Clinical Formulation
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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 Diagnosis is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in many different disciplines, with variations in the use of logic, analytics, and experience, to determine " cause and effect". In systems engin ...
. In clinical practice, formulations are used to communicate a
hypothesis A hypothesis (plural hypotheses) is a proposed explanation for a phenomenon. For a hypothesis to be a scientific hypothesis, the scientific method requires that one can testable, test it. Scientists generally base scientific hypotheses on prev ...
and provide framework for developing the most suitable treatment approach. It is most commonly used by
clinical psychologists Clinical psychology is an integration of social science, theory, and clinical knowledge for the purpose of understanding, preventing, and relieving psychologically based distress or Mental disorder, dysfunction and to promote subjective mental ...
and is deemed to be a core component of that profession. Mental health nurses, social workers, and some psychiatrists may also use formulations.


Types of formulation

Different psychological schools or models utilize clinical formulations, including
cognitive behavioral therapy Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. CBT focuses on challenging and changing cognitive distortions (su ...
(CBT) and related therapies: systemic therapy, psychodynamic therapy, and
applied behavior analysis Applied behavior analysis (ABA), also called behavioral engineering, is a psychological intervention that applies empirical approaches based upon the principles of respondent and operant conditioning to change behavior of social significance. ...
. 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 Applied behavior analysis (ABA), also called behavioral engineering, is a psychological intervention that applies empirical approaches based upon the principles of respondent and operant conditioning to change behavior of social significance. ...
and behavior therapy are built on a rank list of problem behaviors, from which a
functional analysis Functional analysis is a branch of mathematical analysis, the core of which is formed by the study of vector spaces endowed with some kind of limit-related structure (e.g. inner product, norm, topology, etc.) and the linear functions defined ...
is conducted, sometimes based on relational frame theory. Such functional analysis is also used in third-generation behavior therapy or
clinical behavior analysis Clinical Behavior Analysis is one of several ABA subspecialty fact sheets produced by the BACB in partnership with subject matter experts (SMEs). Clinical behavior analysis (CBA; also called clinical behaviour analysis or third-generation behavior ...
such as
acceptance and commitment therapy Acceptance and commitment therapy (ACT, typically pronounced as the word "act") 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 min ...
and
functional analytic psychotherapy 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 conting ...
. 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 Ego psychology is a school of psychoanalysis rooted in Sigmund Freud's structural id-ego-superego model of the mind. An individual interacts with the external world as well as responds to internal forces. Many psychoanalysts use a theoretical c ...
, object relations or
self psychology Self psychology, a modern psychoanalytic theory and its clinical applications, was conceived by Heinz Kohut in Chicago in the 1960s, 70s, and 80s, and is still developing as a contemporary form of psychoanalytic treatment. In self psychology, th ...
), and a prognostic assessment which identifies the potential areas of
resistance Resistance may refer to: Arts, entertainment, and media Comics * Either of two similarly named but otherwise unrelated comic book series, both published by Wildstorm: ** ''Resistance'' (comics), based on the video game of the same title ** ''T ...
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 model A theory is a rational type of abstract thinking about a phenomenon, or the results of such thinking. The process of contemplative and rational thinking is often associated with such processes as observational study or research. Theories may ...
s 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 In mathematics, the concept of a measure is a generalization and formalization of geometrical measures (length, area, volume) and other common notions, such as mass and probability of events. These seemingly distinct concepts have many simila ...
concepts? *''Empirical adequacy'': Are the posited mechanisms within the model empirically validated? *''Comprehensiveness and generalizability'': Is the model
holistic Holism () is the idea that various systems (e.g. physical, biological, social) should be viewed as wholes, not merely as a collection of parts. The term "holism" was coined by Jan Smuts in his 1926 book '' Holism and Evolution''."holism, n." OED O ...
enough to apply across a range of clinical phenomena? *''Utility and applied value'': Does it facilitate shared
meaning-making In psychology, meaning-making is the process of how people construe, understand, or make sense of life events, relationships, and the self. The term is widely used in constructivist approaches to counseling psychology and psychotherapy, espe ...
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 Within personality psychology, 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.For example: (first published 1955); ...
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 Hans Jürgen Eysenck (; 4 March 1916 – 4 September 1997) was a German-born British psychologist who spent his professional career in Great Britain. He is best remembered for his work on intelligence and personality, although he worked on othe ...
, Monte B. Shapiro,
Vic Meyer Victor Campbell Meyer, or Vic Meyer, was a British psychologist at the Middlesex Hospital Medical School of the University of London (now UCL Medical School) and has been called the father of behavioral case formulation, an approach toward unde ...
, 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 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 o ...
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".


See also

*
Clinical decision support system A clinical decision support system (CDSS) is a health information technology, provides clinicians, staff, patients, or other individuals with knowledge and person-specific information, to help health and health care. CDSS encompasses a variety of ...
*
Clinical guideline Clinical may refer to: Healthcare * Of or about a clinic, a healthcare facility * Of or about the practice of medicine Other uses * ''Clinical'' (film), a 2017 American horror thriller See also * * * Clinical chemistry, the analysis of bodily flu ...
* Clinical pathway * Common factors theory * Problem structuring methods * SOAP note * Therapeutic assessment * Treatment decision support (tools for clients)


References


Further reading

* * * * * * * * * * * * * {{Psychotherapy Medical terminology Psychiatric assessment Psychotherapy