Why Understanding Your Story Might Matter More Than Finding the Right Label: A Perinatal Psychologist's Guide to Formulation
Many people arrive in therapy hoping to finally understand what is wrong with them.
By the time they seek support, they have often spent months trying to make sense of what they are experiencing. They may have completed online questionnaires, searched endlessly for answers, listened to podcasts, read books, or spoken to healthcare professionals. Some have received diagnoses that feel validating and helpful. Others are left feeling that, although a label describes what they are experiencing, it doesn't really explain it.
This is particularly common during pregnancy and early parenthood. Someone may recognise that they are experiencing anxiety, low mood, intrusive thoughts, birth trauma, difficulties bonding with their baby, or a profound loss of confidence. However, understanding what something is does not necessarily help us understand why it is happening.
As a perinatal psychologist, I often find that the question people most want answered is not "What diagnosis do I have?" but "Why am I struggling in this way?"
This is where formulation becomes important.
Formulation sits at the heart of clinical psychology. While diagnoses aim to categorise patterns of symptoms, formulation aims to understand the individual person experiencing them. It is a way of bringing together the different pieces of somebody's story in order to develop a meaningful explanation of how their difficulties may have developed, what might be maintaining them, and what might help.
In many ways, formulation is the process of moving beyond labels and towards understanding.
What Is a Formulation?
A formulation is sometimes described as a psychological map.
When people are struggling, there are usually many different factors involved. Current circumstances, previous experiences, personality, relationships, coping strategies, physical health, stress, sleep, social support, and significant life events all interact with one another in complex ways.
A formulation attempts to make sense of these different influences and how they fit together.
Rather than asking whether somebody meets criteria for a particular diagnosis, formulation asks questions such as:
Why has this difficulty emerged now?
What experiences may have contributed to it?
What makes this particular person vulnerable to this particular difficulty?
What keeps the problem going?
What strengths and resources can be drawn upon?
What might help?
Importantly, formulations are individual. Two people can have very similar symptoms but entirely different formulations.
For example, two women may both experience significant anxiety during pregnancy. One may be navigating pregnancy after multiple losses and finding it difficult to trust that things will be okay. The other may have a longstanding tendency towards perfectionism and feel an overwhelming sense of responsibility for preventing anything bad from happening. Although the anxiety may look similar on the surface, the factors driving and maintaining it may be quite different.
This is one of the reasons why psychological therapy is rarely as simple as applying the same intervention to everyone with the same diagnosis.
Why the Perinatal Period Is So Important for Formulation
The transition to parenthood is one of the most significant psychological transitions many people will ever experience. Pregnancy, birth, and early parenthood involve changes in identity, relationships, responsibilities, daily routines, sleep, physical health, and future expectations. For some people, these changes occur alongside fertility treatment, previous losses, traumatic births, financial pressures, relationship difficulties, or a lack of social support.
Even positive experiences can be emotionally demanding. Becoming a parent often brings a heightened awareness of vulnerability, responsibility, and uncertainty. It can prompt reflection on our own childhoods, our relationships, and the kind of parent we hope to become.
When difficulties emerge during this period, it is tempting to search for a single explanation. However, most psychological difficulties are rarely caused by one thing alone. A formulation helps us understand how multiple factors interact.
For example, someone experiencing intense anxiety after the birth of their baby may be coping with sleep deprivation, a traumatic birth experience, a tendency towards self-criticism, a strong sense of responsibility for other people's wellbeing, and a lack of practical support. None of these factors alone fully explains the difficulty. Together, however, they begin to tell a meaningful story.
What Can CBT Contribute to a Formulation?
One of the most useful aspects of Cognitive Behavioural Therapy is its focus on understanding the patterns that maintain distress.
Many people assume that CBT is primarily concerned with changing negative thoughts. Modern CBT is often much more interested in understanding the processes that keep difficulties going. For example, a parent who becomes worried about their baby's health may begin checking constantly for signs of illness, searching online for reassurance, monitoring their baby's behaviour closely, and seeking repeated confirmation from others that everything is okay. All of these responses are understandable. Most begin as attempts to reduce anxiety and protect the baby.
However, they can also create a cycle in which anxiety remains highly active. The more the parent checks and seeks reassurance, the less opportunity they have to learn that uncertainty can be tolerated and that feared outcomes are often less likely than they imagine. From a CBT perspective, formulation helps identify these maintaining cycles. Rather than asking only why anxiety started, it asks what might be keeping it going now.
