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Clinical Formulation
Clinical case formulation involves integrating information gained from a clinical assessment into a theoretically-derived explanation of a client’s difficulties. This includes information concerning the predisposing, precipitating and maintaining factors of a problem. The process is based upon a biopsychosocial model which accounts for biological (genetic predispositions and risk factors), psychological (life events and self-image) and social (relationships, support networks) factors helping or hindering a client’s wellbeing. The process helps to explain difficulties without categorising them, in contrast to diagnosis, which typically uses the DSM-5 or ICD-10 to group presenting problems into a conceptualised condition. Formulation allows both therapist and client to explore these problems and tailor a therapeutic intervention to that client, taking into account possible boundaries to effective treatment and utilising beneficial elements in an individual’s life (e.g. supportive relationships, beneficial behaviours) where possible. Formulation is a collaborative process, allowing the client to make decisions about their treatment in partnership with the therapist. Formulation may take the form of an initial hypothesis about the cause of problems, and develop as the client-therapist relationship develops and more information is exchanged. Clinical formulation is typically used by mental health professionals such as clinical psychologists and psychiatrists.

The 4 P model
While the exact information will differ depending on the model being used, common elements transcend the majority of formulation approaches; the presenting problem(s), a triggering event, factors perpetuating the problem (which may be different to the trigger), and any predisposing elements relevant to that individual. Protective factors, or positive elements in an individual’s life are also noted when formulating. The 4 P model was proposed by Weerasekera, defining the development of difficulties in terms of;
 * Predisposing - vulnerabilities which increase the likelihood of developing a problem, such as a family history of problems or a traumatic event ocurring in early life;
 * Precipitating - triggering events or situations which cause the client to seek mental health services;
 * Perpetuating - while one thing may start a problem developing, another may keep the problem going. For example, losing a job may lead to an individual experiencing low mood, causing excessive alcohol consumption. While the loss of a job may lead to depression, excessive drinking may perpetuate it.
 * Protective - elements of an individual's life which may be preventing the problem from worsening. This may take the form of a sense of humour, a pet, posessing a useful skill or having a hobby.

Theoretical approaches
The model (or models in the case of integrative psychotherapy) used to explain difficulties will depend upon the therapist’s theoretical standpoint as well as the individual’s beliefs about the problem such as its nature, the process of change and any goals or expectations about treatment.

There are a number of approaches which can be used in clinical formulation, including:

Cognitive behavioural formulations typically centre on the client’s interpretations and subsequent responses, both cognitive and behavioural, to events or situations. Beck proposed a model of cognitive disorders which applies to cognitive behavioural formulation. In order to determine the origins of maladaptive thinking and behaviours, early experiences are considered. These experiences are posited to shape perceptions of the self, other people and the world as a whole, and as such are considered fundamental in understanding the development of difficulties. These early experiences can lead to the formation of core beliefs; a set of general rules which apply to the cognitive triad; the self, others and the world. These beliefs influence the way in which events are perceived. From these beliefs, a set of dysfunctional assumptions develop; these are often reflected more in behaviour than vocalised, and influence thoughts, behaviours and emotions. Critical incidents are the events which bring these latent core beliefs into conscious thought; often negative events which confirm an individual’s beliefs and lead to experiencing difficulties. These incidents lead to negative automatic thoughts; statements derived from an individual’s core beliefs which can manifest as recollection of memories, interpretations of present events or predictions about the future.

In cognitive behavioural formulation, the aim is to uncover the client’s maladaptive core beliefs and develop interventions which challenge those beliefs. In doing so, it is proposed that by challenging the foundations of maladaptive thoughts and behaviours, and by providing more adaptive alternative behaviours, the client will experience a reduction of the presenting problem and an increase in wellbeing.

Psychodynamic formulation places emphasis on the effects of unconscious thoughts and emotions on the development of problems. These unconscious elements are thought to stem from early life experiences, and a focus of psychodynamic formulation is in uncovering how and why they developed. Psychodynamic theory posits that human development is a consequence of an interaction between the environment and genetic predispositions, and as such the role of these is factored into psychodynamic formulation. The therapist would typically obtain a description of the problem, relating to a number of areas including the self, relationships with others, thoughts, feelings, vocational and leisure pursuits. The client’s history would then be discussed, including genetic heredity, early memories and relationships. The therapist would then seek to explain the presenting problems with reference to the client’s developmental history. The therapist may share their interpretation of problem and its development in order to allow the client to appraise their own thinking and consider its efficacy, or may use the interpretation to inform the way in which they interact with the client.

Interventions in psychodynamic therapy typically aim to develop an awareness of the influence that the client’s past experiences have on them in the present. By encouraging introspection, it is thought that the client can begin to resolve the problems they are experiencing over the course of the therapist-client interactions. As such, the continuous formulation process is considered a part of the intervention.

Strengths of formulation
When formulating, the protective elements of the client’s life are considered; this allows these elements to be utilised in an intervention, increasing its effectiveness and reducing the amount of change necessary to achieve treatment goals.

When formulating, both the presenting problem and its development are considered; negative elements are identified for interventions, and protective elements are factored into the intervention where possible. In the context of cognitive behaviour therapy, a tailored, formulation-based approach has been found to be more effective than standardised treatment delivered using a manual.

As the formulation process requires the therapist to develop a high level of understanding of the client’s problem, the quality of the therapeutic relationship has been linked to better treatment outcomes, regardless of the therapist’s level of training or theoretical approach. In the study, a number of therapists were evaluated based on the length of time it took for clients to report an improvement in symptoms, and the degree to which their presenting problems improved. After analysing data on 91 therapists, the study found that the highest performing therapist showed a rate of improvement in clients’ symptoms 10 times above the mean for the sample. Conversely, the worst performing therapist whose clients took the longest to show an improvement showed a decrease in wellbeing on average. This effect could not be explained by the theoretical approach being used, or by the level of experience of the therapists. The authors of the study suggest that factors such as the quality of the therapist-client relationship may have a more significant effect on client outcomes than had been considered.

Limitations of formulation
While formulation can lead to better treatment outcomes for some clients, there is evidence that exploring past issues can lead to a deterioration in condition; by discussing problems and their causes, some clients have reported feeling worse than before attending treatment. In such an instance, standardised treatments derived from a diagnosis may be more appropriate to avoid exploring difficult life events.

It has been argued that the application of standardised treatments can lead to a higher degree of expertise in a particular therapeutic technique. This allows the therapist to deliver treatment in a consistent manner, allowing the therapist to hone their approach to treating specific diagnoses. The authors argued that not only does an individualised approach make it more difficult for the effectiveness of treatments to be evaluated, it also makes it more difficult for the therapist to consider weaknesses in their approach and therefore hinders the progress of therapists as professionals.