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Good Practice Guidelines on the use ofpsychological formulationDecember 2011Printed and published by the British Psychological Society.© The British Psychological Society 2011The British Psychological Society, St Andrews House, 48 Princess Road East, Leicester LE1 7DR, UKTelephone: 0116 254 9568 Facsimile 0116 227 1314E-mail: [email protected] Website: www.bps.org.ukIncorporated by Royal Charter Registered Charity No 229642If you have problems reading this document and would like it in adifferent format, please contact us with your specific requirements.Tel: 0116 252 9523; E-mail: [email protected]………………………………………………………………………………………………………… 11. Executive summary……………………………………………………………………………………………. 22. Introduction ……………………………………………………………………………………………………… 33. Structure of the document …………………………………………………………………………………. 34. Brief historical context of formulation ……………………………………………………………….. 45. Formulation in clinical psychology professional documents …………………………………. 56. Defining formulation…………………………………………………………………………………………. 67. Purposes of formulation ……………………………………………………………………………………. 88. Clinical issues: When is a formulation a formulation?………………………………………….. 10– Formulation as a process and formulation as an event …………………………………………….. 10– A partial formulation and a full formulation…………………………………………………………. 109. Principles of formulation in clinical psychology ………………………………………………….. 12– Person-centred and problem-specific formulation …………………………………………… 13– Multiple-model and single-model formulation ………………………………………………… 13– Integration-through-personal-meaning and list-of-factors formulation………………. 15– Formulation and diagnosis …………………………………………………………………………….. 16Psychiatric formulation and psychological formulation …………………………………………….. 17– Formulation and culture………………………………………………………………………………… 1810. Formulation and the service/organisational context ……………………………………………. 1911. Formulation and the wider social/societal context ………………………………………………. 2012. Ethical issues in formulation………………………………………………………………………………. 2113. Formulation: Areas for development ………………………………………………………………….. 23– Research into formulation……………………………………………………………………………… 23– Formulation and electronic records ……………………………………………………………….. 23– Formulation-based alternatives to psychiatric diagnosis……………………………………. 2414. Summary and recommendations ………………………………………………………………………… 2615. Relevant BPS documents……………………………………………………………………………………. 27Appendix 1: Checklist of good practice in the use of formulation ……………………………… 28Appendix 2: Professional guidelines and criteria in relation to formulation ……………….. 31Appendix 3: Formulation and research …………………………………………………………………….. 34References ……………………………………………………………………………………………………………… 36ContentsThe following people have contributed to the guidelines:Dr Lucy Johnstone (Lead author and chair of the Working Party)Dr Stuart Whomsley (Co-author and member of the Working Party)Dr Samantha Cole (Co-author and member of the Working Party)Dr Nick Oliver (Co-author and member of the Working Party)Invited comments were received from:Kamel Chahal (Chair, Faculty of Race & Culture)Dr Stuart Gibson (Chair, Faculty for Sexual Health & HIV)Dr John Hanna (Chair, Faculty for Psychosis and Complex Mental Health)Dr Theresa Joyce (Chair, Faculty for Learning Disabilities)Duncan Law (Chair, Faculty for Children & Young People)Dr Margaret O’Rourke (Chair, Faculty of Forensic Clinical Psychology)Dr Frank Ryan (Committee member, Faculty for Addictions)Jane Street (Chair, Faculty for Holistic Psychology)Other expert commentators were:Professor Mike BergerJan BostockProfessor Mary BoyleIsabel ClarkeDr Sarah CorrieTricia HaganDr David HarperProfessor Peter KindermanProfessor David LaneProfessor David PilgrimSue StaiteService user and carer commentators were:Iola DaviesSheena Foster (DCP Service User & Carer Liaison Committee)Pauline HeslopNick RedmanAcknowledgementsWe would like to thank Catherine Dooley, Chair of the PGP and the PGP committee fortheir support and comments, Tracey Goode for her assistance with formatting andHelen Barnett, BPS Member Network Adviser, and Martin Reeves, BPS P4P Department,for their assistance with production.Good Practice Guidelines on the use of psychological formulation 1Foreword2 Division of Clinical Psychology● Formulation is a core skill for clinical psychologists at all levels and in all specialties.These guidelines outline best practice for the profession of clinical psychology.● This document defines psychological formulation as a hypothesis about a person’sdifficulties, which links theory with practice and guides the intervention.● Psychological formulation can serve a large number of purposes for individuals,teams and organisations.● Formulation can be understood as both an event and a process, and it summarisesand integrates a broad range of biopsychosocial causal factors. It is based onpersonal meaning and constructed collaboratively with service users and teams.● The document recognises the value of all types of formulation, while recommendingthat clinical psychologists always formulate from a broad-based, integrated andmulti-model perspective which locates personal meaning within its wider systemic,organisational and societal contexts.● Current research findings are reviewed, along with ethical considerations relating tothe use of formulation.● Recommendations are made for future developments in theory, practice andresearch.● Principles for best practice formulation and formulating are summarised in achecklist.1. Executive summaryThe guidelines have been developed for the Division of Clinical Psychology for thepurpose of promoting best practice in psychological formulation, which is a corecompetence for clinical psychologists. The guidance is intended to be of benefit to clinicalpsychologists and clinical psychology training courses. Briefer versions suitable for otherstakeholders (e.g. commissioners, service users and carers) are currently being developed.2. IntroductionGood Practice Guidelines on the use of psychological formulation 3There is no universally agreed definition of formulation, and it is understood and used invarying ways by different professional groups. For this reason, a relatively large proportionof the document is devoted to outlining definitions, purposes and general principles offormulation in relation to clinical psychology. These sections may or may not be directlyapplicable to other professions (psychiatrists, nurses, etc.).Formulation raises some areas of debate for the profession of clinical psychology, such asthe use of integrative as opposed to single-model formulations, the use of psychiatricdiagnosis alongside psychological formulation, and the role of formulation within its widerorganisational and societal contexts. While these guidelines are not prescriptive aboutindividual practice in any of these complex areas, they do attempt to establish some broadprinciples for best practice psychological formulations in order to inform the debate.Current evidence on the theory and practice of formulation, which is an under-researchedarea, is summarised. Ethical considerations relating to formulating are also discussed.The document concludes with a summary and recommendations for further developmentand research. Appendix 1 consists of a checklist of good practice for clinical psychologistsin formulation and formulating.3. Structure of the document4 Division of Clinical PsychologyIn a broad sense, constructing meaning out of mental distress has a very long history.For example, Freud wrote:I was trained to employ local diagnoses…and it still strikes me myself as strange that the case historiesI write should read like short stories and that, as one might say, they lack the serious imprint ofscience… Case histories of this kind…have, however, one advantage…namely an intimate connectionbetween the story of the patient’s sufferings and the symptoms of his illness. (Freud & Breuer,1895/1974, p.231)The roots of formulation as a core skill of the profession of clinical psychology can betraced back to the 1950s and the emergence of the scientist-practitioner model. In this,clinical psychologists are seen as applied scientists, drawing on the science of psychology inorder to generate hypotheses about individual clients (Kennedy & Llewelyn, 2001). Thepresenting problems became a puzzle to solve which engaged the clients in the process.Influential clinicians such as Hans Eysenck, Victor Meyer, Monte Shapiro and Ira Turkatused the principles of classical and operant learning theory to develop individualisedalternatives to psychiatric diagnosis. These summaries later came to include thoughtprocesses, in line with the emergence of cognitive-behavioural therapy (see Bruch & Bond,1998; Crellin, 1998; Corrie & Lane, 2010, for a more detailed history).The term ‘formulation’ was first included in clinical psychology regulations in 1969(Crellin, 1998), and it is now one of the core competencies of the profession, along withassessment, intervention, evaluation, audit and research, personal and professional skills,communication and teaching skills, service delivery skills and transferable skills (Divisionof Clinical Psychology, 2010). Formulation is also practised by health, educational, forensic,counselling, and sports and exercise psychologists, as described in the Health ProfessionsCouncil regulations (Health Professions Council, 2009). It features in the curriculum forpsychiatrists’ training in the UK (Royal College of Psychiatrists, 2010), although, asdiscussed below, there are some differences of emphasis in psychiatric as compared topsychological formulation.4. Brief historical context of formulationGood Practice Guidelines on the use of psychological formulation 5Formulation as a core competency within clinical psychology is referenced in a number ofprofessional documents which define clinical psychologists’ standards, activities and skills.Examples are listed below (see Appendix 1 for details).Management Advisory Service (MAS) (1989). Review of clinical psychology services.London: Department of Health.Health Professions Council (HPC) (2009). Standards of proficiency: Practitioner psychologists.London: Health Professions Council.British Psychology Society (BPS) (2010). Accreditation through partnership criteria: Guidance forclinical psychology programmes. Leicester: British Psychological Society.Division of Clinical Psychology (2010). Clinical Psychology: The core purpose and philosophy ofthe profession. Leicester: British Psychological Society.Skinner, P. & Toogood, R. (Eds.) (2010). Clinical psychology leadership development framework.Leicester: British Psychological Society.The recommendations from these documents can be summarised as follows:● Psychological formulation is a core competency for clinical psychologists at all levels,starting with training, and in all aspects of their work.