I greatly enjoyed presenting at ENLIGHT on practical assessment and formulation. Here are some of the key points to make this essential skill/task more workable.
The questionnaires aren’t a formulation substitution
Assess from a schema therapy lens from the start
Start simply and take an iterative approach to formulation
The questionnaires aren’t a formulation substitute
A question I often ask other schema therapists is “how are you formulating this problem.” In other words, what schemas and modes perpetuate or drive the presenting problem? When reflecting on the schemas and modes a client has, many will immediately look at the YSQ and SMI results. While this may seem logical, it often leads to confusion because the questionnaires are like a broad blood test, they provide general information about what schemas and modes a client may have. However, they don’t tell you which schemas and modes are related to the presenting problem.
For example, Mara (a fictitious client), came to see me due to avoiding tasks at work. The more she feared failing (Failure schema) the more she avoided her work tasks (avoidant protector mode). If I had only looked at her YSQ and SMI results, I would have seen she had Failure, Defectiveness, Vulnerability to Harm, and Abandonment. It doesn’t tell me the specific schemas related to the presenting problem. The SMI also lacks common modes such as the overcontroller mode and the avoidant protector mode.
I find a more helpful approach is glean schemas and modes from your own assessment, than to try to gain them from the questionnaires alone. This only works if you assess from a schema therapy lens from the very start. The questions themselves asked on an assessment matter less than using a schema frame.
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Assess from a schema therapy lens
Many assessment questions, such as ones about family and relationships, early childhood experiences and even routines will shed light on schemas and modes if you hone your schema radar. The main question you should ask yourself is what does this assessment information tell me about the client’s schemas and modes and how is that related to reason they have come to see me? This will assist you to answer the main question “what are the schemas and modes related to the presenting problem?” and ultimately help you to formulate.
Start simply and take an iterative approach to formulation
Formulation can feel overwhelming, clunky and extremely time consuming. It can be easy to take one of two approaches. The first is what I call the “narky child mode.” In this mode we say “Arghhhh, too hard. It takes too long to formulate! I’ll just get on with it and treat!” Then there’s the “perfectionistic delaying ninja mode” (true story) in which we get lost in the weeds and try to figure out which of the 170 modes it might be and try to have a comprehensive formulation before beginning treatment. This mode can lead to paralysis.
Ultimately, we want to strike a healthy adult/realistic balance to formulating. That balance will look different for each therapist. However, I find it’s helpful to build a mode map by starting with what you know already, even if you have to metaphorically or literally put it on the back of an envelope.
Ensure your mode map has a vulnerable child mode, a critic mode (e.g., punitive, guilt inducing, demanding, overanxious etc), main coping modes (e.g., detached protector, compliant surrenderer) and notes the role of the healthy adult (e.g., client excels at problem solving but has deficits in self-compassion).
To build a simple mode map I ask myself:
How does the problem make little them feel? This tells you a bit about the flavour of the vulnerable child.
What messages does the critic deliver that make things worse?
What survival coping (overcompensation, avoidance and surrender) is the client using to distance themselves from the painful feelings of the vulnerable child. This tells you the client’s coping modes.
How is the client’s healthy adult helping and/or hindering?
Over time, as you get to know the client and as you treat, this simple formulation can be refined and become more nuanced.
In sum, formulation is an art that is best developed over time. Don’t put pressure on yourself to know everything immediately. Instead, start by assessing from a schema therapy lens. This will help you to know their schemas and modes and formulate in a continuous and iterative fashion by revisiting the formulation in each session. I often ask myself, “what has this session taught me about this client? That insight helps me to refine and enrich formulation.
Tena Davies is a Clinical Psychologist and Advanced Certified Schema Therapist living in Melbourne, Australia. She is passionate about simplifying schema therapy and helping therapists to thrive.
To download two schema therapy assessment and formulation guides, please visit her website here
