FORMULATION Yvonne Edmonstone

Jessie MacDonald

“The science of formulation must be combined with art. Something vital is

lost if the formulation does not capture the essence of the case.”

Denman

Case Formulation

• Initially developed for psychodynamic approaches • Shown to be a replicable procedure• General psychiatric formulation includes genetic,

medical, psychological, phenomenological & social components “Seeing the bigger picture”

• At its simplest “Why has this individual become ill in this way at this particular time?”

• Formulation = “systematic description” Hypothesis about the psychological mechanisms underlying the patient’s current difficulties.

Why Formulate?1. Diagnosis alone is unlikely to be sufficient.

Formulation gives more information as it focuses on more than just symptoms. It looks at why the problem occurred as well as what the problem is.

2. Helps in developing an understanding of the patient and their difficulties

3. Looks at what early experiences may have contributed to current difficulties.

Why Formulate? (Cont.)

4. Provides an individualized understanding of why problems have arisen and what is maintaining them. Looks at current stressors.

5. Helps in understanding relationships between problems. Looks at underlying beliefs, rules, standards & expectations.

6. Assists in choosing which problems should be tackled first i.e. choosing intervention point

Why Formulate? (cont.)

7. Guides selection of most appropriate treatments i.e. choosing intervention strategies like homework to improve treatment outcome.

8. Helps to predict patient’s behaviour i.e. likely response to treatment and potential difficulties

9. Helps to predict and manage setbacks in therapy.

Why Formulate? (cont.)

10.Gives the patient a rationale for therapy

11.Helps in understanding and working on relationship difficulties

12.Assists collaboration particularly if done as a joint venture.

Formulation – other benefits

• May help reduce the length of treatment

• Helps deal with blocks and difficulties that arise

• Allows therapist to treat problems not come across before

Covert & Overt DifficultiesPersons 1989

Covert difficulties in a formulation are the patient’s core beliefs, conditional beliefs and compensatory strategies.

Life events interact with covert difficulties to cause and maintain overt difficulties.

Formulatation – How?1. Begin at “overt” level of difficulty

i.e. What patient presents with? Why patient seeks treatment? Make an exhaustive list of problems –cognitive, behavioural, physical & emotional

Physiology

Emotion Behaviour

Thoughts

Environment

Formulation – How?(cont.)2. Move to “covert” difficulties

i.e. underlying psychological mechanisms such as vulnerabilities and coping strategies. What do all these problems have in common? E.g. beliefs, skill deficits or behavioural patterns which help explain difficulties

Thoughts

Compensatory strategies

Assumptions

Early Beliefs Current

Experiences Experiences

Formulation – How? (cont.)

3. What is the meaning of the chief complaint?

4. What were the critical incidents precipitating the crisis leading to the presenting problems?

5. What are the factors that have lead this client to develop this problem at this time?

6. What significant life events have occurred?

Formulation How? (cont.)

7. What are the common themes of automatic thoughts?

8. What are the principal themes from the past?

9. What early experiences may have affected the formation of beliefs?

10. What early maladaptive schemas might account for this story?

Formulation – How? (cont.)

11. Are there hints about the kinds of underlying assumptions ?

12. What kinds of conditional beliefs are held?13. What are the schemas about self, others and the

world?14. Can you propose an underlying mechanism that

can account for all the problems on the list?15. What further evidence is needed to test out the

formulation?

Generic Formulation (Eden Unit)Patient’s name and date of birth Date of FormulationPREDISPOSING FACTORS

We usually draw a genogram here

We insert all the info from multidisciplinary assessments and the subsequent discussion in ‘bullet point’ form in the appropriate boxes

TO DO/ DISCOVER

Matters of fact, further investigation, conjecture etc

PERPETUATING FACTORS

Alas, much stuff from other boxes also goes here – even stuff from’strengths’ can cut both ways!

