Ah, the process report. No one escapes counselling psychology training without turning out at least a couple, and quite right too, for the process report demonstrates oodles of developing competencies. Make sure your knickers are clean, because this kind of assessment shows everything: whether you understand theory, whether you can apply it in practice, whether you truly understand what process is, what you’re like in the consulting room, what your blind spots are, how reflexive you can or are willing to be, and whether you can manage to convey everything you need to convey within a few thousand words. To quote Victor Hugo, a process report requires you to showcase “Concision in style, precision in thought, [and] decision in life.”
Exact requirements for the process report vary by training context, but the structure is fairly consistent. The heart of the report is an annotated transcript of a psychotherapy session, and your course handbook probably says that this should show “links between theory and practice”. The report is topped by material that contextualises the session excerpt (e.g., working context, client history, formulation, theoretical orientation used) and tailed by a summary reflection of some kind. Sounds pretty straightforward, doesn’t it?
Well, in 10 years of teaching on counselling psychology programmes, I’ve assessed my fair share of process reports. Along the way, I’ve compiled a Buzzfeed-esque list of the Top 5 Process Report Pitfalls. While number one (“The Process-less Process Report”) will never be unseated from the top of that list, it does have a close second. From my vantage point it feels blindingly obvious, but most trainees don’t even know it’s there; I call it “The Forgotten Bridge”.
In a recent blog post, Russel Ayling offered his thoughts on counselling psychology “branding”, and this was closely followed by another post on what CoPs do. Within the latter post were references to pluralism, the relationship, context, and research-informed practice. I would add something else, an activity that incorporates all of those things: formulation. In my opinion, formulation is the central art and the very heart of counselling psychology. The skilled counselling psychologist takes the individual client – their past, their now, their inner life, their external situation, their relating – and melds all that with theory, with research, and with established templates of understanding. In seeking to understand what has landed someone in your consulting room, you and your client identify and follow lots of little threads. Together, you must weave those threads into a fabric that holds together, that makes some kind of sense, that has a useful function. This is formulation. An unreconstructed tangle of wool, after all, never managed to do much that was useful.
But why am I talking about formulation here? Isn’t this a post about process reports? Yes, you’re supposed to put a formulation in the introductory section of a process report, but isn’t a case study more the place to talk about formulation? If you’re asking these questions, you’ve already forgotten the Forgotten Bridge. Remember this mantra: Formulation is the bridge between theory and practice. As counselling psychologists, we are meant to always consider the individual client in their unique context. We are not meant to be therapybots, applying theory in a mechanical and consistent way to every person who sits before us. All too often, however, trainees dutifully stick the client’s formulation into the introductory sections of a process report and then move swiftly onwards, never referring to formulation again. Their annotated transcripts (a) describe something happening in session, (b) describe the response/intervention, and then (c) link or justify their response/intervention by referencing theory. Let’s take two examples:
- “I notice that Mary is holding quite rigidly to this belief, and I decide to try some cognitive restructuring. Cognitive restructuring (Beck, 1995) is intended to dispute and modify irrational beliefs.”
- “Julian’s comment indicates that he is concerned about my judging him negatively; I am aware of the need to maintain and show unconditional positive regard (Rogers, 1961). I lean forward and try to be as open and warm as possible in my tone when I reflect back his comment that he is afraid of what I will think.”
In the examples above, the therapists are doing some “good” things, things that don’t seem out of place in process reports. They notice things happening. They catch hold of them. They demonstrate that they know theory. They choose responses that may make absolute sense. Yet their reflections seem somewhat hollow, as though something is missing. Notice that each of these therapists has jumped straight from a particular moment in practice to the broad, generic expanse of theory, neatly skipping over something quite important: the client.
Meanwhile, back at the ranch, the formulation lolls about in a bored fashion, eating grapes. It has a function and has not just been included for the fun of it, but it has been sadly overlooked. Mary’s formulation may have a lot to say about why she holds this particular belief and why she might be particularly resistant to its being threatened. Julian’s formulation may illuminate how unconditional positive regard is not merely a Generally Good Therapeutic Thing in his case, but something that may be key to the work. Let’s see what could have happened had the Forgotten Bridge been remembered (I include the original examples for contrast purposes):
- Formulation forgotten: “I notice that Mary is holding quite rigidly to this belief, and I decide to try some cognitive restructuring. Cognitive restructuring (Beck, 1995) is used to dispute and modify irrational beliefs.”
- Formulation incorporated: “In Mary’s repeated insistence that she will never find someone to love her, I can see that she is holding quite rigidly to her belief about being unloveable. I remember that our past attempts at cognitive restructuring (Beck, 1995) around this belief have been unsuccessful, and recently we have been talking about this belief as being part of an early maladaptive schema (Young, 2003) that was partly shaped by her mother’s depression and neglect of Mary. I realise that this belief is familiar and comfortable to Mary, as painful as it is, and that “the schema fights for survival.” Reluctant to try cognitive restructuring again when it has not been helpful in the past, I propose an experiential exercise that Young suggests for tackling maladaptive beliefs of early origin.”
- Formulation forgotten: “Julian’s comment indicates that he is concerned about my judging him negatively; I am aware of the need to maintain and show unconditional positive regard (Rogers, 1961). I lean forward and try to be as open and warm as possible in my tone when I reflect back his comment that he is afraid of what I will think.”
- Formulation incorporated: “When Julian says that he is terrified of what I will think, I am once again keenly aware of how critical his parents were, and how he feels that he never received the acceptance that he so craved. I am also aware that in all of his subsequent relationships, Julian has found it impossible to believe that he could be cared for unconditionally. This has kept him constantly chasing approval, disconnected from his own organismic valuing process (Rogers, 1964). Consequently, I am aware that unconditional positive regard (UPR) is extremely important in my work with Julian, in service of providing him with a corrective experience. In this moment, responding to his fear of my judgement, I do everything I can in my voice, body, and face to embody that UPR.”
I have tried to illustrate a few things with these (fictional) examples. First, in the “formulation incorporated” examples, we see how the individual client has reappeared and is being honoured. By linking the moments in session to the formulations, the therapists are able to speak about their interventions with Mary and Julian in a specific way.
Second, we observe how an ongoing awareness of the formulation within the therapeutic work itself (i.e., not just in the post hoc reflection) has steadied and guided these therapists in their responses to their clients. These two examples show therapists using the formulation to guide them in the moment. Had these therapists made interventions that went awry, then they could have reflected on whether this was partly because those interventions were less mindful of this – “off formulation,” as it were.
Finally, we see how the process reflections have become interesting. They no longer have that bland, colour-by numbers feel. Drawing upon the formulation has resulted in richer, more meaningful reflections.
If you have found this post useful, you might be keen to know more about the other items on the “Top 5 Process Report Pitfalls” list. Perhaps I’ll be invited back another time to talk about those! In the meantime, however, try to keep the Forgotten Bridge firmly in mind. It will be of inestimable help in navigating the shift from therapybot to counselling psychologist!
Dr Elaine Kasket is Senior Lecturer and Research Coordinator on the Doctorate in Counselling Psychology at Regent’s University London. If you would like to contact her to check her availability for private supervision, please check out her entry in our supervisors directory.