Constructing Stories, Telling Tales

A Guide to Formulation in Applied Psychology

Sarah Corrie, David A. Lane

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780367323837
• eBook ISBN: 9780429912177
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Formulation remains one of the most important activities that those using psychological approaches undertake as part of their work. Arguably, however, formulation is an activity that remains poorly understood. In a current climate demanding quick fix solutions there is a tendency, which the authors refuse, towards over-simplification. Instead this book sets out to explore the challenging complexity of psychological formulation. By drawing on a wide range of sources from psychology and the arts the authors find ways to honour the stories clients tell yet offer key psychological insights to facilitate change. They provide a clear guide to enable the reader to think about the purpose of their work with clients, the perspectives which inform it and the process used to ensure effective outcomes. The chapters, supported by exercises on key issues, examine key debates on the role of formulation in professional practice, a framework for developing a systematic approach to formulation and a detailed account of the purpose, perspective and process of formulation.

Part I
Formulation: An Introduction to Key Debates and a Framework for Developing a Systematic Approach

Chapter One

Case formulation and its role in professional practice

“Case formulation is not a treatment procedure. It is a method for understanding the patient and their problems that allows for the selection and design of treatment procedures based on the knowledge of their case”

(Adams, 1996, p. 78)

“The significant problems we face cannot be solved at the same level of thinking we were at when we created them.”

(Einstein, 1879–1955)

Introduction

Formulation is deemed to be a cornerstone of skilled psychological practice and, over the course of our careers, much time will be spent engaged in the process of making sense of the psychological puzzles that confront us. However, the ability to master this skill is confounded by a range of factors. These include the myriad and often complex reasons for which clients seek help, implicit agendas driving the request for help of which the practitioner may not be aware, and the extent to which individuals are able to identify describe, and address their needs within a psychological framework. Similarly, practitioners vary in how they approach a client enquiry in terms of prior training and experience, theoretical preferences, and their level of interpersonal and conceptual skill. All factors play a critical role in decision making and represent potential obstacles to arriving at a clear and useful account of a client’s circumstances and needs.

The challenge of arriving at a clear explanatory account is complicated further by the lack of any universally agreed definition of formulation, a dearth of substantive guidelines on how to teach this skill to trainee practitioners, and an ambiguous literature concerning the extent to which formulation, despite official rhetoric, is actually related to outcome. Moreover, although the concept of formulation has a long history within psychology, its status is contentious: for some, it is the central feature around which our data collection and interventions coalesce for client benefit, whereas for others, formulations are essentially therapists’ stories imposed on clients. As a skill, therefore, formulation has not only proved controversial, but it has also proved difficult to operationalize, measure, and teach.

The aim of this chapter is to raise awareness of the current debates surrounding formulation and to help the reader navigate what might otherwise appear to be a literature confounded by unanswered questions and contradictory findings. We begin by considering the functions that formulation is widely believed to serve. We then consider some of the different ways in which formulation has been defined and some of the factors that contribute to different interpretations of its role in practice. The chapter then reviews the controversies surrounding the accuracy and effectiveness of individualized formulations and examines the implications of this for professional practice. Drawing on these debates, we make the case for understanding formulation as a device that helps us organize our thinking about what might be helpful and when; not solely an attempt to “explain” presenting issues from one theoretical approach or another, but, rather, a framework that can support both creative and rigorous thinking in generating potential solutions. We conclude with an exercise to stimulate reflection on how these debates relate to your own practice, in whatever context that takes place.

Before engaging with the chapter, we invite you first to reflect on your own approach to formulation. Specifically:

• what (if anything) do you believe an individualized formulation offers a client that a clinical, educational, or psychometric diagnosis does not?;
• to what extent do you see your formulation as needing to be factually accurate in order to be helpful?’
• is your formulation derived primarily from “evidence-based” models of practice external to the client or crafted principally from the client’s account of the world?;
• who owns the formulation and, therefore, is entitled to endorse, refute, or change it: you, your client, or a third party?

We invite you to revisit your answers as you work through the debates outlined in this chapter. You may also find it helpful to hold in mind a particular case and to consider how the issues raised might be relevant to that case. At the end of the chapter, we will ask you to think about what resonates and why.

The function of formulation in applied psychology practice

There is fairly broad agreement that constructing a formulation is critical to psychology practice (Atter, 2009; British Psychological Society, 2005; Corrie & Lane, 2006; Health Professions Council, 2009; Johnstone & Dallos, 2006; Lane & Corrie, 2006). Indeed, Butler (1998) goes as far as suggesting that, at least in the clinical domain, the process of formulation is what makes us accountable for our work, separating responsible, effective practice from informal, supportive conversations. Malkin (personal communication, cited in Lane, 1990) makes the same point in relation to educational work.

