clinical formulation

6.01Clinical FormulationGILLIAN BUTLER

University of Oxford, Warneford Hospital, UK

6.01.1 INTRODUCTION 1

6.01.2 DEFINITIONS: WHAT IS A FORMULATION? 2

6.01.2.1 Main Principles 26.01.2.2 Formulation and Diagnosis: Assumptions 46.01.2.3 Formulation and Diagnosis: Controversial Issues 56.01.2.4 The Difference Between a Formulation and a Model 66.01.2.5 Types of Formulation 76.01.2.6 Levels of Formulation 7

6.01.3 PURPOSES: WHAT A FORMULATION IS FOR 8

6.01.3.1 Understanding: The Overall Picture or Map 96.01.3.2 Prioritizing Issues and Problems 96.01.3.3 Planning and Selecting Intervention Strategies 106.01.3.4 Predicting Responses and Difficulties 106.01.3.5 Determining Criteria for Successful Outcome 116.01.3.6 Thinking About Lack of Progress 11

6.01.4 METHODS: HOW TO CONSTRUCT A FORMULATION 12

6.01.4.1 Sources of Information 126.01.4.2 Putting the Information Together 146.01.4.3 Key Factors and Basic Elements 176.01.4.4 Issue of Completeness 186.01.4.5 Conceptualizing Processes of Change 19

6.01.5 ACCURACY: HOW TO TELL IF A FORMULATION IS RIGHT 20

6.01.5.1 Criteria of Accuracy 206.01.5.2 Questions for Research 20

6.01.6 USING THE FORMULATION: PRACTICAL ISSUES 21

6.01.6.1 The Value of Organizing and Clarifying 216.01.6.2 Developing an Internal Supervisor 216.01.6.3 Communicating a Formulation 22

6.01.7 CONCLUDING DISCUSSION 22

6.01.8 REFERENCES 23

6.01.1 INTRODUCTION

Patients come to psychotherapy because they aredemoralized by the menacing meanings of theirsymptoms. The psychotherapist collaborates withthe patient in formulating a plausible story thatmakes the meanings of the symptoms more benignand provides procedures for combatting them,

thereby enabling the patient to regain his morale.(Frank, 1986)

Although not all therapists would be happywith the idea that they are ªformulating aplausible story,º the process of clinical formula-tion remains the lynch pin that holds theory andpractice together. This is agreed by proponents

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Copyright © 1998 Elsevier Science Ltd. All rights reserved.

of most major therapeutic traditions: for exam-ple, behavior therapy (Turkat & Maisto, 1985;Wolpe&Turkat, 1985), psychodynamic therapy(Barber&Crits-Christoph, 1993;Perry,Cooper,&Michels, 1987; Silberschatz, Fretter, &Curtis,1986), family therapy (Minuchin, 1974), cogni-tive therapy (Freeman, 1992; Persons, 1989,1993), cognitive analytic therapy (Ryle, 1978,1990), and interpersonal therapy (Klerman,Weissman, Rounsaville, & Chevron, 1984).The attempt to construct and use a clinicalformulation is central to the work of therapy.Variousmethods for systematizing the processesinvolved have recently been proposed (Horo-witz, 1989; Luborsky & Crits-Christoph, 1990)and, thinking specifically about the issues in-volved in psychotherapy integration, Goldfried(1995) has put forward a case for developing acommon language for case formulation that isindependent of theoretical orientation. Personaldiscussions of many kinds may be more or lessvalued and helpful to someone experiencing adifficulty, including the informal advice tradedbetween friends, but one of themajor differencesbetween informal discussions and responsibleclinical practice is that they do not make use ofthe process of formulation. The attempt toformulate a case, so as to apply an appropriatelychosen method of intervention in the light of aparticular theory, is one of the activities thatmakes therapists, as opposed to friends, accoun-table for their practice.This chapter discusses issues concerning

clinical formulation that are relevant to thera-pists from different theoretical backgrounds.However, the illustrations of the general pointsmade will largely be drawn from the author'sown experience and will therefore reflect theauthor's original cognitive-behavioral training,together with a more recent interest in exploringpossibilities for integration between differentkinds of psychotherapy.

6.01.2 DEFINITIONS: WHAT IS AFORMULATION?

6.01.2.1 Main Principles

A formulation is the tool used by clinicians torelate theory to practice. Clinicians use theor-etical as well as practical knowledge to guidetheir thinking about the problems and difficul-ties presented by the people who come to themfor help, and this combination of ideas helpsthem decide how best to help those people.However, although the theories are relativelysimple and clearÐadmittedly to varyingdegreesÐthe information brought to treatment,and gatheredduring the process of assessment, isalways complex and often unclear. The process

of marrying theory and practice is thereforefraught with difficulty. As well as havingdifferent reasons for requesting psychologicalhelp, people vary in their ability to describe orname their difficulties, in their histories andrelationships with their families, friends andcolleagues, in their ability to relate to a therapist,degree of psychological-mindedness, and emo-tional expressiveness. Aswell as having differenttheories, training, and clinical experience, thera-pists vary in the ways in which they understand,communicate with, and relate to their patients.Therapists bring with them to therapy specificskills, expertise, and information, and also theirindividual personalities and inclinations. Theprocess of formulation is influenced by all thesedisparate factors, and thismakes learninghowtoformulate a case with the necessary objectivity,clarity, and attention to the individual to guide asuccessful treatment one of themost fascinating,rewarding, anddifficult tasks facedby clinicians.The assumption that many clinicians of

different orientations probably share aboutthe psychological difficulties of others is this:at some level it all makes sense. Even though ourunderstanding of the processes involved, andparticularly of their inter-relationships, is in-complete, this assumption was given a simple,and relatively uncontroversial, diagrammaticform by Padesky and Mooney (1990). Thedifficulties that people describe to their thera-pists have four inter-related aspects (cognitive,affective, behavioral, and physiological), andchange in any one of these variables affects all ofthe others, as shown by the bidirectional arrowsinFigure 1. So, taking anxiolyticmedication canmake one feel calmer, think about problemsmore constructively, and do some of the thingsthat previously seemed too difficult or over-whelming. Feeling more cheerful can lightenones step, help one to feel more optimistic, andrelate more productively to others. Changingones perspectiveÐor way of thinkingÐcanprovide the sort of new outlook that helps todissipate distress, reduce tension, and encourageconstructive activity, and soon.The fourways inwhich aspects of psychological life are conven-tionally categorized reflect the internal workingsand psychological state of a person at aparticular point in time. This person is at thesame time relating to the external world througha personal social, political, and historicalcontext. The factors that determine this context,and fashioned it to be the way that it now is, arenot easy for psychological therapists to knowabout: hypotheses for explaining and under-standing the way they interact with each of thefour types of phenomena have been made. Theoverall configuration is the source of thenarrative, or story, that a person brings to

Clinical Formulation2

therapy. If we understood the rules governingthe relationships between all these factors wewould, no doubt, be better able to help ourpatients.The business of therapy, to a large extent,

involves intervening to facilitate change in (atleast) one of the four main aspects of psycho-logical life shown in Figure 1, and differentkinds of therapy attend differently to thesedifferent aspects, entering the process of changethrough different gateways. The intention,however, is much the sameÐto help peoplesolve the problem or problems that they bring totherapy. Pharmacological and traditional be-havioral therapies provide perhaps the clearestexamples as the methods that they use, and theformulations upon which these methods arebased, can be isolated relatively easily. Cogni-tive therapies, which adopt both cognitive andbehavioral methods, operate on at least twolevels. They may concentrate on identifying andreexamining particular thoughts, thereby chan-ging feelings and behavior, and/or they mayfocus on underlying meanings and beliefs andadopt more sophisticated and complex methodsof intervention, often related to those used inmore dynamic and experiential traditions.Experiential therapies make specialized use ofthe medium provided by the feelings andthoughts arising in the present context oftherapy, and work with these to facilitate adynamic process of change. In order to do this,it becomes essential to think about, and toformulate, what happens in the relationship

between the two people involved in therapyÐmethods which were originally described andunderstood by proponents of the variouspsychodynamic schools of therapy. Interperso-nal therapy and systems therapy also formulateproblems in terms of relationships between theperson requesting help and others around them,and use this understanding to help peoplechange as they wish. All of these methodsinitiate the process of change in different ways,determined by the way in which they under-stand, or formulate, the problem presented, andit is this understanding that determines whattherapists doÐwhat steps they take to alleviatethe problem.The point is that the way in which a

formulation is constructed will be influencedby the point at which a therapist enters, andattempts to influence, this dynamic relationshipbetween these main aspects of psychologicallife. Some general points are important:(i) each aspect influences all of the others, so

none of the therapies has the exclusive aim ofchanging one factor. Rather, by focusing theprocess of change in one place, the aim is tobring about the change that the patientdesiresÐusually to ªfeel better,º in all therelevant respects.(ii) The main medium of therapy is

languageÐwhat one person says or suggests,to another. To this extent, the cognitive, im-plicational context within which therapies takeplace provides the basis for the way in which thepresenting problems will be formulated.

Theenvironment:

personal,social,historical

context,etc.

Cognition

Behavior

Affect Physiology

Figure 1 Inter-relationships between aspects of functioning (Padesky & Mooney, 1990).

