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6.01
Clinical Formulation
GILLIAN BUTLER
University of Oxford, Warneford Hospital, UK
6.01.1 INTRODUCTION
6.01.2.1
6.01.2.2
6.01.2.3
6.01.2.4
6.01.2.5
6.01.2.6
Main Principles
Formulation and Diagnosis: Assumptions
Formulation and Diagnosis: Controversial Issues
The Difference Between a Formulation and a Model
Types of Formulation
Levels of Formulation
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6.01.4.1
6.01.4.2
6.01.4.3
6.01.4.4
6.01.4.5
Sources of Information
Putting the Information Together
Key Factors and Basic Elements
Issue of Completeness
Conceptualizing Processes of Change
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6.01.8 REFERENCES
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6.01.1 INTRODUCTION
Patients come to psychotherapy because they are
demoralized by the menacing meanings of their
symptoms. The psychotherapist collaborates with
the patient in formulating a plausible story that
makes the meanings of the symptoms more benign
and provides procedures for combatting them,
Clinical Formulation
of most major therapeutic traditions: for example, behavior therapy (Turkat & Maisto, 1985;
Wolpe & Turkat, 1985), psychodynamic therapy
(Barber & Crits-Christoph, 1993; Perry, Cooper,
& Michels, 1987; Silberschatz, Fretter, & Curtis,
1986), family therapy (Minuchin, 1974), cognitive therapy (Freeman, 1992; Persons, 1989,
1993), cognitive analytic therapy (Ryle, 1978,
1990), and interpersonal therapy (Klerman,
Weissman, Rounsaville, & Chevron, 1984).
The attempt to construct and use a clinical
formulation is central to the work of therapy.
Various methods for systematizing the processes
involved have recently been proposed (Horowitz, 1989; Luborsky & Crits-Christoph, 1990)
and, thinking specifically about the issues involved in psychotherapy integration, Goldfried
(1995) has put forward a case for developing a
common language for case formulation that is
independent of theoretical orientation. Personal
discussions of many kinds may be more or less
valued and helpful to someone experiencing a
difficulty, including the informal advice traded
between friends, but one of the major differences
between informal discussions and responsible
clinical practice is that they do not make use of
the process of formulation. The attempt to
formulate a case, so as to apply an appropriately
chosen method of intervention in the light of a
particular theory, is one of the activities that
makes therapists, as opposed to friends, accountable for their practice.
This chapter discusses issues concerning
clinical formulation that are relevant to therapists from different theoretical backgrounds.
However, the illustrations of the general points
made will largely be drawn from the author's
own experience and will therefore reflect the
author's original cognitive-behavioral training,
together with a more recent interest in exploring
possibilities for integration between different
kinds of psychotherapy.
6.01.2 DEFINITIONS: WHAT IS A
FORMULATION?
6.01.2.1 Main Principles
A formulation is the tool used by clinicians to
relate theory to practice. Clinicians use theoretical as well as practical knowledge to guide
their thinking about the problems and difficulties presented by the people who come to them
for help, and this combination of ideas helps
them decide how best to help those people.
However, although the theories are relatively
simple and clearadmittedly to varying
degreesthe information brought to treatment,
and gathered during the process of assessment, is
always complex and often unclear. The process
The
environment:
personal,social,
historical
context,
etc.
Cognition
Affect
Physiology
Behavior
Figure 1
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Clearly, this overall strategy reveals assumptions about how the effects of these events can
be understood, about the effects of talking
about them, and the interventions used
assumptions which formulations clarify, and
which are potentially amenable to research, but
which will differ according to the therapist's
theoretical orientation. A secondary purpose of
clarifying the formulation and its function in
selecting strategies and interventions is to
facilitate evaluation of interventions.
