What Is a Clinical Formulation?

A clinical formulation is a hypothesis based on psychological evaluation to explain a patient’s condition. It is 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 care provider to work together on the development of a treatment plan that will meet the patient’s needs. As the patient progresses in treatment, the care provider can return to the clinical formulation to determine if goals are being met and make adjustments, if necessary.

Care providers like psychologists, mental health nurses, and psychiatrists can develop clinical formulations. They start by meeting with the patient in one or several sessions to talk about why the patient is seeking treatment, and what the patient is currently experiencing. Care providers want to rule out medical explanations, like a neurological condition such as a tumor that might cause behavioral changes. If the case is complex, they may ask for assistance from a colleague or a specialist to evaluate the patient.

The process of developing a clinical formulation can include a review of the symptoms as well as the patient’s psychiatric and personal history. All of this information can be noted in the patient’s chart to develop an explanation for what is going on. For example, a patient might be experiencing 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, the death. This information can be important for the development of a successful treatment plan.

Approaches to treatment can include medications for some patients as well as psychotherapy based on a variety of approaches. The clinical formulation becomes part of the patient’s record, and if it is necessary to refer the patient to a different care provider, the information can be made available by permission from the patient. This can be helpful for providers who want to learn more about the origins of a patient’s condition. Treatment can be tailored to the patient on the basis of the information. Someone who has just experienced a loss, for example, might benefit from counseling or membership in a support group.

People may approach psychology from a variety of perspectives and schools. Each clinical formulation is slightly different, and considers the provider’s approach as well as 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.