Definitions: What is a Formulation? 3

(iii) Understanding of other people, andhence the ability accurately to formulate theirproblems, develops within the context of therelationship between them, mediated by factorssuch as trust and acceptance as well as bylanguage.(iv) Our understanding of the ways in which

the aspects of psychological life are integrated ispartial. At this point in time, psychology is animperfect but developing science. The implica-tion of this is that formulations for the purposeof therapy have to be speculative.Formulations can best be understood as

hypotheses to be tested, and the most obvious,if not the most logical, test of a formulation willbe the response to the selected interventions.This is not to say that an expected changefollowing a specific intervention proves that theformulation on which it was based is accurate.Unfortunately, the reasons why change occursare far more complex and difficult to discernthan this. However, the formulation used in thisway is perhaps the main tool that the therapisthas from which to draw such conclusions in theindividual case. Thus, working in an open-minded way with a formulation provides ameans of contributing as a therapist to thescientific endeavor involved in finding outwhich are the best, most effective, and mostefficient, methods of treatment.Although a formulation provides the link

between theory and practice, it does so at adifferent level of generality. A theory is thesource of general explanations and generalhypotheses, whereas a formulation is specific tothe person to whom it applies, and therefore isthe source of more specific explanations andhypotheses. The specificity of the formulation isthe source of ideas about the selection of specificinterventions and about how to adapt them foruse with a particular person. It is for thesereasons that Wolpe and Turkat (1985) describea formulation as a theoretically guided way ofstructuring the information concerning a pa-tient's problem. It reflects the product of takingan individual approach to clinical phenomenaand combining this with knowledge of relevanttheories, scientific principles, and researchfindings. It involves imposing an explanatorysystem upon the material presented, and raisesquestions concerning the degree to which thisexplanatory system should reflect every aspectof a problem. One view is that it should reflecteverything, including a patient's past develop-ment, characteristic ways of behaving andforming relationships, emotions, beliefs, as-sumptions, attitudes, self-evaluations, expecta-tions, attributions, appraisals, and so on. Inpractice, the degree of elaboration requireddepends upon the purpose for which the

formulation is made. At this point it is probablysufficient to enunciate one of the principles thatwill run through this chapterÐthat of parsi-mony. In principle, it is always better, and moreuseful, to keep the formulation as simple aspossible. The temptation to elaborate a for-mulation is strong, especially when dealing withcomplex cases. However, the simpler and clearerit is the more readily will its implications be seenand the easier it will be to use.Theoretically speaking, the principles that

guide the practice of formulation are derivedfrom the way in which the concept is defined.The three main ones to be proposed here are:(i) A formulation should be based on a

theory, reflecting an attempt to put the theoryinto practice.(ii) A formulation should be hypothetical in

nature, so that it can be modified by informa-tion gained during the course of treatment.(iii) A formulation should be as parsimo-

nious as possible.

6.01.2.2 Formulation and Diagnosis:Assumptions

In psychological practice there appears to bea common assumption that only those patientswho participate in research trials have simplediagnoses, for example, of the kinds defined inthe various versions of the DSM. Diagnosticsystems are useful for ensuring that thepopulations studied in different places aresimilar in the relevant respects, and they areuseful for insurance purposes, but from thepoint of view of the therapist they havelimitations in that they rarely provide specificimplications for treatment. Besides, unselectedsamples of patients often do not have single,clear problemsÐindeed informally they arecommonly said to ªfulfill criteria for an averageof 2.3 diagnoses.º A formulation, however, isdesigned precisely to fit the individual and isintended to help therapists to derivetheoretically-based hypotheses about factorsthat contribute to causing andmaintaining theirspecific problemsÐto explain as well as todescribe. Therefore, the argument runs, diag-noses are less useful than formulations, fromwhich specific treatment implications can bederived, and they may be less necessary thanformulations. For example, one depressedperson's sense of failure may be triggered byan inability to live up to exacting standards andanother person's by an inability to form closerelationships (for any number of reasons, whichmay be discovered during therapy and includedin the formulation). Only having the diagnosistells the therapist nothing about this difference,


and ignoring the difference will reduce thechances of achieving a satisfactory outcome.This argument has much to recommend it to

the therapist, especially as diagnoses are largelyatheoretical descriptions, and therapists can usetheir theoretical knowledge to construct for-mulations that are clinically useful. This doesnot mean thinking anew with each patient, butkeeping in close touch with theoretical andclinical research so that, for example, empiri-cally validated treatments can be selected whenthe diagnosis suggests they would be appro-priate, and individual formulations then used tospecify details of their application. Learning towork with a formulation instead of relying on adiagnosis also has advantages when the pro-blems presented are unusually rare or complexand do not fit readily into a diagnostic system,or when the system does not succeed in ªcarvingnature at the joints,º and the demarcationbetween one diagnosis and another is difficult toestablish. Of course there are difficulties withthis point of view. Seen from the patient'sperspective, over-reliance on the process offormulation may involve a degree of risk.What if the theory iswrong?Or if the therapist

is unclear about it? Or susceptible to bias? Orunable to come up with an adequate formula-tion? Or attempts to combine one theory withanother without understanding sufficiently wellthe implications of doing soÐas when borrow-ing from experiential or dynamic ideas whendoing cognitive therapy for instance? This riskcan be reduced by formalizing the requirementsof responsible clinical practiceÐby providingadequate training and supervision, by clarifyingethical guidelines, and by defining criteria forprofessional accountability, including the ex-pectation that practitioners will keep in touchwith the literature relevant to their practice.Ultimately though, the mysterious faculty ofclinical judgment has also to be brought intoplay. Without thisÐwhatever it isÐcliniciansmay well run into difficulties, both making andusing formulations.The implication of this argument is primarily

that, much of the time, formulations are moreuseful than diagnoses, provided that therapistsare well versed in the theories they are using, andthat diagnoses, which can after all convey alarge amount of information in a few words,may help to streamline the process of assess-ment, and may guide decisions about treatmentin relatively straightforward cases. For exam-ple, knowing someone is socially phobic directsattention towards a fear of being humiliated orembarrassed, and knowing the diagnosis is ofbulimia nervosa focuses attention on over-concern with shape and weight (among otherthings). Underlying problems of self-conscious-

ness and poor self-esteem may be relevant inboth cases, so the assessment which provides anadequate basis for a formulation, and for aspecific treatment plan, must cover more thanthe criteria for inclusion and exclusion thatdetermine whether or not someone qualifies fora diagnosis.

6.01.2.3 Formulation and Diagnosis:Controversial Issues

The assumption behind the argument pre-sented above is that a treatment plan based on aformulation will have a better chance of successthan one based on a diagnosis. However, there isconsiderable debate about this issue, and somerecent research suggests that the assumptioncould be false. Schulte, KuÈ nzel, Pepping, andSchulte-Bahrenberg (1992) and Schulte (1997)found that patients with phobias, assigned to astandardized treatment (exposure in vivo) on thebasis of their diagnoses, responded at least aswell as, and possibly better than, patients whosetreatments had been selected on the basis ofindividual problem analyses. With this findingin mind, Wilson (1996, 1997) summarized thearguments for using manual-based, empirically-validated treatments, also selected on the basisof diagnoses, and argued that there are inherentlimitations involved in basing treatment onidiographic case formulation. As he points out,making formulations involves making judg-ments and judgments are fallible. They aredemonstrably susceptible to bias and usingthem introduces an additional source of error. Itwould be better, he argues, to adopt an actuarialapproach to assessment and treatment as this ismore likely to result in a superior outcome thanusing clinical judgment, at least when treatmentmanuals are available.The issue is complex (Beutler, Williams,

Wakefield & Entwistle 1995; Hayes, Follette,Risley, Dawes & Grady, 1995; Norcross,Alford, & DeMichele, 1992; Seligman, 1995;Stricker & Trierweiler, 1995), and differenceswill not be settled here. Nevertheless, it is usefulto clarify the basis of the disagreement, as twoissues are frequently confounded. The firstconcerns the failure of practicing clinicians toadopt standardized practices and the secondconcerns the dangers of over-reliance onindividual formulations. Those who argueagainst the use of formulations seem to forgetthat it is the job of practicing clinicians to bridgethe gap between science and practice, and indoing so to balance the requirements ofrecommended procedures with clinical flexibil-ity. A formulation, as defined above, is intendedto facilitate this processÐto assist the clinician


in adapting the procedure to the particularcircumstances. When treatments so adapted arereported to be less effective than expected, thenmany factors in addition to formulation couldcontribute to this finding. These include thequality, integrity, structure, and delivery of thetreatment, the accuracy with which the effects oftreatment can bemeasured, and the relevance ofthe measures used to the outcome desired by thepatient. Proponents of the view that treatmentscan be selected on the basis of diagnoses aloneseem to assume that case formulation isidiographic, in the sense that making one isunconstrained by theoretical ideas and using itto select interventions is independent of thefindings of clinical research.Neither of these points is accepted here.

Instead it is argued that individual caseformulation is always relevant, even whenapplying a manual-based treatment (exampleswill be found below). It is also argued thatformulations have to be rooted in theory to beuseful, and that using clinical judgment is notproviding a licence for subjectivity, but recog-nizing that at least someof the timeclinicianswillnot be able to follow the rule book, even whenthere is one. Then they have to use theirjudgment. In doing so, they can appeal to manysources of understanding, including theoriesabout psychological dysfunction, and theirknowledge of the relevant literature. As Strickerand Trierweiler (1995, p. 997) put it ªit is likelythat the practitioner always will be requiredto go beyond firm and available scientificknowledgeºÐless so when treating phobiasthan when treating a complex of depression andanxiety in someone with a dependent person-ality type, and not without keeping in touchwith scientific advanceÐbut individual judg-ment and case formulation remain indispensa-ble clinical tools. Using these tools does notexempt the practitioner from being aware of thepitfalls of basing decisions about treatment onanecdotal case material, intuition, or subjectiveimpression. On the contrary, working with aformulation that can be explained to othersprovides a check on the use of too much specu-lation and too many far-fetched inferences.Therapists need to speak about their patients'

problems in many settings and contexts, and todo so can make use of any of the availablesystemsÐlabels, diagnoses, descriptions, andformulations. Labels (e.g., manipulative, hys-terical, narcissistic, personality disordered) areefficient but can bring assumptions with them(and in these examples, assumptions that maynot be to the advantage of the person beinglabeled). Diagnoses reflect agreed systems ofcategorization and for the most part are basedon particular kinds of descriptions rather than

on theories. They may or may not be subject tothe same disadvantages as labels. Formulationsdiffer in that they bring together the products oftheoretical knowledge and clinical judgment.Their theoretical basis reflects ideas about thefactors that cause and maintain problems, andthat precipitate or prolong particular episodesof distress. This theoretical basis provides aframework for the type of personal, individualformulation on which precise decisions abouttreatment can be based. Their advantages anddisadvantages are discussed further below.

