Authors' reply: psychiatrists' use of formulation

In this issue of the BJPsych Bulletin it is heartening to hear discussion and reflection on our work ¹ from Professor Hughes, ² and how particular issues that interested the research team resonated for her.

Professor Hughes brings a perspective from her work in psychotherapy and her own experience of the role of therapy and formulation in psychiatry. She reflects on the range of understandings of formulation within the profession, and possibly the semantic gap between psychology and psychiatry around this. Psychiatrists' understanding of formulation was a key area of interest for the research team, who come from a range of theoretical backgrounds themselves, and from across the psychiatry and psychology divide. This range of enhanced understandings as a result of different ways of formulating is something the team values, and we hope the research provides some further discussion and thinking of psychiatry's relationship with this.

Professor Hughes writes from an interesting generational perspective while acknowledging some distance from the coalface of the National Health Service (NHS). This perspective was interesting for the research team, given our own experiences working as psychologists and consultant psychiatrist in the NHS over the last 15 to 20 years and also through the generational experiences of those being interviewed. In response to her query about the level of experience in the sample, the 12 psychiatrists interviewed had between 7 and 41 years' experience since qualifying, with 8 of them being at consultant level, ranging from early consultant years to people nearing retirement. We would highlight the finding that formulation appeared to be increasingly valued with greater experience and that more experienced interviewees felt more confident in their ability to use formulation.

Staying with the generational theme, Professor Hughes does highlight with some sadness the challenges faced by psychiatrists today. We also felt these were important emerging narratives in the research, particularly increasing workload, time pressures and the loss of thinking space. These were regretted by the psychiatrists interviewed and should act as an alarm to us all. Like Professor Hughes, the research team were saddened to hear some psychiatrists feeling formulation was an add-on role, an addition to the diagnostic, prescribing and risk management roles. We would echo her words in ensuring that supporting psychiatrists in training around recognising the impact of the range of experiences upon mental distress, and building their skills in formulation, should remain a key area of psychiatric training and examination.

However, like Professor Hughes, we remain hopeful for the opportunities of working together across professions and learning from each other for the future.