Although not all therapies use formulation (e.g. person-centred, narrative) it is a core feature of the main therapies used by NHS clinical psychologists CBT, systemic, psychodynamic and cognitive analytic therapy. Each of these approaches draws on a particular set of concepts in their formulations (e.g. negative automatic thoughts, problem- maintaining patterns, the unconscious) In addition, they each use particular terms for formulation which entail different theoretical assumptions (e.g. case conceptualisation’ (Beck, 1995), dynamic formulation (Malan, 1979) and reformulation (Ryle, However, it has been argued that differences are not as great as commonalities, and that a shared conception of formulation, independent of theoretical orientation, is preferable (Butler, 1998; Goldfried, Good Practice Guidelines on the use of psychological formulation 13
In practice, the majority of clinical psychologists describe themselves as integrative/eclectic. Options for combining different approaches include the use of an ‘off-the-shelf’ overarching model (e.g. cognitive analytic therapy Ryle, 1995); or theme (e.g. the therapeutic relationship Kahn, 1997); or set of techniques (e.g. Egan, 2006); or a personal synthesis of preferred approaches (Dallos et al., Clinical Psychology training criteria require all training courses to teach at least two evidence-based models of psychological therapy, one of which must be CBT (BPS, There is mixed guidance within the profession about whether psychological formulations should be based on the integration of two or more therapeutic models
, or should more simply include a wide range of
factors . The MAS (1989) report claimed that the former was a central defining feature of the profession (Level 3 skills) The Division of Clinical Psychology (2010) definition states that psychologists will be able to draw on a number of different models as required, but does not imply that more than one model will necessarily inform any given formulation. The British Psychological Society criteria for training courses (BPS, 2010) require the incorporation of interpersonal, societal, cultural and biological factors rather than models. HPC (2009) criteria include Understand psychological models related to how biological, sociological and circumstantial or life- event-related factors impinge on psychological processes to affect psychological well-being’ (3a.1) but make no mention of integration as such. It should be noted that despite a number of books on the subject (Norcross & Goldfried, 2005; Palmer & Woolfe, 2000) the theoretical integration of different therapeutic models is very much a work in progress and there are currently no completely satisfactory frameworks for achieving this. It follows that the same is true for integrative formulations. Causal factors that are sometimes neglected or downplayed in clinical psychologists’ formulations are: ● transference and counter-transference (especially relevant in team formulations;
Meadon & van Marle, the personal meaning and service user experience of medical interventions such as diagnosis, medication and admission (Martindale, the potentially traumatising effects of medical and psychiatric interventions Lu et al., 2011; Johnstone, the influence of stigma, discrimination and the mental patient role (Barham Hayward, recent work on the causal role of trauma and abuse in psychosis (Larkin Morrison, 2006; Moskowitz et al., 2008). The impact of abuse is often overlooked in clients with learning difficulty as well social factors such as class, poverty, unemployment, and power relations;
● ethnic and cultural factors. For the purposes of these guidelines, the consideration and inclusion of relevant factors from individual, interpersonal, biological, social and cultural domains is recommended, and it is left to individual preference as to whether this is done by drawing from more than one therapeutic model . In practice there maybe little to distinguish the resulting 14 Division of Clinical Psychology
formulation, especially given the trend for all therapeutic models to absorb ideas and perspectives from each other. It is also noted that not all formulations are based on specific therapeutic models , although within the definition used in this document, they should all draw on psychological principles and evidence . These might derive from, for example, attachment theory, or research into the impact of racism or domestic abuse, or evidence about the psychological effects of head injury, chronic pain, developmental disorders, alcohol abuse and soon. Psychological formulations will also draw upon the current evidence-base as summarised in NICE guidelines, Cochrane reviews and elsewhere. As previously noted, part of the clinical skill in developing a formulation is deciding how inclusive it needs to be to meet the required purpose at any given time. Clearly, most formulations in day-to-day practice will not cover the whole range of possible contexts and causal factors listed above, and nor would this necessarily be the most appropriate way to use formulation in every situation. However, a narrower or single-model formulation needs to be a conscious and justifiable choice from a wider field of possible models and causal influences.