It was great to see all those who attended the Hedge School
yesterday evening. A group of about 10 of us were discussing Craig Newnes’
article on psychological formulation. I think the first thing that people
seemed to bring up was how confronted they felt by what the article claimed.
The critique of formulation was so damming that it seemed to shake the
foundations of our professional identity.
We talked about the fact that the critique was of the professional
discourse of formulation and how we as clinicians felt that we practiced
differently to that. Although there was an acknowledgement that service
pressures and expectations limited our ability to always do this.
For most of us, formulation was what we needed to do more of
in an effort to move away from diagnostic language and simplistic
understandings of people’s distress. We thought that research supported the
idea that people attending therapy wanted to be asked about their history and
previous experiences. It seemed that most of us valued this part of our
practice and saw it as giving a lot of meaning to what we do. In fact, we
talked about creating meaning and how this was viewed as the vehicle for change
in therapy- making sense of one’s situation allowed for change. It was also
acknowledged that different ‘meanings’ or formulations could be created and
that this did not necessarily mean that one was more right. We also discussed
the status of psychological formulation in legal and forensic settings, where a
psychologists' formulation may inform legal outcomes (for instance may identify
aggravating and mitigating factors). The subjectivity of formulation in this
context is particularly problematic given it is requires determinations be made
about distal and proximal causes of behaviour (as opposed to ongoing / dynamic
/ meaning making formulations utilised in therapy).
We also questioned the need for a complex formulation
encompassing everything from birth to present day from a public health
perspective, i.e. was spending limited resources on formulation value for
money? It was also thought that
formulations that were tentative to begin with and continued to develop over
the course of therapy may hold more value than a single static formulation
offered after a brief assessment. Also, we wondered if different therapeutic
approaches practiced by clinical psychologist all took the same approach to
formulation. What about psychodynamic and systemic approaches? Did we have
‘evidence’ to support this and if we thought that we did/didn’t, what counted
as evidence? Apparently not everybody is a CBT therapist??!!
We discussed how at the start of clinical training
inexperienced trainees could often write quite insightful formulations but that
they usually lacked the integration of psychological theory, this seemed to
come over the course of training. We wondered if we were, in fact, still formulating
intuitively (as we did at the beginning of our training) with what we saw to be
the contributing factors and then backing that up with psychological theory
post hoc so that it maintains our expert position? We also, appreciated the authors
critique of the language used in formulation, particularly the professionals
substitution of the word ‘want’ for ‘need’. This seemed to highlight for many
of us that although we might want to formulate collaboratively, the
professional discourse, which we must all become fluent in speaking, will still
get in the way of this.
Finally, a question was asked of the group ‘would you still
practice psychological formulation if it was illegal’?. The consensus was that
people would. The main idea was that people are intuitively curious and when
they are faced with a situation that they do not understand they will usually
attempt to formulate (with some sort of psychological theory) it so that they
can create a meaning for themselves. Perhaps clinical psychologists have just
found a way to claim it as their own expertise as a way of furthering the
profession, but the group seemed to feel that in reality everybody had the
ability to practice it. However, it was generally felt that strict
psychological formulation defined as something that psychologists only could
provide did not necessarily offer much in addition to this more inherent
formulating, and therefore could be dropped with no loss.
As usual there were many more questions than answers
generated! Thank you again to everybody for coming along and to Craig Newnes
for supplying the article!
-Next meeting Wednesday 13th of August.
