Forensic Case Formulation

Peter Sturmey, Mary McMurran, Peter Sturmey, Mary McMurran

• Publisher: Wiley-Blackwell
• Year: 2011
• Print ISBN: 9780470683941, 9780470683958
• eBook ISBN: 9781119976899
• Edition: 1
• Topic: Psychology
• Subtopic: Forensic Psychology
• Index: Psychology

Forensic Case Formulation is the first text that describes the principles and application of case formulation specifically to forensic clinical practice.

• Addresses risk assessment and its implications for case formulation and treatment
• Covers a range of serious forensic problems such as violence, sexual offending, personality disorder, and substance misuse
• Offers guidance in training clinicians on ways to create useful formulations

PART I

GENERAL ISSUES

Chapter 1

THEORETICAL AND EVIDENCE-BASED APPROACHES TO CASE FORMULATION

Tracy D. Eells

University of Louisville, USA

Kenneth G. Lombart

University of Massachusetts Lowell, USA

Our task in this chapter is to introduce the concept of case formulation. We begin by discussing the definition, functions and goals of case formulation, including why formulation is important. We continue by reviewing theoretical and evidentiary sources of information to guide the development of a formulation. Next, we summarize several structured case formulation models that have been developed to increase reliability and validity. Finally, we propose a general framework the therapist can use to structure a formulation and conclude with some practical tips.

WHAT IS A CASE FORMULATION?

Our working definition of case formulation comes from a cross-theoretical perspective: “A psychotherapy case formulation is a hypothesis about the causes, precipitants, and maintaining influences of a person's psychological, interpersonal and behavioral problems” (Eells, 2007, p. 4). A formulation involves inferences about predisposing vulnerabilities, a pathogenic learning history, biological or genetic factors, sociocultural influences, currently operating contingencies of reinforcement, conditioned stimulus–response relationships, or schemas, working models, and beliefs about the self, others, the future or the world. The aim of the formulation is to explain the individual's problems and symptoms. The specifics of the formulation will vary depending on the theoretical orientation of the case formulator. As a hypothesis, a formulation is always subject to empirical test and to revision as new information becomes available.

A case formulation serves multiple functions (Eells, 2007). First, it provides a structure to organize information about a person and his or her problems. Clients produce enormous amounts of information in therapy, including verbal, behavioral, prosodic, gestural, affective, and interactional. Formulation facilitates the management of this information cascade. Second, formulation provides a blueprint guiding treatment. Its primary purpose is to help the therapist develop and implement a treatment plan that will lead to a successful outcome. The formulation therefore enables the therapist to anticipate future events, for example, therapy-interfering events, and to prepare for them. Third, a formulation serves as a gauge for measuring change. Indices to assess change may come from goals included in the formulation, from relief of problems identified in the formulation, or from the revision of an inferred explanatory mechanism that did not seem adequate when tested. Fourth, a formulation helps the therapist understand the patient and thereby exhibit greater empathy for the patient's intrapsychic, interpersonal, cultural, and behavioral world.

Kuyken, Padesky and Dudley (2009) offer another definition of case formulation, emphasizing its collaborative and resilience-building aspects. They define formulation as a “process whereby therapist and client work collaboratively first to describe and then to explain the issues a client presents in therapy. Its primary function is to guide therapy in order to relieve client distress and build client resilience” (p. 3). Using the metaphor of a crucible and focusing on cognitive-behavioral therapy (CBT), these authors emphasize that formulation integrates and synthesizes a client's problems with CBT theory and research. Essential ingredients of a productive conceptualization are empirical collaboration between therapist and client, the development of the formulation over time from the descriptive level to an explanatory level, and the elicitation of both client strengths and problems. These authors also describe functions of a CBT case formulation. These include (1) synthesizing client experiences, relevant CBT theory and research; (2) normalizing and validating clients’ presenting issues; (3) promoting client engagement; (4) making complex and numerous problems more manageable for the client and therapist; (5) guiding the selection, focus, and sequence of interventions; (6) identifying strengths and suggesting ways to build resilience; (7) suggesting cost-efficient interventions; (8) anticipating and addressing problems in therapy; (9) helping the therapist understand nonresponse to therapy; and (10) facilitating high-quality supervision.

