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Formulation in Psychology and Psychotherapy
 
 
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Formulation in Psychology and Psychotherapy (Paperback)

by Lucy Johnstone (Editor), Rudi Dallos (Editor)
5.0 out of 5 stars  See all reviews (3 customer reviews)
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"Buy this book! It is a clear and well articulated approach to formulation in the psychological psychotherapies... The book holds appeal for trainees, trainers, practicioneers and supervisors. It will take its place as required reading on training courses." - Clinical Psychology Forum, May 2007


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This book places the growing interest in formulation in a clinical and historical context. It critiques and takes forward recent work on integration, and provides a lively and challenging critical evaluation of the area as a whole.
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11 of 11 people found the following review helpful:
5.0 out of 5 stars A pleasant surprise!, 23 Nov 2008
By John Rowan (London England) - See all my reviews
(REAL NAME)      
This is one of the most surprising books I have come across. At first it looked like one of those essential but boring books to be used by students on essential but boring courses. The work `formulation' carried, for me, echoes and intimations of `diagnosis' and `medical model'.
It does start off rather like this. Two case vignettes are given, and then experts from various specialities give their accounts of how they would formulate these two cases. These are not easy meat: there is a man of 25 diagnosed with `paranoia' and `persistent delusional disorder', and a girl of 9 with a fear of any form of transport and night terrors, as well as a refusal to eat food prepared by her mother. We start with cognitive-behavioural therapy (Dudley & Kuyken): then comes psychodynamic therapy (Leiper), systemic therapy (Dallos & Stedmon) and a social constructionist approach (Harper & Spellman). This latter is extraordinarily interesting, as it is largely centred on narrative therapy - a fascinating new approach. To see the whole idea of formulation being simultaneously used and subverted is highly stimulating. But even more excitement comes with the next chapter, headed Social inequalities formulation: Mad, bad and dangerous to know (Miller & McClelland). This takes a completely different approach, which involves, among other things, having a group discussion with men of the same age as the client, and with some similar experiences, to get a clearer idea of the social pressures he might have met. This led to a mapping of the social inequalities to which he had been subjected. It then became possible to go more deeply into the world of the client, both internal and external, both private and public. These two chapters give an answer to the accusation that therapy always has to be politically naïve and even ignorant.
The two following chapters are more conventional, representing two different kinds of integrative therapy - Dallos, Wright, Stedmon & Johnstone for the one, and Dallos on his own for the other.
The final chapter is quite brilliant. It is headed Controversies and debates about formulation, and is the best account I have seen of the whole question of categorising clients. They say: "Formulation should be an ongoing process rather than a one-off expert pronouncement, and therefore one would hope that reformulation based on the client's feedback would ensure that unhelpful formulations are revised or abandoned. Unfortunately this does not always happen." (p.215) They are clear that formulations can easily go wrong in the eyes of the client, and quote G Butler to the effect that "Being on the receiving end of a formulation can feel like being weighed up, evaluated or judged - like being `seen through' or `rumbled' rather than understood." (p.216) In their summary they say: "The potential criticisms and limitations of formulation echo the potential criticisms and limitations of therapy itself." (p.230)
This is a very worthwhile book, and could be a revelation to anyone reading it.
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19 of 23 people found the following review helpful:
5.0 out of 5 stars Case Formulation, 31 Oct 2007
By Eoin Stephens (Ireland) - See all my reviews
(REAL NAME)   
Case Formulation is defined by Persons (1989, p. 37) as "...a hypothesis about the nature of the psychological difficulty (or difficulties) underlying the problems on the patient's problem list". Case Formulation in psychotherapy appears to have developed out of the longstanding medical practice of Diagnosis-plus-Treatment-Planning, especially in a psychiatric context. It consists of a hypothesis concerning the aetiology and maintenance of the client's presenting problem(s) and, consistent with this, a plan as to when, where and how to intervene, with a view to bringing about some reduction in troubling symptoms. In therapeutic practice, the case formulation guides and structures the course of therapy by unifying and prioritising presenting issues, influencing the choice and timing of interventions, and predicting possible problems.

This book addresses the growing interest in this idea amongst counsellors and psychotherapists as well as psychologists and psychiatrists. The principal authors, both clinical psychologists, suggest that "Although it is arguably central to the implementation of any psychological intervention, it has until recently been a neglected area of research, training and publication" (p. 1).

They look at a variety of definitions of Case Formulation, and conclude that "...the common elements are that a formulation provides a hypothesis about a person's difficulties, which draws from psychological theory" (p. 4), and that its primary function lies in "...helping to select and guide the interventions" (p. 7).

Looking at case formulation from a variety of perspectives, including Cognitive-Behavioural, Psychodynamic, Systemic, Social Constructionist and Integrative, the authors explore such themes as

* Formulation and Collaboration
* Formulation and Reflective Practice
* Formulation and the Therapeutic Relationship
* Formulation and Context
* Formulation and Integration
* Formulation and Diagnosis
* Formulation, Evaluation and Evidence.

The authors apply the Case Formulation approach to two case studies from the perspective of each of these different schools. This brings the book to life, and makes it an interesting exploration of the current state of the various schools, along with the possibilities for integration.

The process of Case Formulation is of course not carried out explicitly in all forms of counselling/therapy. Rogers, for instance (1951, p. 223), considers that "a diagnosis of the psychological dynamics is not only unnecessary but in some ways is detrimental or unwise." He is concerned that the process of making a diagnosis leads to an inequality in the power dynamic between counsellor and client. However, all therapeutic intervention must presumably be based on some hypothesising and planning of the type outlined above, even if it remains implicit.

In contrast, Cognitive Behavioural Therapy, in my experience, is very comfortable with the Case Formulation process. At its simplest level a CBT formulation focuses on Negative Automatic Thoughts which are locked into vicious cycles with dysfunctional emotions, behaviours and somatic symptoms. It can also be expanded to include more ongoing dysfunctional underlying cognitions in the form of Assumptions and Core Beliefs.

According to Persons (1989) a cognitive case formulation should be

* arrived through collaboration between the therapist and the client
* readily understandable by clients
* grounded in empirical research
* open to disconfirmation
* parsimonious.


Johnstone & Dallos also outline the Case Formulation approach from a Psychodynamic perspective (focusing on Defenses, Capacity for Insight, Ego Strength, Capacity for Emotional Self-Regulation, Modes of Relating), and from a Systemic perspective (Deconstructing the Problem, Problem-maintaining Patterns and Feedback Loops, Beliefs and Explanations, Transitions, Emotions and Attachments, Contextual Factors).

Most interesting in relation to the theme of this issue of Éisteach, however, is their exploration of

* The Social Constructionist approach, which they see as "...a process of ongoing collaborative sense-making rather than one of developing objective or semi-objective descriptions..." (p. 102).
* The Social Inequalities approach, which focuses on questions such as who has power in relationships, and what discourses are at work in a particular case.



Overall, this is a timely, thought-provoking and useful book, for both students and experienced therapists.


References:
Persons, J.B. (1989) Cognitive Therapy in Practice: A Case Formulation Approach. New York: W.W. Norton.




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5 of 6 people found the following review helpful:
5.0 out of 5 stars One of the best recommendation I have ever had., 18 Jul 2008
By Lusitanian (Northampton, England) - See all my reviews
I was recommended this book by a friend and don't ever regret it. HAs become my best friend in my current job.
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