Why I don’t skip assessment and formulation even after all these years

After meeting with hundreds of clients and delivering thousands of therapy sessions, therapists become skilled in quickly seeing themes and areas of difficulties for the client. Sometimes this ease and confidence leads to therapists abandoning assessment and formulation altogether, because they “just know”. Or because it “saves time.”

Abandoning assessment and formulation because you’re experienced and recognise patterns or want to save time is something I strongly discourage.

Maybe it’s because I’m trained as a clinical psychologist and assessment and formulation is drummed into us into our training. It is one of the core skills clinical psychologists are known to be expert at.

Maybe it’s because my first mentor, a renowned psychiatrist in the perinatal space, would not allow practicum students to do therapy until he was confident they could assess and formulate.

Or maybe it’s because I often work with trauma.

But mostly I think it’s because without it, therapists make a lot of assumptions and approach treatment interventions haphazardly or apply routine interventions to all of their clients. Therapists who work without strong assessment and formulation typically apply interventions to symptoms without understanding the origins or function of the symptom or behaviour for the client .

Therapy without assessment and formulation is like taking an unknown journey with someone else’s well-being without a map or guidebook.

This quote from the book Creative Methods in Schema therapy sums it up well.

“I’ve always felt, the case conceptualisation, if it’s off, the treatment won’t work, that it’s actually central to guiding what you do…if you don’t understand what happened in a patient’s childhood and adolescence as they’re growing up, you can’t get them better, you can’t do it by just knowing their schemas and modes, you have to understand how their problems got started.”~ Jeff Young (founder of schema therapy)

If this is Jeff Young’s view on getting case formulation wrong, I can only imagine Jeff Young’s thoughts on doing therapy without a formulation. My guess is, he wouldn’t be for it.

Assessment and formulation is a skill that builds over time and is aided by supervisory support as well as learning the developmental theory associated with the model you work with well.

Assessment and formulation occurs in an ongoing and developing way during therapy as new information is presented by the client in therapy.

Challenging clients can be tricky to formulate. Support from experienced colleagues via supervision is often necessary, even amongst experienced therapists.

Good therapy is more than symptom relief. Good therapy relies on good assessment and formulation.

Good therapy needs a map to guide the journey.

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