The same principle can be applied to many perinatal difficulties. Avoidance may maintain birth-related fears. Withdrawal may maintain low mood. Attempts to suppress intrusive thoughts may make those thoughts feel more significant and threatening. A CBT formulation therefore helps identify the patterns that therapy might usefully target.
What Does a Compassion-Focused Formulation Add?
Compassion-Focused Therapy brings a slightly different perspective. Where CBT often asks what is maintaining a difficulty, Compassion-Focused Therapy asks what function a particular response may be serving. Many parents are highly self-critical. They tell themselves that they should be coping better, enjoying parenthood more, feeling more grateful, or managing without support.
When we look at these patterns through a compassion-focused lens, something interesting often emerges. Self-criticism is rarely random. For many people, it developed as an attempt to motivate themselves, avoid mistakes, gain approval, or prevent rejection. Although it may now be causing distress, it often began as a strategy for coping with difficult circumstances.
A compassion-focused formulation helps us understand these protective intentions. Rather than seeing anxiety, perfectionism, people-pleasing, or self-criticism as evidence that something is wrong, we begin asking what these responses may have been trying to achieve. This shift can be enormously relieving for parents who have spent years blaming themselves for struggling.
What Role Do Attachment and Relationships Play?
One of the things formulation helps us appreciate is that people do not develop in isolation. Attachment theory suggests that early relationships help shape our expectations about ourselves and other people. Through repeated experiences, we develop beliefs about whether others can be relied upon, whether our needs matter, whether it is safe to seek support, and how emotions are handled within relationships.
These expectations are rarely conscious. Most of us are not aware of carrying them around. However, becoming a parent often activates them. Someone who learned early in life that they needed to cope alone may find it difficult to ask for help after having a baby. Someone who experienced inconsistency in relationships may find the uncertainty of pregnancy particularly difficult. Someone who felt responsible for managing other people's emotions may become overwhelmed by the constant demands of caregiving.
An attachment-informed formulation is not about blaming parents or searching for childhood causes of every difficulty. Rather, it recognises that our relational histories help shape how we experience the challenges of parenthood. Parenthood itself is also deeply relational. Difficulties affect partners, babies, families, and support networks. In turn, those relationships influence how difficulties are maintained or resolved. A good formulation therefore considers not only what is happening within a person but also what is happening between people.
What Does Neuroscience Add to Formulation?
One of the most common things people say in therapy is: "I know this doesn't make sense, but I still feel it." A parent may know logically that their baby is safe and yet continue to experience overwhelming anxiety. Someone may recognise that they are not failing and still feel intense shame. Neuroscience helps us understand why.
The brain learns through experience. Emotional learning is not stored only in conscious, verbal memories. It is also reflected in physiological responses, emotional expectations, habits, and patterns of nervous system activation. This means that insight alone is not always enough. Understanding something intellectually and feeling it emotionally are not necessarily the same thing.
A neuroscience-informed formulation helps explain why change often requires more than simply thinking differently. It may involve creating new experiences of safety, support, self-compassion, or connection that gradually allow the nervous system to update old expectations. This can be particularly relevant during the perinatal period, when pregnancy, birth, sleep deprivation, hormonal changes, and caring for a vulnerable baby place considerable demands on the nervous system.
Why Formulation Matters More Than Advice
One of the reasons I value formulation so highly is that it helps us avoid rushing prematurely to solutions. People often seek advice when they are struggling. Advice can certainly be useful. However, before deciding what might help, we need to understand the nature of the difficulty we are trying to address.
Two people may both be anxious, but one may benefit from reducing reassurance-seeking while another may need support processing trauma. One parent may need help developing self-compassion, while another may need practical support and greater connection with others.
Without formulation, it is easy to offer solutions that make sense in theory but miss the complexity of the individual experience. Formulation provides the foundation upon which meaningful therapeutic work is built.
From "What's Wrong With Me?" to "What Makes Sense?"
Perhaps the most valuable thing formulation offers is a shift in perspective. Many people arrive in therapy believing that their distress is evidence that something is wrong with them. They see anxiety, low mood, self-criticism, trauma responses, or relationship difficulties as signs that they are failing. Formulation invites a different question. Rather than asking what is wrong, it asks what makes sense.
Given your experiences, your relationships, your personality, your coping strategies, your responsibilities, and the circumstances you are living through, what makes sense about what you are experiencing?
This does not mean that difficulties become easy. Nor does it mean that painful experiences are inevitable. What it does mean is that distress becomes understandable. And when something becomes understandable, it often becomes easier to approach with curiosity, compassion, and hope.
In my experience, that is often where meaningful change begins. Not with finding the perfect label, but with developing a richer understanding of your own story.
