Clinical formulation

A clinical formulation (or 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 alternative approach to the more categorical approach of psychiatric diagnosis.^[1]. In clinical practice, formulations are used to communicate a hypothesis and provide framework to 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 also use formulations.^[4]

Types of formulation

Different psychological schools or models utilize clinical formulations, including cognitive behavioral therapy (CBT) and its related therapies, systematic, psychodynamic^[5] and applied behavior analysis^[6]. 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.^[7]

Behavioral case formulations used in applied behavior analysis and behavior therapy are built on a rank list of problem behaviors^[6]. from which a Functional analysis (psychology) is conducted (e.g. ]]^[8]) and sometimes B.F. Skinner's account of Verbal behavior or the account from Relational Frame Theory. This holds true even for what is sometimes called third generation behavior therapy or clinical behavior analysis such as acceptance and commitment therapy and functional analytic psychotherapy Functional analysis looks at setting events (ecoloical variables, history effects, and motivating operations), antecedents, behavior chains, the problem behavior, and the consequences short and long term for the behavior.^[8])

A model of formulation that is more specific to CBT is described by Persons.^[9] 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.^[10]

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.^[11]

References

1. ^ Bond, Frank W.; Bruch, Michael (1998). Beyond diagnosis: case formulation approaches in CBT. New York: Wiley. ISBN 0-471-98222-9. 
2. ^ Mace, Chris; Binyon, Sharon (2005). "Teaching psychodynamic formulation to psychiatric trainees. Part 1: Basics of formulation". Advances in Psychiatric Treatment 11 (6): 416–4223. doi:10.1192/apt.11.6.416. 
3. ^ Butler, G. (1998). Clinical formulation. In A.S.Bellack & M. E. Hersen (Eds.), Comprehensive Clinical Psychology (pp. 1-23). New York: Pergammon Press
4. ^ Crowe, Marie; Carlyle, David (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. 
5. ^ The Psychodynamic Formulation: Its Purpose, Structure, and Clinical Application Samuel Perry, MD, Arnold M. Cooper, MD, and Robert Michels, MD American Journal of Psychiatry 1987; 144:543–550
6. ^ ^{a b} Cipani, E. & Golden, J.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. BAO
7. ^ Eells, Tracy; Kendjelic, Edward and Lucas, Cynthia (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. PMID 9527958. 
8. ^ ^{a b} Kanter, J.W., Cautilli, J.D., Busch, A.M. and Baruch, D.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.BAO
9. ^ Persons, J.B. (1989) Cognitive Therapy in Practice: A Case Formulation Approach. New York: W.W. Norton.
10. ^ Perry S, Cooper AM and Michels R (1987) The psychodynamic formulation. American Journal of Psychiatry 144, 543–550
11. ^ Denman, C (2001). Cognitive-analytic therapy. Advances in Psychiatric Treatment, issue 7, pp 243-252