The diagnostic formulation summarizes and integrates relevant issues from the biopsychosocial, developmental, and temporal axes. The biopsychosocial axis refers to multiple systems, from molecular to sociocultural, that interact constantly and are manifest in current objective behavior and subjective experience. The developmental axis is applied to different levels of the biopsychosocial axis in order to determine whether each level is developmentally normal, delayed, advanced, or deviant. The temporal axis refers to the ontogenesis of the individual from his or her origins to the present and beyond.

Biopsychosocial Axis

Current functioning is the expression of multiple biopsychosocial levels within the patient, as he or she interacts with the physical, family, sociocultural, occupational, and economic environment. In order to evaluate present functioning, the clinician examines the levels and systems described in Table 12–1.

Developmental Axis

Each level of the biopsychosocial axis can be assessed with regard to what would be expected for that age. Some of these assessments (e.g., height, weight, head circumference) are very accurate. For others (e.g., intelligence), although a number of assessment instruments are available, existing measures represent a composite of skills potentially affected by extraneous factors (e.g., social class, motivation). For still others (e.g., ego defenses, working models of attachment), measurement techniques are relatively crude and the norms subjective.

Nevertheless, during interviewing and mental status examination, the clinician will scan the levels shown in Table 12–2 for delay, precocity, or deviation from the normal and, when appropriate, order formal special investigations.

Temporal Axis

All individuals have come from somewhere, exist where they are now, and are headed somewhere. Using the temporal axis, the clinician explores the unfolding of a problem up to the present time and attempts to predict where the patient is headed. The mileposts in this evolution can be classified, somewhat arbitrarily, in the following sequence: (1) predisposition, (2) precipitation, (3) presentation, (4) pattern, (5) perpetuation, (6) potentials, and (7) prognosis.

Predisposition

What early biological or psychosocial factors have stunted or deflected normal development, or rendered the patient vulnerable to stress? Table 12–3 lists several examples.

Given the current state of knowledge, it is often difficult or impossible to reconstruct these factors and their effects on the growing organism, particularly with regard to inherited vulnerability or propensity (e.g., as hypothesized for depressive disorder). However, postnatal deprivation or trauma may be recorded, for example, in the patient’s medical record.

Precipitation

A precipitant is a physical or psychosocial stressor that challenges the individual’s coping capacity and causes him or her to exhibit the symptoms and signs of psychological maladjustment. Table 12–4 lists several examples. A temporal relationship exists between the precipitant and the onset of symptoms. Sometimes the precipitant (e.g., parental discord) later becomes a perpetuating factor. Sometimes the precipitant is a reminder of a previous traumatic experience. Sometimes the precipitant ceases, and the patient returns to normal coping. Sometimes the precipitant ceases, but maladaptive coping persists or even worsens. In that case, perpetuating factors must be operating (see below).

Not all current patterns of psychopathology have precipitants. Some psychopathologies (e.g., early infantile autism) may have evolved continuously since infancy or early childhood. The clinician should look for a precipitant when normal functioning is succeeded by the onset of psychopathology.

Presentation

The clinician should consider why the family is presenting at this time. Is it, for example, that the child’s behavior worries them or disrupts family functioning? Has the family’s capacity to tolerate the child’s behavior deteriorated? If so, why?

Pattern

The current pattern represents the current biopsychosocial axis. The clinician should evaluate the patient’s current physical, psychological, and social functioning. To the extent that abnormalities in physical functioning (e.g., somatoform symptoms), information processing (e.g., amnesia), communication (e.g., mutism), internal models (e.g., self- hatred), coping style (e.g., compulsive risk-taking), and social competence (e.g., social withdrawal) can be defined as psychopathologic phenomena, the clinician will assemble configurations of symptoms and signs that form categorical syndromes (e.g., residual posttraumatic stress disorder, dysthymia) and dynamic patterns (e.g., traumatophilia, introversion of aggression, unresolved conflict following trauma).

The clinician also evaluates the family, and the social, school, cultural, and economic environment in which the family lives. Table 12–5 lists the issues to consider in evaluating the quality of family interactions. The clinician also assesses the acuity of the problem pattern (i.e., its imminent danger to the patient and others), its severity (i.e., the levels of biopsychosocial functioning affected and the degree to which they are affected), and its chronicity.

Perpetuation

If the precipitating stress (e.g., parental conflict) does not dissipate, the child’s maladaptation is likely to continue. If the stress is removed, the child is likely to spring back to normality. If not, the clinician must ask why not. The reason could be either within or outside the child.

