The Biopsychosocial Model and Case Formulation (also known as the Biopsychosocial Formulation) in psychiatry is a way of understanding a patient as more than a diagnostic label. Hypotheses are generated about the origins and causes of a patient's symptoms. The most common and clinically practical way to formulate is through the biopsychosocial approach, first described in 1980 by George Engel.[1][2] Biopsychosocial formulation combines biological, psychological, and social factors to understand a patient, and uses this to guide both treatment and prognosis. Your formulation of a patient evolves and changes as you collect more information. Formulation is like cooking, and there is no 'right' or 'wrong' way to do it, but most get better over time with increasing clinical experience.
Cbt Examples Of Case Formulation
Diagnosis is not the same as formulation! In mental health, when there is a group of consistent symptoms seen in a population, these symptoms can be categorized into a distinct entity, called a diagnosis (this is what the DSM-5 does). For example, we diagnose someone with a major depressive episode if they meet 5 of the 9 symptomatic criteria. However, formulation tells us how the person became depressed as a result of their genetics, personality, psychological factors, biological factors, social circumstances (childhood adverse events and social determinants of health), and their environment.
You are probably already formulating, but just don't know it. Like most things in medicine, there are multifactorial causes of diseases, illnesses, and disorders. For example, type II diabetes does not develop because of a single pathophysiological cause. The patient may have a strong family history of the disease, a sedentary job, environmental exposures, and/or a nutritionally-poor diet. These factors all combine to cause the person to develop diabetes. Understanding how each factor contributes to a disease can better guide treatment decisions. In psychiatry, formulation appears more complicated because human behaviour and the brain itself is extraordinarily complex. However, like with anything, the more you practice, the better you will become at formulating.
Now that you've filled in the easy parts from the history, the hardest part is conceptualizing the predisposing social factors (Step 3), and all of the psychological factors (Steps 4, 5, 6, 7). This is where you'll need to be creative and also think more in-depth about your patient. Ideally, each step should flow logically and intuitively into the next based on your framework, as you'll see in our case of Jane Doe. Having a framework for understanding of different psychological treatments and psychological theories can be helpful in making your psychological formulation flow intuitively (e.g. - attachment theory, cognitive behavioural therapy, dialectical behavioural therapy, interpersonal therapy, psychodynamic therapy). However, this can be done intuitively even without an in-depth understanding of these frameworks (we don't need to be Freud to do this). The more cases you go through (and more of the sample formulations below) the more comfortable you will be with formulating!
The narrative formulation of the patient is a less rigid presentation structure where you may not choose to present everything in the 4 Ps table, and instead focus on the key factors that you think are relevant:
A much more advanced and nuanced presentation might be using a more comprehensive formulation that integrates the 4Ps formulation through multiple lenses (e.g. - Eriksonian developmental stages, psychodynamic defenses, and dialectical behavioural):
A good formulation should be integrative, and let you understand how all of the patient's factors interact to lead to the current situation. This gives you a sense of their current level of functioning, prognosis, and guides your direction for treatment and management decisions.
Now here is one potential example of a predisposing social and psychological formulation of psychosis (again, there are no right or wrong ways to formulate, it depends on the patient you have in front of you!)
Notwithstanding the examples above, CBT therapists often describe finding it difficult to apply CBT skills when clients bring relational problems to therapy. Clients might report problems such as fearing and avoiding emotional closeness, finding relationships threatening, repeatedly ending up in abusive relationships, or feeling dissatisfaction in their relationships. Familiar methods of visually representing CBT formulations can struggle to incorporate these reciprocal interactions, with the result that clients are not helped to mentalize and understand how others may perceive and react to their behaviors.
