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Formulation in Psychology
and Psychotherapy

Formulation is attracting an increasing amount of interest in the

fields of psychology, psychiatry, psychotherapy and counselling.
Drawing on psychological theory, it attempts to examine a client’s
or family’s problems in terms of how they arose and what may
currently be holding them in place. It synthesises this information
and explanatory ideas into ‘working hypotheses’, which are then
used to suggest appropriate and effective ways of working to relieve
the problems. It can also be described as the key way of relating
theory to practice in clinical work.
Formulation in Psychology and Psychotherapy places this grow-
ing interest in formulation in a clinical and historical context. It
introduces the reader to the theory and practice of formulation
through the discussion of two clients (one adult and one
child), whose problems are formulated from the perspective of five
different therapeutic traditions: systemic, psychodynamic, com-
munity, cognitive-behavioural and social constructionist/narrative.
It looks at the growing trend for formulations that draw on two
or more therapeutic models and includes two chapters dealing
with integrative formulation. It offers some creative suggestions
for how this can be carried out in a way that is theoretically
coherent and clinically effective. The authors also explore the
important issue of formulation as a collaborative activity, and
consider the ethics of formulation. The final chapter takes a crit-
ical overview of the main research, controversies and debates in
the area, and gives a guide for using, developing and researching
formulation in a way that maximises its strengths while being
aware of its limitations.
The book is unique in including newer therapeutic approaches
such as narrative therapy and social inequalities. It critiques and
takes forward recent work on integration, and provides a lively and
challenging critical evaluation of the area as a whole. It guides
readers through a complex field in a clear, accessible and engaging
way. Both experienced and novice clinicians will be able to enhance
their clinical skills and theoretical knowledge.

Lucy Johnstone is a clinical psychologist and Academic Director of

the Bristol Clinical Psychology Doctorate. Her main interests are in
Adult Mental Health, and in psychological approaches to the more
severe forms of mental distress. She is the author of a number of
publications including Users and Abusers of Psychiatry, Adult
Mental Health (Routledge 2000), and is a regular speaker and guest
lecturer at conferences and training courses.
Rudi Dallos is Programme Director of the Plymouth University
Doctorate in Clinical Psychology. He is also a clinical psychologist
specialising in work with adolescents and their families, and his
clinical interests are in family therapy and attachment theory. He
has conducted and supervised research in these areas and is the
author of a number of books.
Formulation in Psychology
and Psychotherapy

Making sense of people’s problems

Edited by Lucy Johnstone

and Rudi Dallos
First published 2006
by Routledge
27 Church Road, Hove, East Sussex, BN3 2FA
Simultaneously published in the USA and Canada
by Routledge
270 Madison Avenue, New York, NY 10016
This edition published in the Taylor & Francis e-Library, 2006.
“To purchase your own copy of this or any of Taylor & Francis or Routledge’s
collection of thousands of eBooks please go to www.eBookstore.tandf.co.uk.”
Routledge is an imprint of the Taylor & Francis Group, an
informa business
Reprinted 2006
© 2006 selection and editorial material: Lucy Johnstone and Rudi
Dallos. Individual chapters: the contributors.
The right of Lucy Johnstone and Rudi Dallos to be identified as the
Author of this Work has been asserted by them in accordance with the
Copyright, Designs and Patents Act 1988
All rights reserved. No part of this book may be reprinted or
reproduced or utilised in any form or by any electronic,
mechanical, or other means, now known or hereafter
invented, including photocopying and recording, or in any
information storage or retrieval system, without permission in
writing from the publishers.
This publication has been produced with paper manufactured to strict
environmental standards and with pulp derived from sustainable
forests.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
Johnstone, Lucy.
Formulation in psychology and psychotherapy : making sense of
people’s problems / Lucy Johnstone and Rudi Dallos.
p. cm.
Includes bibliographical references and index.
ISBN 1-58391-899-X — ISBN 1-58391-700-4 1. Psychology—
Methodology. 2. Psychotherapy—Methodology. I. Dallos, Rudi,
1948– II. Title.
BF38.5.J64 2006
616.89'14—dc22
2005019377
ISBN13: 978-1-58391-899-9 (hbk)
ISBN13: 978-1-58391-700-8 (pbk)
ISBN10: 1-58391-899-X (hbk)
ISBN10: 1-58391-700-4 (pbk)
Contents

