10. Formulation and the service/organisational context
Division of Clinical Psychology Accreditation criteria for clinical psychology doctorate programmes require trainees to incorporate societal and cultural factors in their formulations (BPS, 2010). The HPC (2009) regulations state that clinical psychologists should understand social approaches such as those informed by community, critical and social constructivist perspectives (3a.1.) These place formulation within a wider context of social inequalities and power relationships (Miller & McClelland, 2006), and remind us that service users are almost always survivors of immensely difficult personal and social circumstances. Interventions will be ineffective if wider causal factors are located at an individual level, thus pathologising the service user and increasing their sense of hopelessness. While it may not be possible to intervene at a more distal level, switching attention from supposed (and feared) personal deficiencies to injuries inflicted by a damaging environment…may nevertheless constitute a form of demystification, bringing with it a significant relief of distress (Hagan & Smail, 1997a, p.266). There is a careful balance to be struck between acknowledging the very real limitations and pressures that people face, while not diminishing their sense of hope or agency. Hagan and
Smail’s power-mapping (Hagan & Smail, ab) and Holland’s (1992) model are examples of how to integrate more distal influences into formulations, rather than simply including social factors as an ‘add-on’. The community/social inequalities/human rights perspective is often poorly integrated into practice. Recent research underlines the importance of this dimension. Wilkinson and
Pickett (2009) have presented compelling evidence that a society’s level of social inequality is causally related to its rates of mental illness If Britain became as equal as the four most equal societies (Japan, Norway, Sweden and Finland, mental illness might be more than halved (p. Particularly relevant to formulation is their suggestion that inequality has its most damaging impact at least partially through its personal meaning to the individual, in terms of feeling devalued, shamed, trapped and excluded. This underlines the importance of being aware of the wider contexts of formulations and clinical work. In the words of a World Health Organisation report on mental health levels of mental distress among communities need to be understood less in terms of individual pathology and more as a response to relative deprivation and social injustice (WHO, 2009, p.111). The implication is that clinical psychologists need to: ● have a critical awareness of the wider societal context within which formulating takes place, even if this dimension is not explicitly included in every formulation.