Academic journal article American Journal of Psychotherapy

Characteristics of Optimal Clinical Case Formulations: The Linchpin Concept

Academic journal article American Journal of Psychotherapy

Characteristics of Optimal Clinical Case Formulations: The Linchpin Concept

Article excerpt

RAYMOND M. BERGNER, Ph.D.*

Clinical assessment would ideally culminate in the construction of an empirically grounded, comprehensive case formulation that would: (a) organize all of the key facts of a case around one causal/explanatory source; (b) frame this source in terms of factors amenable to direct intervention; and (c) lend itself to being shared with the client to his or her considerable benefit. This article elucidates these factors and their rationales, provides two case examples illustrating their use in clinical practice, and discusses relationships between the present approach and other contemporary approaches to caseformulation.

"There is nothing so practical as a good theory." Field Theory in Social Science (1951, p. 20)

-Kurt Lewin

Clinical assessment would ideally culminate in the construction of an empirically grounded, comprehensive case formulation that organizes all of the key facts of a case around a "linchpin."1'2 That is to say, it would organize them around some factor that not only integrates all of the information obtained, but in doing so also identifies the core state of affairs from which all of the client's difficulties issue. Further, it would do so in such a way that this formulation becomes highly usable by the clinician and the client in matters such as their selection of a therapeutic focus, identification of an optimum therapeutic goal, and generation of effective forms of intervention. Most importantly, the existence of such a formulation would allow the clinician to focus therapeutically on that one factor whose improvement would have the greatest positive impact on the client's overall problem or problems.

Based upon a conceptual framework known as Descriptive Psychology,3-5 the purpose of the present article is to explicate the above contentions in a threefold manner. First, those factors that would be embodied in an optimal case formulation, as well as the rationales for these factors, will be discussed at length. Second, two case examples illustrating the use of such formulations in clinical practice will be presented. Third and finally, some relationships between the present approach and other prominent case formulation approaches, such as those from DSM-IV6 and from various therapeutic schools, will be discussed.

OPTIMAL CLINICAL CASE FORMULATIONS

In the optimal case, a clinical case formulation would embody the characteristics listed in this section. In relating these, I shall for simplicity's sake speak as if the client were always an individual, but everything that will be said applies equally to couples and families. Further, since the central concern here is with a desired product of assessment and not with its methods, I will not be concerned with the means (interviews, observations, tests, etc.) that might be used to gather information.

CHARACTERISTICS

1. Organizes Facts Around a "Linchpin."

In the typical clinical case, in addition to presenting a problem (or problems), the client virtually always provides an abundance of further information. This information might include items about his or her emotional state, current situation, personal history, world view, perceptions of self and others, goals, expectations, and more. In some cases, this information has been organized by the client into a personal theory or formulation of the problem, but this formulation has not as a rule been helpful in providing a successful solution.7-9 In other cases, the data have not been organized by the client into any sort of coherent cognitive package, and are experienced for the most part as a somewhat confusing jumble that has rendered focussed, effective remedial action difficult or even impossible.lo They have not, for example, been organized into causal sequences (e.g., "This fact A about me results in facts B and C about me"). They have not been sorted well into those factors that are important and relevant, as opposed to those that are neither. …

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