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.
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.
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:
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.
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." 154 In place of nosological categories, Kelly used the word "formulation" and mentioned two types of formulation: :337 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" :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", :154 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. 4 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. :13 Meyer's original choice of words for clinical formulation were "behavioural formulation" or "problem formulation". :14:
Psychotherapy is the use of psychological methods, particularly when based on regular personal interaction with adults, to help a person change behavior and overcome problems in desired ways. Psychotherapy aims to improve an individual's well-being and mental health, to resolve or mitigate troublesome behaviors, beliefs, compulsions, thoughts, or emotions, and to improve relationships and social skills. There is also a range of psychotherapies designed for children and adolescents, which typically involve play, such as sandplay. Certain psychotherapies are considered evidence-based for treating some diagnosed mental disorders. Others have been criticized as pseudoscience.
Dependent personality disorder (DPD) is a personality disorder that is characterized by a pervasive psychological dependence on other people. This personality disorder is a long-term condition in which people depend on others to meet their emotional and physical needs, with only a minority achieving normal levels of independence. Dependent personality disorder is a Cluster C personality disorder, characterized by excessive fear and anxiety. It begins by early adulthood, and it is present in a variety of contexts and is associated with inadequate functioning. Symptoms can include anything from extreme passivity, devastation or helplessness when relationships end, avoidance of responsibilities and severe submission.
Clinical psychology is an integration of science, theory, and clinical knowledge for the purpose of understanding, preventing, and relieving psychologically-based distress or dysfunction and to promote subjective well-being and personal development. Central to its practice are psychological assessment, clinical formulation, and psychotherapy, although clinical psychologists also engage in research, teaching, consultation, forensic testimony, and program development and administration. In many countries, clinical psychology is a regulated mental health profession.
Personal construct theory (PCT) or personal construct psychology (PCP) is a theory of personality and cognition developed by the American psychologist George Kelly in the 1950s. The theory is concerned with the psychological reasons for actions. Kelly proposed that individuals can be psychologically evaluated according to similarity–dissimilarity poles, which he called personal constructs. The theory is considered by some psychologists as forerunner to theories of cognitive therapy.
Psychodynamic psychotherapy or psychoanalytic psychotherapy is a form of depth psychology, the primary focus of which is to reveal the unconscious content of a client's psyche in an effort to alleviate psychic tension.
Les Greenberg is a Canadian psychologist born in Johannesburg, South Africa, and is one of the originators and primary developers of Emotion-Focused Therapy for individuals and couples. He is a professor emeritus of psychology at York University in Toronto, and also director of the Emotion-Focused Therapy Clinic in Toronto. His research has addressed questions regarding empathy, psychotherapy process, the therapeutic alliance, and emotion in human functioning.
Although modern, scientific psychology is often dated from the 1879 opening of the first psychological clinic by Wilhelm Wundt, attempts to create methods for assessing and treating mental distress existed long before. The earliest recorded approaches were a combination of religious, magical and/or medical perspectives. Early examples of such psychological thinkers included Patañjali, Padmasambhava, Rhazes, Avicenna and Rumi.
Emotionally focused therapy and emotion-focused therapy (EFT) are a family of related approaches to psychotherapy with individuals, couples, or families. EFT approaches include elements of experiential therapy, systemic therapy, and attachment theory. EFT is usually a short-term treatment. EFT approaches are based on the premise that human emotions are connected to human needs, and therefore emotions have an innately adaptive potential that, if activated and worked through, can help people change problematic emotional states and interpersonal relationships. Emotion-focused therapy for individuals was originally known as process-experiential therapy, and it is still sometimes called by that name.
In psychology, constructivism refers to many schools of thought that, though extraordinarily different in their techniques, are all connected by a common critique of previous standard approaches, and by shared assumptions about the active constructive nature of human knowledge. In particular, the critique is aimed at the "associationist" postulate of empiricism, "by which the mind is conceived as a passive system that gathers its contents from its environment and, through the act of knowing, produces a copy of the order of reality".
Functional analytic psychotherapy (FAP) is a psychotherapeutic approach based on clinical behavior analysis (CBA) that focuses on the therapeutic relationship as a means to maximize client change. Specifically, FAP suggests that in-session contingent responding to client target behaviors leads to significant therapeutic improvements.
Peter Fonagy, is a Hungarian-born British psychoanalyst and clinical psychologist. He studied clinical psychology at University College London. He is Professor of Contemporary Psychoanalysis and Developmental Science and Head of the Division of Psychology and Language Sciences at University College London, Chief Executive of the Anna Freud Centre, a training and supervising analyst in the British Psycho-Analytical Society in child and adult analysis, a Fellow of the British Academy, the Faculty of Medical Sciences, the Academy of Social Sciences and a registrant of the BPC. His clinical interests centre on issues of borderline psychopathology, violence and early attachment relationships. His work attempts to integrate empirical research with psychoanalytic theory. He has published over 500 papers, 270 chapters and has authored 19 and edited 17 books.
Common factors theory, a theory guiding some research in clinical psychology and counseling psychology, proposes that different approaches and evidence-based practices in psychotherapy and counseling share common factors that account for much of the effectiveness of a psychological treatment. This is in contrast to the view that the effectiveness of psychotherapy and counseling is best explained by specific or unique factors that are suited to treatment of particular problems. According to one review, "it is widely recognized that the debate between common and unique factors in psychotherapy represents a false dichotomy, and these factors must be integrated to maximize effectiveness". In other words, "therapists must engage in specific forms of therapy for common factors to have a medium through which to operate". Common factors is one route by which psychotherapy researchers have attempted to integrate psychotherapies.
