Once the mental health professional makes a formal diagnosis, they then analyze the factors that may have influenced the patient or client’s current psychological state. A clinical formulation, also known as case formulation or case conceptualization, is that analysis, or a theoretically based explanation of the information obtained from a clinical assessment. It offers a hypothesis about the cause and nature of the presenting problems (e.g., background history, presenting concerns, and manifestation and progression of behavioral signs and symptoms over time), and is considered an adjunct or alternative approach to the more categorical approach of psychiatric diagnosis. These formulations are used to communicate a hypothesis and provide a framework for developing the most suitable treatment approach, rather than labels or diagnostic codes. It gives a rich description of the client’s personal history and pieces together how the disorder evolved. It is most commonly used by clinical psychologists and psychiatrists and is deemed to be a core component of these professions. Mental health nurses and social workers may also use formulations. As mental health professionals, we need to consider both the purpose of our communication and the audience for that communication. As professionals, we must also consider the potential misuse of documents by others, which will influence the way that we present our case formulation.

Types of Formulation

Different psychological schools or models utilize clinical formulations, including cognitive-behavioral therapy (CBT) and related therapies: systemic therapy, psychodynamic therapy, and applied behavior analysis. The structure and content of a clinical formulation is determined by the psychological model (which we will examine more closely in another module). Most systems of formulation contain the following broad categories of information:

• symptoms and problems
• precipitating stressors or events
• predisposing life events or stressors
• an explanatory mechanism that links the preceding categories together
• a description of the precipitants and maintaining influences of the person’s problems

Many psychologists use an integrative psychotherapy approach to formulation, or the integration of elements from different schools of psychotherapy in the treatment of a client. This is to take advantage of the benefits of resources from each model the psychologist is trained in, according to the patient’s needs. The case formulation may pull from several psychological models and formations, such as those mentioned below:

• A cognitive-behavioral model of formulation described by Jacqueline Persons has seven components: problem list, core beliefs, precipitants and activating situations, origins, working hypothesis, treatment plan, and predicted obstacles to treatment.
• A psychodynamic formulation would consist of a summarizing statement, description of nondynamic factors, description of core psychodynamics using a specific model (such as ego psychology, object relations, or self psychology), and prognostic assessment that identifies the potential areas of resistance in therapy.
• Behavioral case formulations used in applied behavior analysis and behavior therapy are built on a rank list of problem behaviors. Such functional analysis is also used in acceptance and commitment therapy. Functional analysis looks at setting events (ecological variables, history effects, and motivating operations); antecedents; behavior chains; the problem behavior; and the consequences, short- and long-term, for the behavior

Cultural Formulation

A cultural formulation is the systematic review of a person’s cultural background and the role of culture in the manifestation of symptoms and dysfunction. It is argued that a cultural perspective can help psychiatrists become aware of the hidden assumptions and limitations of current psychiatric theory and practice and can identify new approaches appropriate for treating the increasingly diverse populations seen in psychiatric services around the world. The DSM-5 includes a Cultural Formulation Interview that aims to help clinicians contextualize diagnostic assessment. A related approach to cultural assessment involves cultural consultation that works with interpreters and cultural brokers to develop a cultural formulation and treatment plan that can assist clinicians.

Cross-cultural psychiatry (also known as ethnopsychiatry, transcultural psychiatry, or cultural psychiatry) is a branch of psychiatry concerned with the cultural context of mental disorders and the challenges of addressing ethnic diversity in psychiatric services. It looks at whether psychiatric classifications of disorders are appropriate to different cultures or ethnic groups. It often argues that psychiatric illnesses represent social constructs as well as genuine medical conditions, and as such have social uses peculiar to the social groups in which they are created and legitimized. It studies psychiatric classifications in different cultures, whether informal (e.g., category terms used in different languages) or formal (for example the World Health Organization’s ICD, the American Psychiatric Association’s DSM, or the Chinese Society of Psychiatry’s CCMD). The field has increasingly had to address the process of globalization. It is said every city has a different culture and that the urban environment, and how people adapt or struggle to adapt to it, can play a crucial role in the onset or worsening of mental illness.