6.01.2.4 The Difference Between a Formulationand a Model

Models are ways of conceptualizing particu-lar disorders (e.g., the cognitive hypotheses ofobsessive-compulsive disorder and of healthanxiety described by Salkovskis (1996), or offormulating particular patterns of functioning(e.g., the role±relationship models developed byHorowitz, Eells, Singer and Salovey (1995) orthe functional analytic causal model of Haynes,Uchigakiuchi, Meyer, Orimoto, and Blaine(1993). Models, as understood here, are con-structed from a particular perspective, so thereare separate cognitive models of panic disorder(Clark, 1988) and social phobia (Clark &Wells,1995), and the psychopharmacological orinterpersonal psychotherapy models of panicdisorder differ from the cognitive model. Thesedifferences are valuable in that they stimulateuseful research, as well as the development ofsets of coherent treatment strategies. Using thecognitive model of panic disorder as anexample, this would suggest that catastrophicmisinterpretation of bodily symptoms plays acrucial role in triggering panic attacks, and thatunderstanding this will help people who sufferfrom panic disorder to identify the symptomsthat trigger their panics. They will then be in aposition to think again about the meaning ofthese symptoms, and to reinterpret them interms of (harmless but distressing) panic ratherthan of real, impending catastrophe. In order tofacilitate the therapeutic process, the model hasto be translated into a conceptualization (orformulation), and structured systems for doingthis can be developed, as in this case has beendone by Dattilio (1994). So the model providesguidelines for an individual formulation whichencourages a new explanationÐthe leap in myheart could be a response to the coffee I havejust drunk, or a normal arrhythmia that I noticemore readily than I used to because it frightensme, and not a sign of imminent cardiac crisis.Although a model has implications for

treatment, it differs from a formulation in that


it operates at a different level of generality, andhas a different content. So, the way in which aformulation applies to particular people willdepend upon their personal history and circum-stances. One person's panic may be triggered byleaps in the heart and another's by losingconcentration when being spoken to (and athird may find that memories of traumaticincidents, flashbacks, or nightmares precipitatepanic, possibly because they trigger associatedsensations that then trigger the panic attacks).There will in practice always be exceptions tothe rule, cases in which, for example, nosensational trigger can be identified. Then theclinician may be best advised to base theformulation on a higher level theory ratherthan on the specific modelÐin this case on thegeneral theory that cognitions, including mean-ings, are closely related to feelings and behavior,and that changing one is likely to change theothers. Thus the formulation illustrates, in waysthat are clinically relevant, how the modelapplies, and does not apply, to the case. It assiststhe therapist in looking for particular theore-tical constructs or processes (catastrophicmisinterpretations in this example), and alsoinmaking a judgment about the degree to whichthe case is typical.Atypical cases arise when patients have more

than one difficultyÐsocial anxiety as well aspanic disorder for exampleÐor when they haveespecially complex or rare problems such aspanic attacks in the context of avoidant orborderline personality disorder. Then, concep-tually speaking, it may be more useful to drawon more than one model to construct a singleformulation, or to look for models with a higherorder of generality. Writing about psychody-namic formulation, Perry et al. (1987) point outthat overlapping models of mental functioningmay emphasize different aspects of develop-ment and psychopathology. They distinguishego-psychological, self-psychological, and ob-ject relations models, and make the importantpoint that a certain amount of trial and errormay be needed in constructing a formulationthat explains the presenting data: ªthe absenceof a meta-model to explain all data makes thistrial and error unavoidableº (p. 546). Whatclinicians are looking for in a formulation is away of explaining and understanding therelationship between a patients' inner livesand their outer lives that is the product of theirpersonal history, explains present difficulties,and guides future therapy. Their sources in thissearch include knowledge of diagnostic systems,of relevant theoretical models, and of outcomeresearch, as well as information about theindividual caseÐotherwise they would have toreinvent the wheel each time.

6.01.2.5 Types of Formulation

Typically, different therapeutic schools arethought to use different types of formulation. Ingeneral, behavioral and cognitive therapiesmake use of more mechanistic formulations,based on theories about learning and detailedfunctional analysis (Hayes & Follette, 1992), oron theories about processes such as thesupposedly circular relationships betweenthoughts and feelings, and more dynamictherapies employ more narrative-based formu-lations, placing current problems in the contextof a developmental history. Some systemic andexperiential approaches to therapy adopt athird, essentially dynamic, approach, claimingthat formulations have constantly to be re-formed in the present, as therapy focuses onmoment-to-moment events (Goldman &Greenberg, 1997). They also point out thatthe process of formulation can be dangerousand limiting when it makes use of presetcategories and ideas. A constantly changingsituation then appears to be fixed, andopportunities for change may be obscured(Eells, 1996; Rosenbaum, 1996). However, theprocess of formulation is still thought to beessential, and its main purpose is still to look forpatterns and links that assist in understanding,and to provide ideas about how to bring aboutchange. So, distinctions can be applied toorigidly. The developmental history of a problemor a person, or the narrative, is always relevant(Nicholson, 1995;White, 1989), although it maybe understood in different ways, and so are ideasabout the mechanisms that precipitate anepisode of distress or perpetuate a problem.Overt differences between types of formulationare therefore relatively unimportant to anunderstanding of the term, and of the functionsthat the activity of formulating a case performsfor the therapist.

6.01.2.6 Levels of Formulation

Whenmaking a formulation, it is necessary tothink at many different levels, and the numberof levels postulated obviously varies with thetheory being applied. Taking an example fromcognitive-behavioural therapy (CBT) to illus-trate the point, at the most superficial level, orthe level of ªovert difficultiesº (Persons, 1989),the main task is to define the problems and theways in which they are maintained, usually interms of vicious cycles. Someone who feelsdepressed may withdraw from company, thinkabout being all alone, and become increasinglydepressed. Even such a simple formulationsuggests a focus for interventionÐworking to


reduce the withdrawal. Thinking about thefactors that precipitated the depression addsanother level to the formulation. The personmight have become depressed when their jobrequired them to move to a new place, whenthey got divorced, or when their children lefthomeÐfactors that would demand differenttypes of adaptation, to be promoted by thetherapist in different ways. Stressors areadditive, so many factors may be involved,and an apparently minor stressor may be thestraw that broke the camel's back (and relativelyirrelevant to the formulation), or it may reflect aparticular personal vulnerability. Factors thatpredispose someone to become depressed,biological as well as psychological factors,add a further level, and the way in which theseare understood, and formulated, will againinfluence the selection of interventions. At themost profound level of all, assuming that ªatsome level it all makes sense,º the formulation issupposedly capable of reflecting the meaning ofstructures through which people interpret andthink about, remember and recount, theirexperiences, and theoretical assumptions aboutthe origin of these things.This is the standard way in which psychiatric

formulations have traditionally been madeÐinterms mainly of predisposing, precipitating, andperpetuating factors. However, there are yetother levels to consider, reflecting social,cultural, and historical factors. Social assump-tions (ªmen should not show their feelingsº orªwomen are bad organizersº) influence theviews of therapists as well as patients, andcultural assumptions may or may not be sharedbetween therapist and patient. Some cultures,for example, do not share the commonWesterntherapeutic goal of autonomy, especially forwomen. Others assume that a relationshipbetween a professional person and their clientis one involving activityÐor authoritativepronouncementsÐon the one side, andpassivityÐor receptivityÐon the other. Inaddition, different hierarchies of values caninterfere profoundly with the therapeutic pro-cess. An example in our culture is when someonethinks it more important to avoid giving offencethan it is to tell the truth. Although it is neverpossible to stand outside all of these factors,making a formulation helps therapists to thinkabout them, to identify them clearly, and tobecome aware of their potential influence on theinterpretation of other people's circumstances.It can help therapists to ensure that the ways inwhich they understand problems and selectinterventions are not influenced by unwantedbiases. Seen in this way, a formulation assiststherapists in achieving a relatively objectivestance.

Formulations are always made from aparticular perspectiveÐin the author's casemade (usually) from a cognitive-behavioralperspective, and from that of a White womanof a certain age, living in Britain now, whoseways of thinking have been formed by her ownlearning and experience. A formulation isneither about fitting information about apatient to a predetermined formula, whetherthat formula be derived from a general theory orfrom a more specific model, nor is it a personaljudgment, though both things are relevant. It isabout developing the kind of understanding ofanother person, their circumstances and theirdifficulties, that enables a therapist to apply thetheoretical knowledge acquired during trainingto help that person. There is no single right wayof making a formulation. The general aim is tomap the territory so that one can then explorethe possibilities for change, and not to let thesebe influenced by factors that are irrelevant to, orunwanted by, the person who is receiving help.

6.01.3 PURPOSES: WHAT AFORMULATION IS FOR

One common view of the purpose offormulation is that it is for explaining the past,making sense of the present, and suggestingwhat to modify in order to influence the future.It can also be an important means of commu-nicating understanding, either to the patient orto another professional, whether in the role ofsupervisor or colleague. However, its primepurpose is to help therapists to apply the theorythey have learned to their practice (a compre-hensive account of different approaches toformulation is given by Eells (1997).In practice, there are many answers to the

question ªWhat is a formulation for?º Themainfunctions of formulation are listed in Table 1.The main point is that making formulations isan essential, and not an optional, element of thetherapeutic process. Formulations do not haveto be 100% accurate or complete in order to beuseful precisely because they provide a source oftestable hypotheses. They can be changed whenthey turn out to be wrongÐand nothing is lostby using a partial or partially mistakenformulation which can be improved andcorrected as the process of therapy continues,and reveals the initial mistake. They guidequestioning, and open the therapist's mind tothe kind of understanding from which effectivetreatment strategies can be derived, applied, andevaluated. Therefore, the author would argue,that therapists should work with a formulationin mind right from the start. Ideas about peopleand their problems cannot be kept at bay or


excluded, even when first meeting them orreading a referral letter about them. One way oftrying to ensure that this information is openlyreceived and accurately assessed is to engageimmediately in the process of formulationÐinapplying both theoretical and clinical knowl-edge to the particular case. Just as when firstvisiting a new place, a rough sketchmapmay setone on the right road at first, but will needexpanding and revising if it is to guide moredetailed exploration.

