she'd [therapist] like mention “behaviours”, and then I'd write the behaviours down, and then she'd mention “what are the safety measures?” and then we'd just connect it all together (Chris).
It was just like, maybes if you could change one thing, other things would change along with it (Chris).
There's masses of it (…) I think there's more [of the diagram] on the back [of the page] (…) got lots of little bits scrolled all over the place (Lucy).
- What did you think of doing a diagram like that?
- I thought it was a bit “I'm confused” at the time (…) I couldn't cope with it. Too much information, you know?
- OK, so would you say you understood the diagrams?
- Some of them I didn't.
As can be seen in Neil's excerpt above, not understanding the written CF diagram can reduce cognitive confidence. This may be further reinforced by stigmatising messages conveyed by the traditional medical model that those with serious mental illness have a ‘broken brain’ (Andreasen, 1985). Indeed, if the CF reduces cognitive confidence, then SUs may drop out of therapy (which Neil did, after only 3 sessions). Consequently, this facet of the theme indicated a tentative relationship with the ‘disempowerment’ subtheme of theme 2 and was associated with the CF inhibiting change (as shown in Figure 1).
This is the first study to explore the personal impact of different levels of CF, for SUs that engaged with CBT for the treatment of a first episode of psychosis. In summary, there appeared to be key differences in the ways in which the content of maintenance, and longitudinal formulations were experienced. Whereas the written process of these different levels were experienced similarly. In addition, certain factors of the CF led SUs to experience the process as ‘a vehicle for change’, whereas other factors did not.
The impact of CBTp maintenance formulations, appeared to evoke self-agency and an internal LoC. Self-agency (defined within the context of social cognitive theory) refers to one's ability to take initiative and responsibility for one's own actions in everyday life (Etelämäki et al., 2021). Similarly, internal LoC (defined within the context of social learning theory) refers to the belief that outcomes in life are attributed to one's own behaviour, or personal characteristics. Conversely, external LoC is the belief that outcomes in life are attributed to external forces such as chance, luck or fate (Rotter, 1966).
Enhanced self-agency and internalised LoC have been linked to ‘readiness’ for treatment (Chambers et al., 2008), therapeutic change, empowerment and progress towards personal goals (Tyler et al., 2020). Indeed, in the context of individualist societies (e.g. the UK), achievement of personal goals is highly valued. Therefore, internalised LoC is considered important (Sullivan et al., 2021).
Diminished self-agency and external LoC, have been documented in relation to psychosis—with one's thoughts and actions misattributed to external agents believed to be controlling and/or communicating with them (Kozáková et al., 2020). Our analysis indicated that maintenance formulations brought about self-agency and an internal LoC, in response to SUs understanding that safety behaviours perpetuated ‘vicious cycles’. This could be interpreted as self-blame, but SUs could also feel self-empowered for change. This supports findings from similar research—that the impact of CF in CBTp is experienced in both positive and negative ways (Chadwick et al., 2003; Gibbs et al., 2020; Pain et al., 2008).
One criticism of maintenance formulations is that they are too focused on the individual. Incorporating a small number of external perpetuating factors within maintenance cycles (e.g. wider systemic issues) may help to acknowledge that personal agency does not (and cannot) always exist in people's lives (Bakker, 2008). Helping SUs to discern between the things they can change versus the things they cannot change, may help alleviate appraisals of self-blame. Furthermore, strengths-based formulations (Kuyken et al., 2009) and approaches to psychosis (McTiernan et al., 2020) may empower SUs to implement change that feels attainable (e.g. enabling SUs to imagine using adaptive coping strategies in areas of difficulty; Kuyken et al., 2009).
Our findings also indicated that SU collaboration regarding maintenance formulations was linked to self-empowerment and readiness for change. This reflects therapists' perspectives that active collaboration in CBTp is associated with SU ‘readiness to change’ (Currell et al., 2016).
In the context of longitudinal formulations, making links between earlier adverse life events and the development of psychosis was helpful for SUs, as this evoked a shared narrative of non-blame. This is interesting, as previous research has reported that some individuals feel partly or fully ‘responsible’ for the onset and early development of their psychosis (seemingly, in the absence of such formulations; Jones et al., 2016).
