Taking collaboration to a deeper level: A counselling psychology stance to psychological formulation

The diminishing divide between clinical and counselling psychology

I recently prepared a workshop on Formulation in Counselling Psychology, and as I was researching the literature on the topic, it struck me that recent developments in clinical psychology (e.g. DCP Good Practice Guidelines on the use of psychological formulation, 2011) have to a large extent bridged what may have previously been seen as a divide between clinical and counselling psychology. For example, clinical psychology guidelines recommend that practitioners should see the person in context and place their own meaning-making central, and they recommend adopting a critical stance towards diagnosis and the medical model. Not only has the divide been successfully bridged, clinical psychology has now clearly made a stake in what we formerly thought of as an inherently counselling psychology perspective. This is likely to lead to mixed feelings among us counselling psychologists. On the one hand, we welcome the fact that our views are now more widely held, and particularly within a politically more powerful division. On the other hand, such a development could lead to (yet) another identity crisis for us in counselling psychology. If clinical psychology now espouses what we have proclaimed for so long as a minority crying in the wilderness, is there still a place for us as a separate discipline?

Can counselling psychology bring something unique to the table?

My motivation for this blog is not to contribute to some kind of turf war. I am an avid follower of Clinical Psychologist Lucy Johnstone’s tweets (@ClinPsychLucy) and would recommend reading her output to anyone chancing upon this blog. In fact, I would love us to join forces more explicitly at all sorts of levels and in all kinds of arenas. However, what I was wondering when I prepared my workshop on formulation was: Is there something that counselling psychology can uniquely contribute to psychological formulation? If we believe that there is still something that distinguishes counselling psychology from other fields of applied psychology and from allied professions such as psychotherapy and counselling, then could this give us a clue as to our very own contribution to this key area of psychological practice?

What clinical and counselling psychology approaches to formulation have in common:

Before looking at what may be unique to counselling psychology, I would first like to briefly list some of the overlaps that I see between a clinical and a counselling psychology perspective on formulation: The DCP Guidelines see formulation as a collaborative endeavour between psychologist and service user(s), an event as much as a process that places the service user’s own meanings central and is not premised on a psychiatric diagnosis. For both disciplines, formulation endeavours to make sense of the issues, draw connections and links between them, and there is a shared understanding of the person and their complaints as inextricably connected with a wider cultural and societal context. Furthermore, clinical psychology has moved away from a symptom orientation and also proclaims the client’s presenting issues as inherently understandable within the context of the person’s life and meaning-making. This is very similar to counselling psychology’s emphasis on the basic intelligibility of the client’s concerns, as very lucidly elaborated by Cooper (2009) in his discipline-defining keynote and paper Welcoming the Other: Actualising the humanistic ethic at the core of counselling psychology practice. Perhaps, as Cooper suggested then, if clinical psychology also embraces a humanistic ethic, the two disciplines could well merge in the future. Whether clinical psychology is indeed on the way to fully embracing such an ethic waits to be seen.

The key difference: theoretical perspective-taking

However, there is another (related) aspect that distinguishes counselling psychology from clinical psychology and which I propose to consider as a source for a uniquely counselling psychology contribution to psychological formulation. When developing a formulation, the main focus within clinical psychology tends to be on incorporating different factors, e.g. biological, sociological, circumstantial etc., whereas in counselling psychology the focus is on being able to formulate from within different theoretical models or perspectives (see also HCPC Standards of Proficiency for Practitioner Psychologists, 2015). As counselling psychologists we aim to approach our work with the awareness that any perspective is a theoretical perspective. We are critical of the belief that there could be such a thing as an objective ‘truth’ stance that would allow us to view different factors in someone’s life a-theoretically. Just as clinical psychologists we are scientist-practitioners, but, as a discipline, we tend not to believe in science as a neutral or value-free practice. Instead, it is suggested that all science is linked to particular epistemological and philosophical assumptions about the world and human nature that we can never fully rid ourselves of. Rather than ridding ourselves of theory per se, we can, however, step out of a particular theoretical angle by adopting a different angle, thus looking at the same phenomenon from more than one perspective and, indeed, formulate from within more than one therapeutic model.

For example, one exercise that I have used in workshops involves dividing workshop attendees into sub-groups, each sub-group formulating the same case from a different theoretical perspective (in accordance with their expertise), for example: person-centred, psychodynamic, CBT, systemic, existential etc. This results in a set of very different understandings of the client’s presenting issues, with each perspective providing a different account of the issues with a different set of hypotheses, in accordance with each model’s specific principles and possibilities, each illuminating the case in a different way.

