Clinical formulation

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

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

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

• 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.^[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

References