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

  • 2 days ago
  • 23 min read
Illustration of a therapy session with a therapist and client facing each other, with a large iceberg between them representing visible struggles such as anxiety and overworking above the surface, and deeper underlying factors including trauma, neurodivergent needs, and cultural or systemic influences below.

Introduction

When psychologists formulate, we are not simply organising information.

We are trying to understand how a person's difficulties came to make sense within the life they have lived: what a person is struggling with, how those difficulties may have developed, what keeps them going, and what might support change (Johnstone & Dallos, 2014). That framing is accurate. It is also incomplete.


Formulation is not only a technical process. It is an interpretative act. It reflects what we notice, what we prioritise, and what we understand as meaningful. For that reason, formulation is never neutral (BPS, 2011).


In this article, I do not return to formulation as a basic concept. What I want to focus on instead is a more specific and increasingly necessary question:

what does formulation need to notice, hold, and stay open to if it is to be clinically accurate and genuinely useful?

A formulation can be coherent, internally consistent, theoretically grounded, and agreed upon by both clinician and client, and still be inaccurate. Coherence alone does not guarantee that the conditions shaping distress have been properly understood, that the adaptations sustaining survival have been recognised for what they are, or that the systems within which a person has had to live have been given their full clinical weight.


In my view, trauma-informed thinking, neurodivergent-affirming practice, and intercultural grounding are not optional additions to formulation. They are foundational to it, across every therapeutic model, and in every formulation that claims to be clinically adequate. The most recent consensus study on what formulation must include found explicit agreement among clinicians that sociocultural factors are essential (Thrower et al., 2024). That consensus matters. But in practice, formulation can still fall short if trauma, neurodivergence, and culture are only mentioned as context rather than built into how the formulation is organised.


For a companion introduction to formulation written for clients and those newer to the concept, see Formulation in Therapy: How a Psychologist Understands You Beyond a Diagnosis.


Watercolour illustration of a therapy session showing a therapist and client, with the therapist’s experiences, values, and cultural background subtly shaping the emotional space, illustrating that psychological formulation and therapy are not neutral processes.

Formulation Is Never Neutral

I do not see formulation as a neutral clinical tool. I see it as an interpretative act, shaped by what we notice, what we prioritise, and what we understand as meaningful.


Formulation is often presented as a structured process of linking information together. In practice, it is shaped by our theoretical orientation, assumptions, and implicit frameworks (Kuyken, Padesky and Dudley, 2009).


This matters because formulation does more than describe. It interprets. It shapes what becomes clinically visible, what remains in the background, which parts of a person’s story are treated as central, and what kind of change begins to seem possible. These are not neutral decisions. They reflect what we have been trained to see, and what may not yet have entered our field of attention.


The key question in practice is not simply whether a formulation is coherent, but whether it is sufficiently contextualised, reflexive, and grounded in the reality of the person's life. A formulation that excludes context may inadvertently locate the problem within the individual, even when the difficulty has been shaped relationally, culturally, or systemically (Johnstone et al., 2018).


This is why reflexivity matters. A formulation becomes more trustworthy when we are willing to examine not only the client’s material, but also the assumptions through which that material is being understood.


It requires remaining open to the possibility that what appears as symptom may be adaptation, that what reads as resistance may be protection, and that what looks individual may be systemic.


How Psychological Formulation Develops in Practice

For me, formulation is iterative. It develops over time and is never finally complete.


It often begins with the presenting difficulty, but not because the presenting difficulty is the whole problem. It is the doorway into understanding how this difficulty has come to make sense in this person’s life.


From there, understanding develops through careful listening, pattern recognition, and attention to what becomes possible in the therapeutic relationship.

Together, the client and I begin to understand their experience across time, including what happened, what patterns emerged, what meanings formed, and what has become habitual. For some clients, especially those who have not had consistent space to express themselves safely, meaningful material often becomes available only when the relationship has become safe enough to hold it.


