A Reflective Guide to Psychological Formulation in Practice

If you have just finished reading Psychological Formulation in Practice, you may not need more information. You may need a little space.

Sometimes we finish reading an article and immediately move on to the next task, the next session, the next piece of work. Yet some of the most important ideas in clinical practice do not become meaningful because we understand them quickly.

They become meaningful because we return to them, because the knowledge stays with us, continuously shaping how we think, listen, formulate, and make sense of the people we work alongside. Sometimes we may discover that we understood a formulation long before we understood our own relationship to it.

This reflective guide accompanies my article on psychological formulation in practice, inviting readers to pause and consider how formulation, reflexivity, trauma-informed thinking, neurodivergent-affirming practice, and intercultural understanding shape their clinical work.

The original article explores formulation through the lenses of trauma-informed practice, neurodivergent-affirming thinking, intercultural understanding, reflexivity, and integrative clinical work. It introduces ideas, frameworks, and ways of thinking that many practitioners may recognise, while also inviting them to consider formulation more broadly and more deeply.

This companion piece serves a different purpose. Rather than introducing new concepts, it offers space to pause and reflect on what those ideas might mean within your own practice.

You might choose to read it immediately after the original article. You might return to it before supervision. Or you might find yourself revisiting particular sections after a difficult session, when a formulation feels uncertain, or when something in the work remains difficult to fully understand.

There is no right way to use this guide. You do not have to work through it in order, or answer every question. You might spend time with one section and leave the others for another day.

Sometimes a single question is enough. The questions here are an invitation to think alongside your own practice for a little while.

Psychological formulation is not only something we learn. It is also something we revisit, question, refine, and continue developing throughout our work.

Many of the ideas explored in the article, trauma-informed thinking, neurodivergent-affirming practice, intercultural formulation, reflexivity, and integrative clinical thinking, are not simply concepts to understand. They often become most meaningful when they are brought back into our own clinical work, our own assumptions, and our own ways of making sense of people.

Perhaps some reflections will feel relevant to current clinical work; others may only become meaningful later. Both are equally valid.

Formulation is rarely something we master once. More often, it is something we return to repeatedly, each time seeing a little more than we could before.

Some questions in clinical work do not become important because they can be answered quickly. They become important because they continue to shape how we think, listen, and remain open to what has not yet been fully understood.

With that in mind, I would like to invite you to revisit some of the central themes from the article, this time with your own practice in mind.

If you have not yet read the accompanying practitioner article, you may find it helpful to begin with Psychological Formulation in Practice: Why Trauma-Informed, Neurodivergent-Affirming, and Intercultural Perspectives Are Not Optional before returning to this guide.

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What Do You Notice First?

One of the themes explored throughout the original article is that formulation is never neutral. Yet neutrality is often not what concerns clinicians most.

Most clinicians spend years developing their ability to notice. We learn to identify patterns, gather information, and recognise themes that may help us understand a person's difficulties.

Less often do we pause to consider how our own ways of noticing have been shaped.

What captures our attention first can feel self-evident. Yet what stands out to one practitioner may not be what stands out to another.

Training, professional identity, personal experience, theoretical preferences, and cultural context all influence what becomes visible to us and what remains in the background.

Over time, these influences can become woven into our thinking in ways that are easy to overlook. This is often where reflexivity begins.

Not with questioning whether our observations are correct.

But with becoming interested in how certain observations came to feel important in the first place.

You might pause and consider:

• When you first meet a client, what tends to capture your attention most quickly?

• What kinds of stories, explanations, or presentations feel most familiar to you as a clinician?

• Which aspects of a person's experience are you naturally drawn towards exploring?

• What aspects of a person's experience are easier to overlook unless you make a deliberate effort to remain attentive to them?

No clinician arrives without a perspective.

Our training, professional identities, values, experiences, and cultural locations all contribute to the lenses through which we understand distress. As these influences become more visible, other possibilities often become easier to notice as well.

A formulation does not become richer because we eliminate our perspective. It becomes richer when we become more aware of how that perspective is shaping what we see.

A thought to sit with

What we notice first often feels obvious. Yet it is rarely neutral.

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What Do You Understand as Adaptation?

Reflecting on Trauma-Informed and Neurodivergent-Affirming Formulation

One of the most significant shifts in formulation often occurs when a response that initially appears problematic begins to make more sense.

The response itself may not have changed. What changes is the way it is understood.

A pattern that once appeared confusing may begin to reveal a history; a behaviour that seemed disproportionate may start to make sense within the context of what a person has experienced, learned, endured, or needed to navigate.

This shift can be subtle. Yet it often changes the questions we ask.

Rather than focusing solely on symptoms, deficits, or difficulties, we begin wondering how a particular response developed, what conditions shaped it, and what it may have been helping a person manage.

Trauma-informed and neurodivergent-affirming perspectives emerge from different traditions, yet both invite a similar movement in thinking. They encourage us to look beyond surface descriptions and consider the possibility that a response may have developed for understandable reasons.

