Formulation is becoming the “lost skill” in psychiatry: implications for clinical practice, training, and professional identity

Abstract

Case formulation has historically been central to psychiatric practice, providing a structured method to integrate biological, psychological, and social factors into a coherent understanding of mental illness. However, contemporary psychiatry increasingly prioritizes diagnostic classification and protocol-driven care over individualized formulation. This shift, driven by time constraints, service structures, and standardization, risks reducing clinical encounters to algorithmic decision-making. The erosion of formulation undermines diagnostic depth, contributes to apparent treatment resistance, and weakens therapeutic engagement. This article argues that formulation is not an optional academic exercise but a core psychiatric competency. By revisiting its conceptual foundations, including the “5 Ps” framework, major formulation models, and its iterative clinical process, it examines the consequences of its decline and proposes strategies for reintegration into routine psychiatric practice.