Constructing Stories, Telling Tales: A Guide to Formulation in Applied Psychology

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Formulation remains one of the most important activities that those using psychological approaches undertake as part of their work. Arguably, however, formulation is an activity that remains poorly understood. In a current climate demanding quick fix solutions there is a tendency, which the authors refuse, towards over-simplification. Instead this book sets out to explore the challenging complexity of psychological formulation.By drawing on a wide range of sources from psychology and the arts the authors find ways to honour the stories clients tell yet offer key psychological insights to facilitate change. They provide a clear guide to enable the reader to think about the purpose of their work with clients, the perspectives which inform it and the process used to ensure effective outcomes.The chapters, supported by exercises on key issues, examine key debates on the role of formulation in professional practice, a framework for developing a systematic approach to formulation and a detailed account of the purpose, perspective and process of formulation. Guest contributions are included from various fields of practice including: clinical, coaching, educational, forensic, occupational, and from the arts.The book will enable all practitioners (whatever the stage of their career) who need to work with client stories to find new ways to enhance their practice.

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Chapter One: Case formulation and its role in professional practice

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“Case formulation is not a treatment procedure. It is a method for understanding the patient and their problems that allows for the selection and design of treatment procedures based on the knowledge of their case”

(Adams, 1996, p. 78)

“The significant problems we face cannot be solved at the same level of thinking we were at when we created them.”

(Einstein, 1879–1955)

Formulation is deemed to be a cornerstone of skilled psychological practice and, over the course of our careers, much time will be spent engaged in the process of making sense of the psychological puzzles that confront us. However, the ability to master this skill is confounded by a range of factors. These include the myriad and often complex reasons for which clients seek help, implicit agendas driving the request for help of which the practitioner may not be aware, and the extent to which individuals are able to identify, describe, and address their needs within a psychological framework. Similarly, practitioners vary in how they approach a client enquiry in terms of prior training and experience, theoretical preferences, and their level of interpersonal and conceptual skill. All factors play a critical role in decision making and represent potential obstacles to arriving at a clear and useful account of a client’s circumstances and needs.

 

Chapter Two: A framework for formulation: purpose, perspective, and process

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“The struggle is to find a way of seeing things that helps”

(Butler, 1998, p. 21)

“… we can trust that together we can create a rich mosaic from all our unique perspectives”

(Wheatley, 2001a)

As a listener, the psychologist’s first duty is to ensure that the story-teller feels heard, that the story is recognized and accepted: to be, in effect, an appreciative audience. However, the teller is also seeking assistance from the psychologist to unravel the puzzle or to solve it with them, not just to be an appreciative audience. The psychologist, therefore, becomes a partner in the story as the client seeks to identify and understand their concern—a journey towards a shared understanding of causation, maintenance, and/or change. This journey may be with an individual seeking personal guidance, a team seeking higher levels of performance, or an organization seeking a strategic change of direction. However, in seeking help from a psychologist, the client is assuming that a psychological perspective on the puzzle is relevant.

 

Chapter Three: Defining the purpose of the enquiry

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“One who ignores context, circumstances, consequences, events, objects, and various social structures and systems risks ignoring a lot”

(Hoyt, 2000, p. 23)

“Stories of past ages live through us and make us aware and blind; competent and incompetent within the limits they define”

(Mair, 2000, p. 343)

Having introduced the purpose, perspective and process model as a useful decision framework (Figure 3), we now consider the first component—purpose—in greater detail and explore some of the factors that shape how this is determined. We begin by describing what is meant by purpose, and then consider some of the dominant influences that shape, if not determine, how practitioners define this in the context of a particular client enquiry. Specifically, we propose that professional practice is bound by three over-arching levels of influence: the local, the national, and the global, which form the professional landscape in which practitioners think and operate and which confer particular identities and roles.

