Explanation of information obtained from a clinical assessment
Aclinical formulation, also known ascase formulation andproblem formulation, is a theoretically-based explanation or conceptualisation of the information obtained from a clinical assessment. It offers a hypothesis about the cause and nature of the presenting problems and is considered an adjunct or alternative approach to the more categorical approach of psychiatricdiagnosis.[1] In clinical practice, formulations are used to communicate ahypothesis and provide framework for developing the most suitable treatment approach. It is most commonly used byclinical psychologists and is deemed to be a core component of that profession.[2] Mental health nurses,[3] social workers, and some psychiatrists[4] may also use formulations.
Different psychological schools or models utilize clinical formulations, includingcognitive behavioral therapy (CBT) and related therapies:systemic therapy,[5]psychodynamic therapy,[6] andapplied behavior analysis.[7] The structure and content of a clinical formulation is determined by the psychological model. Most systems of formulation contain the following broad categories of information: symptoms and problems; precipitating stressors or events; predisposing life events or stressors; and an explanatory mechanism that links the preceding categories together and offers a description of the precipitants and maintaining influences of the person's problems.[8]
A model of formulation that is more specific to CBT is described by Jacqueline Persons.[13] This has seven components: problem list, core beliefs, precipitants and activating situations, origins, working hypothesis, treatment plan, and predicted obstacles to treatment.
A psychodynamic formulation would consist of a summarizing statement, a description of nondynamic factors, description of core psychodynamics using a specific model (such asego psychology,object relations orself psychology), and a prognostic assessment which identifies the potential areas ofresistance in therapy.[6]
One school of psychotherapy which relies heavily on the formulation iscognitive analytic therapy (CAT).[14] CAT is a fixed-term therapy, typically of around 16 sessions. At around session four, a formal written reformulation letter is offered to the patient which forms the basis for the rest of the treatment. This is usually followed by a diagrammatic reformulation to amplify and reinforce the letter.[15]
Many psychologists use anintegrative psychotherapy approach to formulation.[16][17] This is to take advantage of the benefits of resources from each model the psychologist is trained in, according to the patient's needs.[18]
The quality of specific clinical formulations, and the quality of the generaltheoretical models used in those formulations, can be evaluated with criteria such as:[19]
Clarity and parsimony: Is the model understandable andinternally consistent, and are key concepts discrete, specific, and non-redundant?
Comprehensiveness and generalizability: Is the modelholistic enough to apply across a range of clinical phenomena?
Utility and applied value: Does it facilitate sharedmeaning-making between clinician and client, and are interventions based on the model shown to beeffective?
Formulations can vary in temporal scope from case-based to episode-based or moment-based, and formulations may evolve during the course of treatment.[20] Therefore, ongoing monitoring, testing, and assessment during treatment are necessary: monitoring can take the form of session-by-session progress reviews using quantitative measures, and formulations can be modified if an intervention is not as effective as hoped.[21][22]
PsychologistGeorge Kelly, who developedpersonal construct theory in the 1950s, noted his complaint against traditional diagnosis in his bookThe Psychology of Personal Constructs (1955): "Much of the reform proposed by the psychology of personal constructs is directed towards the tendency for psychologists to impose preemptive constructions upon human behaviour. Diagnosis is all too frequently an attempt to cram a whole live struggling client into a nosological category."[23]: 154 In place of nosological categories, Kelly used the word "formulation" and mentioned two types of formulation:[24]: 337 a first stage ofstructuralization, in which the clinician tentatively organizes clinical case information "in terms of dimensions rather than in terms of disease entities"[23]: 192 while focusing on "the more important ways in which the client can change, and not merely ways in which the psychologist can distinguish him from other persons",[23]: 154 and a second stage ofconstruction, in which the clinician seeks a kind of negotiated integration of the clinician's organization of the case information with the client's personal meanings.[25]
PsychologistsHans Eysenck,Monte B. Shapiro,Vic Meyer, and Ira Turkat were also among the early developers of systematic individualized alternatives to diagnosis.[26]: 4 Meyer has been credited with providing perhaps the first training course ofbehaviour therapy based on a case formulation model, at theMiddlesex Hospital Medical School in London in 1970.[1]: 13 Meyer's original choice of words for clinical formulation were "behavioural formulation" or "problem formulation".[1]: 14
^abcBruch, Michael, ed. (2015) [1998].Beyond diagnosis: case formulation in cognitive behavioural therapy. Wiley series in clinical psychology (2nd ed.). Chichester, UK; Malden, MA:John Wiley & Sons.ISBN9781119960768.OCLC883881251.
^Butler, Gillian (1998). "Clinical formulation". In Bellack, Alan S.; Hersen, Michel (eds.).Comprehensive clinical psychology. Vol. 6 (1st ed.). Amsterdam; New York: Pergamon. pp. 1–24.doi:10.1016/B0080-4270(73)00186-3.ISBN0080427073.OCLC38048834.
^abPerry, Samuel; Cooper, Arnold M.;Michels, Robert (May 1987). "The psychodynamic formulation: its purpose, structure, and clinical application".The American Journal of Psychiatry.144 (5):543–550.doi:10.1176/ajp.144.5.543.PMID3578562.
^Tsai, Mavis; Kohlenberg, Robert J.; Kanter, Jonathan W.; Holman, Gareth; Loudon, Mary Plummer (2012).Functional analytic psychotherapy: distinctive features. The CBT distinctive features series. Hove, East Sussex; New York:Routledge.ISBN9780415604031.OCLC698324521.
^Basseches, Michael; Mascolo, Michael F. (2009). "Psychotherapy as a developmental process: implications and future directions for psychotherapy research, practice, and training".Psychotherapy as a developmental process. New York:Routledge. pp. 283–312.ISBN9780805857306.OCLC244063508.
Frank, Rochelle I.; Davidson, Joan (2014).The transdiagnostic road map to case formulation and treatment planning: practical guidance for clinical decision making. Oakland, CA:New Harbinger Publications.ISBN9781608828951.OCLC819383623.
Haynes, Stephen N.; O'Brien, William Hayes; Kaholokula, Joseph Keaweʻaimoku (2011).Behavioral assessment and case formulation. Hoboken, NJ:John Wiley & Sons.ISBN9781118018644.OCLC701808359.
Ingram, Barbara Lichner (2012) [2006].Clinical case formulations: matching the integrative treatment plan to the client (2nd ed.). Hoboken, NJ:John Wiley & Sons.ISBN9781118038222.OCLC723035074.
Johnstone, Lucy; Dallos, Rudi, eds. (2013) [2006].Formulation in psychology and psychotherapy: making sense of people's problems (2nd ed.). London; New York:Routledge.ISBN9780415682305.OCLC894506578.
Kleiger, Mary Jo Peebles (2012) [2002].Beginnings: the art and science of planning psychotherapy (2nd ed.). New York:Routledge.ISBN9780415883085.OCLC706022579.
Persons, Jacqueline B. (2008).The case formulation approach to cognitive-behavior therapy. Guides to individualized evidence-based treatment. New York:Guilford Press.ISBN9781593858759.OCLC226356799.
Zayfert, Claudia; Becker, Carolyn Black (2007).Cognitive-behavioral therapy for PTSD: a case formulation approach. Guides to individualized evidence-based treatment. New York:Guilford Press.ISBN9781593853693.OCLC71139450.
