The conventional method of clinical formulation is considered to be an effective process in the field of clinical psychology. The formulation “aims at describing a person’s presenting problems and use of psychological theories to explain inferences about causes and maintaining factors that can inform interventions” (Kuyken, 2006). It narrates the presenting problem, taking into account social, economic, and biophysical factors, which leads to understanding and explaining a problem and the causes of the problems to both clients and clinicians, unlike diagnosis, which labels people without understanding the problem. It offers useful explanations implanted in the psychological theory describing the problem and suggesting some intervention based on evidence. Hence, the formulation is better than diagnostic methods to solve a psychological disorder as it is based on experiences, causes, predisposition, and socio-economic factors.
Studies showcase formulation in various psychological fields such as psychotherapy, counselling, and psychiatry. It is a listed skill in healthcare professions, education, forensics, sports, and counselling psychology. It is central to the implementation of psychological interventions using the theoretical and empirical basis (Teachman & Clerkin, 2010). Cognitive behaviour therapy has been particularly useful as it links theory, research, and practice to normalizing problems and helping patients understand and approve of the intervention. It helps the patient organize complex information and focus on interventions. It is a process where the client is equally involved in the process of intervention and making the problem comprehensible. The formulation is based on the evidence, symptoms, and the narration of the client. If a patient tells the clinician that he/she hears voices, the clinician will base the problem on a cognitive empirical theory considering the problem underlying socioeconomic, psychosocial, and biophysical factors (Persons & St, 2015). Unlike diagnoses, it prepares evidence to hypothesize and intervene.
The research suggests it has been useful for trainees and qualified clinicians. It takes into account psychodynamic, cognitive-behavioural, systemic, and integrative elements in hypothesizing the problem. It provides an overview of a problem, enabling the experts to differentiate between the essential and secondary. It helps to formulate priorities that are essential to respond to the problem. It is essential to formulate and design the problem correctly to generate a specified response, and formulation helps practitioners do it (Eells, 2011). The explanation assists the therapist in overcoming the bias as the therapist explains the problem to the person to test the accuracy of the information.
Moreover, recent studies imply that formulation can be used to notice the gaps in the information while treating patients. As the patient formulates the information to hypothesize or suggest the problem, the gaps in the information become visible. It can also be used in medical interventions as it considers cultural and social factors that enable physicians to deliver need-based treatment. It strengthens the relationship between therapist and patients or service provider and users (Bieling & Kuyken, 2003). It has proved essential in normalizing problems, reducing self-blame, and helping service users with increased knowledge and understanding of their problems. The service users or patients do not have an agency when they meet their therapists. They rely on the diagnosis instead of participating in the process. Formulating the right formulation is essential in providing that agency and enhancing awareness of the patient’s situation and problems. Then, the therapist incorporates psychological theories that enable the patient to see the pattern in their behaviour and the problems (L. Johnstone, Whomsley, Cole, & Oliver, 2011). They understand the causes of the problem. Therefore, they participate equally in the treatment of the problems, which does not happen in diagnosis.
In diagnosis, the patient fully depends on the therapist’s expertise and does not have any agency. The patients tell the therapist about their problems, and the therapist labels the patient with a problem. It does not leave enough room for interaction and collaboration. The patient trusts the authority of the therapist without questioning and understanding the problem. Unlike formulation, diagnosis defines a person with certain kinds of problems and intervenes with the labelled diagnosis (Macneil, Hasty, Conus, & Berk, 2012). However, this does not happen in the formulation as the formulation is based on experimenting with different procedures and changing the intervention when it seems ineffective. It provides time to assess the intervention and change it to a better option. The diagnosis method oversimplifies the problem when the psychological problem is usually very complex. It does not assess the whole problem within the socio-cultural and biophysical context but rather focuses on the majority of symptoms to diagnose. For instance, if a person has four symptoms of schizophrenia and two of another mental problem, the therapist is more likely to diagnose the person with schizophrenia without paying attention to the other two issues that might have a greater influence on the presenting problem (Macneil et al., 2012). Consequently, diagnosis becomes a problem as it does not focus on the various aspects of a disease.
However, some might argue that formulation and diagnosis are two parts of one process: examining and treating a problem. However, many people do not consider them part of the same process because, in formulation, the therapist does not diagnose only through stated symptoms. The therapist formulates a complete story and integrates theories and empirical research to assist the hypothesis, and then they intervene. However, diagnosis categorizes people according to the disorders to facilitate interventions. It is limiting in the treatment of a problem because it does not include the causal factor and the experiences of the patient to eliminate the problem (Lucy Johnstone & Dallos, 2013). It suggests intervention without understanding the causes of the problems, due to which the diagnosis does not help in treating psychological disorders.
Therefore, the formulation must be used with the Five P’s approach. The P’s present how the problem is presented, predisposing factors such as biological factors, precipitating factors including events preceding the problem, and perpetuating factors that maintain the current difficulties. Lastly, protective or positive factors strengthen the support or mitigate the problem (Teachman & Clerkin, 2010). And the explanation must incorporate cognitive and behavioural models. The formulation tries to solve a disorder holistically, unlike diagnosis, which only considers symptoms and labels the person without considering emotions, experiences, and social, biological, and economic factors. It must be used to respond to a problem. Part B
To form a case formulation for Wendy, who is fearful of people’s reactions to going back to work after her termination, her condition must be evaluated through the CBT model. Firstly, her biopsychosocial problems must be listed. Secondly, the causes of the problem must be formulated to be evaluated and individualized for the problem that Wendy faces. Then, the problem will be hypothesized, and interventions will be formulated to mitigate the problems.
