ArticlePDF Available

Is diagnosis enough to guide interventions in mental health? Using case formulation in clinical practice

Authors:
  • Orygen Youth Health

Abstract

While diagnosis has traditionally been viewed as an essential concept in medicine, particularly when selecting treatments, we suggest that the use of diagnosis alone may be limited, particularly within mental health. The concept of clinical case formulation advocates for collaboratively working with patients to identify idiosyncratic aspects of their presentation and select interventions on this basis. Identifying individualized contributing factors, and how these could influence the person's presentation, in addition to attending to personal strengths, may allow the clinician a deeper understanding of a patient, result in a more personalized treatment approach, and potentially provide a better clinical outcome.
COMMENTARY Open Access
Is diagnosis enough to guide interventions in
mental health? Using case formulation in clinical
practice
Craig A Macneil
1,2*
, Melissa K Hasty
1,2
, Philippe Conus
2,3
and Michael Berk
2,4,5,6
Abstract
While diagnosis has traditionally been viewed as an essential concept in medicine, particularly when selecting
treatments, we suggest that the use of diagnosis alone may be limited, particularly within mental health. The
concept of clinical case formulation advocates for collaboratively working with patients to identify idiosyncratic
aspects of their presentation and select interventions on this basis. Identifying individualized contributing factors,
and how these could influence the persons presentation, in addition to attending to personal strengths, may allow
the clinician a deeper understanding of a patient, result in a more personalized treatment approach, and
potentially provide a better clinical outcome.
Keywords: Formulation, diagnosis, cognitive behavioral therapy, psychological intervention, case conceptualization
Background
In neurosis and personality disorders, formulation i s a
clearer guide to aetiology, prognosis and treatment than
is categorical diagnosis Aveline, p. 199 [1]
This paper describes con cerns around using diagnosis
alone as a tool to select clinical interventions, provides
an overview of some current models of case formula-
tion, and examines its potential clinical utility.
The clinical utility of diagnosis and formulation
With debate and controversy already emerging around
some of the diagnoses proposed in the upcoming Diag-
nostic and Statistical Manual of Mental Disorders
(DSM), Fifth Edition, it may be timely to review the con-
cepts of diagnosis and formulation in ment al health. Psy -
chiatry has traditionally emphasized the i mportance of
diagnostic categories, with the implication that these
offer a reliable guide for treatment options and prediction
of outcomes. Diagnosis has also been regarded histori-
cally as helpful from a research standpoint, allowing cate-
gorization of people by disorders in order to quantify
outcomes, and facilitate discussion around interventions
and etiology.
In reality, however, diagno sis alone may tell us little
about causation of a psychiatric disorder. Diagnosis may
also instruct us poorly about which form of intervention
we should undertake, and offers no information about the
persons experience of their disorder. Kendell and Jablen-
sky [2] acknowledged that while diagnoses may be ...help-
ful working concepts for clinicians (p.4), many are not
val id, in the sense that they are not ...discrete entities
with natural boundaries that separate them from other
disorders (p.4). Furthermore, Tarrier and Calam [3] noted
that, as diagnoses in the DSM and the International Clas-
sification of Diseases (ICD-10) are often based on selecting
from a list in which some items are present and others
absent, it is possible for two people to have the same diag-
nosis with few, and in some cases, no symptoms in
common.
Categorical diagnoses are perhaps most valuable for dis-
orders in which there is gre ater homogeneity, where bio-
marker studies show some demonstrable patterns, and
where categorical diagnosis guides treatment with a degree
of accuracy. Unfortunately, few disorders in psychiatry
match this description. Phenomena such as mood and per-
sonality disorders, psychoses, and anxiety disorders can be
associated with a diversity of etiological factors including
* Correspondence: Craig.Macneil@mh.org.au
1
Early Psychosis Prevention & Intervention Centre (EPPIC), and Orygen Youth
Health Research Centre, Orygen Youth Health, 35 Poplar Road, Parkville,
Melbourne, Victoria, 3052, Australia
Full list of author information is available at the end of the article
Macneil et al. BMC Medicine 2012, 10:111
http://www.biomedcentral.com/1741-7015/10/111
© 2012 Macneil et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Co mmons
Attribution Lice nse (http://creati vecommons .org/licenses/by/2.0), which permits unrestricted use, distribution, and rep roduction in
any medium, provided the original work is properly cited.
early childhood experiences, trauma, personality styles,
family, interpersonal, lifestyle, medical, and social stressors,
with ea ch factor playing a greater or lesser role for each
person. Understanding and incorporating these into an
individualized treatment plan is an essential part of quality
care, with failure to do so not only risking an ineffective
outcome, but potentially impacting negatively on the ther-
apeutic relationship and resulting in exacerbation of the
persons symptomatology.
