I spend a lot of time talking about clinical formulations. I know, that seems like a weird thing to spend time thinking about. But I end up talking about it a bunch with clients when talking about treatment planning, and so it just happens.
The Clinical Formulation is an element of the treatment record which used to be common practice which has fallen out of habit, and in some ways has ceased to be a required part of the treatment record, though some insurance companies do allude to it.
While often not weighed as an official part of the biopsychosocial assessment, the clinical formulation is an invaluable tool for the clinician in establishing language supporting medical necessity and providing, at the same time, a non-diagnosis centered language to describe symptoms and deficits with the client. There have been a number of discussions related to the limitations of the DSM-5 approach to understanding mental health which have prompted considerations to moving away from the medical model and move toward a more narrative approach to the identification of mental disorders.
The clinical formulation is the identification of the symptoms and deficits in context of the factors which may have influenced the current state. In many ways it is a description of the diagnosis in multidimensional terms.
One writer describes it in the following way:
In summary, formulation is a synthetic step in the psychiatric assessment involving clinical judgement. In formulation, ontological (diagnostic hierarchy), causal (biopsychosocial model) and meaning (verstehen) perspectives combine to give an overall picture of an individual case and a basis for treatment and care. It involves a stratified diagnostic scheme to give intelligibility to clinical information, a pluralistic, biopsychosocial 4P mode of causal analysis focused on intervention (and recovery and prognosis) and a verstehen mode of grasping expressivity and intentionality in a human person.
It is the crystallization of everything you have identified through the assessment process – questionnaire, interview, and standardized instruments – which establishes the need of therapy and where the focus of therapy might be.
While the development of the clinical formulation has fallen out of favor with many, it does allow for a clear means of moving from assessment into planning by organizing the salient material from the process to determine where the focus of therapy might be most appropriate.
For example, when a clinician treating an individual for depression using Cognitive Behavioral Therapy develops their plan, the focus is less on pure diagnosis and more on linkages between negative thinking, unhelpful behaviors, emotional responses, and ultimately physiological responses. Through an assessment process and the gathering of history, the clinician should have gleaned this information in order to start the movement toward treatment. The formulation then provides the opportunity for the clinician to specifically identify how these elements may have come together to create the client’s current experience.
This formulation serves multiple tasks. First, as already mentioned, establishes the medical necessity of treatment, which provides supportive language for third-party payers to gain understanding of the clinician’s identification for initiating treatment. Second, it gives the clinician and client an identified starting point in a way that the client may be able to understand and can see the context for the work ahead. Third, it provides an opportunity for the clinician to sit for a bit with the information gathered through the assessment process and consider appropriate directions for treatment. And fourth, then it builds the bridge between assessment and treatment planning – and ultimately treatment.
The formulation allows for some structure which can come in handy in those circumstances where the course of treatment deviates from its original intent. Almost any clinician who has worked with clients has experienced situations where the therapy loses its way through the process of the client bringing new challenging narratives into the therapy room. Treatment can get derailed through a passive avoidance of the core themes. By providing some definition to the identified work of therapy, the formulation has the opportunity to function as a north star of the treatment process. This is not to say that new themes cannot appear, or they are always some means of avoiding the central focus of treatment. But it is a reality that it does happen, and it is easy to get lost in that process.
In some parts of the clinical world the clinical formulation has fallen out of fashion, as it is seen as time consuming and redundant to the BSP document. Of course, the statement does not need to be long-winded, and can be a very effective tool for the clinician to communicate with the client on what they are seeing in relation to the symptoms and deficits while, at the same time, establishing medical necessity wanted by the payor sources. As such, it can function as a bridge between the assessment and the treatment plan as it organizes the central themes identified through the assessment process which are key to establishing the direction of treatment to address the symptoms and deficits. As such, it might be considered, and is often used as the preamble to the treatment plan.
There are a lot of good reasons to make developing a Clinical Formulation a part of the diagnostic process. First and foremost, it engages your clinical thinking in a more holistic way as you synthesize what you learned through the diagnostic process. As a secondary item, and one that many of us angst about, it becomes a clear way of supporting the medical necessity of treatment for any other reader of the record.
I know it takes time, and a lot of clinicians are very leery of spending time on things they don’t get reimbursed for. But I think it’s a sound investment in the work you’re about to do with your client, and so I will continue to encourage its use, even while acknowledging that it’s “extra credit” work.