Is the delivery of psychological formulation associated with proximal changes in working alliance and verbal engagement? A mixed-methods case-series analysis
Creators: name: Author, Unknown
Publisher: name: University of Lincoln
Year: 2023

description: ObjectivesClinical formulation, also known as ‘case conceptualisation’ and ‘psychological formulation’ refers to the synthesis of diffuse clinical information into a coherent, theoretically based narrative. There is scant evidence to support claims made regarding benefits of formulation and extant research in this area is characterised by operational and methodological difficulties. This thesis addresses these difficulties and reports a mixed-methods study, investigating proximal associations between cognitive behavioral therapy specific formulations, therapeutic alliance and client engagement.MethodsA secondary analysis was undertaken of audio data using three sets of participant data recordings of cognitive behaviour therapy. A mixed methods case-series approach was employed to address responsivity to formulation at the level of each participant. Formulations delivered by a therapist were identified using pre-defined criteria and an observational working alliance measure was used to rate working alliance both immediately prior to and post-formulation delivery. Pre and post-formulation working alliance ratings were analysed to identify, or rule out, trends of improvement or deterioration in working alliance associated with formulation delivery. Additionally, qualitative analysis was undertaken to explore the a priori assumption that engagement versus disengagement behaviours could be reliably identifiable at the level of immediate verbal response, post formulation delivery. Categories identified through qualitative analysis were considered in relation to wider therapy outcomes across cases.ResultsVisual analysis (aided by quantitative decision criteria) led to the identification that therapist-delivered formulations were associated with small and ‘questionable’ reductions in working alliance, with similar responsivity demonstrated within each participant case, indicating that formulations may have been associated with a proximal deterioration in working alliance.Framework analysis led to identification that engage and disengage client responses immediately following formulation could be operationalised and reliably identified, with a range of instantiations of each category identified across participants. In addition, a third category of neutral response was also identified. Whilst the majority of immediate responses to formulation were characterised by engage across all participants, one participant exhibited substantially higher levels of the engage response relative to the participant sample. Conversely, another participant exhibited higher levels of the disengage response compared to the sample. Analysis of wider therapy outcome measures such as symptomology and functioning between participants indicated a positive relationship between the category engage and therapy outcome. Conversely, analysis indicated a negative relationship between the category disengage and wider therapy outcomes.DiscussionTo the authors’ knowledge, this is the first study using cognitive behaviour therapy to examine in-session therapist formulations in terms of immediate client responses to these formulations. As well as the first study to address whether there are observable formulation-contingent changes in working alliance.Findings demonstrated a small, replicated negative association between formulation and working alliance across all participants. Different profiles of verbal engagement responsivity were identified and a positive relationship was demonstrated between the overall level of verbal engagement response to formulation and wider therapy outcomes Findings outlined are in contrast to the extant literature in which the majority of quantitative studies have failed to discern any association between therapist formulation delivery and client-therapist working alliance and other therapy processes. Findings should be treated with caution due to the small sample size and lack of control conditions. As such, this study was unable to demonstrate causality or directionality of formulation upon processes investigated. It is possible that individual client factors such as individual differences (e.g. agreeableness) might predict engagement and alliance responses analysed post-formulation, independently of the formulation itself. Additionally, negative associations identified between formulation delivery and working alliance were very small and it is possible that replications were an example of a type-one error. Secondly it is possible that if a true effect of formulations has been identified, that this is highly transient and clinically speaking, insignificant. However, another possibility is that this small effect has an accumulative impact or interaction with other variables that were not addressed in this study. In this thesis, findings, limitations and future research recommendations are critically discussed in relation to the extant literature regarding cognitive case conceptualisation, related models of psychological formulation and psychotherapy processes.