A clinical formulation, also known as case formulation and problem 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. 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 and is deemed to be a core component of these professions. Mental health nurses and social workers may also use formulations.
Types of formulation
Different psychological schools or models utilize clinical formulations, including cognitive behavioral therapy (CBT) and related therapies: systemic therapy, psychodynamic therapy, and applied behavior analysis.
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.
Behavioral case formulations used in applied behavior analysis and behavior therapy are built on a rank list of problem behaviors, from which a functional analysis is conducted, sometimes based on relational frame theory. Such functional analysis is also used in third-generation behavior therapy or clinical behavior analysis such as acceptance and commitment therapy and functional analytic psychotherapy.
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.
A model of formulation that is more specific to CBT is described by Jacqueline Persons.
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.
One school of psychotherapy which relies heavily on the formulation is cognitive analytic therapy (CAT).
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.
Many psychologists use an integrative psychotherapy approach to formulation.
This is to take advantage of the benefits of resources from each model
the psychologist is trained in, according to the patient's needs.
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:
- 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.
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.
History
Psychologist George Kelly, who developed personal construct theory in the 1950s, noted his complaint against traditional diagnosis in his book The 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." In place of nosological categories, Kelly used the word "formulation" and mentioned two types of formulation: a first stage of structuralization,
in which the clinician tentatively organizes clinical case information
"in terms of dimensions rather than in terms of disease entities"
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", and a second stage of construction,
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.
Psychologists Hans Eysenck, Monte B. Shapiro, Vic Meyer, and Ira Turkat were also among the early developers of systematic individualized alternatives to diagnosis. Meyer has been credited with providing perhaps the first training course of behaviour therapy based on a case formulation model, at the Middlesex Hospital Medical School in London in 1970. Meyer's original choice of words for clinical formulation were "behavioural formulation" or "problem formulation".
