The Action Formulation: A Proposed Heuristic

for Clinical Case Formulation

䊲

Golan Shahar
Ben-Gurion University and Yale University
䊲

John H. Porcerelli
Wayne State University School of Medicine

The authors propose the action formulation (TAF), a heuristic for clinical
case formulation. The action formulation relies on the action perspective,
which depicts individuals as actively shaping their environment, and is
premised upon four guidelines: (a) map the client’s social environment,
focusing on sources of support, chronic interpersonal difficulties, and neg-
ative and positive life events; (b) identify how the clients, in the context of
their personalities, psychopathologies, and strengths, actively influence
their environment; (c) differentiate between maladaptive, risk-related, inter-
personal cycles, and adaptive, protective-based ones; and (d) tailor inte-
grative techniques to short-circuit the former cycles and bolster the latter
ones. Links between TAF and emerging issues in clinical assessment are
discussed. © 2006 Wiley Periodicals, Inc. J Clin Psychol 62: 1115–
1127, 2006.

Keywords: action theory; clinical assessment; case formulation;

psychopathology

Case formulation, requiring the organization of a wide array of data for assessment,
diagnosis, and treatment planning, is a major challenge for clinical assessment (Friedman
& Lister, 1987; Handler & Hilsenroth, 1998; Haynes & Williams, 2003; Kelly, 1997;
Melchiode, 1988; Perry, Cooper, & Michaels, 1987; Shapiro, 1989; Summers, 2003).
Working from a behavioral perspective, Haynes, Leisen, and Blaine (1997) argue, “The
clinical case conceptualization, which is an integrated array of treatment-relevant clinical

Correspondence concerning this article should be addressed to: Golan Shahar, The Risk /Resilience Lab, Depart-
ment of Behavioral Sciences, Ben-Gurion University of the Negev, Beer-Sheva, 84105, Israel; e-mail:
shaharg@bgu.ac.il

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 62(9), 1115–1127 (2006) © 2006 Wiley Periodicals, Inc.
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20291
1116 Journal of Clinical Psychology, September 2006

judgments, is the link between clinical assessment data and the design of individualized
treatment programs. The clinical case conceptualization is the integration of multiple
judgments about the client’s behavior problems and their causes” (p. 335). A similar
argument, albeit from a psychoanalytic perspective, was made by McWilliams (1999)
and Summers (2003).
Incorporating the action perspective, which depicts individuals as actively shaping
their environment, we propose the action formulation (TAF) as a heuristic for clinical
case formulation. We begin by describing TAF and its underlying principles, and by
presenting clinical illustrations. We then link TAF to three emerging issues in clinical
assessment: functional assessment, chaos models of assessment, and therapeutic assess-
ment. We conclude with caveats and future plans for further developing TAF.

