In addition to my most typical work and in a separate part of the role, I also support the psychological consultation pathway for looked after children in residential care homes. This has given me the opportunity to observe and be a part of the assessment and formulation process as part of their care plan which is shared with their care staff.
So, what is Formulation? It feels like the buzz word in psychology and something that is will evidently attract your attention at some point during your career. Formulation is a collaborative approach in reaching an understanding of the emotional distress and/or behaviours to arrive at a treatment plan and it is fundamental in a Clinical Psychologist’s role. In layman’s terms, it is a framework for considering what has happened to a person and how they have arrived at their current concern. It allows us to explore the individual’s difficulties and subsequently link theory to practice and how help can best be implemented. It utilises and summarises all information gathered from assessment and allows the client to understand their experiences from a psychological perspective. It is done directly with the client or their care team and it is a work in progress to inform the intervention and can be done in a person-centred way. It is consistently revisited and so reformulation takes place regularly.
There are different modalities to how formation is delivered, however the most common is the cognitive-behavioural model of formulation using the ‘5 P’s’. This consists of:
Presenting problem – presenting thoughts, emotions, and behaviours
Precipitating factors – the factors that triggered the above concerns
Perpetuating factors – the factors that maintain the current issue
Predisposing factors – the factors that increase a person’s susceptibility to the current issue
Protective factors – the persons strengths / positive that help them maintain good emotional health
My experience of formulation is to inform the care plan for looked after children. My role consists of gathering background information from the referral and why the child has been placed into care. After allowing some time to settle, I meet with the child to complete some screening psychometrics to assess their mood and resilience and deliver a cognitive assessment to gather a picture of their strengths and weaknesses. I ask their care and teaching staff to also complete some adaptive functioning measures to gather current information regarding the presentation of the child.
An example of this may be that 14-year-old young person has arrived into care due to displaying increasingly challenging behaviours, which the family and school were no longer able to manage. The family consider that the young person has always been a ‘difficult’ child, however things had escalated since moving to her father’s full time three years ago. Residing at home was no longer an option due to increasingly negative behaviours, missing from home episodes, drinking alcohol and risk taking with unsuitable peers.
Background information also tells us that there were previous concerns surrounding neglect, domestic violence, lack of supervision and being in the company of risky adults when she previously lived with her mother.
As part of the formulation meeting, it became apparent that the young person’s behaviour and psychological distress were the strongest concerns (presenting). History suggests that her early experiences did not provide her with predictable and attuned care, appropriate boundaries, or reliable adult supervision (predisposing). Subsequently, as she was attempting to get her needs met, she discovered maladaptive ways of doing so by displaying attention seeking behaviours. She had not experienced what should be expected regarding boundaries and consequently, she was reacting to them to test them (precipitating). Additionally, there were other young people within in the placement, so she felt that she had to compete for staff attention (perpetuating). Although she was having difficulty in regulating her emotions leading to disruptive behaviours, she was starting to respond well to boundaries in place from her care team and was occasionally showing some remorse following her outbursts (protective factors).
Subsequent to the above collaboration, the formulation process allowed an understanding of where the behaviours were coming from and helped staff understand her needs and how best to implement suitable targets. This is a prime example of how Clinical Psychology works from a leadership perspective, as appose to direct 1:1 work.
Advice – If you are working under the supervision of a Clinical Psychologist, this is highly likely a part of their role and so consider asking if you can be a part of this process. Whether that is sitting in on a multi-disciplinary meeting or if this is not an option ask to work through the formulation process with your supervisor away from the client / meeting. Alternatively if you are working directly with clients (and it is appropriate and supervised) consider how you would apply the same process to your work. Failing these options, do some background reading around the topic and familiarise yourself with the process, in preparation for when the opportunity arises.