From this, we develop hypotheses about how the difficulty has developed, what has shaped it over time, and what may be maintaining it. These hypotheses remain open to revision. They inform decisions about therapeutic focus, pacing, intervention, relational approach, and areas of risk and protection.


Formulation is then reviewed and updated as therapy progresses. Sometimes, earlier assumptions may shift and new patterns become visible. When we reformulate, it usually reflects deeper understanding rather than error.


We connect past to present not to remain there, but because that connection clarifies what is keeping difficulty in place now, and what might therefore be possible going forward. The question formulation is always working toward is not only why did this develop, but what does understanding this open up.


Formulation Across Therapeutic Models

Different therapeutic models help us notice different things. A cognitive behavioural formulation may focus on patterns of thought, emotion and behaviour. A psychodynamic formulation may attend more closely to unconscious meaning, relational templates and early experience. Attachment-informed, trauma-informed and culturally responsive approaches each bring their own ways of understanding what matters clinically.


In practice, many psychologists work integratively, drawing from multiple perspectives to develop a formulation that reflects the complexity of the individual. This resists the flattening that occurs when a single model is asked to carry more than it can hold. It also requires the fluency to recognise when a particular framework is no longer sufficient for the person in front of you.


In the way I teach and use formulation, I find it important to distinguish between the structure that organises information and the lens that gives that information meaning. Alongside these theoretical approaches, formulation is often supported by shared structural frameworks used across disciplines.


One of the most widely used is the 5Ps model: presenting factors, predisposing factors, precipitating factors, perpetuating factors, and protective factors. It is not limited to psychological therapy, but is also used in medical, psychiatric, and multidisciplinary settings to organise complex clinical information.


The value of the 5Ps lies in its ability to hold multiple influences in view at once, linking past and present, vulnerability and protection, development and maintenance. It provides a structure through which different professionals can develop a shared understanding of a person’s difficulties, even when working from different theoretical positions.


At the same time, the 5Ps does not determine meaning. A predisposing factor can be read as vulnerability, adaptation, or context, depending on the interpretative lens applied. A perpetuating pattern may reflect avoidance, regulation, or necessity.


The framework organises information, but it does not determine what that information means. What gives a formulation its clinical value is not how information is arranged, but how it is understood, and what is allowed to be seen within it.


From Structure to Meaning: Mapping a Formulation

Structural frameworks such as the 5Ps organise information. Formulation becomes clinically useful when that information is understood in relation to itself, not as separate categories.


5Ps formulation: psychological formulation which professionals use (psychiatrists, doctors, nurses and psychologists, etc).

In practice, formulation is often represented visually because patterns become easier to see when they are mapped rather than described.


A diagram can make patterns more explicit, showing how beliefs, emotional responses, behaviours, bodily states, relationships, and contextual pressures interact across time. Rather than presenting factors as discrete domains, a formulation map shows how earlier experiences shape beliefs, how those beliefs influence relational and emotional patterns, how present stress activates established responses, and how coping strategies may be both protective and maintaining.


These diagrams are working hypotheses, not definitive accounts. Their value lies in whether they support shared understanding, guide clinical direction, and remain honest about how distress has been shaped by conditions, not only by the person.


Common Pitfalls in Psychological Formulation

Several limitations appear repeatedly in formulation practice. They are worth naming not only as technical errors, but as reflections of clinical stance.


One of the most common problems I encounter in formulation is that distress becomes located too quickly within the individual. When cultural, systemic and relational context is treated as background rather than central, the formulation can begin to describe the person without fully understanding the conditions that shaped the difficulty. A person may be left with an explanation that describes what they feel, but not why those feelings have taken shape in this particular way, in this particular life.


Pathologising adaptive responses is another limitation. What is adaptive within one context is not necessarily pathological in another. The person-centred question is not whether a response fits a normative framework, but whether it still serves the person, and at what cost.


