7 David A. Lane and Sarah Corrie Formulation has been identified as a defining competence of skilled psychological practice (Atter, 2009; British Psychological Society, 2005; Corrie & Lane, 2006, 2010; Division of Clinical Psychology, 2011; Health Professions Council, 2009; Johnstone & Dallos, 2006; Lane & Corrie, 2006). Indeed, some would argue that it is the act of formulation that distinguishes the delivery of systematic and rigorous psychological interventions from the kinds of supportive interventions offered by lay helpers (see Butler, 1998). Since its introduction to clinical psychology regulation in 1969, use of the term now extends to all major disciplines within the psychological professions. However, as noted by Lane and Corrie (2006), ‘…the use of and process by which formulations are created is contentious’ (p. 41). Moreover, the way in which formulation is defined and understood within applied psychology varies from discipline to discipline. For example, within clinical and forensic specialties, strong emphasis is placed on basing formulation on data obtained from the initial assessment, whereas in counselling psychology, this represents a more collaborative process with the formulation unfolding over time. Within educational psychology, priority is given to the knowledge-building process and the structuring of interventions with individuals and systems, whereas for health psychologists, the application of research to formulation of health policy and health promotion is critical. In consequence, the act of formulation cannot be seen as one specific activity, conducted by all practitioners in the same way, but rather depends on the purpose for which, and context within, a given formulation is to be used. This chapter offers readers a model of formulation – the Purpose–Perspectives–Process model – that can assist practitioners in devising a systematic and effective procedure which is consistent with a scientist-practitioner approach.1 We discuss a particular application of this model – DEFINE – as used in the UCL Case Formulation approach. To contextualize this model, we first re-examine the functions that formulation is widely believed to serve and briefly review some of the main controversies surrounding the accuracy and effectiveness of individualized case formulations. We then describe the Purpose–Perspectives–Process model and provide a case illustration2 using DEFINE to demonstrate how this approach assisted a rigorous, creative and effective approach to working with an adolescent client. The case study is embellished with general guidelines for undertaking this method of formulation, in order to enable the reader to better understand the DEFINE model and to help refine the rigour of their own approach. In its broadest sense, a formulation can be understood as a psychologically informed explanatory account of the issues, dilemmas or problems with which a client is presenting. This explanatory account forms the basis of a shared framework of understanding that has implications for change, and thus for any intervention subsequently implemented. As a psychological account, a formulation can reasonably be expected to draw upon psychological theory, general scientific principles (such as how to test hypotheses), research findings from the wider literature, prior professional experience and the guidance of peers and senior colleagues (e.g. in the context of supervision). There are many ways of defining formulation. However, there is a reasonably good degree of consensus about the range of functions that this task can serve. Reasons commonly cited include facilitating a detailed understanding of a client’s needs (including both developmental and maintaining factors); refining the search for relevant theoretical concepts; prioritizing client concerns; planning and delivering an appropriate intervention, determining criteria for a successful outcome and working effectively with obstacles to progress (see Corrie & Lane, 2010, for a review). More specifically, a formulation equips the practitioner with a systematic means of applying relevant psychological knowledge (theoretical constructs, research and other forms of discipline-specific information) to a client’s story, problem or dilemma for the benefit of the client and others involved. The information provided by clients and gleaned from various assessment tools is rarely straightforward to interpret. Understanding the client’s needs is, therefore, often a process of imposing a sense of meaning on the wealth of complex, often ambiguous and even, at times, contradictory, data obtained. In this context, a formulation can function as a framework for clarifying those questions that are likely to uncover fruitful avenues of enquiry, create thematic links between past events, present circumstances and future hopes and refine the search for any additional information that is needed. A second function of formulation is to identify which areas of a client’s experience or behaviour will be prioritized in any intervention subsequently offered. It is important to recognize that not everything is amenable to change, and therefore, informed decisions must be made about the most appropriate focus of the enquiry and what interventions might be used in the service of any specific goals. A third function of formulation is to aid empathic understanding, particularly in those cases where the client’s behaviour may challenge the practitioner’s empathic skills. Consider, e.g. a client’s continual ‘resistance’ to complying with homework tasks. A therapist’s response is likely to be more empathic and effective if grounded in a formulation that includes an appreciation of how the client tends to rely on avoidant coping strategies to manage distressing internal events and lacks adaptive alternatives for managing uncomfortable thoughts, feelings and sensations. Sheath (2010) provides an example of how this function of formulation is even more vital when working with clients whose behaviour can evoke strong negative feelings in practitioners and wider society (in this case, clients who sexually offend). Difficulties in terms of insufficient