The Action Formulation: Description and Guidelines

As demonstrated compellingly in this special section of the Journal of Clinical Psychol-
ogy, individuals play an active role in creating their own well-being by generating inter-
personal risk and protective factors. The purpose of TAF is to identify such action during
the process of client assessment. To that effect, TAF utilizes a host of assessment sources,
including, but not limited to, open-ended and semistructured interviews, interviews with
significant others, objective questionnaires, and projective techniques.
The action formulation relies on four guidelines. The first objective is to map the
client’s social environment, and the role it plays in the pertinent outcomes. Here we rely
on voluminous research attesting to the role that social–interpersonal factors such as
social support, negative and positive life events, and chronic interpersonal difficulties
play in a host of physical and mental health conditions (for review, see Brown & Harris,
1978; Cohen, 2004; Mazure, 1998). This role might not be only causative (e.g., severe,
stressful life events bring about an onset of a major depressive episode), but might also
exacerbate an ongoing condition (e.g., chronic marital discord exacerbates chronic pain;
Ranjan, 2000), or protect against the presence of a risk factor. To illustrate, an adolescent
girl who is very involved in gymnastics is pressured by her coach and peers to lose
weight, and begins to develop symptoms of an eating disorder. However, the adolescent’s
boyfriend serves as a buffer to this pressure by continually reassuring the girl about her
self-worth and by helping her to put her gymnastic activities in perspective.
We submit that for each client, one can identify a set of social–interpersonal vectors
that facilitate or attenuate clinical outcomes. We encourage assessors to employ various
self-report questionnaires and structured interviews that may assist in this process (for an
extended review of pertinent life events and social support instruments, and their use in
clinical practice, see Zalaquett & Wood, 1997).
The second guideline is to identify how the clients, in the context of their personal-
ities, psychopathologies, and strengths, shape their environment. Having identified the
interpersonal circumstances giving rise to the client’s predicament, the assessor now
attempts to understand the client’s role in these circumstances. The focus herein is on
psychopathological and personality configurations that propel clients to generate inter-
personal risk factors, as well as on personal strengths that enable them to generate
interpersonal protective factors.
To illustrate, a 19-year-old, male undergraduate student presents with symptoms
consistent with a major depressive episode. Employing TAF, the assessor identifies a
recent romantic breakup, ostensibly initiated by the client’s girlfriend, as a potential con-
tributing factor to this depressive episode. The next step for the assessor is to ask herself
or himself: What was the client’s role in this romantic breakup? Had his behavior in the
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relationship facilitated the girlfriend’s decision to breakup? Upon further inquiry, the
assessor finds out that the client was excessively jealous and suspicious of his girlfriend,
putting considerable and unremitting pressure on her to prove her love and loyalty to him.
It is quite plausible, the assessor concludes, that by behaving in such a way, this client
actively contributed to his girlfriend’s decision to terminate the relationship, a decision
that, in turn, left him rejected, dejected, and depressed.
Yet, this might only be the beginning of the inquiry into the active role played by the
client in the romantic breakup. The assessor might wonder why does this client become
so jealous and suspicious in romantic relations? Seeking an answer to this question, the
assessor then administers several personality measures. An elevation of the hostility and
paranoia subscales of the Brief Symptoms Inventory (BSI; Derogatis & Spencer, 1982) is
revealed. An elevation of the Paranoia factor of the Minnesota Multiphasic Personality
Inventory–II (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) is found, sug-
gesting that the client’s suspiciousness may be more trait-like than situation-specific. The
assessor then studies the client’s responses to projective techniques. Utilizing an object
relations perspective, the assessor is particularly interested in his mental representations
of self, others, and relationships, and the way these might impact his behavior (Baldwin,
1992; Blatt, Auerbach, & Levy, 1997; Blatt & Ford, 1994; Shahar, Cross, & Henrich,
2005; Westen, 1991). Projective findings suggest that the client views himself, both con-
sciously and unconsciously, as fundamentally inadequate, particularly in interpersonal
situations. He also views others as seductive, constantly promising to love and nurture
without ever delivering. Our hypothetical client experiences relationships as a constant
effort to convince others to care for him and hold him in high regard. The assessor
integrates his or her knowledge of the client’s life history, growing up in an upwardly
mobile family comprised of a professionally successful father and a physically ill, dis-
abled mother, a family marred with fights and altercations because of the mother’s sus-
picion of the father’s infidelity. It is easy to understand how such a family context gave
rise to the client’s mental representation of self, others, and relationships, which, in turn,
influence his romantic relationships, precipitating a maladaptive cycle that contributed to
the romantic breakup and resultant depression.
This example portrays our theoretical approach to personality and assessment, which
draws heavily from object relations theory (Blatt & Ford, 1994; Greenberg & Mitchell,
1983), as well as from social learning theory (Bandura, 1986). Guided by these theoret-
ical influences, we focus on patients’ mental representations of self and others, as formed
in early relationships, and in the ways that these representations bring about behavioral
tendencies and coping strategies that shape relationships (Shahar et al., 2005). Our par-
ticular approach, however, is not the only one relevant to TAF use. Assessors with other
theoretical orientations, e.g., those drawing from clinical–cognitive theory (Beck, Rush,
Emery, & Shaw, 1983) or the humanistic–existential theory (Yalom, 1980), or those
drawing from the trait approach (e.g., the five factor model, FFM; Costa & McCrae,
1990) might use TAF as readily as we do. In this way, TAF is not bound to a particular
theoretical approach to personality and psychopathology. It simply directs the assessor to
identify the way these variables impact upon clients’ pertinent interpersonal conditions.
The third guideline is to differentiate between maladaptive, risk-related, interper-
sonal cycles, and adaptive, protective-based ones. As was mentioned in this issue
(Shahar, this issue, 2006, 1053–1064), an early publication by Wender (1968) describes how
both “vicious,” or to use our term maladaptive, and virtuous cycles might create interper-
sonal feedback loops that exacerbate both risk-related and protective factors. It is very rarely
the case that clients’ lives are characterized only by vicious interpersonal cycles. More
often than not, their predicaments represent a dynamic equilibrium comprised of vicious,
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distress-related, interpersonal cycles, and adaptive, protective, interpersonal cycles. TAF

