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

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]


Psychologists Hans Eysenck, Monte B. Shapiro, Vic Meyer, and Ira Turkat were among the early developers of systematic individualized alternatives to diagnosis.[23]: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. ^ 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. 
  3. ^ Butler, Gillian (1998). "Clinical formulation". In Bellack, Alan S.; Hersen, Michel. Comprehensive clinical psychology. 6 (1st ed.). Amsterdam; New York: Pergamon. pp. 1–24. doi:10.1016/B0080-4270(73)00186-3. ISBN 0080427073. OCLC 38048834. 
  4. ^ Crowe, Marie; Carlyle, David; Farmar, R. (December 2008). "Clinical formulation for mental health nursing practice" (PDF). Journal of Psychiatric and Mental Health Nursing. 15 (10): 800–807. doi:10.1111/j.1365-2850.2008.01307.x. PMID 19012671. 
  5. ^ Pinsof, William; Breunlin, Douglas C.; Russell, William P.; Lebow, Jay (September 2011). "Integrative problem-centered metaframeworks therapy II: planning, conversing, and reading feedback" (PDF). 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 3330487Freely accessible. 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" (PDF). 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. 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. 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. 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. 
  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. ^ "Good practice guidelines on the use of psychological formulation" (PDF). Leicester, UK: British Psychological Society. December 2011. Retrieved 2017-10-22. 

Further reading[edit]