Nevertheless, too much time spent formulating predisposing and precipitating factors (i.e. participants in the current study experienced longitudinal formulation as a lengthy process), may lead to perceptions of external LoC and victimhood, and feelings of disempowerment. Indeed, some authors have argued that models and therapies that emphasise historical precipitants have consistently delivered underwhelming results (Nathan & Gorman, 2002; Roth & Fonagy, 2005). For example, SUs reported dissatisfaction with psychodynamic psychotherapy owing to its preoccupation ‘with the past’ (Nilsson et al., 2007); and elsewhere we have demonstrated that longitudinal formulations in the earlier stages of CBTp may lead to poorer treatment effects (Spencer et al., 2018).
Whilst we are not suggesting that CFs should exclude longitudinal/developmental factors, we concur with other authors that advocate for a primary focus on maintenance processes, to bring about change in the ‘here and now’ (Kennerley et al., 2016). Indeed, our research supports these clinical assumptions, by suggesting that a focus on perpetuating factors is also a preference for SUs.
Formulating a SU's early childhood to uncover core schema/beliefs within the context of a CBT longitudinal formulation, should be handled sensitively, and with caution (James, 2001). This may evoke an external LOC which may be disempowering.
Shaped by early life experiences, core beliefs are believed to be deeply entrenched (Morrison, 2007). Nevertheless, it is possible to target these beliefs in CBTp via use of schema change strategies (see Morrison, 2007). This message should be clearly communicated to SUs to mitigate possible appraisals of being ‘damaged’ or ‘broken’, as these appraisals are likely to discourage self-agency, internal LoC, and any hopes of transformative change. Furthermore, it must be noted that an international sample of CBTp experts endorsed core beliefs as ‘important’ components in the CF of voices and delusions, but not ‘essential’ (Spencer et al., 2020).
Finally, for SUs, clear, simple and parsimonious formulation diagrams facilitated greater understanding of their psychosis and any associated perpetuating factors. If SUs can understand (and visually ‘see’) how vicious cycles are being maintained, then this may self-empower them for change. Conversely the opposite is true—diagrams that are overly complex, confusing, and too detailed, may be disempowering. Indeed, we have argued elsewhere that the CF process in CBT should be parsimonious and simple as possible (Dudley et al., 2015; Spencer et al., 2020). This would seem crucial for SUs with psychosis in the early stages that experience visual memory impairments (Smucny et al., 2020).
The findings have several clinical implications. Table 2 provides an outline of recommendations for therapists.
|Theme||Clinical implications and recommendations for therapists|
|Overarching theme—Case formulation—A vehicle for change?||
|Theme 1—Vicious circles||
|Theme 2—Early life experiences||
|Theme 3—Keep it simple||
Strengths of the study include the real-world representativeness of the sample and the naturalistic timing of the CFs. That five cognitive therapists were involved, suggests that our findings may extend beyond the practice of an individual therapist.
However, we acknowledge that the findings reported here, are partial, situated and contextual (Clarke, 2021f). Our design choices inevitably shaped (and delimited) the knowledge produced (Braun & Clarke, 2022). For example, SUs with a longer duration of psychosis that engage with CBTp delivered by community teams, or inpatient services, may experience the CF process differently. We therefore invite the reader to consider the transferability of these findings, beyond the context in which they were studied (Smith, 2018).
An obvious limitation is that only one participant who ‘dropped out’ of therapy was recruited. Therefore, our research is limited in its exploration of the impact of CF for those that experience the formulation process, then choose to discontinue therapy. Most participants engaged with many CBTp sessions (see Table 1), delivered by highly qualified therapists. However, this may not reflect the provision of CBTp that is available to other SUs. Consequently, the impact of CF for SUs may vary depending upon the quality of the therapy provided, and the pace at which CFs are co-constructed (within the constraints of the number of therapy sessions offered).
Furthermore, we cannot report anything about treatment outcomes, and the interview surrounding the impact of CF may have been influenced by SUs' personal perceptions of recovery. In addition, we acknowledge the limitation of a wholly White British sample of participants, which does not permit broader inferences for the experiences of SUs from minority ethnic groups. This is a recommendation for future research. Future research could also look to assess self-agency and LoC, before and after the co-development of maintenance and/or longitudinal formulations, to test out the theories proposed here.
