Published on April 8, 2013
Formulation WorkshopImplementing theory into practice Dr Funke Baffour Clinical Psychologist UK www.drfunke.co.uk 1
Aims of Workshop1. What is Formulation?2. The Purpose of Formulation3. Predisposing, Precipitating & Perpetuating Factors4. Different Types of Formulation -Psychodynamic -Cognitive Analytical Therapy -Cognitive Behavioural Therapy5. How to Successfully Construct a Formulation6. Ten Tests of a Formulation7. Learning the Art of Formulation8. ENJOY! 2
Objectives of the Workshop Increase awareness of factors to be considered when developing a formulation To be able to draw upon a variety of theories when developing formulations. Develop creativity in developing formulations 3
What is a Formulation? In practice, formulations may be based on information gathered from clinical interview or be highly structured and based on psychometric assessments. However, most are based on a combination of both methods. Formulations should: Have clear theoretical foundations Be sensitive Be specific Have predictive implications Set prescriptive guidelines Capture the essence of the case. 4
Case Formulation Case formulation has been recognised to be a useful conceptual and clinical tool in psychotherapy as diagnosis itself does not focus on the underlying causes of a client’s problem. There is no agreed definition of case formulation by practitioners of a specific model of therapy or between practitioners of different models, and the formulation generally follows the theoretical approach and attempts to integrate different perspectives. One definition of case formulation: “A description of the chief features of a case which has as it’s aim in bringing its details in to some sort of coherent structure” (Denman, C. What is the point of a formulation in The Art and Science of Assessment in 5 Psychotherapy, Routledge, 1994, p167-181).
Case Formulation (2)Another definition: “A hypothesis that relates all of the presenting complaints to one another, explains why these difficulties have developed and provides predictions about the client’s condition” (Wolpe, J. & Turkat, I. D., Behavioural formulations of clinical cases in Behavioural Case Formulation, Plenum Press; New York, 1985, pp5-36). A formulation is the tool used by clinicians to relate theory to practice. However, theory is the source of general explanations, whereas formulation is specific to the person whom it applies. Formulations can best be understood as hypotheses to be tested and the best way to test a formulation will be the response to the selected interventions. 6
Case Formulation (3) Formulations should reflect everything, including past development, characteristic ways of behaving and forming relationships, emotions, beliefs, assumptions, attitudes, self-evaluations, expectations, and so on. By doing this you will begin the process of understanding the predisposing and precipitating factors. Despite the acknowledgement that case formulation is a basic, necessary, and key clinical skill, it is still largely under-taught and under-learned. 7
The Purpose of Formulations Clarify hypotheses and questions Provide an overall picture Prioritise issues and problems (sometimes different priorities resist and then the process of reformulating can help to solve those problems). Plan treatment strategies Select specific interventions Predict responses to strategies and interventions; predicting possible treatment interfering behaviours (i.e. interpersonal difficulties, avoidance strategies etc.) Determining criteria for successful outcome Thinking about lack of progress- trouble shooting (reformulating) Overcoming bias 8
The Purpose of Formulations (2) Offering a diagnostic label is not an explanation. Therapists should be able to develop a coherent explanation for much of what is going on with most clients after several sessions. A case formulation helps the therapist to understand the nature of the therapeutic relationship, relationship difficulties, and experience greater empathy for the client beyond the current presenting problems. clients’ explanatory model for their problems and their own formulation and expectations for treatment should be explored as well. The therapist must seek a formulation that is sensitive to the cultural context within which a client is found so that the client can feel more understood. 9
The Purpose of Formulations(3) Thus, case formulation allows for anticipation and management of therapy interfering events such as non- compliance with homework, acting in and out behaviours, or other forms of resistance to change in therapy. First group of sessions should be aimed in part at evaluating the problem, clarifying its nature, making a “diagnosis”- not just in the sense of finding a “name” for the problem according to the official psychiatric Diagnostic and Statistical Manual (the DSM-IIII); but rather in the original sense of the term, derived from the ancient Greek, “to know-through”. Case formulation is the psychodynamic equivalent of a physician understanding the pathophysiology of a client’s medical problem. 10
The Purpose of Formulations(4) Formulating a case means constructing a meaningful story, placing the client’s present illness within the context of his or her life. Also foundation for rational treatment planning and as such constitutes the key process in clinical practice. An approach to preparing a formulation is to imagine that you were consulting on a case with a colleague or supervisor, and they asked “What do you think is going on with this client?” Exercise your imagination further by considering what you’d say as you attempted to explain your understanding to the client and his or her family, or to communicate succinctly to the subsequent therapist. 11
