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Behavioural and Cognitive Psychotherapy, 2000, 28, 307–310
Cambridge University Press. Printed in the United Kingdom
EVOLVING FORMULATIONS:
SHARING COMPLEX INFORMATION
WITH CLIENTS
Peter Kinderman
University of Liverpool, U.K.
Fiona Lobban
University of Manchester, U.K.
Abstract. Psychological formulations are central to cognitive behavioural approaches. The
use of such formulations presents a number of difficulties when working with clients with
psychotic problems. Despite this, sophisticated psychological formulations can be collaborat-
ively developed with psychotic clients. This paper presents one method of developing such
formulations through an evolutionary process. Early in the therapeutic process, simple for-
mulations involving straightforward theoretical models are presented, which are systematic-
ally elaborated as therapy proceeds. This involves developing, collaboratively with clients,
successive layers of formulation. Each of these layers builds on and incorporates the previ-
ous one, yet involves an incremental increase in complexity, depth and informational con-
tent. The evolutionary process is illustrated with a case example.
Keywords: Formulation, cognitive therapy, psychosis, complexity, information.
Introduction
Formulations in clinical psychology
Psychological formulations are central to the science and practice of cognitive behavioural
interventions (Persons, 1989). Formulations are more than simple enumerations of problems
and cognitive processes. They are designed to link theory with phenomenology, and provide
a theoretically valid framework for understanding and explaining the mechanisms and pro-
cesses underlying the observed problems in a particular case (Persons, 1993).
Developing collaborative cognitive behavioural formulations with clients with psychotic
problems may be difficult. Individualized psychological case formulations are highly com-
Reprint requests and requests for extended report to Peter Kinderman, Department of Clinical Psychology, Univer-
sity of Liverpool, Whelan Building, Quadrangle, Brownlow Hill, Liverpool L69 3GB, U.K.
E-mail: p.kinderman@liverpool.ac.uk
2000 British Association for Behavioural and Cognitive Psychotherapies
P. Kinderman and F. Lobban308
plex, and change as the clinician gathers information about the client (Brewin, 1988). Both
the complexity and the changing nature of formulations may present difficulties for psych-
otic clients, who frequently demonstrate deficits in abstract reasoning, mental flexibility and
comprehension (see David & Cutting, 1994).
Evolving formulations
A model of ‘‘evolving formulations’’ is proposed. Formulations can, and should, be
developed and presented sequentially and progressively. Simple preliminary formulations
should be developed and presented to clients early in therapy. An evolution from simple
but comprehensible and basic to elegant, idiosyncratic and detailed is then possible. This
aspect of cognitive behaviour therapy is useful in therapy for all kinds of problem. It is an
implicit element in many accounts of cognitive behavioural practice, but has not been widely
discussed. The processes and benefits of evolutionary development of individual case formu-
lations will be illustrated with a case example.
Case example
Mr Farmer was a 19-year-old man admitted to a psychiatric intensive care unit following
increasingly bizarre behaviour. This had culminated in Mr Farmer being found naked and
incoherent, apparently responding to auditory hallucinations and having defecated on the
floor of his living-room.
Assessment with standardized measures confirmed the psychiatric opinion that Mr Farmer
was suffering from some form of psychotic problem, characterized by anxiety, auditory
hallucinations, paranoid delusions and mild thought disorder. Mr Farmer was also intrusive
in his behaviour with staff on the unit, apparently highly needful of attention and reassur-
ance.
Cognitive behavioural therapy was initiated. In line with the specific point of the present
paper, an initial formulation was collaboratively developed. This initial formulation com-
bined a normalizing rationale (Kingdon & Turkington, 1994) with the stress-vulnerability
model (Zubin & Spring, 1977). It is illustrated graphically in Figure 1, section 1. This is
the format in which this formulation was shared between the therapist (FL) and Mr Farmer
and was intended primarily as a ‘‘seed’’ for further evolution. Nevertheless, even this had
clinical benefits. Mr Farmer adopted a stress-management approach to his auditory hallu-
cinations, and began to discuss in depth aspects of possible psychosocial and biological
vulnerability factors, potential stressors and the nature of his psychological problems. This
allowed further evolution of the case formulation, and permitted greater collaboration
between psychologist and client.
Mr Farmer discussed with the therapist a number of potential vulnerability factors. These
included possible biological elements; a history of emotional and psychiatric problems in
both aspects of his family and his own perceptions of his sensitive nature. Mr Farmer also
discussed psychosocial vulnerabilities, including his cultural background (he came from a
mixed English and AfroCaribbean background but felt alienated from black culture).
Mr Farmer also described possible stressors. In particular, two distressing episodes were
discussed: an episode of inappropriate sexual behaviour between Mr Farmer and his younger
sister, and an episode of unwanted sexual contact with an older adult known to Mr Farmer’s
Evolving formulations 309
Figure 1. Example of an evolving formulation
P. Kinderman and F. Lobban310
family. Within this context, Mr Farmer was able to discuss the consequences of the interac-
tion between vulnerability and stress. For Mr Farmer these were feelings of anxiety, guilt
and confusion, the experience of distressing intrusive thoughts related to themes of abuse
and the misattribution of some of these thoughts as voices. These elements of Mr Farmer’s
evolving formulation are illustrated in Figure 1, section 2.
On the basis of this second evolution of Mr Farmer’s formulation, an attempt was made
further to formulate the processes fuelling his intrusive thoughts and quasi-hallucinations.
On the clinical and interpersonal level, the ensuing discussions focused on Mr Farmer’s
behavioural and cognitive responses to intrusive thoughts, auditory hallucinations and
related distress. The third stage of Mr Farmer’s evolving formulation is illustrated in Figure
1, section 3. This developed Mr Farmer’s understanding of the nature of his difficulties,
especially the way in which his understandable responses to disturbing experiences may, in
fact, have made matters worse. An intervention strategy, addressing these metacognitive
beliefs and attempted coping responses, was initiated. Later in the therapeutic contact, this
was coupled with work to identify early warning signs of relapse.
Discussion and conclusions
Adapting the benefits of systematic individual psychological case formulations to the
demands of cognitive behavioural work with psychotic clients is difficult but rewarding. We
present, in this paper, a suggestion that formulations be developed and presented as they
evolve. Interventions evolve in parallel. We do not suggest that these ideas are revolutionary.
It is probably the case that the advice in the present paper is, itself, a natural evolution of
the use of case formulations easily recognized by clinicians. Many clinicians already work
with evolving formulations. This paper highlights the need to do so and the potential advant-
ages of this approach.
References
Brewin, C. (1988). Cognitive foundations of clinical psychology. London: Lawrence Erlbaum.
David, A. S., & Cutting, J. C. (Eds.) (1994). The neuropsychology of schizophrenia. Hove: Erlbaum.
Kingdon, D. G., & Turkington, D. (1994). Cognitive-behavioural therapy of schizophrenia. Hove:
Lawrence Erlbaum.
Persons, J. B. (1989). Cognitive therapy in practice: A case formulation approach. London: W.
Norton & Company.
Persons, J. B. (1993). Case conceptualization in cognitive-behavior therapy. In K. T. Kuehlwein &
H. Rosen (Eds.), Cognitive therapy in action: Evolving innovative practice. San Francisco: Jossey
Bass.
Zubin, J., & Spring, B. (1977). Vulnerability: A new view of schizophrenia. Journal of Abnormal
Psychology, 86, 103–126.
