Foundations, terminology and evidence limits

3.1 Distinguish the products of assessment

| Product | Main question | |---|---| | History and chronology | What happened, when, and according to whom? | | Phenomenology and MSE | What experiences, signs, behaviours and cognitive changes are present? | | Diagnostic formulation | Which syndrome or diagnosis fits the pattern, and what alternatives remain? | | Explanatory formulation | How might selected factors and processes interact in this individual? | | Risk formulation | What current needs, changes and foreseeable scenarios require preventive action? | | Management plan | What will be done, why, by whom and with what review arrangements? | | Capacity and legal reasoning | What decision is being considered and what separately established criteria or authority apply? |

The last row is a boundary, not legal guidance: a persuasive formulation cannot establish capacity, consent, detention authority or a statutory threshold by itself. Do not insert a legal conclusion merely because a mechanism or diagnosis has been selected.

3.2 Four Ps and five Ps

Four Ps: predisposing, precipitating, perpetuating and protective. Five Ps: add the presenting problem. The order is an organising convention. An event may have more than one role and that role can change over time. The finished formulation should prioritise explanatory relationships, not reproduce a complete matrix. ^S02

A recent loss, for example, may be temporally associated with deterioration without being its sole cause. Continuing housing insecurity may both precipitate distress and restrict recovery. Protective factors are not an arithmetic subtraction from risk.

3.3 Observation, report, inference and absence

Use these labels consistently in the clinical record and data model:

• Observed: directly seen or measured, with context and time.
• Reported: attributed to the person, collateral informant or prior record. Record disagreement rather than silently choosing a version.
• Inferred: a clinician’s interpretation, including a mechanism or developmental explanation.
• Unknown / not assessed: information is missing. This does not mean absent.

A quotation in the teaching library is synthetic patient-language illustration, not an elicited statement from the current patient. A laboratory result, medicine timeline or collateral account should retain its source and date when it informs a hypothesis.

3.4 What the evidence does and does not establish

The corrected Flinn review concerns inter-rater and test–retest reliability, not a comprehensive demonstration of validity, treatment benefit or outcome superiority. Results varied between methods, and methodological differences prevent a simple ranking of theoretical schools. It therefore does not justify either “formulation is objective causal truth” or “psychodynamic formulation is always less reliable than CBT”. ^S20

A systematic review can support an association between a construct and symptoms without establishing the causal explanation in a particular person. A professional competency can justify including a domain without establishing the effectiveness of a specific intervention. A workbook can offer practical language without being a clinical guideline. These distinctions determine how sources are used throughout this guide.

3.5 Clinical notes versus OCA/IOCA assessment

The RANZCP OCA/IOCA guidance describes an explanatory formulation that precedes the diagnostic statement, with management and prognosis treated separately in that assessment convention. Broader clinical documentation may deliberately connect diagnostic reasoning, formulation and management. Use the appropriate context rather than turning one assessment format into a universal clinical-note rule. The current PDF’s revision history also does not mean every older vignette or diagnostic term has been revalidated. ^S02

3.6 Shared understanding and disagreement

Offer a comprehensible, tentative explanation and ask what fits or does not fit for the person. Preserve their wording and important disagreements. A person’s rejection of a hypothesis is not, by itself, evidence of denial, poor insight or resistance. Collaborative care should incorporate goals and preferences, while urgent care and decision-specific capacity questions require their own processes. NICE NG197 is a supplementary shared-decision source and explicitly excludes immediate life-saving emergencies and decisions for adults lacking capacity at the time. ^S05S08S19