6.01.3.1 Understanding: The Overall Picture orMap

A formulation ªprovides the map of theterritory and once you have that you can usewhatever vehicle you are most comfortablewithº (Beck, 1991). Formulations, just likemaps, provide an overall view (often indiagrammatic, conventional form) of some-thing that it is not possible to see directly all atonceÐthe wood as well as the trees. Theyindicate which are the important features, theirsize and shape, and the way in which they relateto each other. Mapping the territory is clearlythe product of accurate assessment (see Section6.01.4), and formulating enables therapists tomake and to justify such statements as ªthis lackof energy is part of the depression,º or ªin thiscase the anxiety seems to be primary and thedepression secondary.º Similarly, formulationscan indicate where information is missing andprompt appropriate questions: where did thislow self-esteem come from?Why does it becomeapparent in the context of close personalrelationships but not at work?

6.01.3.2 Prioritizing Issues and Problems

An overall formulation helps to differentiatewhat is essential from what is secondary in ageneral sense. It also helps in a more particularway todecidewhich issuesorproblemsshouldbeprioritized. Someone who believes that theycannot change is unlikely to remain engaged in

therapy unless they can see the point of it.Creating hope, or the context for a developingrelationshipÐsomething with a future, in whichchange is inherent and undeniableÐthen be-comes a priority. Likewise, an initial assessmentmay indicate primarily that inability to trustpeople will make it hard to disclose distressingmaterial, and building trust within the ther-apeutic relationship is necessary before a moredetailed and accurate formulation can be made.It is probably not unusual for patients and

therapists to start the process of therapy withsomewhat different priorities. Usually thisproblem can be overcome during assessmentand those early stages of therapy during whichgoals becomeclear or are specifically agreed.Butsometimes different priorities persist, and thenthe process of re-formulating can help to solvethe problem. For example, an anxious andhypochondriacal patient who was worried,among other things, about seeing ªfloatersº inhis visual field, started to respond well totreatment that was formulated in terms of hisunderlying sense of vulnerability. The formula-tion reflected the way in which his variousconcerns made him feel threatened, and thinkthat he was at risk for being unable to handle anumber of initially rather vaguely specifieddistressing eventualities. However, althoughhis confidence increased, his distress about thefloaters did not diminish. If anything it in-creased, in tune, it must be acknowledged, withthe therapist's frustration when discussing thisissue became his main priority. Focusing thework of one session on the meaning or under-standing of this problem revealed (for reasonswhich later became clear) that visual anomaliesfor this person felt, in his words, ªlike abereavement.º Formulating this aspect of theproblem in terms of loss rather than in terms ofvulnerability changed the focus of treatment,which then became more productive. Thisexample also illustrates how characteristics ofthe process of therapy can contribute to ideasabout the formulation, especially in those casesin which change is not proceeding as well asmight otherwise be expected.

Table 1 Summary of the purposes of formulation.

Clarifying hypotheses and questionsUnderstanding; providing an overall picture or mapPrioritizing issues and problemsPlanning treatment strategiesSelecting specific interventionsPredicting responses to strategies and interventions; predicting difficultiesDetermining criteria for successful outcomeThinking about lack of progress; trouble shootingOvercoming bias

Purposes: What a Formulation is for 9

6.01.3.3 Planning and Selecting InterventionStrategies

Once a hypothesis about how the presentingproblem can be understood has been formu-lated, the most important functions of aformulation are in planning a treatmentstrategy and selecting appropriate methods ofintervention. Persons (1989) provides somelucid examples: someone who avoids exercisebecause they are bad at time management,scheduling, or self-organization has a differentproblem to overcome, and needs to acquiredifferent skills from the person who avoidsexercise because they are embarrassed abouttheir appearance; insomnia that is associatedwith the fear of letting go may require differentinterventions from insomnia that results fromovercommitment.The way in which a problem is formulated

thus determines what should be done about it(Blackburn & Twaddle, 1996; Butler & Low,1994; Eells, 1997). If avoidance maintains theproblem, then facing the fear is likely to reduceit, and in individual cases the formulation helpsto specify idiosyncratic aspects of the avoid-ance (the spider phobic who will not walkunder trees; the social phobic who is morefearful of silence than of conversation). Thegeneral vicious cycle model is common tobothÐand indeed, a standardized method oftreatment of proven effectiveness, exposure invivo, is readily available. The individualformulation is still necessary because itspecifies exactly what steps to encourage theperson to take.Planning overall strategies is just as impor-

tant a product of formulation as the selection ofspecific methods of intervention, but is a morecomplex task, and requires of the therapist morethan one level of understanding. The way inwhich depression or anxiety is understood maysuggest, for instance, that it would be helpful toincrease levels of activity before discussingthoughts associated with depression; or to buildup a repertoire of coping skills before facingfears. Many such imprecations are based onclinical judgment (or clinical intuition) as muchas on theoretical or experimental work, and inthese cases it is especially important that theyshould be made clear by means of a formula-tion. For example, it is often said that whenworking with people who have suffered abusiveexperiences in childhood, one should help themto develop a variety of support systems, ways ofdealing with intense feelings or suicidal impulsesand of creating around themselves a sense ofsafety, before exploring memories of earlytraumatic experiences, and the meanings ofsuch events, in depth.

Clearly, this overall strategy reveals assump-tions about how the effects of these events canbe understood, about the effects of talkingabout them, and the interventions usedÐassumptions which formulations clarify, andwhich are potentially amenable to research, butwhich will differ according to the therapist'stheoretical orientation. A secondary purpose ofclarifying the formulation and its function inselecting strategies and interventions is tofacilitate evaluation of interventions.

6.01.3.4 Predicting Responses and Difficulties

Because a formulation reflects theoreticalassumptions, it helps therapists make two kindsof predictions that are essential in therapy: topredict the effect of the intervention, assuming itis successfully applied, and to predict thestumbling blocks and difficulties that will beencountered during therapy. An anxious persontreated during a clinical research trial (Butler,Fennell, Robson, &Gelder, 1991) held the beliefthat ªall my ideas are bound to be wrong.º Shebecamemore confident as she learned to identifyher ideas, to act upon them, and consciously toevaluate the consequences of doing so. Herformulation enabled us to predict first that shewould feel especially vulnerable and be likely toovergeneralize and catastrophize the conse-quences when she made mistakes, and second,that she was likely to find it especially difficult toapply the new strategy when relating to herpartner, but easier tobuildup thenecessary skills(and courage), and to increase her confidence, inthe context of other relationships (includingours). Treatment in this case was guided by therequirements of a treatment manual, and theexample illustrates the important role played byclinical formulation in the application ofstandardized treatments.It is probably true to say that interpersonal

difficulties are one of the most common sourcesboth of patients' problems and of problemsencountered during psychological therapy; forexample, an ability to form superficial relation-ships without being able to sustain deeperfriendships, or veering between passivity andaggression when interacting closely with others.Such difficulties also play their part within thetherapeutic relationship, and they are muchmore easily dealt with if the processes involvedhave been understood in terms of the theorybeing used, and problems predicted in advance.Formulating helps people to recognize suchpatterns, to develop hypotheses about theirorigins, functions and effects, and to thinkaboutwhether and how to engage in a process ofchange.


6.01.3.5 Determining Criteria for SuccessfulOutcome

Theoretically a formulation provides thebasis for hypotheses about what needs tochange for someone to feel better, or the goalsof therapy in the broad sense of the term. This isobvious when a theoretical model for thecondition being treated is available, but thepoint applies more generally as well. Thepresent version of the cognitive model of socialphobia (Clark & Wells, 1995), for example,suggests that self-awareness, or self-focusedattention, plays a central role in the disorder. Inoutline, when in a socially frightening situationa social phobic feels self-conscious, noticessymptoms of anxiety and tries to keep safe. Anindividual formulation based on this modelwould specify the way in which this actuallyhappens. For example, when speaking to others(e.g., colleagues during a lunch break), Mariebecame aware of the sound of her own voice, feltanxious, flustered, hot, and shaky, and found ithard to listen to what was being said. Shethought other people must be able to see hownervous she felt and tried to fade into thebackground as quickly as possible (keepingherself safe by avoiding eye contact, sayinglittle, speaking in a quiet voice). Both generaland specific goals for change can be derivedfrom thinking along these lines. In simple terms,if Marie can focus her attention outside herself,and listen without self-criticism to those aroundher, if she can reverse the safety behaviors (makeappropriate eye contact, speak more audibly,move around freely), she will break the cycleand start to feel less anxious. The generalcriteria for change are reflected in the threeelements of the model specified here, the self-awareness, safety behaviors, and symptoms ofanxiety, and specific ones reflect the individualways in which these factors aremanifested in thecase of Marie.Of course this might not be the whole story.

Marie's social anxiety may be based on a beliefin her own unworthiness relative to others, andreflect an unhappy history of family relation-ships. Such formulations again indicate criteriafor changeÐa sense of worthiness or the abilityto form more satisfying relationships in thepresent. The difficulty here is that moreabstract and general phenomena are harderto identify, define with any precision, andmeasure than more superficial and specificones. Criteria for change are therefore moreeasily derived from formulations at lower thanat higher levels of abstraction, and indeed themore specific the formulation the easier it willbe to be clear about what exactly needs tochange.

