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.[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 is deemed to be a core component of that profession.[2] Mental health nurses,[3] social workers, and some psychiatrists[4] may also use formulations.

Types of formulation[edit]

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[edit]

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]


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."[23]: 154  In place of nosological categories, Kelly used the word "formulation" and mentioned two types of formulation:[24]: 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"[23]: 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",[23]: 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.[25]

Psychologists Hans Eysenck, Monte B. Shapiro, Vic Meyer, and Ira Turkat were also among the early developers of systematic individualized alternatives to diagnosis.[26]: 4  Meyer has been credited with providing perhaps the first training course of behaviour therapy based on a case formulation model, at the Middlesex Hospital Medical School in London in 1970.[1]: 13  Meyer's original choice of words for clinical formulation were "behavioural formulation" or "problem formulation".[1]: 14 

See also[edit]


  1. ^ a b c Bruch, Michael, ed. (2015) [1998]. Beyond diagnosis: case formulation in cognitive behavioural therapy. Wiley series in clinical psychology (2nd ed.). Chichester, UK; Malden, MA: John Wiley & Sons. ISBN 9781119960768. OCLC 883881251.
  2. ^ Butler, Gillian (1998). "Clinical formulation". In Bellack, Alan S.; Hersen, Michel (eds.). Comprehensive clinical psychology. Vol. 6 (1st ed.). Amsterdam; New York: Pergamon. pp. 1–24. doi:10.1016/B0080-4270(73)00186-3. ISBN 0080427073. OCLC 38048834.
  3. ^ Crowe, Marie; Carlyle, David; Farmar, R. (December 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.
  4. ^ Mace, Chris; Binyon, Sharon (October 2005). "Teaching psychodynamic formulation to psychiatric trainees. Part 1: Basics of formulation". Advances in Psychiatric Treatment. 11 (6): 416–423. doi:10.1192/apt.11.6.416.
  5. ^ Pinsof, William; Breunlin, Douglas C.; Russell, William P.; Lebow, Jay (September 2011). "Integrative problem-centered metaframeworks therapy II: planning, conversing, and reading feedback". Family Process. 50 (3): 314–336. doi:10.1111/j.1545-5300.2011.01361.x. PMID 21884073.
  6. ^ a b Perry, Samuel; Cooper, Arnold M.; Michels, Robert (May 1987). "The psychodynamic formulation: its purpose, structure, and clinical application". The American Journal of Psychiatry. 144 (5): 543–550. doi:10.1176/ajp.144.5.543. PMID 3578562.
  7. ^ a b Cipani, Ennio; Golden, Jeannie 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. doi:10.1037/h0100821.
  8. ^ Eells, Tracy D.; Kendjelic, Edward M.; Lucas, Cynthia P. (Spring 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. PMC 3330487. PMID 9527958.
  9. ^ a b Kanter, Jonathan W.; Cautilli, Joseph D.; Busch, Andrew M.; Baruch, David 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. doi:10.1037/h0100055.
  10. ^ Zettle, Robert D. (2007). ACT for depression: a clinician's guide to using acceptance & commitment therapy in treating depression. Oakland, CA: New Harbinger Publications. ISBN 9781572245099. OCLC 148853276.
  11. ^ Hayes, Steven C.; Strosahl, Kirk D.; Luoma, Jayson; Smith, Alethea A.; Wilson, Kelly G. (2004). "ACT case formulation". In Hayes, Steven C.; Strosahl, Kirk (eds.). A practical guide to acceptance and commitment therapy. New York: Springer. pp. 59–73. doi:10.1007/978-0-387-23369-7_3. ISBN 0387233679. OCLC 55534832.
  12. ^ Tsai, Mavis; Kohlenberg, Robert J.; Kanter, Jonathan W.; Holman, Gareth; Loudon, Mary Plummer (2012). Functional analytic psychotherapy: distinctive features. The CBT distinctive features series. Hove, East Sussex; New York: Routledge. ISBN 9780415604031. OCLC 698324521.
  13. ^ Persons, Jacqueline B. (1989). Cognitive therapy in practice: a case formulation approach (1st ed.). New York: W.W. Norton & Co. ISBN 0393700771. OCLC 19125638.
  14. ^ Ryle, Anthony (2005). "Cognitive analytic therapy". In Norcross, John C.; Goldfried, Marvin R. (eds.). Handbook of psychotherapy integration. Oxford series in clinical psychology (2nd ed.). New York: Oxford University Press. pp. 196–217. ISBN 0195165799. OCLC 54803644.
  15. ^ Denman, Chess (July 2001). "Cognitive–analytic therapy". Advances in Psychiatric Treatment. 7 (4): 243–252. doi:10.1192/apt.7.4.243.
  16. ^ Caspar, Franz; Silberschatz, George; Goldfried, Marvin; Watson, Jeanne C. (March 2010). "Similarities and differences in four views of David". Journal of Psychotherapy Integration. 20 (1): 101–110. doi:10.1037/a0018886.
  17. ^ Eells, Tracy D. (December 2013). "In support of evidence-based case formulation in psychotherapy (from the perspective of a clinician)". Pragmatic Case Studies in Psychotherapy. 9 (4): 457–467. doi:10.14713/pcsp.v9i4.1836.
  18. ^ Persons, Jacqueline B. (December 2013). "Who needs a case formulation and why: clinicians use the case formulation to guide decision-making". Pragmatic Case Studies in Psychotherapy. 9 (4): 448–456. doi:10.14713/pcsp.v9i4.1835.
  19. ^ Dawson, David L.; Moghaddam, Nima G. (2016). "Formulation in action: an introduction" (PDF). In Dawson, David L.; Moghaddam, Nima G. (eds.). Formulation in action: applying psychological theory to clinical practice. Berlin; New York: Walter de Gruyter. pp. 3–8 [7]. ISBN 9783110470994. OCLC 932645602.
  20. ^ Schacht, Thomas E. (December 1991). "Formulation-based psychotherapy research: some further considerations". American Psychologist. 46 (12): 1346–1347. doi:10.1037/0003-066X.46.12.1346. PMID 1801616.
  21. ^ Eells, Tracy D. (December 2013). "The case formulation approach to psychotherapy research revisited". Pragmatic Case Studies in Psychotherapy. 9 (4): 426–447. doi:10.14713/pcsp.v9i4.1834.
  22. ^ Basseches, Michael; Mascolo, Michael F. (2009). "Psychotherapy as a developmental process: implications and future directions for psychotherapy research, practice, and training". Psychotherapy as a developmental process. New York: Routledge. pp. 283–312. ISBN 9780805857306. OCLC 244063508.
  23. ^ a b c Kelly, George (1991) [1955]. The psychology of personal constructs: volume two: clinical diagnosis and psychotherapy. London; New York: Routledge in association with the Centre for Personal Construct Psychology. ISBN 9780415037983. OCLC 21760190.
  24. ^ Kelly, George (1991) [1955]. The psychology of personal constructs: volume one: theory and personality. London; New York: Routledge in association with the Centre for Personal Construct Psychology. ISBN 9780415037976. OCLC 21760190.
  25. ^ See also, for example, the summary of Kelly's concepts in: White, Lauren (March 2014). Borderline personality disorder: a personal construct approach (D.Clin.Psy. thesis). Hatfield, Hertfordshire, UK: University of Hertfordshire. pp. 23–24. hdl:2299/14439. OCLC 894598148.
  26. ^ "Good practice guidelines on the use of psychological formulation" (PDF). Leicester, UK: British Psychological Society. December 2011. Archived from the original (PDF) on 2017-11-17. Retrieved 2017-10-22.

Further reading[edit]