Clinical formulation

A clinical formulation, also known as case 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 psychiatric diagnosis.^[1] In clinical practice, formulations are used to communicate a hypothesis and provide framework for developing the most suitable treatment approach. It is most commonly used by clinical psychologists and psychiatrists^[2] and is deemed to be a core component of these professions.^[3] Mental health nurses and social workers also use formulations.^[4]

Types of formulation

Different psychological schools or models utilize clinical formulations, including cognitive behavioral therapy (CBT) and related therapies: systemic therapy,^[5] psychodynamic therapy,^[6] and applied 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]

Behavioral case formulations used in applied behavior analysis and behavior therapy are built on a rank list of problem behaviors,^[7] from which a functional analysis is conducted,^[9] sometimes based on relational frame theory.^[10] Such functional analysis is also used in third-generation behavior therapy or clinical behavior analysis such as acceptance and commitment therapy^[11] and functional analytic psychotherapy.^[12] Functional analysis looks at setting events (ecological variables, history effects, and motivating operations), antecedents, behavior chains, the problem behavior, and the consequences, short- and long-term, for the behavior.^[9]

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 as ego psychology, object relations or self psychology), and a prognostic assessment which identifies the potential areas of resistance in therapy.^[6]

One school of psychotherapy which relies heavily on the formulation is cognitive 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 an integrative 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]

Critical evaluation of formulations

The quality of specific clinical formulations, and the quality of the general theoretical models used in those formulations, can be evaluated with criteria such as:^[19]

• Clarity and parsimony: Is the model understandable and internally consistent, and are key concepts discrete, specific, and non-redundant?
• Precision and testability: Does the model produce testable hypotheses, with operationally defined and measurable concepts?
• Empirical adequacy: Are the posited mechanisms within the model empirically validated?
• Comprehensiveness and generalizability: Is the model holistic enough to apply across a range of clinical phenomena?
• Utility and applied value: Does it facilitate shared meaning-making between clinician and client, and are interventions based on the model shown to be effective?

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]

See also

• Clinical decision support system
• Clinical guideline
• Clinical pathway
• Common factors theory
• Problem structuring methods
• Therapeutic assessment

References

1. Bruch, Michael; Bond, Frank W., eds. (1998). Beyond diagnosis: case formulation approaches in CBT. The Wiley series in clinical psychology. Chichester, UK; New York: John Wiley & Sons. ISBN 0471975257. OCLC 38486295.
2. Mace, Chris; Binyon, Sharon (October 2005). "Teaching psychodynamic formulation to psychiatric trainees. Part 1: Basics of formulation". Advances in Psychiatric Treatment. 11 (6): 416–423. doi:10.1192/apt.11.6.416.
3. Butler, Gillian (1998). "Clinical formulation". In Bellack, Alan S.; Hersen, Michel. Comprehensive clinical psychology. 6 (1st ed.). Amsterdam; New York: Pergamon. pp. 1–24. doi:10.1016/B0080-4270(73)00186-3. ISBN 0080427073. OCLC 38048834.
4. Crowe, Marie; Carlyle, David; Farmar, R. (December 2008). "Clinical formulation for mental health nursing practice" (PDF). Journal of Psychiatric and Mental Health Nursing. 15 (10): 800–807. doi:10.1111/j.1365-2850.2008.01307.x. PMID 19012671.
5. Pinsof, William; Breunlin, Douglas C.; Russell, William P.; Lebow, Jay (September 2011). "Integrative problem-centered metaframeworks therapy II: planning, conversing, and reading feedback" (PDF). Family Process. 50 (3): 314–336. doi:10.1111/j.1545-5300.2011.01361.x. PMID 21884073.
6. Perry, 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. PMID 3578562.
7. Cipani, Ennio; Golden, Jeannie A. (2007). "Differentiating behavioral & traditional case formulations for children with severe behavioral & emotional problems". International Journal of Behavioral Consultation and Therapy. 3 (4): 537–545. doi:10.1037/h0100821.
8. Eells, Tracy D.; Kendjelic, Edward M.; Lucas, Cynthia P. (Spring 1998). "What's in a case formulation?: development and use of a content coding manual". The Journal of Psychotherapy Practice and Research. 7 (2): 144–153. PMC 3330487. PMID 9527958.
9. Kanter, Jonathan W.; Cautilli, Joseph D.; Busch, Andrew M.; Baruch, David E. (2005). "Toward a comprehensive functional analysis of depressive behavior: five environmental factors and a possible sixth and seventh" (PDF). The Behavior Analyst Today. 6 (1): 65–81. doi:10.1037/h0100055.
10. Zettle, Robert D. (2007). ACT for depression: a clinician's guide to using acceptance & commitment therapy in treating depression. Oakland, CA: New Harbinger Publications. ISBN 9781572245099. OCLC 148853276.
11. Hayes, Steven C.; Strosahl, Kirk D.; Luoma, Jayson; Smith, Alethea A.; Wilson, Kelly G. (2004). "ACT case formulation". In Hayes, Steven C.; Strosahl, Kirk. A practical guide to acceptance and commitment therapy. New York: Springer. pp. 59–73. doi:10.1007/978-0-387-23369-7_3. ISBN 0387233679. OCLC 55534832.
12. 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. ISBN 9780415604031. OCLC 698324521.
13. Persons, Jacqueline B. (1989). Cognitive therapy in practice: a case formulation approach (1st ed.). New York: W.W. Norton & Co. ISBN 0393700771. OCLC 19125638.
14. Ryle, Anthony (2005). "Cognitive analytic therapy". In Norcross, John C.; Goldfried, Marvin R. Handbook of psychotherapy integration. Oxford series in clinical psychology (2nd ed.). New York: Oxford University Press. pp. 196–217. ISBN 0195165799. OCLC 54803644.
15. Denman, Chess (July 2001). "Cognitive–analytic therapy". Advances in Psychiatric Treatment. 7 (4): 243–252. doi:10.1192/apt.7.4.243.
16. Caspar, Franz; Silberschatz, George; Goldfried, Marvin; Watson, Jeanne C. (March 2010). "Similarities and differences in four views of David". Journal of Psychotherapy Integration. 20 (1): 101–110. doi:10.1037/a0018886.
17. Eells, Tracy D. (December 2013). "In support of evidence-based case formulation in psychotherapy (from the perspective of a clinician)". Pragmatic Case Studies in Psychotherapy. 9 (4): 457–467. doi:10.14713/pcsp.v9i4.1836.
18. Persons, Jacqueline B. (December 2013). "Who needs a case formulation and why: clinicians use the case formulation to guide decision-making". Pragmatic Case Studies in Psychotherapy. 9 (4): 448–456. doi:10.14713/pcsp.v9i4.1835.
19. Dawson, David L.; Moghaddam, Nima G. (2016). "Formulation in action: an introduction" (PDF). In Dawson, David L.; Moghaddam, Nima G. Formulation in action: applying psychological theory to clinical practice. Berlin; New York: Walter de Gruyter. pp. 3–8 [7]. ISBN 9783110470994. OCLC 932645602.
20. Schacht, Thomas E. (December 1991). "Formulation-based psychotherapy research: some further considerations". American Psychologist. 46 (12): 1346–1347. doi:10.1037/0003-066X.46.12.1346.
21. Eells, Tracy D. (December 2013). "The case formulation approach to psychotherapy research revisited". Pragmatic Case Studies in Psychotherapy. 9 (4): 426–447. doi:10.14713/pcsp.v9i4.1834.
22. 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. ISBN 9780805857306. OCLC 244063508.

