Formulation and Diagnosis; Differences in Clinical Practice

Several definitions have been produced by researchers and clinicians from a theoretical stance. Speaking of eclectic perspective, Weerasekera (1996) defined formulation as “a provisional explanation or hypothesis of how an individual comes to present with a certain disorder or circumstances at a particular point in time … [that] include[s] biological, psychological and systemic factors” (p. 4). Typical characteristics of case formulation involves:

a) highlighting key features of the case,

b) Providing details to guide treatment and predict effectiveness of one treatment over another,

c) integration and summation of unified set of ideas acquired through assessment,

d) Drawing upon theoretical frameworks to explain the hypothesized etiology and maintaining factors of a problem

e) Is tentative in nature, relying on the information provided to the clinician so far, and

f) Is constantly reviewed and revised in case of new facts and discoveries.

According to Stein, Phillips, Bolton, Fulford, Sadler, and Kendler (2010), diagnosis is used for the identification and labeling of a disease based on its signs and symptoms. It is a medical term that labels patterns of experience(s) and/or behaviours, which impair functioning on a personal, social or occupational level to an extent that requires clinical attention. These behaviours are assumed to deviate from the definition of normality. The three basic manuals used to guide treatment include

a) The Diagnostic Statistical Manual (American Psychological Society),

b) International Classification of Diseases (World HealthOrganization),

c) The Psychodynamic Diagnostic Manual (Alliance of Psychoanalytic Organizations).

All these sources are constantly revised to increase fidelity in psychological and psychiatric practice.

There are many advantages that can be observed if case formulation is compared to diagnostic practice. Perhaps most of that can be drawn from the work of Lucy Johnstone (2013). She contrasts between formulation and diagnosis on the following points:

a) Formulation creates meaning while a diagnosis removes it. It involves looking at a problem through a specific framework grounded in psychological theory. Different models can be used to explain the problem, for instance the 5 P model by Weersakeera (1996). The Behaviourists can explain the same problem in terms of an ABC model of behaviour change (Stern, 2000) or the Cognitive Behavioural Therapy model. This shows the variety of ways in which meaning can be created for the client to develop insight which has therapeutic effects (Castonguay & Hill, 2007). Since formulation is a collaborative process it can also be shared with the client to not only better understand their circumstances but also, to devise a cooperative intervention plan.

b) Diagnosis removes agency making the client assume a sick role while formulation on the other hand promotes agency. This means that a diagnosis can make a client feel like a victim to a disease and promote helplessness while formulation allows the client to see things in perspective and view themselves as an agent of change.

c) A diagnosis does not include the social context while formulation takes a comprehensive biopsychosocial approach which aids to indepth understanding of a given problem.

d) Formulation takes a holistic approach of including relationships of the client in understanding the problematic behavior while a diagnosis individualizes the client and sees the problem in seclusion of other variables that interplay and contribute to the presenting complaint. Formulation also considers the changes in the relationship due to the improvement in the client’s condition while a diagnosis does not. For example, formulation can hypothesize that initiating spending quality time with children can possibly improve the parent child relationship, and offer the client hope in terms positive changes while a diagnosis does no such thing.

e) Formulation is a collaborative effort where the clinician uses different techniques to elicit information regarding different aspects of the client’s life while a diagnosis is expert derived and relies on clinical judgement.

f) Importantly, formulation works towards normalizing symptoms (Johnston, 2013) while a diagnosis stigmatizes. The usage of words like “disorder” implies there a certain underlying defect. It may take away the internal locus of control and can possibly render the client helpless. For example, a clinician says the client performed a certain act because they have schizophrenia, the circularity of that argument is not considered.

g) Formulation is culture sensitive and takes into consideration normative practices in the client’s surroundings, and their beliefs. While a diagnosis tends to be culture blind (Johnston, 2013). What is viewed as the dependent personality disorder per DSM might be how women in the east assume their gender role. Research conducted in the eastern cultures is far less than that conducted in western cultures (Roudi-Fahimi & Moghadam, 2006).

h) A diagnosis revolves more around the deficit or defected approach implying there is something that lacks an individual to be considered normal while formulation identifies not only the problem but also the possible strengths and competencies in a client that can aid to treatment. These positives can be used as supporting factors in evaluating the prognosis (Scheel, Davis & Henderson, 2012).

i) The slightest error in a diagnosis can have medical consequences with the psychiatrist prescribing the wrong medication while the harm associated with a mistake in a formulation is far less (Johnston, 2013).

Considering the above-mentioned differences, it is important to critically evaluate the functional purpose of both. A diagnosis is a medical approach which tends to be generalizable and has higher reliability but surely has its drawbacks where formulation can be considered as a suitable alternative. The major criticism arises from the concept where diagnosis uses definitions of abnormality but has no definition of normality (Ramsden, 2013). Having said that, the context of the applicability of diagnosis is more psychiatric than psychological. It is the psychiatrists that prescribe medicine and, hence, need to follow a standardized protocol that caters to larger groups of people rather than the individually tailored approach (Johnston, 2013). Clinical psychologists, however, have a completely different role to play. They help people understand the problem using non-pharmacological approaches where understanding the client and delivering individually tailored treatment becomes significant.

References

Castonguay, L. G., & Hill, C. E. (2007). Insight in psychotherapy. American Psychological Association.

Johnstone, L., & Dallos, R. (2013). Formulation in psychology and psychotherapy: Making sense of people’s problems. Routledge.

Ramsden, P. (2013). Understanding abnormal psychology: Clinical and biological perspectives. Sage Publications Limited.

Roudi-Fahimi, F., & Moghadam, V. M. (2006). Empowering women, developing society: Female education in the Middle East and North Africa. Al-Raida Journal, 4-11.

Scheel, M. J., Davis, C. K., & Henderson, J. D. (2013). Therapist Use of Client Strengths: A Qualitative Study of Positive Processes. The Counseling Psychologist, 41(3), 392-427.

Stein, D. J., Phillips, K. A., Bolton, D., Fulford, K. W. M., Sadler, J. Z., & Kendler, K. S. (2010). What is a mental/psychiatric disorder? From DSM-IV to DSM-V. Psychological medicine, 40(11), 1759-1765.

Weerasekera, P. (1996). Multiperspective case formulation: A step towards treatment integration. FL: Krieger Publishing Company.