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Psychological formulations integrate assessment with psychological theory, helping therapists understand a client’s difficulties and develop a plan of intervention.

However, there is some disagreement among professionals about which factors must be included in them.

Guidelines for psychological formulations (also called case conceptualizations) were created by the British Psychological Society’s Division of Clinical Psychology (DCP) in 2011, but have not been updated since then. These guidelines are taught by most of the UK clinical doctoral study programmes.

Now researchers at the University of Manchester have surveyed more than 100 clinical psychologists about what they think psychological formulations need. Lead researcher Dr Naomi Thrower explains: “as the DCP guidelines were created over 10 years ago, and were created by a relatively small number of experts, we wished to explore whether the developments in the field of psychology since 2011 had influenced what might be included in a formulation, and whether many clinical psychologists working in a range of fields held similar views.”

The study was published in the British Journal of Clinical Psychology, and it found mixed evidence regarding consensus on the key components of formulations. There was agreement that formulations should be client-led and incorporate strengths and sociocultural factors, but also included disagreement about whether they should be kept simple, needed to adhere to a model, or had to be explicitly shared with the individual.

Gathering opinion

The team used the Delphi method for their study – a questionnaire technique that uses multiple iterations to develop a consensus on a topic. They first trawled through the literature to generate statements about psychological formulations. These were then put to 10 expert clinical psychologists, who were asked whether a statement should be removed, included, or refined, as well as to provide their own components for formulations. To qualify as an expert for this study, psychologists needed to have created a model of a formulation, written a book on the topic, delivered formulation training, or given a keynote presentation on a formulation at a conference.

The resulting 50-statement survey was then sent to 110 UK-based clinical psychologists to rate their level of agreement with each item. After the second round of rating, consensus had been achieved for 30 statements. “There was a clear consensus that sociocultural factors are important to incorporate in formulations,” write the researchers. “Conceptual frameworks such as Burnham's social GGRRAAACCEEESSSS, which highlights several characteristics, such as gender, race, age, class and spiritual beliefs, may be helpful to understand and integrate social factors into clinical practice and formulation.” This suggests a marked change from when the DCP guidelines were published in 2011, as it stated that social factors were often neglected in formulations.

Inclusion of the power threat meaning framework (PTMF) might also be useful. The PTMF, developed by Lucy Johnstone and colleagues in 2018, focuses on understanding how power dynamics lead to threats, and the meaning people attribute to these experiences.

Recognizing strengths

The study findings also show the importance of including clients’ strengths in formulations. The team suggests that “psychologist training should, therefore, better equip them to formulate strengths by incorporating more teaching on positive psychology and solution-focused approaches.”

Dr Thrower explains that people seeking support for difficulties “have usually found incredible ways of surviving, and it’s important to recognize their strengths and ingenuity.”

Problem-focused formulations can lead to people “feeling hopeless and damaged”, and so the inclusion of strengths “allows us to create a more balanced and comprehensive view of an individual, promoting confidence in their ability to make changes and manage their difficulties. It can also help inform what kind of support might be most helpful.”

Formulations should be client-led and personally meaningful to clients. The researchers suggest that ‘doing with’ activities may helpful, such as engaging the client in drawing diagrams or allowing them to take the formulation and edit it in a way that makes sense to them.

Consensus was also found for including each P in the 5Ps framework: predisposing, precipitating, perpetuating and protective factors that help describe a client’s current problems. “However, the 5Ps framework has limitations as the factors may not be synthesized into a coherent narrative that includes personal meaning of events and factors described,” write the researchers. “As our findings suggest that including personal meaning is important, it may be more helpful to use the 5Ps as an assessment framework and incorporate the information gathered into a formulation, such as the longitudinal CBT model.”

However, consensus was not achieved across the board. Dr Thrower comments: “The finding that interested me the most was that clinical psychologists couldn’t agree on whether a formulation should be parsimonious. This is likely due to formulations being individualized in clinical practice: some individuals may prefer a simpler formulation and some may work better with something more complex. Because formulations are a dynamic and evolving piece of work, they may begin simply, but evolve throughout the process.”

Limitations

One limitation of the study was that only UK-based clinical psychologists were consulted, so the results may not generalize to countries with different cultures regarding mental health, or with different healthcare systems.

Another was that the literature used to generate statements regarding formulation was predominantly CBT-based (probably because cognitive behavioral therapy is a predominant model in the UK). This may have alienated participants who do not have a preference for this model and may partly explain the high attrition rate, with 51% of psychologists dropping out between rounds.

What’s next?

Dr Thrower outlines several potential future steps, such as exploring clients’ views of formulations, and how these compare to the clinicians’ perspectives. A tool to help inform training or supervision could also be developed. For example, a formulation checklist based on the key components that reached consensus in the study could be used by trainee psychologists and their supervisors across clinical placements. Further studies could also track whether the elements of formulation identified by therapists in this study are predictive of outcomes.

Key takeaways

1. Sociocultural factors should be included in formulations. Burnham's social GGRRAAACCEEESSSS might be helpful for this.

2. Formulations should be client-led and personally meaningful to them – try ‘doing with’ activities, such as creating diagrams together, or inviting clients to revise the formulation so it reflects their own understanding and experiences.

3. Including the client’s strengths, such as creativity or persistence, can promote confidence in their ability to change.