● Clinical psychologists’ formulations should draw on and integrate a wide range ofinterpersonal, biological, social and cultural factors.● Clinical psychologists should be using, sharing, promoting and offering training informulation and formulating within multi-disciplinary teams and organisations aswell as with individual service users and their families and carers.5. Formulation in clinical psychologyprofessional documents6 Division of Clinical PsychologyDespite the widespread use of the term in key clinical psychology documents, there is nouniversally agreed definition of formulation, and different professions bring their owncharacteristic perspectives to the subject (see Corrie & Lane, 2010, pp.10–12; andJohnstone & Dallos, 2006, ch.1). For the purposes of these guidelines, definitions will bedrawn from the field of clinical psychology.A recent clinical psychology textbook (Johnstone & Dallos, 2006) lists the essential featuresof formulations across different therapeutic modalities. All formulations:● summarise the service user’s core problems;● suggest how the service user’s difficulties may relate to one another, by drawing onpsychological theories and principles;● aim to explain, on the basis of psychological theory, the development andmaintenance of the service user’s difficulties, at this time and in these situations;● indicate a plan of intervention which is based in the psychological processes andprinciples already identified;● are open to revision and re-formulation.(NB: The term ‘service user’ in this document may include family/carers, especially in Child andAdolescent and Learning Disability settings where systemic formulations are commonly used.)Clinical psychologist Gillian Butler (1998, p.2) puts this succinctly:A formulation is the tool used by clinicians to relate theory to practice… It is the lynchpin that holdstheory and practice together… Formulations can best be understood as hypotheses to be tested.The Core Purpose and Philosophy of the Profession (DCP, 2010, pp.5-6) states:Psychological formulation is the summation and integration of the knowledge that is acquired by thisassessment process that may involve psychological, biological and systemic factors and procedures. Theformulation will draw on psychological theory and research to provide a framework for describing aclient’s problem or needs, how it developed and is being maintained. Because of their particulartraining in the relationship of theory to practice, clinical psychologists will be able to draw on a numberof models (bio-psycho-social) to meet needs or support decision making and so a formulation maycomprise a number of provisional hypotheses. This provides the foundation from which actions mayderive… Psychological intervention, if considered appropriate, is based upon the formulation.Both Health Professions Council criteria and British Psychological Society criteria fortraining courses state that clinical psychologists should: Be able to use professional and researchskills in work with clients based on a scientist-practitioner and reflective-practitioner model thatincorporates a cycle of assessment, formulation, intervention and evaluation (HPC, 2009; BPS, 2010).The influence of our core professional identity as scientist-practitioners can be seen in theemphasis, in these definitions, on applying psychological principles and theory in order todevelop hypotheses about service users’ difficulties. The assumption is that this process willrender even the most unusual or disturbing behaviour and experiences understandable:‘…at some level it all makes sense’ (Butler, 1998, p.2).6. Defining formulationAs the definitions indicate, clinical psychology also draws on the tradition of reflectivepractice (Schon, 1987). Reflective practice is a loose term, but implies that the subjectmatter of our discipline, human beings and human distress, is not best served by thenarrow ‘technical-rational’ application of research to practice. Rather, it requires a kind ofartistry that also involves intuition, flexibility and critical evaluation of one’s experience.In other words, formulation is ‘a balanced synthesis of the intuitive and rational cognitivesystems’ (Kuyken, 2006, p.30).This approach allows for the view of formulation as a shared narrative, or a story that is‘constructed rather than discovered’ (Harper & Spellman, 2006). These unique individualstories are centrally concerned with the personal meaning to the service user of the eventsand experiences of their lives, and it is the personal meaning that is the integrating factorin the narrative. A formulation is not an expert pronouncement, like a medical diagnosis,but a ‘plausible account’ (Butler, 1998, p.1), and as such best assessed in terms ofusefulness than ‘truth’ (Butler, 1998; Johnstone, 2006).The task of the clinical psychologist is to use their clinical skills to combine these twoaspects, psychological theory/principles/evidence on the one hand, and personalthoughts, feelings and meanings on the other, through ‘a process of ongoing collaborativesense-making’ (Harper & Moss, 2003, p.8) in order to develop a shared account thatindicates the most helpful way forward.It should be acknowledged that all human beings are meaning-makers who createnarratives about their lives and difficulties. Formulations differ from this kind ofexplanation by being strongly rooted in psychological theory and evidence. Given thewidespread dissemination of psychological ideas in the media, self-help books and so on,this is a relative rather than an absolute distinction.Good Practice Guidelines on the use of psychological formulation 78 Division of Clinical PsychologyClinical psychologists use formulation with individuals, couples, families and groups.There is also a growing trend for using formulation in multi-disciplinary teamwork, bothinpatient and community-based. In this, a group of staff is supported to construct a sharedformulation for and with service users known to some or all of the team members.Formulations may also be developed and shared with professionals from other agenciesand services – wards, hostels, schools, day centres, care homes, courts, and so on – and withthe wider organisation in which the psychologist is employed.The quality of a formulation is dependent in large part on the quality of the assessmentand the information derived from it. Clinical psychologists are expected to be competentto use a range of procedures such as psychometric tests, risk assessments and structuredinterviewing. Information may also be gathered from relatives and carers, otherprofessionals, diaries, medical notes, observation, feedback from homework tasks, and soon. Quality also depends on supporting the service user (and sometimes family/carers) toconvey their understanding of the difficulties as fully as possible, along with strengths andresources. High quality formulations should also be informed by the most recent evidence,as summarised in NICE guidelines, Cochrane reviews and scientific journals.The main purpose of a formulation in any setting is:● identifying the best way forward and informing the intervention.Reviews and practice-based reports have suggested that formulation can serve a range ofother purposes, including:● clarifying hypotheses and questions;● providing an overall picture or map;● noticing gaps in the information about the service user;● prioritising issues and problems;● selecting and planning interventions;● minimising decision-making biases and increasing transparency, by making choicesand decisions explicit;● framing medical interventions;● predicting responses to interventions; predicting difficulties;● thinking about lack of progress; troubleshooting;● determining criteria for successful outcome;● ensuring that a cultural understanding has been incorporated;● helping the service user (and carer) to feel understood and contained;● helping the therapist to feel contained;● strengthening the therapeutic alliance;● encouraging collaborative work with the service user (and carer);● emphasising strengths as well as needs;● normalising problems; reducing service user (and carer) self-blame;● increasing the service user’s sense of agency, meaning and hope.(Based on Butler, 1998; Johnstone & Dallos, 2006; Kuyken et al., 2009; Corrie & Lane, 2010.)7. Purposes of a formulationClinicians have reported additional benefits from using formulation in teamwork in orderto 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 andchallenging;● 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, 2009;Berry et al., 2009; Hood, 2009; Craven-Staines et al., 2010; Wainwright & Bergin, 2010;Walton, 2011; Christofides et al., 2011.)Formulation does not necessarily lead to intervention; it may indicate that no further inputfrom professionals is needed. It should also be noted that developing a formulation can bea powerful intervention in itself, and may be enough on its own to enable the service useror team to move forward and make changes.Team formulation is in keeping with the profession’s wider remit to work at a team, serviceand organisational level. The clinical psychology leadership framework lists one of theroles of a qualified psychologist as: Lead on psychological formulation within your team (Skinner& Toogood, 2010). This might include supervising and training other members of themulti-disciplinary team in formulation. It has been suggested that using formulation inteamwork is a particularly effective way of achieving culture change and promoting a morepsychosocial perspective in services as a whole: (‘A good formulation can be a powerfulsystemic intervention’, Kennedy et al., 2003; ‘Taking formulation into a wider setting canbe 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 910 Division of Clinical PsychologyThe boundaries of what actually constitutes a formulation are somewhat arbitrary. There isno absolute or definite cut-off point on the dimensions listed below.Formulation as a process and formulation as an object or 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 may be summarised inwriting or a diagram, although these two aspects are not completely distinct fromeach other.In practice, ‘formulation-as-a-process’ may be the more common clinical activity.However, formulations in letters to referrers and training coursework are likely to bepresented as a one-off ‘formulation-as-event.’ Written versions might also take theform 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 aCPA form or in the electronic record; and so on.A partial formulation and a full formulation.There is always the possibility of re-formulation in order to include new informationand insights, and in this sense all formulations are partial and dynamic; in the wordsof one psychologist, they are ‘broad snapshot summaries of complex evolvingstories’ (Cole & Johnstone, in press). However, some formulations are necessarilyand appropriately more comprehensive and detailed than others. For example,a coursework assignment may be several paragraphs long and focus on a complex setof difficulties in the context of a person’s whole life story; this is suited to its mainpurpose of assessing a trainee’s competence. In contrast, a qualified psychologistmay find that simple diagrammatic formulations (e.g. demonstrating how automaticthoughts lead to anxiety which leads to avoidance) are often more suitable forroutine clinical practice. CBT-based formulations typically develop through asequence of descriptive summaries, cross-sectional formulations and longitudinalformulations, as more information is gathered (Kuyken et al., 2009; Persons, 2008).Another type of partial formulation is evident in the formulation-informed thinkingthat, evidence suggests, is used by clinical psychologists in almost every aspect oftheir daily practice and seen by them and other multi-disciplinary team members asan invaluable aspect of their role (Christofides et al., 2011; Hood, 2009).For example, a psychologist may suggest during a team discussion that a serviceuser’s behaviour can be understood in the light of their history of rejection. Thiskind of on-the-spot contribution to case discussions, ward rounds, CPA reviews andteam meetings is not necessarily documented in writing, or defined as formulationin a formal sense.8. Clinical issues: When is a formulation a formulation?In order to decide how full a formulation needs to be, whether or not it should bedocumented in writing and where its main focus should lie, a psychologist will need toconsider factors such as: where the most pressing concern or ‘stuck point’ is; the extent towhich wider systemic factors seem relevant; the stage of the therapy or intervention; theamount of information available; the likely receptiveness of the service user, family, team orservice; and the usual constraints of time and resources.While the principles outlined in this document will be broadly relevant to formulationused in a more partial, informal or evolving way, for obvious reasons it will not always bepossible, necessary or appropriate to incorporate them in full. Clinical judgement must beexercised in making these decisions. However, the guidelines can still be seen as a usefulreference point and checklist of good practice for all stages and versions of formulationand formulating.Good Practice Guidelines on the use of psychological formulation 1112 Division of Clinical PsychologyFor the purposes of these guidelines, psychological formulation will mainly be used in its‘formulation-as-an-event’ sense (i.e. the written or diagrammatic version which isdeveloped with service users/teams/referrers, and appears in letters/medicalnotes/electronic records.) However, the written formulation necessarily evolves, andcontinues to evolve, out of ‘formulation-as-a-process.’ For this reason close attention willalso be paid to the process of formulating. Thus, best practice in both formulation andformulating will be addressed. (A complete set of criteria is presented in the checklist inAppendix 1.)The following principles of psychological formulation in clinical psychology are widelyaccepted:● it is grounded in psychological theory and evidence;● it is constructed collaboratively, using accessible language;● it is constructed reflectively;● it is centrally concerned with personal meaning;● it is best understood in terms of usefulness than ‘truth’.In addition, it will be argued that best practice clinical psychology formulation andformulating has the following characteristics:● it is person-specific not problem-specific;● it draws from a range of models and causal factors;● it integrates, not just lists, the various possible causal factors through anunderstanding of their personal meaning to the service user;● it is not premised on functional psychiatric diagnoses such as schizophrenia orpersonality disorder. Rather, the experiences that may have led to a psychiatricdiagnosis (e.g. low mood, hearing voices) are themselves formulated;● it includes a cultural perspective and understanding of the service user’spresentation and distress;● it is clear about who is the service user and who are the stakeholders in any givensituation;● it starts from a critical awareness of the wider societal context of formulation, even ifthese factors are not explicitly included in every formulation.(NB: ‘service user’ will include carers if a systemic/family formulation is employed.)These additional principles raise some complex issues that merit discussion in more detail.The first five items are expanded in the sections below, while the last two are covered in thesections on Formulation and the service/organisational context and Formulation and thewider social/societal context.In discussing these potentially controversial aspects, the guidelines start from the generalposition that all types and versions of formulation can be valuable in the appropriatecircumstances and settings. Any increase in the integration of psychological theory,9. Principles of formulation in clinical psychologyprinciples and evidence into clinical practice is to be welcomed. Simpler, single-modelformulations may be a useful starting point for training purposes: for example, on clinicalpsychology doctoral programmes or with members of a multi-disciplinary team. In seekingto promote culture shift in teams and organisations, it may be helpful and strategic forclinical psychologists to use ‘list-of-factors’ formulations, or formulations that includepsychiatric diagnosis, as a first step. Additionally, it is acknowledged that it will not berelevant or necessary to include a complete range of causal factors and contexts in everypsychological formulation. However, the fullest use of clinical psychologists’ professionalskills implies a broad-based, integrated and multi-model perspective which locates personalmeaning within its wider systemic, organisational and societal contexts. Best practiceshould be based on a considered choice about what to include or exclude in any givenformulation, in line with the principles discussed in these guidelines, and adapted asnecessary to the service user’s or team’s particular circumstances and contexts.Person-centred and problem-specific formulationThis refers to the difference between a standardised formulation of a problem as opposed to aformulation of a particular person’s problematic experiences. As examples of the former,CBT protocols have been developed for typical cognitive processes in anxiety, depression,personality disorders, PTSD, psychosis and so on (e.g. Ehlers et al., 2004; Wells, 2004).Problem-specific formulation has its place, especially with less complex difficulties(for example, in the Increasing Access to Psychological Therapies programme for anxietyand depression). It has strong links to the evidence base, and can serve as a starting pointfor a more broadly-based formulation. However, as it stands it does not fulfil all of theprinciples of psychological formulation as outlined in this document because it allows foronly a limited range of causal and process factors. For example, it may overlook ordownplay the significance of transference, cultural, service/organisational andsocial/societal factors. In addition, it does not allow for debate about who is the serviceuser and who are the stakeholders; and it is based on problematic diagnostic categories.(All these aspects of psychological formulation are discussed further below.) Problemspecific formulation thus typifies Level 2 skills (MAS, 1989) rather than the Level 3 skillsthat are said to be the defining feature of the profession.Multiple-model and single-model formulationAlthough not all therapies use formulation (e.g. person-centred, narrative) it is a corefeature of the main therapies used by NHS clinical psychologists: CBT, systemic,psychodynamic and cognitive analytic therapy. Each of these approaches draws on aparticular set of concepts in their formulations (e.g. negative automatic thoughts, problemmaintaining patterns, the unconscious.) In addition, they each use particular terms forformulation which entail different theoretical assumptions (e.g. ‘case conceptualisation’(Beck, 1995), ‘dynamic formulation’ (Malan, 1979) and ‘reformulation’ (Ryle, 1995).However, it has been argued that differences are not as great as commonalities, and that ashared conception of formulation, independent of theoretical orientation, is preferable(Butler, 1998; Goldfried, 1995).Good Practice Guidelines on the use of psychological formulation 13In 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 therapeuticrelationship: Kahn, 1997); or set of techniques (e.g. Egan, 2006); or a personal synthesis ofpreferred approaches (Dallos et al., 2006).Clinical Psychology training criteria require all training courses to teach at least twoevidence-based models of psychological therapy, one of which must be CBT (BPS, 2010.)There is mixed guidance within the profession about whether psychological formulationsshould be based on the integration of two or more therapeutic models, or should more simplyinclude a wide range of factors. The MAS (1989) report claimed that the former was acentral defining feature of the profession (‘Level 3 skills’.) The Division of ClinicalPsychology (2010) definition states that psychologists will be able to draw on a number ofdifferent models as required, but does not imply that more than one model will necessarilyinform any given formulation. The British Psychological Society criteria for trainingcourses (BPS, 2010) require the incorporation of ‘interpersonal, societal, cultural andbiological factors’ rather than models. HPC (2009) criteria include: ‘Understandpsychological models related to how