Experience of Psychosocial Formulation
within a Biopsychosocial
Model of Care for First- Episode Psychosis
Dr Victoria Anne Cairns1&3,Bsc
(Hons) Psychology with Spanish, DClinPsy.
Dr Graeme Stewart Reid 1&2,Bsc
(Hons) Psychology, DClinPsy.
Dr Craig David Murray 1, Phd,
Dr Stephen John Weatherhead 1, Bsc
(Hons) Psychology & Sociology,
Msc Psychology and its Applications,
DClinPsy, PgDip Clinical Neuropsychology.
1 Division of Health Research, Doctorate in
Clinical Psychology, Lancaster University, Lancaster, LA1 4YG.
2 Lancashire Care NHS Foundation Trust,
Scarisbrick Centre, Ormskirk and District General Hospital, Wigan Road,
Ormskirk, L39 2JW.
3 Department of Pain Management, Royal Preston
Hospital, Sharoe Green Lane North, Preston, Pr2 9HT.
Cairns VA, Reid GS, Murray CD, & Weatherhead SJ (2015)
Experience of psychosocial formulation within a biopsychosocial model
of care for first- episode psychosis.. International Journal of Psychosocial Rehabilitation. Vol 19(2) 47-62
Dr V. Cairns
Department of Pain Management
Royal Preston Hospital
Sharoe Green Lane North
Preston, Pr2 9HT
A biopsychosocial model of care (integrating biological and
psychosocial supoprt) is often applied within Early Intervention for
Psychosis services. The current study aims to explore the experience of
people engaging with a process of psychosocial formulation whilst also
being supported by clinicians representing a biological understanding
of psychosis. Design: A qualitative design is used, with data
collected through semi-structured interviews. Methods: 9
individuals from Early Intervention services were interviewed regarding
their experience of engaging in psychosocial formulation whilst
concurrently receiving ongoing support from a medical
perspective. Results: 3 common themes were identified across the
experience of the participants. These were (i) a joined-up
‘package’ of support (ii) formulation makes a distinctive contribution
to the ‘package’ (iii) shaping the experience. Conclusions: The
biopsychosocial model of care for first episode psychosis was
experienced by participants as offering a sense of a coherent support
‘package’. This was multi-faceted, of which psychosocial
formulation was identified as making a distinctive contribution.
Participants also exerted agency upon their experience of the
biopsychosocial model of care and were able to shape their support in a
way that was most personally meaningful. Suggestion of the
existence of a continuum of experience of psychosocial formulation
within this context is discussed, in addition to implications for
clinical practice regarding the need to enhance the malleable nature of
the biopsychosocial model.
Keywords: biopsychosocial, formulation, early intervention, psychosis.
medicine has viewed the mind and body as two distinct entities to be
analysed, diagnosed and treated separately (McDaniel, 1995). The
complex interaction between biological, psychological and societal
experiences, including their bi-influential roles, began to be
recognised following an influential article published by George Engel
in 1977. This called for a new approach, which Engel (1977) named
the ‘biopsychosocial model’, highlighting a gap to be bridged between
the two parallel but differing ideologies of biology and psychology.
The main theory underpinning the biopsychosocial model
involves a ‘vulnerability-stress’ hypothesis, the interaction of
environmental stressors and characteristics of vulnerability, which may
be genetic in nature or acquired due to adverse life events
(Nuechterlein & Dawson, 1984; Zubin & Spring, 1977). This
model is now commonplace in a variety of clinical settings (McDaniel,
1995; Main, Sullivan & Watson, 2008; Read, Mosher & Bentall,
One area of mental health research where a
biopsychosocial understanding is often drawn upon is that of
first-episode psychosis (FEP; Read et al., 2004). Within this
setting the biological component of support is provided through the use
of neuroleptic medication, aiming to reduce psychotic symptoms (Kerr,
2003). Alongside this, the biopsychosocial model addresses the role of
social factors such as housing and employment (Read, 2004).
Additionally, a psychological perspective emphasises the role of
adverse life events and pays attention to the sense people make of
their experiences (Geekie, 2004; Read & Haslam, 2004).