Internal perpetuating factors can be biological or psychological. For example, overwhelming psychic trauma can trigger a train of unreversed biochemical derangements, involving catecholamines, corticosteroids, and endogenous opiates, that cause the numbing and hyperarousal associated with the traumatic state. Unresolved psychic trauma can also produce a personality that seeks compulsively to reenter traumatic situations, thus reexposing the self to victimization and further trauma.

External perpetuating factors include the reinforcement of child psychopathology that occurs in dysfunctional family systems, for example, the protective parent who shields a delinquent child from punishment, or the anxious, enmeshed parent who unwittingly reinforces a child’s separation anxiety and school refusal.

Potentials

In addition to addressing psychopathology and defects, the clinician should consider the child’s physical, psychological, and social strengths. A child with a learning problem may be talented at sports, or be physically attractive, or have a talented, supportive family. In treatment planning, the clinician must consider how strengths can be harnessed in order to circumvent or compensate for defects or problems.

Prognosis

The clinician should predict what is likely to happen with or without treatment, remembering that it is impossible to anticipate all the unfortunate and fortuitous happenstance that can block, divert, or facilitate a particular life trajectory.

The clinician should summarize the diagnostic formulation in a succinct manner. Consider the following example:

Susan is a 14-year-old adolescent who has a 2-month history of the following symptoms, which were precipitated by her observation of a house fire in which the 4-year-old brother she was baby-sitting perished: traumatic nightmares, intrusive memories, frequent reminders, emotional numbing, avoidance of situations that remind her of the event, startle responses, irritability, depressive mood, social withdrawal, guilt, and suicidal ideation. She has acute posttraumatic stress disorder with complicated bereavement and secondary depression precipitated by psychic trauma.

Susan’s physical health is good and her sensorimotor functioning intact. She is of low average intelligence and approximately 2 years retarded in reading, language, and mathematical attainment. She has very low self-esteem, views herself as the family drudge, and is resentful of her alcoholic father’s domination of her mother and her siblings. She has a close relationship with a married sister.

Susan’s symptoms are reinforced by her mother’s bereavement and the family’s emotional insensitivity and poor communication. This is a large family, in which Susan has played the role of parentified child, supporting the mother and taking responsibility for much of the housekeeping and child care. Susan was predisposed to develop a depressive trauma reaction by her long-standing (but suppressed) resentment at being the family drudge and at being the frequent target of her father’s emotional abuse.

Susan has the following strengths and potentials: She has supportive friends; her older married sister is very helpful; and she enjoys child care.

Without treatment, the current posttraumatic stress disorder is likely to continue. There is a risk of suicide.

The purpose of treatment can range from short-term crisis management to long-term rehabilitation, remediation, or reconstruction. For that reason, the goals of treatment will vary according to the level of care the patient is receiving. The following levels of care are provided in child and adolescent mental health services: very brief hospitalization, brief hospitalization, brief partial hospitalization, extended day programs, residential treatment, intensive outpatient care, and outpatient care (see Chapter 16). Very brief hospitalization (1–14 days) is suited to crisis alleviation and the reduction of acuity. Brief hospitalization (2–4 weeks) aims at stabilization, as do brief partial hospitalization programs. Residential treatment programs, extended partial hospitalization programs, and outpatient treatment have more ambitious goals related to remediation, reconstruction, or rehabilitation.

Components of Goal-Directed Treatment Planning

The essence of goal-directed planning is the extraction of treatment foci from the diagnostic formulation and the expression of the foci as goals and objectives, with predictions of the time required for goal attainment. On the basis of the goals, treatment methods can be selected. On the basis of the objectives, goal attainment (i.e., treatment effectiveness) can be monitored until the goal is attained and treatment terminated (see Figure 12–1).

Foci

Those problems, defects, and strengths that can be addressed, given the resources and time available, should be extracted from the diagnostic formulation. The clinician should not merely list behaviors in an unintegrated “laundry list.” Pivotal foci, those internal or external factors that activate, reinforce, or perpetuate psychopathology, are especially important. For example, mother–child enmeshment may be the key to a problem of separation anxiety. A behavioral program for separation anxiety applied in the school setting will fail unless the clinician addresses the mother’s involvement in her child’s fear of leaving home.

