The formulation of the case represents the arrival point of the First phase of psychotherapyrelating to the collection of information with respect to the problem complained of by the patient.
It is therefore outlined as a report of the information collected in the evaluation phase and as a compass capable of orienting the subsequent therapeutic path.
Within the cognitive behavioral approach, the formulation of the case is oriented to identify all those factors that determine the maintenance of symptoms. The situations responsible for its appearance and all those elements that, historically, have prepared the individual to the risk of developing that specific psychopathology.
Difference between diagnosis and formulation
Based on what has been said so far, it is evident that the formulation of the case is distinguished in a marked way from the psychopathological diagnosis.
The main difference lies in the fact that, through the diagnostic process, the clinician collects the information regarding the signs and symptoms related to suffering, focusing on the question of the “thing” afflicts the patient.
The ultimate purpose of the diagnosis is therefore to identify any symptomatological characteristics that can bring together the patient’s condition in oneknown diagnostic label.
This process is essential to give indications on the most appropriate type of treatment and its prognosis. It serves to facilitate communication, even between clinicians, of the situation and normalize the patient’s experience.
Limits of diagnosis
The questions to which, however, the diagnosis is not a degree of providing a clear response are related to “how” that particular pathology occurs within the functioning of that specific person and the “why” has been established.
Without the answer to these two questions it is difficult to think of being able to structure a targeted and effective therapeutic interventionrunning the risk of “navigating” in the use of psychotherapeutic techniques.
A careful formulation of the case is therefore essential precisely to respond to the “how” and the “why” the person we face manifests that specific diagnostic label.
Behavioral formulation as a response to “how”
The behavioral approach provides valuable information about the elements that contribute to maintaining certain symptoms, helping clinical and patient to answer the question of “how” that diagnosis is manifested within everyday life.
The behavioral model, referring to the principles of learning, such as the theories of Classic and operating conditioningin fact, it postulates that certain behaviors (in the case of presumably dysfunctional psychopathology) are maintained as they can generate, at least in the short term, a reduction in suffering.
Very often, however, the implementation of these behaviors, although it is reinforced by the temporary decrease in negative emotions, in fact, ends up being the main factor of maintaining symptoms since it does not allow to experiment with alternative solutions and to correct beliefs (irrational in the case of psychopathology) at the basis of the genesis of negative emotion.
Not only that, on the basis of the principles of the generalization of learning, over time, the unpleasant emotions and the consequent behaviors aimed at arguing them, will tend to expand towards similar stimuli, increasingly limiting individual freedom and generating real vicious circles that, ultimately, will keep suffering.
A clinical example
Let’s imagine, for example, the hypothesis of which a person has an irrational fear of pigeons. In the face of the view of the bird, to stem the unpleasant emotion, it will tend to leave the fastest possible. This behavior will reduce fear in the short term, but will not allow that individual to experience that, on balance, pigeons are not so dangerous.
With the passage of time, this person will begin to avoid more and more places where you can meet these birds (limitation of freedom), will begin to mulch with a noteworthy share of anticipatory anxiety The environments in order to reassure themselves that there are no pigeons (monitoring and selective attention) and, subsequently, will also tend to avoid other types of birds (generalization).
The meticulous collection of the information relating to the “thing” the individual does to avoid or reduce short -term negative emotions and the consequent identification of the vicious circles of maintenance of suffering responds to the question of the “How” the person suffers from that disorder.
From a therapeutic point of view, moreover, it is of fundamental importance to be able to act in the here and now through an intervention that leads the person to divest from such behaviors. This with the aim of generating new learning, more functional, and being able to change those irrational beliefs that have first generated the unpleasant emotion and that are reinforced by these behaviors.
Cognitive formulation as a response to “why”
Speaking of the behavioral formulation, we talked about the presence of irrational beliefs which, in the first instance, generate a negative emotional response in the face of neutral stimuli.
The investigation regarding the content and origin of these beliefs is the task of evaluation and cognitive formulation of the case.
The cognitive theory postulates that suffering derives from the relationship between two types of beliefs that human beings develop throughout their history. These beliefs, in the case of psychopathology or psychological suffering, frequently assume the characteristics of irrationality and inflexibility.
The two types of beliefs originate from life experiences, often early, and are called respectively basic beliefs and intermediate beliefs.
Basic beliefs
The basic beliefs represent content with which the individual represents internally and describes himself, the others and the world. In the case of psychopathology, basic beliefs tend to be negative.
Based on the studies of Aaron Beck, father of classical cognitive therapy, basic beliefs revolve around Three fundamental nuclei:
- non -Amability (I not worthy of love/others refuse, disinterested)
- the non -value (I unworthy/other critics)
- The inadequacy (I incapable, inadequate, weak /other devaluers, humiliating).
Intermediate beliefs
In response to these very painful beliefs, over time the individual generates intermediate beliefs. They represent rules that, if satisfied, are able to deactivate the painful nuclear content of basic beliefs.
Intermediate beliefs frequently take on the form of hiring and generate Life purposes. In the event that dismissal factors come (specific situations or life contexts that put at risk the possibility of adhering to the purposes) these can be super-investigated, becoming pathogens.
The clinical example
Returning to the example of ornitophobia, hypothetically, the individual who develops this fear, in the course of his childhood, may have found himself faced with external dangers (dangerous world) in the presence of people of reference not able to cultivate in him/she the sense of autonomy and capacity in the face of negative emotions.
These execution, in turn, could have generated one internal representation of oneself As deeply vulnerable and weak (I inadequate).
In order to deactivate their basic, deeply painful beliefs, this person could have generated intermediate beliefs Type: “If I protect myself from the dangers, then I am adequate”, “if I don’t feel afraid, then I am strong”. With the consequent purpose of never exposing themselves to dangers and never feel fear.
In this context, his irrational fear of pigeons could have been generated following an event that has sensitized him on this specific theme by putting at risk the possibility of adhering to the super-invited purpose not to expose himself to the dangers and not to feel fear. For example, having read an article in which the danger is described in terms of the vehicle of diseases, or having frightened following the sudden and unexpected flight of the pigeons in Piazza San Marco in Venice.
The role of beliefs
As is evident, the identification of the elements of life, basic beliefs and intermediate beliefs, as well as any dismissal factors is of fundamental importance to understand why that particular person has developed that particular type of psychological disorder.
Not only that, knowing the origins of suffering can guide the therapeutic path towards the use of appropriate strategies aimed at renovating the irrational beliefs which generate negative emotions, to divert from pathogens and, ultimately, to make nuclear images of self, more flexible, realistic and, consequently, less painful.
Sharing and usefulness of the formulation of the case
The cognitive behavioral formulation of the case, therefore, represents the report of the behavioral and cognitive assessment and is able to highlight the maintenance factors of the symptoms and the proximal and distal ones that generated it.
It is important to highlight how the collection of this information and their conceptualization within an operating profile of the person, in addition to representing a fundamental ingredient for the planning of the treatment, can already represent a therapeutic and normalizing intervention for the patient.
Share the formulationFurthermore, it contributes to making the person aware of the therapeutic rational and the reasons why techniques will be used rather than others. Thus motivates to therapy and makes the person active active of his own change.
Bibliography
- Beck, J. (2022). Cognitive-behavioral therapy. Astrolabio publishing house.