Psychological intervention within the biopsychosocial model for FEP is
usually delivered as Cognitive Behaviour Therapy (CBT), consistent with
good practice guidance (e.g., International Early Psychosis
Association, 2005; McGorry, 2005; National Institute for Health and
Clinical Excellence [NICE], 2013; 2014). This approach posits
that it is the way that people think about their experiences that
causes distress, rather than the (psychotic) experiences themselves
(Beck, 1976) and aims to “place the individual’s . . .search for
meaning at the heart of the process of formulation and therapy”
(Chadwick, Birchwood & Trower, 1996, p. 177).
The process of
formulation (e.g. BPS; 2008) not only aids care planning, but also
provides a tool for meaning making. The meanings people make of
their lives and the stories they tell in doing so have been suggested
to be a “unique dimension of recovery” that cannot be reduced to simply
identifying the presence of symptoms (Roe & Lysaker, 2012).
Helpful components of formulation within CBT have been found to include
understanding of the onset and coping with psychotic experiences,
normalising experiences and considering alternative explanations (Berry
& Hayward, 2011; Judge, Estroff, Perkins & Penn, 2008).
CBT perspectives appear to contradict a medical perspective that views
psychosis as a chronic, biologically determined illness that
prioritises pharmacology and symptom reduction (Heriot-Maitland, 2011),
distinguishes normal from abnormal within a diagnostic system (Pilgrim
& Bentall, 1999) and considers the content of the experience as
having no inherent value or meaning (Jameson, 2003). Furthermore,
contrasts exist between the qualitative accounts of individuals who
have accessed traditional medically led mental health services and
those who have engaged in psychological approaches to support for
FEP. In stark contrast to the normalising and validating
experience described earlier (Berry & Hayward, 2011; Judge et al.,
2008), traditional medically led mental health services in the United
Kingdom (UK) and North America have been described as involving
“patronizing attitudes and feelings of stigma” (Dinos, Stevens,
Serfaty, Weich & King, 2004, p. 176) and provoking feelings of
being labelled, invalidated and unheard (Hagen & Nixon,
2011). However, it is proposed that the provision of a
therapeutic space within the biopsychosocial model facilitates
reflection upon the personal understanding of psychosis, potentially
limiting the impact of any perceived discrepancies between the
different components to support and allowing improved communication and
negotiation of shared goals (Mackler, 2009).
provision of a biopsychosocial model of care, Early Intervention (EI)
services provide an alternative to traditional medically led community
psychiatric services for individuals experiencing FEP (Johannessen,
2004). EI services consider psychotic experiences to be dynamic
and reversible in their nature and focus upon recovery rather than
management (Johannessen, 2004). EI services have been shown to
have effective clinical, social and vocational outcomes (Bird et al.,
2010; Craig et al., 2004), though little is known about long-term
benefits (Bird et al., 2010).
Within FEP settings, service
users have reported EI services as enabling their personal journey
towards recovery, citing the importance of developing relationships,
increasing a sense of agency and understanding, whilst also helping to
reduce perceived stigma (Harris, Collinson & das Nair, 2012).
Despite this, opinion on the utility of the biopsychosocial approach
remains divided. The model has been criticised for failing to
fully address issues related to the relationship between the different
natures of its three component elements; biological, psychological,
social (Kinderman, 2005). Read et al. (2004) further argue that
the biopsychosocial model simply creates an “illusion of balance” (p.
4), focusing on pathology and relegating the role of psychosocial
factors to triggers of an “underlying genetic time bomb” (p. 4).
For those with personal experience of psychosis however, understanding
that environmental factors may have impacted upon a biological
predisposition to psychosis has been found to allow sense to be made of
personal feelings regarding the interaction between the brain and
senses (Kerr, 2003).
Given the apparent conflicts
between the biological and psychosocial perspectives on psychosis, the
current study has adopted a qualitative approach to understanding the
way in which people experience a model of support that attempts to
integrate differing theoretical perspectives. This question
has been addressed by asking people to reflect upon their experience of
simultaneously engaging with psychosocial formulation (as part of a
therapeutic process) and support regarding biological treatment whilst
accessing an EI service. The guiding research question was, ‘How
do people receiving support for psychosis within a biopsychosocial
model of care experience the process of psychosocial formulation whilst
concurrently engaging with a biological approach to support?’
