Making sense of psychosis in the context of formulation: the impact of power and paradigm

Abstract

Section A
Background: Limited literature exploring client experiences of formulation shows mixed findings, with less research on experiences of those with psychosis. This study explored clients’ experiences of co-creating a formulation for psychosis.

Method: A systematic search of three databases (PsycInfo [OVID], Medline [EBSCO], and Web of Science, identified 10 papers representing 98 participants. Paper quality was assessed using the Critical Appraisal Skills Programme (CASP) checklist for qualitative studies. A thematic synthesis was conducted on the results sections of the 10 papers.

Results: Participants valued formulation when it fostered personal agency, supported by formulation content and interpersonal dynamics. Formulations were most effective when they provided non-pathologising, multi-dimensional understandings of difficulties that normalised experiences and validated emotions. Collaborative, clear, and accessible processes enhanced participants’ engagement, empowerment, and hope, promoting active involvement and tangible change. Conversely, formulations perceived as dismissive, overly complex, or reinforcing blame diminished participants' sense of agency.

Conclusion: Formulation should prioritise content that normalises and contextualises experiences avoiding reductionist or stigmatising narratives. Collaborative processes respecting service users’ input and emphasising clear communication empower individuals, strengthen therapeutic alliances, and support recovery by fostering agency and autonomy.

Section B
Background: Eye Movement Desensitisation and Reprocessing (EMDR) is increasingly used to address trauma underlying experiences commonly labelled as psychosis. However, little is known about how service users experience the development of psychological formulations within EMDR. Both medical and trauma-informed approaches risk imposing a fixed interpretation of a person’s experiences if not developed collaboratively. This is particularly significant for people who have experienced psychosis, many of whom have also encountered power imbalances within mental health services.

Aim: This study explored service user narratives of EMDR for psychosis, focusing on how collaborative formulation unfolded, and whether it supported changes in how individuals made sense of their experiences.

Method: Narrative inquiry was used to analyse in-depth interviews with 11 participants who had received EMDR for psychosis in NHS services in England. A bespoke narrative analysis drew on structural (how stories were told), content (what was said), and social-context (how stories related to broader power structures and discourses) approaches to explore meaning-making and identity positioning.

Results: Participants described a shift from disempowerment within medical model frameworks to increased agency through collaborative formulation. EMDR was experienced as a relational process that supported emotional integration, personal storytelling, and re-authoring of identity. Trust in the therapist and flexibility in approach were central. Many reframed psychosis through trauma-informed, spiritual, or personally meaningful lenses.

Date of Award	2025
Original language	English