6.01.3.4 Predicting Responses and Difficulties
Because a formulation reflects theoretical
assumptions, it helps therapists make two kinds
of predictions that are essential in therapy: to
predict the effect of the intervention, assuming it
is successfully applied, and to predict the
stumbling blocks and difficulties that will be
encountered during therapy. An anxious person
treated during a clinical research trial (Butler,
Fennell, Robson, & Gelder, 1991) held the belief
that all my ideas are bound to be wrong. She
became more confident as she learned to identify
her ideas, to act upon them, and consciously to
evaluate the consequences of doing so. Her
formulation enabled us to predict first that she
would feel especially vulnerable and be likely to
overgeneralize and catastrophize the consequences when she made mistakes, and second,
that she was likely to find it especially difficult to
apply the new strategy when relating to her
partner, but easier to build up the necessary skills
(and courage), and to increase her confidence, in
the context of other relationships (including
ours). Treatment in this case was guided by the
requirements of a treatment manual, and the
example illustrates the important role played by
clinical formulation in the application of
standardized treatments.
It is probably true to say that interpersonal
difficulties are one of the most common sources
both of patients' problems and of problems
encountered during psychological therapy; for
example, an ability to form superficial relationships without being able to sustain deeper
friendships, or veering between passivity and
aggression when interacting closely with others.
Such difficulties also play their part within the
therapeutic relationship, and they are much
more easily dealt with if the processes involved
have been understood in terms of the theory
being used, and problems predicted in advance.
Formulating helps people to recognize such
patterns, to develop hypotheses about their
origins, functions and effects, and to think
about whether and how to engage in a process of
change.
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Under stress
Cant sleep
well
Figure 2
Worries keep
coming to mind
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Im incompetent
I have to do what others ask
Im thick
Protective wall:
If I always please others theyll never find out
Ill be OK if I stick to doing easy things
People will reject you if you dont toe the line
Me with my
problems
Figure 3
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Clinical Formulation
beliefs, preferred coping mechanisms, maintenance cycles, and so on. Focusing on critical
incidents is thus theoretically helpful when
stuck in constructing a cognitive formulation.
This is not to say that all cognitive therapists
think about them, or base their formulations
upon them. An alternative method might
involve working from a problem list, weighting
the problems for importance, and going on to
abstract and understand the connecting themes
and links in ways that fit with the theory. The
point is that within a particular method of
working there are many ways of constructing a
formulation, but it can be helpful to keep those
factors in mind which play a central part in the
theory, or in revealing the manifestations of
important theoretical constructs whether these
are core beliefs, core interpersonal schemata, or
core conflicts. To repeat, there is no single
correct method.
Use of the word core suggests that
formulations may be thought to have certain
basic elements, and that unless these are
identified the formulation will, in Perry et al.'s
words, lack an integrative coherence. When
writing about psychodynamic formulation and
about central conflicts, Perry et al. (1987, p. 546)
say The aim is to find a small number of
pervasive issues that run through the course of
the patient's illness and can be traced back
through his or her personal history, and then to
explain how the patient's attempts to resolve
these central conflicts have been both
maladaptive . . . and adaptive. The overall
intention is clearly closely similar across
different therapeutic orientations, as is the
general approach: first, apply a particular,
theory-driven model; if that does not in practice
fit the particular case, explore further using
questions and trial and error in the (scientific)
search for a formulation that fits better.
This process might be facilitated if there was
agreement over which were the basic elements of
a formulation and an atheoretical way of linking
them together. One way of doing this has been
developed by Goldfried and his collaborators.
This transtheoretical coding system was developed as a common language for use in
conducting comparative process research across
orientations (Goldfried, 1995, p. 222). It
specifies which are the relevant components
of functioning (e.g., self-observation, self-evaluation, intention, emotion, and action) and the
types of links that can be made between them
(vicious cycles, patterns, contradictions). These
can be manifested both in intra- and interpersonal contexts, involving other people or
not, over a particular time frame. One advantage of this type of formulation, the coding
system of therapeutic focus (CSTF), is that it
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thoroughly familiar with the theoretical background to their work, and with the process of
map-making, the activity of formulation cannot
be wholly suspended. Once able to recognize
signs of core beliefs or core conflicts, for
example, such theoretically meaningful constructs cannot suddenly be rendered invisible
again. Formulation skills may still need sharpening, and there is certainly a need for more
and better training (Sperry, Gudeman, Blackwell, & Faulkner, 1992), especially now that
clinicians appear increasingly likely to incorporate ideas from theoretical orientations other
than their main one into their work (Messer,
1996b). The effects of working with (or without)
a formulation will remain hard to evaluate. The
more important question, in practical terms, is
whether or not a particular way of seeing things
is put to good use, successfully to do the things
that a formulation is for. The struggle is to find a
way of seeing things that helps. Although the
assumption that at some level it all makes
sense still underpins much clinical work, it is
not necessary to believe that there is such a thing
as a correct formulation. As Messer (1996a,
p. 136) says, An alternative outlook is that
there is no one version of truth possible because
we largely construct our realities, which inevitably leads to multiple perspectives on that
reality. Wearing different glasses provides
different views of the world.