The Purpose of Formulations(5) Good formulation should be a kind of story, weavingtogether many threads, and ideally should take at leasttwenty minutes to present. If you can encapsulate the person’s story in less thanfive minutes, the chances are that your understandingis still too sketchy and oversimplified, if not just partialor even mistaken! Because psychiatric clients suffer from as diverse arange of psychosocial problems as there are differentkinds of medical problems, there is no single formulafor describing the relevant dynamics in every case. 12
The Purpose of Formulations (6) As with all theoretical models and approaches, a therapist must not be too confined to a single model or approach. The therapist should be able to view it as part of a holistic approach, encompassing the biological, psychological, and social, cultural, and spiritual perspectives of the client. You will need to tailor your formulation to fit the relevant themes in the case. 13
The Purpose of Formulations (7) Do not be lulled into complacency by your ability to categorize the client’s symptoms and signs according to the American Psychiatric Association’s DSM-IV. Such “diagnoses,” in fact are little more than a exercises in nosology. Only assigns a general category of phenomena and tells us relatively little about the “why,” the dynamics of the individual person behind the “label”. Each case of anxiety disorder or schizophrenia is unique. Case formulation is the next step past case presentation. 14
The Purpose of Formulations (8) Formulating a case involves making appropriate inferences about a person’s problem in light of an understanding of the nature of normal and pathological development. Drawing inferences and constructing a story goes beyond a mere summary of the relevant facts of a case and addresses a higher level of abstraction. Many professionals jumble bits of summary in with formulation, and this habit results in muddled thinking. In the process, we need to identify a client’s main problems and understand the predisposing, precipitating and perpetuating factors of these problems as well as the relationship between these factors within the client. 15
Group Exercise Whatdo you understand by the term predisposing, precipitating & perpetuating factors? 16
Predisposing, Precipitating,Perpetuating Factors The predisposing factors are those which make someone more likely to behave in a particular way. Precipitating factors are those which make an action happen sooner or faster than expected and without enough thought or preparation. A perpetuating factor is something that causes the difficulty or problem to continue. Events leading up to the crisis—the “stressors,” and events that finally “push it over the edge”— are known as the “precipitants.” Stressors may arise from many sources. For example, a man may have been losing sleep, having family and job problems. Becomes more isolated at work and in the 17 community, caught up in political ideology, and cultish subgroup.
Predisposing, Precipitating,Perpetuating Factors(2) These events may have played on each other, andthe precipitating event could then occur also at anylevel, perhaps an opportunity to join in a terrorist actor an episode of family or work-related violence. Add to these more current stressors thepredispositions from the more distant past. Where psychoanalytically-oriented theories havemore relevance. What are the client’s significant stressors and whydo they cause the client to react in a unhelpful 18fashion?
Predisposing, Precipitating,Perpetuating Factors (3) What other weaknesses and strengths in theclient’s life must be taken into account in order todesign a comprehensive and appropriate treatmentplan? Key to formulation is to aim at what is obvious, toaddress the more subtle implications. A client suffering from an “Adjustment Disorder” inthe face of the obvious stress of the death of asignificant other , the question to be raised is whythe client is not coping. In some cases, the major stresses and perpetuating 19factors are fairly obvious.
Predisposing, Precipitating, Perpetuating Factors (4) Other cases, clients do not know why they are experiencing psychiatric symptoms, and often the reasons are not that apparent to their therapists. There are those who do not even think they have a problem but are identified by their family or others in their social network. Even when the stresses are obvious, though, there remains the more subtle questions, why this client and not another? Why now? Under what circumstances would this not have happened? 20
Group Exercise Think about one of your clients What were the predisposing, precipitating, perpetuating factors? 21
Different Types of Formulation A) Psychodynamic Formulation Psychodynamics may be simply defined as the interactions among the various parts of the mind/ body. These are often problematic due to conflict, ambiguity, distortion, and habits of suppression, compartmentalization and illusion. 22
Psychodynamic(2) A good formulation structure in dynamic psychotherapy was devised by Perry et al (1987) and includes: A summarising statement A description of non-dynamic factors A description of core psychodynamics using the id, ego and super-ego Object relations-(places less emphasis on the drives of aggression and sexuality as motivational forces and more emphasis on human relationships) Prognostic assessment which identifies the potential areas of resistance in therapy (defence mechanisms e.g. denial, projection etc) 23
B) Cognitive Analytic TherapyFormulations Cognitive Analytic Therapy (CAT) is the result of the work of Dr Anthony Ryle and his collaborators in the 1980s. CAT arose out of three commitments: a desire to develop effective and practicable psychotherapy within the National Health Service, involvement in psychotherapy research, and a growing conviction that the time was ripe for a unified psychotherapy theory. This approach draws on psychoanalytic as well as cognitive techniques. A structured and focused framework is used to encourage patients to understand the origins of their attitudes and beliefs, and the effect they have on present feelings and behaviour in order that change 24 may occur.