Sample and Participants
recruitment took place across seven EI for psychosis teams within three
NHS providers in the North of England. Participants were eligible
for the study if they were under the care of an EI team at the time of
recruitment, were within three years of onset of first treated episode
of psychosis (as assessed by the service using the Positive and
Negative Syndrome Scale [PANSS; Kay, Fiszbein & Oplar, 1987]
criteria), were over the age of 18 and had, within the last three
years, engaged in a process of longitudinal psychosocial formulation
with a clinical psychologist or psychological therapist whilst engaging
in regular discussions regarding neuroleptic medication with relevant
professionals (e.g., psychiatrist, community psychiatric nurse).
were not approached if substance misuse, head injury or organic
disorder were judged to be the primary cause of psychotic symptoms, if
they met ‘at risk’ criteria on the Comprehensive Assessment of At Risk
Mental State (CAARMS; Yung et al., 2005) but had not met PANSS (Kay et
al., 1987) criteria for a psychotic episode, if doubts existed about
the individual’s capacity to consent or they were unable to converse in
Approximately 25 potential participants were provided
with information about the research. Nine of these chose to take
part; these were recruited across five of the seven host teams.
Participants were aged between 19 and 36; the majority were of White
ethnicity, with one individual of mixed White and Black African
ethnicity. All had engaged in a notable amount of individual
psychosocial therapy prior to participation (between 3 and 16 months of
regular sessions with a psychological therapist) and had concurrently
engaged in regular discussions regarding medication with other members
of the care team. Table 1 displays this participant demographic
information (pseudonyms are used).
information was gathered using a questionnaire based upon categories
represented within the national census (Office for National Statistics,
2011). The main research question was approached using a
semi-structured interview schedule. This was developed through
consideration of extant research literature and consultation with a
Open questions were used to explore the
research topic. For example, in reference to seeing a therapist
following a psychiatrist: “how did you then find thinking about your
personal experience from a psychological angle?” Additional
prompt questions were used where necessary to gain further insight into
an experience, for example “was there anything helpful/unhelpful about
NHS ethical approval and
permission was gained from each host NHS trust prior to conducting the
research. Potential participants were identified and given
information about the research by clinicians within the host
teams. Interested persons were asked to respond directly to the
researcher, at which point their understanding of the information sheet
was confirmed and they were given the opportunity to ask
questions. Consent was also gained to contact care-coordinators
to discuss any potential risk issues (no concerns were raised) and
meetings were then arranged in familiar community locations (e.g.,
local health centres). Two interviews were conducted by telephone.
meeting, a further opportunity for questions was provided before
gaining informed written consent. Where interviews were conducted
by telephone, the signed consent form was returned in advance of the
interview. Prior to interview participants were asked to complete
a demographic information questionnaire. Interviews then commenced
(lasting between 22 and 55 minutes). These were audio recorded and
followed by a debrief discussion. Each recording was transcribed
were analysed using Interpretative Phenomenological Analysis (IPA), an
approach that aims to understand how participants make sense and
construct meaning from experience (Smith & Osborn,
2008). In taking the individual’s description of their
experience as the object of enquiry (Baker, Wuest & Stern, 1992),
IPA was chosen for its consistency with the aims of the research
question. IPA also acknowledges the researcher’s own conceptions
and recognises the role these have to play in interpreting the
interview data, creating a “two-stage interpretation process” (Smith
& Osborn, 2008, p. 53) whereby the participant tries to make sense
of their experience and the researcher tries to makes sense of the
participant trying to make sense of their experience.
was approached following the IPA procedure described by Smith and
Osborn (2008). Each trancripst was analysed separately following
an iterative process that initially involved the development of themes
for each participant. A narrative was written for each of these
themes, reflecting a level of abstraction however linked clearly back
to the data and supported by indicative quotes. Consistent with
the aims of IPA, the researcher took an idiographic approach throughout
analysis and attempted to bracket-off thoughts regarding preceding
transcript analysis, approaching each from a fresh stance as much as
possible (Smith et al., 2009).
