At the recent Advanced Learning in Palliative Medicine conference held in Winnipeg, there was a workshop on the psychologic support we can provide patients in palliative care. Some concepts from the field of psychotherapy have been found to be useful for therapeutic communication, including the concept of formulation. Formulation is a hypothesis, theory, or framework to understand a patient’s psychology… the why beneath a patient’s thoughts, emotions, and behaviors.
Family physicians are well-situated as primary care providers that deeply understand the ‘why’s behind patients’ behaviors and form strong formulations. By incorporating the formulation as part of our assessment, we can offer the most appropriate management / therapeutic communication. For example, a more directive communication style may be offered to a patient’s family who has a formulation suggesting they feel overwhelmed by responsibility, while a more open-ended communication style may be offered to a patient who feels empowered when included in decision-making. Formulations are not rigid, like diagnoses - they may evolve over time and are influenced by transference/countertransference.
Rather than acting as a fixed label for patients, the intent behind formulation is to deepen patient understanding and heighten empathic attunement. While we often intuitively make many similar assessments of patients as clinicians, this framework can be helpful to explicitly define such that our assessment results in the most therapeutic communication for our patients. This approach could likely be useful outside of the palliative care context as well.