At least in part due to recognition of the limitations of
diagnosis in mental health, the concept of formulation or
case conceptualization has attracted increasing interest in
recent years. Formulation has been defined as synthesiz-
ing the patient s experience with relevant clinical theory
and research [4], as ...the bridge between assessment and
treatment [[5], p.210] and has been utilized for multiple
disorders in children, adults and older adults. [6-8]. How-
ever, formulation may be particularly helpful for people
who have not had an adequate response to traditional
interventions, people who have Axis II disorders, or
when comorbidity compli cates w hich interventions
should be utilized first [9,10].
Formulation can serve a number of functions. These
include: understanding significant etiological factors that
have influenced the person s presentation; identify ing key
difficulties; guiding which int erventions should be uti-
lized and in what order; and anticipating challenges that
may occur during the course of treatment [4,6,7,11].
What should a formulation comprise? The Five
Ps approach to formulation
Despite some differences between theoretical orientations,
some key themes exist around the content of formulations,
with one of the more popular recent approaches utilizing
the Five Ps.Theseare:
1. Presenting problem. This goes beyond diagnosis to
include wha t the person and clinician identify as difficul-
ties, how the persons life is aff ected, and when a particu-
lar difficulty should be targeted for intervention. For
example, while a person may meet criteria for the diagno-
sis of borderline p ersonality d isorder, presenting difficul-
ties may include not b eing abl e to maintain employment,
erratic friendships, and p hysical he alth complications
resulting from self-harm. Specifying such difficulties can
allow for a more focused intervention.
2. Predisposing factors. This comprises identifying pos-
sible biological contributors (for example, organic brain
injury and birth difficulties), genetic vulnerabilities
(including family history of mental health difficulties),
environmental factors (such as socio-economic status,
trauma, or attachme nt history) and psychological or per-
sonality factors (includi ng core beliefs or personality fac-
tors) which may put a person at risk of developing a
specific mental health difficulty.
3. Precipitating factors. This can include significant
events preceding the onset of the disorder, such as sub-
stance use, or interpersonal, legal, occupational, physical,
or financial stressors.
4. Perpetuating factors. This comprises factors which
maintain the curre nt difficulties. These can include
ongoing substance use, repeating behavioral patterns
(including avoidance or safety behaviors in anxiety dis-
orders, or withdrawal in depressive disorders), biological
patterns (such as insomnia in mania, and insomnia or
hypersomnia in depression) or cognitive patterns such
as attentional biases, memory biases, or hypervigilance.
5. Protective/positive factors. This involves identifying
strengths or supports that may mitigate the impact of
the disorder. These can include social support, s kills,
interests, and some pe rsonal characte ristics. Kuyke n et
al. [4] suggested that this is a particularly important ele-
ment which has traditionally been lacking in mental
health interventions, but inclusion of which results in a
higher likelihood of reduced symptomatology and
increased resilience (p.4). We would add that identifica-
tion of protective factors also creates increased opti-
mism in both the clinician and patient and contributes
to a positive therapeutic relationship.
Importantly, formulations should be flexible, and
should incorporate new information as it emerges. As
Persons [6] noted, ... assessment and treatment are a
continuous process of proposing, testing, re-evaluating,
revising, rejecting, and creating new formulations (p. 55).
Cautions Regarding Formulation
Despite numerous strengths, some caution is required
when using a formulation-based approach. Chadwick et
al. [12] reported that while most of their participants
reported an ...increased sense of hope and understand-
ing (p. 679) following formulatio n, some also described
negative aspects, including that it has been saddening,
upsetting and worrying (p. 674). This study highlights
the importance of developing collaborative formulations
within a strong therapeutic relationship and at a reason-
able pace. We would also suggest that similar risks exist
when discussing diagnoses with patients. It is also notable
that the formulation undertaken in this study did not
include identifying participants strengths or protective
factors. It may be, therefore, that had protective factors
and strengths been included, the outcome could have
been better.
