Evaluating the Adequacy of a Psychological Formulation
Critical realism is a philosophical position, not a model or theory. But that position allows counselling psychologists to check the adequacy of their preferred model or theory when creating and revising formulations about their clients. This checklist can be compared and contrasted with the criteria for a good medical diagnosis described in the core chapter. Three main headings are used below linked to the main premises of critical realism (epistemological relativism, ontological realism and judgmental rationality).
- How does the client understand their problem?
- How does your frame of reference, routine working assumptions, model or theory selectively attend to and modify their understanding?
- What alternative perspectives are implied, in the light of answers to questions 1 and 2?
- What shared cultural resources exist between you and the client to enable a consensus of understanding?
- What cultural differences might exist to disable that consensus-building with the client?
- What has happened to the client in their life, according to their report, which might be relevant to your formulation?
- Do you have any other information (for example from third parties or pre-existing case notes) that might have a causal relevance, when making your formulation?
- What limits exist – for you and the client – in establishing what has happened in their life that is of relevance to your formulation: what might you be ignorant about that is of importance?
- How does your own biographical background (especially your age, race, class, gender and family experience) affect your ability to develop empathy (in relation to questions 1–5, above) and a full and nuanced grasp of the client’s life and account of their life?
- When making causal claims in a formulation, what are the sources, if any, of your corroborating evidence (see question 7) and what is your confidence in the latter?
- Given your answers to all of the above questions, what is your best educated guess about why this person is presenting with these problems at this particular point in his or her life?
- When you share this formulation with them, do you know why you are working with them to change, and do you understand your motives for that shared pursuit?
The above checklist will only make sense to you if you are committed to combining elements of causation and meaning in your preferred way of creating formulations about your clients. If you are committed in this way then the list is a reminder of how to appraise the strengths and limitations of your work. Given that a formulation is always more than the client’s own monologue about their life and its difficulties, because it emerges from a particular dialogue, then your contribution is as important to consider as their own. Not only will they have a particular view but so will you: epistemological relativism is pertinent then to both parties in the generation of any formulation.
In addition to this point though, both you and the client exist in a set of real social relations in the present and have been affected by those of the past. Your life situation and background (not just the psychological model you deploy in your work) sensitises you to the life of the client. And with that degree of sensitisation comes points of ready empathy and clarity, as well as points of inevitable ignorance, confusion or perplexity on your part. Moreover, your access to corroborating material about their life circumstances is always limited by the empirical evidence available to you – from them directly or from other sources. Because you do not know what you do not know, this aspect of producing a formulation is a form of absence that is inevitable and so implies the need to proceed cautiously in your sense-making. If our experience and behaviour emerge from a complex set of dynamic processes in an open system (a core assumption of critical realism) then it is not possible for any of us to offer a completely comprehensive formulation of the biological, psychological and social factors of relevance in a particular case. A partial view is always inevitable; formulations are inevitably incomplete accounts.
Finally then, in the light of these strengths and limitations of your particular version of educated guess-work, when offering a particular formulation about a particular client (or family or group if that is your mode of work), then the last set of questions about judgmental rationality are relevant. Your evidence is limited. Your model shapes this way of understanding and not another. Your value system shapes not only how you are selectively attending to the communications of the client but which goals you consider are worthy in the relationship. Good will, good faith and good judgment interplay in this part of your reflection about your way of formulating the psychological problems of others. This is a value-saturated activity and so psychological formulations, like their implied or incipient psychological interventions, can be reflected upon with the answers to my final questions on the list in mind.
If critical realism rejects diagnostic psychiatry as a pseudo-science, then the offers of improvement from psychological formulations are implied as preferred alternatives. But in turn, the adequacy of those formulations can be tested out by applying the checklist I offer above, supported by the premises of critical realism, which reconcile epistemological relativism, ontological realism and judgmental rationality. Formulation is consistent with the method preferred by critical realists of ‘retroduction’ – basically the sort of detective-, or educated-guess-, work referred to in the checklist above. Like all versions of retroduction, formulation is a useful but fallible human activity.