Understanding
the difficulty together.
She decided it was avoidance. It was pain.
How to build a working understanding with the client, take the body and the world seriously, and keep revising it.
What this is: a guide to collaborative formulation in pluralistic therapy.
Why it matters: a wrong understanding leads to the wrong help.
The sharpest reframe: a formulation is a hypothesis the client can correct.
One thing to take away: keep the body and the world in the picture.
The short version
A formulation is a working understanding of someone’s difficulties and possible routes to change. In pluralistic therapy, it is built with the client, draws on more than one theory where that helps, and is revised as the work goes on. For disabled clients, a good formulation takes the body, access and the world seriously, without reducing everything to disability or ignoring it. This page uses this site’s six-area map as a teaching tool and follows one fictional formulation as it changes.
You might recognise this
Illustrative statementsDrawn together from common experiences. They are not quotes from individual people.
What a formulation is
Established conceptFormulation is widely used across psychological therapies to make sense of a person’s difficulties: what might have contributed, what keeps them going, and what might help. Different approaches formulate in different ways. Johnstone and Dallos’s edited book sets out formulation across several traditions, and the idea that a formulation is a hypothesis to be tested and revised, not a fixed truth.
Our frameworkIn pluralistic work, it makes sense for formulation to be collaborative and open to more than one theory. A painful experience might be understood through relationships, learned expectations, the body, money and current exclusion, all at once.
The six-area map
Our frameworkThis is a teaching map used on this site. It isn’t part of Cooper and McLeod’s framework, and it isn’t a diagnostic tool.
Person and direction
What matters to you, and what do you want help with?
Body and access
What sensations, impairments, energy demands and arrangements matter here?
Relationships
What happens with other people, including the therapist?
World
What material conditions and barriers play a part?
Meaning
What does this experience say to you about yourself or others?
Method, feedback and revision
What shall we try, how will we know, and what would make us change it?
Siún is 44 and has rheumatoid arthritis. She was referred for “activity avoidance and low mood”. She hasn’t been to her book club for four months.
Siún is a fictional teaching example, not a real person.
Building it together
Our frameworkWhat the referral suggested
Low mood leads to avoiding activities, which leads to lower mood. This is a reasonable starting idea, and it points towards behavioural methods.
The therapist’s thinking
It’s a hypothesis, not a finding. I’ll put it on the table and see what Siún makes of it.
What she added
Siún crossed out “avoidance”. The therapist didn’t simply swap one explanation for another. They asked more: was she avoiding other things too, or just this? She wasn’t; she still saw friends one to one. The book club meets upstairs in a pub with no lift, and sitting on hard chairs for two hours leaves her in pain for two days. She does miss it. She also said she felt like “the sick one” there since her diagnosis, and that she’d stopped being invited to the walks afterwards.
Using the map
Body and access: stairs, seating and the pain cost of going. World: an inaccessible venue. Relationships: feeling sidelined by friends. Meaning: “I’m the sick one now.” Person and direction: she wants to keep her friendships, not necessarily the book club.
What wasn’t clear
The therapist wasn’t sure how much was mood and how much was the situation. Siún said: “Both, probably.” They left it like that.
What they tried
Siún decided to suggest to the group that they meet at a member’s house with comfortable chairs. Alongside that, they looked at the “sick one” story: where it came from, and whether her friends saw her that way.
Revision
Why this method? Looking at the “sick one” story
Our framework- The reasoning: to understand a meaning that seemed to be affecting Siún’s sense of belonging and her friendships, separately from the practical barriers.
- What would challenge this understanding: if her friends clearly didn’t see her that way, or the feeling disappeared once access was sorted.
- What burden it might create: talking about how others see you can be painful, and could imply the problem is in her head.
- What would tell us to adapt or stop: if the work started to feel like blaming her for being left out.
- What the therapist needs to offer it: skills in exploring meaning and identity, and care not to psychologise exclusion.
The group agreed to move. Siún went twice, enjoyed it, and felt less like the sick one. But her mood stayed low on flare days, regardless of anything else. They added a new strand: planning for flares, and grief about the unpredictability of her condition.
Principles for formulating together
Our frameworkHypotheses, not verdicts
Offer ideas as possibilities, and invite correction. A correction is information to explore, not automatically the final answer, for either of you.
Make it visible
Draw it, write it, or use a format the person can change.
Don’t reduce to disability
Not everything is about impairment.
Don’t ignore it either
Pain, access and barriers are part of the picture.
Keep the world in
Some contributors are in services, buildings and money, not in the person.
Revise it
A formulation that never changes has probably stopped listening.
What needs attention here?
A behaviour looks like avoidance
Possible focus: asking what it costs the person
Watch for: assuming a psychological cause
The person corrects the formulation
Possible focus: treating the correction as information
Watch for: defending the original idea
Everything is being explained by disability
Possible focus: looking for other contributors
Watch for: reading all distress through impairment
Disability is left out entirely
Possible focus: including body, access and barriers
Watch for: treating the person as if impairment didn’t matter
Possible starting points, agreed with the person, not rules.
How you’d know it helped
Two different questions: whether the work is going well, and whether it is actually helping.
Is the work collaborative and accessible?
- The person recognises themselves in the formulation.
- Their corrections were explored and taken seriously.
Is it helping with what matters?
- It points to things to try, inside and outside therapy, that help.
- The person understands their difficulty in a way that is useful to them.
Words you can use
For clientsQuestions worth carrying, as a therapist
Therapist Reflection- Did I offer my understanding as a possibility, or a conclusion?
- When did the person last change the formulation?
- Where have I left out the body, or the world?
- Where have I explained too much by disability?
Evidence & sources
Sources checked in October 2026, using targeted searches rather than a systematic review. “We have not located” means our searches did not find it.
Johnstone, L. & Dallos, R. (Eds.) (2014), Formulation in Psychology and Psychotherapy: Making Sense of People’s Problems (2nd ed.). London: Routledge.
Cooper, M. & McLeod, J. (2011), Pluralistic Counselling and Psychotherapy. London: Sage.
The six-area map, the principles and the worked formulation are this site’s synthesis. The map is a teaching tool, not a validated instrument.
Siún and her formulation are constructed for learning. She is not a real person.
Our targeted searches did not find studies of collaborative formulation in pluralistic therapy designed around disability.
Last reviewed: October 2026.
How to cite this page: Donaghey, C. (2026). Understanding the Difficulty Together. Disability in Psychotherapy. Available at: https://disabilityinpsychotherapy.online/what-is-psychotherapy/pluralistic-psychotherapy/understanding-the-difficulty-together/ (Accessed: [date]).