progress, challenges associated with implementing a specific intervention or ruptures in the relationship with the client can be reflected upon in an impartial manner in order to identify potential ways forward. Along similar lines, having a formulation can help protect against decision-making biases that could impede effective working. The literature on decision-making in professional practice (see Lane & Corrie, 2012) has consistently highlighted a wide range of cognitive errors that permeate our work, often without our awareness. By ensuring that practice-based choices are underpinned by a robust, psychologically informed explanatory account of the relationship between different aspects of a client’s experience, it becomes possible to articulate and, where necessary, challenge the thinking that underpins the approach taken. Arriving at a formulation does, therefore, permit a degree of transparency in the decision-making process that supports reflective practice and allows for a critique of any decisions made. Formulation can also function as a form of professional communication in order to organize professionals around the development of a shared understanding. This then benefits the client through ensuring a consistency of approach. For example, if multiple professionals are involved in a client’s care, there is the potential for the client to be subjected to conflicting opinions that hamper effective service provision. A formulation can, therefore, unite many professionals who may be involved in a client’s care around the same issues, priorities and goals (Lane, D. A., & Green, F., 1990). However, formulation also has the potential to become a means of communicating with other professionals about the status of one’s knowledge. In her review of the use of the term in clinical psychology, Crellin (1998) describes the influences on how the concept of formulation emerged. Specifically, she highlights how formulation came to represent a form of political leverage through which psychology established its autonomy from psychiatry. For many years, psychology remained within the grip of psychiatric description through the use of symptom matching and diagnostic labelling. As Bruch and Bond (1998) pointed out, clinicians were traditionally expected to define their work with clients in terms of psychiatric classification systems which determined the treatment offered. Influential psychologists at that time (most notably, Eysenck, 1990; Shapiro, 1955, 1957; Shapiro & Nelson, 1955) argued for an approach which emphasized clinical–experimental work (the beginnings of the scientist-practitioner model in the United Kingdom) centred on learning principles, thus challenging these expectations. This was elaborated by Meyer (see Bruch & Bond, 1998) who highlighted that the dilemmas for the clinician are that (a) not all clients sharing the same complaint respond to the procedural requirements of techniques and (b) practitioners are rarely presented with clients with isolated complaints, particularly in mental health settings. Meyer rejected diagnostic systems as a means of determining choice of treatment and instead advocated individualized formulations that were shared with clients rather than devised by the therapist and then imposed. Further contributions to this approach have followed (see Corrie & Lane, 2010; Kinderman & Lobban, 2000; Kuyken, W., Padesky, C. A., & Dudley, R., 2008; Lane, 1974, 1978, 1990; Lane & Corrie, 2006; Mumma, 1998; Turkat, 1985). Formulation based on diagnostic models was, therefore, counterbalanced by formulations informed by a scientist-practitioner perspective (see Lane & Corrie, 2006). Although, for reasons of space, we do not elaborate this issue here (the interested reader is referred to Corrie & Lane, 2010), the debate about the role of diagnosis continues, particularly in the current climate where health care delivery faces concurrent demand for both tighter quality control and value for money. Equally, we would argue that the issue of formulation as a political tool is re-emerging in professional dialogues today. As Corrie and Lane (2010: p.8) explain: …in an already over-crowded market, the degree of sophistication, complexity and explanatory power of their formulations may become part of how certain professional groups differentiate themselves from others. In this sense, being able to construct formulations and using these as a basis for communicating with other professionals (1) provides practitioners with a degree of reassurance about their ability to explain clients’ concerns and thus, their own competency and (2) provides a vehicle for communicating with other professionals about the veracity and authority of that knowledge. It follows, then, that the act of formulation can serve multiple functions. Some of these will be explicit and some less so. Despite the professional rhetoric, it is yet to be empirically determined whether or not having a formulation has any direct impact on therapeutic outcome. Indeed, there is some evidence to suggest that practitioners’ faith in formulation as a means of achieving improved outcomes may be somewhat over-optimistic (see, e.g. Schulte, Kunzel, Pepping, & Shulte-Bahrenberg, 1992). Wilson (1996, 1997), e.g. has argued in favour of manual-based, empirically validated interventions on the basis that individually tailored formulations always rely upon professional judgement that can all too easily prove flawed (see also Dawes, 1994; Dawes, Faust, & Meehl, 1989). Within a cognitive-behavioural approach, a number of attempts have been made to evaluate the inter-rater reliability and predictive validity of formulations (see Barber & Crits-Christoph, 1993; Horowitz & Eells, 1993; Persons, Mooney, & Padesky, 1995). Bieling and Kuyken (2003) have found that while practitioners can agree at the descriptive level about key features of a case, their interpretations of the more explanatory components vary widely. They distinguish top-down and bottom-up criterion for evidence-based conceptualization. The former works from inferences from theory or research applied to the single case. Hence, the theory is used to structure understanding of