Case formulation—A vehicle for change? Exploring the impact of cognitive behavioural therapy formulation in first episode psychosis: A reflexive thematic analysis

Abstract

Objectives: Formulation is considered a fundamental process of cognitive behavioural therapy for psychosis (CBTp). However, an exploration into the personal impact of different levels of case formulation (CF) from a service user perspective (SU) is lacking, particularly for those experiencing a first episode of psychosis. Design: This Big Q qualitative design used semi-structured interviews. Methods: Reflexive thematic analysis (TA) was used to analyse 10 participant interviews. NVivo 12 computer-assisted qualitative data analysis software aided data organisation and analysis. Results: One overarching theme 'CF -A vehicle for change?' was developed as a pattern of shared meaning across the data set. Three main themes related to the overarching theme:(1) Vicious cycles: 'I never really thought about it being me maintaining the problems' (including one subtheme -Self-empowerment: 'Only you can make the changes for yourself '); (2) Early life experiences: 'My experiences have shaped the person that I am, therefore, it's not my fault' (including one subtheme -Disempowerment: '[My] core beliefs have been damaged'); and (3) Keep it simple: 'Don't push it too far over the top in case it becomes like spaghetti'. Conclusions: Maintenance formulations may be experienced as self-blaming, but also self-empowering, which may help to facilitate change. Longitudinal formulations may be

The key components of a clinical psychology formulation: A consensus study

“…The findings further highlight the importance of including strengths in formulations. Although psychologists reported the value of incorporating strengths, clients have reported that formulations are often problem‐focused leading them to feel hopeless and damaged (Kilbride et al., 2013; Spencer et al., 2022). This discrepancy may indicate that there are barriers to integrating strengths into formulations in clinical practice.…”

“…Ensuring formulation is client‐led and meaningful can be achieved with empowering clients to engage in collaborative formulations and beginning with simple formulation that evolve with time to include early experiences. “Doing with” activities may also be helpful, such as engaging the client in drawing diagrams, agreeing between session work, the use of person‐specific analogies and drawings, balanced timelines and genograms, and the client taking the formulation and editing it in a way that makes sense to them (Spencer et al., 2022).…”

“…Recent research has suggested that keeping formulations simple helps prevent negative societal messaging about individuals with mental health difficulties being reinforced and can help prevent distress associated with confusing formulations. Recommending simple formulations is based on the views of clients who described their experiences of formulations and suggested that simpler diagrams are more accessible (Spencer et al., 2022). Furthermore, the Case Formulation Quality Checklist includes “Simplicity – the formulation is free from unnecessary details” as one of its criteria, suggesting parsimony is linked to good quality formulations (McMurran & Bruford, 2016).…”

Confronting the dialectic between quality and access in early psychosis care in the United States: Finding the synthesis by leveraging psychological expertise.

“…In some contexts, psychologists may help teams generate case formulations based on evaluation and assessments to facilitate more focused and effective care (Berry et al, 2017;Frank & Davidson, 2014). A recent reflexive thematic analysis among CBTp service users suggests that the manner in which case formulations are developed and communicated has implications for the perceived utility; specifically, collaboratively developed, parsimonious diagrammed formulations are most likely to engender feelings of agency, empowerment, and motivation to engage in change behaviors (Spencer et al, 2023). Psychologists can assist team members in approaching formulations with care in individual therapy and at the team level, ensuring proper collaboration with the client, encompassing sometimes-overlooked factors like trauma, incorporating more culturally sensitive approaches, and ensuring treatment follows from this (Brabban et al, 2017;Rathod et al, 2019).…”