As the definitions indicate, clinical psychology also draws on the tradition of reflective practice (Schon, 1987). Reflective practice is a loose term, but implies that the subject matter of our discipline, human beings and human distress, is not best served by the narrow ‘technical-rational’ application of research to practice. Rather, it requires a kind of artistry that also involves intuition, flexibility and critical evaluation of one’s experience. In other words, formulation is a balanced synthesis of the intuitive and rational cognitive systems (Kuyken, 2006, p.30). This approach allows for the view of formulation as a shared narrative, or a story that is ‘constructed rather than discovered (Harper & Spellman, 2006). These unique individual stories are centrally concerned with the personal meaning to the service user of the events and experiences of their lives, and it is the personal meaning that is the integrating factor in the narrative. A formulation is not an expert pronouncement, like a medical diagnosis,
this is a relative rather than an absolute distinction. Good Practice Guidelines on the use of psychological formulation 7
Division of Clinical Psychology Clinical psychologists use formulation with individuals, couples, families and groups. There is also a growing trend for using formulation in multidisciplinary teamwork, both inpatient and community-based. In this, a group of staff is supported to construct a shared formulation for and with service users known to some or all of the team members. Formulations may also be developed and shared with professionals from other agencies and services – wards, hostels, schools, day centres, care homes, courts, and soon and with the wider organisation in which the psychologist is employed. The quality of a formulation is dependent in large part on the quality of the assessment and the information derived from it. Clinical psychologists are expected to be competent to use a range of procedures such as psychometric tests, risk assessments and structured interviewing. Information may also be gathered from relatives and carers, other professionals, diaries, medical notes, observation, feedback from homework tasks, and soon. Quality also depends on supporting the service user (and sometimes family/carers) to convey their understanding of the difficulties as fully as possible, along with strengths and resources. High quality formulations should also be informed by the most recent evidence, as summarised in NICE guidelines, Cochrane reviews and scientific journals. The main purpose of a formulation in any setting is: ● identifying the best way forward and informing the intervention.
Reviews and practice-based reports have suggested that formulation can serve a range of other purposes, including:
● clarifying hypotheses and questions; ● providing an overall picture or map; ● noticing gaps in the information about the service user; ● prioritising issues and problems; ● selecting and planning interventions; ● minimising decision-making biases and increasing transparency, by making choices and decisions explicit framing medical interventions predicting responses to interventions predicting difficulties; ● thinking about lack of progress troubleshooting; ● determining criteria for successful outcome; ● ensuring that a cultural understanding has been incorporated; ● helping the service user (and carer) to feel understood and contained; ● helping the therapist to feel contained; ● strengthening the therapeutic alliance; ● encouraging collaborative work with the service user (and carer); ● emphasising strengths as well as needs; ● normalising problems reducing service user (and carer) self-blame; ● increasing the service user’s sense of agency, meaning and hope. (Based on Butler, 1998; Johnstone & Dallos, 2006; Kuyken et al., 2009; Corrie & Lane, 2010.)