Problem List:
Wendy feels anxious to go back to work as she was fired from his job. She is fearful of people and stays at home most of the time. According to her husband, she is obsessed as she thinks their two children might be harmed. She has lost weight. She has insomnia. She lacks interest in day-to-day activities. She thinks that she cannot return to her job. She feels uncertain about her future. She focuses on keeping herself busy. She is anxious. She checks windows and doors several times, and she feels a need to check and confirm that the doors are locked. She wants her children to remain visible all the time. She has been anxious throughout her life, but she considers the anxiety has controlled her life. She was bullied in her childhood. She stopped exercising after she was attacked by a colleague and her termination from work. This is a comprehensive list of the problems that Wendy faces at the moment. Listing the problems is also crucial because it helps identify various problems that might contribute to some disorders, but not always. Therefore, it helps in sorting the problems that might be more associated with disorders than others (Teachman & Clerkin, 2010). Moreover, it provides a pattern to the disorders, marking them as social, biological, or personality issues, which can be tested using various tests.
Testing And Evaluating Diagnostic Tests:
Wendy might need some physical tests to illuminate other causes of her problems. Moreover, psychological evaluations can be performed through discussions regarding symptoms and behaviour patterns. Diagnostic and Statistical Manual of Mental Disorders (DSM-5) may be used to confirm if the person is likely to have some sort of disorder. GAD tests can also be performed to evaluate the beliefs and personalities which might contribute to the problems (Teachman & Clerkin, 2010). It is essential to associate the problems with predisposing factors and perpetuating factors and assist the therapists in finding precipitating and protective factors in order to assist Wendy. The various tests will expose whether the issue with Wendy is due to family history or due to the assault and termination. It will help to understand that their predisposed fear and anxiety in Wendy escalated due to the incident with the coworker. The tests will help to build a causal relationship between the event and the problem.
Hypothesizing:
Wendy was always anxious, but the assault and dismissal have escalated her lack of trust in people. As she has mentioned in the problem list, she was always anxious, and further anxiety was added due to the dismissal and assault. She has become protective of her children and wants to keep them in front of her at all times as she thinks it might be dangerous. She is also obsessed with the windows and doors, as she wants to keep them closed all the time. It is because she has become anxious.
Moreover, she has been at home for three months without her job, which has given her plenty of time, due to which her anxiety has increased, and she wants to keep herself busy. If a person is habitual of living a busy life and suddenly she is free, it will make her anxious. Such a person will need something to work on, which is the same for Wendy. She has been working throughout her life, but she was sent home after termination, due to which she became anxious.
Furthermore, she is a pessimist about the future, due to which her anxiety has increased. Wendy believes she cannot return to her career, and she feels uncertain about her future, which contributes to her anxiety. She is a pessimist about her career even though she has gotten her job back. She fears that she might not be able to go back to work as she is fearful of people’s reactions. Due to all the fear and pessimistic outlook, her condition and anxiety have worsened.
When Wendy is busy, she is not anxious. As work and keeping Wendy engrossed in activity helps her to control her fear and anxiety, this can be introduced to her as an intervention.
As there are three hypotheses to explain the possible causes of her worsening condition, this helps the therapist to assess the situation from various perspectives and suggest a suitable treatment or intervention (L. Johnstone et al., 2011). The hypothesis can also help Wendy maintain protective factors to assist in reducing the symptoms and problems.
Interventions:
As Wendy’s main problems are anxiety and fear, Wendy must keep herself positively busy at work. She can go to the Gym or exercise at home instead of staying at home. Exercise will keep her busy and will be beneficial for her health. She can be encouraged to join the office, but before that, she must be trained to respond to her anxiety. She must control her anxiety by practising it regularly. She can start by not focusing on the windows or doors, as it might make her restless. Or she must endure restlessness by increasing the endurance time every day to five minutes to be able to control her compulsive behaviour. She can be conscious of her actions and reinforce positive behaviour regularly. The family can also become part of the intervention by showing care and love, assisting Wendy, and reassuring her when she feels anxious. Family help can be essential in solving her problem (L. Johnstone et al., 2011). Moreover, medication for anxiety can be prescribed if it is uncontrollable. However, all of the measures must be evaluated for their effectiveness. And if they are not effective on Wendy, the interventions can be changed. Therefore, the intervention must focus on the holistic approach while keeping in mind the needs of the patients.
References
Bieling, P. J., & Kuyken, W. (2003). Is cognitive case formulation science or science fiction? Clinical Psychology: Science and Practice, 10(1), 52–69.
Eells, T. D. (2011). Handbook of Psychotherapy Case Formulation, Second Edition. Guilford Press.
Johnstone, L., & Dallos, R. (2013). Formulation in Psychology and Psychotherapy: Making Sense of People’s Problems. Routledge.
Johnstone, L., Whomsley, S., Cole, S., & Oliver, N. (2011). Good practice guidelines on the use of psychological formulation. Leicester: British Psychological Society.
Kuyken, W. (2006). Evidence-based case formulation. Case Formulation in Cognitive Behaviour Therapy, 12–35.
Macneil, C. A., Hasty, M. K., Conus, P., & Berk, M. (2012). Is diagnosis enough to guide interventions in mental health? Using case formulation in clinical practice. BMC Medicine, 10, 111. https://doi.org/10.1186/1741-7015-10-111
Persons, J. B., & St, L. (2015). Developing and Using a Case Formulation to Guide Cognitive-Behavior Therapy. Journal of Psychology & Psychotherapy, 5(3), 1–9. https://doi.org/10.4172/2161-0487.1000179
Teachman, B. A., & Clerkin, E. M. (2010). A case formulation approach to resolve treatment complications. In Avoiding treatment failures in the anxiety disorders (pp. 7–30). Springer.
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