the client’s presenting concerns, shaping both the information sought and the interpretive lens through which the client’s narrative comes to be understood. Bottom-up approaches (i.e. those that adopt a data-driven approach to enquiry) work from an attempt to map a reliable and valid case formulation on to the client’s presenting difficulties. The practitioner works back to theory as necessary to elaborate upon that understanding. Based on research into the application of cognitive-behavioural theory, Bieling and Kuyken (2003) propose that accuracy is too varied to provide confidence in any formulation achieved. If we add to this what is known about some of the biases in professional decision-making (Lane & Corrie, 2006, 2012), it is not easy for even highly experienced practitioners to have confidence in the formulations we generate. Kuyken, Padesky, and Dudley (2009) have responded to these, and other, challenges of cognitive-behavioural therapy formulations by proposing the metaphor of a crucible. As they explain, The crucible is where theory, research, and client experiences are integrated to form a new description and understanding of client issues. While grounded in evidence-based theory and research, the conceptualization formed in the crucible is original and unique to the client and reveals pathways to lasting change. (p. 26) They also propose that one of the reasons why our formulations are not always favourably received by our clients is that they have tended to take the form of therapist-driven accounts presented to the client, rather than being constructed in partnership with them. Their use of the metaphor of a case conceptualization crucible identifies three key features: (1) heat drives chemical reactions in a crucible (the collaborative empiricism between therapist and client provides the heat); (2) like the chemical reaction in a crucible, the formulation develops over time, starting with more descriptive elements and gradually expanding to include predisposing and protective factors and (3) the new substances formed in a crucible are dependent on the characteristics of the chemical compounds put into it. In her examination of the issue of reliability, Butler (1998) has argued that a direct comparison of the effectiveness of manual-based versus individually tailored approaches may obscure rather than illuminate some of the complexities involved. Specifically, she points out how practitioners use covert formulations, derived from prior theoretical knowledge and experience, that frame how they listen to their clients’ concerns form the earliest stages of the therapeutic encounter. Far from being ‘less reliable’, such an approach may represent an example of practice-based evidence, where evidence derived from knowledge of the client’s story and the lessons from our own professional experience form the basis of effective and ethical practice (Corrie, 2003, 2009). For Butler (1998), the purpose of a formulation is not to arrive at clear-cut answers, but rather to generate multiple hypotheses that can assist choices about the direction of the enquiry. Thus, the benchmark criterion may ultimately be one of usefulness rather than accuracy. Bieling and Kuyken (2003) also observe how issues concerning the reliability and validity of therapists’ formulations always contain inconsistencies and that the extent to which the ‘quality’ of any given formulation directly impacts on outcome (as opposed to exerting a more indirect effect) remains ambiguous. Perhaps this is why Crellin (1998) has argued in favour of a formulation that emerges at the end of therapy, and one that is essentially owned by the client rather than the therapist. Nonetheless, the debate about the standing of individualized case formulations, and the merits of these relative to disorder-specific models, is not easily dismissed. Moreover, in recent years, the importance of delivering empirically supported interventions has taken on a new meaning in the context of official guidelines, such as those from the National Institute for Health and Clinical Excellence, as well as the UK Government’s Improving Access to Psychological Therapies initiative for training and employing an extra 3,600 therapists to deliver evidence-based psychological therapies for depression and anxiety disorders (Department of Health, 2008). Such developments can, if misunderstood, appear to offer straightforward answers about what is indicated for which clients and when. Drake (2008) has proposed that professionals are increasingly operating in ‘a culture of pragmatism’ where swift solutions are privileged over more exploratory interventions. In such circumstances, as Josselson (1999) observes, there can be a tendency for practitioners to seek prescriptive guidance on what to do and when. The promise of well-defined procedures that, when systematically applied, can obtain predictable positive results holds an understandable allure for the practitioner confronted with large amounts of clinical information. Nonetheless, many of the challenges encountered in practice cannot be neatly categorized and so do not lend themselves to protocol-based interventions as Meyer long ago argued (Bruch & Bond, 1998). Disorder-specific models and other protocols and frameworks are often very useful. However, in our view, there is no protocol that can eliminate the need for professional judgement and still allow us to practice safely. Effective professional practice demands the capacity to think at multiple levels, hold in mind diverse sources of data and aim for understanding about what contributes to particular concerns whilst simultaneously being able to devise potential solutions. This complexity was acknowledged in the British Psychological Society Guide to Good Practice in Case Formulation (Division of Clinical Psychology 2011). Having reviewed, albeit briefly, some of the main debates surrounding and development and use of formulation in clinical practice, we make the case for an individualized approach to formulation that retains rigour, holds the practitioner accountable for their clinical decision-making but also allows for the creative application of