July Meeting- Critique of formulation

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.