Clinical formulation

Last updated

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. [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 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.

Contents

Types of formulation

Different psychological schools or models utilize clinical formulations, including cognitive behavioral therapy (CBT) and related therapies: systemic therapy, [5] systemic hypothesising, [6] psychodynamic therapy, [7] and applied behavior analysis. [8] 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. [9]

Behavioral case formulations used in applied behavior analysis and behavior therapy are built on a rank list of problem behaviors, [8] from which a functional analysis is conducted, [10] sometimes based on relational frame theory. [11] Such functional analysis is also used in third-generation behavior therapy or clinical behavior analysis such as acceptance and commitment therapy [12] and functional analytic psychotherapy. [13] 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. [10]

A model of formulation that is more specific to CBT is described by Jacqueline Persons. [14] 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. [7]

One school of psychotherapy which relies heavily on the formulation is cognitive analytic therapy (CAT). [15] 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. [16]

Many psychologists use an integrative psychotherapy approach to formulation. [17] [18] This is to take advantage of the benefits of resources from each model the psychologist is trained in, according to the patient's needs. [19]

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: [20]

Formulations can vary in temporal scope from case-based to episode-based or moment-based, and formulations may evolve during the course of treatment. [21] 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. [22] [23]

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." [24] : 154  In place of nosological categories, Kelly used the word "formulation" and mentioned two types of formulation: [25] : 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" [24] : 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", [24] : 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. [26]

Psychologists Hans Eysenck, Monte B. Shapiro, Vic Meyer, and Ira Turkat were also among the early developers of systematic individualized alternatives to diagnosis. [27] : 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. [1] : 13  Meyer's original choice of words for clinical formulation were "behavioural formulation" or "problem formulation". [1] : 14 

See also

Related Research Articles

<span class="mw-page-title-main">Cognitive behavioral therapy</span> Therapy to improve mental health

Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. Cognitive behavioral therapy is one of the most effective means of treatment for substance abuse and co-occurring mental health disorders. CBT focuses on challenging and changing cognitive distortions and their associated behaviors to improve emotional regulation and develop personal coping strategies that target solving current problems. Though it was originally designed to treat depression, its uses have been expanded to include many issues and the treatment of many mental health conditions, including anxiety, substance use disorders, marital problems, ADHD, and eating disorders. CBT includes a number of cognitive or behavioral psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.

Psychotherapy is the use of psychological methods, particularly when based on regular personal interaction, to help a person change behavior, increase happiness, and overcome problems. 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. Numerous types of psychotherapy have been designed either for individual adults, families, or children and adolescents. Certain types of psychotherapy are considered evidence-based for treating some diagnosed mental disorders; other types have been criticized as pseudoscience.

Clinical psychology is an integration of human science, behavioral 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.

Person-centered therapy, also known as person-centered psychotherapy, person-centered counseling, client-centered therapy and Rogerian psychotherapy, is a form of psychotherapy developed by psychologist Carl Rogers and colleagues beginning in the 1940s and extending into the 1980s. Person-centered therapy seeks to facilitate a client's actualizing tendency, "an inbuilt proclivity toward growth and fulfillment", via acceptance, therapist congruence (genuineness), and empathic understanding.

Psychodynamic psychotherapy and psychoanalytic psychotherapy are two categories of psychological therapies. Their main purpose is revealing the unconscious content of a client's psyche in an effort to alleviate psychic tension, which is inner conflict within the mind that was created in a situation of extreme stress or emotional hardship, often in the state of distress. The terms "psychoanalytic psychotherapy" and "psychodynamic psychotherapy" are often used interchangeably, but a distinction can be made in practice: though psychodynamic psychotherapy largely relies on psychoanalytical theory, it employs substantially shorter treatment periods than traditional psychoanalytical therapies. Psychodynamic psychotherapy is evidence-based; the effectiveness of psychoanalysis and its relationship to facts is disputed.