CAT Formulations (2) An approach to formulation known as reformulation is central to CAT. CAT’s approach to formulation as a guide to therapy is one of illumination rather than the rigid exclusion of new knowledge. The aim in the first four sessions is to concentrate on gathering and formulating (or reformulating) information. First, the clients presenting problems are semi-formalised in to a list of target problems or traps. 25
CAT Formulations (3) The traps are then reformulated jointly by therapist and client in to a wider understanding of the clients difficulties and brief descriptions of the maladaptive patterns which are known as dilemmas or snags. The dilemmas and/or snags provide a template for planning intervention. The reformulation can help to predict transference and response to therapy. The insistence that dilemmas or snags and traps be explicitly related keeps the reformulation close to the clients presenting difficulties. 26
CAT Formulations (4)The Basic Patterns of (a) Traps, (b) Dilemmas and (c) Snags(taken from Sheffield DClin Psych 2000) (a) Belief about self (e.g. bad or must be cross) Which confirms Role or Action (e.g. placation or avoidance) Consequences (e.g. loss of control or rejection) Own Needs Ignored Either Powerfully Care giving (b) Unmet Emotional needs Desire to relate to others Dilemma – as if Loss of Control Or Submissively Dependent (c) Pursuit of Happiness Success or Happiness or Success Imminent As if Not Allowed or Unhappiness or Failure Undo or Pay For Dangerous 27
C) CBT Formulation CBT has it’s basis in the experimental method, so the early sessions are used to devise an initial formulation and treatment plan. The formulation is then tested out in subsequent homework and treatment sessions, and modified if necessary. The cognitive model hypothesises that people’s emotions and behaviours are influenced by their perception of events. 28
CBT Formulation (2) It is not a situation in and of itself that determines what people feel but rather the way in which they construe a situation. It is our perception of events (based on early experiences) that impacts upon our emotions, physiology, and behaviour, and reinforcing our cognitions. The Padesky and Greenberger’s Model of emotional disorders (1995) illustrates the links between current symptoms and problems 29
Padesky & Greenberger’s Cognitive Model ofEmotional Disorders (1995) Environment e.g. presenting training Cognition e.g. I don’t know what I’m talking about Behaviour Emotione.g. avoid presenting e.g. fear to people Biological e.g. sweating, shaking, stuttering 30
CBT Formulation(4) Theoretically, experience in early life gives rise to a set of beliefs and assumptions about the world, other people, and the self. These beliefs are seen as a product of the ways in which earlier events have been perceived, understood, and remembered. These can be functional or dysfunctional, actively influential or latent. 31
CBT Formulation(5) A critical incident is an event that fits with a belief – being rejected for someone who believes they are not socially acceptable, or being let down for someone who believes that other people are unreliable or untrustworthy. Critical incidents activate the relevant beliefs and assumptions, and thus negative thoughts. Then a variety of interacting cognitive, affective, behavioural, and physiological reactions follows. At this level the problem is theoretically maintained by cyclical processes. 32
Longitudinal Formulation Using CBT (Blackburn & Twaddle, 1996) Experience (early) Beliefs, about the self, the world, and others, which can be expressed in categorical statements: I am…; the world is…; others are… Assumptions derived from beliefs, which can be expressed in conditional statements; If I… then…; One should… otherwise… Critical incidents Activated beliefs and assumptions Negative automatic thoughts (NATs) Cognitive, behavioural, motivational, affective, and physiological reactions 33
Early experience Unfavourable comparisons with twin sister Father (and main supporter dies) Core Beliefs I am inferior as a person My worth depends on what other people think of me Dysfunctional Assumptions Unless I do what other people want, they will reject me If I express how I really feel, people will reject me Critical incident Marriage breaks down Negative automatic thoughts It’s all my fault – I’ve made a mess of everything I can’t handle my life I’ll be alone forever – it’s going to be dreadful I’m stupid Symptoms Behavioural: Lowered activity levels, social withdrawal Motivational: Loss of interest and pleasure, everything an effort, procrastination Affective: Sadness, anxiety, guilt, shameCognitive: Poor concentration, indecisiveness, ruminations, self-criticism, suicidal thoughts Somatic: Loss of sleep, loss of appetite 34