biological, sociological and circumstantial or lifeevent-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 isvery much a work in progress and there are currently no completely satisfactoryframeworks 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, 2008);● the personal meaning and service user experience of medical interventions such asdiagnosis, medication and admission (Martindale, 2007);● the potentially traumatising effects of medical and psychiatric interventions(Lu et al., 2011; Johnstone, 1999);● the influence of stigma, discrimination and the ‘mental patient’ role (Barham &Hayward, 1995);● 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 inclients 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 factorsfrom 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 thanone therapeutic model. In practice there may be little to distinguish the resulting14 Division of Clinical Psychologyformulation, especially given the trend for all therapeutic models to absorb ideas andperspectives from each other.It is also noted that not all formulations are based on specific therapeutic models, althoughwithin the definition used in this document, they should all draw on psychological principlesand evidence. These might derive from, for example, attachment theory, or research intothe impact of racism or domestic abuse, or evidence about the psychological effects ofhead injury, chronic pain, developmental disorders, alcohol abuse and so on. Psychologicalformulations will also draw upon the current evidence-base as summarised in NICEguidelines, Cochrane reviews and elsewhere.As previously noted, part of the clinical skill in developing a formulation is deciding howinclusive it needs to be to meet the required purpose at any given time. Clearly, mostformulations in day-to-day practice will not cover the whole range of possible contexts andcausal factors listed above, and nor would this necessarily be the most appropriate way touse formulation in every situation. However, a narrower or single-model formulation needsto be a conscious and justifiable choice from a wider field of possible models and causalinfluences.Integration-through-personal-meaning formulations and list-of-factorsformulationsWhile the inclusion of causal factors from a number of different dimensions and models isdesirable, this does not necessarily result in integration. Some well-known approaches toformulation advocate the use of templates for filling in lists of relevant factors frombiological, social, interpersonal and other domains (e.g. Weerasekera, 1996). Psychologistssometimes use a similar template known as PPPP (predisposing, precipitating, perpetuatingand protective.) This format is also used in psychiatric training (Royal College ofPsychiatrists, 2010) in order to ‘…integrate information from multiple sources to formulatethe case into which relevant predisposing, precipitating, perpetuating and protective factorsare highlighted’ (p.27).While these kinds of templates may be a useful starting point, they have two limitations:firstly, they do not require the various factors to be synthesised into a coherent narrative,as opposed to simply being listed in an additive fashion (X happened, then Y happened, inthe context of Z.) In other words, these formulations are not necessarily integrated, althoughthey are sometimes described as such. Secondly, the templates do not necessarily include thepersonal meaning of the factors and life events, as opposed to a list of external triggers (abused bystepfather; diagnosed with cancer; bullied at school; etc.). Psychological theory suggests thatthe impact of difficult circumstances or events is mediated through the meaning they holdfor the individual (Kinderman et al., 2008). As noted in Section 9, personal meaning is theintegrating factor in a psychological formulation as defined in this document.(NB: In some client groups, for example, people with a severe learning disability or older adults withadvanced dementia, personal meaning may need to be inferred by the clinician and/or a Best Interestprocedure.)Good Practice Guidelines on the use of psychological formulation 15One of the risks of the list-of-factors approach is the conjoining of incompatible theoreticalmodels. This is true of some versions of the widely-used diathesis-stress or biopsychosocialmodel, as discussed below.Formulation and diagnosisMedical conditions such as cancer, Down’s syndrome, Alzheimer’s disease, head injury andvarious kinds of physical disability frequently play an important causal role in presentationsin Clinical Health, Learning Disability, Older Adults and Neuropsychology specialties, andto a lesser extent in Child and Adolescent and Adult Mental Health. Clinicians may alsohave to take account of the psychological effects of alcohol, street drugs, stroke, starvation,and so on, depending on specialty. These medical/organic/developmental factors are anessential part of a holistic biopsychosocial formulation. The clinical psychologist will aim toconstruct a formulation that explores the personal meaning and impact of the condition,and that also includes the service user’s wider interpersonal and environmental context.This is consistent with Kinderman et al.’s (2008) model of psychological processes as amediating factor and final common pathway in all cases of mental distress, whatever theparticular combination of biological, psychological and social factors in any given situation.The use of so-called ‘functional’ psychiatric diagnoses such as schizophrenia, bipolardisorder and personality disorder is more contentious (Boyle, 2002; Bentall, 2003). Thereis no space within these guidelines to repeat the long-standing debates about the validity ofsuch diagnoses (but see forthcoming Division of Clinical Psychology position statement onclassification). However, psychological formulation starts from the assumption that ‘atsome level it all makes sense’ (Butler, 1998, p.2). From this perspective, mood swings,hearing voices, having unusual beliefs and so on can all be understood as psychologicalreactions to current and past life experiences and events, in the same way as morecommon difficulties such as anxiety and low mood. They can be rendered understandablein the context of an individual’s particular life history and the personal meaning that he orshe has constructed about it. They may also be understandable within a cultural context –for example, beliefs about supernatural possession or witchcraft.Describing these experiences within an illness model is based on the very differentassumption that the primary causal factor is biological dysfunction. This obscures thepersonal meaning of difficult events by framing them as ‘triggers’ of an underlyingbiological vulnerability, which lead to ‘symptoms’ rather than understandable responses tooverwhelming life circumstances. It also reduces agency, or the service user’s belief in theirability to work towards their own recovery, rather than simply waiting for medicaltreatment to take effect. Psychological formulation’s meta-messages about personalmeaning, agency and hope can act as a helpful corrective to some of the well-documentednegative consequences of receiving a psychiatric diagnosis, such as increasing a serviceuser’s sense of powerlessness and worthlessness (Rogers et al., 1993; Barham & Hayward,1995, Mehta & Farina, 1997; Honos-Webb & Leitner, 2001). A label of learning disabilitycan also have a profound impact on a service user’s sense of identity.16 Division of Clinical PsychologyThis does not imply that biological factors should be excluded from formulations inmental health settings. Clearly we have bodies and brains as well as minds, and there is anincreasing amount of evidence about how they shape each other (e.g. the effect of traumaand attachment styles on the developing brain; Schore, 2009). This growing area ofresearch contributes to a genuinely integrated version of a biopsychosocial model that isnot based on unwarranted prioritisation of biological factors but which recognises, in thewords of biologist Steven Rose, that ‘every aspect of our human existence is simultaneouslybiological, personal, social and historical’ (2001).Psychiatric formulation and psychological formulationA psychiatric formulation, in other words a formulation that is partially based on apsychiatric diagnosis such as schizophrenia or personality disorder, differs in severalimportant ways from a psychological formulation. The curriculum for Specialist CoreTraining in Psychiatry (Royal College of Psychiatrists, 2010) requires trainee psychiatrists to‘demonstrate the ability to construct formulations of patients’ problems that includeappropriate differential diagnoses’ (p.25). Psychiatric formulation as described in thecurriculum is based on the description of ‘the various biological, psychological and socialfactors involved in the predisposition to, the onset of and the maintenance of commonpsychiatric disorders’ (p.27). Thus, it may take the form of ‘bipolar disorder triggered bythe stress of bereavement’ or similar.Psychiatric diagnoses are sometimes included in the types of formulation discussed above:problem-specific protocols, ‘list-of-factor’ frameworks, and some diathesis-stress andbiopsychosocial formulations. However, with the exception of conditions of clearly organicorigin such as dementia, it is recommended that best practice psychological formulationsin mental health settings are not premised on psychiatric diagnosis. Rather, theexperiences that may have led to a psychiatric diagnosis (low mood, unusual beliefs, etc.)are themselves formulated. If this is carried out successfully, the addition of a psychiatricdiagnosis becomes redundant. In Bentall’s words (2003, p.141): ‘Once these complaintshave been explained, there is no ghostly disease remaining that also requires anexplanation. Complaints are all there is.’Since some service users and carers find psychiatric diagnoses helpful, it is in keeping withthe spirit of respectful and collaborative work to include this perspective. In such a case,the formulation might recognise their views by, for example, noting that ‘You find thediagnosis of bipolar disorder a useful way of explaining your difficulties to family andfriends.’ For others, the meaning may be less positive, and this too needs to beacknowledged; for example, ‘The diagnosis of personality disorder seemed to confirm yourfeelings of being unacceptable’, and so on. What is important is that enough commonground can be agreed between psychologist and service user to provide a basis for theintervention, if one is required. The process of formulating provides an opportunity todiscuss and negotiate a shared psychological perspective with the service user (and his/herfamily and carers if appropriate) – one that may not have been offered before. One of theadvantages of psychological formulation over diagnosis is that it allows for this kind ofnegotiation.Good Practice Guidelines on the use of psychological formulation 17Formulation and cultureCulture can be defined as a framework that guides and bounds our lives, and throughwhich actions are filtered or checked as individuals go about daily life. These culturalframeworks are constantly evolving and being reworked (Anderson & Fenichel, 1989). It isimportant to remember, however, that even people sharing the same race or ethnicity candiffer in their cultural backgrounds; for example their values, spiritual and religiousbeliefs, health beliefs and so on. It is therefore important to consider cultural issues withevery service user.Research has shown that black and minority ethnic groups are disadvantaged groupswithin 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 especiallyvulnerable to developing mental health problems due to the experience of famine, war,persecution and other traumatic events in their home country. Language differences maycreate an additional barrier to the communication of distress. There can also be culturalvariance in how distress is expressed.Western models of psychology and psychological therapy, and, therefore, the formulationsthat are based on them, often privilege ideas of independence and self-actualisation asindicators 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 andcommunality and see the individual as secondary to the family (Webster, 2002). Mentalhealth may not be seen as separate from physical, emotional and spiritual well-being, andthere may be very different ideas about causation and intervention (Kanwar & Whomsley,2011). Formulations may, therefore, need adaptation for use in a culturally appropriateway. One framework for this is the Cultural Formulation model, which has been used inrelation to psychiatric diagnosis (Lewis-Fernandez & Dias, 2002) but also has widerrelevance. 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 degreeof 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’spsychosocial environment;● cultural elements of the relationship between the individual and the clinician, andtheir impact on the therapeutic relationship.The concept of formulation, especially an individual one that prioritises internal causalfactors, is itself culturally-based. Much work remains to be done to develop culturallyappropriate forms of formulation, along with mental health interventions in general(Fernando, 2002).18 Division of Clinical PsychologyGood Practice Guidelines on the use of psychological formulation 19Formulation is carried out within a service/organisational context. There are stakeholdersat all levels of the services, and their interests may not coincide. Formulation ‘is not aneutral, impartial, non-political statement of fact based on evidence leading to the bestpossible intervention for the client. Rather, it is a story told to meet specific needs – anaccount agreed between the stakeholders to access whatever change process seems to themto be appropriate at that time’ (Corrie & Lane, 2010, p.21). One of the essential tasksfacing the psychologist at the start is to clarify who these people or organisations are(relatives, schools, GPs, managers, teams, and so on), whether/how to take their interestsinto account, and what the likely consequences will be (Kennedy, 2009). A skilled andsensitive approach may be needed to ensure that the formulation is accepted in its widersystemic context. For example, there may be resistance at various levels, and for variousdifferent reasons, to a formulation which re-frames a problem as a marital/family conflictor a trauma reaction, rather than as an illness to be diagnosed and treated. It may be evenharder to locate the apparent problem at a service or organisational level rather than at anindividual one.In relation to psychiatric services in particular, it is important to remember that medicalinterventions such as diagnosis, medication and admission have their own psychologicalmeanings for the individual (Johnstone, 2000; Martindale, 2007) as does the ‘mentalpatient’ role itself (Rogers et al., 1993; Barham & Hayward, 1995). These meanings maycompound the difficulties that the service user initially presents with. For example,psychiatric interventions can be re-traumatising (Lu et al., 2011; Johnstone, 1999); manyservice users with learning difficulty have been affected by institutionalisation; and poorstandards of care in Older Adult settings may exacerbate confusion and distress. Serviceusers have attachment styles to services as well as to individual clinicians, and staff countertransference responses sometimes replicate earlier damaging relationships (Meadon &van Marle, 2008). These possibilities must be considered, especially when formulating withinpatients and multidisciplinary teams.Research suggests that, in keeping with the general principles of formulating, aformulation-based approach is best presented to teams and wider systems tentatively andwith respect for existing views (Christofides et al., 2011); in other words offered ratherthan imposed. At the same time, the Leadership Framework makes it clear that it is aclinical psychologist’s duty to ‘advocate a psychological stance in conjunction with orinstead of other health care models even in difficult circumstances, demonstrating ethicsand values’ (Skinner & Toogood, 2010). This can be a difficult balance to achieve.The principle that emerges from these considerations is that clinical psychologists shouldat all times:● be clear about who the service user is and who the stakeholders are in relation toany given formulation.10. Formulation and the service/organisational context20 Division of Clinical PsychologyAccreditation criteria for clinical psychology doctorate programmes require trainees toincorporate societal and cultural factors in their formulations (BPS, 2010). The HPC(2009) regulations state that clinical psychologists should ‘understand social approachessuch as those informed by community, critical and social constructivist perspectives’ (3a.1.)These place formulation within a wider context of social inequalities and powerrelationships (Miller & McClelland, 2006), and remind us that service users are almostalways survivors of immensely difficult personal and social circumstances. Interventions willbe ineffective if wider causal factors are located at an individual level, thus pathologisingthe service user and increasing their sense of hopelessness. While it may not be possible tointervene at a more distal level, ‘switching attention from supposed (and feared) personaldeficiencies to injuries inflicted by a damaging environment…may nevertheless constitutea 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 andpressures that people face, while not diminishing their sense of hope or agency. Hagan andSmail’s power-mapping (Hagan & Smail, 1997a, 1997b) and Holland’s (1992) model areexamples of how to integrate more distal influences into formulations, rather than simplyincluding social factors as an ‘add-on’.The community/social inequalities/human rights perspective is often poorly integratedinto practice. Recent research underlines the importance of this dimension. Wilkinson andPickett (2009) have presented compelling evidence that a society’s level of social inequalityis causally related to its rates of mental illness: ‘If Britain became as equal as the four mostequal societies (Japan, Norway, Sweden and Finland), mental illness might be more thanhalved’ (p.261). Particularly relevant to formulation is their suggestion that inequality hasits most damaging impact at least partially through its personal meaning to the individual,in terms of feeling devalued, shamed, trapped and excluded. This underlines theimportance 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 mentaldistress among communities need to be understood less in terms of individual pathologyand 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 takesplace, even if this dimension is not explicitly included in every formulation.11. Formulation and the wider social/societal contextGood Practice Guidelines on the use of psychological formulation 21As already noted, psychological formulation gains much of its credibility and usefulnessfrom being rooted in evidence and psychological theory. This has both benefits and risks.Research suggests that adult clients find it hard to disagree with formulations that arepresented to them (Johnstone, 2006). One reason may be that:…what is often obscured is that a psychological perspective also offers a story, albeit, at least initially,a more coherent story as it is grounded in a theoretical framework. Moreover, as the psychological storyis rooted in the meta-narratives of science and professionalism, it is likely to be more powerful than theclient’s story. (Strawbridge in Corrie & Lane, 2010, p.xxiv)This applies even more strongly with potentially vulnerable groups such as older adults,children and people with learning disabilities. In Learning Disabilities services, it may beimportant to seek the service user’s consent to work with carers whom they trust. If theperson does not have the capacity to give consent for this, then a best interest process mayneed to be considered.Formulation has potential limitations and drawbacks. It can be influenced by decisionmaking biases such as the availability heuristic and the anchoring heuristic (Kuyken et al.,2009; Corrie & Lane, 2010). Reflectiveness provides some safeguard against bias byensuring that our practice-based choices are underpinned by a systematic, psychologicallyinformed account of the service user’s circumstances and needs which can be articulatedand, therefore, challenged if necessary.Formulation can be used in insensitive or disempowering ways (Johnstone, 2006). There isevidence that as well as finding formulations helpful, encouraging and reassuring, serviceusers can also (sometimes at the same time) experience them as saddening, upsetting,frightening, overwhelming and worrying (Chadwick et al., 2003; Evans & Parry, 1996;Morberg Pain et al., 2008). While it is possible that the longer-term impact is beneficialoverall, much