Behaviour therapy or behavioural psychotherapy is a broad term referring to clinical psychotherapy that uses techniques derived from behaviourism and/or cognitive psychology. It looks at specific, learned behaviours and how the environment, or other people's mental states, influences those behaviours, and consists of techniques based on behaviorism's theory of learning: respondent or operant conditioning. Behaviourists who practice these techniques are either behaviour analysts or cognitive-behavioural therapists. They tend to look for treatment outcomes that are objectively measurable. Behaviour therapy does not involve one specific method, but it has a wide range of techniques that can be used to treat a person's psychological problems.

Acceptance and commitment therapy is a form of psychotherapy, as well as a branch of clinical behavior analysis. It is an empirically based psychological intervention that uses acceptance and mindfulness strategies along with commitment and behavior-change strategies to increase psychological flexibility.

Leslie Samuel 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.

<span class="mw-page-title-main">History of psychotherapy</span>

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 set 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.

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.

Psychology encompasses a vast domain, and includes many different approaches to the study of mental processes and behavior. Below are the major areas of inquiry that taken together constitute psychology. A comprehensive list of the sub-fields and areas within psychology can be found at the list of psychology topics and list of psychology disciplines.

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.

Paradox psychology is a counter-intuitive approach that is primarily geared toward addressing treatment resistance. The method of paradoxical interventions (pdxi) is more focused, rapid, and effective than Motivational Interviewing. In addressing resistance, the method seeks to influence the clients' underlying attitude and perception by providing laser beam attention on strengthening the attachment-alliance. This is counter-intuitive to traditional methods since change is usually directed toward various aspects of behavior, emotions, and thinking. As it turns out, the better therapy is able to strengthen the alliance, the more these aspects of behavior will change.

<span class="mw-page-title-main">Mike Abrams (psychologist)</span> American psychologist

Mike Abrams is an American psychologist and co-author with Albert Ellis of several works on rational emotive behavior therapy (REBT) and cognitive behavioral therapy (CBT). He is best known for extending CBT to include principles of evolutionary psychology and collaborating with the founder of CBT Albert Ellis to develop many new applications to for these clinical modalities. His new clinical method which applies evolutionary psychology and behavioral genetics to CBT is called Informed Cognitive Therapy (ICT).

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.

Nancy McWilliams, Ph.D., ABPP., is emerita visiting professor at the Graduate School of Applied and Professional Psychology at Rutgers University. She has written on personality and psychotherapy.

Eclectic psychotherapy is a form of psychotherapy in which the clinician uses more than one theoretical approach, or multiple sets of techniques, to help with clients' needs. The use of different therapeutic approaches will be based on the effectiveness in resolving the patient's problems, rather than the theory behind each therapy.

Dr. Paul L. Hewitt is a Full Professor in the Department of Psychology, an Associate Member of the Psychotherapy Program in the Faculty of Medicine at the University of British Columbia, and a Registered Psychologist in British Columbia, Canada. He is a Fellow of the Canadian Psychological Association and of its Section on Clinical Psychology. He has won numerous awards. In 2017, Hewitt was named one of the top 10 Canadian clinical psychology professors for research productivity and, in 2019, he was awarded the Canadian Psychological Association’s Donald O. Hebb Award for Distinguished Contributions to Psychology as a Science. Dr. Hewitt is a researcher and clinician and has had a private practice since 1988 which focuses on psychodynamic/interpersonal assessment and psychotherapy for individuals experiencing difficulties from perfectionistic behavior, early trauma, depression, anxiety, personality, and interpersonal problems.

Donald H. Meichenbaum is an American psychologist and Distinguished Professor Emeritus of Psychology at the University of Waterloo, Ontario. He is a research director of the Melissa Institute for Violence Prevention and Treatment at the University of Miami. Meichenbaum is known for his research and publications on psychotherapy, and contributed to the development of the technique of cognitive-behavioural therapy (CBT). In 1982, a survey of 800 members of the American Psychological Association voted Meichenbaum the tenth most influential psychotherapist of the 20th century. At the time of his retirement from the University of Waterloo in 1998, Meichenbaum was the most-cited psychology researcher at a Canadian university.