As noted in the Introduction, in general terms, formulation can be understood as an explanatory account of the issues with which a client is presenting. This account forms the basis of a shared framework of understanding that has implications for change. As a psychological explanation of a client’s needs, a formulation can reasonably be expected to draw upon a wide range of data, including psychological theory, general scientific principles (such as how to test hypotheses), research findings from the wider literature (the latter becoming particularly influential since the political and professional endorsement of empirically-supported interventions and evidence-based practice), supervision, and prior professional experience.

Although there are many ways of defining formulation (we address this later in the chapter), there is broad consensus about the range of functions that it can serve. These include:

• clarifying key hypotheses and identifying relevant questions;
• facilitating understanding of the client’s needs as a whole;
• prioritizing client issues and concerns;
• planning and selecting appropriate intervention strategies;
• determining criteria for a successful outcome, including organizing practitioner and client around the same goals;
• predicting client reactions to specific interventions;
• predicting obstacles to progress;
• thinking systematically and productively about lack of progress;
• identifying patterns in a client’s actions and responses that can be examined conjointly and impartially;
• identifying missing information;
• helping refine the search for relevant theoretical constructs or processes;
• deriving a coherent understanding of the links between past and present;
• forming judgements about the extent to which a case is typical (and how any intervention plan may need to be adjusted in the light of atypical features).

(See Bieling & Kuyken, 2003; Butler, 1998; for a fuller description of these issues.)

From these criteria, a number of essential themes can be identified. First, and most obviously, a formulation equips the practitioner with a systematic means of applying psychological knowledge to a client’s story, problem, or dilemma for the benefit of the client and others involved. The information provided by clients and gleaned from various assessment tools is typically complex and ambiguous. Understanding the client’s needs is, therefore, a process of constructing a sense of meaning out of the mass of data obtained. In this context, the formulation functions as a framework for clarifying those questions which are likely to drive the enquiry forward. It creates thematic links between past events, present circumstances, and future aspirations, and refines the search for any additional information that is needed.

A second component of formulation is to identify which areas of a client’s experience or behaviour will be prioritized. It is not possible to change everything. Informed decisions must be made about which concerns will be addressed, the most appropriate goals of the enquiry (based on a psychologically-informed understanding of what is amenable to change) and what interventions might be used in the service of those goals.

A third function of formulation is to aid empathic understanding, particularly in those cases where the client’s actions or presenting concerns may challenge the practitioner’s empathic skills (see Haarbosch & Newey, 2006; Sheath, this volume). Difficulties in terms of insufficient progress, apparent “resistance”, or obstacles to collaboration that might otherwise contribute to problems in working together can be reflected upon in an impartial manner in order to identify ways forward.

In a similar vein, formulation can help protect against decision-making biases that could impede effective working. The literature on practitioners’ decision making and judgement skills (see Lane & Corrie, 2006, for an overview) has consistently demonstrated the range of biases that permeate our work, often without our awareness. By ensuring that practice-based choices are underpinned by a systematic, psychologically informed account of the relationship between different aspects of a client’s experience, it becomes possible to articulate and, where necessary, challenge the thinking that underpins the approach taken. Formulation, then, permits a degree of transparency in the decision-making process. It has the potential to protect our clients and contribute to the enhanced effectiveness of psychological interventions.

A further function of formulation—and one that is often overlooked—is its use as a form of professional communication. In its most straightforward form, this can mean the development of a shared understanding that benefits the client through ensuring a consistency of approach. If a client’s journey through services entails contact with a number of professionals, for example, there is the potential for the client to be subjected to conflicting opinions that hamper effective service provision. A formulation can, therefore, unite the many professionals who may be involved in a client’s care around the same issues, priorities, and goals.

However, at a more tacit level, formulation also has the potential to become a means of communicating with other professionals about the status of one’s knowledge, representing a distinct form of political leverage in the workplace. For example, in an already overcrowded market, the degree of sophistication, complexity, and explanatory power of their formulations may become part of how certain professional groups differentiate themselves from others. In this sense, being able to construct formulations and using these as a basis for communicating with other professionals (1) provides practitioners with a degree of reassurance about their ability to explain clients’ concerns and, thus, their own competency, and (2) provides a vehicle for communicating with other professionals about the veracity of their knowledge and the authority of that knowledge (we explore this in Chapter Three, where we consider the implications for ourselves and our clients of what Mair, 2000, terms “tribal membership”).

It follows, then, that the act of formulation can serve many purposes, some of which will be more explicit than others. At the most obvious and official level, it supports decisions about the content of a psychological enquiry (e.g., knowing what to prioritize, which hypotheses to test, and which interventions might be useful). It also supports understanding of process (e.g., by allowing the practitioner to predict and interpret clients’ reactions to the work undertaken). However, formulation may also serve a more political function, enabling the practitioner to demonstrate their epistemic authority in the understanding of client concerns and the stories they can construct about those concerns.