The themes from all transcripts
constituted the subthemes of the final analysis. The
commonalities of these were then compared and merged in order to
develop overarching themes, whilst care was taken to ensure that the
connections being made were representative of the actual participant
accounts. Each final theme was developed to include a narrative
that aimed to reflect original participant experience (based upon its
subthemes and supported by indicative quotes) and given a name that
reflected the experience of the theme.
Ensuring the Credibility of Analysis
number of measures were taken in order to enhance the rigour and
credibility of the analysis (Elliot, Fisher & Rennie, 1999).
A service user consultant helped to develop the participant information
sheet, interview schedule and consent form, increasing the
accessibility of these documents. The researcher completed a
reflective diary (Yardley, 2008) which was discussed with the second
and third authors to aid reflexivity, acknowledging areas of bias
and/or preconceptions and subsequently reducing the influence of these
upon the research process (Elliot et al., 1999; Smith, Flowers &
Larkin, 2009). Methodological rigour was also ensured by the
grounding of themes in examples from transcripts and these being
audited by the second and third authors (Elliot et al., 1999).
This process ensured that the analysis “is not confined to one
perspective, and makes sense to other people” (Yardley, 2008, p. 241).
resulted in the identification of three themes; (i) a joined-up
‘package’ of support (ii) formulation makes a distinctive contribution
(iii) shaping the experience. These are presented in narrative form
below, alongside supporting indicative quotes taken from the original
data, as recommended by Elliot et al., (1999). Table 2 displays each
theme with identified sub-themes.
A Joined-up ‘Package’ of Support
all except Steven, the biopsychosocial approach was experienced as a
‘package’ of support. The experiencing of therapy, medication and
social support as different but complimentary components, provided a
sense of coherence:
It was easy to let me key worker in on what was
going on [in therapy], I could even let me psychiatrist in on what was
going on and how things were progressing, because I felt like it was a
complete support package. (David)
The different components of
support within the biopsychosocial approach were often experienced as
having individual roles, but delivering a consistent message. For
Simon, this increased a sense of learning and understanding: “I’ve
learnt a lot of that though. . .you pick bits, you do learn bits from
your therapist and from your care workers”. For some participants
these various components appeared fully integrated, with little
distinction made between the different aspects of support. This
further increased the sense of coherence, demonstrated as Jason
attempted to reflect upon his experience of both medical and
psychosocial support: “I think they’ve both helped, but it’s hard for
me to say oh yeh it’s…”.
For Kim, the consistency in the
message being delivered by different professionals reinforced this
sense of coherence, but also created some difficulty. Kim
struggled to understand a biopsychosocial formulation of her experience
and this impacted upon her ability to engage with the whole team as
various members advocated the same message that didn’t make sense to
Kim – [care coordinator] used to say erm, you need to do the work that [therapist] was giving out and that
Int – and how did you find that, hearing that from [care coordinator] and having conversations about that?
Kim – I found it quite difficult to believe what they were saying. (Kim)
experience of support being delivered as a ‘package’ impacted upon the
participants’ experience in a number of ways. Kenyon reflected
upon a sense of security that this provoked: “I knew I weren’t on me
own”. For Adam, this went further as he experienced the two
strands of therapy and medication as safety nets for each other: “it
felt to me really really good and really supportive, coz it felt like I
had something to fall back on if one of them wasn’t working”.
the interaction of the different components of support impacted upon
the experience of understanding. A number of participants, e.g.,
Kenyon, David and Simon, identified the way in which understanding
developed through psychosocial formulation was transferred into other
areas of support. For example, David experienced formulation as
aiding his communication skills when then discussing his experience
with his psychiatrist: “I could explain it in words and visions rather
than getting confused and muddled up on what I was saying”.
with team members were also experienced as significant within the
experience of the ‘package’ of support. Participants commonly
reflected upon these being characterised by a theme of guidance during
early contact with the teams, something that many experienced as
important at that time: “But if I didn’t get the help, erh I think to
be honest something else could have gotten worse” (Andy). The
care coordinator was often experienced as holding a significant role as
someone with whom all aspects of the support ‘package’ could be
discussed. For example, prior to discussing his childhood during
formulation in therapy, Kenyon found himself considering this with his
care coordinator: “I’d spoke to me CPN about it, erh and she said that
it could be a trigger to cause me illness”. For Jess, the care
coordinator’s flexible and supportive presence, alongside more
strutcutred sessions with a psychological therapist, appeared to
increase her sense of security: she’s been such a huge part of me
life for like 3 years, even though like she’s not there constantly. . .