more research is needed into service user and carer reactions toformulation.Some specific issues arise in relation to team formulation. Frequently the request for aformulation is made because staff are stuck or struggling, or have strong countertransference feelings about a service user. In team formulation the primary client is often,in effect, the team. While the team may need their reactions to be included andformulated, it will not always be helpful for the service user to be presented with theseresponses. The team formulation may, therefore, not be shared with the service user in itsentirety. This would follow the same principles of information shared in a professionals’meeting or in supervision. However, it is good practice for a parallel formulation to bedrawn up with the service user, with staff feelings and reactions only incorporated andadded to the official records if appropriately phrased.12. The ethics of formulationWorking collaboratively with service users (and where relevant, families and carers), usingeveryday language, emphasising strengths as well as needs, and making good use ofsupervision will help to minimise formulation’s potentially unhelpful aspects. Special careis needed with children and people with learning disabilities for whom the use of clearlanguage, pictures or tapes/CDs will increase accessibility. These groups may beparticularly vulnerable to being ‘formulated’ without their knowledge or consent.A formulation that is not understood by, or acceptable to, the service user is not a usefulformulation, and implies, at the very least, the need for further collaborative discussion inorder to develop a shared perspective. Complete agreement may not be achieved, or maybe the subject of negotiation throughout the intervention (see May’s 2011 discussion about‘Relating to alternative realities’). However, it is essential to try and identify some commonground, and to respect the service user/team’s right to differ in other areas.Reflectiveness is seen by many clinical psychologists as an essential aspect of formulating,enhancing collaboration, sensitivity, flexibility, and awareness of one’s own assumptions,and avoiding the danger of ‘a diagnostic style of formulation which is just a list ofproblems…an inflexible and concrete bunch of ideas’ (Ray, 2008).As discussed above, awareness of the service/organisational and social/societal contexts offormulation will help to guard against meta-messages of blame and individual deficiency.It will also alert clinicians to be prepared to question assumptions about who has ‘theproblem.’To avoid the risk of objectifying the service user, the phrase ‘Formulation for/with X’rather than ‘…of X’ is recommended. This makes it clear that the formulation iscollaboratively constructed and at the service of the person.22 Division of Clinical PsychologyGood Practice Guidelines on the use of psychological formulation 23Formulation is a developing field. Three areas that need more work are research, inclusionin electronic records, and formulation-based alternatives to psychiatric diagnosis. Theseare discussed briefly below.Research into formulationClinical psychologists, like other health professionals, are committed to practice that isbased on the best evidence. Evidence-based practice can be understood in two differentways in relation to formulation. Firstly, there is the research into the theoretical contentand psychological principles on which formulation is based. This is extensive, particularlyin areas such as CBT, attachment theory, developmental psychology, and the therapeuticrelationship. In addition, there is substantial evidence about the psychological effects oftrauma, bereavement, poverty, discrimination, domestic abuse, head injury, physicaldisability, stroke, alcohol, illicit drugs, and so on. Secondly, there is the question of whetherthere is evidence to support formulation as a specific intervention. Currently, most of thisevidence, that is for reliability, usefulness, effect on outcomes, positive impact on theservice user/family/carers and on teams and so on, is lacking. This is despite the fact thatformulation is considered to be a central component of the psychological therapies thatare most commonly practised within NHS settings, and a starting point for the process ofintervention.The lack of a service user perspective is a major gap in the literature, as is anunderstanding of the process by which clinicians draw up formulations (although someattempts have been made to fill this gap, Corrie & Lane, 2010; Kuyken et al., 2009).Further research is needed in order to develop formulations in a way that is respectful ofservice users’ and carers’ experiences, and that maximises benefits while minimisingpotential negative effects. We also need to know much more about whether and howformulation enhances interventions and care packages, facilitates recovery, improvesoutcomes, and fulfils the many other purposes claimed for it. Margison et al. (2000) haverecommended that evidence for the effectiveness of psychological therapy, includingformulation, should come from practice-based evidence as well as evidence-based practice.(See Appendix 2 for a fuller summary of existing research on formulation.)Formulation and electronic records.Many NHS Trusts now use electronic information systems for mental health services, andthe aim is for this to become universal. Every patient will have an electronic clinical record(ECR) containing clinical information and demographic, care and outcome data. The aimis for the ECR to contain all the information necessary to support the business, policy, andresearch requirements for NHS organisations in England (Department of Health, 2010).Some Adult Mental Health electronic systems, for example, Rio, do include a space forformulation. However, initial research has found that without specific training, mostCMHT staff are likely to use leave this section blank or use it incorrectly (Thomas, 2008).13. Formulation: Areas for developmentAs Berger (in press, a) has pointed out:Making the ECR the primary, if not sole source of future NHS information requirements means that ifsomething is not available for processing in the electronic record, it is unlikely to be taken into accountin the analyses and decisions that underpin NHS services. Hence, unless the ECR records psychologyinvolvement in a way that reflects psychology thinking and practices, psychology will be off the record,not just literally, but in other important ways. The overarching challenge, therefore, is to makepsychological perspectives part of the ECR.He makes proposals for psychology-specific datasets which code the information fromassessment and formulation, among other aspects of a psychologist’s work (Berger,in press, b). This task is still at a very early stage.SNOMED CT has recently been approved as the standard clinical terminology for the NHSin England. SNOMED CT stands for the ‘Systematised Nomenclature of Medicine ClinicalTerms’, and it is used in more than 50 countries. It consists of a recognised set of clinicalterms for ECR systems and can be utilised across all care settings and all clinical domains.www.connectingforhealth.nhs.uk/systemsandservices/data/uktc/snomedAs with all types of ECRs, much work remains to be done on incorporating psychologicalactivity in general, and formulation in particular, in a meaningful way with due regard forconfidentiality (see Guidelines on the use of electronic health records, BPS 2011.)Formulation-based alternatives to psychiatric diagnosisPsychiatric diagnosis is deeply embedded in practice, research and clinical governance,as well as in other areas of public life such as the criminal justice system and the benefitssystem. This is likely to remain true for the foreseeable future. For example, Trusts arerequired to return Mental Health Minimum Data Sets based on psychiatric diagnoses.The IAPT initiative is based on diagnostic criteria for depression and anxiety disorders(with others to be included soon). NICE recommendations and most outcome measuresare diagnostically-based, and a diagnosable mental illness is a pre-requisite for access tomental health services. Court reports and risk assessments are based on psychiatricdiagnoses. Most evidence-based practice is based on classification by psychiatric diagnosis,despite the fact that these terms are not evidence-based themselves; that is, they have poorreliability and validity (Boyle, 2002; Bentall, 2003). Although it could be argued thatformulation is a viable alternative to some psychiatric diagnoses at an individual level, thereis no agreed system of non-medical terms to replace psychiatric diagnosis for broader,clustering purposes.Some clinical psychologists and psychiatrists have suggested new categories thatincorporate recent evidence about the causal role of trauma, and can perhaps be seen asoccupying a place halfway between functional psychiatric diagnoses and formulation.For example, it has been proposed that in many cases ‘personality disorder’ is betterunderstood as ‘complex PTSD’ (Herman, 2001). Similarly, Callcott & Turkington (2006)have suggested ‘traumatic psychosis’ as an alternative to some diagnoses of ‘schizophrenia’.24 Division of Clinical PsychologyThese terms have the obvious advantage, from the point of view of documents and records,of brevity. They do not necessarily imply wholesale rejection of existing psychiatricdiagnoses. They do, however, represent initial attempts to develop coherent, crediblealternative forms of categorisation which are based on psychological theory and whichhave direct implications for both aetiology and intervention. In fact it could be argued thatsome current psychiatric diagnoses, for example, bereavement reaction, adjustmentdisorder and dissociative disorder, are better understood as broad-level formulations,implying primarily psychosocial rather than medical/biological causes.Among a number of new developments is the concept of ‘trauma-informed’ services in theUSA (Harris & Fallot, 2001). These are based on the recognition that violence, trauma andabuse are causal factors across the whole range of psychiatric presentations and need acommon, trans-diagnostic approach grounded in a different model of service delivery.Although the model has yet to make an impact in the UK, it implies a much greater rolefor formulation-based categorisation of mental distress.Good Practice Guidelines on the use of psychological formulation 2526 Division of Clinical Psychology1. Best practice psychological