List of figures xiii

List of tables xv
List of contributors xvi

1 Introduction to formulation 1
LUCY JOHNSTONE AND RUDI DALLOS

Formulation in psychology and psychotherapy 1

What do we mean by formulation? 4
What is the purpose of a formulation? 5
Cognitive-behavioural 5
Psychodynamic 5
Systemic 5
Integrative 6
How did the concept of formulation arise? 8
Cognitive-behavioural approaches 8
Psychodynamic approaches 9
Systemic approaches 10
Other therapeutic traditions 11
Summary 11
Jack 12
Janet 13
References 15
vi Contents

2 Formulation in cognitive-behavioural therapy:

‘There is nothing either good or bad, but thinking
makes it so’ 17
ROBERT DUDLEY AND WILLEM KUYKEN

What is a cognitive-behavioural approach? 17

Formulating within a CBT approach 18
The empirical basis of CBT 19
The process of CBT formulation: the five Ps 20
Presenting issues: what are the problems? 21
Precipitating factors: what triggers the
problems? 22
Perpetuating factors: what keeps the problems
going? 23
Predisposing factors: what led to the problems
starting? 26
Protective factors: what are the person’s
strengths? 28
Practical aspects of formulation 28
Towards intervention 30
Jack: a cognitive-behavioural formulation 31
Presenting problems 31
Precipitating factors 32
Perpetuating factors 32
Predisposing factors 33
Protective factors 36
Towards intervention 36
Janet: towards a cognitive-behavioural formulation 39
Reflections 42
References 43
Further reading 46

3 Psychodynamic formulation: A prince betrayed

and disinherited 47
ROB LEIPER

What is a psychodynamic approach? 47

Core features of a psychodynamic approach 48
The dynamic perspective 49
 Contents vii

The developmental perspective 52

The structural perspective 56
The adaptive perspective 59
Jack: a psychodynamic formulation 61
A prince betrayed and disinherited 61
Reflection on the formulation 64
Towards intervention 65
Janet: a psychodynamic formulation 66
A girl unheld 66
Reflections 68
References 70

4 Systemic formulation: Mapping the family dance 72

RUDI DALLOS AND JACQUI STEDMON

The systemic approach 72

Symptoms and family processes 72
Exploration of the problem 74
Progressive hypothesising 75
Family therapy and social constructionism 76
A proposed model of systemic formulation 77
Jack: a systemic formulation 78
Mapping the family dance 78
Deconstructing the problem 78
Problem-maintaining patterns and feedback loops 80
Beliefs and explanations 81
Contextual factors 84
Summary 85
Synthesis and preliminary formulation for Jack 85
Janet: a systemic formulation 87
Deconstructing the problem 87
Problem-maintaining patterns and feedback
loops 89
Beliefs and explanations 90
Transitions, emotions and attachments 91
Contextual factors 91
Synthesis and preliminary formulation for Janet and
Mary 92
Comments 94
viii Contents

The politics of formulation 95

References 97

5 Social constructionist formulation: Telling a

different story 98
DAVID HARPER AND DAVID SPELLMAN

Social constructionism 98
Where did social constructionism come from? 98
What is social constructionism? 99
The influence of social constructionism on
therapy 100
Narrative therapy 101
Social constructionism and formulation 101
Case examples 102
Jack: a social constructionist formulation 104
Telling a different story 104
Externalising conversations: naming the
problem 104
Tracing the history of the problem 107
Exploring the effects of the problem 107
Situating the problem in context:
deconstruction 108
Unique outcomes 109
Re-membering conversations 111
Therapeutic documents 111
Expanding the conversation: leagues and teams 112
Outsider-witness groups and definitional
ceremonies 112
To formulate or not to formulate? 113
Janet: a social constructionist formulation 115
The context of the referral 115
Collaboration 115
Externalisation 117
Reflections 120
The need for critique and debate 120
References 121
 Contents ix

