Professional Documents
Culture Documents
Formulation Manual
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A Guide for
Mental Health Professionals
William H. Campbell
Robert M. Rohrbaugh
R726.7.C36 2006
616.89--dc22 2005020806
Introduction vii
5. Differential Diagnosis 71
6. Risk Assessment 75
8. Prognosis 107
9. Putting It All Together 111
References 159
Index 161
CD Contents 166
The term “patient” will be used throughout this manual in place of “client” to empha-
size the importance and uniqueness of the clinician–patient relationship. We view
health care as a profession, not a trade, and therefore eschew any reference to the term
“client” in this text. It is our belief that patients should be treated with the utmost
respect for their dignity and autonomy. In keeping with this view, we fully endorse
the principle of informed consent. Disclosing relevant information and educating our
patients using terms they can understand is key to establishing a truly collaborative
relationship.
vii
ing; the psychological system addresses the contributions of
developmental factors, motivation, and personality on the
patient’s experiences of and reactions to illness; and the social
system examines the cultural, environmental, and familial
influences on the expression of, as well as the patient’s experi-
ences of, illness.
Faculty members in departments of psychiatry, nursing,
psychology, and social work typically invest considerable
time and effort in teaching their trainees how to interview
patients. Although interviewing is a process that is continu-
ally refined throughout one’s career, trainees soon find them-
selves capable of eliciting a reasonably comprehensive database
from their patient interviews. However, having obtained the
requisite data, they find organizing the information in a
meaningful way to be an altogether different challenge. The
predominant mode of instruction in many contemporary
training programs does a disservice to the biopsychosocial
model. Depending on the orientation of the discipline (i.e.,
psychiatry, nursing, psychology, or social work), the formula-
tion emphasized to respective trainees focuses predominantly,
and in some instances exclusively, on one or at most two of
the three components. This approach limits the development
of a truly comprehensive formulation and adversely impacts
patient care.
Introduction ix
Each database is then analyzed and further organized to
assist the clinician in providing a comprehensive formulation,
including a summary of the data, additional information
needed (i.e., further history, diagnostic studies), and recom-
mended therapeutic interventions. We believe that this will
greatly assist clinicians in their written intake evaluations as
well as in their oral presentations.
This model has been used for training psychiatry resi-
dents for over 10 years and has been taught in a course for-
mat at the American Psychiatric Association’s (APA) annual
meetings. Evaluations and feedback from our residents and
the APA courses exceeded our expectations and served as the
initial impetus for us to write this Biopsychosocial Formulation
Manual. We will continue to refine the manual over time but
realize that, as with all works, its most valuable future revi-
sions will result from the feedback obtained from those using
it. We hope that you find this manual and the accompanying
CD to be valuable learning tools. Enjoy the process — we
look forward to hearing from you.
William H. Campbell Robert M. Rohrbaugh
Department of Psychiatry Department of Psychiatry
University Hospitals of Cleveland Yale University School of Medicine
11100 Euclid Avenue 300 George Street
Cleveland, OH 44106 Suite 901
William.Campbell@uhhs.com New Haven, CT 06511
Robert.Rohrbaugh@yale.edu
comprehensive care management plan for ongoing work with
the patient. Many beginning clinicians wonder, “How did
they do that?” Although trainees read the standard textbooks
and study the Diagnostic and Statistical Manual of Mental
Disorders (DSM), the process of organizing the patient data
in a meaningful way and marrying it with the theory in an
effort to explicate the patient’s difficulties eludes them. There
is so much information from the patient and the literature
that it is difficult to imagine generating a comprehensive bio-
psychosocial formulation. This manual was written with that
purpose in mind.
The Biopsychosocial Formulation Manual will assist clini-
cians by providing them with a structured paradigm to follow
both in the initial collection and organization of patient data
and in the process of crafting the data into a biopsychosocial
formulation. The manual is not meant to take the place of a
comprehensive textbook or the DSM. Students will need to
know the symptoms and diagnostic criteria for mental disor-
ders and have an understanding of the biological, psychologi-
cal, and social theories that pertain to mental illness. We hope
that by identifying the range of pertinent data, organizing the
data, and providing a framework for analysis of that data, our
readers will become more proficient and confident in their
ability to develop biopsychosocial formulations.
1. Genetics
2. Physical conditions
3. Medications/Substances
Figure 1.1
The Biopsychosocial Formulation Model.
a. Strong emotions
b. Thoughts/fantasies
c. Subtle changes in cognition
4. Coping Mechanisms
a. Adaptive
b. Maladaptive
B. Psychodynamic Formulation
Recurrent difficulties around specific issues (Freudian stage or
Eriksonian crisis)
C. Cognitive Perspective
D. Behavioral Perspective
1. Family 6. Housing
2. Friends/Significant others 7. Income
3. Social issues 8. Access to health care
services
4. Education 9. Legal problems/Crime
5. Work 10. Other
V. Risk Assessment
1. Suicide Risk
2. Violence Risk
A. Biological
a. Laboratory studies
b. Neuroimaging
c. Other studies
B. Psychological
VII. Prognosis