Robert Dudley: Conceptualization; methodology; resources; supervision; validation; visualization; writing – original draft; writing – review and editing. Lynne Johnston: Conceptualization; formal analysis; methodology; resources; supervision; validation; writing – review and editing. Mark H. Freeston: Conceptualization; supervision; validation; writing – review and editing. Douglas Turkington: Conceptualization; supervision; writing – review and editing. Sarah Tully: Formal analysis; methodology; supervision; validation; writing – review and editing. Helen M. Spencer: Conceptualization; data curation; formal analysis; investigation; methodology; project administration; resources; visualization; writing – original draft; writing – review and editing.
The authors would like to thank the SUs that kindly participated in this study, as well as the CBTp therapists. Special thanks are given to Ron (pseudonym) who co-developed and piloted the interview topic guide. We would also like to thank the Manchester PRU, SU Reference Group (SURG), who provided consultation and feedback on the study materials. Finally, we would like to thank Andrew Gumley for his methodological guidance in the earlier phases of this study and Gordon Turkington for proofreading the interview transcripts.
The lead author Helen M. Spencer was supported by an award from Funds for Women Graduates (FfWG) in the United Kingdom (grant number: 17136). This is the trading name of the British Federation of Women Graduates (BFWG) Charitable Foundation.
CONFLICT OF INTEREST
H.M.S., R.D. and D.T. declare royalties received for books, book chapters and workshops on the topic of formulation in CBT and CBTp. M.H.F. declares royalties received for books and workshops on CBT for anxiety disorders. L.J. and S.T. have no conflicts of interest.
DATA AVAILABILITY STATEMENT
The authors do not intend to make the data publicly available in a data repository to ensure the privacy and confidentiality of all participants.
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- 1985). The broken brain: The biological revolution in psychiatry. HarperCollins INC International Concepts.
- 2008). Problem-maintaining circles: Case illustrations of formulations that truly guide therapy. Clinical Psychologist, 12(1), 30–39.
- 2013). Qualitative data analysis with NVivo ( 2nd ed.). SAGE Publications Ltd.
- 1979). Cognitive therapy of depression. Guilford Press.
- 2020). Critical realism and the ontology of persons. Journal of Critical Realism, 19(2), 113–120.
- 2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101.
- 2013). Successful qualitative research: A practical guide for beginners. SAGE Publications Ltd.
- 2019a). Reflecting on reflexive thematic analysis. Qualitative Research in Sport, Exercise and Health, 11(4), 589–597.
- 2019b). Novel insights into patients' life-worlds: The value of qualitative research. The Lancet Psychiatry, 6(9), 720–721.
- 2020). Can I use TA? Should I use TA? Should I not use TA? Comparing reflexive thematic analysis and other pattern-based qualitative analytic approaches. Counselling and Psychotherapy Research, 21(1), 37–47.
- 2021a). Thematic analysis: A practical guide. SAGE Publications Ltd.
- 2021b). One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qualitative Research in Psychology, 18(3), 328–352.
- 2022). Conceptual and design thinking for thematic analysis. Qualitative Psychology, 9(1), 3–26.
- 2022). ‘A starting point for your journey, not a map’: Nikki Hayfield in conversation with Virginia Braun and Victoria Clarke about thematic analysis. Qualitative Research in Psychology, 19(2), 424–445.
- 2015). Experience of psychosocial formulation within a biopsychosocial model of care for first- episode psychosis. International Journal of Psychosocial Rehabilitation, 19(2), 47–62.
- 2003). Impact of case formulation in cognitive behaviour therapy for psychosis. Behaviour Research and Therapy, 41(6), 671–680.
- 2008). Treatment readiness in violent offenders: The influence of cognitive factors on engagement in violence programs. Aggression and Violent Behavior, 13(4), 276–284.
