One definition of case formulation is ‘Case formulation aims to describe a person’s presenting problems and use theory to make explanatory inferences about causes and maintaining factors that can inform interventions’. What this means is that it is essentially a story not just to describe, but explain, how a person’s problem has developed, and how it is maintained so that treatments can be based on influencing those factors. There are many different frameworks for case formulation, but several key elements are usually present: 1. A description of the presenting issues;
2. The factors that act to create vulnerability or precipitate the problems developing; 3. Factors that may not have been involved in the initial problem developing, but are helping to maintain the problems; and finally, 4. Factors that can help the person cope or act as resources. To move beyond just describing these factors, a case formulation should describe the relationships between these various factors and the problems that are present – and should reflect not just the visible features of the problem (i.e. what we can see, or what the person reports that are unique to his or her situation), but also the underlying phenomena or stable, recognizable features that are present. Case formulation has been recognized to be a useful conceptual and clinical tool in psychotherapy as diagnosis itself does not focus on the underlying causes of a patient’s problems. Case formulation can fill the gap between diagnosis and treatment, with the potential to provide insights into the integrative, explanatory, prescriptive, predictive, and therapist aspects of a case. Despite the acknowledgment that case formulation is a basic, necessary, and key clinical skill, it is still largely under taught and under learned. Some of the issues faced in the development of a case formulation include that of immediacy versus comprehensiveness, complexity versus simplicity, observation versus organization, and the need for cultural sensitivity toward each individual patient. The science of formulations must be combined with art. Something vital is lost if the formulation does not capture the essence of the case. Case formulation is a topic of interest in psychotherapy not only in its utility as a conceptual and clinical tool but also because of its potential as a research tool into the outcomes of psychotherapeutic work. As clinicians, we seek to help our patients with accurate diagnoses and effective management plans. In the process, we need to identify a patient’s main problems and understand the predisposing, precipitating, and perpetuating factors of these problems as well as the relationship between these factors within the patient. The subsequent treatment plans can and often do involve psychotherapy with goals ranging from reduction of symptoms, improvement of functioning, prevention of relapse, increase in insight, and recognizing obstacles to progress in therapy. However, diagnosis itself does not complete the process of evaluation just as descriptive and theoretical classifications such as DSM—IV criteria do not necessarily focus on the underlying cause of a patient’s problems. Certainly they do not help us predict which patients are suitable for which therapy. Suitability is an ill-defined concept but commonly refers to an individual’s psychological characteristics that facilitate a good fit between the method and the establishment of a therapeutic alliance. Therapists must evaluate patient suitability for specific types of psychotherapy and information such as demographic features, and symptom presentation are often inadequate; hence something more is needed. Case formulation can fill this gap between diagnosis and treatment and can be seen to lie at the intersection of etiology and description, theory and practice and science and art. This is the case for psychotherapies such as dynamic psychotherapy, interpersonal psychotherapy, and cognitive...
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