I could go weeks and weeks without seeing her, months, but I know I can
ring her, and it’s the security. (Jess)
The only participant who
did not appear to share this experience was Steven who appeared to
experience psychosocial formulation and medical intervention as
entirely disconnected aspects of his support. This is reflected
in his response when discussing his experience of reviews with the
psychiatrist and whether these included any discussion of his
developing psychosocial formulation: “he just sees me and like assesses
medication and that’s it” (Steven).
The experience of a
joined-up ‘package’ of support with different, yet often complimentary
parts, represents a sense of coherence within the biopsychosocial
model. This was experienced by some as containing distinct but
complimentary components, and others as fully integrated with less
awareness of difference between various aspects of support.
Relationships with clinicians appear key in enhancing this sense of
coherence. Whilst participants occasionally reflected upon some
unhelpful aspects to experiencing all aspects of support in this
joined-up manner, this more often aided understanding and enhanced a
sense of security.
Formulation Makes a Distinctive Contribution
of the nine participants (the exceptions being Kenyon and Kim)
experienced the role of psychosocial formulation as a distinct feature
within the overall ‘package’ of support. The process of
psychosocial formulation was frequently described as providing an
opportunity to view the experience of psychosis from a unique
perspective. This was compounded by participants’ observations of
different professionals as being interested in very different aspects
of their experience. For Adam for example, psychosocial
formulation provided the first opportunity to explore his experience in
depth, over being asked to simply quantify his experiencing of
talking to a psychiatrist erm, it was really only talk of “are you
still experiencing hallucinations, yes right we need to up your
medication” and that was kind of the jist of every conversation. .
.whereas when I spoke to [therapist] about it, even though my psychosis
had gone she still sort of counselled me through what I’d experienced.
Int: had that been the case with any other members of the team?
Adam: no, noone else had spoke about what I was actually seeing or feeling. (Adam)
within therapy was consistently described as aiding understanding about
the experience of psychosis. This was experienced as a crucial
aspect of the recovery process. Exploring childhood experiences
appeared key within this helpful experience of formulation:
we’d worked out that it was me childhood that had started it we could
understand why they [voices] were there and what they were doing there
coz there was no point in working out where they- like why they were
there if I didn’t know where they’d come from in the first place. (Jess)
a new understanding through psychosocial formulation played a distinct
role that was also then incorporated within the overall support
Int: before you described to me how you understand erm
that a lot of your psychosis has come following a difficult upbringing,
how did you find fitting the role of medication in there, into that
understanding of psychosis?
once I knew what the problem was it made me understand why I was seeing
things and why I was hearing things and why I was feeling like
everybody was against me and hated me and, so it, it made me understand
what I was going through and then having [care coordinator] and
[psychiatrist] and [therapist] all going through it with me makes it
easier for me to fit along with the medication as well as the sessions
I was having with [therapist]. (David)
some participants however, the psychosocial component to support was
experienced as the only setting within which to discuss personal
feelings and issues from the past. An example of this includes
Jason’s description of his experience of psychosocial formulation as at
times upsetting and something he preferred to only share with his
Int: has that been quite a new experience for you? Talking about that kinda stuff?
Jason: yeh, I didn’t really wanna go into it with anyone else. (Jason)
participants were able to engage with the different components of
support separately but concurrently: “like the psychiatrist was mainly,
like ‘how are your meds, how are you, how’s your psychosis’ and the CBT
therapist was like ‘right lets do this today, lets work on these
thoughts’ they never really crossed over” (Adam). Similarly, Andy
reflected upon the way in which he chose to engage entirely with
psychosocial formulation and in doing so, put his experience of
medication to one side rather than attempting to integrate these two
approaches: “I didn’t fit anything in, it was just a completely new
Participants did not identify any
drawbacks to psychosocial formulation as making a distinctive
contribution to the support ‘package’. This was experienced as
either integrating well into the overall ‘package’ e.g., David, or
working well alongside other parts within this e.g., Jess, Andy, Adam,
Jason, Simon. For those whose experience is not represented
by this theme i.e., Kenyon and Kim, psychosocial formulation was not
recognised as making a distinct contribution. Instead, for these
two participants all aspects of the support ‘package’ were experienced
as very similar, meaning that psychosocial formulation was not
experienced as any different to the support received from other members
of the team.