 

Chapter Four: Identifying the perspective that informs the journey

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“It is the theory which decides what we can observe”

(Einstein, cited in Hebb, 1975)

“Men in search of a myth will usually find one”

(Native American Proverb, cited in Zona, 1994, p. 112)

In Chapter Three we made the case that our interventions do not take place in a context that is socially and politically neutral, but, rather, that our decisions are shaped—with or without our awareness—by the dominant local, national, and global influences in which we are immersed. These levels of influence further shape our practice through equipping us with what we might term a “legacy of tales”. As the inheritance of our local, national, and global scripts, these tales represent the perspectives through which we come to understand our clients’ needs and, as such, both inform and structure our practice.

Figure 4. The purpose, perspective, and process model.

In this chapter we consider the perspective component of the purpose, perspective, and process model (Figure 4) and how the perspective chosen influences the course of the enquiry that unfolds. We begin by briefly recapping on what we mean by “perspective,” and then identify and examine what we believe are five perspectives that currently dominate how practitioners approach the task of formulation. Each of these perspectives (tales) has become powerful across a range of psychological interventions that span the clinical, educational, forensic, and occupational professions, as well as newer areas such as business, sports, health, and coaching psychology. They also operate in parallel professions, including counselling, psychotherapy, human resource management, and business consulting, as well as in older professions such as medicine (including psychiatry and general practice).

 

Chapter Five: Devising a process that is fit for purpose

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“… all of life comes to us in narrative form; it’s a story we tell”

(Zander & Zander, 2000, p. 9)

“The one who tells the stories rules the world”

(Native American Proverb, cited in Zona, 1994, p. 90)

Once the purpose of the work has been established, and the perspective that underpins it is clear, then it is possible to structure a process for the work that is to take place (Figure 5). Without the purpose and perspective being clearly defined, the process runs the risk of becoming a technical application uninformed by a sophisticated understanding of psychological principles, theory and research.

Figure 5. The purpose, perspective, and process model.

Devising a process that is fit for purpose presents a confection of choices. Decisions must be made about the type of information needed and where to “pitch” data-gathering efforts. For example, should the practitioner prioritize an understanding of the client’s subjective experience, or aim to develop a symptom profile? What weight should be given to predispositional as opposed to maintaining factors? Is it preferable to focus on understanding the influence of constitutional (personality or traits) or variable (state) factors? Should the focus be on the personal, interpersonal, or systemic? In light of these factors, decisions must also be made about the most appropriate procedures and methods to use (e.g., should self-report data be the primary source of information, or are observational methods to be preferred? Are interview procedures sufficient, or is psychometric testing required?). Finally, choices must be made concerning how the information obtained will be synthesized into a meaningful explanatory account that has implications for the client’s future. In this context, critical questions (which we suggest might be usefully considered as preparation for this chapter) include the following.

 

Chapter Six: Introducing our guest contributors

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In this section, we provide a series of illustrations of some of the different ways in which formulation can be approached through the chapters of our guest contributors. It should be noted that it is not our intention to represent all forms of applied practice, as there are too many to do justice to them all. Moreover, to lay claim to any degree of representativeness would be problematic, as there is increasing variation among practitioners within these same disciplines. The chapters from our guest contributors are not, therefore, offered as statements about the position of a particular discipline on the formulation debate, but, rather, examples of what it means to engage with the task of formulation. Varied in subject matter, work context, and approach to investigation, each author represents a different “strand” of professional practice and shares their own approach to working with purpose, perspective and process, however tightly or loosely defined.

The first of the chapters in this section comes from Michael Sheath. Working in the context of assessing adults who sexually offend against young people, his approach to formulation is couched in an awareness of society’s strong negative reactions to perpetrators and the potential costs of formulating risk incorrectly. Sheath describes some of the dilemmas facing the practitioner whose responsibility to client, victim, and society is to assess and formulate accurately, but who must do so in the absence of a suitably robust knowledge and evidence base. His chapter considers how, in this setting, formulation might be both scientifically rigorous and grounded in humanistic engagement.

