Enhancing Clinical Case Formulation

Theoretical and Practical Approaches for Mental Health Practitioners

Patrick Ryan, Patrick Ryan

• Publisher: Routledge
• Year: 2019
• ISBN:
  9780429942891
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Clinical formulation lies at the heart of how mental health professionals understand psychological distress. It is the application of a framework that cohesively integrates scientific knowledge with the symptoms of distress. In essence, it is the creation of order to what is often experienced as disorder. The aim of this book is to bring awareness to the theoretical and practical opportunities for mental health professionals that exists by using atypical information when adapting typical formulation models.

Each chapter reflects some variation in how formulation is defined, conceptualised and practiced, by using information that regularly materializes from professional encounters but often is omitted from the formulation of a particular presenting problem. Chapters on diet and exercise, sleep, spirituality, sexuality and meaning-making highlight how approaches to formulation can be extended to provide additional opportunities for intervention for the client and practitioner.

A professional encounter orientated in the manner proposed will generate a type of formulation that will raise interesting and testable hypotheses that can assist in understanding 'stuck' points in therapy, difficulties within the therapeutic relationship, low motivation or inability to engage in particular approaches and will assist in devising person-specific mental health interventions. This book will appeal to clinical psychologists and psychotherapists in practice and training.

Chapter 1

Enhancing formulation

Patrick Ryan and Aoife Kilroe

The process of clinical formulation 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). Despite this core skill being considered the ‘bread and butter’ of mental health practitioners in the fields of psychology and psychotherapy, professionals often struggle to assimilate substantial quantities of information into a coherent framework. In addition, the varying emphases in different approaches necessarily give precedence to specific but disparate information from assessment practices.

In the cognitive behavioural approach, constructing a formulation focuses on presenting, precipitating, perpetuating, predisposing and protective factors (Dudley and Kuyken, 2014; Kuyken et al. 2009). The psychodynamic perspective targets the matrix of dynamic, developmental, structural and adaptive patterns in which individuals approach inner conflict (Leiper, 2014). The systemic perspective constructs a formulation based on interpersonal interactions between the individual and their wider systems, in particular, the family system (Dallos and Stedmon, 2014). Although each has its own merits and relevance for how to approach an individual case, each is also limited in terms of the boundaries they place on what type of information is incorporated into the formulation. Information that may be integral to understanding a person’s difficulties (e.g. personality factors, spiritual belief systems) can be ignored, thus significantly reducing the clinician’s capacity to generate a comprehensive profile of the individual and their difficulties, therefore limiting important opportunities for intervention.

The aim of this book is to bring awareness to the theoretical and practical opportunities and values for mental health professionals, in considering atypical information when adapting typical formulation models. Such awareness may help to expand the basis for how mental health practitioners go about understanding the distress that their clients experience. In doing so, the hypothesis is set that additional ‘points of access’ to the clients distress, symptoms or narrative may enhance not just the formulation of symptoms, but also the nature of consequent intervention strategies adopted. Underpinning this objective, is the premise that practices in mental health services have been dominated by a constraint in thinking and professional behaviour associated with an over-reliance on formulaic diagnostic categories, which ignore significantly important information generated in routine professional encounters.

Typical approaches have often constrained a freedom of conceptualisation in how mental health practitioners engage with patients, service users and clients. Arguably, professionals have become too tentative in choosing not to complement traditional approaches that would build formulations that are as comprehensive as possible. It is likely that this has been driven by external resource influences which, by definition, cannot understand the form and function of mental well-being and mental distress. Thus, it is preferable to screen, administer tests, look for information on symptoms, and reduce data load to that which fits with preordained but contested disorders, and to diagnose rather than take into account the vast volume of information that emerges in therapeutic sessions that have little to do with symptoms and disorders. And so, for example, the client who reports being depressed will be interviewed about depression and not about how he learned to play as a child, which would give insight into a host of rich data streams related to freedom of expression, creativity, problem solving, emotional regulation, sibling relationships, social network building and overall development of self.

The capacity to generate, capture and utilise information about well-founded psychological constructs and principles in routine therapeutic dialogue would be a useful start in assisting the client. To shift attention from symptoms of distress and disorder by facilitating open exploration of parts of the story of life not normally seen as relevant to well-being. This approach would focus alternatively from symptom oriented self-identifying strategies that bind clients into social expectations about what is right and wrong with who they are. Most importantly, it would assist clients and professionals to apportion balance and care when determining what factors are relevant, salient, accurate and important when working on a formulation of the information that is generated during therapeutic engagement.

In constructing a more broad-based formulation, it will become obvious to both parties what components of the client’s story are missing, what parts are only partially accessible from conscious memory, what parts have been retrospectively added to ‘complete the circle’ and what parts appear implausible, inaccurate or based in thinking errors. A professional encounter orientated in this manner, will generate a type of dialogue that in addition to traditional approaches to information processing and management, will raise interesting and testable hypotheses that can assist in understanding ‘stuck’ points in therapy, difficulties within the therapeutic relationship, low motivation or inability to engage in particular approaches.

For example, the adult who learned as a child that play was equated with invasive sexual abuse will not readily access information pertaining to creating fun or interest-sharing opportunities that are necessary to buffer against mental distress. A formulation that focuses attention on increasing social networks will therefore only serve to raise stress, which obviously will be avoided by the client even if it makes logical sense to him. However, a formulation that focuses on reducing the trauma experienced in social networks or that focuses on empowering the client in decision making to stay safe will at least go beyond the prescription of, ‘join a club’ or ‘increase hobbies and interests’ that can be implicit in the words and actions of well-intentioned practitioners.

