Lecture 15: Clinical Case Formulation Flashcards
1.) Be able to describe the meaning and purpose of formulation, including how it differs to diagnosis. 2.) Be able to begin applying existing psychological knowledge to understanding a person's experiences. 3.) Be able to critically discuss different types of formulation. 4.) Be aware of ethical considerations. 5.) Be aware of ideas about reflection.
What is the ‘Clinical Cycle’?
Assessment > Formulation> Intervention >Evaluation (with additional Re-formulation).
What is a formulation?
Lots of definitions have been provided in research however, common themes across them are:
“hypothesis about a person’s difficulties, which draws from psychological theory” (Johnstone & Dallos, 2006).
“Psychological formulation is the summation and integration of the knowledge that is acquired by this assessment process that may involve psychological, biological, and systemic factors and procedures. The formulation will draw on psychological theory and research to provide a framework for describing a client’s problem or needs, how it developed and is being maintained”.(DCP, 2010; pp. 5-6)
-Important to remember that this is often done collaboratively, based on personal meaning of someone’s difficulties.
-We are therefore focusing on ‘What is helpful or useful?’ not ‘What is the truth?’
-Critical to use the language of the patient.
Discuss the BPS guidelines on formulation.
-Formulation should be grounded in psychological theory and evidence.
-Formulation should also be person-specific, not problem-specific, and ought to draw on a range of models and factors.
-Formulations are based primarily on “Western models”, and it is important you work to ensure that yours are culturally sensitive.
-Strive to balance the experiences of the patient with psychological theory.
What are the advantages of a diagnosis?
Some advantages include:
-Psychiatrists need a diagnosis in order to prescribe medication (which may be helpful to some patients alongside Psychology).
-A diagnosis can be a source of validation to patients, for e.g. if they were of the belief that they were untreatable or that their experience could not be grasped by others.
-It can be another way to explain the patients experience and the way to treat it to the patient themselves, and to others involved in their life (be they other professionals, or family members etc).
Why might we formulate?
- It may be helpful to summarise what a person and their family is experiencing.
-We can think about how current difficulties relate to past experiences, and support the person to make sense of what is happening for them.
-To try and make sense of questions like ‘why now?’
-To think about what might be maintaining someone’s difficulties.
-To help plan interventions which might be helpful.
-TO EMPHASISE A PERSON’S STRENGTHS
-To cultivate and strengthen the therapeutic relationship
-To validate and help people to feel contained and understood, supporting safety and trust.
-To normalise problems.
-To reduce self-criticism and blame (and shame, guilt).
-Formulation allows us to think about how our own ‘stuff’ may interact with someone’s difficulties.
Why might formulation benefit a team?
-Multiple perspectives, i.e. can help avoid problems that might arise from your own ‘stuff’ interacting with the patient, or that might be skewing your perspective, stopping you from seeing a particular problem etc.
-Generates new ways of thinking.
-Allows staff to support each other in challenging work.
-Helps achieve a consistent team approach to intervention.
-Gathers key information in one place.
-Increases understanding, empathy, and reflectiveness.
-Minimising disagreement and blame.
-To challenge unfound ‘myths’ or beliefs about patients/service users. i.e. problematic language, misunderstanding presentation, putting in a box etc. To then also recognise this as a team, and to work past this.
Discuss the issues around ‘Diagnosis’ as a concept.
- Linking distress to specific categories/illness assumes there is some sort of ‘condition’ or illness that can be categorised - which may not be the case.
-The expert categorises the experiences of the patient in order to make the diagnosis, which removes the patient.
-Diagnosis is atheoretical.
-Diagnosis assumes a shared understanding, but this understanding could in fact differ between people and professionals. E.g. a clinical psychologist’s understanding of ‘psychosis’ may differ from a psychiatrist’s.
-Diagnosis is supposedly evidence-based and scientific, but is it? Criticism of this includes the idea that diagnosis is not always valid - construct validity - i.e. sometimes things do not always fit neatly into categories, and the idea of distinct categories within the DSM is therefore questionable.
Being catergorical may be useful if it is a homogenous, and clear guide to treatment.
-Diagnosis/ categorising does not necessarily provide a clear, shared eitology. Which is arguably a serious limitation.
-Some categories have difficult connotations which may impact experiences in mental health pathways and treatment.
-Can blinker future professionals.
-Can be highly damaging.
What are some limitations of Formulation?
-Because it moves away from the medical/diagnostic model, and from categories, it is less simple to convey to others.
-Based on theory, which isn’t always going to apply to the individual. May end up moving away from categories (i.e. diagnosis) just to fit a theoretical understanding instead.
-Can give pt’s hope, but also be a distressing process.
-There is an unclear impact on outcomes, and poor inter-rater reliability.
-It can be difficult for some mental health pathways who require ‘diagnosis’, or outside agencies e.g. social services, court proceedings etc.