Notably, research on the impact of formulation on out-
come is still somewhat li mited, and questions remain
regarding inter-rater reliability [4,13]. However, training
and therapist experience have consistently been found to
impact on the quality of formulations for clinicians work-
ing with either cognitive behavioral or psychodynamic
frameworks [14]. Encouragingly, Kendjelic & Eells [15]
Macneil et al. BMC Medicine 2012, 10:111
http://www.biomedcentral.com/1741-7015/10/111
Page 2 of 3
reported that even brief cli nician training produced ...
formulations rated as higher in overall quality and as more
elaborated, comprehensive, complex, and precise (p.66).
Conclusions
When done well, formulation provides an opportunity for
a s hared understanding of a persons difficulties, and can
offer a way of answering the classic questions of why this
person?, why this problem?, and why now? in ways that
diagnosis alone does not. Importantly, it can also provide
a rationale and shared agenda for what to target and in
what order. While there may be some risks involved in
formulation, if done sensitively, collaboratively, and
accounting for strengths, we suggest it can be a clinical
tool with the potential to provide considerably better out-
comes than diagnosis alone. A challenge is the integration
of a formulation-based management plan with categorical
diagnosis and the current evidence base to provide a
broad-based clinical understandi ng and an individualized
therapeutic strategy.
Acknowledgements
PC is supported by a grant from the Leenaards Foundation, Switzerland.
CAM is funded part-time by the Orygen Youth Health Research Centre.
Many thanks to Dr Melanie Evans for reviewing and helpful comments on
the paper.
Author details
1
Early Psychosis Prevention & Intervention Centre (EPPIC), and Orygen Youth
Health Research Centre, Orygen Youth Health, 35 Poplar Road, Parkville,
Melbourne, Victoria, 3052, Australia.
2
Orygen Research Centre, 35 Poplar
Road, Parkville, Victoria, 3052, Australia.
3
Treatment & Early Intervention in
Psychosis Program (TIPP), Département de Psychiatrie CHUV, Université de
Lausanne, Clinique de Cery, 1008 Prilly, Switzerland.
4
School of Medicine,
Deakin University, 1 Gheringhap Street, Geelong, Victoria, 3220, Australia.
5
Department of Psychiatry, The University of Melbourne, Level 1 North, Main
Block, Royal Melbourne Hospital, Victoria, 3050, Australia.
6
Mental Health
Research Institute, Kenneth Myer Building, 30 Royal Parade, Parkville Victoria,
3052, Australia.
Authors contributions
CAM and MKH were involved in the conceptual background and drafting
the manuscript. PC and MB were involved in critically revising the paper.
Competing interests
CAM has received past honoraria and travel grants from AstraZeneca, Eli
Lilly, Sanofi-Aventis and Janssen-Cilag for speaking engagements and
attendance of advisory committees. MKH has received a travel grant from
Pfizer and research funding from AstraZeneca. PC has received research
grants and travel grants to attend conferences from Bristol Meyers Squibb,
Astra Zeneca, Jannsen Cilag, and Eli Lilly. MB has received Grant/Research
Support from the NIH, Cooperative Research Centre, Simons Autism
Foundation, Cancer Council of Victoria, Stanley Medical Research Foundation,
MBF, NHMRC, Beyond Blue, Geelong Medical Research Foundation, Bristol
Myers Squibb, Eli Lilly, Glaxo SmithKline, Organon, Novartis, Mayne Pharma
and Servier, has been a speaker for Astra Zeneca, Bristol Myers Squibb, Eli
Lilly, Glaxo SmithKline, Janssen Cilag, Lundbeck, Merck, Pfizer, Sanofi
Synthelabo, Servier, Solvayand Wyeth, and served as a consultant to Astra
Zeneca, Bristol Myers Squibb, Eli Lilly, Glaxo SmithKline, Janssen Cilag,
Lundbeck and Servier. None of the above companies were involved in any
way in the drafting, reviewing or in providing financial assistance for this
paper.
Received: 26 June 2012 Accepted: 27 September 2012
Published: 27 September 2012
References
1. Aveline M: The advantages of formulation over categorical diagnosis in
explorative psychotherapy and psychodynamic management. Eur
J Psychother Couns Health 1999, 2(Suppl 2):199-206.
2. Kendell R, Jablensky A: Distinguishing between the validity and utility of
psychiatric diagnoses. Am J Psychiatry 2003, 160:4-12.
