Abstract
The capacity to formulate a case is at the heart of all psychiatric and psychotherapeutic work and is a core competency in training. So what do we mean by formulation? There is a summary and organisation of a patient’s case into a concise hypothesis that explains, describes and predicts. For any individual case, the formulation evolves with growing experience and understanding of the patient and their situation. The skill and expertise developed over time by the clinician comes into practice. The formulation can be used by the psychiatrist, therapist, treating team and patient, and when constructed, at times it can be similar to a piece of art or poetry – capturing the essence of the patient’s difficulties and providing a deep insight in a condensed form.
Introduction
The capacity to formulate a case is at the heart of all psychiatric and psychotherapeutic work and is a core competency in training. So what do we mean by formulation? There is a summary and organisation of a patient’s case into a concise hypothesis that explains, describes and predicts. For any individual case, the formulation evolves with growing experience and understanding of the patient and their situation. The skill and expertise developed over time by the clinician comes into practice. The formulation can be used by the psychiatrist, therapist, treating team and patient, and when constructed, at times it can be similar to a piece of art or poetry – capturing the essence of the patient’s difficulties and providing a deep insight in a condensed form.
Models of Formulation
There are different methods of formulating specific to different theoretical models, but the core principles are similar. In this part of the chapter three different but related and interlinking models of formulation currently used in mental health will be described.
The first two, the biopsychosocial and the ‘five Ps’, are descriptive. These models identify different contributory aetiological factors in the history and current situation. The psychodynamic model aims to integrate the history with the current situation to identify patterns repeated from childhood and acted out in the patient’s present relationships.
Information Required for Formulation
Formulation requires information about the patient. The more data gathered, the more accurate and helpful the formulation is likely to be. The information required includes:
A personal history as a pathway or timeline from before birth to the present
A transgenerational and family history
Relationships with caregivers and others
Significant events, including separations, losses and trauma, and the emotional responses to these experiences
Description of psychological problems and symptoms and how they have emerged and developed, including circumstances and events leading up to current crisis or illness
Countertransference responses and relationships created with caregivers and teams. How this is demonstrated in the therapeutic encounter
Theoretical Background
Two areas of theory important in formulation are:
Symptoms and symptom formation
The repetition compulsion
Symptoms and Symptom Formation
What one sees, the presenting problem is often only the marker for the real problem which lies buried in time, concealed by the patient shame, secrecy and sometimes amnesia – and frequently clinician discomfort
In this model symptoms are not seen as the problem but important signifiers of the underlying difficulty which needs attending to. They represent the mechanisms the mind uses to contain anxiety when it cannot be easily escaped or avoided. Anxiety is the body’s alarm system. Danger posed by either an external event, or an internal source that jeopardises the psychic status quo, raises anxiety. In both situations the body’s physiological response is flight, fight or freeze [2]. This response is more easily seen with external danger where an avoidance, escape or fight response is visible. This response is more complex when the threat is internal. In this case flight is accomplished by the creation of symptoms that contain and transform the anxiety. This maintains the equilibrium but does not address the underlying cause of the anxiety. Symptoms therefore, while often distressing, are important, meaningful and containing. Why and when they arose is of utmost importance.
Case Example
Ellen, an 18-year-old young woman, was seen by the psychiatric liaison team on a medical ward where she had presented with a sudden inability to move her left arm. She said she had been looking forward to starting university that summer but because of these symptoms this had to be postponed until the following September. She had been investigated by the neurology team and no organic cause for this difficulty was found. Angela, one of the nurses from the psychiatric team, sat with Ellen and took a full history. In this history Ellen described how her mother had developed multiple sclerosis when she was transferring from primary to secondary school. Ellen had spent a lot of time at home caring for her mother and missing school. Ellen was not sure her mother would cope when she went to university. Angela asked about the first symptoms of her mother’s illness. Ellen looked a bit shocked and said that the first sign of this was the loss of use of her left arm and she started crying. She engaged with her feelings of loss over the next few days and gradually started to move her arm again. After attending weekly therapy for a few months she was able to leave home and start at university.
In this case the symptom Ellen developed had meaning. The fear about separating from her mother was not consciously known and the anxiety transformed into dissociative symptoms that expressed both her fear that separation was dangerous, and the identification with her mother. The symptom itself also served to prevent her leaving home.
The Repetition of Historical Trauma
… the patient does not remember anything of what he has forgotten and repressed, but acts it out. He reproduces it not as a memory but as an action: he repeats it, without, of course, knowing that he’s repeating it. … in the end we understand that this is his way of remembering … the patient yields to the compulsion to repeat, which now replaces the compulsion to remember, not only in his personal attitude to the doctor but also in every other activity and relationship which may occupy his life …
In his very accessible book, The Body Keeps the Score, the psychiatrist Bessel van der Kolk describes profound differences in the storage and processing of traumatic and non-traumatic memories [2]. These disparities have been discovered through neuroimaging and provide a coherent explanation for the long-term physiological and psychological effects of developmental disturbance. When traumatic memories are triggered later in life there is a regression to early behavioural responses that in turn elicit powerful reciprocal responses in others. This leads to the repetition of the early dysfunction. The seminal Adverse Childhood Experience Study (ACE 3) conducted in the USA between 1995 and 1997 showed that abused girls were seven times more likely, than those who had not been mistreated, to be raped in later relationships, and boys who witnessed domestic violence were more than seven times more likely to abuse their partners [1].
This neurobiology provides the physiological and biological background to the ‘repetition compulsion’ described by Freud and considered important in contemporary psychoanalytic thinking [3]. This postulates that disturbed and traumatic memories that cannot be symbolically represented are repeated throughout life. It is only through becoming cognisant of these patterns and transforming them into words that gradually over time there is an attenuation of pain and an escape from this repetition. Therapy provides a safe environment for these patterns to emerge in the transference, allowing the therapists to help the patient translate them into words in a suitably containing environment. These patterns are very important to identify and key to formulating and predicting the progress of future treatment. What has happened before will happen again. There is more discussion of the effect of trauma in Chapter 16.
Biopsychosocial Model
The average physician today completes his formal education with impressive capabilities to deal with the more technical aspects of bodily disease, yet when it comes to dealing with the human side of illness and patient care, he displays little more than the native ability and personal qualities with which he entered medical school. The considerable body of knowledge about human behaviour which has accumulated since the turn of the century and how this may be applied to achieve more effective patient care and health maintenance remain largely unknown to him. Neglect of this important dimension of the physician’s education lies at the root of frequently voiced complaints by patients that physicians are insensitive, callous, neglectful, arrogant, and mechanical in their approaches. There undoubtedly are many reasons for this situation, but the most important is the pervasive influence of the biomedical model of disease …
Related posts:
Chapter 3 – Referral for Psychodynamic Psychotherapy: Processes and Considerations
Chapter 10 – Cognitive Analytic Therapy (CAT):
Chapter 11 – Group Analytic Psychotherapy and the Group Analytic Model: A Clinician’s Guide
Chapter 16 – Complex Post-traumatic Stress Disorder
Chapter 20 – Forensic Psychotherapy
Chapter 25 – Therapeutic Communities
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