Persons (2008) embeds her approach to formulation within a framework of clinical hypothesis testing. She emphasizes that the formulation is fundamentally a hypothesis that is constantly refined in the course of treatment. She views a complete formulation as one that ties the following elements together into a coherent whole: (1) the patient's symptoms, disorders, and problems, (2) hypotheses about the mechanisms causing the disorders and problems, (3) precipitants of those disorders and problems, and (4) a statement of the origins of the mechanisms. Following similar lines, Tarrier and Calam (2002) define formulation as “the elicitation of appropriate information and the application and integration of a body of theoretical psychological knowledge to a specific clinical problem in order to understand the origins, development and maintenance of that problem. Its purpose is both to provide an accurate overview and explanation of the patient's problems that is open to verification through hypothesis testing, and to arrive collaboratively with the patient at a useful understanding of their problem that is meaningful to them” (pp. 311–12). The case formulation is then used to inform treatment or intervention by identifying key targets for change.

WHY FORMULATE?

Multiple mental health care disciplines view case formulation as an essential clinical skill. A core competency for psychiatrists trained in the United States is the ability “to develop and document an integrative case formulation that includes neurobiological, phenomenological, psychological and sociocultural issues involved in diagnosis and management” (American Board of Psychiatry and Neurology, 2009, p. 1). Similarly, the American Psychological Association promotes evidence-based practice, which includes the application of “empirically supported principles of psychological assessment, case formulation, therapeutic relationship, and intervention” (APA Presidential Task Force on Evidence-Based Practice, 2006, p. 284). The British Psychological Society views formulation as a core skill (Division of Clinical Psychology, 2001, p. 2). Multiple authors support the importance of case formulation as a “lynchpin concept” (Bergner, 1998), the “first principle” underlying therapy (J. S. Beck, 1995) and the “heart of evidence-based practice” (Bieling and Kuyken, 2003).

Formulation is a core skill for several reasons. First, and most importantly, formulation is where theory and empirical knowledge about psychotherapy, psychopathology, personality, development, culture, and neurobiology merge to inform the understanding and treatment of an individual, group, couple, or family. Formulation provides a structure to apply nomothetic knowledge to an idiographic context.

Second, current nosologies are almost exclusively descriptive and symptom-focused. Thus, they provide no account of why a client has symptoms, what the origins of those symptoms are, and what triggers and maintains them. Major depressive disorder, one of the most commonly diagnosed disorders, is a case in point. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (American Psychiatric Association, 1994, DSM-IV) to be diagnosed with this condition, one must meet five of nine criteria for two weeks, including depressed mood or loss of interest or pleasure. In addition, one must exhibit distress or impairment in one's social or occupational functioning and meet other rule out criteria. The criteria say nothing about biochemical, psychological, behavioral, situational, or environmental factors that may be producing the depression. Formulation fills this explanatory gap between diagnosis and treatment.

A third reason that formulation is essential is that diagnosis alone does not provide a sufficient guide to treatment selection. The same diagnosis might be treated with different types of empirically defensible treatments and interventions, creating the dilemma of which one to choose. Further, few psychotherapy outcome studies include diagnosis by treatment interactions and thus do not address the sensitivity and specificity of treatment for a specific diagnosis (Sturmey, 2008). A single treatment that is found effective for one diagnosis may also be effective for other diagnoses.

Fourth, a case formulation approach tailors treatment to address individual circumstances. Empirically supported treatments (EST) do not provide guidance in a number of situations (Persons, 2008). These include when the client has multiple disorders and problems, when multiple providers are treating the individual, when a situation arises that is not addressed by an EST, when no EST is available, when the client does not adhere to an EST, when establishing a collaborative therapeutic relationship proves problematic, and in cases of treatment failure. With regard to the latter point, as many as 40–60% of individuals do not respond to a first-line empirically supported treatment (Westen, Novotny and Thompson-Brenner, 2004).

