Psychiatric 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 (: diagnoses) is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in a lot of different academic discipline, disciplines, with variations in the use of logic, analytics, and experience, to determine " ...
. In clinical practice, formulations are used to communicate a
hypothesis A hypothesis (: hypotheses) is a proposed explanation for a phenomenon. A scientific hypothesis must be based on observations and make a testable and reproducible prediction about reality, in a process beginning with an educated guess o ...
and provide framework for developing the most suitable treatment approach. It is most commonly used by
clinical psychologists 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 Mental disorder, dysfunction and to promote ...
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 form of psychotherapy that aims to reduce symptoms of various mental health conditions, primarily depression, PTSD, and anxiety disorders. Cognitive behavioral therapy focuses on challenging and chang ...
(CBT) and related therapies:
systemic therapy Systemic therapy is a type of psychotherapy that seeks to address people in relationships, dealing with the interactions of groups and their interactional patterns and dynamics. Early forms of systemic therapy were based on cybernetics and syste ...
, psychodynamic therapy, and
applied behavior analysis Applied behavior analysis (ABA), also referred to as behavioral engineering, is a behavior modification system based on the principles of respondent and operant conditioning. ABA is the applied form of behavior analysis; the other two are: ...
. 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 referred to as behavioral engineering, is a behavior modification system based on the principles of respondent and operant conditioning. ABA is the applied form of behavior analysis; the other two are: ...
and
behavior 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 oth ...
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 (for example, Inner product space#Definition, inner product, Norm (mathematics ...
is conducted, sometimes based on
relational frame theory Relational frame theory (RFT) is a behavior analytic theory of human language, cognition, and behaviour. It was developed originally by Steven C. Hayes of University of Nevada, Reno and has been extended in research, notably by Dermot Barnes-H ...
. Such functional analysis is also used in third-generation behavior therapy or
clinical behavior analysis Clinical behavior analysis (CBA; also called clinical behaviour analysis or third-generation behavior therapy) is the clinical application of behavior analysis (ABA). CBA represents a movement in behavior therapy away from methodological behavi ...
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 mindfu ...
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 conti ...
. 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 Object relations theory is a school of thought in psychoanalytic theory and psychoanalysis centered around theories of stages of ego development. Its concerns include the relation of the psyche to others in childhood and the exploration of re ...
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, t ...
), 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 Cognitive analytic therapy (CAT) is a form of psychological therapy initially developed in the United Kingdom by Anthony Ryle. This time-limited therapy was developed in the context of the UK's National Health Service with the aim of providing ef ...
(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 systematic and rational form of abstract thinking about a phenomenon, or the conclusions derived from such thinking. It involves contemplative and logical reasoning, often supported by processes such as observation, experimentation, ...
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 magnitude, mass, and probability of events. These seemingly distinct concepts hav ...
concepts? *''Empirical adequacy'': Are the posited
mechanism Mechanism may refer to: *Mechanism (economics), a set of rules for a game designed to achieve a certain outcome **Mechanism design, the study of such mechanisms *Mechanism (engineering), rigid bodies connected by joints in order to accomplish a ...
s within the model empirically validated? *''Comprehensiveness and generalizability'': Is the model
holistic Holism is the interdisciplinary idea that systems possess properties as wholes apart from the properties of their component parts. Julian Tudor Hart (2010''The Political Economy of Health Care''pp.106, 258 The aphorism "The whole is greater than t ...
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 (and other living beings) Construals, construe, Understanding, understand, or make sense of life events, relationships, and the self. The term is widely used in Constructivism (psychologi ...
between clinician and client, and are interventions based on the model shown to be
effective Effectiveness or effectivity is the capability of producing a desired result or the ability to produce desired output. When something is deemed effective, it means it has an intended or expected outcome, or produces a deep, vivid impression. Et ...
? 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. He is best remembered for his work on intelligence and personality psychology, personality, although he worked on other issues in psychology. At t ...
, Monte B. Shapiro, Vic Meyer, 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 ot ...
based on a case formulation model, at the
Middlesex Hospital Medical School Middlesex Hospital was a teaching hospital located in the Fitzrovia area of London, England. First opened as the Middlesex Infirmary in 1745 on Windmill Street, it was moved in 1757 to Mortimer Street where it remained until it was finally clo ...
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 that provides clinicians, staff, patients, and other individuals with knowledge and person-specific information to help health and health care. CDSS encompasses a varie ...
*
Clinical guideline A medical guideline (also called a clinical guideline, standard treatment guideline, or clinical practice guideline) is a document with the aim of guiding decisions and criteria regarding diagnosis, management, and treatment in specific areas of ...
*
Clinical pathway A clinical pathway, also known as care pathway, integrated care pathway, critical pathway, or care map, is one of the main tools used to manage the quality in healthcare concerning the standardisation of care processes. It has been shown that th ...
*
Common factors theory 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 ...
*
Problem structuring methods Problem structuring methods (PSMs) are a group of techniques used to model or to map the nature or structure of a situation or state of affairs that some people want to change. PSMs are usually used by a group of people in collaboration (rather ...
*
SOAP note The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as the admission note. Documen ...
* Therapeutic assessment *
Treatment decision support Treatment decision support consists of the tools and processes used to enhance medical patients’ healthcare decision-making. The term differs from Clinical decision support system, ''clinical'' ''decision support'', in that clinical decision supp ...
(tools for clients)


References


Further reading

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