encourages assessors to identify both types of interpersonal cycles, as well as the inter-
play between them.
To illustrate from empirical research, recent conceptualizations and findings depict
the personality trait of dependency as a complex one, comprised of both aspects of risk
and resilience (Bornstein, 1995, 1998; Mongrain, 1998; Priel & Shahar, 2000; Shahar,
2001; Shahar & Priel, 2003). Specifically, once construed as a serious vulnerability marker
for a host of psychopathological conditions, principally depression (Abraham, 1927),
dependency is now shown to elicit both risk factors, such as negative life events, and
protective factors, such as social support positive life events (Mongrain, 1998; Priel &
Shahar, 2000; Shahar & Priel, 2003). The two action patterns, one reflecting a maladap-
tive cycle (dependency r negative events r distress) and the other reflecting a adaptive
one (dependency r social support and positive events r low levels of distress) tend to
cancel each other out, resulting in an overall association between dependency and dis-
tress that is lower than the one initially expected (Shahar, 2001). These findings are
consistent with Bornstein’s call to “depathologize” dependency (Bornstein, 1998).
In clinical practice, similar patterns are frequently encountered. Mr. D’s case illus-
trates how his perfectionist dispositions contributed to both adaptive and maladaptive
cycles. A bright, 25-year-old, part-time computer technician, Mr. D began psychotherapy
because of distress over his perfectionism. In the last three college semesters, he dropped
two of three classes because he was “only getting a B.” This would result in worry that it
would take him many years to complete his degree. His worries affected the quality of his
relationship with a woman he had been dating for the past year. Nevertheless, his main
source of self-esteem was his work: His perfectionisms resulted in glowing reports from
customers. He stated, “My work keeps me sane and balanced. I’m an all-star there.”
The fourth and final guideline is to tailor integrative techniques to short-circuit the mal-
adaptive cycles and bolster the adaptive ones. To illustrate how this might be executed, we
incorporate our interest in integrating psychodynamic–object relational, and cognitive–
behavioral therapeutic modalities (e.g., Layne, Porcerelli, & Shahar, in press; Shahar, 2004).
A successful application of TAF has the potential to assist clinicians in selecting the most
effective psychodynamic and cognitive–behavioral techniques that will (a) help clients under-
stand ways in which they actively, if inadvertently, generate interpersonal stress and strife,
and refrain from generating positive interpersonal exchanges; and (b) help them identify
ways to strengthen their skills of eliciting social support, generating positive life events, and
navigating themselves into “holding environments” (Winnicott, 1971).
Various models of integrative psychotherapy are currently available and may greatly
assist in translating TAF into treatment planning. Particularly pertinent to the application
of TAF is Wachtel’s cyclical psychodynamics (Wachtel, 1977, 1997). This approach rests
upon three principles: (a) the contextual unconscious (i.e., unconscious processes are
constantly manifested in interpersonal behavior), (b) the vicious cycle (i.e., psychopa-
thology emerges and is maintained by individuals’ unintended creation of negative social
relations), and (c) the ironic vision of behavior (i.e., individuals create the very same
conditions that they dread). Cyclical psychodynamics proposes a therapeutic approach
that integrates insight-oriented work with active, cognitive–behavioral techniques. The
objective of the former type of work is to understand unconscious processes, whereas
the objective of the latter techniques is to reduce the likelihood of maladaptive inter-
personal behaviors (Wachtel, 1977). Cyclical psychodynamics has been elaborated by
Connors (1994, 2001), Frank (1990), and Gold and Stricker (2001).
The following example is taken from a case study by Layne, Porcerelli, and
Shahar (in press). Ms. A was a 34-year-old, unmarried mother of three who presented for
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 The Action Formulation 1119

