on 31 October 2007
Case Formulation is defined by Persons (1989, p. 37) as "...a hypothesis about the nature of the psychological difficulty (or difficulties) underlying the problems on the patient's problem list". Case Formulation in psychotherapy appears to have developed out of the longstanding medical practice of Diagnosis-plus-Treatment-Planning, especially in a psychiatric context. It consists of a hypothesis concerning the aetiology and maintenance of the client's presenting problem(s) and, consistent with this, a plan as to when, where and how to intervene, with a view to bringing about some reduction in troubling symptoms. In therapeutic practice, the case formulation guides and structures the course of therapy by unifying and prioritising presenting issues, influencing the choice and timing of interventions, and predicting possible problems.
This book addresses the growing interest in this idea amongst counsellors and psychotherapists as well as psychologists and psychiatrists. The principal authors, both clinical psychologists, suggest that "Although it is arguably central to the implementation of any psychological intervention, it has until recently been a neglected area of research, training and publication" (p. 1).
They look at a variety of definitions of Case Formulation, and conclude that "...the common elements are that a formulation provides a hypothesis about a person's difficulties, which draws from psychological theory" (p. 4), and that its primary function lies in "...helping to select and guide the interventions" (p. 7).
Looking at case formulation from a variety of perspectives, including Cognitive-Behavioural, Psychodynamic, Systemic, Social Constructionist and Integrative, the authors explore such themes as
* Formulation and Collaboration
* Formulation and Reflective Practice
* Formulation and the Therapeutic Relationship
* Formulation and Context
* Formulation and Integration
* Formulation and Diagnosis
* Formulation, Evaluation and Evidence.
The authors apply the Case Formulation approach to two case studies from the perspective of each of these different schools. This brings the book to life, and makes it an interesting exploration of the current state of the various schools, along with the possibilities for integration.
The process of Case Formulation is of course not carried out explicitly in all forms of counselling/therapy. Rogers, for instance (1951, p. 223), considers that "a diagnosis of the psychological dynamics is not only unnecessary but in some ways is detrimental or unwise." He is concerned that the process of making a diagnosis leads to an inequality in the power dynamic between counsellor and client. However, all therapeutic intervention must presumably be based on some hypothesising and planning of the type outlined above, even if it remains implicit.
In contrast, Cognitive Behavioural Therapy, in my experience, is very comfortable with the Case Formulation process. At its simplest level a CBT formulation focuses on Negative Automatic Thoughts which are locked into vicious cycles with dysfunctional emotions, behaviours and somatic symptoms. It can also be expanded to include more ongoing dysfunctional underlying cognitions in the form of Assumptions and Core Beliefs.
According to Persons (1989) a cognitive case formulation should be
* arrived through collaboration between the therapist and the client
* readily understandable by clients
* grounded in empirical research
* open to disconfirmation
Johnstone & Dallos also outline the Case Formulation approach from a Psychodynamic perspective (focusing on Defenses, Capacity for Insight, Ego Strength, Capacity for Emotional Self-Regulation, Modes of Relating), and from a Systemic perspective (Deconstructing the Problem, Problem-maintaining Patterns and Feedback Loops, Beliefs and Explanations, Transitions, Emotions and Attachments, Contextual Factors).
Most interesting in relation to the theme of this issue of Éisteach, however, is their exploration of
* The Social Constructionist approach, which they see as "...a process of ongoing collaborative sense-making rather than one of developing objective or semi-objective descriptions..." (p. 102).
* The Social Inequalities approach, which focuses on questions such as who has power in relationships, and what discourses are at work in a particular case.
Overall, this is a timely, thought-provoking and useful book, for both students and experienced therapists.
Persons, J.B. (1989) Cognitive Therapy in Practice: A Case Formulation Approach. New York: W.W. Norton.