3. Tarrier N, Calam R: New developments in cognitive behavioural case
formulation. Beh Cogn Psychother 2002, 30:331-328.
4. Kuyken W, Padesky CA, Dudley R: Collaborative Case Conceptualization:
Working Effectively with Clients in Cognitive-Behavioral Therapy New York:
Guilford Publications; 2009.
5. Restifo S: An empirical categorization of psychosocial factors for clinical
case formulation and treatment planning. Australas Psychiatry 2010,
18(Suppl 3):210-213.
6. Persons JB: Cognitive Therapy in Practice: A Case Formulation Approach New
York: Norton and Co.; 1989.
7. In Formulation in Psychology and Psychotherapy: Making Sense of Peoples
Problems. Edited by: Johnstone L, Dallos R. East Sussex: Routledge; 2006:.
8. In Clinical Case Formulation: Varieties of Approaches. Edited by: Sturmey P.
West Sussex: Wiley-Blackwell; 2009:.
9. Mumma GH: Improving cognitive case formulations and treatment
planning in clinical practice and research. J Cogn Psychother 1998,
12:251-274.
10. Tompkins MA: Using a case formulation to manage treatment
nonresponse. J Cogn Psychother 1999, 13(Suppl 4):317-330.
11. Eells TD: Update on psychotherapy case formulation research.
J Psychother Pract Resh 2001, 10(Suppl 4):277-281.
12. Chadwick P, Williams C, Mackenzie J: Impact of case formulation in
cognitive behaviour therapy for psychosis. Behav Res Ther 2003,
41:671-680.
13. Persons J, Mooney K, Padesky C: Inter-rater reliability of cognitive-
behavioural case formulations. Cogn Ther Res 1995, 19:21-34.
14. Eells TD, Lombart KG, Salsman N, Kendjelic EM, Schneiderman CT, Lucas CP:
Expert reasoning in psychotherapy case formulation. Psychother Res 2011,
21(Suppl 4):385-399.
15. Kendjelic EM, Eells TD: Generic psychotherapy case formulation training
improves formulation quality. Psychotherapy 2007, 44(Suppl 1):66-77.
Pre-publication history
The pre-publication history for this paper can be accessed here:
http://www.biomedcentral.com/1741-7015/10/111/prepub
doi:10.1186/1741-7015-10-111
Cite this article as: Macneil et al.: Is diagnosis enough to guide
interventions in mental health? Using case formulation in clinical
practice. BMC Medicine 2012 10:111.
Submit your next manuscript to BioMed Central
and take full advantage of:
Convenient online submission
Thorough peer review
No space constraints or color figure charges
Immediate publication on acceptance
Inclusion in PubMed, CAS, Scopus and Google Scholar
Research which is freely available for redistribution
Submit your manuscript at
www.biomedcentral.com/submit
Macneil et al. BMC Medicine 2012, 10:111
http://www.biomedcentral.com/1741-7015/10/111
Page 3 of 3
... 605 Formulation assists in choosing which medication, psychotherapeutic, or lifestyle approaches to treatment and care a person might need or expect, as well as identifying individuals at risk of death by suicide. 606 It can also mould expectations of therapy; for example, evidence suggests that a history of childhood trauma or personality disorders might predict a poorer response to initial interventions than in people without such history. 607 Formulation typically assembles five domains of information and understanding that are based on awareness of the factors shown in panel 2 and are crucial in clinical decision making. ...
... These results also have practical implications for the management of loneliness in clinical and community settings. First, while loneliness is not a recognized clinical condition, it is nevertheless important to screen for people's perceptions of loneliness alongside social group connectedness and maladaptive emotion regulation during intake as this may provide clinicians with an early indication of their vulnerability and risk of developing psychological distress or disorder symptomology (Macneil, Hasty, Conus, & Berk, 2012). Second, identifying potential problems with loneliness, maladaptive emotion regulation, and social support helps clinicians to identify when it might be important to provide education about the role of these factors in enhancing mental health (Lyman et al., 2014). ...