Goals

Goals indicate what the clinician or clinical team aims to achieve, at the given level of care, on the patient’s behalf (Table 12–6). A goal is a focus preceded by a verb. The focus “depressive mood,” for example, becomes “Alleviate depressive mood” when rewritten as a goal. As described in the introduction to this section, goals are categorized according to whether they promote crisis alleviation, stabilization, reconstruction, remediation, rehabilitation, or compensation. Crisis alleviation, stabilization, reconstruction, and remediation foci are preceded by verbs such as “alleviate,” “ameliorate,” “remediate,” “eliminate,” “reduce the intensity of,” “reduce the frequency of,” “stabilize,” or “counteract.” Rehabilitation and compensation goals are preceded, for example, by “enhance,” “augment,” “facilitate,” or “increase the intensity/frequency of.” Behavioral goals are best suited to crisis alleviation and stabilization settings (e.g., inpatient hospitalization).

Objectives

Goals assert what the clinician aims to do. Objectives indicate what the patient will (be able to) do, say, or exhibit at the end of that stage of treatment. Objectives should always be stated in behavioral terms. Goals and objectives may be intermediate (e.g., at the point of discharge from hospital) or terminal (e.g., at the end of outpatient treatment). Goals and objectives may be ambitious (e.g., “Resolve internal conflict regarding punitive father  figure” or “The patient will be able to cooperate appropriately with his superior at work in the performance of his assigned tasks”) or advisedly limited (e.g., “Gain weight. At the end of hospitalization, the patient will weigh 79 pounds”).

Whereas goals take the long, abstract view, objectives indicate when enough is enough, making the clinician or team accountable, and alerting them when treatment is not progressing as well as anticipated.

Target Date

For each set of goals and objectives, a time is predicted. For example, the goal “Alleviate depressive mood and suicidal ideation” may have the objective “The patient will express no suicidal ideation spontaneously or during mental status examination for a period of 1 week.” The clinician may predict that such a stabilization objective will be attained, for example, in 3 weeks.

Therapy

For each goal, the clinician selects a therapy or set of therapies, according to the following criteria: greatest empirical support, resource availability (i.e., clinical resources, time, finances), least risk, greatest economy (i.e., time, expense), and appropriateness to family values and interaction style.

The modes of therapy are discussed in the next section of this chapter. Do not confuse the term “objective” with a therapeutic strategy or tactic. An objective is the behaviorally stated endpoint of a phase of treatment. Treatment strategies or tactics (e.g., “Encourage father to attend patient’s baseball games”) represent the means of getting to the endpoint, that is, the adaptation of a particular intervention to the needs of the patient and family.

Treatment Monitoring

Objectives are the key to monitoring both the patient’s progress and the treatment plan’s effectiveness. Progress can be assessed by periodic milieu observations, mental status examinations, measurement of vital signs or other physical parameters, laboratory testing, standard questionnaires, rating scales, or psychological testing. To the extent that an objective can be measured, the measure should be stated (e.g., “The patient’s score will drop to below 12 on the Conners Parent–Teacher Questionnaire”). Not all objectives can be measured numerically, and for some, subjective, qualitative monitoring is required. The clinician should not fall into the trap of deleting objectives that cannot be measured objectively. Some pivotal goals and objectives, particularly those related to psychodynamic or family systems issues, require qualitative monitoring; and ingenious assessments of dynamic issues can sometimes be planned. For example, the goal “Resolve conflict about past sexual abuse” could be monitored, for a particular patient, in terms of the frequency, duration, and acuity of dissociative episodes.

Revision

If progress stalls, the patient deteriorates, or unforeseen complications arise, the clinician or team will be alerted by the treatment monitors. Then a decision must be made. Continue? Change the goals? Modify the objectives? Reconsider the therapy? Periodic treatment monitoring (e.g., monthly for outpatient treatment, daily for inpatient or partial hospitalization) keeps the clinician or team accountable and prevents therapeutic drift.

Termination

When the objectives are reached, the patient is ready either to move on to the next phase or level of treatment or to terminate the treatment.

Disadvantages & Advantages of Goal-Directed Treatment Planning

Goal-directed treatment planning must be learned. It does not build on the naturalistic process of treatment planning (which usually starts from treatments rather than goals). It requires the clinician to be explicit about matters that are customarily avoided or blurred (e.g., target dates). Imposed on uncomprehending or resistant clinicians, goal-directed treatment plans are typically relegated to the status of irrelevant paperwork or to a mindless printout from a computerized treatment planning menu.

Goal direction has numerous advantages, however. It provides a common intellectual scaffolding with which a clinical team can plan. It serves notice to clinicians to monitor progress and review their plans if they are ineffective. It provides a useful basis for negotiating with families, obtaining truly informed consent, and facilitating or consolidating the treatment alliance. Finally, it is a potentially useful tool for utilization review and outcome research.