One of the things I’ve been thinking about more and more over the last few years is why people can receive genuinely thoughtful, evidence-based care and still leave feeling as though they’ve somehow failed.
Not because the advice was poor. Not because the clinician lacked expertise. Not because the person wasn’t trying.
And yet somewhere between understanding the advice and being able to apply it in the context of their own life, something didn’t quite fit.
By the time many people come to see me they have already done an enormous amount of work. They’ve read the books, listened to the podcasts, seen multiple health professionals, diligently completed worksheets, followed meal plans, challenged thoughts, practised mindfulness, and repeatedly promised themselves that this time they will finally get it right. They aren’t arriving because they haven’t tried. If anything, they’re arriving because they’ve tried so many different things that they’re beginning to wonder whether they’re simply beyond help.
I’ve come to think that this is one of the saddest conclusions people reach because it usually isn’t the one that makes the most sense. If somebody has spent years genuinely trying to understand themselves and repeatedly finds themselves asking, “Why has nothing worked?”, I don’t immediately wonder whether they aren’t motivated enough or whether they’re resistant to change. I wonder whether we’re still missing something. Not because every explanation is equally valid. But because every explanation is a hypothesis.
The question is not whether an explanation could account for somebody’s behaviour. The question is whether it does. Does it adequately explain this person’s experience, with this brain, this body, this learning history, these relationships, these values, these constraints and this set of circumstances as they exist today?
That has become one of the guiding questions in my clinical work. Interestingly, it has also been a recurring theme throughout my career.
During my PhD I remember presenting a conceptual model and receiving feedback that it had become a “spaghetti diagram”. I had continued adding arrows until almost everything seemed to influence everything else, and the criticism was that I was making the model unnecessarily complicated. At the time I assumed they were probably right (and changed it accordingly).
Looking back, I think I was wrestling with a different problem. I wasn’t trying to make the model more complicated. I was trying to stop it becoming too simple.
Good models simplify reality. They have to. Otherwise, they become impossible to use. At the same time, there comes a point where removing another arrow, another contextual factor, or another interaction no longer makes the model clearer – it makes it less accurate. Somewhere along that continuum, we stop describing the person sitting in front of us and start describing an idealised version of them that is easier to fit into a diagram. I’ve realised over the years that this tension probably sits at the heart of how I think about therapy.
I’ve always found it difficult to separate people into neat categories because life simply doesn’t unfold that way. I don’t mean that everything is equally important or that every possible explanation should be included. Quite the opposite. One of the most important parts of formulation is working out which factors are actually doing the heaviest lifting for this person, at this point in time. What I do mean is that people rarely experience one difficulty in isolation.
Take somebody living with ADHD, chronic illness, and an eating disorder. It can be tempting to ask whether their difficulties with eating are driven by executive functioning, sensory sensitivities, years of dietary restraint, changes in hunger and fullness cues, chronic fatigue, grief, body image, perfectionism, or emotion regulation. My experience is that the answer is often some version of, “Yes… and.”
Not because every explanation is correct, but because these factors influence one another over time. Dietary restraint changes hunger, which changes eating behaviour, which influences shame, which affects emotional capacity, which alters executive functioning, which changes the decisions available to somebody, which then feeds back into eating again. Chronic illness influences energy, but it also influences identity, opportunities, social relationships, and what is realistically possible in any given week. Neurodivergence shapes sensory experiences, but those sensory experiences also influence eating, movement, routines, emotional regulation, and interactions with other people. The relationships aren’t linear, and they aren’t static. They change over time as circumstances change.
This is one of the reasons I find myself becoming cautious whenever an explanation feels too neat. Not because simple explanations are always wrong. Sometimes they are exactly right. But because I think it’s worth asking one more question before we settle on them.
What aren’t we accounting for yet?
That question has probably shaped my work more than any particular therapeutic model.
People often ask me what approach I use, and while I absolutely draw on psychological theory and evidence, I don’t tend to start there. I start by listening for the way somebody explains themselves. I’m listening for where those explanations came from, what assumptions they rest upon, whether they adequately account for the person’s context, and whether there are important influences that have quietly dropped out of the story.
Sometimes people have overlooked something obvious because they are too close to it. Sometimes they’ve inherited explanations from diet culture, healthcare, family, school or broader societal messages that have become so familiar they no longer recognise them as assumptions. Sometimes the explanation fit ten years ago but no longer fits the person they have become. Sometimes the explanation was never quite right in the first place.
Research is enormously valuable in helping us test those hypotheses. I’ve spent much of my career conducting research and I remain deeply committed to evidence-informed practice. Research tells us about averages. It tells us what tends to happen across groups of people, what variables appear to be connected, and which interventions are associated with better outcomes. Those are incredibly important questions because they illuminate patterns that none of us could observe through clinical work alone.
Therapy, however, asks a different question.
“Given everything we know from research, how does that help us understand this particular person?”
Those are related questions, but they are not identical.
Between-person research can never fully explain an individual, just as one person’s lived experience can never replace research. Both have strengths. Both have limitations. The task isn’t to choose between them. It’s to integrate them until the explanation fits well enough that it begins to illuminate a path forwards.
One of my favourite pieces of research that I ever conducted involved collecting intensive data from individuals over time before sitting down with them in what we called a data-driven interview. The data identified patterns that the person hadn’t noticed. The person provided context that the data could never have captured. Neither source of information was sufficient on its own. Together they became something much richer than either could have achieved independently.
Looking back, I think that project quietly shaped the way I practise today.
People sometimes assume that therapy is primarily about giving advice. Advice certainly has its place. So do skills. So does psychoeducation. But I’ve increasingly come to think that one of the most valuable things therapy can offer is a formulation that genuinely fits. Because once an explanation adequately accounts for the reality of a person’s life, they’re no longer trying to force themselves into someone else’s model. They’re able to make decisions that are grounded in who they are, the circumstances they’re living in, and the capacity they have available to them today.
