Full Transcript for You are doing case formulation wrong

WEBVTT 00:00:00.160 --> 00:00:07.919 Something I'm seeing a lot at the moment is my interns and my registrars who are really struggling with clinical case formulation. 00:00:08.160 --> 00:00:11.359 It's like they've never learned how to do it properly. 00:00:11.519 --> 00:00:19.760 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. 00:00:19.920 --> 00:00:29.039 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? 00:00:29.600 --> 00:00:34.479 Does it belong to predisposing, does it belong to precipitating, or does it belong to perpetuating? 00:00:34.560 --> 00:00:35.920 Because maybe it's both. 00:00:36.159 --> 00:00:39.840 Typically, I see formulations like the one on the screen right now. 00:00:40.000 --> 00:00:57.840 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. 00:00:58.000 --> 00:01:02.640 If your formulations look like the one on the screen right now, you are doing it wrong. 00:01:02.799 --> 00:01:05.200 So let's think about how do we do it right. 00:01:05.439 --> 00:01:11.120 Firstly, all that a formulation is, all that it can ever be, is a hypothesis. 00:01:11.439 --> 00:01:22.159 Your clinical case formulation is simply your hypothesis as to how psychological theory applies to the person in front of you. 00:01:22.400 --> 00:01:24.799 What do you think is going on for them cognitively? 00:01:24.959 --> 00:01:26.719 What do you think is going on behaviorally? 00:01:27.040 --> 00:01:29.120 What do you think is going on developmentally? 00:01:29.280 --> 00:01:30.879 Or in terms of values? 00:01:31.200 --> 00:01:35.040 How do you understand the problems that they are presenting with? 00:01:35.280 --> 00:01:40.959 As we're trying to state our hypothesis, we often think in terms of three key questions. 00:01:41.200 --> 00:01:46.560 The first question is why did this person develop this set of problems? 00:01:46.799 --> 00:01:48.560 Why don't they have an eating disorder? 00:01:48.719 --> 00:01:49.840 Why aren't they suicidal? 00:01:50.000 --> 00:01:51.040 Why don't they have depression? 00:01:51.200 --> 00:01:52.560 Why don't they have trauma? 00:01:52.799 --> 00:02:00.000 What is it that can be understood about this person that has led to them having this set of problems? 00:02:00.319 --> 00:02:02.879 The second thing we think about is why now? 00:02:03.120 --> 00:02:09.439 This person has gone through their entire life without turning up in a psychologist's office, or maybe they haven't. 00:02:09.680 --> 00:02:17.039 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? 00:02:17.280 --> 00:02:21.680 And then finally, why are they not getting better of their own accord? 00:02:22.000 --> 00:02:28.159 Most people, when they have psychological distress, spontaneously remit. 00:02:28.319 --> 00:02:31.439 They get better using only their own resources. 00:02:31.680 --> 00:02:41.840 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. 00:02:42.000 --> 00:02:51.280 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. 00:02:51.599 --> 00:02:56.000 It is not true until the client gets better. 00:02:56.240 --> 00:03:01.599 Your formulation is simply your best guess as to what you think is going on. 00:03:01.840 --> 00:03:09.360 And then you work on that formulation with the client collaboratively to come up with an agreed hypothesis. 00:03:09.520 --> 00:03:13.599 And then that agreed hypothesis forms the basis of treatment. 00:03:13.840 --> 00:03:19.840 Then finally, when the client gets better, you can look at your formulation and say it was probably right. 00:03:20.080 --> 00:03:28.560 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. 00:03:28.879 --> 00:03:34.319 For a clinical case formulation to be useful, it must be testable. 00:03:34.639 --> 00:03:40.240 We need to think like scientists when we're writing up our clinical case formulations. 00:03:40.479 --> 00:03:47.439 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. 00:03:48.080 --> 00:03:49.199 I hope you find this helpful.