You are doing case formulation wrong

Psychologists frequently present lists of 3 Ps, 4 Ps, and even 7 Ps, but somehow they still get formulation wrong.  In this episode Aaron explores the idea of case formulation as hypothesis

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Transcript

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Something I'm seeing a lot at the moment is my interns and my registrars who are really struggling with clinical case formulation. It's like they've never learned how to do it properly. They've been taught the 3Ps or the 4Ps or the 5Ps, but they haven't really understood what it's for and how it works. And one of the big signs that I know that somebody doesn't understand how clinical case formulation works is when they ask me questions like, what does this particular factor belong? Does it belong to predisposing, does it belong to precipitating, or does it belong to perpetuating? Because maybe it's both. Typically, I see formulations like the one on the screen right now. We start with presenting problem, then we work through what are the predisposing factors that are leading the person to have the problems that they're having, and then we think about the precipitants that are causing the problem right now, then we look at the perpetuating factors that are keeping the person stuck, and then finally we look at the positives. If your formulations look like the one on the screen right now, you are doing it wrong. So let's think about how do we do it right. Firstly, all that a formulation is, all that it can ever be, is a hypothesis. Your clinical case formulation is simply your hypothesis as to how psychological theory applies to the person in front of you. What do you think is going on for them cognitively? What do you think is going on behaviorally? What do you think is going on developmentally? Or in terms of values? How do you understand the problems that they are presenting with? As we're trying to state our hypothesis, we often think in terms of three key questions. The first question is why did this person develop this set of problems? Why don't they have an eating disorder? Why aren't they suicidal? Why don't they have depression? Why don't they have trauma? What is it that can be understood about this person that has led to them having this set of problems? The second thing we think about is why now? This person has gone through their entire life without turning up in a psychologist's office, or maybe they haven't. What is it about the factors that have happened in the here and now that have led to this set of problems developing right now? And then finally, why are they not getting better of their own accord? Most people, when they have psychological distress, spontaneously remit. They get better using only their own resources. To answer these three questions, we draw upon our understanding of psychological theory and we come up with our best hypothesis as to what we think is going on. Now I've used the word hypothesis a few times already in this video, and the key reason is everything that I've said right now is just a theory. It is not true until the client gets better. Your formulation is simply your best guess as to what you think is going on. And then you work on that formulation with the client collaboratively to come up with an agreed hypothesis. And then that agreed hypothesis forms the basis of treatment. Then finally, when the client gets better, you can look at your formulation and say it was probably right. But if the client doesn't get better, you need to go right back to the drawing board with your client and come up with a completely new hypothesis. For a clinical case formulation to be useful, it must be testable. We need to think like scientists when we're writing up our clinical case formulations. Because if your case formulation looks like the one I showed you before, that's not a case formulation, that's just a list with categories. I hope you find this helpful.