6 Social inequalities formulation: Mad, bad and

dangerous to know 126
JOE MILLER AND LYNN McCLELLAND

What is a social inequalities approach? 126

Formulating within a social inequalities model 131
Formulating power 131
Theory–practice links 131
Guidelines on formulation 132
Jack: a social inequalities formulation 133
Mad, bad and dangerous to know 133
Masculinity 137
Delusions, lies and stereotypes 139
Janet: a social inequalities formulation 141
The socio-economic context 144
Formulation from a social inequalities perspective:
some guidelines 146
Towards intervention 147
Reflections 148
References 149

7 Integrative formulation 154

RUDI DALLOS, JOHN WRIGHT, JACQUI STEDMON AND
LUCY JOHNSTONE

Integrative formulations 154

Approaches to integration 154
Off the shelf 155
Aptitude–treatment mix (A–T) 155
Idiosyncratic formulation 156
Key differences 156
Implicit integration 157
Integration strategies 159
Making conceptual connections 159
Making practical connections 159
Weerasekera’s integrative formulation 159
x Contents

Jack: an integrative formulation 162

Predisposing factors 162
Precipitating factors 163
Perpetuating factors 163
Protective factors 164
Coping styles 165
Reflections on the model 165
Advantages 165
Disadvantages 166
Extending the integrative model 167
The therapeutic relationship in ‘live’
formulation 167
Reflexivity 168
The choice of models 168
Certainty and pattern matching 169
Collaboration 170
The context in which we practise 171
Summary 172
A contextual-dynamic view of integrative
formulation 172
Contexts 172
Who does the formulating? 174
Gathering information actively 174
Feedback 177
Confirming and disconfirming evidence 177
Summary 179
References 179

8 Integrative formulation: CAT and ANT 182

RUDI DALLOS

Introduction 182
CAT formulation 182
Personal construct theory (PCT) 183
Procedural sequence model (PSM) 184
Systemic theory 185
Object relations theory 185
Reciprocal role procedures (RRP) 186
 Contents xi

Narrative approaches 186

Jack: a CAT reformulation 187
ANT formulation 191
Integration based on the strengths and limitations of
models: complementing and compensating 192
Systemic therapy 193
Narrative therapies 194
Attachment theory 195
Formulating within ANT 197
Individual level 197
Interpersonal level 197
Socio-cultural level 197
JACK: an ANT formulation 198
Attachments and narratives 198
Attachments and systemic processes 201
Cultural contexts and narratives 202
Integration 203
Implications for intervention 205
Overview 206
References 206

9 Controversies and debates about formulation 208

LUCY JOHNSTONE

Jack and Janet: the formulations 208

Formulations: a central process in the role of the
scientific practitioner? 209
Formulations: truth versus usefulness 210
Formulations: useful to whom? 212
Useful to the client? 212
Harmful to the client? 213
Useful to the therapist? 217
Useful to professions? 218
Formulation versus diagnosis? 220
Are formulations individualising? 224
Can anyone make formulations? Do we need them
at all? 226
So what are formulations then? 228
xii Contents

Summary 230
Jack and Janet: an update 231
References 232

Index 237
Figures

2.1 An illustration of the ABC model 23

2.2 Perpetuating factors 24
2.3 An illustration of a longitudinal formulation 29
2.4 Jack’s presenting problems 33
2.5 A cross-sectional model 34
2.6 Jack’s longitudinal formulation 37
3.1 The triangle of conflict 50
3.2 The triangle of person combined with the triangle
of conflict 55
4.1 Many problems arise from the failing solutions
applied to difficulties 74
4.2 Genogram of Jack’s family system 79
4.3 Circularity: mixed feelings 81
4.4 The transition to a family–hospital system 84
4.5 Process maintaining the definition of Jack as ‘ill’ 84
4.6 Family therapy and reflecting teams – sharing
formulations 86
4.7 Janet’s family tree 88
4.8 Problem-maintaining cycle between Janet
and Mary 89
4.9 Professional–family dependency cycle 92
4.10 Escalating pattern of distrust between Mary and
social services 95
6.1 Working model: mapping social inequalities 128
6.2 Mapping sources of social inequalities for Jack 138
7.1 A contextual-dynamic view of integrative
formulation 173
7.2 Formulation eco-map 176
8.1 Procedural sequence for Jack 188
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Photo 18

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