The experience of psychosocial formulation as
making a distinctive contribution to the support ‘package’ involves
this being very different to other areas of support such as
medication. This often involved participants’ first experiences
of exploring their early life experiences, a highly valued aspect of
the recovery process and often experienced solely within psychosocial
formulation. For some this was well incorporated with other areas
of support, however others kept this experience very separate although
still remaining part of an overall support ‘package’.
Shaping the Experience
biopsychosocial approach was experienced by seven of the nine
participants as something that could be shaped to be used in the most
meaningful personal way. This suggests the biopsychosocial
approach was sufficiently flexible to engender a sense of personal
agency for the participants, Having a variety of components to
the biopsychosocial model enabled participants to take learning from
various sources and apply this to themselves in a way that felt helpful.
This can be seen within Simon’s reflections over the course of the interview,
learn from talking to people, getting a better understanding, like
psychiatrists, like the way we behave and the way things affect us. .
.the therapist has an understanding of certain, your behaviour . . .
mainly I’ve just learnt to tell people when I’m feeling stressed.
Most participants described benefits of
using psychosocial formulation to gain an increased understanding of
their personal difficulties:
was hard to understand but once I understood it was easy to like, at
first like, I was in a state over it then once I understood it I was
like “oh this is nothing, just go with the flow like”. (Jess)
Int – did therapy have any impact on how you understood the voices?
– yeh it had a big impact…I used to think it was real and it used to
get me into trouble…and the fact that they’d said like they explained
to me…it made me understand that they are not real…and I’ve got nothing
to worry about really coz before I was worrying. (Steven)
many participants described developing useful ‘tools’ from
formulation. For example, Kenyon discussed taking a thought
challenging exercise into his daily life after his formal therapy had
ended, and the increased confidence he gained from this:
before erh my erh time was up we was gonna go to X and do it in X coz
it’s erh a crowded place, but we didn’t have time to do it. . .but it
still reassures me coz I can do it myself now, can just go out and
think sort of and it reassures meself so its another like tool to
understand me illness. (Kenyon)
some participants, the process of formulation itself was viewed as the
useful ‘tool’ upon which to draw when experiencing difficulties in
everyday life: “now and again I go back to that [the formulation] and
that helps” (David) and: “I try and think of what I’ve talked
about with [therapist] when I’m having a difficult day” (Jason).
some, this experience was enhanced by the flexibility of the
biopsychosocial model to allow them to draw upon different aspects of
biological and psychosocial support in response to their personal
need. This was reflected upon by Jason, who discussed the way in
which having therapy available helped him address the barriers to the
progress he has made by taking medication alone: “generally
everything’s going quite well…the only thing what’s stopping me is erm,
delusional thoughts, so that’s why I’m having CBT to challenge them”.
the range of understandings of psychosis demonstrated by the
participants, the flexibility of the biopsychosocial approach supported
the most useful application of psychosocial formulation for each
individual. For those with a dominant medical perspective of
psychosis, aspects of formulation such as education, tools and
techniques appeared to increase understanding and help manage
distress. Alternatively, other participants engaged more
thoroughly in developing a longitudinal psychological formulation and
drew heavily upon this understanding during their recovery.
Finally, the clinicians supporting these participants appear to have
been responsive to the service user’s needs, being flexible and
allowing therapy to be shaped in the most meaningful manner for each
identified themes offer insight into the way in which individuals
experience concurrently engaging in medical and psychosocial components
of support within a biopsychosocial model of care for psychosis.
literature identifies typical differences between medical and
psychosocial approaches to understanding psychosis (e.g., Kerr, 2003)
and raises concerns in attempting to incorporate these within a
biopsychosocial model (Heriot-Maitland, 2011). However, the
current findings suggest that service users do not always differentiate
between medical and psychosocial components of the biopsychosocial
Where discrepancies between the different components
were acknowledged by the participants within this study, e.g., diverse
styles of interaction with different professionals and practical
variations between the differing components to support, these appeared
not to present difficulty for the participants. The current
research suggests that overall, participants often continued to
experience these in a coherent manner (Kerr, 2003).