psychotherapy with dysthymia, dependent personality features, and a Global Assessment

of Functioning (GAF) score of 54 indicating moderately severe symptoms and social
impairment. A complicating factor of her depression was her intense self-criticism as
expressed through her (irrational) belief that she was a bad mother. A daughter of drug-
addicted parents, Ms. A experienced significant neglect in her teen years leaving her with
both intense desire for love and denial of this longing. This led to a series of brief disap-
pointing relationships. Ms. A claimed to be looking for a “good man,” she was in fact
becoming quickly physically involved with men who used her for sex. She later married
her high school sweetheart and became pregnant shortly after the wedding. During her
pregnancy, her husband became abusive and Ms. A chose to leave him. At the time of
intake, she complained of being stuck in a long-standing relationship with an uninvolved
man—the father of her second and third children. He never lived with her and did not
provide child support for his two children. In terms of Ms. A’s psychotherapeutic treat-
ment, the therapist used both cognitive therapy techniques to challenge her (irrational)
self-critical attitude, and psychodynamic techniques both to understand her pathological
identification with her neglectful and critical parents and to link her painful child and
adolescent experiences with her struggles with men. In addition to confronting her self-
critical attitude, the therapist took every opportunity to point out her strengths and resil-
ience to allow her to take pride in her ability to care for her family under such difficult
circumstances. She was then able to use her energies and psychological resources to
return to college and pursue a degree. The vicious cycle of involving herself with neglect-
ful men began to give rise to the beginnings of a adaptive cycle of taking better care of
herself (i.e., being less self-critical and pursuing a college degree) and ending her patho-
logical relationship with her boyfriend. Although she had not developed a new relation-
ship at the time therapy had ended, she was evidencing interest in men who were responsible
and kind to her.

From Guidelines to Application: A Clinical Illustration

Billy, an overweight, 12-year-old preadolescent, was brought to a therapist for an evalu-
ation because he was extremely oppositional at home toward his parents, had experienced
difficulties getting along with his older brother and sister, and had frequent temper out-
bursts. His mother stated that he was once a sweet boy but is now “nearly impossible” to
live with, “no one wants to be around him.” During the intake session, it became apparent
that Billy was experiencing academic as well as social difficulties in school. His grades
had fallen to the average range. Some of his friends were shunning him. Several months
prior to the evaluation, he had been suspended for a day for bullying. During an evalua-
tion interview, Billy talked about his siblings’ dislike for him. He said, “I hate it ‘cuz they
won’t even talk to me . . . . that’s why I’ve been bad lately.” When asked if there was
anything he had done to contribute to their avoidance of him, he said no.
Billy’s behavioral problems had gotten worse since his adolescent sister was diag-
nosed with an inoperable brain tumor that was being treated successfully with chemo-
therapy. She had always been, and continued to be, very popular in school and in Billy’s
eyes, “gets a lot of special stuff from all kinds of people, including my parents, because
she’s sick.” His parents said that Billy gets distraught over his siblings’ behavior, but
were puzzled about his inability to understand how he does in fact contribute to the
problem through his sarcastic and, at times, hurtful comments to both siblings. “When he
gets really mad he tells his sister that he wishes she would die.”
During the evaluation, Billy was able to talk about his concern for his sister’s health
and mentioned how supportive her friends were. He literally began to squirm in an anxious
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1120 Journal of Clinical Psychology, September 2006