6.01.3.6 Thinking About Lack of Progress

There are many possible reasons for lack ofprogress in therapy, including working withoutmaking a formulation. The first line of defencewhen this happens must be to formulate or toreformulate the problem. The way in which thisis done will have specific implications for thenext steps in therapy. For example, if theproblem is a long-standing, chronic one, it maybe that much practice is needed and that it isunrealistic to expect faster change, in which caseit may be important to think about how to keepthe momentum of change goingÐabout how tomaintain hope and create the energy for changewhen doing so is difficult. If the originalformulation was inaccurate or incomplete, thefailure to change may suggest that differentstrategies and interventions are needed. Whenlack of progress leads to frustration, and thereactions of both the patient and the therapistinterfere with subsequent progress, includingthese factors in the reformulation can revealways of overcoming them. Blocks in treatmentare nearly always informative and formulationskills should be used to identify their specificnature.Often this is complex and involves making

hypotheses about past events, the exact natureof which can never be known. Possibleformulations in these circumstances, oftenderived from a combination of observationand understanding of the apparent effects of thepast on the present, can suggest which avenuesto explore so as to make further progress. Forexample, a patient who provided a cold anddispassionate account of a childhood in whichshe was neglected, often frightened and some-times threatened with physical abuse, appearedto have developed a variety of ways ofcontrolling both the experience and the expres-sion of her emotions. Many, but by no meansall, of these ways were dysfunctional. A possibleformulation of this case suggests that improve-ment will remain blocked unless or until shebecomes able to experience and express therelevant feelings. Doing this is likely in the firstinstance, to precipitate periods of distress, andthe precise implications for therapy to bederived from it will depend on both the skilland the emotional sensitivity of the therapist aswell as on a willingness to adapt the formulationaccording to what happens.Drawing these points together, it is clear that

formulations cannot be treated as a matter oflast resort, only to be constructed and workedon when the going gets difficult, when dealingwith chronic problems, when treatment hasapparently gone on too long, or when preparingto report to someone else. Formulations do not

Purposes: What a Formulation is for 11

provide the answers to questions, but a richsource of questions and ideas of potentialtherapeutic value. They should not becomethe tool for applying a preconceived theoreticalplan to someone for whom the plan does not fit,nor should they focus exclusively on someone'sproblems and difficulties. Accurate formulationtakes account of a person's strengths as well asfailures, talents and potential, as well as short-comings and failures.If formulations can be so useful it is surprising

that so little attention has been devoted to themboth within training programs and in theliterature. One reason for this may be thatformulations were supposed to follow logicallyfrom the processes of assessment and functionalanalysis, and additional skills were not oftenspecified.Amore important one is probably thatformulating is difficult. As already indicated, inpractice it involves exercising clinical judgmentas well as the ability to relate theory to practice.Also, until recently, there was less communica-tion between people with different theoreticalbackgrounds, and fewer challenges to thinkabout alternative methods of formulating spe-cific cases. So, the next important question isªHow do you construct a formulation?º

6.01.4 METHODS: HOW TO CONSTRUCTA FORMULATION

Themain reason for considering the purposesof formulation before thinking about how itshould be done is that there is no single correctmethodÐhow you do it is in general determinedby understanding the purposes that it serves,and in particular by the theoretical orientationof the therapist. The end product should enablethe therapist to relate theory to practice in a waythat can direct and inform the process oftherapy, and the methods used vary enor-mously. For the student this is both confusingand liberating, as it demands creativity and theability to deal with abstractions as well as themore mundane skills primarily involved inassessment. Assessment is a necessary step inthe development of a formulation, but it is not asufficient condition for it. Unfortunately, it ispossible to assess, in the data collection sense,without developing a formulation.

6.01.4.1 Sources of Information

An account of presenting problems, informedby knowledge of psychological processes anddiagnostic systems, provides a common startingpoint, and assessment covers all of the fouraspects of functioning illustrated in Figure 1 andtheir determinants: cognition (thoughts, as-

sumptions, attitudes, beliefs, images, etc.);affect, behavior, and physiological sensation;the present context for the ways in which thesethings are manifested; and an account of theirbackground and associated developmental his-tory. It also draws on information gatheredduring the process of referral, such as a summaryof the problems as understood by the referrer, ofthe reasons for requesting help and of responsesto treatment received so far, and on theimpressions and observations made during thefirst encounter with the therapist when theprocesses of mutual interaction are set inmotion.Therapists use many skills in helping them to

understand this material: theoretical know-ledge; products of academic learning andprofessional training; and clinical judgment.The process of encapsulating this understandingin a formulation, which at first takes time andbecomes quicker with practice, is facilitated byadopting a questioning stance. The aim wouldbe to be able adequately to answer three of thekey questions that patients ask: Why me? Whynow? What keeps it going? and in doing so ithelps to draw on a further set of questionscentral to the process of formulation, whichtherapists can pose either to themselves or totheir patients: How do you understand that (ormake sense of it)? What do you think is goingon? How does this all fit together? What mightbe the missing links? What does that meanabout you now? Is there a pattern here?Formulations are useful in helping people to

think again about their difficulties, and see themin a new (e.g., clearer, more realistic, or moreilluminating) light, and the process of assess-ment potentially reveals the patient's presentpoint of view. In order to develop an under-standing of such personal and unique phenom-ena, it is particularly useful to pay attention tothe ways in which people react to theirexperiences. Their comments provide a richsource of such informationÐªI have to keepcontrolº or ªI need to know I am succeedingºare remarks that suggest hypotheses about theself and about underlying processes andmechanisms. Ideas expressed about others, suchas ªshe'll be miserable aloneº may fit withassumptions that precipitate or maintain pre-senting problems. General comments of thekind ªyou have to conform or you can't get onºreveal attitudes that may (or may not) dominatewithin the real world in which the person lives.Expectations about the future, including thoseabout the process and outcome of therapy, arealso revealing: ªI won't be able to do what isneeded,º ªThere are some things I would rathernot talk about,º ªI'm relying on you tomakemebetter.º In order to formulate, it is important to


understand the personal significance of experi-ences as well as their phenomenology. Thesecomments illustrate well how the processes offormulation and assessment meet, and indeedmay overlap. Therapists assess to find out aboutproblems and their context, and they formulatedifferently according to what they think theirfindings mean.Patients' comments may need clarifying

during assessment if they are to inform theprocess of formulation maximally. Statementsthat are apparently clear to the person expres-sing them may not be clear to the therapist, ormay reveal ambiguities and contradictions, aswhen angrily saying ªI'm not capable as aparentº (when sadness sounds more likely and,superficially, more appropriate), or whencommenting wryly that ªI felt sorry for myself,ºwithout elaborating on what that means. One ofthe most useful sources of information forformulation comes from themutual reactions ofthe patient and therapist to each otherÐinformation that is used differently in differenttypes of therapy, and which is understood usingdifferent theoretical systems, of varying degreesof sophistication, but which is always relevant.The processes of assessment and formulation

therefore go hand in hand, and inform eachother, but they remain different processes. Ideasabout how to understand (conceptualize orformulate) what is being said, about its personalmeaning and implications for theorized psy-chological structures and processes, guidequestions and observations. When formulatingas well as when assessing, the informationgathered changes and shapes these ideas ashypotheses are formed, revised, and (theoreti-cally) refined. So, making a formulation is not aone-off activity that defines a fixed state, but thereflection of a dynamic process, and theresulting system of understanding developsand changes over time. This is why the processof formulation should start at the same time asthe process of assessmentÐjust as the process offinding ones way around a new place starts withthe first encounter with itÐandmay be on paperrather than in person.Two points that follow from this line of

argument help to determine how a formulationis made. First, if therapists are always for-mulating as well as assessing, then theirquestions and statements should be guided byconceptual hypotheses. They should always beable to answer the question ªWhy did you askthat then?º The answer should not just bephrased in terms of curiosity or informationgathering, but should relate to a hypothesisabout how to understand the minutiae of thecase. The patient's response to the therapist'scomment or question is then maximally in-

formative. This may sound unrealisticallydemanding, as if every sentence the therapistutters should be shaped by the developingformulationÐindeed, it is intended as a rule ofthumb rather than as a categorical imperative.However, it is less unrealistic than it might seem.The initial question in the therapist's mindcould be quite a simple one, for example: Is thewithdrawal described by this person associatedwith feelings of depression and sadness or is it akind of avoidance motivated by fear? Willattentive listening help this person feel suffi-ciently comfortable to disclose significantmaterial? Are my questions too specific andintrusive at this stage? Answers to thesequestions could of course lead to more complexones: Is this person's reticence a product ofexperiences that have destroyed trust? Does itreflect a preference for an autonomous style ofrelating to others? Is it a product of inexperienceand lack of practice or opportunity in talkingabout intimate and personalmatters? Is this wayof interacting culturally unfamiliar to them?The second point is that the process of

therapy should not be artificially separated intodiscrete stages of assessment, formulation, andtreatment (or intervention). It is not that theseprocesses cannot be distinguished, or that oneor other of them may not predominate at aparticular time, but that they cannot in practicebe wholly separated from each other. Thus, oneof the hardest tasks therapists have to learn ishow to bear all three of them in mind atonceÐhow to gather information, think aboutit in theoretical/structural terms, and remainaware of the various ways in which they arelikely to exert an influence, so as to enhance thepotential for productive change, rather thanlimit or delay it.The many sources of information available to

therapists when starting to develop a formula-tion, assuming an adequate process of assess-ment has been set in motion, are summarized inTable 2. This list includes both direct andindirect sources of information, informationfrom standardized questionnaires, and frominitial interventions such as self-monitoring andhomework assignments (when these are used).The purpose of this summary, in the context ofthe preceding discussion, is not to overwhelmtherapists with long and exhaustive lists ofmaterial to be gathered, items to consider,processes to complete, and soon,but to illustratethat there is an enormously rich source ofrelevant material potentially available, and theprocess of formulation can draw on any of it,beginninganywhere.Theprocess of formulationis essentially one of abstraction and it works byrelating observable phenomena to hypotheticalunderlying processes and mechanisms. It is not

Methods: How to Construct a Formulation 13

necessary to observe everything beforemaking aguess at what lies underneath. An (informed)guess may either indicate the need for moreassessment or it can short circuit the process.Because formulating is a dynamic process, anddepends on the ability of the therapist to retainan openmind, the process can productively startto serve the functions listed in the previoussection straight away. Therapists can focus theirminds on the process of formulation by askingmore formal questions: How can I understandthe information I have been given in terms thatmake theoretical sense? What implications doesthat understanding have for what to do next?What difficulties will I have, working with thisperson? What difficulties will they have (work-ing in this way) with me? What use will thisperson be able to make of treatment? Answershelp todeterminehowto interveneand topredictwhat will or will not happen as a consequence.