 

Chapter Seven: Case formulation: the dilemmas posed by child sex offenders

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Michael Sheath

Case formulation in cases where children’s sexual safety is at stake is neither morally neutral nor emotionally disconnected. Child sex offenders evoke extraordinarily strong feelings in most individuals and communities, and those who assess and attempt to manage their current and future dangerous-ness do so in a climate that is unforgiving and hyperbolic. The assessor is required to make a judgement, or to assist others to make a judgement, where the consequences of an error and faulty formulation are life changing.

A conservative approach, where the assessor always operates on the side of caution, can result in children being removed from home, or a father being removed from his children’s lives, when the potential risk posed may have been entirely manageable. This approach simply transposes one real harm for an imagined one: children raised in Local Authority care do not necessarily prosper, nor do children brought up in the absence of a father who has been wrongly but conservatively labelled as a paedophile. On the other hand, and in risk assessment there almost always is one, an assessment that fails to recognize inherent and predictable risk can lead to the sexual abuse of a child, with all the contingent trauma and psychological harm that entails. “False positive” and “false negative” risk assessments can flow from a failure to identify relevant features in the case, or to lay too great an emphasis upon features that are actually of no consequence in predicting risk.

 

Chapter Eight: Every child does matter: preventing school exclusion through the Common Assessment Framework

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Peggy Gosling

Exactly thirty years ago, I obtained a post in an inner city primary school with the dubious title of Disruptive Teacher. While I was clear that I would be looking to prevent rather than create disruption, how I would go about that task was less certain. During the next few months, I met a motley assortment of children described by their teachers as sad, mad, or bad, for whom all strategies had apparently failed. I was asked to “do something” about them. But what was it I was meant to be doing? What could be done to make a difference in these children’s lives? My subsequent career as an educationalist and academic has been devoted to answering these questions. My purpose in writing this chapter is to reflect on that experience, considering the following factors.

•   The social, emotional, and behavioural difficulties associated with disruption and disaffection are the most challenging problems in education. Children and young people presenting such problems are the one group who are permanently excluded from school in large numbers year on year. Our continuing failure to address these problems seriously diminishes the life chances of these children, having a negative impact on their families, communities, and society as a whole.

 

Chapter Nine: The role of formulation in cognitive–behaviour therapy: a concept hidden in plain view?

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David Leigh-Smith

The niche occupied by case formulation as an essential cornerstone in cognitive–behaviour therapy is almost universally acknowledged within contemporary literature. The therapist’s ability to synthesize a clear, valid, and testable narrative from the assessment process has long been lauded as an indispensable component of therapeutic success. However, the empirical evidence to support this status over the past decade has been ambiguous, and there remains considerable debate regarding the clinical significance of formulation. This chapter will examine the scope that exists to standardize aspects of case conceptualization and describe how this elusive concept can be more scientifically studied and taught.

A great deal has been written by noted authors regarding the significance and influence of case conceptualization within cognitive–behaviour therapy (Beck, 1995; Bieling & Kuyken, 2003; Needleman, 1999; Persons, 1989). The consensus within the available literature demonstrates that this process of reviewing the patient’s story through a “corrective lens” is an elementary component in the empirical status of CBT (Beck, Freeman, Davis, & Associates, 2004; Eells, 1997; Persons, Mooney, & Padesky, 1995). However, if case formulation is to continue in its position as one of the underpinning structures of CBT, there are several questions that require examination regarding the validity and meaning of this long established practice. Considering the almost unanimous popular appraisal of case formulation within the CBT literature, one could legitimately ask why is it so often described in indefinable terms. What reasons do therapists give for formulating cases, and what are they looking for when they do so? Does conceptualization have any impact on the client and the process of therapy?