manner when he talked about all of the nice things that her friends do for her. “My brother
is real nice to her too. Sometimes he buys her stuff she likes. She lost all her hair and
everybody still likes her. When she goes into the hospital, everybody in her class sends
her cards. They would all visit her if they could.” His envy and anger were quite palpable.
His father reported evidence of an adaptive cycle in Billy. He described Billy as a
good worker. He often agreed to help his father with woodworking and home improve-
ment projects. This tended to elicit affection and support from his father.
As part of his evaluation, Billy was administered the Adolescent Psychopathology
Scale-Short Form (Reynolds, 2000), a self-report diagnostic instrument, as well as the
Thematic Apperception Technique (TAT; Murray, 1943), a projective procedure. On the
Psychopathology Scale-Short Form, Billy presented clinically significant elevations on
Oppositional Defiant Disorder, Anger/Violence Proneness, Generalized Anxiety Disor-
der, Interpersonal Problems, and Academic Problems. His responses to the TAT cards
were coded using the Affect-Tone of Relationship Paradigms dimension from the Social
Cognition and Object Relations Scale of Westen (Westen, Lohr, Silk, Gold, & Kerber,
1990). In object–relational terms, Affect-Tone rates the affective coloring of an individual’s
object world from benevolent to malevolent. In social–cognitive terms, Affect-tone assesses
an individual’s interpersonal expectancies. Three TAT stories from Billy’s protocol are
presented to illustrate both his malevolent expectancies, as well as material that contrib-
uted to a better understanding of his oppositional behavior.
Card 1 (boy contemplating violin): “This is a boy with a violin. The boy’s mother is mad
because he wasn’t doing anything constructive. So they bought him a violin. He doesn’t even
try playing it and gave it up. Mom started to pressure him and he got . . . ah . . . let’s just say
he got really mad and kind of yelled at her “Let me do it on my own . . . on my own time!”
Maybe he only wanted to do a little at a time. His sister can do anything she wants. She doesn’t
have to play an instrument. He wanted a tutor but they probably won’t get him one because
they don’t like him. (Who are “they?”) I don’t know, maybe his friends or his close relatives.
(His friends and close relatives won’t get him a tutor?) No. I mean his parents.”

Card 6 BM (old woman standing at a window with a young man holding a hat and looking
down): “The old woman is the guy’s mother. The husband, the guy’s father, is dead. She’s
depressed. The son tries to give her money to make her feel better. She doesn’t want it. She’s
going to die of depression. The mother dies and he feels guilty. He knows he didn’t kill her but
he still feels guilty—like he did something. He didn’t kill her though. The rest of his family
doesn’t like him and won’t talk to him. [Outcome?] He ends up hating them all.”

Card 8 BM (an adolescent boy in the forefront of the picture. There is a rifle barrel off to the
side and in the background is a dim scene of a surgery): “This boy had some surgery for some
reason. Let’s call it a kidney transplant. He’s reflecting back. He was shot in the kidney lets
say. He’s reflecting on what happened. He’s scared now and he’s a gloomy kid. A sad kid. A
lonely person now and so he’s sad. He won’t let anyone into his life. [Outcome?] He won’t get
help. He doesn’t think about it and gets better and then he grows up to become a preacher or
minister.”

The story provided in response to Card 1 is moderately negative in feeling-tone,

suggesting negative interpersonal expectancies. More subtle, however, is the way in which
the boy provokes his mother by not trying to play the violin. This elicits pressure from the
mother and causes the boy to become angry and oppositional. The story told to Card 6
BM is highly negative in overall feeling-tone. Strong feelings of guilt emerge in the man
following the death of his mother, and Billy uses the defense of negation to disguise
murderous feelings (“He didn’t kill her”). His guilt results in his not allowing anyone into
his life, causing the rest of the family to dislike him. He, in turn, hates his family. Again,
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 The Action Formulation 1121

a provocative element emerges within the story. In the story told to Card 8 BM, a boy who
was shot in the kidney had to undergo a transplant. He is scared, sad, and lonely; he will
not let anyone into his life. He doesn’t allow himself to get help for his feelings, represses
these feelings, and then becomes a preacher.
Based on these findings, the following TAF was employed:

