Abstract
Background. Psychosocial treatment has a persistent difficulty at its beginning. Patients arrive with a presenting problem, urgency, and hope, and roughly half leave treatment early, especially in the opening sessions. Assessment that postpones relief risks losing the patient; treatment that begins without adequate information risks harming the patient. A solution that engages patients while emphasizing strengths and promoting resilience is needed.
Aim. This article describes Screening Functional Formulations, as brief, structured screening tools, and asks whether they can engage patients in treatment while assessing their needs and identifying strengths.
Methods. Screening Functional Formulations gather information across ten brief tasks: seven gather information, two integrate the information, and one generates a treatment plan. For each task, the clinician records briefly what was learned, what strengths were identified, what discrepancies remain, and how the clinician’s understanding changed. Information is organized around two topics, protection from danger and sexual opportunity. In this single-case, proof-of-concept study, the protocol was applied prospectively by the first author, under the supervision of the second author, with a self-referred couple and their two school-aged sons.
Results. The ‘Attard’ couple presented complaining that their marriage was no longer satisfying. The initial impression, based on their urgency, the therapist’s ratings of their childhood adversities, and their somatic complaints, was of substantial risk requiring extensive services. After completing the ten tasks, that impression resolved into a focused, developmentally normative difficulty in a well-functioning family. The couple was observed to use a pursue-and-withdraw cycle in which early romance had been replaced by the wife’s work of raising young children and the husband’s establishing his career. In addition, three normative transitions, the wife’s perimenopause, the husband’s mid-life change, and the older son’s approach to puberty, had converged on a marriage that had been left unattended. Instead of psychotherapy, the clinician built on the parents’ strengths (affection, reciprocity, and thoughtfulness) while refocusing them on their marriage. Short-term counseling was indicated, delivered, and closed at the tenth session, thus protecting the family from possible divorce and its consequences.
Interpretation. A brief screening tool focused on danger, sexual opportunity, and family strengths can meet patients’ need for immediate help while providing therapists with information to guide treatment. Moreover, Screening Functional Formulations structure the treatment to follow while not risking doing harm before the situation is understood. Recording what the clinician learned and how the clinician’s understanding changed made it possible to revise an early over-estimate of risk into a more accurate formulation. The revised formulation prevented the breakdown of the marriage and resulted in a less costly and successful brief treatment.