Pluralistic formulation as counselling psychology’s particular contribution

Essentially, what I am describing here could perhaps be approximating a pluralistic approach to psychological formulation. As a discipline, counselling psychology embraces pluralism (McAteer, 2010), and what I am arguing here is that this commitment to pluralism could and perhaps should also extend to our approach to psychological formulation. A pluralistic approach is not to be mistaken for eclecticism (Cooper & McLeod, 2011). Eclecticism is based on utilitarian principles: using whatever seems to fit best or work best at a given time. Philosophical pluralism differs from this, as its fundamental commitment is to diversity and dialogue between different perspectives without attempting to skim over points of difference and conflict but instead allowing tension and even contradiction and attempting to value and include the richness of a whole range of different understandings and angles, suggesting a ‘both/and’ rather than an ‘either/or’ view of the person (Milton, Craven & Coyle, 2010).

Applying pluralistic formulation in practice

There could be many different ways of applying such a vision in practice. All counselling psychologists have been trained in at least two theoretical models, thus they should be able to view a case from at least the angles afforded by these approaches. However, a pluralistic perspective extends also to our appreciation of perspectives in which we have not been trained, thus at least opening ourselves to the possibility that there are other ‘truths’ out there that may not be easily accessible or that could be invited in the form of consultation with other colleagues and so forth. The idea is to develop a multi-perspectival picture that offers different avenues for moving forward rather than a unitary clean and smooth storyline that leads to specific interventions as if by magic. Psychologists working in busy NHS settings may perhaps shake their heads at the suggestion of adding complexity to situations often already characterised by chaos and confusion. However, bringing philosophical pluralism even into these settings is not as outlandish as it may appear at first. Buzzwords in modern healthcare settings such as client choice and personalisation, recovery and empowerment are waiting to be filled with meaning by professionals and clients. In many settings, we are already dedicated to collaborative case formulation, and we often set out different therapeutic options to clients. What is different when we formulate not only collaboratively but also pluralistically is that we make the different perspectives we might apply more transparent, thus not just secretly ‘socialising’ the client into our way of thinking but putting our cards on the table by making the theories behind the words visible. Such communication obviously needs to be done in a way that is appropriate to the individual client. However, when we explain complex problem-specific models to clients, we are doing just that. Giving clients insight into theoretical thinking is therefore nothing new. What may be new here is to suggest there is more than one theory to choose from and that we do not claim superiority of one theory over another. This way, we not only provide the client with a choice between Intervention A and Intervention B, but we invite clients to actively judge for themselves which theoretical model makes more sense to them and may suit them better, thus taking transparency and collaboration to new levels.

Power to the client

The most significant suggestion I would like to make here is to include the client/service user in the decision-making around which type of formulation and therapy may work best for them. Just as advances in pluralistic practice (Cooper & Norcross, in press) are helping to extend the repertoire of collaborative and client-led therapy approaches, a case can be made for advancing such collaboration at the assessment and formulation stage. Again, there is an overlap here with the recent DCP Guidelines and their emphasis on service user involvement and collaboration. What counselling psychology could contribute above and beyond the DCP recommendations is an active and open sharing of theoretical models from within the different approaches, enabling the giving away of psychology at a deeper and more honest level.

Acknowledgements

I want to acknowledge Prof Adrian Coyle, Kingston University, who introduced me to interpretative pluralism in qualitative research, which has informed the views expressed in this blog. I also want to acknowledge Prof Martin Milton, Regent’s University, who master-minded cross-cohort pluralistic case discussions for counselling psychology trainees at the University of Surrey, which enabled me to experience pluralistic perspective-taking on clinical cases in action.

References

Cooper, M. (2009). Welcoming the Other: Actualising the humanistic ethic at the core of counselling psychology practice. Counselling Psychology Review, 24(3&4), 119–129.

Cooper, M. & McLeod, J. (2011). Pluralistic counselling and psychotherapy. London: Sage.Cooper (2009)

Cooper, M. & Norcross, J.C. (In press). A brief, multidimensional measure of clients’ preferences: The Cooper-Norcross Inventory of Preferences (C-NIP). International Journal of Clinical and Health Psychology.

—Division of Clinical Psychology (2011). Good practice guidelines on the use of psychological formulation. Leicester: British Psychological Society. https://www.canterbury.ac.uk/social-and-applied-sciences/salomons-centre-for-applied-psychology/docs/resources/DCP-Guidelines-for-Formulation.pdf, accessed on 14.09.2015.

Health and Care Professions Council (2012). Standards of proficiency: Practitioner psychologists. http://www.hcpc-uk.org/assets/documents/10002963SOP_Practitioner_psychologists.pdf, accessed on 14.09.2015.

McAteer, D. (2010). Philosophical pluralism: Navigating the sea of diversity in psychotherapeutic and counselling psychology practice. In M. Milton (Ed.). Therapy and beyond: Counselling psychology contributions to therapeutic and social issues (pp. 5–19). Chichester: John Wiley & Sons.

Milton, M., Craven, M. & Coyle, A. (2010). Understanding human distress: Moving beyond the concept of ‘psychopathology’. In M. Milton (Ed.). Therapy and beyond: Counselling psychology contributions to therapeutic and social issues (pp. 57–72). Chichester: John Wiley & Sons.