Holding formulations too rigidly is also a related concern. For clients with longstanding patterns of adjusting their self-presentation to relational or cultural expectations, meaningful material often emerges slowly. What did not appear relevant in the first few sessions may be central later. Remaining open to reformulation, not as correction, but as development, is therefore both a clinical skill and a clinical responsibility.


Disconnecting formulation from intervention is a final pitfall worth naming. A formulation that explains but does not change how the work is approached has not yet done its full job. Understanding is the precondition for change, not the destination.


I find that these limitations may reflect the internal world of a clinician: how they are attending to therapy, what they are willing to hold uncertain, and how much of the person's complexity they are prepared to stay with. These limitations often share a common root: formulation becomes too narrow when trauma, neurodivergence, and intercultural context are not built into the way the person is understood. These principles are not automatically included in standard practice, regardless of therapeutic model or structural framework.


Watercolour illustration of a person surrounded by layered psychological and contextual influences, showing formulation as understanding beyond visible symptoms.

Three Necessary Foundations for Clinically Adequate Formulation

Trauma-informed, neurodivergent-affirming and intercultural approaches are not optional additions. They change what we notice from the beginning. They shape the questions we ask, the meanings we consider, and the kinds of explanations we are willing to hold.


A CBT formulation needs to be trauma-informed. A psychodynamic formulation needs to be neurodivergent-affirming. An attachment-based formulation needs to hold intercultural context. They do not simply add nuance to a model. They change whether the model can be applied accurately at all. They are what allow any model to be applied with clinical accuracy.


Without them, the pitfalls described above are not only possible but predictable. Distress is over-individualised because cultural and systemic conditions have not been given their full weight. Adaptive responses are pathologised because survival strategies have not been read as such. Difference becomes deficit because neurodivergent experience has not been understood on its own terms.


The next three sections are outlined separately for clarity. Though the argument throughout, as developed more fully in the integration section, is that they do not operate independently. They intersect, and the clinical picture they produce together is different from what any one of them reveals alone.


Watercolour illustration of a person within a soft protective cocoon, representing trauma-informed therapy where emotional responses such as withdrawal and shutdown are understood as adaptive protection rather than dysfunction.

Trauma-Informed Formulation in Therapy

Understanding Adaptation and Protection

A trauma-informed formulation asks not what is wrong, but what has this response made possible, and under what conditions did it become necessary?


Patterns such as hypervigilance, emotional shutdown, avoidance, or relational sensitivity are understood as protective responses developed by a nervous system organising itself around safety when safety was not reliably available. The concept of allostatic load describes how the body and mind adjust to prolonged stress exposure in ways that are physiologically coherent even when they carry long-term cost (McEwen, 1998). Polyvagal theory adds to this by describing defensive responses as autonomic rather than voluntarily chosen (Porges, 2011).


Without this, formulation risks pathologising survival strategies. A client may be described as resistant, avoidant, or dysregulated when they are in fact operating within a coherent survival system (van der Kolk, 2014; Herman, 1992). Many adult presentations reflect not a single traumatic event, but a system built incrementally over years, often in contexts where naming the experience as trauma was not available.


Sometimes, these adaptations become so familiar that they no longer feel like responses at all. They begin to feel like personality, responsibility, or simply the way life is. I explore this further in: When Coping Becomes a Way of Living


Watercolour illustration showing trauma responses such as vigilance, shutdown, and avoidance as protective adaptations to threat rather than signs of pathology.

In practice, this shifts the first clinical question. Assessment does not begin by asking what triggered the current difficulty, but what this response has been organising around, and whether the nervous system has ever had reliable evidence that the threat has passed.

There is often a quiet but significant moment when a client stops apologising for a response they have spent years trying to manage, and begins instead to understand it. Something shifts in the room. The pace changes. And what becomes possible in the work changes with it.


The clinical aim is not simply to reduce symptoms, but to help a person recover agency within a system that has long been organised around protection. When a client understands why a response developed, not as something wrong with them, but as something that made sense under the conditions they were living in, recognition becomes the beginning of choice. What follows, over time, is earlier recognition of activation, more deliberate access to what already helps, and a growing sense that the pattern can be noticed, understood, and gradually related to differently.


