Formulation
last authored: Oct 2009, David LaPierre
Introduction
Case formulation is the integration of therapeutic connection, diagnosis, and treatment, representing the process of identifying a patient's psychic signs and symptoms and understanding them in the context of heredity, upbringing, and life events. Formulation ties together emotional, behavioural, and cognitive responses to life and leads to an appropriate treatment plan based on this information. Formulations develop over time, with further interactions, insights, and with healing.
It ties together theory and a patient's real story.
During formulation, a person's history and resulting psychic structure are defined in order to effectively frame their current siutation.
It involves the ABC's: affect, behaviours, and cognition.
The mental health assessment, namely the psychiatric history, identifies symptoms and past demographics, but often goes no further. Formulation extends this data to a fuller understanding of cause and moves into the art of healing.
Models of Formulation
Different practitioners have different definitions and models of formulation, though each encompasses descriptions of a patient's situation, prescriptions for therapeutic pathways, and predictions of outcome (Sim, Gwee, and Bateman, 2005).
A formulation from a CBT perspective will likely focus on a problem list, core beliefs, precipitants and activating situations, origins, a working hypothesis, a treatment plan, and predicted obstacles to treatment. Alternatively, a dynamic psychotherapy approach would also include a description of psychodynamic factors, core psychodynamic ego states and transactions, and model of self psychology.
Effective Formulation
An effective formulation captures the essence of a patient's situation, providing a theoretical basis for it rooted in emotions, cognitions, and choices rooted in past experiences.
Formulation is often poorly taught due to misconceptions about their being time-consuming and useful only in long-term cases, although neither are true.
Formulations should be written down as a record and to organize thoughts.
There is a balance between being overly simplistic and complex, as well as relying too much on either observation or hypothesis. Movement in either direction will hinder effective understanding of a patient.
Effective formulations have the following characteristics (Sim, Gwee, and Bateman, 2005):
Integrative: Identification and summarization of symptoms and origins, especially for complex cases, can help narrow focus on key components.
Explanatory: Formulation allows insight into the history of a patient's views and responses to self and others, as well as providing a framework for understanding interactions between biology and psychology through a developmental lens.
Prescriptive: Understanding a patient's past and present guides future treatment choices with some certainty, especially as various emotions and behaviours emerge during therapy and threaten second-guessing.
Predictive: Formulation assists with prognosis and assessment of treatment success.
Compassionate: A greater understanding by the therapist allows greater empathy, including during acting out, nonadherence to homework plans, or other patient resistance.
Formulation must also be done in a cultually-sensitive manner in order to ensure a patient feels, and is, understood.
Can be structural, gathered from interview and analysis of responses.
- past history
Can be functional, gathered from the interview itself and other interactions by observing patient ABC's.
Formulation can depend on the specfic psychotherapy used.
Observe words, tone of voice, body language,
- ie parents will say "he should do this" or "why doesn't he"
Observe in interactions (reciprocal roles) and identify examples of health/unhealth
Evidence for Formulation
Additional Resources
Sim K, Gwee KP, Bateman A. 2005. Case formulation in psychotherapy: revitalizing its usefulness as a clinical tool. Acad Psychiatry. 29(3):289-92.
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