1. Map the client’s social environment, and the role it plays in the pertinent outcomes.
Billy is faced with considerable life stress, namely, his sister’s illness and
treatment. His support system is inconsistent. On the one hand, he can rely on a
concerned, warm, and loving mother. On the other hand, his family’s attention is
largely directed towards his sister. Moreover, his father, while caring, is at times
combative and threatening, due to his moderately poor affect control. In addition,
Billy’s older brother tries to avoid him because he can be so aversive, leaving
Billy feeling rejected and lonely.
2. Identify how the clients, in the context of their personalities, psychopathologies,
and strengths, shape their environment.
Billy’s externalizing symptoms, expressed in the context of his relationships
with his family members and peers, have caused people to distance themselves
from him. This, in turn, enrages Billy, setting into motion anger, guilt, and self-
punishing behaviors, which complete the feedback loop and exacerbate his exter-
nalizing behavior. His mother understands that his distress leads to his negative
interpersonal behaviors and at times can intervene and empathize with him, thus
temporarily lessening his self-defeating behaviors. In addition, if Billy volunteers
to help his father at home, his father’s opinion of him will improve and his frus-
trations with Billy will lessen, enlisting the father’s support.
3. Differentiate between maladaptive, risk-related, interpersonal cycles, and adap-
tive protective-based ones.
Maladaptive cycle: anger and acting out r sister, peers, or other family mem-
bers reject Billy r retaliatory anger r resultant low self-esteem and emotional
distress r expressed by means of externalized problem.
Adaptive cycles:
Cycle 1—Responds to mother’s affection with affection, thus enlisting her
support of him r increased self-esteem.
Cycle 2—Helps father work around the house r enlists father’s support of
him r increased self-esteem.
4. Tailor integrative techniques to short-circuit the maladaptive cycles and bolster
the adaptive ones.
In an effort to short-circuit maladaptive cycles, therapy should focus on help-
ing Billy regulate his negative feelings (e.g., envy, rage) toward his sister and
avoid expressing these feelings by means of externalizing behaviors. An integra-
tive approach is espoused, comprised of (a) an empathetic–supportive therapeutic
stance that enables Billy to express these feelings in a safe environment; (b)
insight-oriented work geared to interpreting Billy’s defenses that interfere with
him experiencing, owning, and/or expressing these feelings; and (c) cognitive
restructuring aimed at normalizing Billy’s ambivalence towards his sister’s illness
and challenging his irrational belief that his ambivalence means he is a bad kid
and deserving of punishment. To bolster adaptive cycles, behavioral activa-
tion techniques could be utilized to encourage Billy to participate in enjoyable
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1122 Journal of Clinical Psychology, September 2006

activities with his father, which, in turn, would bring them closer together and
lessen Billy’s experiences of being excluded by his parents. Individual psycho-
therapy should be complemented by parental counseling, to assist the parents in
appreciating Billy’s distress in the face of his sister’s illness, consequently enabling
them to be more empathic, and less retaliatory, towards his outbursts.

Relevance to Other Issues in Psychological Assessment

Herein we briefly relate TAF to three emerging issues in clinical assessment: functional
analytic clinical case models, chaos models in personality assessment, and therapeutic
assessment.

Functional Analytic Clinical Case Models

Haynes and colleagues developed the functional analytic clinical case models (FACCM;
e.g., Haynes, 1994; Haynes et al., 1997; Haynes & Williams, 2003) as a heuristic for
clinical case formulation. Functional analytic clinical case models encourages the asses-
sor to rely on extant empirical research, interview and test data, and clinical judgment in
identifying contributing factors to the clients’ symptoms. These factors are then mapped
and quantified in terms of their (a) interrelations, (b) causal preponderance, (c) modifi-
ability, (d) importance, and (e) moderating variables. A vector-graphic representation of
the putative causal chain leading to the clients’ problems is prepared based on this map-
ping, and this graphic representation assists in individualizing and customizing behav-
ioral interventions.
We find FACCM highly consistent with TAF. Like FACCM, TAF aims at mapping
factors contributing to the clients’ psychopathology. However, whereas FACCM is silent
about the specific theoretical resources that can guide such a search, TAF draws from the
action perspective to understand specific ways in which clients, in the context of their
personalities and psychopathologies, elicit environmental conditions that contribute to
their distress. Hence, superimposing TAF on FACCM can potentially assist in identifying
specific, action-oriented, contributory pathways. The statistical tools provided by Haynes
and colleagues for estimating and comparing the magnitude of the various factors con-
tributing to the client’s distress (Haynes et al., 1997; Haynes & Williams, 2003) can be
readily applied in TAF, yielding an estimation of those person r context r distress
pathways that are most pertinent to intervention.
Note, however, that TAF goes beyond FACCM in identifying contributory factors—
not only for the client’s distress—but also for the client’s resilience. Specifically, drawing
from the action perspective, the assessor employing TAF should be able to identify ways
in which clients, endowed by strengths and resources, are able to (a) avoid even greater
distress than that which they experience, and (b) grow in the face of current adversity.
Here, TAF may guide FACCM by graphically representing both risk-related and resilience-
related contributing pathways, estimating their relative magnitudes, and tailoring inter-
ventions to derail risk-related pathways and bolster resilience-related ones.