Article
Full-text available
Objective: Emotion regulation and social identity theorizing provide two influential perspectives on loneliness. From an emotion regulation perspective, loneliness is understood as a negative emotional state that can be managed using emotion regulation strategies. A social identity perspective views loneliness as resulting from a loss or lack of important social groups and related identities. This study aimed to explore the relationships between key constructs drawn from both perspectives, with a view to understanding loneliness in adults with and without a history of mental illness. Design and methods: Participants (N = 875) with a mental illness history (MH Hx, n = 217; Mage = 45 years, 59% female) and without a mental illness history (No MH Hx, n = 658; Mage = 47 years, 48% female) completed a survey comprising measures of group membership and connectedness, emotion regulation strategies, and loneliness. Results: The MH Hx group reported higher internal affect worsening strategy use and loneliness than those No MH Hx. Hierarchical regressions indicated that the unique contributions of emotion regulation strategies and social identity factors to loneliness were equivalent between the groups. Together, social identity and emotion regulation explained 37% of the variance in loneliness in the No MH Hx subsample and 35% in the MH Hx subsample. Conclusion: These findings suggest that both emotion regulation and social identity had significant unique contributions to the reported loneliness of people when controlling for demographics and each other in those with and without a history of mental illness. Integration of the two frameworks may provide novel avenues for the prevention and management of loneliness. Practitioner points: Individuals with a history of mental illness report more use of internal emotion worsening regulation strategies and greater loneliness than those with no such history, but there were no differences in social identity factors. Internal emotion worsening strategies and social support received from others explained the variance in reported loneliness for both those with and without a history of mental illness. Internal emotion improving strategies were significant for those with a history of mental illness, while social support given was significant for those without a history of mental illness. Screening clients for emotion regulation difficulties, social disconnectedness, and loneliness may provide clinicians with an indication of risk for developing psychological distress/disorders.
... A 5-P's framework (Macneil et al., 2012) was used to (i) help Tom and Ruth make sense of Tom's 'story' (shared verbally but depicted here visually; Fig. 1); (ii) inform suitability for a CBT-based approach; and (iii) aid the therapist in holding in mind the developmental context. A finer-grained cognitive behavioural formulation for OCD ( Fig. 1), developed collaboratively later with Tom, informed the core therapeutic tasks targeting maintenance factors only. ...
Article
Full-text available
Sexual obsessions are common in adolescents with obsessive compulsive disorder (OCD), but how to address these obsessions in a developmentally sensitive manner remains under-explored. This report presents the case of an adolescent who experienced unwanted sexual imagery, undergoing conventional exposure and response prevention, which was subsequently augmented with imagery-based techniques. This approach was associated with remission in symptoms of OCD and marked improvements in symptoms of anxiety and depression. The imagery-based approach was well received and valued as key to treatment success by the adolescent. This raises the tantalising possibility that working directly with images can fuel treatment innovation in tackling sexual (and non-sexual) obsessions in youth OCD. Key learning aims (1) Sexual obsessions are common in adolescent obsessive compulsive disorder (OCD). (2) Little guidance is available on how to conduct exposure and response prevention sensitively for sexual obsessions in adolescent OCD. (3) Imagery-based techniques can be used effectively for reducing sexual obsessions. (4) Imagery-based techniques delivered by videoconferencing can be acceptable for young people.
... the Five P's method (Macneil et al., 2012), which stands for presenting problem, predisposing factors, precipitating factors, perpetuating factors, and protective/positive factors. We will now describe each of the areas in more detail. ...
Chapter
Within forensic settings, case formulations (CF) are used to explain and understand offending behaviour. Craig and Rettenberger (An etiological approach to sexual offender assessment: CAse Formulation Incorporating Risk Assessment (CAFIRA), Current Psychiatry Reports, 20 (6), 20–43, 2018) proposed an aetiological model of assessment of offending behaviour incorporating developmental theory, offence behaviour, and risk assessment theory into one model, referred as the CAse Formulation Incorporating Risk Assessment (CAFIRA) model. There is considerable evidence that adverse childhood experiences (ACEs) cause enduring brain dysfunction affecting memory, sensory and information processing systems having direct neurological relevance when understanding the psychological functioning of offenders with a history of trauma. In this chapter, we present an update to the model taking into account neurobiological considerations when completing forensic risk assessments, which we refer to as Forensic CAse Formulation Incorporating Risk Assessment-Sexual (CAFIRA-S).