Further reading

• Eells, Tracy D., ed. (2007) [1997]. Handbook of psychotherapy case formulation (2nd ed.). New York: Guilford Press. ISBN 9781593853518. OCLC 65617415.
• 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. ISBN 9781608828951. OCLC 819383623.
• Goldman, Rhonda N.; Greenberg, Leslie S. (2015). Case formulation in emotion-focused therapy: co-creating clinical maps for change. Washington, DC: American Psychological Association. ISBN 9781433818202. OCLC 878667783.
• Hallam, Richard S. (2013). Individual case formulation. Practical resources for the mental health professional. Amsterdam: Elsevier/Academic Press. ISBN 9780123982698. OCLC 819717435.
• Haynes, Stephen N.; O'Brien, William Hayes; Kaholokula, Joseph Keaweʻaimoku (2011). Behavioral assessment and case formulation. Hoboken, NJ: John Wiley & Sons. ISBN 9781118018644. OCLC 701808359.
• Ingram, Barbara Lichner (2012) [2006]. Clinical case formulations: matching the integrative treatment plan to the client (2nd ed.). Hoboken, NJ: John Wiley & Sons. ISBN 9781118038222. OCLC 723035074.
• Johnstone, Lucy; Dallos, Rudi, eds. (2013) [2006]. Formulation in psychology and psychotherapy: making sense of people's problems (2nd ed.). London; New York: Routledge. ISBN 9780415682305. OCLC 894506578.
• Kleiger, Mary Jo Peebles (2012) [2002]. Beginnings: the art and science of planning psychotherapy (2nd ed.). New York: Routledge. ISBN 9780415883085. OCLC 706022579.
• Persons, Jacqueline B. (2008). The case formulation approach to cognitive-behavior therapy. Guides to individualized evidence-based treatment. New York: Guilford Press. ISBN 9781593858759. OCLC 226356799.
• Wilson, F. Robert (2012). "Assessment, diagnosis, and treatment planning from the ecological perspective". In Cook, Ellen Piel. Understanding people in context: the ecological perspective in counseling. Alexandria, VA: American Counseling Association. pp. 179–206. doi:10.1002/9781119222743.ch8. ISBN 9781556202872. OCLC 764589015.
• Woody, Sheila R.; Detweiler-Bedell, Jerusha; Teachman, Bethany A.; O'Hearn, Todd (2003). Treatment planning in psychotherapy: taking the guesswork out of clinical care. New York: Guilford Press. ISBN 1572308052. OCLC 49743479.
• 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. ISBN 9781593853693. OCLC 71139450.