formulation is a highly skilled process that combinesscientific principles with intuition and reflectiveness. It serves a range of purposes inpsychological work with individuals, carers, teams and organisations, and has thepotential to enhance core aspects of clinical work across roles and specialties.It helps to ensure that our interventions are evidence-based by linking theory withpractice. It can be seen as a prime example of ‘level 3 skills’ in action.2. A distinguishing characteristic of psychological formulation is its sophisticated,multiple-model perspective which integrates theory and evidence frompsychological, biological, social/societal, and cultural domains through a sharedunderstanding of their personal meaning to the service user.3. Clinical psychologists receive the most in-depth training in formulation, and arewell-placed to promote its use through practice, teaching, supervision, consultancyand research.4. Emerging evidence suggests that formulation is highly valued by other MDTmembers. Further research into the impact of formulation on team functioning andon the quality of care is needed.5. Formulation also has the potential to promote collaborative work with service usersby enhancing the therapeutic relationship and increasing their sense of meaning,agency and hope. More research is needed into service user and carer experiencesof formulation in order to ensure that it is used sensitively, respectfully andproductively.6. Formulation can facilitate culture change by promoting a more psychosocialperspective in services as a whole. New evidence about common psychosocial causalfactors across psychiatric diagnostic categories suggests the potential for formulationto take a more central role in mental health settings, including the development offormulation-based categorisation systems.7. Although much of the theory and research on which formulation draws is firmlyestablished, to date there is only limited evidence to support it as a specificintervention in its own right. This is a significant gap that needs to be filled.8. Culturally-sensitive formulation is another underdeveloped area which is ripe forresearch. This, along with other aspects of formulation, is recommended for clinicalpsychology trainees’ doctoral projects.9. Clinical psychologists need to ensure that formulation has a central place inelectronic records so that it can be integrated into care packages and pathways.10. The checklists in this document are recommended as a means of enhancing goodpractice in clinical work, training, supervision, consultancy, audit and research inthe field of formulation.14. Summary and recommendationsGood Practice Guidelines on the use of psychological formulation 27These guidelines should be read in conjunction with the following documents.Division of Clinical Psychology (2000). Clinical psychology and case notes: Guidance on goodpractice. Leicester: British Psychological Society. http://goo.gl/Pwzt7Division of Clinical Psychology (2008). Clinical psychologists and electronic records:The new reality. Leicester: British Psychological Society. http://goo.gl/IxjHbDivision of Clinical Psychology (2010). The core purpose and philosophy of the profession.Leicester: British Psychological Society. http://goo.gl/RXi8KDivision of Clinical Psychology (2010). Clinical psychology leadership development framework.Leicester: British Psychological Society. http://goo.gl/YOhuDBritish Psychological Society (2009). Code of ethics and conduct. Leicester: BritishPsychological Society. http://goo.gl/RLwDUNewton, S. (2008). Record keeping: Guidance on good practice. Leicester: British PsychologicalSociety. http://goo.gl/EcVqHDivision of Clinical Psychology (2001). Working in teams. Leicester: British PsychologicalSociety. http://goo.gl/3sfiQOnyett, S. (2007). Working psychologically in teams. Leicester: The British PsychologicalSociety.15. Relevant BPS documents28 Division of Clinical PsychologyThis checklist summarises the principles of recommended best practice in formulation andformulating. The phrase ‘service user’ should be taken to encompass families/carers whereappropriate.As noted in the main body of the guidelines, while these principles and standards will bebroadly relevant to formulation used in a more partial, informal or evolving way, forobvious reasons it will not always be possible, necessary or appropriate to incorporate themin full. Clinical judgement must be exercised in making these decisions. However, thecriteria can still be seen as a useful reference point and checklist of good practice for allstages and versions of formulation and formulating.Clinical psychologists may use this checklist for the following purposes:● Supporting and evaluating their clinical practice in relation to formulation, in orderto maintain the highest standards throughout their careers.● Aiding supervision and appraisal within the profession.● Informing supervision and consultation to other professionals and to teams.● Teaching and assessing trainees on clinical psychology doctorate courses.● Teaching and training with other professional groups.● Checking the quality of formulations for inclusion in records and other paperwork.● As psychology leads and managers, for auditing psychology services.● As a basis for research into formulation, either clinician-led or jointly with serviceusers.Appendix 1:Checklist of good practice in the use of formulationRationale for auditDate ………………………………………………………………………………………………………………………………Clinician’s name ……………………………………….. Job title………………………………………………………Assessor’s name ……………………………………….. Job title………………………………………………………Brief description of the area being audited……………………………………………………………………………………………………………………………………………………………………………………………………………..Good Practice Guidelines on the use of psychological formulation 29 Standardmet?CommentsGrounded in an appropriate level and breadth of assessmentBased on psychological theory, evidence and principlesInformed by a range of models and/or causal factorsIntegrates, not just lists, the models and causal factorsMakes theoretical senseIncludes service user’s strengths and achievementsImportant aspects of the history and the problems areaccounted forIndicates how the main difficulties may relate to each otherSuggests explanations for the development of the maindifficulties, at this time and in these situationsThe personal meaning to the service user is an integratingfactor (either directly or through an indirect or‘Best Interest’ procedure)Provides a basis for making decisions aboutintervening/moving forwardSuggests how to prioritise interventions, if indicatedCan be used to make and test predictions, including risksCan be used to anticipate responses to the intervention,including setbacksCan be used to set goals and desired outcomesIs not premised on a functional psychiatric diagnosis(e.g. schizophrenia, personality disorder)Is person-specific not problem-specificIs culturally sensitiveIs expressed in accessible languageTakes a non-blaming stance towards service user and othersConsiders the possible role of trauma and abuseIncludes the impact and personal meaning of medical andother health care interventionsConsiders possible role of services in compoundingthe difficultiesInformed by awareness of service/organisational factorsInformed by awareness of social/societal factorsHas clear links backward to the assessment and forward tothe intervention Characteristics of the formulation30 Division of Clinical Psychology Standardmet?CommentsIs clear about who the formulation is for(individual, family, team, etc.)Is clear about who has the ‘problem’Is clear about who are the stakeholders and their interestsIs respectful of the service user/team’s view of what isaccurate/helpfulConstructs the formulation collaboratively withservice user/teamPaces the development and sharing of the formulationappropriatelyCan provide a rationale for choices within formulation(integrative, single model or partial)Is reflective about own values and assumptions Characteristics of formulating: The clinicianGood Practice Guidelines on the use of psychological formulation 31Division of Clinical Psychology (2010):‘Core purpose and philosophy of the profession’‘Psychological formulation is the summation and integration of the knowledge that isacquired by this assessment process that may involve psychological, biological and systemicfactors and procedures. The formulation will draw on psychological theory and research toprovide a framework for describing a client’s problem or needs, how it developed and isbeing maintained. Because of their particular training in the relationship of theory topractice, clinical psychologists will be able to draw on a number of models (bio-psychosocial) to meet needs or support decision making and so a formulation may comprise anumber of provisional hypotheses. This provides the foundation from which actions mayderive… Psychological intervention, if considered appropriate, is based upon theformulation.’Core competencies of a clinical psychologist:● psychological assessment;● psychological formulation;● psychological intervention;● audit and evaluation;● research;● personal and professional skills;● communication and teaching skills;● service delivery skills;● transferable skills.Health Professions Council (2009) criteria:● Be able to develop psychological formulations using the outcomes of assessment, drawing ontheory, research and explanatory models.● Be able to use psychological formulations to plan appropriate interventions that take the client’sperspective into account.● Be able to use psychological formulations with clients to facilitate their understanding of theirexperience.● Be able to use psychological formulations to assist multi-professional communication and theunderstanding of clients and their care.● Be able, on the basis of psychological formulation, to implement psychological therapy or otherinterventions appropriate to the presenting problem and to the psychological and socialcircumstances of the client.● Be able to decide how to assess, formulation and intervene psychologically from a range ofpossible models and modes of intervention with clients and/or service systems.