Sometimes those reasons are connected to safety. Sometimes they are connected to adaptation. Sometimes they reflect a relationship between the individual and the environments they have been required to navigate.

You might reflect on:

• When you encounter a response that feels difficult to understand, where does your thinking tend to go first?

• Which client responses do you find easiest to understand as protective?

• Which responses are harder for you to view through a lens of adaptation?

• What changes when you move from asking "What is wrong?" to asking "What has this response been helping this person manage?"

Some forms of adaptation are easier to recognise than others. Vigilance following threat may feel understandable. Withdrawal following repeated hurt may feel understandable. Other responses can be more difficult to sit alongside with the same level of understanding.

At times, those responses may challenge our assumptions about what adaptation should look like.

Formulation often deepens when we remain with the question a little longer. Some responses may never fit neatly into a single explanation. Even so, staying with the question can reveal meanings, functions, or histories that were not initially apparent.

A thought to sit with

Some responses become easier to understand when we stop asking what is wrong and begin asking what they have been helping someone carry.

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What Has Not Yet Become Visible?

Cultural Humility and the Limits of Clinical Understanding

There are times when a formulation appears coherent, and yet something about it continues to feel unfinished. The main themes have been identified. Important experiences have been explored. A reasonable understanding has begun to emerge. And yet there remains a sense that something sits just beyond the edges of what has been understood so far.

Sometimes that feeling points towards information that has not yet been gathered. At other times it points towards something less tangible:

a perspective that has not yet entered the conversation, a cultural meaning that has not yet been explored, an assumption that has not yet been recognised, or an aspect of a person's experience that remains difficult to see from where we are standing.

Intercultural and systemic formulation often invite us into this territory.

They help us recognise that understanding is always shaped by perspective, not simply expanded by more information.

Culture, identity, migration, belonging, social position, power, and wider systems do not sit outside psychological experience.

They are often woven through it. Yet their influence may remain difficult to recognise until we begin actively attending to them.

As you reflect on a recent formulation, you might consider:

• What assumptions about culture, identity, family, independence, success, or belonging might I be bringing into this formulation?

• What aspects of this person's context have been explored, and what remains largely unexplored?

• If another clinician from a different cultural background reviewed this formulation, what might they notice that I have not?

• What aspects of this person's experience feel furthest from my own lived understanding?

• Where might I be relying on assumptions because I do not yet have enough understanding?

• What would it be like to acknowledge that there may be aspects of this person's experience that I cannot yet fully appreciate?

Reflection

Every formulation reflects both what has become visible and the limits of what we are currently able to see. This becomes particularly relevant when working across differences in culture, identity, language, social position, or lived experience.

No amount of knowledge allows us to stand fully inside another person's world. What often becomes possible, however, is a growing awareness of where our understanding begins to reach its limits.

That awareness can create space for a different kind of listening.

One that remains open to being surprised, challenged, or changed by what we encounter.

A thought to sit with

Some aspects of a person's experience remain unseen not because they are hidden. Sometimes they sit beyond the limits of what we are currently able to recognise.

When Understanding Feels Incomplete

There are moments in practice when a formulation that once felt coherent begins to feel less settled. New information emerges.

Different aspects of the work begin pointing in different directions.

What initially appeared straightforward starts to feel more layered.

Experiences that once seemed separate begin to overlap. The more we understand, the harder it can become to separate one influence from another.

At these moments, there can be a strong pull towards certainty. We may find ourselves searching for the explanation that finally brings everything together.

A framework that feels familiar. An answer that reduces the ambiguity.

A formulation that feels complete. Yet some of the most important formulation work often begins precisely here. A formulation that starts to feel stretched may be telling us that there is more to understand.

You might pause and consider:

• Where do you notice yourself wanting the formulation to become clearer, simpler, or more certain?

• What parts of a person's experience fit comfortably within your preferred framework?

• What parts feel harder to explain?

• What kinds of experiences seem to resist neat organisation?

• What might happen if the goal were not to find the best explanation, but to develop a richer understanding?

Reflection

As our clinical thinking develops, we often become more able to organise complexity into coherent narratives. Yet there are moments when a person's experience resists neat organisation.

Those moments can be frustrating. They can also become some of the most important opportunities for reflection.

A formulation may become more clinically useful while still containing unanswered questions. Different influences may continue operating alongside one another, shaping the person's experience in ways that cannot always be neatly separated.

What initially appears contradictory may begin to make more sense when we consider how different experiences have shaped one another over time.

This kind of uncertainty can feel uncomfortable. Particularly when we care deeply about understanding the people we work with well.

Yet remaining alongside uncertainty is often different from remaining stuck.

One narrows our thinking. The other allows it to keep developing.

A thought to sit with

A formulation does not become more useful because it is simpler.

It becomes more useful when it remains spacious enough to hold what does not fit neatly into a single explanation.

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What Does Reflexivity Ask of Us?

Reflexivity in Psychological Formulation and Clinical Practice

Reflexivity often enters our awareness gradually.