Chaos Models of Clinical Assessment

Intimately related to FACCM is work conducted by Heiby, as well as by Haynes and his
colleagues, on the application of chaos theory to clinical assessment (Heiby, 1995a, 1995b;
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 The Action Formulation 1123

Haynes, 1995; Haynes, Blaine, & Meyer, 1995). As argued by these authors, many mod-
els of clinical assessment are predicated upon an untenable assumption that the putative
clinical outcomes are stable, or at least cyclical, and that they are linearly related to causal
factors. Nevertheless, argue these authors, clinical outcomes such as anger outbursts and
mood fluctuations are frequently chaotic, and effects of contributing factors on these
outcomes are highly nonlinear.
To model these chaotic and nonlinear patterns, assessors need to refrain from col-
lecting cross-sectional, aggregate data of behavior, and analyzing these data by general
linear modeling approaches. Instead, assessors should adopt a longitudinal, multimethod,
time-series approach, employing as many observations as possible of the putative out-
comes and hypothesized causes, and espousing nonlinear dynamic models to identify
chaotic patterns.
Towards this objective, an assessor should consult the three basic premises of chaos
theory. First, bifurcations denote a disproportionate change in the parameter of the puta-
tive outcome (e.g., when mild expressions of sadness become drastic, acute, and poten-
tially suicidal manifestations of depression). Second, sensitivity to initial conditions reflect
the fact that “the bifurcation is affected by historical values” (Heiby, 1995a, p. 7). Thus,
a rapid escalation of sadness into suicidal depression during adulthood may on the sur-
face appear to have been provoked by minor interpersonal stress (e.g., a confrontation
with a co-worker), but might also be related to early childhood maltreatment (Huprich,
2004; Toth, Manly, & Cicchetti, 1992). Third, self-similarity reflects a positive feedback
loop in the putative outcome, which takes place subsequent to the bifurcation. Using the
previous example, a chaotic manifestation of a suicidal depressive episode might resem-
ble previous expressions of sadness, but it will also assume novel characteristics (e.g.,
suicidal ideations and plans), which are unlikely to disappear without vigorous intervention.
Often, the active influence of individuals on their social environment is neither linear
nor stable. Rather, action might be chaotic, in the sense that it is manifested in rapid
changes in behavioral parameters and affected by initial conditions, and that it conforms
to positive feedback loops. Indeed, one could argue that the routes of many, mental
breakdowns are consistent with this description, in that they involve individuals rapidly
selecting or evoking noxious social situations that might result in psychopathology (cf. Sty-
ron, 1990). Similarly, some forms of recovery might involve rapid, seemingly chaotic,
adaptive interpersonal cycles. Employment of TAF while relying on the recommenda-
tions stipulated by Heiby (1995a, 1995b) and Haynes (1995b) should greatly assist in
identifying these risk and resilience cycles.

