There is a conversation happening across mental health services at the moment. You will have heard it. Trauma-informed care is being spoken about as though it has arrived fully formed from nowhere, a new framework that progressive services are now scrambling to adopt. Colleagues are attending training days on it. Commissioners are writing it into contracts. People are being certified in it. And meanwhile, mental health occupational therapists are sitting quietly in MDT meetings thinking the same thing: we have been doing this for decades. We just did not put it on a lanyard.
This is not a territorial complaint. It is a clinical one. Because the conflation of novelty with innovation in mental health services has real consequences, not least for the patients who deserve to understand what different professionals actually offer, and for the commissioners who are funding services without always knowing what they are buying. So let us be clear about what occupational formulation is, where it comes from, and why it demonstrates that trauma-informed, person-centred, functionally grounded care is not a trend in occupational therapy. It is the foundation.
What is occupational formulation?
Occupational formulation is the way in which a mental health occupational therapist makes clinical sense of a person's difficulties. It is not a checklist or a screening tool. It is a structured clinical reasoning process that draws together everything an OT learns about a person: their history, their roles, their daily life, their environment, their sense of self, and what they can and cannot do. It organises that information into an explanation of why their occupational functioning has broken down, what is keeping it broken, and what needs to change.
The word occupational here is important and routinely misunderstood. It does not mean employment. It means everything a person does: the activities, roles, and routines that make up a life. Going to work. Looking after children. Maintaining a home. Sleeping. Eating. Connecting with other people. Finding meaning. When mental health deteriorates, it is these things that collapse first and take the longest to recover. Occupational formulation asks why that collapse has happened for this particular person, in this particular life, at this particular time.
A psychiatric history tells you what is wrong with a person in clinical terms. An occupational formulation tells you what their life looks like, what they have lost, what they are fighting to hold on to, and what the illness means for how they function from day to day.
This is categorically different from a psychiatric history, which organises information around diagnosis, symptoms, and clinical trajectory. Both are clinically necessary. They are not the same thing.
Why this is inherently trauma-informed
Trauma-informed care, as it is currently being taught to practitioners who are new to the concept, rests on a set of principles: understanding the pervasive impact of trauma, recognising its signs across physical, psychological, and behavioural presentations, integrating that knowledge into practice, and actively avoiding re-traumatisation. These are sound principles. They are also, for any mental health OT trained in the last thirty years, simply a description of what we do.
Occupational formulation by its nature asks not just what is happening but what has happened. When an OT explores predisposing factors: the history, the early experiences, the life circumstances that laid the ground for a person's current difficulties, they are doing trauma-informed practice. When they explore the environmental context in which a person is struggling, recognising that housing, poverty, isolation, and relational history shape function as powerfully as diagnosis, they are doing trauma-informed practice. When they resist organising a person's story around their diagnosis and instead centre the human being in front of them, with their roles and values and losses and aspirations, they are doing trauma-informed practice.
The occupational formulation framework does not bolt trauma onto assessment as an afterthought. It cannot produce a meaningful formulation without accounting for a person's history, because history is precisely what shapes occupational identity. Who a person is, in terms of what they do, what they value, and how they see themselves, is inseparable from what has happened to them. This is not new thinking in OT. It is foundational.
The talking piece that gets overlooked
There is another misunderstanding about occupational therapists that is worth addressing plainly. Some colleagues, and some commissioners, operate under the impression that OTs are primarily practical practitioners: the people who assess kitchen function, recommend equipment, and help people back to work after a physical injury. In mental health, this misapprehension is both common and damaging.
Mental health OTs are trained in talking modalities not as an optional addition to their practice, but as a clinical necessity. You cannot conduct an occupational formulation interview without the skills to create psychological safety, to hold a conversation that moves into difficult territory, to recognise when a person is becoming overwhelmed and to adjust accordingly, and to hear what is being said beneath the words. Our training includes group analysis, psychodynamic thinking, motivational approaches, and solution-focused methods, not because we are trying to be therapists, but because you cannot engage a person in occupational change without understanding the psychological terrain you are working in.
The formulation is built through conversation. It is relational from the start. That is not a skill we developed on the job; it is embedded in how we are trained.
This is the piece that distinguishes mental health occupational therapy from other rehabilitation-oriented OT practice, and it is the piece that makes occupational formulation a genuinely clinical rather than purely functional document.
The degree that people underestimate
OT training in the UK is a three or four year honours degree, and qualifying requires not only academic achievement but the completion of substantial supervised clinical placement hours, face to face with patients, across a range of settings. By the time an OT sees their first client as a qualified practitioner, they have already accumulated thousands of hours of direct clinical contact. This is not incidental. It is a regulatory requirement. The Health and Care Professions Council does not register occupational therapists who have only sat in lecture theatres.
Those placement hours include working with people living with serious mental illness, with complex trauma presentations, with dual diagnosis, and with the full range of conditions that a mental health service encounters. They include learning how psychiatric medication affects functional capacity, because if you do not understand the side effects of antipsychotics on motivation and physical movement, or the impact of mood stabilisers on cognitive function and sleep, you cannot accurately assess whether a person's occupational difficulties reflect their illness, their medication, or both. This pharmacological literacy is embedded in OT training. It is not a bonus specialism.
The result is a clinician who understands the person, the diagnosis, the medication, the environment, and the functional impact of all of the above. The occupational formulation is where all of that knowledge lands.
What this means at Purpose People
At Purpose People, occupational formulation is not a framework we have adopted from elsewhere or retrofitted to our practice. It is the clinical foundation on which every assessment, every intervention, and every therapeutic relationship is built. When our OTs meet a new client, they are not asking what diagnosis brings them here. They are asking what their life looks like, what it used to look like, what they want it to look like, and what is getting in the way. They are asking about roles that have been lost, routines that have collapsed, and identity that has been eroded. They are asking these questions with the clinical knowledge to understand the answers in full, and with the therapeutic skills to hear them.
This is not a new way of thinking about mental health. It is a rigorous, evidence-based, deeply humanistic clinical discipline that has been practised by mental health occupational therapists for generations. The conversation about trauma-informed care, about person-centred practice, about looking at the whole human being rather than the diagnosis, is a welcome one. We are glad the rest of the field is arriving.
Purpose People Ltd is a specialist private mental health occupational therapy practice based in London and the surrounding areas. Our OTs work with adults experiencing a wide range of mental health difficulties, using occupational formulation to guide every stage of assessment and intervention.