6.01.4.2 Putting the Information Together

Given that a formulation provides connectinglinks between theory and practice, the preciseform that it takes will be partly determined bythe theoretical approach of the person makingit. Nevertheless, some general points apply, andthese are illustrated here using the cognitive-behavioral approach.First, initial formulations can provide cross-

sectional understanding of an aspect of thepresenting problem. The most obvious exampleis probably that of a vicious cycle whichsummarizes the way in which a particular,readily accessible, symptom pattern is thoughtto be maintained. It is used here to illustrate theway in which a formulation helps to specifyprocesses, links, and mechanisms. In this casethe focus is on certain kinds of links. Othercross-sectional formulations might focus on

other patterns, for instance in interpersonalfunctioning, sequences of behaviors and theirconsequences; thoughts, feelings, attitudes, andbeliefs; dilemmas and traps. In this example(Figure 2), a woman living through a stressfulperiod described feeling tired much of the timeand being unable to relax. Asked about whatgoes through her mind when trying to switchoff, she described a stream of worries, most ofwhich were rather vague and hard to specify indetail. The worry disturbed her sleep pattern,which exacerbated the tiredness. A cycle, whichsymbolizes how one thing leads to another, caneasily be illustrated diagrammatically, and it hasobvious implications. Breaking the links willhelp to solve the problem, and this can be donein various ways, such as learning to relax,identifying and dealing with the worries, ortaking hypnotic medication. The assumptionbehind the formulation so far is that theproblem will subside if the process thatmaintains it is interrupted, and the interventionselected could be determined by the preferences,understanding, or skill of either of the partiesinvolved.However, a formulation essentially relates

theory to practice. Applying the cognitivemodel to this case would suggest that a closerelationship between thoughts and feelings islikely to be of central importance. There are atleast three ways in which this initial formula-tion, in its hypothetical and simplified form, canhelp the cognitive therapist to focus on factorsthat theoretically are likely to be relevant. Itidentifies worry as an important cognitive-maintaining factor, it reflects an overall under-standing of the problem, suggesting that thesymptom pattern is recognizable, understand-able, and changeableÐattitudes which maydiffer strikingly from those the patient startswithÐand it poses questions about the contextof the problem. Nothing has been specified

Table 2 The main sources of information for use in formulation.

Examples of direct informationReports of present phenomena: cognitive, affective, behavioral, and physiologicalThe context: historical background and development, real life problemsReactions, comments, and expectations, about the self, others, therapy, events, etc.Interactions within therapy: ability to relate, tenor of relationshipsObservations of body position, movement, facial expression, eye contact, etc.The outcome of interventions such as self-monitoring, homework assignments,behavioral experiments, etc.

Products of questionnaires, tests, standardized interviews, systematic observation, etc.Examples of indirect informationKnowledge about diagnosis: DSMReferral information: summaries, previous treatment, opinionsKnowledge of cultural norms (of the therapist and of the patient)The socioeconomic and political context


about why this is, for this person, a stressfulperiod. Theory-driven questions help to developmore hypotheses: What does it mean about herhabitual response to stress? How does sheconstrue her present situation? What does herreaction to it mean to herÐabout herself, aboutother people, and/or about the world in whichshe finds herself? So, the initial formulationtriggers further inquiry, and starting from asimple cross-sectional map can lead to moresophisticated levels of understanding, and tomore complex formulations, as well as beingpractically useful. The precise way in which thishappens will be determined by the theory beingused.Cross-sectional formulations can also pro-

vide an outline summary of the way in whichcomplex underlying factors are understood, orof the way in which aspects of a problem arelinked. Three statements made by an unem-ployed, unconfident young man with a widerange of social, interpersonal, and affectiveproblems were used as the starting point for theinitial formulation illustrated in Figure 3: ªIf I

always please others they'll never find out aboutme,º ªI'll be OK if I stick to doing easy things,ºand ªPeople will reject you if you don't toe theline.º In this diagram, three aspects of hisproblem are represented in different ways. Firstthere is a rather shapeless ªthought bubbleº atthe top in which hypotheses about underlyingcognitive structures, beliefs, attitudes, and rulesabout himself have been put into words: ªI'mincompetentº; ªI have to do what others askº;ªI'm thick (stupid) . . . º These actual wordswere his responses to specific (theory-driven)questions, and they illustrate how the process offormulation interacts with that of assessment,and depends on the ability to abstract and togeneralize. The broken line is labeled aªprotective wallº because it represents the ideathat the three statements listedÐstarting pointsfor a more detailed formulationÐreflect beha-viors that serve a function. Reacting in theseways protects him from having to confront (thehypothetical) underlying beliefs and attitudes,and prevents others from discovering them,both of which would be painful experiences for

Feel tired andunable to relax

Worries keepcoming to mind

Can’t sleepwell

Under stress

Figure 2 Example of a simple cross-sectional formulation: basis for a more complex formulation.


him. However, these protective reactions causeproblems, not specified here but referred to inthe box in Figure 3. This formulation con-tributed to the process of developing a sharedunderstanding of some complex problems, andit was used to explain how change wouldprobably involve working at all three levels. Italso has implications for decisions aboutgeneral aspects of therapy. For example, itsuggests that at times this will be a distressingprocess that will demand sensitivity and a goodsense of timing from the therapist.Cross-sectional formulations potentially re-

flect ideas about psychological processes and

mechanisms as well as about the relevance andrelative importance of different facets of aproblem. Longitudinal formulations reflectassumptions about etiology as well. They areused in most kinds of therapy, and are readilyillustrated in the case of CBT. The basis forusing this theoretical model in clinical practicehas been summarized in the form of a template(Table 3) which can be used to illustrate howtheoretical understanding can be translated intopractice. This shows that, theoretically, experi-ence, both early in life and subsequently, givesrise to a set of beliefs and assumptions about theworld, about other people, and about the self.

Me with myproblems

I’m incompetentI have to do what others ask

I’m thick

Protective wall:“If I always please others they’ll never find out”“I’ll be OK if I stick to doing easy things”“People will reject you if you don’t toe the line”

Figure 3 Example of a cross-sectional formulation.


These beliefs are seen as a product of the ways inwhich earlier events have been perceived,understood, and remembered. They can befunctional or dysfunctional, actively influentialor latent at any particular time, and relativelyeasy or hard to identify and to recognize. Acritical incident (see also below) is an event thatfits with a beliefÐbeing rejected for someonewho believes they are not socially acceptable, orbeing let down for someone who believes thatother people are unreliable or untrustworthy.Critical incidents activate the relevant beliefsand assumptions, and thus produce negativeautomatic thoughts (NATs). Then a variety ofinteracting cognitive, affective, behavioral, andphysiological reactions follows. At this level theproblem is theoretically maintained by cyclicalprocesses of the kind summarized in the cross-sectional vicious cycle described above.Clearly a template such as this can be used to

structure information about a patient, and thiswill have implications for what the therapistdoes. For instance, if it appears that dysfunc-tional beliefs play a small part in the presentingproblem, or are well balanced by a set of positivebeliefs, the theory (and the formulation derivedfrom it) suggest that the work should focuspredominantly on the level of maintainingfactors. Another type of implication mightreflect the degree of verification available for thetheory. For example, psychologists do not yetknow which are the most effective ways ofchanging beliefs (the cognitive frameworks withwhich people approach the world). One com-mon strategy is therefore to beginworking at thelevel of the NATs and to evaluate the degree of

belief change that follows. The processes ofchange may, or may not, be set in motion bywork at this level. If not, then anotherhypothesis might be that one of the manyprocesses now available for changing beliefsshould be adopted as well as or instead of. Thisexample is not meant to explain how to doCBT,but to illustrate how the internal map providedby a theoretical understanding relates to aspecific formulation, and how therapists can usesuch maps as guides even when there isincomplete evidence for the theories uponwhich they are based. Doing so enables themto explain what they have been doing, and itenables others to decide whether their actionswere skilful, appropriate, and so on.

6.01.4.3 Key Factors and Basic Elements

This example also illustrates that whenlearning how to construct a formulation, itcan be helpful to think in terms of key factors.Critical incidents provide a good example ofthese as they reflect the way in which hypothe-tical underlying mechanisms are manifested,and link these with observations about presentphenomena. Critical incidents are ªcriticalºbecause they provoke a high degree of affect,often in excess of what might otherwise beexpected (an over-reaction, such as becomingenraged if kept waiting for 10 minutes); they areeasy to notice and remember, and are of specialsignificance for the person who experiencesthem. Examining them potentially reveals otherelements of the CBT template: underlying

Table 3 Template for a longitudinal formulation using cognitive-behavior therapy.

Experience (early or otherwise)

;

Beliefs, about the self, the world, and others, which are expressed incategorical statements: I am . . . ; the world is . . . ; others are . . .

;

Assumptions derived from beliefs, which can be expressed inconditional statements: If I . . . then . . . ; One should . . . otherwise . . .

