A super interesting article today, brought to you by Dr. Laura Jean Wells.
By Dr Laura Jean Wells, Clinical Psychologist
My Masters placement was my first experience of clinical psychology work in practice. A big part of what I learned at that stage was that there are broadly four different tasks when working clinically: Assessment, Formulation, Intervention and Evaluation. Great I thought… but just one question… what is this ‘formulation’? I know it’s important… and I know everyone’s talking about… but what exactly… is it? How do I do it? Is it something I do myself? Is it something I do with clients? Do I write it? Do I draw it? Is it a process? Is it a finished product? Where do I find out more about it?!
As a Clinical Psychologist, formulation is central to my work now. However, I often think back to my days as a student and Assistant Psychologist, and remember how it was hard to get my head round what formulation actually was, as well as not being quite sure where to go to learn more about it. This is why I started the Psy Fiction blog, which aims to be an accessible educational resource on formulation, using characters from movies as ‘case examples’ to explain different models of psychological formulation. In this post, I’ll outline a brief introduction to what formulation is, but add some links to Psy Fiction posts of specific models, for those interested in delving a bit deeper into the topic!
What is formulation?
Formulation is the cornerstone of psychological therapy. It is defined as a hypothesised explanation of an individual’s difficulties, which is underpinned by psychological theory. It provides an understanding of how an individual’s problems (i.e. ‘mental health issues’) may have developed based on their past experiences, and how these difficulties are then being maintained in the present. These definitions are taken from “Formulation in Psychology and Psychotherapy”, by Lucy Johnstone and Rudi Dallos. I found this particular book super helpful in my training and would totally recommend it.
Formulation is often a collaborative process between the therapist and client, to facilitate sense-making for the client. This means, a big aim of formulation is to help the client make sense of why they are experiencing their current difficulties. This can sometimes be an intervention in itself, as a lot of people have a goal in therapy to understand ‘why’ they feel a certain way. Formulation may take the form of a narrative e.g. written paragraphs in a letter, or in diagrammatic form. There are different diagrams or ‘models’ of formulation – some for different presentations (e.g. panic, phobias) and some have different theoretical underpinnings (e.g. cognitive, systemic). Formulation is also not ‘set in stone’, as it is an ongoing process which can be built upon and changed over time.
Finally, formulation is used to guide treatment and intervention planning. For example, if a child’s distress is stemming from anxiety and negative thinking patterns around social situations, perhaps following something embarrassing happening in a school assembly, then a 1.1 intervention for social anxiety may be helpful. However, if distress is stemming from an inconsistent parenting approach at home, then a parenting intervention may be more appropriate. This may not be clear from a brief initial assessment, which is why a formulation looking into past experiences and current triggers/maintaining factors, is important to ensure the right focus is targeted in therapy.
Are Formulation and Diagnosis the same thing?
Formulation is often presented as an alternative to medical diagnosis for mental health difficulties. The ‘Diagnosis vs Formulation’ debate is ongoing in Clinical Psychology, and the field of mental health in general. I would encourage you as an aspiring psychologist to do a wee bit of your own reading on this debate and reflect on what your personal stance is on this hot topic.
I am of the view that there may be a place for psychiatric diagnosis for some individuals, as some people find it a helpful way of understanding their difficulties. However, I also think that there are many drawbacks of this dominant diagnostic medical model, which has been used in mental health care for decades. For example, the pathologizing normal human stress responses, attributing the problem to lie “within” the person, as well as diagnoses attracting stigma.
I prefer to think about these mental health issues as ‘normal human responses to abnormal experiences’, rather than someone’s difficulties being ‘abnormal’ or a ‘pathological illness’. Psychological formulation provides a framework for this alternative understanding of mental health problems, with its goal to create a more collaborative, validating, non-blaming and compassionate understanding of a person’s problems. This in turn helps to facilitate change and promote feelings of agency and control in one’s recovery. This links to the main aim of formulation being to move away from the question “what’s wrong with you?” (i.e. what medical illness do you have) towards the question “what’s happened to you?” (i.e. how can we understand your current difficulties in the context of your past experiences and how you tried to cope with these).