References

  1. 1 2 3 Bruch, 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. ISBN   9781119960768. OCLC   883881251.
  2. ↑ 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. ISBN   0080427073. OCLC   38048834.
  3. ↑ Crowe, Marie; Carlyle, David; Farmar, R. (December 2008). "Clinical formulation for mental health nursing practice". Journal of Psychiatric and Mental Health Nursing. 15 (10): 800–807. doi:10.1111/j.1365-2850.2008.01307.x. PMID   19012671.
  4. ↑ 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 .
  5. ↑ Pinsof, William; Breunlin, Douglas C.; Russell, William P.; Lebow, Jay (September 2011). "Integrative problem-centered metaframeworks therapy II: planning, conversing, and reading feedback". Family Process . 50 (3): 314–336. doi:10.1111/j.1545-5300.2011.01361.x. PMID   21884073.
  6. ↑ Rhodes, Paul; Whatson, Lesley; Mora, Lucinda; Hansson, Anders; Brearley, Kate; Dikian, Jack; Drucker, Peter F. (March 2011). "Systemic hypothesising for challenging behaviour in intellectual disabilities: a reflecting team approach". Australian and New Zealand Journal of Family Therapy . 32 (1): 70–82. doi:10.1375/anft.32.1.70.
  7. 1 2 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.
  8. 1 2 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.
  9. ↑ 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.
  10. 1 2 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". The Behavior Analyst Today. 6 (1): 65–81. doi:10.1037/h0100055.
  11. ↑ 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.
  12. ↑ Hayes, Steven C.; Strosahl, Kirk D.; Luoma, Jayson; Smith, Alethea A.; Wilson, Kelly G. (2004). "ACT case formulation". In Hayes, Steven C.; Strosahl, Kirk (eds.). 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.
  13. ↑ 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.
  14. ↑ Persons, Jacqueline B. (1989). Cognitive therapy in practice: a case formulation approach (1st ed.). New York: W.W. Norton & Co. ISBN   0393700771. OCLC   19125638.
  15. ↑ Ryle, Anthony (2005). "Cognitive analytic therapy". In Norcross, John C.; Goldfried, Marvin R. (eds.). Handbook of psychotherapy integration. Oxford series in clinical psychology (2nd ed.). New York: Oxford University Press. pp. 196–217. ISBN   0195165799. OCLC   54803644.
  16. ↑ Denman, Chess (July 2001). "Cognitive–analytic therapy". Advances in Psychiatric Treatment. 7 (4): 243–252. doi: 10.1192/apt.7.4.243 .
  17. ↑ 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.
  18. ↑ 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 .
  19. ↑ 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 .
  20. ↑ Dawson, David L.; Moghaddam, Nima G. (2016). "Formulation in action: an introduction" (PDF). In Dawson, David L.; Moghaddam, Nima G. (eds.). Formulation in action: applying psychological theory to clinical practice. Berlin; New York: Walter de Gruyter. pp. 3–8 [7]. ISBN   9783110470994. OCLC   932645602.
  21. ↑ 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. PMID   1801616.
  22. ↑ 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 .
  23. ↑ 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.
  24. 1 2 3 Kelly, George (1991) [1955]. The psychology of personal constructs: volume two: clinical diagnosis and psychotherapy. London; New York: Routledge in association with the Centre for Personal Construct Psychology. ISBN   9780415037983. OCLC   21760190.
  25. ↑ Kelly, George (1991) [1955]. The psychology of personal constructs: volume one: theory and personality. London; New York: Routledge in association with the Centre for Personal Construct Psychology. ISBN   9780415037976. OCLC   21760190.
  26. ↑ See also, for example, the summary of Kelly's concepts in: White, Lauren (March 2014). Borderline personality disorder: a personal construct approach (D.Clin.Psy. thesis). Hatfield, Hertfordshire, UK: University of Hertfordshire. pp. 23–24. hdl: 2299/14439 . OCLC   894598148.
  27. ↑ "Good practice guidelines on the use of psychological formulation" (PDF). bps.org.uk. Leicester, UK: British Psychological Society. December 2011. Archived from the original (PDF) on 2017-11-17. Retrieved 2017-10-22.

Further reading

This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.