;

Critical incidents

;

Activated beliefs and assumptions

;

Negative automatic thoughts (NATs)

; :

Cognitive, behavioral, affective, and physiological reactions


beliefs, preferred coping mechanisms, main-tenance cycles, and so on. Focusing on criticalincidents is thus theoretically helpful whenstuck in constructing a cognitive formulation.This is not to say that all cognitive therapiststhink about them, or base their formulationsupon them. An alternative method mightinvolve working from a problem list, weightingthe problems for importance, and going on toabstract and understand the connecting themesand links in ways that fit with the theory. Thepoint is that within a particular method ofworking there are many ways of constructing aformulation, but it can be helpful to keep thosefactors in mind which play a central part in thetheory, or in revealing the manifestations ofimportant theoretical constructs whether theseare core beliefs, core interpersonal schemata, orcore conflicts. To repeat, there is no singlecorrect method.Use of the word ªcoreº suggests that

formulations may be thought to have certainbasic elements, and that unless these areidentified the formulation will, in Perry et al.'swords, ªlack an integrative coherence.º Whenwriting about psychodynamic formulation andabout central conflicts, Perry et al. (1987, p. 546)say ªThe aim is to find a small number ofpervasive issues that run through the course ofthe patient's illness and can be traced backthrough his or her personal history, and then toexplain how the patient's attempts to resolvethese central conflicts have been bothmaladaptive . . . and adaptive.º The overallintention is clearly closely similar acrossdifferent therapeutic orientations, as is thegeneral approach: first, apply a particular,theory-driven model; if that does not in practicefit the particular case, explore further usingquestions and trial and error in the (scientific)search for a formulation that fits better.This process might be facilitated if there was

agreement over which were the basic elements ofa formulation and an atheoretical way of linkingthem together. One way of doing this has beendeveloped by Goldfried and his collaborators.This transtheoretical coding system ªwas devel-oped as a common language for use inconducting comparative process research acrossorientationsº (Goldfried, 1995, p. 222). Itspecifies which are the relevant componentsof functioning (e.g., self-observation, self-eva-luation, intention, emotion, and action) and thetypes of links that can be made between them(vicious cycles, patterns, contradictions). Thesecan be manifested both in intra- and inter-personal contexts, involving other people ornot, over a particular time frame. One advan-tage of this type of formulation, the codingsystem of therapeutic focus (CSTF), is that it

indicates what the problem is, and where tointervene, but (being atheoretical) cannotindicate how to do so. It cannot thereforeprovide specific implications for treatment, butit does provide a common language, and usingthis it is potentially easier to find out preciselyhow theories differ when put into practice.

6.01.4.4 Issue of Completeness

The formulations illustrated so far have beenkept simple for the sake of clarity, to emphasizethe point made at the beginning about theprinciple of parsimony, and because theydemonstrate the point that it is never too soonto start formulating. They are examples ofinitial hypotheses. As treatment progresses theywould be likely to become more complex andalso to take more account of a person'sdevelopmental history and the supposed under-lying mechanisms.This raises an important issue for discussion.

Many people assume that formulating is adifficult and lengthy process, the aim of which isto encompass, systematize, and explain allrelevant factors about a particular case. Thisview can lead therapists either to bypass theprocess of formulation and start treatmentstraight away, or to delay the start of treatmentuntil they have got the picture right. Both ofthese reactions cause problems: bypassing theprocess makes it hard to move beyond the stageof trial and error; interventions are selected inthe absence of a coherent underlying strategy.This seems to be successful when the patientresponds well (asmany patients do initially), butit leaves both parties feeling confused andunable to understand what has happened whenhalf a dozen sessions later progress is halted andsetbacks are encountered. It is rather like tryingto stop a car rattling by cleaning and adjustingthose parts of the engine that are mostaccessible. Delaying the start of treatment isanother false economy, for many reasons: theinitial momentum provided by a fresh start anda new encountermay be lost; the impact of beinglistened to, heard, and understood by someonenew may be dissipated; and the goodwill,advice, and new ideas derived from interactingwith a trained therapist may not be harnessed ina way that is either helpful or informative (orboth). So, opportunities to test hypotheses maybe lost.In an ideal world therapists, believing that ªat

some level it all makes senseº, would be able touse their formulations to make sense of thematerial presented in a particular case. But atpresent complete formulations, like completetheories, are not possible. A person cannot be


summarized in a diagram. But some of theirproblems and patterns of behaving can beunderstood in theoretical terms and this under-standing can be represented in a way that helpsto guide treatment. The complexity and accu-racy with which this is done varies according tothe stage of treatment.The emphasis on completeness that is often

found in discussions about conceptualizationmay be a consequence of the historical associa-tions between medical practice, psychiatry, andpsychology, and the common use of the wordªtreatmentº to refer to the actions of peopletrained in those professions when they are tryingto help others. The assumption is that it could bedangerous tomiss something serious or to applythe wrong treatment. So, a complete under-standing is supposedly an essential (or impor-tant) prerequisite for deciding how to intervene.The situation is different in psychotherapy (or

psychological therapy), first because the psy-chological influence of one person on anothercannot bewithheld (as can amedical treatment),and then applied when ready, in a self-containedpackage. Various (partially unspecified) factorsare always operating, and in psychotherapy theways in which these function will to some degreebe influenced by the theoretical views andassumptions of the therapist (as well as by theirpersonal characteristics). The business of for-mulating can direct this process, clarify what isintended, and make the way in which theoriesare being applied accessible. Formulations donot have to be complete to perform this functionbut the method of working with them does haveto be in place. Second, when dealing withpsychological matters, the process of formula-tion is overtly interactive. Patients' commentsand reactions contribute to the process; theiropinions are relevant, and these may changeover the course of treatment.

6.01.4.5 Conceptualizing Processes of Change

Therapists seek understanding of the way inwhich change takes place as well as of the way inwhich problems arise and persist, and they mayalso formulate this understanding in theoreticalterms. Conceptualizing the processes of changeis thus another way of relating theory topractice, and formulations may be technical,phrased in terms that are derived from theparticular theory being used, or metaphorical.Technical formulations might explain howchanging reinforcement patterns would changebehaviors, how change in one person willprompt the system around them to adjust, orhow changing patterns of defensiveness mightchange opinions of the self. Examples of

metaphorical formulations are provided in thissection to illustrate how metaphors can en-capsulate information about complex processesthat may be hard to specify otherwise. Someexamples are well known and their use hasbecome quite conventional, such as ªa journeyof a thousand miles begins with the first step.ºOthers are created in a particular therapycontext. For example, a manager of anengineering company, whose habitual rigiditywas exacerbated by various (personal andindustrial) crises, saw himself as ªhanging onfor dear life,º and being unable to contemplatechange. He was asked to think about how tobuild a building to withstand an earthquake.Thinking about this enabled him to reconcep-tualize change as a way of developing thecombination of flexibility and rigidity needed toprovide stability in difficult times. Anotherrelatively simple way of representing andsummarizing a complex process of changewas spontaneously developed by a woman withlongstanding problems involving low self-esteem and lack of confidence. She saw herselfas ªwobblyº and at risk of falling, as if trying tosit on a two-legged stool. The process of changefor her was like ªputting down the third leg.º Inpractice this meant many things that contrib-uted to a sense of stability: developing new skillsand abilities, thinking about herself in newways, and making more respectful and openrelationships with those around her.People often use metaphorical language to

communicate their experience of distress.Indeed, it might be more accurate to say thatit is difficult to describe such experienceswithout using metaphorÐpeople explain toclinicians how they feel broken, trapped, fencedin, cast adrift, close to the edge, messed up, outof reach, cut off, high, low, and so on. Perhapsthe most common methaphors describe life as ajourney and ourselves as traveling throughdifferent kinds of emotional weather. Patients'understanding (or personal formulation) of theprocesses involved is also reflected in the wordsused to describe their experiences: ªI've hiddenmyself away . . . built a protective wall aroundme . . . had to harden my shell . . . can't see myway out of the tunnel . . . waited to be rescued.ºIt is hardly surprising that the processesinvolved in therapy are similarly described.Someone who came to understand the stultify-ing and self-destructive effects of overt com-pliance with the wishes of those around her,despite her own inclinations, and the relation-ship of this pattern of behavior to the fear andanger for which she was requesting help, saidthat she felt as if she had spent her whole lifetrying to grow flowers in her garden and cuttingoff the buds before they could flower. She saw


therapy as a process that would help her toallow the flowers in her garden to bloom.Undoubtledly, the process of developing ashared understanding is a complex one, andthe more abstract the material considered, themore difficult this process will be. Although ametaphor is not a formulation, and it mayreflect only part of what is involved, using onecan help to fulfill some of the purposes offormulation that were described above, and itcan do so with a startling degree of economyand emotional sensitivity because it operates atmore than one level.These examples have been chosen because

they illustrate a point not so far emphasizedabout formulation, that it is a way ofsummarizing meanings, and of negotiating forshared ways of understanding them and com-municating about them. When these are com-plex it can be helpful to use metaphor, and ofcourse this applies generally, not just whenformulating processes of change. A formulationprovides a source of common language, andwhen this is available it can then be used torelate a theoretical framework, at a high level ofabstraction, to practice, so as to facilitate theprocess of change.

6.01.5 ACCURACY: HOW TO TELL IF AFORMULATION IS RIGHT

Formulations can never be shown to be rightas they are hypotheses not statements of facts.The evidence may support them or it may not,and they should be judged according toprobabilities rather than on an absolute scaleof rightness. Like other scientific hypotheses,formulations can only be shown, conclusively,to be wrong. Nevertheless, practical guidelinesare useful, and a number of attempts haverecently been made to evaluate their inter-raterreliability and predictive validity (Barber &Crits-Christoph, 1993; Horowitz & Eells, 1993;Persons, Mooney, & Padesky, 1995).

6.01.5.1 Criteria of Accuracy

A summary of the kinds of practical guide-lines that might provide clinicians with criteriaof accuracy is given in Table 4. Unfortunately,the fact that a formulation makes good internalsense (provides a plausible narrative for in-stance) is not a guarantee of its accuracy, whichshould therefore be tested out in practice. It goeswithout saying perhaps that a formulationwhich is simple, clear, and easy to understand,and therefore easy to explain, is more readilytestable than one which is overly complex. Onewhich is more specific and low level will have

clearer implications than one which is phrasedin more general, abstract, and high-level terms.Presenting the formulation to someone else, orputting it onto paper, is therefore a useful andrevealing exercise.