What’s an example of formulation?
There are different forms of formulation models. Some are ‘Situational formulations’, which look at maintenance cycles in specific ‘here and now’ situations. Then there are ‘Longitudinal formulations’, which take into account the influence of past experience on current distress. Some of the most commonly used types of formulation are Cognitive Behavioural Therapy (CBT) models. One of the most widely used of these is the ‘Situational CBT Formulation’, also known as the ‘5 areas formulation’ or ‘hot-crossed bun’.
The CBT Situational Formulation suggests that there are 5 inter-connected systems which we can explore to understand someone’s psychological distress and behaviour in a specific situation. These are:
- The external situation or environment
- Thoughts about the situation – in CBT these are called “Negative Automatic Thoughts”.
- Body sensations
- Behaviour – or what someone ‘does’
All these 5 areas link together and feed into each other like a vicious cycle, which maintains psychological distress. The ideas is, that if one of these areas can be targeted and changed, then it breaks the cycle and distress reduces, (e.g. challenging the negative automatic thoughts). This is an example of how doing a formulation can help decide what is best to target in an intervention. I have written a post on Situational CBT Formulation, using everyone’s favourite ogre ‘Shrek’ as a case example. There are a number of situations in the movie where Shrek becomes angry, due to ‘Negative Automatic Thoughts’ about himself or others (e.g. thinking Fiona doesn’t want to be with him). This then leads to him pushing others away, which only perpetuates his difficult emotions. If you would like to see this example in more detail, please check out this post here.
If you are interested in other commonly used formulation models, you can find other Psy Fiction posts illustrating these. The Longitudinal CBT formulation is an extension of the Situational CBT Formulation, which considers past experiences and core beliefs (see Game of Thrones themed Longitudinal formulation post here). Then there is the 5Ps formulation, which is one of the most widely used formulation models in clinical practice. Although it is criticised for not being very well grounded in psychological theory, it is a simple model which can be easily used with clients, as well as multi-disciplinary teams, due to it’s universal nature (see Star Wars themed 5Ps formulation post here). Other formulation models focus more on specific presentations, such as PTSD, Panic and Anxiety (examples of which can also be found here).
How can I develop my Formulation knowledge and skills?
- If you’re working in a service, ask Clinicians if they have any examples of formulation letters or formulation diagrams they have completed in session which you can look at.
- Ask your supervisor if they could bring one of their case formulation examples to supervision. Perhaps see if you can do put together a formulation together as an exercise.
- Some services do ‘team formulation meetings’, which can be helpful to attend.
- If you are doing 1.1 work, scope out with your supervisor whether there are any opportunities for doing some formulation work in your sessions if appropriate.
- If you are not seeing patients at the moment, then you could try your own ‘Psy Fiction’ style formulation. Watch your favourite movie or TV show and notice if there are any situations where a character is displaying a form of distress e.g. anxiety, upset, frustration. Then, see if you can fill in a hot-crossed bun diagram for them – what are their negative automatic thoughts? What are they feeling? How do they react? This just gets you in the swing of using this model. (Would love to hear from anyone who gives this a go!)
Whatever stage you are at in your psychology journey, it is a real asset to have a sound understanding of formulation. It is also a great thing to be able to speak confidently about in interviews! I therefore hope this introduction to formulation has been helpful.
A big thank you to The Psych Journey for having me as a guest blogger. This is a brilliant website which supports aspiring psychologists – so do sign up and following on social media (Instagram / Twitter) so you don’t miss out on these helpful posts!
Finally, if you found this post helpful and want to learn more about different models of psychological formulation in an accessible way, please check out Psy Fiction blog and subscribe to keep up with posts! Please also get in touch with any feedback or questions.
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