Therapeutic Assessment
In a series of publications, Finn and colleagues put forth a model of therapeutic assess-
ment (Finn, 1996a, 1996b, 2003; Finn & Tonsager, 1992, 1997). In this model, psycho-
logical tests are used not only as information-gathering instruments, but also as vehicles
for successful interventions. This is done by (a) engaging clients in the assessment pro-
cess, (b) encouraging them to pose assessment questions, (c) summoning their impres-
sion and advice, (d) joining with them in generating and testing hypotheses, (e) paying
particular attention to assessor–client relationships, and (f ) building on these exchanges
to provide empathic, therapeutically facilitating feedback (for an extended case descrip-
tion, see Finn, 2003; for preliminary empirical evidence for the utility of this model, see
Finn & Tonsager, 1992).
We believe that Finn’s therapeutic assessment model may be enhanced considerably
by employing TAF. Assessors can reframe assessment questions posed by clients in action
Journal of Clinical Psychology DOI 10.1002/jclp
1124 Journal of Clinical Psychology, September 2006

terms, focusing on ways in which clients actively, if inadvertently, generate interpersonal

risk factors. Accordingly, employment of TAF has potential to assist assessors and
clients in identifying and understanding active, maladaptive interpersonal cycles. The
realization that these interpersonal cycles are invariably enacted in transference–
countertransference exchanges (Shahar, 2004; Shahar, Blatt, Zuroff, Krupnick, & Sotsky,
2004) should prompt assessors to identify these processes, thereby gaining additional
insight into their clients’ difficulties. Moreover, TAF ’s emphasis on both maladaptive and
adaptive cycles is likely to sensitize the assessor and the client to identify the latter’s
resilience, as well as vulnerability. Finally, a TAF-guided therapeutic assessment should
be reflected in the empathic and therapeutic feedback provided by the assessor to the
client. This feedback would include jointly developed insights as to how the client creates
interpersonal risk and resilience both within and outside the assessment situation.

Caveats and Future Directions

It is incumbent upon us to reiterate and emphasize the preliminary nature of TAF. Clearly,
further conceptual developments are needed in our proposed action-based heuristic for
clinical case formulation. Moreover, an empirical demonstration of the incremental and
clinical validity of TAF, similar to the one described for Finn’s model of therapeutic
assessment (Finn & Tonsager, 1992), is necessary. We will address these two challenges,
the theoretical and empirical, in future articles.
In describing their FACCM, Haynes and Williams (2003) note several limitations
that also pertain to TAF. FACCM, TAF, as well as any other clinical case conceptualiza-
tions, are subjectively construed by the assessor, and hence are susceptible to confirma-
tion bias. As in the case of FACCM, TAF should be viewed as a dynamic process, in that
it might change as additional information is obtained during assessment and/or therapy
sessions. Furthermore, as indicated by Haynes et al. (1997) with respect to FACCM, the
translation of nomothetically derived empirical findings to TAF is all but straightforward.
Because nomothetic findings are obtained with large groups of people, they vary greatly
in terms of their applicability to the individual case. To illustrate, voluminous reports
attest to the adverse effect of self-critical perfectionism on interpersonal relationships
(for review, see Shahar, 2001, 2004). Yet despite the robustness of this pattern, the extent
to which self-critical perfectionism may account for the generation of interpersonal risk
factors can greatly vary across individuals.
A related caveat to TAF is that several clinical conditions might result from severe
external stress independent of individuals’ actions. Accordingly, we predict that the appli-
cation of TAF would be most effective in assessing clinical problems such as unipolar
depressive disorders, personality disorders, eating disorders, and social anxiety, for which
the contributory role of maladaptive interpersonal cycles has been adequately demon-
strated. It remains to be seen whether TAF is applicable to other psychopathological
conditions.
Finally, we are cognizant of the danger of “blaming the victim” in applying TAF. Our
focus on individuals’ active generation of risk and protective interpersonal factors might
be construed as an attempt to accuse clients of their predicament. This is not our inten-
tion. Although we draw from action theory and research in identifying ways in which
clients contribute to their distress, we are fully aware that they do so unwittingly, often
unconsciously, and always to avoid greater mental pain (Watzlawick, Weakland, & Fisch,
1974). Nevertheless, to minimize the danger of blaming the victim, we recommend that
in employing TAF, the assessor should constantly seek to identify adaptive cycles in
addition to maladaptive ones.
Journal of Clinical Psychology DOI 10.1002/jclp
 The Action Formulation 1125

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