Sometimes it begins with noticing a recurring reaction. Sometimes through a formulation that feels unexpectedly difficult to hold. Sometimes through supervision, when another perspective helps us see something that had previously remained outside awareness.

Reflexivity often becomes most meaningful when it moves beyond theory and enters our day-to-day clinical work.

Over time, practitioners may discover that formulation reveals something about the people they work with. It can also reveal something about practitioners themselves.

Particular themes repeatedly draw our attention.

Certain client experiences feel easier to remain alongside than others.

Some uncertainties feel manageable.

Others evoke a stronger pull towards explanation, certainty, or resolution.

This is part of being a clinician. Every act of understanding is shaped, at least in part, by the person doing the understanding. As formulation develops, awareness of this process often develops alongside it.

You might consider:

• Which client experiences feel easiest for you to stay alongside?

• Which experiences do you notice yourself moving away from, simplifying, or trying to resolve quickly?

• What responses in you seem to emerge repeatedly across different pieces of work?

• What assumptions about distress, recovery, resilience, dependence, culture, or change do you find yourself returning to most often?

• If your current formulation reflects both the client's experience and your own way of making sense of it, what might still remain outside the frame?

A further layer of reflection

As you sit with these questions, you might also consider:

• Which forms of complexity do I feel most able to stay alongside?

• Which experiences feel harder for me to hold when they do not organise easily within my current psychological formulation?

• What kinds of uncertainty do I tolerate reasonably well?

• What kinds of uncertainty make me want to move more quickly towards explanation, certainty, or resolution?

• What happens in my thinking when I encounter something that feels difficult to understand?

• How do I usually respond when I realise I do not yet know what to make of something?

Over the course of practice, many clinicians notice a shift.

Greater experience often brings confidence in clinical thinking.

It can also bring a growing awareness of how much remains difficult to fully know.

There are aspects of another person's experience that may never become entirely accessible to us. There are meanings we may only partially understand. There are cultural, relational, and personal realities that remain, at least in part, beyond our perspective.

For many practitioners, this awareness becomes woven into the work itself. Rather than diminishing formulation, it often helps formulation remain thoughtful, ethical, and responsive.

Humility is sometimes associated with uncertainty or a lack of expertise.

Yet many experienced practitioners describe something different.

The longer they work, the more aware they become of what cannot be known quickly, assumed, or taken for granted.

In this sense, humility and expertise often develop alongside one another.

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One final reflection

When a formulation feels difficult to hold, where do you usually turn?

Do you seek another perspective?

Do you return to the client's experience?

Do you move towards a familiar framework?

Do you become more tentative?

Do you become more certain?

Do you find yourself widening the frame, or narrowing it?

None of these responses are inherently right or wrong. Yet they often tell us something important about how we relate to uncertainty, ambiguity, and not knowing. Sometimes they also point towards areas where further reflection, consultation, or supervision may be helpful.

A thought to sit with

Perhaps humility in formulation is not about knowing less. Perhaps it emerges through recognising that there will always be aspects of another person's experience that remain difficult to fully understand.

Holding that awareness is not a weakness of formulation. It may be one of the conditions that allows formulation to remain alive.

Closing

As you come to the end of this guide, you may find yourself leaving with more questions than answers. That does not mean the reflection has been unsuccessful. Some questions in clinical work become valuable precisely because they resist easy resolution.

They continue shaping how we listen, how we formulate, and what remains possible for us to notice.

Perhaps the most useful question after reading about formulation is not "Do I understand formulation better?"

but "What has become more visible in the way I think?"

Throughout this guide, we have returned to questions about trauma, neurodivergence, culture, reflexivity, and formulation.

Yet perhaps the deeper invitation has been to consider how these ideas meet your own way of thinking:

How do those ideas meet your own practice?

How do they influence the questions you ask?

What do they help you notice?

What remains difficult to hold?

What continues to invite further thought?

Formulation rarely develops through certainty alone. More often, it deepens through reflection, dialogue, and a willingness to remain in relationship with ambiguity.

This is true of the people we work with. And it is equally true of ourselves as practitioners.

Continue Reflecting

• Psychological Formulation in Practice: Why Trauma-Informed, Neurodivergent-Affirming, and Intercultural Perspectives Are Not Optional

  Explore the longer practitioner article that this reflective guide accompanies.

• Formulation in Therapy: How a Psychologist Understands You Beyond a Diagnosis A client-facing introduction to psychological formulation and how psychologists move beyond symptoms and diagnoses to understand the wider context of a person's experience.

• What is Trauma-Informed Therapy? Why Safety Matters in Healing A deeper exploration of protection, adaptation, safety, and how trauma-informed thinking shapes therapeutic understanding.

• Clinical Supervision for Therapists and Psychologists Reflective supervision focused on formulation, reflexivity, uncertainty, and professional development.

• Intercultural Clinical Supervision: A Guide to Safety, Cultural Humility, and Reflective Growth An exploration of cultural humility, identity, power, and intercultural awareness within supervision and clinical practice.