Schema therapy was developed by Jeffrey E. Young for use in treatment of personality disorders and chronic DSM Axis I disorders, such as when patients fail to respond or relapse after having been through other therapies. Schema therapy is an integrative psychotherapy combining theory and techniques from previously existing therapies, including cognitive behavioral therapy, psychoanalytic object relations theory, attachment theory, and Gestalt therapy.
Future-oriented therapy (FOT) and future-directed therapy (FDT) are approaches to psychotherapy that place greater emphasis on the future than on the past or present.
A decisional balance sheet or decision balance sheet is a tabular method for representing the pros and cons of different choices and for helping someone decide what to do in a certain circumstance. It is often used in working with ambivalence in people who are engaged in behaviours that are harmful to their health, as part of psychological approaches such as those based on the transtheoretical model of change, and in certain circumstances in motivational interviewing.
Paradox psychology is an approach that aims to advance the general field of psychology and treatment. These advances include: An approach that specifically addresses a 'hard-to-treat' or resistant client; A scientific understanding that supports a process for 'spontaneous change'; Unifying behavioral, cognitive, and psychodynamic orientations under a single umbrella theory; A science-based model showing how treating secondary non-criminogenic behaviors will impact primary targeted (volatile) criminogenic behaviors
Metacognitive therapy (MCT) is a psychotherapy focused on modifying metacognitive beliefs that perpetuate states of worry, rumination and attention fixation. It was created by Adrian Wells based on an information processing model by Wells and Matthews. It is supported by scientific evidence from a large number of studies.
Vittorio Filippo Guidano was an Italian neuropsychiatrist, creator of the cognitive procedural systemic model and contributor to post-rationalist constructivist cognitive psychotherapy. His cognitive post-rationalist model was influenced by attachment theory, evolutionary epistemology, complex systems theory, and the prevalence of abstract mental processes proposed by Friedrich Hayek. Guidano conceived the personal system as a self-organized entity, in constant development.
Victor Campbell Meyer, or Vic Meyer, was a British psychologist at the Middlesex Hospital Medical School of the University of London and has been called the father of behavioral case formulation, an approach toward understanding complex psychiatric problems using learning principles derived from scientific psychological research and uniquely adapted to the individual case by means of the experimental method as a way to develop an effective intervention regimen. Meyer is credited by the British Psychological Society for his influential work in creating case formulation along with three other innovators: Hans Eysenck, Monte B. Shapiro, and Ira Turkat. Turkat credited Meyer as the pioneer of the framework of what is generally known today as case formulation, a required core skill for all British practicing psychologists since 2011.
Robert L. Leahy is a psychologist and author and editor of 28 books dedicated to cognitive behaviour therapy. He is Director of the American Institute for Cognitive Therapy in New York and Clinical Professor of Psychology in the Department of Psychiatry at Weill Cornell Medical College. In 2014, Robert L. Leahy received the Aaron T. Beck Award from the Academy of Cognitive Therapy. He is Past President of The Association of Behavioral and Cognitive Therapies, The Academy of Cognitive Therapy, and The International Association of Cognitive Therapy. He is the former Editor of The Journal of Cognitive Psychotherapy. Leahy was born in Alexandria, Virginia, the son of James J Leahy, a salesman, and Lillian DeVita, an executive secretary. His parents separated when he was 18 months old and his mother moved Robert and his older brother Jim to New Haven, Connecticut. He was educated at Yale University and later completed a Post-doctoral Fellowship in the Department of Psychiatry at the University of Pennsylvania Medical School under the direction of Aaron T. Beck, M.D., the Founder of Cognitive Therapy. He is a Distinguished Founding Fellow of the Academy of Cognitive Therapy. Leahy became interested in Beck's Cognitive Therapy model after becoming disillusioned with the psychodynamic model which he felt lacked sufficient empirical support. Many of his clinical books have been instrumental in disseminating the cognitive therapy model in its application to the treatment of depression, bipolar disorder, anxiety disorders, jealousy, and emotion regulation. In addition, he has published widely on the application of the cognitive model to the therapeutic relationship, transference and counter-transference, resistance to change, and beliefs about emotion regulation that may underpin problematic strategies for coping with or responding to emotions in the therapeutic context. His clinical and popular audience books have been translated into 21 languages. Leahy has expanded the cognitive model with his social cognitive model of emotion which he refers to as Emotional Schema Therapy. According to this model individuals differ in their beliefs about the legitimacy of certain emotions, their duration, the ability to express emotions, the need to control emotions, how similar their emotions are to those of others and the ability to tolerate ambivalent feelings. These beliefs and the strategies connected to them are referred to as "emotional schemas". The Emotional Schema Model draws on Beck's cognitive model, the metacognitive model advanced by AdrIan Wells, the Acceptance and Commitment Model advanced by Steven C. Hayes, and on social cognitive research on attribution processes and implicit theories of emotion. Leahy has described how his model can help in understanding and treating jealousy, envy, ambivalence and other emotions and how these emotional schemas can impact intimate relationships and affect the therapeutic relationship. In addition to his work on emotional schemas, Leahy has written about problematic styles of judgment and decision making that are relevant in depression and anxiety disorders. These include biased evaluations in over-estimating or under-estimating risk, sunk-cost effects, regret anticipation, rumination over regret, and inaccurate predictions of emotions following anticipated outcomes.