Group Exercise Think about one of your clients Carry out a formulation using the CBT Longitudinal Model 35
Cognitive Conceptualisation Diagram (Beck, J., 1993) Clients Name:_________________ Date:___________ Diagnosis: Axis I________________ Axis II_____________ Relevant Childhood Data Which experiences contributed to the development and maintenance of the core belief Core Beliefs What is the most central belief about self? Conditional assumptions/Beliefs/Rules Which positive assumption helped her cope with the core belief? What is the negative counterpart to this assumption? Compensatory Strategy(ies) Which behaviours help her cope with the belief? Situation 1 Situation 2 Situation 3 What was the problematic situation? Automatic Thought Automatic Thought Automatic Thought What went through her mind Meaning of the AT Meaning of the AT Meaning of the ATWhat did the automatic thought mean to her? Emotion Emotion EmotionWhat emotion was associated with the AT? Behaviour Behaviour Behaviour What did the client do then? 36
How to Successfully Construct aFormulation How you do it is generally determined by understanding the purposes it serves, and in particular by the theoretical orientation of the therapist. Formulation demands creativity and the ability to deal with abstractions as well as the more mundane skills primarily involved in assessment. Therapists use many skills in helping them to understand this material: theoretical knowledge; products of academic learning and professional training; and clinical judgment. 37
How to Successfully Construct a Formulation(2) Themes across prototypical problematic situations (functional analyses) Questionnaires Person’s own “theory” Developmental history Downward arrow technique Affective shifts in therapy session(s) Therapist’s thoughts and feelings 38
Butler’s (1998) Ten Tests of a Formulation1. Does it make theoretical sense?2. Does it fit with the evidence?3. Does it account for predisposing, precipitating and perpetuating factors?4. Do others think it fits? (the client, supervisors, etc)5. Can it be used to make predictions? (about difficulties, aspects of the therapeutic relationship etc) 39
Butler’s Ten Tests of aFormulation (cont)6. Can you work out how to test these predictions? (select interventions, anticipate response to therapy etc)7. Does the past history fit?8. Do interventions based on the formulation progress as would be expected?9. Can it be used to identify future sources of risk or difficulties for the client?10. Are there important factors that are left unexplained? 40
Learning the Art of Case Formulation As you begin to practice, let your goal be just a partialformulation, addressing only a few themes, two or threeparagraphs. Discuss these with supervisors or colleagues and takenotes as prompt you further for a deeper evaluation. Push yourself to write out at least two pages offormulation. Keep in mind that what you are describing should leadto treatment strategies. 41
Learning the Art of Case Formulation(2) Let this also serve as a case summary for future therapists. Imagine that you are writing for a person who really needs to know what has been happening; imagine what you would like to know if you were receiving the case as a referral. Another approach is to work backward from what you have discovered has been most helpful, or what your intuition suggests would probably be most useful. 42
Learning the Art of Case Formulation (3) Then work backwards to check if those intuitions have any basis in the client’s realistic situation. Making these dynamics explicit becomes part of the formulation. The best way to learn the art of case formulation is to practice it as a skill, like playing a musical instrument. Push yourself to do it repeatedly, get feedback, use the feedback to refine your performance. It is easy to do a half-hearted job. 43
Summary Keep your formulation free of details from the case summary. There should be no re-statement of the case in the formulation, only a shift to a more abstract level. Use these guidelines as an aid to constructing viable formulations. Skill requires practice and can only be learnt through doing. Constructing a succinct and plausible case formulation is the one activity I know of which will impress your supervisors, clients, and colleagues more than a clear and organized case presentation. No matter how far you are in your career there is still a lot to learn about formulation. The art of formulation is to reformulate. 44
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