CLINICAL CASE

FORMULATION
KEY LEARNING:
1. To understand clinical case formulation and its importance
2. To provide an overview of different theoretical orientation in psychology towards clinical case
formulation
3. To understand clinical case formulation based on case study
1.1 Clinical Case Formulation- by Definition
● “a conceptual scheme that organizes, explains, or makes sense of large amounts of
data and influences the treatment decisions” (Lazare, 1976).
● case formulation is a hypothesis about the causes, precipitants, and maintaining
influences of a person's psychological, interpersonal and behavioral problems" (Eells,
2007, p. 4).
● create a formulation that fits the client, rather than squeeze the client into your
preferred formulation. ( Ingram, 2012)
● a process aims to provide a psychological understanding of a person’s difficulties and
generally act as a guide for the clinician towards a particular intervention plan to
help address these difficulties (Brown and Völlm, 2013).
Why do we formulate?
- Heart of evidence-based practice
- Core clinical skill
- Theory and empirical knowledge merge to inform the understanding and treatment
- Formulation fills the explanatory gap between diagnosis and treatment
- Diagnosis alone does not provide sufficient guide to treatment selection
- Case formulation approach are customised to address individual circumstances
 1.2 Purpose of Clinical Case Formulation from the lens of Theoretical
Orientation

Orientation Purpose
Team formulation
Psychodynamic Explain how and why the patient’s equilibrium has become
A recent development is the use of
diaturbed
formulation in teamwork, in order to
How the problems have arisen and maintained
facilitate a group or team of professionals to
Cognitive- 1. relates all the client’s complaints to one another,
develop a shared understanding
behavioural 2. explains why the individual developed these difficulties,
of a service user’s difficulties.
and
Team formulations can, like individual ones,
3. Provides predictions concerning the client’s behaviour
be based either on specific therapeutic
given any stimulus.
approaches or on an integrative model.
Systemic @ Family hypothesis based upon the information possesses regarding
Therapy the family being interviewing.

Integrative/ Eclectic hypothesis of how an individual comes to present with a

certain disorder or circumstances at a particular point in time.
A number of factors may be involved in understanding the
etiology of the disorder or condition. These include
biological, psychological and systemic factors. A
comprehensive formulation then needs to examine all three
models carefully.
1.2.1 Case Formulation in Cognitive Behavioural Therapy
- Essential element of CBT
- helps merge together the unique experience of the client with the skills, theory
and knowledge we bring as therapists to help us understand and alleviate the
client’s presenting issues.
- CBT formulation is developed from the cognitive models
- How we view ourselves, the world and the future shapes our emotions and behaviour
- Emotional disorder developed then client are locked into unhelpful patterns of interpretation
and behaviour- social anxiety ex: early experience of being laughed in class- forming core
belief of other people will hurt me- rules of living is i will not speak in crowds
- Unlocking unhelpful thinking, enable to profoundly affect emotional wellbeing
- Change of behaviour- able to modify dysfunctional beliefs and learn healthier and more
adaptive beliefs.
- Formulation helps link person’s experiences to the cognitive model
Psychodynamic formulation
-No single psychodynamic theory hence no single way of constructing psychodynamic
formulation.

- Core feature of psychodynamic approach is the focus on psychological or emotional pain

-The dynamic@turbulence between our id, ego and superego which much of this activity takes
place out of awareness (unconsciously) helps to avoid pain

- Unconscious attempts to avoid pain often fail but since our awareness are limited, nonetheless
repeated again and again.

- Failing defences are what give form to and maintain patterns of psychological disorder.

- Psychodynamic therapy is about helping the client to “re-formulate” what they experience in a
more inclusive and to tolerate the discomfort that involves.
4 main psychodynamic perspective to formulation
1. Dynamic
2. Developmental
3. Structural
4. Adaptive

The Triangle of Conflict

4 main psychodynamic perspective to formulation
1. Dynamic
2. Developmental
3. Structural
4. Adaptive

The Triangle of Person combined with

the triangle conflict
4 main psychodynamic perspective to formulation
1. Dynamic ● Based on an understanding of the mental
structures that enable the psyche to maintain
2. Developmental some balance in the face of internal and external
3. Structural stresses.
4. Adaptive
● Therapeutic change consists of an increased
capacity to take responsibility for our behaviour
and to become more flexible, capable and aware.