- 2021a). Foundations of qualitative research 2. Part 1: Key characteristics of qualitative research [Webinar]. YouTube. https://www.youtube.com/watch?v=-XWrpqPrHPk&t=144s
- 2021b). Foundations of qualitative research 1. Part 3: Orientations to meaning in Big Q qualitative [Webinar]. YouTube. https://www.youtube.com/watch?v=_fG6-I-c_Oc&t=206s
- 2021c). Foundations of qualitative research 2. Part 2: Experiential and critical qualitative research [Webinar]. YouTube. https://www.youtube.com/watch?v=OfwtzhE4HtQ&t=5s
- 2021d). Foundations of qualitative research 2. Part 3: Key (theoretical and philosophical) concepts in qualitative research [Webinar]. YouTube. https://www.youtube.com/watch?v=bgZuPmO9130&t=5s
- 2021e). Thematic analysis. Part 4: Avoiding common problems [Webinar]. YouTube. https://www.youtube.com/watch?v=tHeLh1XrWS0
- 2021f). Foundations of qualitative research 1. Part 1: What is qualitative research? [Webinar]. YouTube. https://www.youtube.com/watch?v=qH0XvEe6DzI&t=1s
- 2021g). Thematic analysis. Part 3: Six phases of reflexive thematic analysis [Webinar]. YouTube. https://www.youtube.com/watch?v=BhL113ye9Ss
- 2016). Patient factors that impact upon cognitive behavioural therapy for psychosis: Therapists' perspectives. Behavioural and Cognitive Psychotherapy, 44(4), 493–498.
- 2019). Explaining society: Critical realism in the social sciences ( 2nd ed.). Routledge.
- 2015). The utility of case formulation in treatment decision making; the effect of experience and expertise. Journal of Behavior Therapy and Experimental Psychiatry, 48, 66–74.
- 2014). Case formulation in cognitive behavioural therapy: A principle-driven approach. In L. Johnstone & R. Dallos (Eds.), Formulation in psychology and psychotherapy: Making sense of people's problems (pp. 18–44). Routledge.
- 2009). What do people with psychosis think caused their psychosis? A Q methodology study. Behavioural and Cognitive Psychotherapy, 37(1), 11–24.
- 1999). Evolving guidelines for publication of qualitative research studies in psychology and related fields. British Journal of Clinical Psychology, 38, 215–229.
- 1957). Rational psychotherapy and individual psychology. Journal of Individual Psychology, 13, 38–44.
- 2021). Distributing agency and experience in therapeutic interaction: Person references in therapists' responses to complaints. Frontiers in Psychology, 12, 585321.
- 2020). A grounded theory of how service users experience and make use of formulation in therapy for psychosis. Psychosis: Psychological, Social and Integrative Approaches, 12(3), 245–256.
- 2012). Service-users' experiences of an early intervention in psychosis service: An interpretative phenomenological analysis. Psychology and Psychotherapy, 85(4), 456–469.
- 2007). Researching clients' experiences: A review of qualitative studies. Clinical Psychology & Psychotherapy, 14(3), 157–163.
- 2001). Schema therapy: The next generation, but should it carry a health warning? Behavioural and Cognitive Psychotherapy, 29(4), 401–407.
- 1997). General psychopathology. (J. Hoenig & M. W. Hamilton, Trans.). The Johns Hopkins University Press. (Original work published 1963).
- 2016). “Did I push myself over the edge?”: Complications of agency in psychosis onset and development. Psychosis: Psychological, Social and Integrative Approaches, 8(4), 324–335.
- 2014). Experiences of cognitive behavioural therapy formulation in clients with depression. The Cognitive Behaviour Therapist, 7, E8.
- 2021). Evaluation of collaborative cognitive-behavioural case formulations in a clinical psychology program: A client perspective. Clinical Psychologist, 25(3), 339–349.
- 2016). An introduction to cognitive behaviour therapy: Skills and applications. SAGE Publications Ltd.
- 1987). Qualitative and quantitative methods. When stories converge. In M. M. Mark & L. Shotland (Eds.), New directions for program evaluation (pp. 57–75). Jossey-Bass.
- 2000). Evolving formulations: Sharing complex information with clients. Behavioural and Cognitive Psychotherapy, 28(3), 307–310.
- 2020). Disrupted sense of agency as a state marker of first-episode schizophrenia: A large-scale follow-up study. Frontiers in Psychiatry, 11, 570570.
- 2009). Collaborative case conceptualization: Working effectively with clients in cognitive-behavioral therapy. The Guilford Press.
- 2020). An exploration of strength use and its relationship with life satisfaction, positive self-beliefs and paranoia. The International Journal of Wellbeing, 10(2), 53–70.
- 2007). Case formulation and cognitive schemas in cognitive therapy for psychosis. In L. P. Riso, P. L. Toit, D. J. Stein, & J. E. Young (Eds.), Cognitive schemas and core beliefs in psychological problems: A scientist-practitioner guide (pp. 177–197). American Psychological Association.
