Formulation

Formulation is a word that professions other than psychology have often not even heard of! And that completely baffles me, as I see it as such a core skill and absolutely key in deciding what to do with a client. Along with being able to conduct a multi-dimensional assessment, formulation allows us to individualise our understanding of a client, and thus create an individualised intervention which may draw on many models. This ability to individualise our intervention, rather than use one intervention in a one-size-fits-all way is something I regard as one of the core skills we bring to our work that most other professions don't.

Some psychiatrists will formulate, but I have met psychiatrists who believe that diagnosis is the same, because a diagnosis comes from an assessment and informs a medical intervention. There is a discourse that because psychiatrists only have medical interventions to provide, they leave formulation (which also includes psychological and social factors) to other professions, who might be able to intervene in this way. Whilst this is extreme, I do believe that psychologists and psychotherapists are the key proponents of formulation.

The main formulation model I use identifies the predisposing factors (genetics, early experiences, neurology, temperament, etc) and then looks at the narratives this has led to (in a CBT model these might be called core beliefs) such as "I am unlovable" or "no-one else looks after me, so I have to be self-sufficient" and then looks at the thoughts, feelings and behaviour cycles that maintain the symptoms the client is having (there might be loads and loads of different cycles, but each will help you identify where change is possible). Your formulation should be about making sense of the information you have gathered in the assessment, which would include setting up some hypotheses for what is going on for that person. You might then investigate these hypotheses in your intervention.

Here is my generic formulation diagram (its a simplistic one, for teaching non-psychologists). Please don't copy/print/distribute these sheets without asking me first.

http://i41.photobucket.com/albums/e270/tegmim/formulation.gif

and here is an example formulation (much simplified again, and with only one maintenance loop illustrated):

http://i41.photobucket.com/albums/e270/tegmim/formulation2.gif

FTT = non-organic failure to thrive (meaning she wasn't growing well, and was often sickly, but there was no medical explanation for this)

I should say, that the basic principles of formulating are the same whatever the client group, but I obviously work in a CAMHS setting, so my teaching was based on formulting a child's presenting problems (and the example I chose was to show it may be as much an issue in the parent, even if the symptoms are in the child).

So, formulation is the summation and integration of knowledge acquired through assessment (which may involve a number of procedures). It draws on psychological theory and data to provide a framework for describing a problem, how it developed and is maintained. A formulation may draw on many different explanatory models, and comprise of a number of provisional hypotheses and targets of intervention.

The formulation can also be shared with the client, to help them see their difficulties in a different way and understand the intervention plan. It can be a helpful intervention in its own right, as it may increase insight and consequently change behaviour.

Strengths of formulation over diagnosis
Formulation seeks to understand a person’s difficulties, in a much more holistic way than giving a diagnosis. Formulation allows for an understanding of how an individuals difficulties arise and are maintained in the system that surrounds them, as well as the wider environment, of cultural and societal norms. This tries to specify and understand the thoughts, emotions and behaviours evoked in/from an individual, and those who interact with them. This can then be targeted in therapy; providing an idiosyncratic, creative, integrative approach, which is grounded in theory and evidence.

This is appropriate, as everyone’s experience is different even if symptoms show some commonality with others. Diagnosis does lead to a shorthand way of communicating with others, which allows some sense of understanding about the difficulties someone may face. However, this can lead to assumptions which may hinder understanding.

It could be argued that diagnosis is more reliable (consistent), even though it lacks some of the validity (accuracy) formulation brings. Formulation is a much more complex way of understanding (and then working with) an individual, and what they bring. As such, mistakes can be made. Clinicians who are not very experienced, or are relatively inflexible in their approach (CBT/Psychodynamic/Systemic), can or may overlook important factors in an individual’s life, which may be paramount. Assumptions can be made in formulation, just as they can be in diagnosis. It may be important to refresh ideas and look at how we work and formulate through CPD, supervision, and where necessary consultancy. Whilst formulation has many models to guide us, it could be argued that it is a more subjective process than diagnosis.

The following book, has different chapters for different ways to formulate, including CBT, but to intergrative and social constructionist formulations.

Dallos, R. & Jhonstone, L. (2006) Formulation in Psychology and Psychotherapy.

There is a paper about the reliability of formulation:
Kuyken, W., Fothergill, C.D., Musa, M., & Chadwick, P. (2005). The reliability and quality of cognitive case formulation. Behaviour Research and Therapy, 43, 1187-1201

Some further references, and reading that you may find helpful:

Kang Sim, M.D., Kok Peng Gwee, M.D. and Anthony Bateman, M.D. (2005).Case Formulation in Psychotherapy: Revitalizing Its Usefulness as a Clinical Tool. Acad Psychiatry 29:289-292

From the DCP forum: The value of formulation: A question for debate. April 2006, pages 7-12

Weerasekeera, P. (1995) Multiperspective Case Formulation: A Step Towards Treatment Integration. Krieger Publishing Company

Lemma, A. (2003) Chapter 4: Assessment and Formulation. In Introductions to the Practice of Psychoanalytic Psychotherapy: A practical Treatment Handbook. John Wiley and Sons ltd

Eells, T.D. (1997) Handbook of Psychotherapy Case Formulation. Guildford Press.

This is good reading material and breaks formulation down:
Teaching psychodynamic formulation to psychiatric trainees: Part 1: Basics of formulation

Teaching psychodynamic formulation to psychiatric trainees. Part 2: Teaching methods

These are CBT papers:
A cognitive–behavioural therapy assessment model for use in everyday clinical practice

Using the Five Areas cognitive–behavioural therapy model with psychiatric patients

Identifying and challenging unhelpful thinking

Overcoming reduced activity and avoidance: a Five Areas approach

(Contributions from Miriam, Dorothy, and Mr.M)

Here are two useful references for formulation that I ask my trainees to read:

Havighurst, S. S. & Downey, L. (2009) Clinical Reasoning for Child and Adolescent Mental Health Practitioners: The Mindful Formulation. Clinical Child Psychology and Psychiatry, 14 (2), p.251-271

Shahar, G. & Porcerelli, J.H. (2006) The Action Formulation: A Proposed Heuristic for Clinical Case Formulation. Journal of Clinical Psychology, 62 (9), p.1115-1127.

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