If you would like to explore more deeply what a trauma-informed perspective means in practice, and why safety sits at the centre of therapeutic change, you may also find helpful: What is Trauma-Informed Therapy? Why Safety Matters in Healing


Watercolour illustration of a person in a café showing neurodivergent experience of environmental mismatch, where social and sensory demands require increased effort rather than reflecting individual dysfunction.

Neurodivergent-Affirming Formulation in Clinical Practice

Recognising Difference, Not Deficit

A neurodivergent-affirming formulation shifts the frame from deficit to difference. Rather than asking why the individual struggles to meet expectations, it asks what happens between this person and the environments they are navigating.


Much of the distress experienced by neurodivergent individuals arises not from intrinsic dysfunction but from sustained person-environment mismatch (Milton, 2012). Milton's double empathy problem identifies that difficulties in mutual understanding between neurodivergent and neurotypical people are bidirectional, not located solely within the neurodivergent person.


Watercolour image showing a person’s natural rhythm meeting a structured demanding environment, representing neurodivergent distress as mismatch rather than deficit.

Without a neurodivergent-affirming lens, systemic mismatch is easily mistaken for individual deficit. We regard overload as anxiety disorder, masking as wellness, or shutdown as deliberate disengagement.


Walker (2021) takes this further by challenging the pathology paradigm itself: neurodivergence is not a defect to be corrected, but part of human neurological variation. Therapeutic goals organised around adjustment to neurotypical norms may be both clinically insufficient and ethically questionable. The question formulation must ask is therefore not how to help the client fit the environment better, but what the environment has been demanding of them, and at what cost.


In practice, pacing adjusts. Rather than moving from assessment to formulation on the usual timeline, the neurodivergent-affirming clinician treats early sessions as relational orientation, holding preliminary hypotheses lightly, and staying alert to what the adapted presentation may be obscuring.


Late identification is especially relevant here, particularly for those whose neurodivergence has often remained hidden, including women, adults, and people from non-Western cultural backgrounds. Neurodivergent presentations have often been invisible, attributed to personality, or misread through other frameworks. The same clinical and ethical logic extends to gender-affirming practice, where distress is understood in relation to minority stress and marginalisation rather than intrinsic pathology.


What often becomes apparent in early sessions with neurodivergent clients who have been unidentified for a long time is a quality of self-monitoring just beneath the surface, a constant calibration of whether what they are expressing is legible, appropriate, or too much.

Part of the formulation work is creating enough safety for that self-monitoring to ease. When it does, what was always there but never quite said begins to become available.


What is presented early may reflect what the client has learned to present, not what is most clinically central. A formulation built on what is explicitly offered risks becoming a formulation of the adapted self. Fluency is not the same as access.


If you are interested in how neurodivergence can remain unrecognised for many years, and the impact this can have on identity and self-understanding, you may also find helpful: Late ADHD or Autism Diagnosis as an Adult: What the Relief and the Grief Both Mean


Watercolour illustration of a therapy session showing intercultural and systemic formulation, with soft layered environments blending into the room to represent how cultural and social contexts shape the therapeutic space.

Intercultural and Systemic Formulation

Context as Explanation, Not Background

An intercultural formulation recognises that experience does not arrive without context. It is shaped within systems of meaning: family roles and obligations, cultural norms and values, migration and bicultural identity, belonging and social positioning, and the experience of navigating multiple cultural frameworks simultaneously.


These factors are often not background details. They help explain why distress has taken this particular shape in this particular life.


Kleinman's (1988) concept of explanatory models is foundational here. People understand the cause, course, and appropriate response to distress through culturally situated frameworks. When our explanatory model and the client's diverge, a formulation may appear coherent while remaining misaligned with how the client actually makes sense of their experience. This misalignment is one of the most common and least-examined sources of therapeutic impasse.