experienced by the majority as a coherent whole, some participants
experienced different team members and their roles as separate
components within this ‘package’ i.e., recognising differences between
medical and psychosocial approaches to support and viewing these as
parallel processes that may be engaged with concurrently. This
appeared to be facilitated by a view that it is ok for the psychiatrist
to only be interested in ‘symptoms’ (Jameson, 2003), as the
psychological therapist is available for a different understanding, but
that the two may be incorporated within the overall support
‘package’. Steven’s experience provides an exception to this
viewing the two elements as entirely separate support systems with a
limited acknowledgement of them being part of a ‘package’.
theme ‘shaping the experience’ offers interesting insights into the way
in which participants drew upon psychosocial formulation in many
different ways. For example, Jess appeared to make sense of her
experience of psychosis drawing predominantly upon psychosocial theory,
whilst Jason appeared to understand his experience based upon a
biological perspective of psychosis as an illness. Interestingly,
both Jess and Jason engaged in psychosocial formulation with clinicians
with similar professional backgrounds (both clinical psychologists),
however each described drawing upon this in different ways. For
Jess, the longitudinal nature to formulation appeared key in helping
her make sense of her experience and work towards her goal of improved
quality of life, however Jason described formulating his current
experience of ‘delusional thoughts’ the most helpful approach to
reaching his goal of ‘symptom’ reduction.
The above two
examples of differing applications of psychosocial formulation
highlight stark contrasts in the way in which this component of the
biopsychosocial model may be experienced. One potential
interpretation of these findings involves viewing the experiences of
Jess and Jason as representing two extreme points upon a continuum
representing the experience of psychosocial formulation within a
biopsychosocial model of care. Jess’ experience appears to
represent the application of psychosocial formulation grounded
predominantly within psychological theory, and Jason’s the use of
psychosocial formulation to make sense of a biological understanding of
The varied experiences of participants within the
current study could be considered to represent different points upon
this continuum. For example, the experiences of David, Kenyon,
Andy and Adam could represent a middle point, as these participants
often used medical language to describe their ‘illness’, however
described this as being ‘caused’ by traumatic early experiences.
As such, working through these traumas within longitudinal psychosocial
formulation, exploring both early childhood experiences and current
maintenance cycles, appeared helpful to these participants.
the current findings suggest that the participants in this study were
able to move along this proposed continuum throughout their experience
of recovery. For example, at times Jess described feeling so
distressed by her experience of hearing voices that she would have
considered taking medication to be rid of this. This suggests
that despite holding a predominantly psychosocial understanding of her
experience, the flexibility of the biopsychosocial model enabled Jess
to consider a medical perspective alongside this.
variation between participant experiences, commonalities also appear to
exist. These also reflect previous literature exploring the
experience of CBT for psychosis. One example includes the way in
which, similar to Messari & Hallam (2003), the majority of
participants experienced psychosocial formulation as a healing and
educational process. The ability for participants to gain similar
benefits whilst approaching psychosocial formulation from very
different angles demonstrates further benefits of the flexible
The current findings also
suggest that the biopsychosocial model manages to overcome previously
identified concerns regarding a message of passivity that may
potentially accompany the prescription of medication (Ross & Read,
2004). The clear role of formulation discussed within the
findings indicates a focus upon active participation in a process of
recovery. A number of participants appeared to experience
feelings of motivation to engage in psychosocial formulation whilst
concurrently holding a perspective of being medically ‘unwell’ and
These participants appeared to shape
their experience of psychosocial formulation in order to reflect a
personal understanding that incorporated aspects of both medical and
psychosocial perspectives. This seemed to facilitate an
assimilation of new understanding developed through formulation, into
personal explanatory frameworks (whether these be predominantly medical
or psychological in nature), drawing upon psychosocial formulation as a
tool for exploration. This supports previous suggestion that the
biopsychosocial model is advantageous in providing a therapeutic space
within which to explore potential discrepancies between different
perspectives to psychosis (Mackler, 2009).