● The ‘structural theory’ is clear too about the limits

to change: we are always engaged in a balancing
act between conflicting demands. However, if the
ego is strengthened and the power of the primitive
superego reduced, a more effective, satisfying and
less self-defeating balance is achievable.
4 main psychodynamic perspective to formulation
1. Dynamic ● the relationship of the internal to the
2. Developmental external ‘real’ world,
3. Structural ● the way in which the underlying dynamic
and developmental issues intersect with
4. Adaptive
the current situation in the person’s life.
● what may have changed in the life
situation in order to understand what
has created the perceived need for
outside help
● encourage an interest in what is going
well for an individual.
Systemic @ Family Therapy
- Involves working with families or subsections of families
- Symptoms seen as a product of the interactional dynamics in the family
- Cause and effect @ problems are maintained through vicious cycles of unhelpful feedback
- Emphasis on understanding triadic relationships- conflictual processes between two person
may recruit third person
- Recognise importance of trans-generational processes for contextualising current difficulties
@ parents ideas about caregiving connect with their early childhood experiences of being
parented.
- Formulation in systemic practice;
- Co-constructional process: Process to do with the family vs does to the family
- Interventive interviewing @ how formulation is undertaken have potential to bring about significant changes
- The poison is the medicine @ the symptoms in families served a function of stabilising a family system
Integration
Four approaches to integration:
1. Technical eclecticism: Procedures are drawn from different sources, without the clinician
subscribing to the theories.
2. Theoretical integration: There is a synthesis of two or more therapies, and the combination is
expected to be more effective than either therapy alone.
3. Common factors: Emphasis is placed on the core ingredients that different therapies share in
common, and that may contribute more to the success of therapy than those procedures specific
to a theory.
4. Assimilative integration: This approach combines elements of technical eclecticism and
theoretical integration; it is commonly used by therapists who have been trained in one system
and then add other tools when they discover the limitations of their original approach.
1.2 Common factors in formulation
● summarise the client’s core problems;
● indicate how the client’s difficulties may relate to one another, by drawing on
psychological theories and principles;
● suggest, on the basis of psychological theory, why the client has developed
these difficulties, at this time and in these situations;
● give rise to a plan of intervention which is based in the psychological processes
and principles already identified;
● are open to revision and re-formulation.

Source: Johnstone, L., & Dallos, R. (2014)

Case Formulation based on Case Study
Case Study- Jack .docx

1. Which clinical case formulation approach will you

choose for Jack?
2. What will affect your choices of case formulation
for Jack?
CBT Formulation for Jack
Presenting feeling low, lacking in focus on trying to feel better in mood, to have
Issues motivation, feeling afraid when out or more money and to be able to go out without
having no money fear of being
beaten up.
CBT Formulation for Jack
CBT Formulation for Jack
Stress-vulnerability models

Precipitating factors- Triggers 1. Quantity of stressors

2. Quality of stressors

Predisposing factors-generate understanding of 1. Quantity of events

the events leading to the emergence of the 1st 2. Quality of events
psychotic symptoms
CBT Formulation for Jack
Predisposing factors-generate
understanding of the events
leading to the emergence of the
1st psychotic symptoms
Precipitating factors- Triggers
Early Experiences: Father physically and verbally abusive when drunk
Only son in a family in which the expectations are
men will provide for the family
Successful father works hard and provides a high
standard of living
Core Beliefs: I am not good enough/I am a failure/weak
Others are cruel and rejecting
Rules and Assumptions or If I work hard and provide for others then I am ok and
Conditional Beliefs: not a failure
If I show my emotions others will be cruel and reject
me
Compensatory Strategies: Work hard to achieve and provide for others through
work
Do not show emotions, mask them with drink or drugs
Triggering events: Sexual abuse, end of the parental relationship, social
changes, change in house and lifestyle
CBT Formulation for Jack

Music, school, previous community, mother

Protective factors @ and sisters
Client strengths & his ability to form and make good use of a
conceptualising number of family relationships in the past,
notably with his sisters; and his
resilience positive engagement with mental health
services, which bodes well for
considering integrated interventions. In
Jack’s case we might try and
encourage him to revisit some of his
previous strengths such as playing music,
rebuilding his relationship with his sisters,
and other activities that indicate
he is a good person.
Key characteristics of CBT formulation

• Based on the cognitive model.