Formulation is the key tool for both initiating and sustaining change in psychological therapeutic work. The British Psychological Society is succinct in its 2017 iteration of what formulation is – ‘the summation and integration of the knowledge that is acquired by the assessment process’ (British Psychological Society, 2017). Thus, one accepted purpose of a formulation is to encapsulate a client’s main problems, illustrate the relationship between client’s difficulties, explain how difficulties developed from a psychological perspective and guide psychological intervention (Johnstone and Dallos, 2013).

And therein presents a problem – the conceptual basis for formulation has been constrained so that ‘difficulties’ are understood better. Not so that ‘people’ are understood better. Hence it makes sense that difficulties, distress, and disorder become the focus of assessment, formulation and intervention. The intellectual and practical cost is that other information, data and material are deemed to be irrelevant, unimportant, and unusable in clinical and other professional settings. This book sets out to challenge this consequence by arguing for a space for information outside of rigid theoretical models of disease and disorder to be considered.

Whilst formulation has consistently been described as being inherently dynamic, ever-changing and ‘moment in time’ based, it has become coupled with the evolving tendency to present human distress in categorizable format, primarily through the influence of, or over-reliance, on diagnostic conceptualisations and intervention manuals. Such methodologies are not necessarily bad in and of themselves, but what is of concern, is that the significant majority of client data that practitioners are exposed to is left unused in the formulation of the distress with which they present. It becomes the detritus of the clinical interviewing process, seen as vaguely relevant but not usually scientific; seen as interesting but not professionally valuable; seen as partial voyeurism, a soft data story but clinically irrelevant.

Interview schedules, screening instruments, psychometric tests and open-ended clinical interviews generate and collect vast amounts of data that cannot be added to the structures and confines of pre-determined categories, diagnoses or labelled clinical frameworks. Therefore, this information is either ignored or treated as anecdotal and less relevant to the distress of the client. Over time, it is then forgotten or is diluted in memory as symptoms that fit with models of practice, or predominant theories play centre stage in how a service, a team or an individual practitioner perceives the needs of the client.

Practitioners in mental health, regardless of discipline, theoretical orientation or ethos at best do not routinely find time or justification to consider the full range of information that is made available to them, or at worst don’t know how to. Or perhaps they don’t know that it can be validly used to complement current formulation models. For example, clinical psychology – as practised in mental health services – in its endeavour to apply its science to the assessment, diagnosis and treatment of psychological distress, regularly falls short in examining issues beyond the presenting problems of the client. There are few clinical tools used to assess the spiritual world of the person but many tools to assess his depression. As a science based profession, it often struggles to address the usable context of the abstract internal and external environment of the person. In particular, it fails to comprehensively account for and use obvious experiences that fall outside of the neat categories of behaviour, thought, emotion and biology, exclusively coupled to the symptoms of the presenting problem.

As a comparator, client-centered psychotherapeutic approaches will manage the experience of client as the primary valid perspective for understanding distress, and be less concerned about the objective opinion of an ‘outside’ professional, despite their training and experience, and despite research that clearly shows how poor we are at generating an external view of our own internal world. Neither discipline is wrong in their respective approaches – it is just that there is more on offer, readily available and often easier to use, as it lacks the burdensome weight of the presenting distress.

Formulating psychological distress as partly being linked to poor nutrition or lack of physical activity, immediately opens avenues of potential activation of behavioural change outside of the symptoms being reported, if that is how the client learns best. That same client may not benefit at all from sessions of talk-only therapy that is focused on learning from emotional experience. So the formulation needs to be built around how the client makes sense of experiences, how the client eats, how the client shops, how the client exercises, who taught the client about these experiences, or indeed, who didn’t. When constructed in this manner, that formulation is different from one that solely sees distress in terms of reduced appetite, low mood, or problematic sexual functioning, with a focus on changing these.

The lack of capacity to use all information generated in professional encounters is important not only for the purpose of comprehensive and complete understanding of mental distress, but also in terms of ethical competence and practice. The simple but profoundly important ethical principle of being responsible means that the welfare of the client is paramount in all engagement with professionals. That welfare can only be held in the highest regard if all pertinent information is used to further an understanding of distress. Or, that it is ensured that only pertinent information is gathered so that the value and privacy of the client’s story is protected from tangential interest. If professionals do not or cannot use information with regard to fundamental human experiences such as sexuality or spirituality, how responsible are their motivations in claiming to have created a thorough understanding of a client’s depression or anxiety? Indeed do professionals become subject to that ever-present attention bias central to most psychological distress – that of selective attention? Or of only using information that fits will pre-conceived ideas of what may or may not precipitate and perpetuate a client’s psychological distress?

The problematic methodology of how formulation is currently used by professionals is made obvious when it is taken into account that healthy people do not categorise their wellness solely in terms of the absence of symptoms in their behaviour, emotion and thinking. A range of human experiences such as expectations of what self is and how spirituality influences responses, make the story of what a person experiences in their daily life. Often, in the clinical domain, the world of the existential experience is seen as the remit of others, like professionals in psychology, counselling and psychotherapy fields not directly involved in the harsh reality of day-to-day mental health services. It does not belong in the clinical world of state funded health services; and in the insurance driven world of private enterprise, is seen as relevant only if directly attached to clinically proven disorders. Even with the current fascination with and influence of positive psychology, the basis of practice for most clinicians’ remains rooted in more traditional categorical approaches to mental health that reflect disorder-formulation, rather than person-...

Table of contents

• Cover
• Half Title
• Endorsements
• Title Page
• Copyright Page
• Dedication
• Contents
• Contributors
• Preface
• Acknowledgements
• 1. Enhancing formulation
• 2. Meaning making in formulation
• 3. Integrating neuroscience in formulation
• 4. Diet and nutrition
• 5. Personality
• 6. Sleep
• 7. Spirituality
• 8. Sexuality
• 9. Physical activity
• Index