People come to see us because they have a problem. So the formulation approach I’m taking today begins from “the problem” and works back and forward. It’s called a “network” model, and is something many of us do without knowing that’s what we’re doing. The network model can also be called a functional analysis where we’re looking at what happens, and what a person does, and the ongoing consequences or loops that occur over time.
Angelina comes to see you because her neck is very sore. She’s not sure why it’s sore, or what happened to start it off, but she thinks it could be after working for a week at a new workstation where she had to look to the right to read documents, and straight ahead to work on the main monitor. It’s been there for over six months, and she’s come to see you now because she has a week of annual leave and some time to spend on herself. She’s played with changing her pillows because her neck is more uncomfortable in the morning, and it gets painful towards the end of the day just before she heads to sleep. She’s having trouble turning her head to reverse down her driveway, and looking up is almost her least favourite thing. Her sleep is OK once she’s got off to sleep, but initially it takes her a while to fall asleep because she can’t get comfortable. Her partner is getting frustrated with her because she doesn’t want to kiss him because that means she has to look up, and she doesn’t sit on the couch with him any more because he likes to rest his arm around her shoulders – and that increases her pain. She’s irritable and finds herself getting snappy at him. Angelina is in her mid-50’s, otherwise well, but has always lived with various aches and pains, most of which she ignores until they go away. She has had a painful shoulder and lateral elbow pain that lasted for over a year, but has gradually settled down – she didn’t do anything special to manage those after having only a small response to a steroid injection into her shoulder.
Angelina’s main concern is to establish whether her neck pain is anything to worry about, or whether it’s just more of the same, like her shoulder and elbow pain. Her other focus is on getting a comfortable position to go off to sleep because she thinks this is adding to her problem.
OK, so we have a lot of information about Angelina, and we can organise this information in many different ways. Given her main concern is her prognosis and then her sleep, we need to make sure the way we organise the information offers a possible explanation – a hypothesis.
Take a look at the network diagram below to see how I’ve sketched the information out – you’ll note that at this point I’m not trying to develop a diagnosis, I’m focusing on the problem as she sees it.
The matrix I’ve used here comes from Hofmann, Hayes & Lorscheid (2021) Learning Process-based Therapy, published by Context Press, New Harbinger.
What I’ve done is summarised the processes that I think might be relevant to Angelina’s presentation, and drawn the relationships between various aspects that she’s described. You might organise this information differently – and I’d usually do this in collaboration with the person.
If you look closely at the networks, you’ll see several loops that likely will continue if something doesn’t change. One to spot is this set below:
You can see that she’s worrying about her sleep, doesn’t get comfortable as she goes off to sleep, feels fed up, has changed her pillow (in line with her self-concept of someone who is a practical person), and the whole network will likely remain winding itself up unless “something” comes to disrupt this pattern.
This set of relationships raises some factors we need to consider when we’re thinking of interventions. As someone who sees herself as a practical person who doesn’t seek healthcare often, and has had previous bouts of pain that settled without specific treatment (though she sought it for her shoulder), we could interpret this as meaning she doesn’t panic about her situation too much – but we could also wonder if, because she’s seeking help now, she’s seeing her problem as different from previous pain problems and maybe this one is worrying her more than she’s ready to acknowledge. Just to the right of the loop I’ve shown above, you’ll see a box where she says “I’ll deal with it if it doesn’t get in the way of my family and relationship”. This is important – it’s an expression of how she sees herself, an important value, and her motivation for seeking help is also framed in terms of maintaining her loving relationship. For this reason, I’d be looking for interventions that either won’t intrude on her family life and routines, or I’ll be looking for ways to frame whatever treatment suggestions I make in terms of how this will support her relationship.
By drawing a network diagram showing potential processes that might be influencing Angelina’s presentation, I’m answering my question “why is she presenting in this way at this time, and what might be maintaining her predicament” – she really wants a prognosis so she can establish a strategy to maintain her relationship with her family, keeps her “practical person” view of herself alive, and in a way that she can still fulfill her desire (and others’ expectations) to be fully productive at work.
I could analyse (or organise) Angelina’s information in lots of different ways. This is just one – and in some ways, the particular model I use to assemble her information is less important than ensuring Angelina is an equal partner in sketching out these relationships. I could have drawn the Tim Sharpe CBT model or used an ACT-based model and looked for patterns of psychological flexibility. I could have used Vlaeyen’s fear-avoidance model – and I’m sure there are plenty of others that might have been useful.
Irrespective of the model, what needs to be evident is using the information the person offers us, modifying the way we approach therapy as a result, and collaborating with the person to decide treatment priorities. This means we as clinicians need to be nimble, responsive, adaptive, and stop using treatment protocols! Any approach that suggests offering the same approach irrespective of the unique things influencing a person’s presentation is doomed to do a half-arsed job. These protocols might work for some, but they won’t work for all, and they may fail to address the real reason the person came to see us in the first place.