 

Chapter Ten: Existential formulations of therapeutic practice

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Michael Worrell

“The therapeutic situation is what it shows: two people concerned with the story of one of them. There is no ‘deeper reality’ behind it”

(Cohn, 2002, p. 78)

Existential therapy is characterized by a strong tradition of sceptical engagement with the fundamental and basic beliefs of psychotherapy. At present, the belief that “formulations,” and the activity of “constructing formulations,” is at the heart of effective psychotherapy and one of the essential skills distinguishing the skilled and well-qualified therapist is one such fundamental belief.

Across currently dominant models of therapeutic practice, it is believed that for effective “treatment” of a patient’s or client’s “symptoms” or “problems” to occur, the therapist must conduct an adequate assessment leading to the construction of a more or less complete formulation of the client’s difficulties. The formulation will be based upon the therapist’s currently favoured theoretical models and assumptions (it would be unusual for cognitive therapists to employ notions of the Oedipus complex in their formulations, or for Kleinians to be overly anxious to distinguish levels of meta-cognition for instance), themselves based upon the therapist’s biases regarding theories and, possibly, currently available research findings. The formulation is ideally the way in which the therapist applies the theory to the specifics of the client’s situation, so that clear hypotheses can be formed as to appropriate therapeutic techniques that will lead to problem resolution. This is so regardless of whether the goals sought are framed in very broad strokes, such as “making the unconscious conscious,” “arriving at a more adequate, flexible, and positive life narrative,” or in far more specific or operationalized terms, such as “achieving a reduction in the frequency of negative automatic thoughts”. The degree of success following these interventions is then commonly taken as evidence of the veracity of the therapist’s formulations.

 

Chapter Eleven: What story are you in? Four elements of a narrative approach to formulation in coaching

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David B. Drake

Robert (in order to ensure confidentiality, all names and any potentially identifying features have been changed), a quiet, middle-aged man, calls your office saying that he may be interested in working with you as a coach. In speaking with him, you get a sense that he is somewhat depressed. He has tried for six months to find a new job but, even with his credentials, he has yet to find one. Being out of work has created friction with his wife, and he has noticed a lack of energy lately. However, he is also adamant that he does not need to “see a shrink” because he knows that all he needs is to find a new job. As a busy coach, you ponder whether to take him on as a coachee, or refer him to someone else. As you ponder, the formulation process has already begun, as you and the potential coachee each form a story about the other and decide whether or not to work together.

However, at this point, what do you or Robert really under-stand—at a conscious, verbal level, at least—about why he cannot find work, what he truly needs, and how best to serve him? Is it about a deep personal issue, for which a psychotherapist would be helpful? Did his wife stop having sex with him when he lost his job because of the lost masculinity and status in her eyes, in which case a couples’ counsellor would be useful? Is his skill set no longer marketable in his geographic area, and, therefore, he needs a head-hunter to help him relocate? Does he need a more general focus on vision setting and goal attainment from a life coach? Is he having a midlife existential crisis, for which a spiritual director would be appropriate? And this is just one of the facets of the presenting story; it does not begin to address the possibilities within the narrative of “depression,” for example.

 

Chapter Twelve: Fabricating fictions, telling tales

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Bryan Rostron

“God created man because he wanted to listen to stories”

(Barney Simon, founder of the Market Theatre, Johannesburg)

Let me tell you a story I have long wanted to write, either as a novel or a play, but probably never will. It is about Wilhelm Bleek, his sister-in-law Lucy Lloyd, and a small group of what were then known as Bushmen, including //Kabbo and Dia!k-wain (the symbols //, /, !, and # denote different linguistic clicks in the /Xam language), who lived together in a small thatched cottage in Cape Town in the 1870s. Bleek was a German philologist who realized that these indigenous hunter-gathers, today known as the San, were being wiped out. The San were often hunted like wild animals, and then sometimes were even stuffed, or their heads were mounted as trophies. In a doomed fight against colonial dispossession, hundreds had been sentenced to forced labour in Cape Town harbour. Wilhelm Bleek obtained permission from the British Governor for two members of the /Xam group to be placed in his custody.

