Writing a Formulation – Sasha Rose

Learning to write clinical and research reports is a feature of most Psychology and Counselling training.  Formulations are increasingly used in clinical, mental health and forensic settings to make sense of a client’s issues and to provide recommendations for treatment.

 

This guide will outline the key elements of a formulation report and offer some tips for creating an effective hypothesis and treatment plan.

 

What is a formulation?

A formulation is a theoretically based explanation of a client’s issues gathered from a clinical assessment.  It is rooted in psychological theory with the aim of setting out an hypothesis about the client’s experiences and possible outcomes.

 

Its purpose is to summarise the key issues, identify areas relevant for intervention and recommend a treatment plan with measurable goals.  In an assessment the therapist will explore a range of factors in the client’s life and consider where their core beliefs originated from and how they have been shaped e.g. key life events, formative experiences and important relationships.  It is similar to a personal narrative or life story and usually reveals the intersection of biopsychosocial factors in the client’s experience.

 

A formulation should also provide a framework for therapeutic interventions.  As part of the summary, the therapist should propose a hypothesis for what the significant issues are and recommend an appropriate approach.  By rooting the hypothesis in psychological theory, the therapist can ensure that interventions are evidence-based and operate within a clear framework.  This provides clarity for both the therapist and client on how the treatment plan should progress, expected outcomes and will ensure that therapy is delivered in a safe and structured way.

 

Ideally a formulation is developed collaboratively with the client and helps form the basis of a strong, trusted therapeutic relationship.  This helps the client understand how their current beliefs relate to the issues they are experiencing and encourages them to actively participate in their treatment plan.  A positive therapeutic relationship is one of the key factors determining successful outcomes of therapy (Goldfried, 2013)

 

Three key questions to answer when writing a formulation;

 

What has caused the problems?

What factors are maintaining the problems?

What might facilitate change?

 

Formulation vs diagnosis

A formulation is different from a diagnosis.  A diagnosis typically uses medical labels based on symptoms related to psychological states rather than considering underlying processes.  A diagnosis rarely reflects the client’s individual context or experiences and can be quite impersonal.  Instead, a formulation looks at the whole person and seeks to offer a personalised explanation for their issues and a way forward.

 

Often a person accessing mental health support will have experienced a range of issues or traumatic events.  Sometimes these can involve a diagnosis but it is important to consider the surrounding factors as well. While a diagnosis may be reassuring in some instances because they validate the person’s issues, labelling may also lead to medical or drug-based solutions rather than considering therapeutic interventions.  Some diagnoses also carry stigmas or presumptions and make it harder for the client to access the support they need.

 

Structuring your report: What should it cover?

Your formulation report should cover the following areas;

Summary of the client’s issues:

Provide an overview of the issues currently faced and identify which would be suitable for therapeutic intervention

Provide evidence-based rationale for proposed approached:

For example when recommending a cognitive behavioural approach (CBT), you should outline the theoretical basis for this intervention explaining why it is relevant for your client and their specific issues

Recommended treatment plan:

Outline a therapy plan for the client including treatment goals and measurements of success

Highlight issues arising in treatment:

Explore some of the issues or challenges you think may arise for your client in therapy.  These could be dealing with painful feelings and memories, or challenges around how therapy is structured.  By considering these ahead of time you can identify potential solutions and facilitate a positive experience

 

Writing a Treatment Plan and setting goals

An effective treatment plan should translate the client’s issues into a meaningful set of measurable goals.  It is important to consider the client’s strengths and other protective factors as well as the issues they face.  Also consider the time scale for therapy and how/when to review progress, as well as any environmental factors such as location or accessibility.

 

Treatment goals should be SMART (specific, measurable, achievable, realistic and time-bound).  Larger goals can be broken down into small, achievable steps that are not overwhelming for the client.

 

It is essential to document progress towards each goal and review these regularly with the client.  By discussing progress together the client can see evidence of their own progress and the therapist is able to adapt the plan where necessary.

 

Treatment goals example

Goal Measurement Reviewed Rating (1-5)
Build emotional regulation and coping skills Identify negative thoughts and feelings when they arise and rate strength Keep a thought diary at home and review each week in therapy Agree a rating with the client e.g.

5 = confident reconising negative feelings and assigning strength rating

1 = still not able to identify negative feelings and assign strength rating

 

Summary

As a therapist, a comprehensive formulation can provide a solid basis for therapeutic interventions.  By rooting recommendations in evidence-based theory as well as considering your client’s individual circumstances, you can build a framework that is both effective and tailored to their needs.  While there may be some universal outcomes associated with your recommended approach, work with your client to ensure that goals reflect their specific needs and hopes for the future

 

References and further reading

BPS ‘Understanding formulation’ guide [Online] Available at https://www.bps.org.uk/sites/www.bps.org.uk/files/Member%20Networks/Divisions/DCP/Forumlation%20WEB%20ID3412.pdf

 

Goldfried, M. (2013), ‘What should we expect from psychotherapy?’ in Clinical Psychology Review 33 (2013) p. 862–869 [Online] Available at http://cleostudies.lecture.ub.ac.id/files/2015/03/Goldfried-2014-What-to-expect-from-psychotherapy.pdf

 

Johnstone, L. (2018). Psychological Formulation as an Alternative to Psychiatric Diagnosis. Journal of Humanistic Psychology, 58(1), 30–46 [Online] Available at https://doi.org/10.1177/0022167817722230

 

Biography

Sarah is a BSc Psychology student with the Open University.  She is studying part-time alongside her current career in media & advertising and has a degree in Philosophy from the University of Birmingham

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