The place of hypothesis formulation and feedback
It will have become clear by now that this framework of time-limited psychodynamic psychotherapy is one that is continuously active and reflective, and takes a direct, transparent and interactive approach to working with children, parents and young people. Within this model, the creation of hypothesis and formulation represent the engine room of the approach. How the clinicians particularly those in training, can be helped to develop a systematic approach to the formulation of clinical problems is described in detail in an excellent paper by Havighurst and Downey (2009). The psychologist authors pose the question of how are we to make sense of the stories told to us by the families we see, given our contemporary understanding of the literature and clinical evidence concerning development, relationships and personality functioning? The authors advocate an approach that is not simply ‘a description of symptoms’ but one that identifies ‘patterns of difficulties and strengths through a rich understanding of the case history and current dynamics’ (Havighurst and Downey, 2009, p.252).
The authors propose a bio-psycho-social model of working towards a formulation that encompasses predisposing, precipitating, perpetuating and protective factors. They describe how each of these steps can be broken down, and how data can be systematically collected in order to arrive at a meaningful formulation known as the mindful formulation. Arriving at the formulation enables the practitioner in turn to make appropriate recommendations for treatment. It is interesting to note that the mindful formulation does not advocate any particular therapeutic orientation, but emphasises instead, the need to create a discrete period of assessment that should not get lost within a contemporary cost-cutting climate. Most significantly, the paper highlights the need for clinicians to move away from a narrow problem-based focus of blaming either the child or the parent, to one that explores individual child and parent intra- and inter-personal dynamics, as well as systemic and intergenerational factors all of which throw light on the presenting problem.
Havighurst and Downey emphasise the importance of involving fathers in this process, who as they point out, have become marginalised from many therapeutic services. The inclusion of fathers also leads to another key element in the formulation process, which at its best is a collaborative exercise. This includes the opinion and hypotheses of the clients or patients themselves. Working with parents in partnership, and providing containment for them, is intrinsic to this collaborative process. This takes place through a review and reframing of the problem as the therapy progresses, which comes particularly to the fore in time-limited psychodynamic psychotherapy through working with what takes place in the ‘here and now’.