 

Chapter Thirteen: Acting as narrative

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Simon Callow

When faced with a play, a screenplay, or any other text that requires performance, an actor is faced with a swirling mass of impressions: of language, of emotion, of character, of argument, of style, of shape. But the first, all-important and insistent question is: what is the story? What is being told? What is being shown? Actors are taught to confront their work with a series of questions: who, what, where, why, initially, then more complex formulations such as, what does the character want? What is his thrust through the play? What is his purpose in life? And so on. But first, middle, and last is the question of story: what happens to the character during the play? How is he different at the end of the play from the way he was at the beginning?

It would seem that these are very straightforward questions, but that is far from the case. First, a play or a screenplay constitutes the tip of an iceberg. They record what the character says; they also show what he does—hitting, hugging, smashing, building. They show us certain moments in the character’s life. But they do not, inherently, tell us why the character does these things or says these things, nor do they show us their whole lives. Nor do they offer, as a novel might, a commentary on those characters. There is no author to tell you what to think, and anything that other characters may say about them is by no means trustworthy. As in a criminal case, witnesses may be hostile, prejudiced in their favour, or simply unreliable. The actor needs to delve, to discover, to intuit. Moreover, the further the play is from us in historical time, the harder it is to penetrate. Above all, what we are looking for is a sort of logic. A coherence. A clarity. Not, of course, in the sense of being rational: behaviour and, indeed, character is often highly irrational. What we are after are the rules that govern the behaviour of this individual, the structure that makes a person function, just as a botanist or a biologist would be looking for the cell structure. You might say, on the one hand, that we are looking for the inside story; on the other, we are looking for a recognizable pattern of behaviour that makes sense.

 

Chapter Fourteen: Understanding character: an actor's approach to formulation

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Sarah Corrie and David A. Lane, in conversation with Prunella Scales and Timothy West

In this chapter, we have three principal goals. The first is to chart how a conversation between the four of us (Scales, West, Corrie, and Lane) elicited particular themes that confront Scales and West as professional actors when approaching the task of portraying a character. (For the purposes of this chapter, the terms “portraying a character,” “understanding character,” and “formulation” are used interchangeably.) The second is to identify themes that might represent shared concerns between actors and those working in the psychological disciplines. The third is to identify methods that professional actors use to understand a character and to consider how, if at all, these methods might be used to support, critique, or refine psychology practice.

In order to capture the richness of the ideas that emerged, as well as the conversational mode of data gathering employed, we found it helpful to adapt Gergen and Davis’s (2003) framework, organizing our discussion into what we term “conversational themes”. These conversational themes, illustrated by direct quotations, represent distinct and recurring motifs that appeared to have a critical importance for how Scales and West made sense of their work. We summarize each theme by highlighting key issues and seemingly shared dilemmas, concluding with some specific questions that we believe are worthy of further scholarly investigation. A summary of the conversational themes is provided in Table 5, as a means of navigating the chapter.

 

Chapter Fifteen: Creating stories for complex times

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Sarah Corrie, David B. Drake, and David A Lane

“… individually and collectively we have the ability to construct our own futures, albeit in circumstances not of our own choosing”

(Stephen Rose; cited in Lane & Corrie, 2006, p. 186)

“I am because we are”

(Mpofu, 2009)

Our starting point for this chapter is that knowledge gained in one domain of practice has the potential to be applied to another domain, even if the process of doing so poses conceptual and practical questions. As we see it, there are many potential ways of working with the material provided by our contributors.

Our aim in this chapter is to identify the recurring themes offered by our guest contributors and to consider how awareness of these themes might assist us in responding to an uncertain future for our professions and our clients. Working with these themes enables us to develop, critique, and refine our individual approach, as well as offer anchor points for the future. In particular, these themes can be categorized to assist in the process of devising appropriate and effective narratives in the wake of some shared concerns for our respective practices. Despite representing a diverse set of disciplines and professions, these themes can, we believe, inform a broader understanding for all psychologically-based professionals who work with stories.

 

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