3: Case formulation

Question 1

Definition of case formulation

Answer 1

Developing a hypothesis about, and a plan for causes, precipitants and maintaining influences of a person’s psychological, interpersonal and behavioural problems in the context of that individual.

It’s the tool used by clinicians to relate theory to practice.

Question 2

Diagnosis vs formulation

Answer 2

• Diagnosis: descriptive, based on aggrupation of signs and symptoms, general structures to match patient to case
• Formulation: explanatory, based on psychological theories and principles, specific to each patient-case

Question 3

Case conceptualization:

Answer 3

• therapist and client work together to describe and explain an issue.
• guide therapy, to relieve client distress and build client resilience.

Question 4

Purposes of formulation

Answer 4

• Clarify, hypothesize, understand, prioritize issues and problems, plan treatment strategies, select specific interventions, troubleshoot and overcome bias
• Synthesize client experience, theory and research, promote client engagement, focus and sequence of interventions, identify client strengths, suggest simple and most cost-effective interventions, suggest alternative routes and enable high-quality supervision.

Question 5

Differences between approaches in formulation

Answer 5

• Factors they see as most relevant
• Explanatory concepts they draw on (schemas, unconscious…)
• Emphasis they place on reflexivity
• Degree to which they adopt an expert vs collaborative stance
• Their position in relation to diagnosis
• The way it is developed, shared and used within therapy

Question 6

Guide to case formulation

The 5 P’s Model

Answer 6

Key principles: levels of conceptualization, collaborative empiricism and incorporation of client strengths.

• Presenting issues: define the problem + its consequences. Also future goals of therapy
• Precipitating factors: define significant events preceding the episode. Include risk factors.ç
• Perpetuating factors: factors that maintain current difficulties
• Predisposing factors: factors contributing to the person’s risk (relapse prevention)
• Protective factors: strength/resources and abilities

Question 7

Guide to case formulation

Answer 7

1. Reasons for therapeutic demand
2. How has the complaint been made? Demand analysis (complainant vs identified patient)
3. List of problems, worries, symptoms…
4. Context and precipitating factors: how, when and with whom?
5. Identify patterns of response: emotions, ideas, behaviours and relationships
6. Reason of perpetuation: reinforcements…
7. Origin: evolution of problem, biography, transgenerational perspective
8. What facilitated their appearance or facilitates maintenance? (vulnerability and deficits)
9. What can facilitate change? (resources, strengths…)
10. Attitude for change
11. Expectations: limits and time expected
12. Objectives: operative terms
13. Resources used to achieve goals: strategies or techniques