Good practice guidelines on the use of psychological formulation

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Purposes of a formulation

Clinicians have reported additional benefits from using formulation in teamwork in order to develop a shared understanding of a service user’s difficulties:

achieving a consistent team approach to intervention;

helping team, service user and carers to work together;

gathering key information in one place;

generating new ways of thinking;

dealing with core issues (not just crisis management);

understanding attachment styles in relation to the service as a whole supporting each other with service users who are perceived as complex and challenging;

drawing on and valuing the expertise of all team members;

challenging unfounded myths or beliefs about service users;

reducing negative staff perceptions of service users;

processing staff counter-transference reactions;

helping staff to manage risk;

minimising disagreement and blame within the team;

increasing team understanding, empathy and reflectiveness;

raising staff morale conveying meta-messages to staff about hope for positive change.

(Based on Summers, 2006; Clarke, 2008; Lake, 2008; Kennedy, 2009; Whomsley, Berry et al., 2009; Hood, 2009; Craven-Staines et al., 2010; Wainwright & Bergin, Walton, 2011; Christofides et al., Formulation does not necessarily lead to intervention it may indicate that no further input from professionals is needed. It should also be noted that developing a formulation can be a powerful intervention in itself, and maybe enough on its own to enable the service user or team to move forward and make changes. Team formulation is in keeping with the profession’s wider remit to work at a team, service and organisational level. The clinical psychology leadership framework lists one of the roles of a qualified psychologist as

Lead on psychological formulation within your team
& Toogood, 2010). This might include supervising and training other members of the multidisciplinary team in formulation. It has been suggested that using formulation in teamwork is a particularly effective way of achieving culture change and promoting a more psychosocial perspective in services as a whole (A good formulation can be a powerful systemic intervention, Kennedy et al., 2003; Taking formulation into a wider setting can be a powerful way of shifting cultures towards more psychosocial perspectives, Onyett,
2007). Another purpose of formulation is, therefore:

facilitating culture change in teams and organisations. Good Practice Guidelines on the use of psychological formulation

Division of Clinical Psychology
The boundaries of what actually constitutes a formulation are somewhat arbitrary. There is no absolute or definite cutoff point on the dimensions listed below.
Formulation as a process and formulation as an objector event
(Cole & Johnstone, in press;
Ingram, 2006). Formulations are developed through a recursive process of assessment, discussion,
intervention, feedback and revision. At some point this maybe summarised in writing or a diagram, although these two aspects are not completely distinct from each other. In practice, ‘formulation-as-a-process’ maybe the more common clinical activity.

However, formulations in letters to referrers and training coursework are likely to be presented as a one-off ‘formulation-as-event.’ Written versions might also take the form of a letter to the service user a section of a psychologist’s letter to the referrer;
a summary for the team which will be added to the medical notes a section on a

CPA form or in the electronic record and soon.
A partial formulation and a full formulation.
There is always the possibility of reformulation in order to include new information and insights, and in this sense all formulations are partial and dynamic in the words of one psychologist, they are broad snapshot summaries of complex evolving stories (Cole & Johnstone, in press. However, some formulations are necessarily and appropriately more comprehensive and detailed than others. For example, a coursework assignment maybe several paragraphs long and focus on a complex set of difficulties in the context of a person’s whole life story this is suited to its main purpose of assessing a trainee’s competence. In contrast, a qualified psychologist may find that simple diagrammatic formulations (e.g. demonstrating how automatic thoughts lead to anxiety which leads to avoidance) are often more suitable for routine clinical practice. CBT-based formulations typically develop through a sequence of descriptive summaries, cross-sectional formulations and longitudinal formulations, as more information is gathered (Kuyken et al., 2009; Persons, Another type of partial formulation is evident in the formulation-informed thinking that, evidence suggests, is used by clinical psychologists in almost every aspect of their daily practice and seen by them and other multidisciplinary team members as an invaluable aspect of their role (Christofides et al., 2011; Hood, 2009). For example, a psychologist may suggest during a team discussion that a service user’s behaviour can be understood in the light of their history of rejection. This kind of on-the-spot contribution to case discussions, ward rounds, CPA reviews and team meetings is not necessarily documented in writing, or defined as formulation in a formal sense.

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