Representación cultural

attempt to understand the whole o f a client’s life and tends to be complementary to psychiatric diagnoses as most o f the evidence base uses diagnostic categories (for example, the NICE guidelines; PTSD, 2005, depression, 2004, anxiety, 2004, Schizoprenia, 2002)

Systemic formulations share some similar traits with CBT formulations in that developing a formulation is a collaborative and dynamic process. Within systemic therapy, formulation is not seen as an objective process but rather a way o f provoking thought within a family, to affect change. The process o f developing a formulation, the questions asked and the way in which they are asked are all seen as part o f the change process and influence the relationship with the family. Systemic therapy has murkier boundaries between assessment, formulation and intervention than many other therapies. (Dallos & Stedman, 2006). Systemic formulation focuses on deconstructing the problem, problem maintain patterns, beliefs and explanations, transitions, emotions and attachments and contextual factors (Dallos & Draper, 2003).

Psychodynamic theory uses formulations quite differently to other models. There is no single psychodynamic theory and, therefore, no single method o f constructing a psychodynamic formulation (Leiper, 2006). Psychodynamic formulation is typically based on psychoanalytic assumptions about personality functioning (Ivey, 2006). It assumes that personality is a dynamic system, characterized by inevitable psychological conflict between opposing mental forces and by unconscious defenses used to avoid or remedy the resulting mental discomfort. (Ivey, 2006). All psychodynamic formulations conceptualize in terms o f conflicting wishes, needs or motives, anxiety or distress caused by these conflicts and unconscious strategies that are used to avoid any awareness o f this

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conflict or the resulting mental distress. According to Smith (as cited in Ivey 2006), within a psychodynamic framework different schools o f thought understand the nature o f psychological conflict differently. Nonetheless, psychodynamic formulations emphasize the role o f early experience and focus on repeated maladaptive patterns o f behaviour occurring in relationships and how these are related to the patient’s internal world and unconscious conflicts (Johnstone & Dallos, 2006).

Psychodynamic formulations are not typically shared with the client. The psychodynamic approach believes that formulations may become a barrier for empathy by objectifying the client. It is believed that sharing formulations hinders the client’s own self exploration and discovery. The understanding is developed through the transference and counter­ transference in the therapeutic relationship. Seeking an abstract formulation could be a method by which the therapist avoids the anxiety and discomfort that sometimes comes with this transference within the relationship (Leiper, 2006).

Traditionally, formulations are proffered after assessment in order to guide treatment. However, it is argued, particularly within more psychodynamic approaches, that a ‘true’ formulation can only be developed at the end o f treatment (Crellin, 1998). It is my opinion that an initial formulation is a beneficial tool to guide therapy. However, it is important to continuously reformulate, which may result in the most accurate and complete formulation only being achieved at the end o f an intervention. It is also important that these hypotheses are not rigid and change constantly as more information is revealed and the therapeutic relationship develops.

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Why do we formulate?

Formulation was formed out o f this need for empiricism. Clinical psychology practice uses formulation as a means o f assessing an individual’s suitability for psychotherapy (Denman, 1995). It also has the benefit o f adding context to diagnosis. A diagnosis classifies what is wrong, but a formulation helps to explain onset, development and maintenance o f disorders and difficulties, in a way that psychiatric diagnosis cannot. Thus, formulations have the advantage o f being able to tightly link assessment and intervention (Persons, 2006).

Formulations can give structure and meaning to experiences that may seem chaotic. They are also a means o f understanding the evolution o f the difficulties and the impact on the client and their social network. This can be helpful for both therapists and clients. They can provide an alternative view of the situation, based upon psychological models and understanding. Formulations can also act as a means of understanding interactions between dynamic and non-dynamic forces, for example, psychological and neurobiological vulnerability (Sim et a l, 2005).

I worked with a client who had a diagnosis o f schizoaffective disorder. He was very uncertain about what this meant fo r him and how it related to his difficulties. We worked through his experiences and developed a formulation together. This included drawing on theories, such as the stress-vulnerability model (Nelson, 1997) to help explain the onset o f some o f his difficulties. He was able to create an alternative view o f his diagnosis, from it being something over which he had no control and thus meaning he was “m a d ”, to being able, to recognize certain signs and symptoms and develop strategies to manage

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shifting his uncertainty and allaying some o f his fears. I perceive that developing the formulation in this way was also part o f the intervention. In addition, it informed further

work on relapse prevention (Birchwood et ah, 2000).

Formulation allows an individualized approach to a client’s difficulties. This is advantageous to clinical psychology practice because clinicians are able to draw upon different theories and skills as appropriate. However, feminist research argues that by individualizing a client’s problems the social significance o f these problems are ignored and the difficulties are reduced to personal psychological inadequacies of the client themselves (Davis, 1986). I would argue that clinical psychology formulations also take social circumstances into account, for example, systemic formulations, in which a client’s systems are considered pivotal.

Issues for the Clinician

Often, a large amount of information is gathered during the assessment process. It can be difficult, particularly for me as a trainee, to know which information to include in a formulation and which to leave out. This is often influenced by the theoretical orientation of the therapist. As a trainee, I frequently feel inclined to try to include everything. This makes formulations very lengthy for both me and the client and can be disadvantageous. If a formulation is too simple, salient aspects o f the case may be overlooked, however if it is too complex, it may become too cumbersome and time consuming for practical use (Sim et a l, 2005). Formulations are also advantageous for conveying information (Ross, 2000) to others, particularly within a multidisciplinary team. In this context it is also important to make formulations clear and succinct. In a training capacity, formulation can