What’s a clinical formulation?

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A clinical formulation is a hypothesis based on psychological evaluation to explain a patient’s condition. It’s not simply a psychiatric diagnosis like depression or anxiety, but rather a more comprehensive discussion of why the patient has the condition. This allows the patient and healthcare professional to work together on developing a treatment plan that meets the patient’s needs. As the patient progresses in treatment, the healthcare professional can return to the clinical formulation to determine if goals have been met and make adjustments if necessary.

Healthcare professionals such as psychologists, mental health nurses and psychiatrists can develop clinical formulations. They begin by meeting with the patient in one or more sessions to talk about why the patient is seeking treatment and what she is currently experiencing. Healthcare professionals want to rule out medical explanations, such as a neurological condition like a tumor that could be causing behavioral changes. If the case is complex, they may enlist the assistance of a colleague or specialist to evaluate the patient.

The process of developing a clinical formulation may include a review of the patient’s symptoms and psychiatric and personal history. All of this information can be noted in the patient record to develop an explanation of what is happening. For example, a patient might experience depression after the death of a partner, which is a sudden life change. This explains not only the patient’s condition, depression, but also its origins, death. This information can be important in developing a successful treatment plan.

Treatment approaches may include medication for some patients and psychotherapy based on a variety of approaches. The clinical wording becomes part of the patient’s medical record and, if there is a need to refer the patient to another care provider, the information can be made available with the patient’s permission. This can be useful for providers who want to learn more about the origins of a patient’s condition. The treatment can be adapted to the patient based on the information. Someone who has just experienced a loss, for example, might benefit from counseling or membership in a support group.

People can approach psychology from a variety of perspectives and schools. Each clinical formulation is slightly different and takes into account the provider’s approach and the patient’s condition. If a care provider does not meet a patient’s needs or causes discomfort, the patient may request a referral to a different provider to seek more appropriate treatment.

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