THE CENTRALITY OF PATTERN ANALYSIS IN THE CLINICAL FORMULATION

As noted earlier, a pattern is described as the predictable and consistent style or manner of thinking, feeling, acting, coping, and defending one’s self in stressful and nonstressful circumstances (Sperry et al., 1992).

Pattern analysis is the process of examining the interrelationship among four elements or factors: precipitating factors, predisposing factors, per-petuating factors, and presentation factors, including relational re-sponse factors.

A precipitant is a trigger or stressor that activates the pattern. Presen-tation refers to the characteristic and predictable manner in which the client responds to the precipitants. Perpetuants are the processes by which a client’s pattern is reinforced and confirmed by both the client and the client environment. Predisposition refers to all the intrapsychic, interpersonal, and systemic factors, including early life experiences, at-tachment style, and trauma, that render a client or client system vulner-able to maladaptive functioning. In short, a client’s pattern is a predicable style of behavior and functioning that reflects and is reflected in precipitants, presentation, perpetuants, and predisposition.

Although it may appear that predisposing factors such as traumatic events, maladaptive beliefs or schemas, defenses, personality style, or system factors primarily drive one’s thoughts, feelings, and actions, we would contend that both individual and systemic dynamics are a func-tion of all four factors and thus should be included in a pattern analysis.

Furthermore, we contend that a pattern analysis that includes these fac-tors, along with associated individual and systemic dynamics, is central to developing and articulating a clinically useful clinical formulation.

Developing a Clinical Formulation

Here are some specific guidelines for developing a clinical formulation statement:

• Begin by analyzing a critical incident resulting in distress or dys-functional behavior. Note the nature of the presentation, including individual and relational responses of all those involved. Look for relevant precipitants or triggers, perpetuants, and predisposing factors.

• Specify relevant biological, psychological, and social—cultural consid-erations for presentation, precipitants, perpetuants, and predisposing factors. On a sheet of paper, list any biological, psychological, and social indicators for each of the four factors where applicable. For example, in the case of Jack, a social indicator for precipitant would be his mother’s preferential treatment, whereas a social in-dicator for presentation would be Jack’s angry outburst.

• Analyze and specify the basic pattern of the client. Look for possible causal relationships among the four factors, starting with precipi-tants and presentation. For example, when Jack’s mother acts provocatively, as when she makes demands that Jack believes are unreasonable or when she gives preferential treatment to Jack’s brother (precipitant), Jack is likely to act out with angry words or threats (presentation). Next, look for possible reasons to explain why Jack would act out rather than act in, such as hurting himself or ignoring and downplaying his mother’s behavior by making a joke of it. Presumably, Jack perceives that he is being treated un-fairly, which could reflect early maladaptive beliefs or schemas that life is unfair and that he must be on guard and aggressively look out for his own needs and safely, lest he be hurt or lose even more in the process (predisposition). Review the seven contem-porary perspectives on clinical formulations (described previ-ously) for one that provides a realistic explanation or clinical rationale for the pattern and convincingly links precipitants and presentation.

• Write a clinical formulation statement. Strive to develop a formula-tion statement with high explanatory power, that is, one that best answers the questions “Why did it happen?” and “Why does the client behave or respond in this way?” Then write a formulation statement that realistically and compellingly links the precipitants and presentation.

Treatment Formulation The treatment formulation provides a blue-print for treatment intervention and expected treatment outcomes (Sperry et al., 1992; Sperry, 2001). It is assumed that the therapist has al-ready elicited the client’s treatment expectations. These include the out-comes the client is hoping for, the client’s expectations about roles and responsibilities, and the extent of the collaboration between the thera-pist and client. Ideally, these expectations will be included as part of a general treatment formulation mutually agreed to by the client and therapist. For instance, when the client can now manage the anxiety of

leaving home without a panic attack, it is time to terminate therapy be-cause the mutually agreed treatment outcome has been achieved.

After this overall goal/outcome has been agreed upon, it is then pos-sible to formulate a specific treatment plan with targeted treatment goals and specific intervention methods. It goes without saying that specific goals should be realistic and achievable for the client. It should also be added that these specific goals should be manageable for the therapist. Targeted goals are manageable when specific and measurable steps can be specified. Some examples of manageable goals would be talking to one individual at work before the next scheduled session, re-ducing the number of angry outbursts from four to one per week, and spending 20 minutes every day alone reading or listening to music.

Specified in this manner, these manageable goal/steps become the tasks that the therapist and client work on during therapy, and which are as-signed between sessions.

Developing a Treatment Formulation

Here are some guidelines for developing an integrative or biopsychoso-cial treatment formulation statement:

• Specify targeted psychological treatment goals based on the diag-nostic and clinical formulations and specify treatment interven-tions to achieve these goals. Psychological treatment goals are often specified as the opposite of the targeted symptom or skill deficit; that is, when a lack of assertiveness is a targeted symptom, the goal might be specified as “increase assertive communication”

and the targeted intervention might be “assertiveness training.”

• Specify targeted social treatment goals based on the diagnostic and clinical formulations and specify treatment interventions to achieve these goals. Social treatment goals are often specified as the opposite of the targeted symptom or skill deficit. That is, job stress could be a targeted symptom, so the goal might be specified as “decrease job stress” and the targeted intervention might be

“workplace job accommodation.”

• Specify targeted biological treatment goals based on the diagnos-tic and clinical formulations and treatment interventions to achieve these goals. Biological treatment goals are often specified as the opposite of the targeted symptom or skill deficit. When de-pressive symptoms are the targeted problem, the goal might be specified as “decrease depressive symptoms” and the targeted in-tervention might be “referral for medication evaluation.”

• Write an integrative treatment formulation statement incorporat-ing these goals and interventions. This statement incorporates the psychological and social treatment goals and interventions (as well as the biological goals and interventions, if applicable).