Therapists’ perspectives on using case formulationDawn Leeming; Jo Brooks; Viv Burr; Mike Lucock University of Huddersfield, UK

Psychological case formulation

Using generic psychological theory to develop interlinked hypotheses about difficulties experienced

by individuals, in order to guide intervention

Insecure attachments

Safety behaviours

Experiential avoidance

Negative automatic

thoughts

Reciprocal role

procedures

An increasingly valued therapeutic practice

• Now used by range of MH professionals, across range of therapeutic approaches• Alternative to psychiatric diagnosis• Focus on formulation skills in therapy

training• Growth in use of generic ‘off-the-shelf’

templates (alongside individualised, multi-model, integrative formulations)

Evaluating formulations

Can we conceive of accuracy or reliability of formulations?

Butler (2006): May be more appropriate to consider

‘usefulness’

A relatively under-researched therapeutic practice

“the lack of a service user perspective [on formulation] is a major gap in the literature, as is an understanding of the process by which clinicians draw up formulations” (Johnstone et al., 2011)

Aim of current study

To explore therapists’ reports of their practices in relation to formulation and their views on the usefulness of formulation for

themselves and clients

Methods

• On-line survey of psychological therapists working in public sector mental health services•Mostly open-ended questions:• Nature of formulation• Practices • Benefits / challenges for self/clients• Thematic analysis

Preliminary analyses of data from 13 therapists

• 3 trainees, 10 qualified therapists• Nursing, clinical psychology, psychiatry,

counselling• A range of theoretical influences• CBT & CAT slightly more common than others

Key preliminary findings

• Formulation valued highly• particularly for enabling understanding• Variation in practices• can be varied experience for clients?• Formulation viewed as powerful• potential to be challenging• need for ‘protection’, care & compassion when

formulating

Perceived value of formulation

Facilitating understanding

“It is essential. Without it there is no psychological understanding.”

An understanding that is:

• Collaborative• Values theory• Individualised / bespoke• Useful & meaningful to both• Holistic, comprehensive & contextualised• Tentative

“Firstly that it is meaningful, clear and understandable to the client. It should hopefully help a client to understand where they might be able to work together with the therapist to make some changes. It would hopefully draw on the different aspects of a person's life which are linked to the problem, such as past experiences, unhelpful behaviours, protective factors, and so on. I think a good formulation should aim to help move a person on in their own insight and understanding of their issues. “

“…a collaborative process of building a greater understanding. The client brings their expertise with respect to their life and difficulties, I hope I can bring a theoretical framework that helps to contain, explain and ultimately allow for improvement of those same difficulties.”

Facilitating understanding

Differences in approaches & views:

• Differing approaches to ‘collaboration’

• Differing ideas about the relevance and role of psychiatric diagnostic concepts to formulations

I am mostly assessing the extent of the client's experiential avoidance. I ask how others perceive their difficulties or what they are prevented from doing by the problem (Nurse, 3rd wave CBT)

I tend to follow the client’s lead and assume that they will bring the relevant material into the session, then explore the information provided (Clin Psych, CAT)

Differing accounts of collaboration:

Observing the way the client presents in the room i.e. the way they relate to me, the way they talk about themselves, the way they experience/ relate to emotions (Clin Psych, CAT.

I invite the client to share her historical experiences …and describe examples of her current problems . I encourage the client to identify any links between current thoughts/ behaviours and her history (Nurse, CBT)

Theory led vs. client led

Observing expert vs. facilitator

Method Me Client Both of us Varies Total Responses

Standardised template 1 1 2 0 4

Draw diagram 2 0 5 1 8CAT reformulation letter

2 0 3 0 5

Another kind of letter 4 0 3 0 7

Written summary 4 0 1 0 5

Oral explanation / discussion

1 0 8 1 10

Other 1 0 1 0 2

How formulations are represented & shared

Conclusions

• Formulation was highly valued by this small self-selected sample of therapists (though with some caution)• ‘Formulation’ incorporates a range of

practices• Research could usefully explore the impact

of these for clients in a range of settings