Good practice guidelines on the use of psychological formulation

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Formulation and culture

Culture can be defined as a framework that guides and bounds our lives, and through which actions are filtered or checked as individuals go about daily life. These cultural frameworks are constantly evolving and being reworked (Anderson & Fenichel, 1989). It is important to remember, however, that even people sharing the same race or ethnicity can differ in their cultural backgrounds for example their values, spiritual and religious beliefs, health beliefs and soon. It is therefore important to consider cultural issues with every service user. Research has shown that black and minority ethnic groups are disadvantaged groups within health services in general and are less likely to be referred to psychological services
(Karlsen, 2007; Keating et al., 2002). Refugee and asylum seeker populations are especially vulnerable to developing mental health problems due to the experience of famine, war,
persecution and other traumatic events in their home country. Language differences may create an additional barrier to the communication of distress. There can also be cultural variance in how distress is expressed.
Western models of psychology and psychological therapy, and, therefore, the formulations that are based on them, often privilege ideas of independence and self-actualisation as indicators of good mental health, and focus on the individual as the basic unit of therapy.
In contrast, non-Western cultures tend to focus more on notions of spirituality and communality and seethe individual as secondary to the family (Webster, 2002). Mental health may not be seen as separate from physical, emotional and spiritual well-being, and there maybe very different ideas about causation and intervention (Kanwar & Whomsley,

2011). Formulations may, therefore, need adaptation for use in a culturally appropriate way. One framework for this is the Cultural Formulation model, which has been used in relation to psychiatric diagnosis (Lewis-Fernandez & Dias, 2002) but also has wider relevance. It includes the effect of culture on the service user’s difficulties in four key areas:

cultural identity of the service user, including their language preference and degree of involvement with both the culture of origin and the host culture;

the service user’s preferred explanation of their difficulties;

cultural factors related to both stresses and levels of support in the service user’s psychosocial environment cultural elements of the relationship between the individual and the clinician, and their impact on the therapeutic relationship.
The concept of formulation, especially an individual one that prioritises internal causal factors, is itself culturally-based. Much work remains to be done to develop culturally- appropriate forms of formulation, along with mental health interventions in general
(Fernando, 2002). Division of Clinical Psychology

Good Practice Guidelines on the use of psychological formulation
Formulation is carried out within a service/organisational context. There are stakeholders at all levels of the services, and their interests may not coincide. Formulation is not a neutral, impartial, nonpolitical statement of fact based on evidence leading to the best possible intervention for the client. Rather, it is a story told to meet specific needs – an account agreed between the stakeholders to access whatever change process seems to them to be appropriate at that time (Corrie & Lane, 2010, p. One of the essential tasks facing the psychologist at the start is to clarify who these people or organisations are

(relatives, schools, GPs, managers, teams, and soon, whether/how to take their interests into account, and what the likely consequences will be (Kennedy, 2009). A skilled and sensitive approach maybe needed to ensure that the formulation is accepted in its wider systemic context. For example, there maybe resistance at various levels, and for various different reasons, to a formulation which re-frames a problem as a marital/family conflict or a trauma reaction, rather than as an illness to be diagnosed and treated. It maybe even harder to locate the apparent problem at a service or organisational level rather than at an individual one. In relation to psychiatric services in particular, it is important to remember that medical interventions such as diagnosis, medication and admission have their own psychological meanings for the individual (Johnstone, 2000; Martindale, 2007) as does the mental patient role itself (Rogers et al., 1993; Barham & Hayward, 1995). These meanings may compound the difficulties that the service user initially presents with. For example,

psychiatric interventions can be re-traumatising (Lu et al., 2011; Johnstone, 1999); many service users with learning difficulty have been affected by institutionalisation and poor standards of care in Older Adult settings may exacerbate confusion and distress. Service users have attachment styles to services as well as to individual clinicians, and staff counter- transference responses sometimes replicate earlier damaging relationships (Meadon & van Marle, 2008). These possibilities must be considered, especially when formulating with inpatients and multidisciplinary teams.
Research suggests that, in keeping with the general principles of formulating, a formulation-based approach is best presented to teams and wider systems tentatively and with respect for existing views (Christofides et al., 2011); in other words offered rather than imposed. At the same time, the Leadership Framework makes it clear that it is a clinical psychologist’s duty to advocate a psychological stance in conjunction with or instead of other healthcare models even in difficult circumstances, demonstrating ethics and values (Skinner & Toogood, 2010). This can be a difficult balance to achieve.
The principle that emerges from these considerations is that clinical psychologists should at all times:

be clear about who the service user is and who the stakeholders are in relation to any given formulation.

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