The historical context of formulation and its place within professional practice

The political function of formulation as a means of professional differentiation can be further understood through considering its historical context. In her review of the use of the term in clinical work, Crellin (1998) has traced some of the historical and social contexts in which the concept emerged and evolved, highlighting how formulation came to represent a form of political leverage through which psychology established its autonomy from psychiatry. At the time, she notes that psychology was a fledgling profession, competing with other professions claiming to treat emotional distress, and needing to establish itself as an independent profession.

For many years, psychology remained within the grip of psychiatric description through the use of symptom matching and diagnostic labelling. As Bruch and Bond (1998) have pointed out, clinicians were traditionally expected to define their clinical work in terms of psychiatric categorization systems, with treatment determined by these criteria. Influential psychologists at that time, such as Eysenck (1990) and Shapiro (1955, 1957; Shapiro & Nelson, 1955), later argued for an approach which emphasized clinical-experimental work (the beginnings of the scientist-practitioner model in the UK) centred on learning principles and, thereby, challenged these expectations. This was elaborated by Meyer (see Bruch & Bond, 1998), who summed up the problems from the clinician’s point of view by pointing out that (1) not all clients sharing the same complaint respond to the procedural requirements of techniques, and (2) psychologists are rarely presented with clients with isolated complaints, particularly in mental health settings.

Meyer developed an alternative approach that rejected diagnostic formulations and instead advocated an approach based on individualized formulation, shared with the client rather than imposed on them (see examples in Bruch & Bond, 1998). Further key contributions were made by Lane (1974, 1978, 1990), Turkat (1985), and other reformulations have followed (see Kinderman & Lobban, 2000; Lane & Corrie, 2006; Mumma, 1998). Formulation based on diagnostic models was, therefore, counterbalanced by formulations derived from a scientist-practitioner perspective (see Lane & Corrie, 2006). Specifically, in arguing for an approach related to the individual client, the relationship between the accuracy of any data collected and their utility in terms of value to the client became central.

Since its introduction to clinical psychology regulation in 1969, formulation has become a defining skill (Division of Clinical Psychology, 2001) and, as Johnstone and Dallos (2006) observe, is a core competency expected of all newly qualified clinical psychologists. However, the use of the term now extends to all major disciplines within the psychological professions. The British Psychological Society (2005) outlined the basis of different forms of applied psychology in which five areas of psychology are presented: clinical, forensic, counselling, educational, and health. While for clinical, forensic, and counselling psychology, formulation is identified as a key competence, the extent to which formulation has a scientific basis and is drawn directly from psychological theory varies between disciplines. While its assessment pedigree is emphasized for clinical and forensic specialities, for counselling psychology, formulation represents a more collaborative and unfolding process. Within educational psychology, priority is given to the knowledge building process and the structuring of interventions with individuals and systems. The formulation of policy and practice is seen as a central part of the psychologist’s role. For health psychologists, the application of research to formulation of health policy and health promotion is key. The act of formulation cannot, therefore, be seen as consisting of one enterprise, uniformly defined and undertaken in the same way by all disciplines. Navigating the different definitions and understanding what different professionals mean when they use this term can be a challenge in itself. This is considered next.

Dealing with definitions: different interpretations in different contexts

While there is fairly broad agreement about the wide ranging functions that formulation serves (at least at the level of official discourse), there is less agreement on die specific components or tasks of which a formulation should comprise. Reviewing even a small sample of standard definitions highlights that not all practitioners understand formulation in the same way. Consider, for example, the following, taken from the clinical, educational, forensic, and behavioural medicine fields.

• ”A formulation is … a concept that organizes, explains, or makes clinical sense out of large amounts of data and influences the treatment decisions” (Lazare, 1976, p. 97).
• “[Formulation is] conducting hypothesis-driven interventions that are constantly monitored for effectiveness” (Bruch & Bond, 1998, p. xviii).
• “[A formulation is] a t...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• CONTENTS
• LIST OF EXERCISES
• ACKNOWLEDGEMENTS
• ABOUT THE AUTHORS AND GUEST CONTRIBUTORS
• PROLOGUE: Telling stories
• INTRODUCTION
• PART I: FORMULATION: AN INTRODUCTION TO KEY DEBATES AND A FRAMEWORK FOR DEVELOPING A SYSTEMATIC APPROACH
• PART II: WORKING WITH PURPOSE, PERSPECTIVE, AND PROCESS: ELABORATING THE FRAMEWORK TO ENHANCE YOUR APPROACH
• PART III: THE MANY FACETS OF FORMULATION: AN INTERDISCIPLINARY PERSPECTIVE
• PART IV: IMPLICATIONS FOR THE FUTURE
• CONCLUSION: Formulation and the future
• EPILOGUE: Formulation and developing the creative practitioner
• REFERENCES
• INDEX