- 2017). A manualised treatment protocol to guide delivery of evidence-based cognitive therapy for people with distressing psychosis: Learning from clinical trials. Psychosis: Psychological, Social and Integrative Approaches, 9(3), 271–281.
- 2002). A guide to treatments that work. Oxford University Press.
- National Institute for Health and Care Excellence (NICE). (2020). Implementing the early intervention in psychosis access and waiting time standard: Updated commissioning guidance. NHS England Publications. http://iris-initiative.org.uk/wordpress/wp-content/uploads/2020/12/EIP-Guidance-2020_Final_2_KE.pdf
- National Institute for Health and Clinical Excellence (NICE). (2014). Psychosis and schizophrenia in adults: Prevention and management. (Clinical Guideline 178). https://www.nice.org.uk/guidance/cg178/resources/psychosis-and-schizophrenia-in-adults-prevention-and-management-pdf-35109758952133
- NHS England. (2019). The NHS long term plan. NHS England Publications. https://www.longtermplan.nhs.uk/wp-content/uploads/2019/01/nhs-long-term-plan-june-2019.pdf
- 2007). Patients' experiences of change in cognitive-behavioral therapy and psychodynamic therapy: A qualitative comparative study. Psychotherapy Research, 17(5), 553–566.
- 2008). Clients' experience of case formulation in cognitive behaviour therapy for psychosis. British Journal of Clinical Psychology, 47(2), 127–138.
- 2015). Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Administration and Policy in Mental Health, 42(5), 533–544.
- 2020). Critical realism for psychologists. Routledge.
- QSR International Pty Ltd. (2018). NVivo (Version 12). https://www.qsrinternational.com/nvivo-qualitative-data-analysis-software/home
- 2015). Clients' experiences of formulation in cognitive behaviour therapy. Psychology and Psychotherapy, 88(4), 453–467.
- 2005). What works for whom? Guilford Press.
- 1966). Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs: General and Applied, 80(1), 1–28.
- SAGE Publishing. (2021). Thematic analysis: In conversation with Virginia Braun and Victoria Clarke [Webinar]. YouTube. https://www.youtube.com/watch?v=hns-tlUx1_Q
- SAGE Publishing. (2022). Common challenges in thematic analysis and how to avoid them with Virginia Braun and Victoria Clarke [Webinar]. YouTube. https://www.youtube.com/watch?v=tpWLsckpM78
- Segen's Medical Dictionary. (2012). Bad habit. https://medical-dictionary.thefreedictionary.com/bad+habit
- 2018). Generalizability in qualitative research: Misunderstandings, opportunities and recommendations for the sport and exercise sciences. Qualitative Research in Sport, Exercise and Health, 10(1), 137–149.
- 2020). Are visual memory deficits in recent-onset psychosis degenerative? The American Journal of Psychiatry, 177(4), 355–356.
- 2019). Making sense of psychosis. In D. Turkington & H. M. Spencer (Eds.), Back to life, back to normality: CBT informed recovery for families with relatives with schizophrenia and other psychoses (Vol. 2, pp. 27–32). Cambridge University Press.
- 2020). What are the essential ingredients of a CBT case conceptualization for voices and delusions in schizophrenia spectrum disorders? A study of expert consensus. Schizophrenia Research, 224, 74–81.
- 2018). Cognitive behavioural therapy for antipsychotic free schizophrenia spectrum disorders: Does therapy dose influence outcome? Schizophrenia Research, 202, 385–386.
- 2021). The association between locus of control and psychopathology: A cross-cohort comparison between a UK (Avon longitudinal study of parents and children) and a Japanese (Tokyo teen cohort) cohort. Frontiers in Psychology, 12, 600941.
- 2015). Formulation as intervention: Case report and client experience of formulating in therapy. The Cognitive Behaviour Therapist, 8, E25.
- 2020). Reorienting locus of control in individuals who have offended through strengths-based interventions: Personal agency and the good lives model. Frontiers in Psychology, 11, 553240.
- 2009). A person-in-context relational view of emergent motivation, self and identity. In Z. Dörnyei & E. Ushioda (Eds.), Motivation, language identity and the L2 self (pp. 215–228). Multilingual Matters.