• Utilises core concepts of schemas/beliefs, conditional assumptions and rules, and

maintenance cycles to explain onset and maintenance of emotional difficulties.

• Formulation developed in levels from presenting issues to more predisposing factors.

• Client and therapist work as a partnership or team to co-create a formulation.

• Strong emphasis on evidence-base for the effectiveness of the intervention.

• Strong emphasis on empiricism in session so that appraisals are treated as ideas to be

tested and alternatives considered.
Jack: Psychodynamic formulation
main themes of Jack’s developmental history -the success and then the failure of his father and its effect on the family- violence and drunken

How Jack’s relates to this- he is offered and responds to a vision of himself as inheriting the business; he has a sense of himself as growing into a man entitled to power, seemingly secure and enabled to
develop and use his talents and social position.

dynamic perspective- anxiety: the nature of masculinity; its roots in the identification with both parents and their images of manhood as a foundation for self-esteem and entitlement to success in life and for
sustaining work, creativity and personal relationships in the real world; and the relation of sexuality and aggression to these.

Jack’s identification with his father is highly ambivalent – as perhaps it would inevitably be in a family situation where this father, and hence perhaps men in general, are both idealised and denigrated.

To be strong and in charge is also to be violent and untrustworthy; success leads to failure and failure is not sustainable and leads to collapse, abandonment of others and shame for oneself. This
ambivalence is intense enough to lead to confusion over what is reliable and, indeed, what is real.

Jack’s history may be thought of as defensive responses to these core anxieties and conflicts. Initially there is acting-out in delinquency, violence and substance misuse – all are, of course, identifications with
the father but are also escapes from overwhelming affect and anxiety – and, one would guess, chiefly experienced in terms of shame and humiliation.

The delusional system is a defensive retreat but at the same time, reveals in a rather obvious way the fantasies which structure Jack’s anxieties:

He has retreated into increasingly regressive defensive strategies and finally resorted to manic and paranoid psychotic delusional positions to which he is liable to return under stress. Adaptively, this has
created a trap for him in heightening the sense of risk associated with efforts to build a life in the real world and of engaging in intimate personal relationships,

The evidence suggests the presence of considerable structural ego weakness, in his difficulty sustaining his sense of self-coherence and reality and the dangers of severely regressive, particularly psychotic,
strategies to deal with interpersonal or other life pressures.
Key characteristics of a psychodynamic formulation
1. • Looks at symptoms and life problems as expressing an underlying order of meaning
in the client’s emotional life, arising from conflicting relationships, feelings, desires and
fears.
2. • Identifies these key conflicts as ones which repeat across different contexts and
which are being managed by characteristic defensive strategies giving rise to recurring
cycles of dysfunctional and self-limiting solutions.
3. • Relates these conflicts and defences to the individual’s developmental history, main
past relationships and attachment patterns – finds meaning in the person’s unique
experience of their life course.
4. • Draws heavily on the notion of the unconscious and its workings – meanings are
viewed as symbolised and purposefully concealed, as complex and multi-layered, fluid
and shifting.
5. • Identifies what in the client’s recent life situation has destabilised previous ways of
resolving the core conflicts, in order to give meaning to the client’s seeking help now.
Key characteristics of a psychodynamic formulation
6. • Validates these hypotheses by observing how they are played out within the therapeutic
relationship (the transference) and the therapist’s own experience of participating in it (the
counter-transference), seeking parallel patterns and themes in these specific relational contexts.
7. • Uses the therapist’s feelings/emotional resonances, not just thoughts and theories, as a guide to
eliciting and understanding meanings.
8. • Does not explicitly share the whole formulation with the client, but validates it by observing how
the client responds to the construction of specific meanings (interpretations) of his or her actions
and experience based on that understanding.
9. • Looks for coherent responses and elaborations more than explicit agreement: the evidence being
sought is hermeneutic (that is, it enriches meaning and understanding) and contextual rather than
generalised.
10. • In considering such ‘structural’ issues as the degree of maturity, stability and flexibility or the
stylistic regularities of typical defences in a person’s psychological functioning, the psychodynamic
approach can sometimes take on a broadly ‘diagnostic’ character – but its deeper thrust is
intensely individualising and suspicious of general categorical statements about people.
Jack-Systemic formulation
1. Deconstructing the problem

