Formulation as a Basis for Planning Psychotherapy Treatment
utilizes a step-by-step structure and copious case illustrations to
teach psychiatrists, residents in psychiatry and psychology, social
workers, and marriage and family counselors how to plan treatment
after the initial diagnosis. This new edition arrives two decades
after the first, with revised content, updated case studies, and
new insights gleaned over the author's noteworthy career. Clinical
formulation, also known as case formulation and problem
formulation, is a theoretically-based explanation or
conceptualization of the information obtained from a clinical
assessment. Although formulation systems vary by different schools
of psychotherapy, the author has adopted and here explores a
systematic approach based on an integrative effort. This system of
configurational analysis combines concepts derived from
psychodynamic, interpersonal, cognitive-behavioral, and family
system approaches. After an overview of psychological change
processes, each of the five steps of configurational analysis is
covered systematically: * Step one involves selecting and
describing the patient's currently most important symptoms, signs,
problems, and topics of concern. For example, symptoms may consist
of trouble sleeping or feelings of depression; signs may include
discordant verbal and physical expression; problems may include
reluctance to go to work or care for family members; and topics of
concern might be unresolved grief the patient feels helpless to
process without assistance. Since both patient and therapist want
to know if these observable phenomena are changing, this list is
modified as treatment progresses.* Step two entails describing
states in which the patterns of phenomena do and do not occur, with
attention to patterns of shifts in states, especially maladaptive
state cycles. The therapist is taught how to aggregate and organize
this information by describing states of mind-for example,
undermodulated (e.g., unthinking rage) or overmodulated (e.g.,
numbness and lack of affect).* Step three involves describing the
challenging topics that patients may both approach and avoid
because they are conflicted or unresolved, as well as the obstacles
patients may create to divert attention from those topics. For
example, patients may avoid a topic or shift attention from it by
changing the subject and so forth.* Step four entails describing
the organizing roles, beliefs, and scripts of expression and action
that seem to organize repetitions in each state, with an effort
made to identify dysfunctional attitudes and how these may have
evolved from past attachments and traumas. * Finally, step five
involves figuring out how to stabilize working states by enhancing
the therapeutic alliance and helping the patient contain and master
emotional attitudes. At this point, the clinician plans how to
counteract avoidances by direction of attention and promotes
adaptive social cognitive capacities. From surface observation to
deeper inferences, Formulation as a Basis for Planning
Psychotherapy Treatment transcends DSM diagnoses, helping
clinicians to use information gleaned in the immediacy of the
moment to make sound, sensitive, and effective psychotherapeutic
decisions.
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