● Be able to use professional and research skills in work with clients based on a scientistpractitioner and reflective-practitioner model that incorporates a cycle of assessment,formulation, intervention and evaluation.Appendix 2:Professional guidelines and criteria in relation to formulationAccreditation through partnership handbook (2010):Guidance for clinical psychology programmes2.1 Required learning outcomes1. The skills, knowledge and values to develop working alliances with clients, includingindividuals, carers and/or services, in order to carry out psychological assessment,develop a formulation based on psychological theories and knowledge, carry outpsychological interventions, evaluate their work and communicate effectively withclients, referrers and others, orally, electronically and in writing.2.2 Learning outcomes3. Clinical and research skills that demonstrate work with clients and systems based ona scientist-practitioner and reflective-practitioner model that incorporates a cycle ofassessment, formulation, intervention and evaluation.2.3.1 Transferable skills1. Deciding, using a broad evidence and knowledge base, how to assess, formulate andintervene psychologically, from a range of possible models and modes ofintervention with clients, carers and service systems.2.3.3 Psychological formulationDeveloping formulations of presenting problems or situations which integrate informationfrom assessments within a coherent framework that draws upon psychological theory andevidence and which incorporates interpersonal, societal, cultural and biological factors.2. Using formulations with clients to facilitate their understanding of their experience.3. Using formulations to plan appropriate interventions that take the client’sperspective into account.4. Using formulations to assist multi-professional communication, and theunderstanding of clients and their care.5. Revising formulations in the light of ongoing intervention and when necessaryreformulating the problem.32 Division of Clinical Psychology2.3.4 Psychological intervention1. On the basis of a formulation, implementing psychological therapy or otherinterventions appropriate to the presenting problem and to the psychological andsocial circumstances of the client(s), and to do this in a collaborative manner with:● individuals;● couples, families or groups;● services/organisations.2. Understanding therapeutic techniques and processes as applied when working witha range of different individuals in distress, including those who experiencedifficulties related to: anxiety, mood, adjustment to adverse circumstances or lifeevents, eating, psychosis and use of substances, and those with somatoform,psychosexual, developmental, personality, cognitive and neurological presentations.Clinical Psychology Leadership Development Framework (2010)‘Clinical drivers’ for all levels of the profession include:To sensitively and confidently lead on psychological assessment and formulation in teams.‘Use of leadership skills’ includes:Trainee: Take a lead in MDT meetings regarding psychological formulation of a client’s care.Qualified clinical psychologist: Lead on psychological formulation within your team.Consultant clinical psychologist: Ensure psychological formulation work is appropriately shared.‘Outcome for practitioners’: Show psychological formulation skills that integrate social, cultural,religious, ethnic factors as well as age, gender and ability level.NB: The first criterion also applies to health psychologists and educational psychologists,while counselling psychologists must be able to ‘make formulations of a range ofpresentations’ and ‘be able to formulate clients’ concerns within the chosen therapeuticmodels’. Sports and exercise psychologists must ‘be able to formulate clients’ concernswithin the chosen intervention models’ and forensic psychologists must ‘be able to usepsychological formulations to assist multi-professional communication and theunderstanding, development and learning of service users.’Good Practice Guidelines on the use of psychological formulation 3334 Division of Clinical PsychologyWhat we know so far is:Most of the limited body of available research focuses on establishing whether formulationis reliable. A review of research using standardised methods to assess inter-rater reliabilityin psychodynamic formulations found moderate-to-good agreement (Luborsky & Diguer,1998). A review of cognitive case formulation research found more mixed results for interrater reliability, concluding that it was ‘modest at best’ (Bieling & Kuyken, 2003, p.52).The emerging consensus is that reliability is compromised as clinicians move fromdescriptive to more inferential levels. However, it is unclear whether problems inestablishing reliability are due to difficulties in the process, such as the use of heuristicsthat affect clinical judgement (see Dumont, 1993), or to methodological issues, such as theabsence of information available to practitioners in normal service conditions (includingthe possibility of developing the formulation in collaboration with the client). Moreover, asBieling and Kuyken (2003) concede, reliability does not imply validity. It is unclear how,if at all, psychologists reliably formulating in the same way relates to the ‘truth’ or accuracyof the formulation. In addition, formulation could be reliable and valid but have no impactin terms of helping the client; conversely, it could be unreliable and invalid but lead toimproved outcomes.For these reasons, another strand of research has tried to establish whether formulationleads to positive change for clients. A few studies (Jacobson et al., 1989; Emmelkamp et al.,1994; Schulte et al., 1992) have attempted to compare individualised treatments (whichare, by implication, formulation-driven) with standardised treatments (which are not).Taken together, the results do not support claims that formulation improves outcomes,although they are all under-powered studies from which little can be safely concluded.Furthermore, it is unclear how closely the individualised conditions in these studiescorrespond to practice, since they were defined as treatment plans that combined thestandardised components more flexibly.Qualitative data from structured interviews suggest that clients are ambivalent aboutformulation. As finding formulations helpful, encouraging and reassuring, and increasingtrust in their psychologist, clients can also experience them as saddening, upsetting,frightening, overwhelming and worrying (Chadwick et al., 2003; Evans & Parry, 1996; Hess,2001). A content analysis of 13 clients’ experience of formulation in CBT for psychosisindicated that individuals’ reactions to receiving a formulation were complex, involvingapparently opposing emotional and cognitive responses, which changed over time(Morberg Pain et al., 2008).Professional guidelines recommend the use of a formulation based approach whenworking within multidisciplinary teams (Division of Clinical Psychology, 2010).Additionally, service users are reported to value the role of psychologists in teams asoffering an alternative perspective to the ‘medical model’ (Onyett, 2007). Christofides’(2011) qualitative study of clinical psychologists working within adult mental health teamsfound that formulation was used in many different ways, often unacknowledged, withinAppendix 3: Formulation and researchteams. Research on the use of formulation in teams has so far been limited to relativelysmall practice-based studies in inpatient settings. For example, Kennedy et al. (2003),evaluating a new inpatient service in which a key intervention was the collaborativeproduction of a formulation, concluded that it was a powerful systemic intervention initself which was regarded positively by both service users and staff. Summers (2006)explored staff views of the impact of introducing psychological formulations to a highdependency rehabilitation service and found that they believed that formulation benefitedcare planning, staff-patient relationships, staff satisfaction and team-working, throughincreasing understanding of patients, bringing together staff with different views andencouraging more creative thinking. Wainwright and Bergin (2010) provided a similarassessment of staff views on the effectiveness of introducing formulation meetings onto anacute inpatient ward for older adults. Lake (2008) has described a team formulationapproach facilitated in regular meetings by a psychologist, which was evaluated verypositively by all staff (2008). Berry et al. (2009) found that formulation meetings resultedin staff feeling increased confidence in their work, and perceiving service users morepositively and optimistically.Among the conceptual and methodological hurdles to be overcome in researchingformulation are:● Defining formulation (process versus event).● Separating the effects of the formulation from the therapy of which it is an integralpart. (Although team formulations avoid this problem because they are by definitionseparate from individual therapy; in fact therapy may not be a feature of theintervention at all.)● Deciding the terms in which formulation is evaluated. A narrative/personalmeaning approach would see ‘usefulness’ as a more appropriate criterion than‘truth’, or reliability, validity etc., although ‘usefulness’ immediately raises thequestions: useful to whom? and how would this be assessed? On the other hand, the‘truth’ perspective implies a consensus on what it means to say that a formulation is‘valid’, and who makes this judgement. Suggestions for assessing the quality offormulations have been made by Butler (1998) ‘Ten tests of a formulation’; Lane(1990) ‘Stopthengo’ checklist; Kuyken (2006) ‘Evidence-based guidelines’; andPersons (2008) ‘Five tests’.Margison et al. (2000) have recommended that evidence for the effectiveness of therapy,including formulation, should come from practice-based evidence as well as evidencebased practice.Good Practice Guidelines on the use of psychological formulation 3536 Division of Clinical PsychologyAnderson, P. & Fenichel, E. (1989). Serving culturally diverse families of infants and toddlerswith disabilities. Washington: National Center for Infant Programs.Barham, P. & Hayward, R. (1995). Relocating madness: From the mental patient to the person.London: Free Association Press.Beck, J.S. (1995). Cognitive therapy: Basics and beyond. 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Copenhagen: WHO Regional Office for Europe.Good Practice Guidelines on the use of psychological formulation 41Incorporated by Royal Charter Registered Charity No 229642 REP100/12.2011The British Psychological SocietySt Andrews House, 48 Princess Road East, Leicester LE1 7DR, UKTel: 0116 254 9568 Fax 0116 227 1314 E-mail: [email protected] Website: www.bps.org.uk

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