Reflecting advances in medical anthropology, the DSM-5 replaced the term culture-bound syndrome (or folk illness—a combination of psychiatric and somatic symptoms that are considered to be a recognizable disease only within a specific society or culture) with a set of terms covering cultural concepts of distress: cultural syndromes (which may not be bound to a specific culture but circulate across cultures), cultural idioms of distress (local modes of expressing suffering that may not be syndromes), causal explanations (that attribute symptoms or suffering to specific causal factors rooted in local ontologies), and folk diagnostic categories (which may be part of ethnomedical systems and healing practices).

Following an initial assessment, the client or patient and therapist come to an agreement called the treatment plan. This is a type of contract that specifies the goals of treatment; treatment procedures; and a regular schedule for the time, place, and duration of their treatment sessions. Sometimes this treatment contract is written down explicitly, but more often it is discussed between the individual seeking therapy and therapist.^[3] Services are based in psychiatric hospitals or in the community. Determining the treatment site (most often private therapist’s outpatient clinic or office) is an important part of planning treatment. Community mental health centers (CMHCs) provide for community-based care as an alternative to institutionalization. At these centers, patients can be treated while working and living at home.

The importance of the therapeutic relationship, also known as therapeutic alliance, between client and therapist is often regarded as crucial to psychotherapy. Psychotherapy focuses on the use of psychological methods, particularly when based on regular personal interaction with adults, to help a person change behavior and overcome problems in desired ways. Psychotherapists may be mental health professionals such as psychiatrists, psychologists, mental health nurses, clinical social workers, marriage and family therapists, or professional counselors. Psychotherapy aims to improve an individual’s well-being and mental health; to resolve or mitigate troublesome behaviors, beliefs, compulsions, thoughts, or emotions; and to improve relationships and social skills. There is also a range of psychotherapies designed for children and adolescents, which typically involve play. Certain psychotherapies are considered evidence-based for treating diagnosed mental disorders. Others have been criticized as pseudoscience. There are over a thousand different psychotherapy techniques, some being minor variations, while others are based on very different conceptions of psychology, ethics (how to behave professionally), or techniques. Most involve one-to-one sessions between the client and therapist, but some are conducted with groups, including families.

In practice, clinical and counseling psychologists work with individuals, couples, families, or groups in a variety of settings, including private practices, hospitals, mental health organizations, schools, businesses, and non-profit agencies. Other than providing psychological treatment (psychotherapy), clinical and counseling psychologists can offer a range of professional services, including administering and interpreting psychological assessment and testing, and providing expert testimony (forensics). 

Although clinical and counseling psychologists and psychiatrists share the same fundamental aim—the alleviation of mental distress—their training, outlook, and methodologies are often different. Perhaps the most significant difference is that psychiatrists are licensed physicians, and, as such, psychiatrists are apt to use the medical model to assess mental health problems and to also employ psychotropic medications as a method of addressing mental health problems. Psychologists generally do not prescribe medication, although in some jurisdictions they do have prescription privileges. In five U.S. states (New Mexico, Louisiana, Illinois, Iowa, and Idaho), psychologists with post-doctoral clinical psychopharmacology training have been granted prescriptive authority for mental health disorders. Clinical and counseling psychologists receive extensive training in psychological test administration, scoring, interpretation, and reporting, while psychiatrists are not trained in psychological testing.

Goals of Treatment

Therapy includes immediate, short-term, and long-term goal setting. Goals are an essential part of the treatment plan as they help a client work towards cognitive and behavioral changes. For example, a therapist may use the SMART goals approach by setting goals that are specific, measurable, achievable, realistic, and time-limited.

• Specific—The goal is to be as clear as possible, such as setting a goal to reduce social anxiety levels so that a client can eat lunch with coworkers by the end of the month.
• Measurable—The goal should be something you can measure, such as tallying up the number of social interactions a client has, or reducing feelings of anxiety from a 9/10 level to a 4/10 level.
• Achievable—The goals should be feasible and within reach. If a person has severe social anxiety, having them host a party or go out every night for a week would be difficult short-term goals that are likely unachievable.
• Realistic and Resourced—Is the goal realistic and possible given the time and resources available to you?
• Time-limited—The goal should have a specific time frame when it will be reached.^[4]