Watercolour illustration showing an individual surrounded by layered cultural, relational, and social environments, representing how intercultural context, identity, and systemic influences shape psychological experience and formulation.

In practice, attending to this means asking explicitly, rather than inferring: what does this person understand as the cause of their difficulty? What do they expect from this process? What would change or recovery mean within their own framework of meaning? These are not supplementary assessment questions. They are the formulation.


Moreover, overworking may reflect culturally situated meanings of worth, sacrifice, and belonging. Emotional restraint may reflect relational or cultural necessity rather than avoidance. Hyper-attunement to others' states may reflect long-term adaptation to environments where reading the room was necessary for safety. Minority stress, the chronic experience of stigma, discrimination, and social marginalisation, adds systemic weight that individual-level formulation alone cannot hold (Meyer, 2003).


Socioeconomic position and class, consistently identified in UK research as among the most under-addressed factors in therapeutic practice, also shape meaning, opportunity, and the material conditions of distress. The assumption that psychological difficulty can be understood without attending to the economic and structural realities of a person's life is itself a form of over-individualisation.


There are moments in therapy when it becomes difficult to understand why distress has taken this particular shape in this particular life. It is often at this point that questions of culture, identity, power, belonging, and social position begin to matter.

Burnham's Social GRRRAAACCEEESSS framework, a reflexivity tool commonly known in UK counselling and systemic practice, offers one way of thinking about social difference, including gender, geography, race, religion, age, ability, class, culture, ethnicity, education, employment, sexuality, and spirituality (Burnham, 2012). Used especially in supervision, it helps clinicians stay aware of which aspects of social difference are visible or invisible, voiced or unvoiced, in the therapeutic relationship.


Many people arrive in therapy already carrying an explanation for what is wrong with them. The difficulty is that this explanation often tells us very little about how the difficulty developed, what it has been responding to, or what purpose it may once have served. This is one reason the Power Threat Meaning Framework can be clinically useful. It provides structural understanding that distress is shaped by power, social context, and meaning, not solely by individual psychology (Johnstone et al., 2018). A formulation that does not hold this produces an explanation that describes what a person feels, but not why those feelings have taken this particular shape in this particular life.


This is where reflexivity becomes essential. When clinician and client hold different cultural frameworks, the formulation reflects not only the client's experience but the clinician's interpretive lens. Naming uncertainty, checking understanding, and revisiting interpretations is part of what makes intercultural formulation ethical, rather than merely well-intentioned.


Watercolour illustration of a therapy session showing integrated psychological formulation, where trauma, neurodivergence, and cultural context interact and are explored together between therapist and client.

From Additive to Integrative Psychological Formulation in Practice

Why Holding All Three Together Changes the Formulation

The three foundations above are sometimes approached as though they can be applied sequentially. You may have heard formulation language like this before: “There is a cultural factor here.”

“Do not forget the ADHD.”


The problem is not only that these observations are partial. It is that they remain separate. They identify strands of the picture without asking how those strands interact, amplify one another, or change the meaning of the presentation as a whole.


In the way I understand formulation, intersectionality offers the clearest theoretical basis for understanding why additive approaches fail (Crenshaw, 1989). Originally developed in legal studies, it describes how multiple systems of social identity and disadvantage produce qualitatively distinct experiences, not simply the sum of their parts. Applied to formulation, it helps explain why holding trauma, neurodivergence, and cultural context as separate accounts misses what is actually shaping the person's experience.


Consider a client presenting with chronic exhaustion, emotional shutdown, and difficulty sustaining relationships. Additively: shutdown as trauma response; shutdown as neurodivergent overwhelm; shutdown as the consequence of emotional restraint within a culture that offered limited space for expressed distress. Each may be accurate. What the additive approach cannot show is how these processes change one another.