6.01.5.2 Questions for Research

It would probably be fair to say that, of themany questions that could be asked, few havebeen studied and none have been conclusivelyanswered. Persons, Padesky, and Mooney(1996) found only moderately good inter-raterreliability of cognitive-behavioral formulationswhen tapes of initial therapy sessions were ratedby a large group of therapists who had beentrained in CBT, and who varied in their level ofexperience. Surprisingly perhaps, agreementwas better with respect to underlying mechan-isms than in listing patients' overt problems.Barber and Crits-Christoph (1993) found, whenreviewing the psychodynamic literature, thatwhen clinicians based their formulations onpreset categories, formulations were morereliable, and in addition the predictions of thepsychotherapy process and outcome werebetter. Both these findings fit with the viewthat the more clearly specified the activity (as inCBT and interpersonal psychotherapy, or whenusing clearly defined conceptual categories), theless room there is for wide-ranging, speculativeinferences, and themore agreement there is bothabout particular case formulations and abouttheir utility.As discussed above, there has been some

suggestion that making overall decisions abouttreatment purely on the basis of a diagnosis maybe at least as useful as basing them on anidiographic formulation. However, a diagnosisonly enables therapists to make general deci-sions about which set of interventions toemploy; for example, to use exposure in vivoto help someone with a simple phobia, or thosetechniques that will assist in resolving a roledispute in a case of depression treated withinterpersonal psychotherapy. In both cases theactual steps used will still depend on the way inwhich the individual case is formulated (Mar-kowitz & Swartz, 1997). The question as towhether treatment that is based on a formula-tion is more successful than treatment that is notis more complex than at first appears. Mostclinicians bring their theoretical knowledge tobear in the way that they understand, andcommunicate understanding about, a case.They use covert formulations, which may notbe made overtly communicable even thoughthey inform and direct the process of treatment.This happens because, once therapists are


thoroughly familiar with the theoretical back-ground to their work, and with the process ofmap-making, the activity of formulation cannotbe wholly suspended. Once able to recognizesigns of core beliefs or core conflicts, forexample, such theoretically meaningful con-structs cannot suddenly be rendered invisibleagain. Formulation skills may still need shar-pening, and there is certainly a need for moreand better training (Sperry, Gudeman, Black-well, & Faulkner, 1992), especially now thatclinicians appear increasingly likely to incorpo-rate ideas from theoretical orientations otherthan their main one into their work (Messer,1996b). The effects of working with (or without)a formulation will remain hard to evaluate. Themore important question, in practical terms, iswhether or not a particular way of seeing thingsis put to good use, successfully to do the thingsthat a formulation is for. The struggle is to find away of seeing things that helps. Although theassumption that ªat some level it all makessenseº still underpins much clinical work, it isnot necessary to believe that there is such a thingas a ªcorrectº formulation. As Messer (1996a,p. 136) says, ªAn alternative outlook is thatthere is no one version of truth possible becausewe largely construct our realities, which inev-itably leads to multiple perspectives on thatreality. Wearing different glasses providesdifferent views of the world.º

6.01.6 USING THE FORMULATION:PRACTICAL ISSUES

A formulation does not have to be correct,but it does have to be useful. The purposes offormulation are discussed in Section 6.01.3.Here, three practical factors that influencewhether a particular formulation succeeds infulfilling its purposes are mentioned briefly.

6.01.6.1 The Value of Organizing and Clarifying

Formulating is a way of classifying informa-tion, putting it into (conceptual) boxes, anddrawing links between them. It organizesinformation, treatment strategies, and the choiceof interventions, and it also clarifies under-standing of a case, and therefore the meaning ofwhat is observed. This process has some lessobvious advantages as well as the obvious ones.In particular, it helps therapists to see problemsand difficulties as understandable, and thisinfluences their attitudes and expectations. Forexample, hostile orpassive±aggressive behaviorsfrequently create frustrations and difficultiesfor therapists, especially when they persistdespite all their best efforts. Organizing andformulating the information helps therapists tosee these as characteristic and predictabledifficulties for which they can plan appropriatestrategies.

6.01.6.2 Developing an Internal Supervisor

The process of formulation provides thera-pists with an opportunity to achieve on theirown many things that otherwise they wouldachieve through supervision. It prompts them toreflect about their work with individual cases,and to rethink when progress seems blocked. Ithelps them to become aware of their ownassumptions and beliefs, and to look out forways in which these may cause problems, suchas making it hard for them to notice, under-stand, or work with particular issues. It helpsthem to work well with unusual cases or withtypes of problems that they have not previouslyencountered. In doing so it helps to buildconfidence. Formulation is no substitute forsupervision but, used well, it complements andextends itÐprovided that the formulation does

Table 4 Ten tests of a formulation.

1. Does it make theoretical sense?2. Does it fit with the evidence? (symptoms, problems, reactions to experiences)3. Does it account for predisposing, precipitating, and perpetuating factors? (both

overall and with respect to episodes of difficulty)4. Do others think it fits? (the patient, supervisors, colleagues)5. Can it be used to make predictions? (about difficulties, aspects of the therapeutic

relationship, etc.)6. Can you work out how to test these predictions? (to select interventions, to

anticipate responses and reactions to therapy)7. Does the past history fit (with respect to the person's strengths as well as

weaknesses)8. Does treatment based on the formulation progress as would be expected,

theoretically?9. Can it be used to identify future sources of risk or difficulties for this person?10. Are there important factors that are left unexplained?

Using the Formulation: Practical Issues 21

not become a fixed way of seeing things thatobscures the significance of information thatdoes not fit.

6.01.6.3 Communicating a Formulation

Some obvious principles can be derived fromthe preceding arguments: the simpler theformulation, the easier it will be to commu-nicate; it should be presented as a hypothesis,not as fact; and initial guesses are worthchecking out as they can indicate whether aparticular way of seeing things is likely to beproductive.To some degree a formulation is a matter of

judgment. It is based on clinical judgment aswell as on knowledge and facts. As judgmentsabout people are bound to reflect some of theattitudes and assumptions of the person whomakes them, the question arises as to whatshould be done with those judgments. Whoshould be told about them? Are there peoplewho should not be told, or circumstances inwhich they should not be disclosed?Answers to these questions are partly deter-

mined by practitioners' ethical guidelines andprocedures for professional accountability.They also depend partly on the theoreticalorientation of the therapist. In cognitiveanalytic therapy, interpersonal psychotherapy,CBT, and in some forms of short-termpsychodynamic psychotherapy, therapistsmake their formulations explicit, and havetherefore considered carefully how and whenthis should be done (Beck, 1995; Beck, Free-man, & associates, 1990; Butler & Booth, 1991;Markowitz & Swartz, 1997; Ryle, 1995). Themethod used is immensely variable, usingimagery, metaphor, diagram, or verbal expla-nation, presented in person or in a letter. Thereis room here for creative thinking, and sensitiveadaptation of communication skills, though itmay help to specify some general principles.Being on the receiving end of a formulation

can feel like being weighed up, evaluated, orjudgedÐlike being ªseen throughº orªrumbledº rather than understood. This is lesslikely if the formulation is presented questio-ningly and collaboratively, at a time whentherapists are clear that patients are ablehonestly to give feedback, and while thinkingabout how to facilitate the process of feedingback reactions in a way that is not justsuperficial or polite. It is important to focuson strengths as well as weaknesses, and to drawout implications for change, otherwise patientswith chronic problems may conclude that ªthisis the way that they are,º and become hopelessabout change. The language used should be

simple and jargon free. It may help to give asmall amount of information at a time and to beready to repeat explanations, or introducetechnical terms, as necessary. Therapists oftenunderestimate how much patients can them-selves contribute to the process of formulation,for instance, by elaborating details, filling inmissing links, or providing contradictory in-formation that shows how the formulation canusefully be adjusted.Formulation thus goes hand-in-hand with

reformulation, and it is this, as Rosenbaum(1996) points out, that stops it becoming a wayof ªfitting something to a known formula.º

6.01.7 CONCLUDING DISCUSSION

Formulations reflect the way in whichtherapists make sense of someone else's pre-dicament. They reflect the assumptions broughtto bear when thinking about it, the theorieslearned, and the meaning made of it. However,making sense is not the only thing that they do.All therapists are aware that sometimes (albeitrarely) providing a formulation can be sufficientto bring about change. Such cases show thatformulations do more than supplyunderstandingÐthey enable someone to seethings differently, to reformulate, or to find anewmeaning. A business executive whose wholecareer was threatened by an episode of severestress and anxiety was suddenly able to seehimself as engaged in a genuine struggle. It wasthen legitimate, in his view, to experiencereactions indicative of both fight and flight.His symptoms became acceptable, diminishedimmediately, and he remained well over thefollowing six months. Of course this could beunderstood in many ways: as a healthyconsequence of a reformulation, as a miraclecure, or as a flight into health. So therapists arealso in a predicament. Most of the time onlysome of the facts are available to them, whetherthese are about someone's past life, theirinternal experience or their present relation-ships, and the facts that are available areconsistent with a wide range of plausibleinterpretations. Different mechanisms can beinferred from the same event, as in the exampleabove, or from the same overt problemsÐthebather's hand movements could signify wavingor drowning. Equally, the same mechanismscould be inferred from different problemsÐafear of abandonment could underlie bothhostile and dependent behavior. The skills offunctional analysis may help to advance theprocess of formulation here. To end where webegan, Frank (1986, p. 343) said that ªthe besthope of bringing conceptual order into the field


of psychotherapy may lie in thinking of allpsychotherapeutic enterprises as lying in therealm of meaningsº . . . thinking, feeling, andbehavior are . . . ªresponses to the meanings ofevents asmuch as to the events themselves.ºOurassumptions and knowledge about the ways inwhich these meanings are stored, represented,and recalled, and about the degree to which theycan be brought into awareness, will thereforegreatly influence the meaning we give to ourformulations and the uses we make of them.Therapy can be understood inmanywaysÐas

managing anticipated transferences, counter-transferences, and resistances; as seeking newperspectives and using these to restructure abelief system; as a process of constantly meetingand adjusting to what is happening eachmoment; or as a way of influencing thecontingencies that relate behaviors to theirantecedents and consequences. In all of them,the process of formulation serves similar func-tions. It is useful because it helps to determinewhat we, as therapists, do and enables us tounderstand and to explain that better.

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