theoretical constructs and permits a flexibility of approach. A good formulation, as we see it, is not necessarily one that can be demonstrated to be ‘correct’ in any factual sense, but is rather a framework through which the practitioner can demonstrate the following: In the next section, we present an approach to formulation that is consistent with the earlier principles and that can be adapted to the needs of any specific enquiry regardless of the theoretical perspective taken. We then provide an illustration of this approach through a case study. Drawing on the literature reviewed in this chapter, as well as our previous work on both formulation and the scientist-practitioner model (Corrie & Lane, 2010; Lane, 1978, 1998; Lane & Corrie, 2006), we define formulation in broad terms, as the co-construction of a narrative which provides a specific focus for a learning journey. This learning journey takes the client from where they are now to where they want to be, based on a process of negotiating agreed goals. The task of formulation centres on the creation of a shared framework of understanding that has implications for change. In our work, we have found it helpful to focus on three domains which we would see as a useful guide to constructing helpful formulations with clients. These are the following: This model is presented here, following an illustration of its use in practice. These domains provide a generic framework for thinking about formulation. The DEFINE model we use later is a specific application of those domains. In carrying out any psychological enquiry, it is vital to be clear about its fundamental purpose. The shape that your enquiry subsequently takes will follow on from here. Neither conducting an assessment of, nor devising explanatory hypotheses about, a client’s concerns can proceed in any truly informed way until the nature of the enquiry has been agreed by all parties involved. Therefore, the starting point on the shared journey between you and your client begins as you work together to define a clear sense of purpose to the work that lies ahead. This gives rise to the following types of questions: According to the requirements of a particular case, establishing the Purpose for which an explanation is required may be a relatively swift and straightforward process or a significant piece of work in its own right. Determining factors will be numerous and varied, ranging from the practitioner’s preferred approach, to case management issues and the service in which the work is provided, as well as the number of stakeholders involved and how each party understands the issues of concern and defines their involvement. The combination of factors in each particular case will lead to the privileging of certain types of information over others, shaping beliefs about the choices that practitioner and client have available to them (Honeychurch, 1996). In consequence, the landscape of knowledge and prevailing conditions do not merely reflect the realities in which practitioners provide their services; they also organize them (Gonçalves & Machado, 2000). As part of developing a shared purpose, it is important for the practitioner to be able to define what they bring to the encounter. This includes their values, beliefs, prior knowledge and preferred therapeutic approach, as well as the models that inform their work (and those of the service in which they see their clients). However, clients also bring perspectives of their own which will inform the work that is undertaken and which must, therefore, be given equal consideration in the enquiry that follows. Identifying and exploring these perspectives gives rise to questions like the following: Traditionally, those who use psychological interventions have tended to enter the journey towards a shared understanding from one of two positions. The first is the view that they, as the professional, hold the key to the client’s dilemma and that this lies in a single theory or model – i.e. a particular perspective. The second is a preference for hearing the story first and then seeking the perspective which best fits. In the first example, practitioners will look at specific aspects of the client’s concerns rather than the client as a whole. Practitioners operating from this position do not need to hear the entire story first. Certain aspects of the client’s story will be privileged over others, as a function of practitioners’ allegiance to their chosen perspective (such might be the case for those practitioners who listen selectively for examples of unhelpful, biased cognitions). Of course, this does not mean that such practitioners do not seek to ensure that the client feels heard. However, the formulation which follows will be filtered through the particular lens of a specific theoretical or conceptual worldview which identifies a limited number of key events as critical to bringing about change. For those who favour the second approach, the starting point is one of hearing the story first and then seeking the perspective which best fits. There have always been practitioners who seek multiple explanations. Carkhuff and Berenson (1967), Meyer (see Bruch & Bond, 1998) and Lane (1975), amongst others, aim to hear the story and then consider it through multiple perspectives as they work with the client to construct, deconstruct and reconstruct its meaning. Indeed, as Bruch (1998) pointed out, one of the features of Meyer’s work was his willingness to draw upon a wide range of perspectives in addition to his core model. Thus, the formulation that emerges will take varied forms; key events are identified and explanations for their impact derived from a range of approaches that are subsequently woven into a coherent clinical theory specific to the client.
Cognitive-Behavioural Formulation and the Scientist-Practitioner
Working with an Adolescent Boy
Introduction
The Functions of Formulation: A Review of the Key Debates
Do Formulations ‘Work’: A Brief Review of the Evidence
A Generic Framework for Developing Formulations: The Purpose–Perspectives–Process Model
Purpose
Perspectives
Process
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