6.01.6 USING THE FORMULATION:
PRACTICAL ISSUES
A formulation does not have to be correct,
but it does have to be useful. The purposes of
formulation are discussed in Section 6.01.3.
Here, three practical factors that influence
whether a particular formulation succeeds in
fulfilling its purposes are mentioned briefly.
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Clinical Formulation
References
of psychotherapy may lie in thinking of all
psychotherapeutic enterprises as lying in the
realm of meanings . . . thinking, feeling, and
behavior are . . . responses to the meanings of
events as much as to the events themselves. Our
assumptions and knowledge about the ways in
which these meanings are stored, represented,
and recalled, and about the degree to which they
can be brought into awareness, will therefore
greatly influence the meaning we give to our
formulations and the uses we make of them.
Therapy can be understood in many waysas
managing anticipated transferences, countertransferences, and resistances; as seeking new
perspectives and using these to restructure a
belief system; as a process of constantly meeting
and adjusting to what is happening each
moment; or as a way of influencing the
contingencies that relate behaviors to their
antecedents and consequences. In all of them,
the process of formulation serves similar functions. It is useful because it helps to determine
what we, as therapists, do and enables us to
understand and to explain that better.
6.01.8 REFERENCES
Barber, J. P., & Crits-Christoph, P. (1993). Advances in
measures of psychodynamic formulations. Journal of
Consulting and Clinical Psychology, 61, 574585.
Beck, A. T. (1991). Workshop on cognitive therapy of
personality disorders. Brighton, UK: Royal College of
Psychiatrists.
Beck, A. T., Freeman, A., & associates (1990). Cognitive
therapy of personality disorders (chap. 4). New York:
Guilford Press.
Beck, J. S. (1995). Cognitive therapy: basics and beyond.
New York: Guilford Press.
Beutler, L. E., Williams, R. E., Wakefield, P. J., &
Entwistle, S. R. (1995). Bridging scientist and practitioner perspectives in clinical psychology. American
Psychologist, 50, 984994.
Blackburn, I-M., & Twaddle, V. (1996). Cognitive therapy
in action: A practitioner's casebook. London: Souvenir
Press.
Butler, G., & Booth, R. (1991). Developing psychological
treatments for generalized anxiety disorder. In R. M.
Rapee & D. H. Barlow (Eds.), Chronic anxiety and
generalized anxiety disorder (pp. 187209). New York:
Guilford Press.
Butler, G., Fennell, M., Robson, P., & Gelder, M. (1991).
A comparison of behavior therapy and cognitive
behavior therapy in the treatment of generalised anxiety
disorder. Journal of Consulting and Clinical Psychology
59, 167175.
Butler, G., & Low, J. (1994). Brief psychotherapy. In M.
Pokorny & P. Clarkson (Eds.), A handbook of psychotherapy (pp. 208224). London: Routledge.
Clark, D. M. (1988). A cognitive model of panic attacks. In
S. Rachman & J. D. Maser (Eds.), Panic: Psychological
perspectives (pp. 7190). Hillsdale, NJ: Erlbaum.
Clark, D. M., & Wells, A. (1995). A cognitive model of
social phobia. In R. G. Heimberg, M. K. Liebowitz, D.
A. Hope, & F. R. Schneier (Eds.), Social phobia:
Diagnosis, assessment and treatment (pp. 6993). New
York: Guilford Press.
Dattilio, F. M. (1994). SAEB: A method of conceptualisa-
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