By: PETER
STURMEY
There are many definitions of case formulations. Eells (2007a) defined case formulation as a hypothesis about the causes, precipitants, and maintaining influences of a person’s psychological, interpersonal and behavioral problems ... [which] helps organize information about a person, particularly when that information contains contradictions or inconsistencies in behavior, emotion and thought content ... it contains structures that permit the therapist to understand these contradictions ... it also serves as a blueprint guiding treatment ... It should help the therapist experience greater empathy for the patient and anticipate possible ruptures in the therapy alliance ... The nature of this hypothesis can vary widely depending on which theory ... the clinician uses ... (p.4)
Eells’ definition is deliberately broad and attempts to avoid any theory-specific constructs. His definition specifies that case formulations serve several functions, such as unifying information concerning development and maintenance of the presenting problems, resolving conflicting information, guiding treatment and improving the relationship between the therapist and client.
Others have
defined case formulation from the perspective of specific theories. For example, McWilliams (1999) noted from a
dynamic formulation that when her supervisor first asked her to make a
dynamic formulation of a case she should suggest how the person’s symptoms, mental status,
personality type, personal history, and current circumstances all fit together
and make sense ... (p. vii)
Later, she noted that we
put all the assessment information into a narrative that makes this human being and his or her
psychopathology comprehensible to us, and we derive our recommendations and our
way of relating to the client from that narrative ... (p. viii)
Thompkins (2007)
gave this definition of case formulation from the cognitive-behavioural perspective: [A] hypothesis about the
patient’s disorders and problems, and which is used as the basis for intervention ... it is parsimonious; that is,
it offers the minimum
detail necessary to
accomplish the task of guiding treatment ... (p. 291)
Turkat (1990)
defined problem formulation from a behavioural perspective as (1) a hypothesis about the relationship among the
various problems of the individual; (2) hypotheses about the aetiology of the
aforementioned difficulties; (3) predictions about the patient’s future behaviour ... (p. 17)
From an eclectic
perspective, Weerasekera (1996) wrote that ‘formulation’
is defined as a provisional explanation or hypothesis of how an individual comes to present
with a certain disorder or circumstances at a particular point in time ... [that] include[s] biological,
psychological and systemic
factors ... (p. 4)
As these definitions illustrate, researchers and clinicians have offered definitions of case formulation from an atheoretical stance and from the perspective of both specific and eclectic approaches to case formulation. These definitions come from very different authors. Yet, they share several features. First, most of them emphasize that a formulation abstracts out key features of the case. A formulation is not a list, chronology or summary of all the details of the case. Persons and Thompkins hit the nail on the head when they suggested that a formulation should have enough detail to guide treatment, and, by implication, nothing more.
A second related
idea is that case formulations should
integrate all the information about the case into a unified and related idea or set
of ideas. The formulation should tie together the onset, development,
maintenance of the problem(s) and should link these ideas to the treatment that
should grow out of and relate to the formulation.
Third, these
definitions note or imply the tentative and provisional nature of case formulation. A case formulation is only based
on what the clinician knows so far. Further assessment, events, response to
treatment and relapses may all cause a formulation to be revised in some
potentially significant way. For example, Haynes and O’Brien (2000) pointed
out that formulations have boundaries.
Finally, one of
the key functions of case formulation is to guide treatment. Specifically, case formulations
should predict individually designed treatments that will be more effective than
treatments that would otherwise have been implemented.
Different
approaches to case formulations share these several features. However, the authors’ differing theoretical
perspectives result in very significant differences between approaches to case
formulation. Specifically, approaches to case formulation differ in terms of the following:
(1) The nature of the behaviour that therapy should change;
(2) Which
independent variables
are important in a case formulation?
(3) The role of
history in a case formulation;
(4) How to use
the case formulation with the client;
(5) The role of psychiatric diagnosis, if any, in case formulation;
and
(6) How
prescriptive the definitions of case
formulation are.
References
Peter
Sturmey, Clinical Case Formulation; Varieties of Approaches, 2009, John Wiley
Ltd.
Read Also
The Clinical Interview
Diagnostic Principles
The Need For A Clear Boundary Between Assessment And Treatment
Completing the Diagnostic Assessment
The Comprehensive Diagnostic Assessment and Evaluation
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