THE GOALS OF FORMULATION

If a formulation is to serve the above functions, it should meet at least five goals. First, a formulation should be accurate and fit the individual for whom it is constructed. The benefits of an accurate formulation have been demonstrated in a number of studies (Crits-Christoph, Cooper and Luborsky, 1988; Crits-Christoph et al., 2010; Silberschatz, 2005b). One way to assess accuracy of an individual formulation is to evaluate the patient's response to a formulation-consistent intervention and to compare those responses to how the patient responds to formulation-inconsistent interventions. If the patient responds as the formulation predicts, one has evidence of its accuracy. Another way to assess accuracy is to share the formulation with the patient and get the patient's opinion. Opinions vary as to whether and to what degree a formulation should be shared with a patient. CBT therapists tend to prefer sharing the formulation and see this as an important component of developing a collaborative relationship with the patient (Kuyken et al., 2009) More psychodynamically oriented therapists have expressed caution in sharing the formulation. Luborsky and Barrett (2007) advise sharing it in its component parts rather than as a whole. Curtis and Silberschatz (2007) advise deciding whether to share or not on the basis of what the formulation predicts the patient's response will be. Ryle's (1990), cognitive-dynamic model, on the other hand, includes sharing the formulation, composed as a letter from the therapist to the patient, as part of treatment.

A second goal of formulation is that it have treatment utility (Hayes, Nelson and Jarrett, 1987). The formulation should contribute to the treatment beyond what would have been achieved in the absence of a formulation. One measure of utility is the contribution of the formulation to treatment outcome. There is little research in this area, and research that has been done has produced equivocal results (Bieling and Kuyken, 2003; Kuyken, 2006). Another index of treatment utility is the extent to which the formulation benefits the process or efficiency of the delivery of the therapy. Further, a formulation may have benefits for the therapist that filter indirectly to the patient and therapeutic process, for example by increasing the therapist's confidence or improving his/her communication with the client. For example, Chadwick, Williams and Mackenzie (2003) found that while formulation-guided therapy did not predict alliance ratings among a group of psychotic patients, it was associated with improved therapist ratings of the therapeutic relationship.

A third goal of formulation is that it should be parsimonious yet sufficiently comprehensive. Some problems and clients require relatively simple and circumscribed formulations whereas others need multifaceted and complex formulations, especially when the client behaves in contradictory ways, meets criteria for multiple disorders, or has major problems in multiple spheres of functioning. The formulation should provide a structure to optimally and efficiently represent enough information about the patient to benefit treatment, but not more.

A fourth goal of formulation is to strike the right balance between description and explanation. Research has shown that it is difficult to achieve good reliability when formulations are based on psychological constructs that are too distant from the experience and behavior of the patient (Seitz, 1966). On the other hand, if a formulation is to be genuinely explanatory, it must do more than summarize biographical information about a client. Notwithstanding this distinction, it is noteworthy that description and explanation can blur as one proposes an underlying mechanism. As Kazdin (2008, p. 12), wrote, “Depending on the detail, level of analysis, and sequence of moving from one to the other, description can become explanation” (p. 12).

A final goal of formulation is that it should be evidence-based. The APA Task Force on Evidence-Based Practice in Psychology stated that evidence-based formulations apply the best research, knowledge, experience, and expertise to the task: Wh...

Table of contents

• Cover
• Wiley Series in Forensic Clinical Psychology
• Title Page
• Copyright
• About the Editors
• About the Contributors
• Series Editors’ Preface
• Preface
• PART I: GENERAL ISSUES
• PART II: VIOLENCE
• PART III: SEXUAL OFFENDING
• PART IV: SPECIFIC POPULATIONS
• PART V: CONCLUSION
• Index