Clinical formulation
A clinical formulation, also known as 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 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 psychiatrists[2] and is deemed to be a core component of these professions.[3] Mental health nurses and social workers also use formulations.[4]
Contents
Types of formulation
Different psychological schools or models utilize clinical formulations, including cognitive behavioral therapy (CBT) and related therapies: systemic therapy,[5] psychodynamic therapy,[6] and applied behavior analysis.[7] 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.[8]
Behavioral case formulations used in applied behavior analysis and behavior therapy are built on a rank list of problem behaviors,[7] from which a functional analysis is conducted,[9] sometimes based on relational frame theory.[10] Such functional analysis is also used in third-generation behavior therapy or clinical behavior analysis such as acceptance and commitment therapy[11] and functional analytic psychotherapy.[12] 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.[9]
A model of formulation that is more specific to CBT is described by Jacqueline Persons.[13] 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.[6]
One school of psychotherapy which relies heavily on the formulation is cognitive analytic therapy (CAT).[14] 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.[15]
Many psychologists use an integrative psychotherapy approach to formulation.[16][17] This is to take advantage of the benefits of resources from each model the psychologist is trained in, according to the patient's needs.[18]
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:[19]
- 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.[20] 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.[21][22]
See also
References
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Further reading
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