A nervous system shaped by early threat does not encounter neurodivergent processing demands as a separate challenge. Hypervigilance and sensory overload amplify each other. Regulation resources stretched by one reduce capacity for the other. Likewise, a cultural context in which naming distress was unavailable or unsafe does not sit alongside these as a separate variable. It shapes whether trauma could be processed at all, whether the neurodivergent experience could be recognised, and what meanings were available to make sense of either.


Integrative formulation asks what happens when all three are held simultaneously. How does cultural context shape the way trauma was stored? How does neurodivergence shape which aspects of the environment create the most friction? How does trauma history limit current capacity to navigate environments that do not fit?


In my experience, the clinical cost of fragmentation is concrete. A client whose shutdown is formulated only through a trauma lens may be supported toward regulation work, appropriate but incomplete if the environment continues generating sensory overload that regulation alone cannot address. A client whose overworking is formulated only through a cultural lens may be supported toward examining expectations around worth, useful but insufficient if the hypervigilance beneath it has a trauma organisation that cognitive reframing will not reach.


What integrative thinking produces is greater accuracy, not greater complexity. The client's experience no longer needs to be simplified to fit the framework. The framework becomes adequate to the person.


It is worth being honest about what this requires. Holding three intersecting perspectives in a live session, with a real person and the limits of our own theoretical formation, is not straightforward. There are sessions where the complexity exceeds what can be held in the moment. Naming that something is not yet understood is not a failure of formulation. It is part of what integrative thinking asks of us.


And in formulation, accuracy is where the ethics live.


Many of these same themes can also be seen in people-pleasing, where trauma, adaptation, identity, culture, and belonging often become intertwined. If you would like to explore this further: The Psychology of People-Pleasing: Models, Research, and Clinical Formulation


Watercolour illustration of a person walking through a gently flowing river landscape, symbolising psychological integration as an ongoing process where multiple experiences blend into a single system rather than remaining separate.

Clinical Example: Integrative Formulation in Action

A client may come to therapy feeling exhausted and unable to switch off from work. At first glance, this may look like occupational stress. As formulation develops, a more layered picture emerges.


Through a trauma-informed lens

Early experiences of responsibility, where capability became closely linked to safety and worth. The body remains in readiness even without external demand, not as habit, but as a protective system that has never received reliable evidence that stopping is safe.


Through a neurodivergent-affirming lens

A processing style requiring significantly more energy to navigate communicative and social demands. What appears as long hours is partly the recovery time required after sustained social calibration. The exhaustion is not proportionate to task content. It is proportionate to what the environment has been demanding.


Through an intercultural lens

A migration context in which professional success carries meaning beyond achievement: proof of belonging, repayment of sacrifice, evidence that displacement was worth sustaining. Slowing down threatens a system of meaning organised around demonstrating worth.


Formulated additively, these three accounts sit alongside one another. Formulated integratively, something different becomes visible: a system in which threat, effort, and meaning converge on the same behaviour. The overworking is not three separate things happening at once. It is one pattern that makes sense at all three levels simultaneously.


This changes what the intervention must be, and what it cannot be. Not only reducing workload, but working with meaning, nervous system organisation, and environmental demands in relation to each other. Not in sequence. Together.


An intervention that addresses only one thread will reach a limit. The integrative formulation tells you where that limit is, and what has not yet been reached.


Watercolour illustration of a person standing calmly at a forked path, pausing between two directions, representing psychological formulation supporting conscious choice, agency, and reduced automatic responses.

What Good Formulation Practice Requires

In my work, I have come to think of good formulation practice less as a checklist and more as a clinical orientation.


Good formulation practice begins with curiosity rather than certainty. It holds formulation as a working hypothesis, not a conclusion. It remains genuinely open to what has not yet been understood. It is flexible, able to revise as new material becomes available without treating revision as failure. It is collaborative, developed with the client, shaped by their perspective and their sense of what resonates, rather than applied to them from outside.


It avoids pathologising adaptation, flattening complexity, and disconnecting formulation from intervention. A formulation that explains but does not inform treatment decisions remains incomplete, however carefully constructed.