Book
Full-text available
La formulación de casos en psicología jurídica tiene como objetivo establecer, de manera sistemática y organizada, información sobre los aspectos psicológicos y conductuales de personas y grupos que tienen implicaciones judiciales; esta información relacionada con el estado mental, personalidad, historia personal, interacciones grupales, dinámica relacional, motivación, etc., es utilizada para fundamentar las decisiones de los operadores jurídicos. Recientemente, la formulación de caso se ha convertido en un método clave para el desarrollo de procesos de sistematización, organización, formulación y análisis explicativo de la información en la práctica psicológica, especialmente, para quienes ejercen su actividad desde el campo aplicado de la psicología clínica, ya que esta se vincula directamente con procedimientos interventivos. No obstante, es importante considerar que la actividad profesional del psicólogo no se reduce exclusivamente al área de la salud, y por tanto, su ejercicio desde otros campos, como el de la psicología jurídico-penal, exige también una forma ordenada y esquemática que permita la realización de intervenciones ideográficas más objetivas. De acuerdo a lo anterior, en la presente investigación se propone un modelo de formulación de caso para la psicología jurídico-penal basada en la experiencia práctica y en el conocimiento teórico y científico de psicólogos jurídicos en el sistema de administración de justicia penal colombiano
Article
This is the protocol for a Campbell systematic review. The objectives are as follows: the first objective of the review (Objective 1—Prevalence) is to present a synthesis of the reported prevalence rates of mental health difficulties in terrorist samples. Where sufficient data is available, the synthesis will be sensitive to the heterogeneity of the terrorism phenomenon by exploring the rates of mental health difficulties for different forms of terrorism and for different terrorist roles (e.g., bombing, logistics, finance, etc.). The second objective (Objective 2—Temporality) will synthesise the extent to which mental health difficulties pre‐date involvement in terrorism within prevalence studies. Finally, the third objective (Objective 3—Risk) aims to further establish temporality by examining the extent to which the presence of mental disorder is associated with terrorist involvement by comparing terrorist and non‐terrorist samples.
Article
Clinical learning experiences are known to exacerbate nursing student anxiety, causing them to present to clinical placement in distressed, meaning anxious, states. Students already living with anxiety are also more likely to suffer setbacks at this time. Supervising Registered Nurses (RNs), in the clinical settings, struggle to support this student cohort. A professional development activity was designed to introduce RNs to higher education and nursing students’ known mental health concerns (such as anxiety) and to arm them with strategies for working with distressed students. A research approach that enabled researchers to collaborate with participants was employed to design the intervention. A study evaluated the impact of the educational intervention with 45 Australian RN supervisors. Two tailed T‐tests were chosen to explore the statistical difference between pre‐ and post‐test mean results across the survey items. A 95% confidence interval was used. Statistical significance was set at <0.05. The evaluation indicated the activity could be useful for improving supervising RNs’ mental health literacy, thus enhancing their understanding of how to work with distressed students. Participants recommended the activity be offered to any staff supporting student clinical learning. Collaboration between nursing researchers and nursing clinical staff produced a meaningful professional development activity and motivated the participants to increase their mental health literacy and understanding of strategies to support distressed students. Future projects should adopt similar approaches that would support both RNs’ ability to support students’ during clinical learning and students in distress would also benefit.
Article
Full-text available
In forensic mental health care, a risk management plan forms the transition between the assessment and the treatment phase. Research and practice have shown that clinicians often experience difficulties in the transition from assessment to risk management. Available methods often do not provide sufficient guidelines. The current narrative review aimed to provide an overview of available methods for the translation of the risk assessment information into a risk management plan and to evaluate these methods. A literature search led to the identification of 21 methods, of which only two provided concrete guidelines for all of the steps of the pathway from risk assessment to management. Results underline the importance of providing clinicians with structured methods to guide the risk management pathway. KEYWORDS
Article
Case formulations (CF) have been the cornerstone of effective practice in clinical psychology since the 1950s and now forms one of the core competencies in clinical and forensic training. The use of CFs within forensic settings is becoming more relevant when working with offenders who have experienced significant trauma, suffer from personality disorder, or who have displayed sexually abusive or violent behaviour. By integrating risk relevant information into the CF provides a conceptually robust link between the etiologically development of the problematic behaviour and effective assessment and risk management of violent offenders. In this chapter, we present an etiological framework for understanding risk by integrating a case formulation model to include the use of (static, stable, and acute) actuarial and forensic risk assessment measures as well as protective risk factors.