PRECIPITATING FACTORS

O f this and any previous episodes, listed here in order

PROTECTIVE FACTORS AND STRENGTHS

Including individual, interpersonal, family supports, acceptance of treatment etc

 

PRESENTING PICTUREIncluding co-morbidities

Formulation:CBTPhysiology

Emotion Behaviour

Thoughts

Compensatory strategies

Assumptions

Early Beliefs Current Experiences Experiences

Formulation IPT (Bio-Psycho-Social Model)

Biological FactorsGeneticsMedical illnessesMedical treatmentsSubstance use

Social factorsIntimate relationshipsSocial support

Psychological Factors

Attachment styleTemperamentCognitive styleCoping mechanisms

Unique Individual

Interpersonal Crisis (Focus) - Grief - Dispute- Transition - Sensitivity

Interpersonal Distress Diagnosis

DBT Formulation

EMOTIONS (that interfere with a more skilful response)

OVERDEVELOPED BEHAVIOURS UNDERDEVELOPED BEHAVIOURS

Goals

Life threatening Behaviours

Therapy Interfering Behaviours

Quality of Life

Core Beliefs about Self Core Beliefs about Others

CURRENT PROBLEMSLife Threatening Therapy Interfering Quality of Life

Background Factors

Formulation – Test it!

• Does it make sense? • Do the early life experiences explain the formation of

the schemas held?• Is the formation of conditional beliefs explained?• Does the impact of the critical incident make sense

in relation to the rest of the formulation?• Do the presenting symptoms fit?• Does patient (& supervisor) agree with formulation?

Formulation – What next?• Complete formulation and agree therapy goals • Make treatment plan - An accurate formulation

will assists selection of appropriate treatment strategies / interventions

• Helps to predict how patient will respond • Consider obstacles to treatment

e.g. what impact do patient’s beliefs, attitudes, personality etc have on treatment

• May help to predict potential difficulties and suggest how to deal with them.

Case Formulation Exercise

• AB is 23yr old woman “Depressed several months” “Binging and vomitting increasingly frequently”• 2nd Year nursing student – struggling with recent clinical placement• Some anxiety about completing course and finding work – describes self as

“Perfectionist”• Boyfriend 6mths – Mechanic• Parents separated – Dad alcohol problems• Living at home with mother and brother

• Husband has bad heart, stressful job with a lot of travelling• Pension reduced – paid off some of mortgage but financial worries with

debts & credit cards beyond means

Formulation:ExercisePhysiology

Emotion Behaviour

Thoughts

Compensatory strategies

Assumptions

Early Beliefs Current Experiences Experiences

Case Conceptualisation worksheet“OVERT”

PhysiologyTired Lacking motivation Losing weight (BMI 18) Difficulty concentrating

Emotion Behaviour

Down / Depressed Withdrawal & avoidanceWorried/Anxious Rarely go out except to work

Restricting, binging and vomiting

Thoughts“I’m rubbish, no good at this, will never make a nurse” “Mustn’t worry Mum”

“Don’t want to see other people. Don’t do anything, nothing to talk about” “Not pretty – too fat – expect boyfriend will dump me”

Environment

Difficult, busy training placement Financial worries Parental dispute

New relationship

Case Conceptualisation worksheet“COVERT”

Compensatory strategies Avoidance & Perfectionism

Assumptions Others look down on me because I’m not god enough

I should do betterI cant afford to make any mistakes if I am going to succeed in nursing

If I was slim and pretty, then my relationship would last I mustn’t upset Mum as she has too much to deal with already

Past Beliefs Current Experiences I’m useless Experiences Parents separated I’m no good Busy training placement Dad alcoholic I’m a failure Financial worries Ashamed of family Others are better than me Parental dispute New relationship

Further Reading

• Case Formulation in Psychotherapy: Revitalizing Its Usefulness as a Clinical Tool

Sim, Kang;Kok Peng Gwee;Bateman, Anthony

Academic Psychiatry; Jul/Aug 2005; 29:289 – 299

• The Quality of Psychotherapy Case Formulations: A Comparison of Expert, Experienced, and Novice Cognitive–Behavioral and Psychodynamic Therapists

Tracy D. Eells, Kenneth G. Lombart, Edward M. Kendjelic,

L.Carolyn Turner, and Cynthia P. Lucas

Journal of Consulting and Clinical Psychology 2005,

Vol 73,No. 4, 579–589