results also suggest that the biopsychosocial approach provides
an experience largely consistent with the positive and helpful features
previously identified within psychological approaches to support (Berry
& Hayward, 2011; Judge et al., 2008). This includes staff
qualities such as a normalising and supportive approach, as highlighted
within the attention paid to relationships within the theme ‘a
joined-up ‘package’ of support’. These findings show that despite
clinicians within a biopsychosocial model of care having various
professional backgrounds (i.e. both medical and/or psychosocial), their
relational style appears more consistent with that more traditionally
represented by psychological approaches to psychosis. This may be
as a consequence of the input provided by psychological therapists
within the development of guidelines that underpin EI services (e.g.,
International Early Psychosis Association, 2005).
current findings raise important implications for clinical
practice. The seemingly malleable nature of the biopsychosocial
model appears to play a role in enabling individuals with differing
understandings of psychosis, to engage simultaneously in both medical
and psychosocial components of support.
The sense of coherence
between different components appeared further facilitated for the
current participants, by the use of a language shared between all team
members and individual service users. According to the
participants, this appeared to often (although not in all cases)
include diagnostic labels and descriptors such as ‘delusional
thoughts’. The consistent use of such medicalised language
between all team members, including psychological therapists, was
experienced as helpful in enhancing a sense of overall coherence
between the different components to support.
potential benefits of all team members adopting the use of a shared
language, the current research suggests that clinicians adopt a
flexible approach to such aspects of their practice when working within
a biopsychosocial model of care. However, this may present
challenges to those who hold a view that the use of diagnostic labels
and language that medicalises distress is unhelpful to service users
working towards recovery (e.g., Scott, 2010).
formulating the effects of trauma in the context of ‘symptoms’ of a
medical ‘illness’, may be considered a retrogressive step by those that
view this as misinterpretation of psychosocial theory e.g., Read and
Bentall (2012). However, the way in which some participants
within the current study described experiencing psychosocial
formulation in this manner (and experienced this as helpful) emphasises
the need for psychological therapists working within a biopsychosocial
model to remain open to formulating with service users in ways that may
draw upon both biological and psychosocial perspectives.
the current research highlights the influence of the therapeutic
relationship upon the sense of coherence experienced between the
different elements of support within a biopsychosocial model of
care. This builds upon previous findings by Harris et al. (2012)
that central to good care are relationships between team members and
service users that involve feeling understood (Johansson & Ekland,
2003). Continued attention to the therapeutic relationship,
through the adoption of a normalising and valuing approach, is
therefore encouraged by the findings of the current study.
Strengths and Limitations
current study has provided insight into a novel research question
within an area of high interest within current research. Although
findings from qualitative research are always limited in their
generalisability, by recruiting across three NHS trusts the current
study has attempted to maximise this as much as possible, though it is
acknowledged that the application of a biopsychosocial model of care
may vary . Purposive sampling was used in order to recruit a
sample that was homogenous in that all participants had experienced
concurrently engaging in both medical and psychosocial support for
FEP. This approach to sampling is consistent with the aims of IPA
research, where researchers “usually try to find a fairly homogeneous
sample, for whom the research question will be meaningful” (Smith et
al., 2009, p. 49).
Additionally, it is important to
acknowledge that the data has been subjected to a process of analysis
that is interpretative in nature. This must therefore be
recognised as representing the way in which it has been understood and
organised by the researcher (although validated by a second researcher
as discussed above) and is open to critique and further interpretation
Conclusions and Future Directions
current study has provided valuable insight into the discrete
experience of concurrent engagement in psychosocial and medical
approaches to support for first-episode psychosis, as contained within
a biopsychosocial model of care. The participants within this
study generally experienced this as offering a sense of a coherent
support ‘package’, of which psychosocial formulation was identified as
making a distinctive contribution. Participants were also found
to shape their experience of the biopsychosocial model of care in a way
that was most personally meaningful. The findings additionally
suggest the potential existence of a continuum representing a range of
experience of psychosocial formulation within this context.
for clinical practice include highlighting the importance of a
flexible, client centred application of a biopsychosocial approach
through underpinned by the use of a psychosocial formulation.
Future research may wish to build further upon the current findings by
exploring the experience of clinicians working from a biopsychosocial
model of care for psychosis.
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