What Is Case Conceptualization / Case Formulation?Types of Case FormulationCase formulations can vary according to their purpose, and according to the information they attempt to convey. A number of types of formulation have been described:
Case formulation in psychology is an activity that allows a therapist to combine all relevant patient data in a single structure, outline possible underlying issues and propose a plan for future action. Many psychiatrists consider the use of case formulation in Cognitive Behavioural Therapy a necessary part of treatment (Beck 7; Nezu et al., 62; Persons and Tompkins 291). Nevertheless, research on its effectiveness has not found an abundance of supporting evidence, with some scholars raising concerns about the employment of case formulation or conceptualisation (Aston 65; Dudley et al. 67).
Therefore, it is important to describe and assess various aspects of formulation in order to understand what benefits it can bring to both therapists and patients. First, one should consider why the topic of case formulation is relevant to research on CBT. Second, the role of formulation in the process of CBT should be reviewed.
As case formulation is one of the steps in treatment, its position between the initial assessment and goal setting needs to be discussed. Conceptualisation implies that all gathered data will be synthesised, which may raise concerns or overwhelm a therapist or patient. Thus the utility of case formulation and how patients perceive it may also influence its effect on therapy. Finally, one should consider how the use of formulation may inform nursing practice. This paper aims to show the critical role of formulation in CBT as well as discuss its characteristics and features.
The investigation into the characteristics and impacts of case formulation on CBT is guided by the fact that the existing literature does not provide sufficient evidence to prove that it should be the basis for treatment. For example, Persons and Tompkins argue that formulation is one of the most valuable strategies for helping therapists develop a treatment plan (295). Some authors show how beneficial this approach can be for both experienced and novice medical professionals (Dudley et al. 66). This strategy is also approved by Zayfert and Becker, who experiment with CBT in cases of PTSD.
The scholars provide evidence that case formulation leads to rapid improvement of patients and their understanding of their core issues (58). Naeem et al. show that formulation can be utilised in self-help CBT and note that it is more effective than other methods since it provides insight and systematises patient information (771). Therefore, one should understand how formulation works and what knowledge it requires.
On the other hand, a poor assessment may cause a patient to become unresponsive to the proposed treatment. If a therapist is imposing a certain bias by focusing on a single diagnosis and refusing to review the situation in detail, therapy sessions may end in the patient becoming disinterested in further communication. According to Persons, this outcome can be avoided if the case formulation is viewed as a template with changing contents (14).
It should be noted that formulation uses a nomothetic approach to investigating patient data. This means that most conclusions are made with the general laws of psychiatry in mind. For instance, a formula for treating eating disorder-related obesity is that the majority of clients express a positive response to food and eating which then cause them to overeat (Dalle Grave et al. 196; Murphy et al. 615). Similarly, the notion that physical illnesses have a negative impact on mental health and exacerbate disorders is another nomothetic statement (Farrand and Woodford 14). However, not all clients can be treated using nomothetic theories alone; they require an idiographic (person-specific) strategy. In case formulation, idiographic aspects are applied to nomothetic statements in order to build the treatment up from general beliefs into a personalised plan.
Therapists perform formulation in multiple steps; these include symptom, problem and case. The symptoms of a disorder or an issue represent separate concerns such as mood changes, insomnia, social isolation, or high pulse. A problem is a combination of symptoms, and it can be described with a diagnosis. For example, Major Depressive Disorder is a problem that includes negative emotions and automatic thoughts caused by previous events and stress (Persons and Tompkins 295).
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Case formulation aims to describe a person is presenting problems, and his theory to make explanatory inferences about causes and maintaining factors that can inform interventions. First, there is a top-down process of cognitive behavioural theory providing clinically useful descriptive frameworks. Second the formulation enables practitioners and clients to make explanatory inferences about what caused and maintains the presenting issues. Thirdly case formulation explicitly and centrally informs intervention. Case formulation is a cornerstone of evidence-based CBT practice. For any particular case of CBT practice, formulation is the bridge between practice and theory and research. It is the crucible, where the individual particularities of a given case relevant theory and research synthesise into an understanding of the persons presenting issues in CBT. 2ff7e9595c
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