@ what is the nature of the problem/s

visual depiction, or genogram, of the
immediate family and its connections
with external systems.
map of the family system and its
relationships and sources of support,
and helps to direct the gathering of
further information.
Jack-Systemic formulation
2. Problem-maintaining patterns and feedback loops
Jack-Systemic formulation
3. Belief and explanation

-exploration of beliefs and thefeedback loop

patterns that maintaining the problem of the family
members

-Scaling questions: An effective way of exploring

and clarifying family members’ shared formulations
is by the use of ‘scaling’ or ‘least–most’ questions

- The role of illness

Jack-Systemic formulation

4.Transitions, emotions, attachments

Mapping transitions and changes is through
the use of “family sculpts”.
- distances between the objects representing
emotional closeness and proximity
- assist in promoting re-formulations, or
therapeutic changes.
- This integration of exploration/
formulation/intervention is central to
systemic practice.

The information gathered can also prompt

different ideas, questions and formulations
about the changes and causes of events in
the family:
Jack-Systemic formulation
5.Contextual factors
Contextual system of Jack.
1. Cultural factors,
2. The extended family,
3. The community
4. Different environmental situations
Key characteristics of a systemic formulation

Problems are regarded as residing in relational processes as opposed to within individuals.

• Formulation is seen as centrally concerned with exploring the meanings, understandings and
explanations that family members hold about the problems.

• Formulation is seen as an active, recursive, dynamic process (progressive hypothesising).

• Exploration and gathering information for formulation is seen as also promoting change. There is not
considered to be a clear distinction between exploration–formulation–intervention.

• Formulation is seen as collaborative in that the therapist is jointly developing formulation with family
members in order that new ways of understanding the problems can evolve.

• Family members may have different and conflicting formulations and therapists need to try and gain a
picture of the range of different formulations held.
Jack: formulation using
Weerasekera’s framework
Jack: formulation using Weerasekera’s
framework

- The first axis comprises the origins of the

problems (individual and
systemic/relational)
- different therapeutic approaches, such as
CBT, psychodynamic approaches and
behavioural interventions at the individual
level
-
- the second uses the PPPP framework.
- considers coping styles – characteristic
- aspects of clients’ ways of dealing with
problems in their various different
- Family relationship patterns of coping are
also included; this corresponds to the
systemic family therapy concept of
‘attempted solutions’.
Jack: formulation using
Weerasekera’s framework
1.2 Common factors in formulation
● summarise the client’s core problems;
● indicate how the client’s difficulties may relate to one another, by drawing on
psychological theories and principles;
● suggest, on the basis of psychological theory, why the client has developed
these difficulties, at this time and in these situations;
● give rise to a plan of intervention which is based in the psychological processes
and principles already identified;
● are open to revision and re-formulation.

Source: Johnstone, L., & Dallos, R. (2014)

1. Which clinical case formulation approach will
you choose for Jack?
2. What will affect your choices of case
formulation for Jack?
REFLECTION- At this point

- Start somewhere.
- It is a learning process:
- An attitude of flexibility rather than dogmatism, there is
more than one possible approach with each client.
- It is both science and art
- It is the quality of the relationship that is the most important factor
within the therapy room in achieving change.
Reference
Johnstone, L., & Dallos, R. (2014). Formulation in Psychology and Psychotherapy: Making Sense
of People’s Problems (2nd edn). London, UK: Routledge.

Eells, Tracy & Lombart, Kenneth. (2011). Theoretical and Evidence‐Based Approaches to Case
Formulation. 10.1002/9781119977018.ch1.

Ingram, B.L. (2006). Clinical Case Formulations: Matching the Integrative Treatment Plan to the
Client.