There is also a relational dimension that is easy to understate. The quality of formulation does not depend only on theoretical knowledge. It is shaped by the quality of attention we bring, what we are willing to see, what we stay curious about, and what we allow to unsettle our existing understanding.


In this sense, good formulation practice is as much about who we are as clinicians as about what we know. Formulation asks something of us the clinicians too. It asks us to notice what we can stay with, what we move away from, and what we may be tempted to simplify too quickly.


What we cannot hold in ourselves, we cannot hold for a client either.


Formulation in Complex Clinical Contexts: Beyond Individual Therapy

Formulation has a central role beyond the individual therapy room.


When clinical work moves beyond one clinician and one client, formulation becomes even more important. The more people involved in a person’s care, the easier it is for understanding to become fragmented.


Different professionals may each see something important. One person may be focused on risk. Another may be focused on symptoms. Another may be holding the relational picture, the family context, or the wider system around the person.

These perspectives do not necessarily contradict one another. But without a shared formulation, they can remain separate. In complex cases, formulation can become the thread that helps the work stay connected.


In risk and forensic settings, formulation supports understanding of triggers, patterns, protective factors, and the person’s actual history, rather than relying on categorical risk assessment alone.


In supervision, formulation is one of the central objects of clinical thinking. It is where we clinicians’ theoretical assumptions become visible, where the interaction between the therapist’s own frameworks and the client’s experience can be examined, and where reflexive practice is developed.


Supervising formulation means supervising not only the case, but the thinking that produced it. This is where much of the most important clinical learning happens.


Watercolour illustration of two people sitting in a calm shared space, with a soft, evolving abstract form between them, representing psychological formulation as a collaborative and emerging process of shared understanding.

Psychological Formulation in Clinical Supervision

The kind of formulation described in this article is not a model to be applied. It is a way of attending to what is present, what is adaptive, what is systemic, and what is produced when these layers meet.


In my own practice, formulation is a continuous process. It is not finalised at assessment and revisited only when therapy stalls. It develops through the relationship, refined by what becomes available as safety increases and as material that was not yet accessible begins to emerge. The three foundations described here are part of how I orient to a presentation from the beginning: what questions I stay curious about, and what I hold lightly rather than conclude too quickly.


In supervision, I am particularly interested in formulation as a live process: not what was understood at the start of a case, but how thinking develops as the work deepens, where it gets stuck, and what those sticking points reveal about both the client and we clinicians' own frameworks. This is supervision for clinicians working with presentations that resist easy categorisation: those navigating the intersection of trauma and identity, late-identified neurodivergent adults, clients from bicultural and migration backgrounds, or cases where single-model formulation has reached its limits.


The supervision relationship is held with the same principles described throughout this article: collaborative, reflexive, and attentive to the way we clinicians' own experience, history, and cultural positioning shape what they are able to see. My aim is not to offer a more elaborate formulation. It is to support the development of clinical thinking that can stay with complexity without closing it down too quickly.


If this reflects the kind of clinical thinking you are developing, I would be glad to have a conversation.


Conclusion

Psychological formulation is not only a method of understanding. It is a clinical process that shapes how therapy is approached, how decisions are made, and how change is supported.

Its value lies in creating a framework that connects past and present, holds complexity rather than reducing it, and informs the direction of therapeutic work. When formulation is trauma-informed, it recognises adaptation. When it is neurodivergent-affirming, it attends to difference and the cost of mismatch. When it is interculturally grounded, it holds the systemic and relational conditions that shaped how distress developed and has been carried.


When these perspectives are held together as genuinely integrated thinking rather than separate analyses placed alongside each other, formulation becomes more accurate, more ethical, and more clinically useful. I do not think formulation is at its best when it asks people to become simpler than they are. I think it is at its best when it becomes adequate to the person.