Article
Full-text available
Psychotherapy case formulations written by 20 clinicians who received a 2-hr training session in case formulation were compared with those of 23 clinicians not receiving training. Formulations based on intake interviews conducted at a university-based psychiatric outpatient clinic, two to three per clinician, were reliably coded for quality and content. Clinicians in the training group produced formulations rated as higher in overall quality and as more elaborated, comprehensive, complex, and precise. These formulations were also more likely to address precipitants, predisposing factors, and an inferred mechanism to explain symptoms and problems. Effect sizes indicated that the average clinician in the training group produced a better formulation than 86% of those in the control group. (PsycINFO Database Record (c) 2010 APA, all rights reserved).
Article
Edited by Peter Sturmey Wiley-Blackwell, 2009 Clinical Case Formulation is an impressive collection of case studies gathered in a volume coordinated and edited by Peter Sturmey. The book provides an overview of the general features of case formulation and how it can drive treatment. Featuring clinical cases from a variety of populations and focusing on a range of different problems, the volume covers all the major theoretical perspectives in clinical practice -behavioral, cognitive behavioral, psychodynamic, medical and eclectic. Each chapter describes a case, presenting two contrasting formulations and a commentary from a different perspective. These examples not only provide the reader with clear models of case formulations, they also highlight the different constructs and world views that characterize alternative theoretical approaches to case formulation.
Article
Most clinical psychologists and psychotherapists respect case formulation as an aid to good practice. For many psychiatrists, it remains a source of anxiety and confusion. Although the former are this book’s natural audience, I think it has much to offer inquiring psychiatric trainees. Comparative
Article
All clinicians must at times manage a treatment that isn't progressing. A case formulation offers clinicians a systematic way to think about a case, thereby increasing the likelihood that they will be able to overcome difficulties and achieve a successful treatment outcome. This article describes the use of a cognitive-behavioral (CB) case formulation to solve problems in the client-therapist collaborative relationship and to improve compliance with the goals and tasks of therapy. The use of CB case formulation to plan and adjust the treatment of a multiproblem client is presented.
Article
An individualized case formulation may be useful for determining when and for how long components of certain manual-based (MB) treatments should be used. Such a formulation is essential for treatment planning and implementation for cases where empirically supported standardized treatments are not available. Yet, procedures to develop valid individualized cognitive case formulations and to use them in treatment planning and implementation lag behind the standards used to develop MB treatments. The present article describes some of these problems and issues and suggests procedures that clinicians may use to address these issues in research or practice.
In neurosis and personality disorder, formulation is a clearer guide to aetiology, prognosis and treatment than is categorical diagnosis. Diagnosis and formulation have different and complementary functions. The formulation is an essential component in explorative psychotherapy but also has wide application in psychodynamic management. The content and the making of a formulation are described. the value of a psychodynamic approach in decision making, and in choosing between explorative psychotherapy and psychodynamic management, is illustrated by case examples.
Book
This book gives a nitty-gritty account of cognitive behavior therapy in practice. At the heart of this cognitive therapy model is the case formulation—the therapist's hypothesis about the psychological mechanism underlying the patient's problems. The book opens with a discussion of the model, emphasizing the connections between overt difficulties and underlying psychological problems, often encapsulated in such irrational beliefs as "I must be perfect or I am a failure," or "I don't deserve happiness." The central chapters describe numerous behavioral and cognitive strategies for ameliorating the problems anxious and depressed patients bring to treatment, as well as for changing underlying beliefs. In discussing these topics, as elsewhere, the author uses case examples to show how the case formulation guides the therapist's actions. In addition, she applies cognitive behavioral strategies to suicidality, one of the most troublesome difficulties encountered by therapists. Finally, Dr. Persons turns her attention to the needs of therapists themselves, offering strategies for handling anxiety, anger, and uncertainty about competence. The general model presented here will allow therapists to understand their patients' problems and generate solutions to them based on this understanding in a coherent, systematic way. It will be valuable to both beginning and experienced cognitive behavior therapists. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
This study tested the hypothesis that clinicians can agree on two aspects of a cognitive-behavioral case formulation: the client's overt problems and underlying cognitive mechanisms. To test this hypothesis, 46 clinicians listened to part or all of an initial interview for two anxious, depressed clients and then listed each client's overt difficulties and rated each client's underlying cognitive mechanisms. When groups of five clinicians were considered, clinicians showed moderate agreement in listing overt problems, and, except for one type of belief (dysfunctional attitudes) for one client, high agreement on ratings of underlying cognitive mechanisms.