I do not think formulation is a skill that is mastered and then maintained. It develops alongside clinical experience, reflexive practice, and a willingness to hold uncertainty about what we think we already understand. That is not only a clinical standard. It is an ethical one.



Suggested Reading



Frequently Asked Questions

What is the difference between trauma-informed formulation and standard psychological formulation?

Standard formulation develops an understanding of how difficulties have developed and what maintains them. Trauma-informed formulation does this with a specific orientation: it begins from the premise that many psychological responses are adaptations to threat or overwhelming experience, rather than symptoms of disorder. The question shifts from what is wrong to what has this made possible, and under what conditions. This changes how patterns are interpreted: avoidance, shutdown, and hypervigilance are understood as protective before their cost is considered.


What does neurodivergent-affirming formulation involve in practice?

It involves holding the distinction between difference and deficit throughout the formulation process. This means attending to person-environment mismatch, recognising the effort behind presentations that appear functional, and not interpreting neurodivergent adaptations, particularly masking, as evidence of wellness. It also means slowing the formulation process and remaining open to revision, particularly in early sessions where what is presented may reflect a learned, adapted self rather than the full clinical picture.


How does intercultural context change clinical formulation?

It changes what counts as an explanation. Behaviours that might be formulated as cognitive patterns, emotional avoidance, or interpersonal difficulties often have a cultural dimension that is central rather than peripheral. Intercultural formulation asks what the behaviour means within the client's cultural and relational context, not only what function it serves psychologically. This requires us to attend to their own cultural frameworks and what those frameworks may be imposing on the clinical material.


What is the difference between additive and integrative formulation?

Additive formulation applies each perspective in sequence and places the analyses alongside each other. Integrative formulation asks how they interact, how cultural context shapes the experience of trauma, how neurodivergence shapes what aspects of the environment produce the most friction, and how the trauma history limits the capacity to navigate environments that do not fit. The clinical difference is significant: integrative formulation identifies the compound effects that additive formulation misses, and produces interventions more precisely aligned with how the difficulty is actually organised.


How is formulation used in clinical supervision?

Supervision offers a space to examine the formulation itself, not only the clinical material, but the thinking that produced it. This includes identifying theoretical assumptions shaping what is visible, attending to what has been formulated and what has not, and considering whether the clinician's framework is the right fit for the case. Supervising formulation as a live process is often where the most significant clinical development happens, particularly for clinicians working with presentations at the intersection of trauma, neurodivergence, and cultural context.


How do I know if a formulation needs to be revised?

Reformulation is not always signalled by crisis or stuck points. Sometimes it becomes necessary when earlier assumptions feel increasingly insufficient, when the client's experience seems to exceed what the current formulation can hold, or when progress in one area reveals something that was not previously visible. Remaining genuinely open to this, rather than investing in the coherence of an existing account, is both a clinical skill and an ethical stance. The formulation is always a hypothesis, not a conclusion.



Author bio

Dr Tiffany Leung is a UK-based chartered psychologist with 14+ years of experience in therapy, clinical supervision, and training. She holds a Professional Doctorate in Counselling Psychology from the University of Manchester, where she is also an Honorary Lecturer in Intercultural Public Health. She works within the NHS and in independent practice, supporting clients in English, Cantonese, and Mandarin.


Clinical Supervision with Dr Tiffany Leung

I offer integrative clinical supervision to therapists, counsellors, and counselling psychologists working at the intersection of trauma, neurodivergence, and intercultural experience. My focus is on formulation as a live process: how clinical thinking develops as the work deepens, where it gets stuck, and what those sticking points reveal about both the client and our own frameworks.


This space is for clinicians ready to stay with complexity rather than resolve it prematurely: those working with late-identified neurodivergent adults, clients from bicultural and migration backgrounds, or cases where single-model formulation has reached its limits.



Dr Tiffany Leung · UK-based psychologist practising in Cantonese, Mandarin, and English · Honorary Lecturer in Intercultural Public Health, University of Manchester · NHS background in complex mental health.



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