In Episode 2 of Be Well, Practice Well, Michael McGee, MD, spoke about delivering empathy as perhaps the most important clinical skill to master. More recently, he noted that treatment can go well, or not go well, depending on the development of what he calls an “empathic formulation.”¹ Here, we dive into what this means in practice and how clinicians can use key factors of the patient’s journey to guide treatment decisions. Patient examples provided. Moderated by Executive Managing Editor Angie Drakulich.
Listen to the full conversation below.
A lightly edited transcript follows.
What is an Empathic Formulation?
Drakulich: Delivering empathy in a clinical setting involves both understanding a patient’s experience and reflecting that understanding back to them. As the therapeutic relationship evolves, “empathic formulations” are needed to guide treatment.¹ Can you explain what this term means?
Dr. McGee: Absolutely. In simple terms, “empathic” means that there is a shared understanding between the clinician and the patient. I use the term “formulation” to refer to gathering the full scope of the patient’s problem or challenge and then using that information to decide what can be done to address the problem. Combined, an empathic formulation means that both the problem and the treatment plan make sense to the patient. This understanding and clinician support is crucial to a patient’s adherence to a treatment plan, which ultimately affects treatment outcomes.
The real art of practicing medicine is to get on the same page with our patients, even when we may see things differently than they do.
Why is an Empathic Formulation Needed?
Drakulich: Why do you think this type of approach is necessary?
Dr. McGee: Traditional treatment programs and approaches sometimes take a “my way or the highway” approach, in which patients may be inadvertently shamed, blamed, and retraumatized. When treatment fails in these cases, I believe it is due to a lack of an empathic, shared formulation. In stark contrast, an empathic formulation approach to making assessment and treatment decisions not only involves the patient’s direct input but, more importantly, takes treatment in a direction they are willing and ready to go in.
How to Formulate an Empathic Treatment Decision
Drakulich: Can you dive deeper into the idea of “formulation” as it may be applied to clinical empathy?
Dr. McGee: Yes, I like to think about a formulation as having five elements.¹ These include impairments, precipitants, vulnerabilities, strengths, and agendas. (See Figure 1)
Drakulich: OK, let’s take these one by one, starting with impairments.
Dr. McGee: Impairments can also include distress or risk. Impairments essentially point to what is the matter—what is the problem or challenge? A primary impairment or problem is something that requires attention first, such as suicidality, while a secondary problem may refer to the underlying issue, such as depression.
Impairments usually arise due to precipitants. Rarely does a problem appear out of the blue. There may be both proximal precipitants, such as abandonment by a significant other or loss of a job, and more distal precipitants, such as substance misuse or conflicts at work. Precipitants can be biological or neurobiological, such as major mental illness. But they can also be psychological or behavioral, such as medication nonadherence, or social, including loss, trauma, abuse, neglect, or financial stress.
The third part of the formulation is vulnerabilities. These can include a lack of coping strategies, self-care or social skills deficits, character vulnerabilities, physical or bio-psychiatric illnesses, or natural resource deficits, such as lack of housing or lack of family support.
Drakulich: Can I assume that the next two elements of the formulation, strengths and agendas, are more centered on the potential solutions?
Dr. McGee: Yes, when talking about a person’s strengths, we think of family and friends, financial resources, housing, work, social services, access to care, coping skills education, and vocational skills.
And then, we consider agendas, which can be overt or covert. Agendas can also be goals. For example, a client may say they want help with their drinking, but what they may truly want is to have their spouse not to be so angry with them. Different people involved in the same problem may have different agendas. For instance, the partner of the client who is drinking too much may have an agenda for them to quit drinking, which may be different from the agenda of the client.
Drakulich: I am seeing the full equation now. A patient comes in for care, whether medical or psychiatric. They have a problem that involves personal impairments, precipitants, and vulnerabilities, but they also present with strengths and goals. And the clinician needs to use all of these to make a full assessment and treatment plan.
Dr. McGee: Exactly. Think of this formulation as a story that deepens and evolves over time. As a patient goes through their healing journey, our goal is to help them create a coherent, compassionate, forgiving, and accountable narrative. This journey includes all the five elements of the formulation I just described. To capture this journey, we need to understand the sequence of events that brought a patient to our doorstep.
A good place to start is to ask the question, “Why now?” Why is the patient here now? So much can be understood by diving into the details of what led to a patient to make that call and come in for treatment.
Patient Example
Drakulich: Could you give an example of how empathic formulation may work with a particular patient or client?
Dr. McGee: Of course. Let’s consider a woman brought into the ER due to an overdose. As part of a follow-up consult before discharge, she shared with me that she lost her job. I could have stopped there and formulated that she was suicidal because of losing her job. Upon further exploration, however, I learned that she lost her job because of missing work due to hangovers from her excessive drinking. When she came home after being fired and told her husband, who had been frustrated with her drinking for some time was angry and said he wanted a divorce.
So, the “Why Now” that triggered her overdose was the threat of abandonment by her husband, who was angry about her drinking and wanted her to get sober. In this situation, the patient’s agenda and her husband’s agenda were different; he wanted her to get sober, and she wanted him to stay with her. The problem for her was not her drinking, but how to save her marriage while still drinking.
This is where the art of clinical excellence comes in. It may be obvious to a medical professional that this woman should get treatment for her alcohol use disorder. But sending her to AA, for instance, would not be an empathic, client-centered treatment plan. In these situations, we must work with one foot planted in our world and one foot empathically planted in our client’s world. This way, we become a bridge for learning, growth, healing, and change.
Drakulich: I love the bridge analogy where empathy is really bringing the patient and the clinician together, as you said earlier, on the same page. Where did this case example lead?
Dr. McGee: As I explored more with this particular patient and her husband, I learned that there was a history of sexual abuse and that the patient used alcohol both as a way of numbing painful memories but also to allow for sexual intimacy with her husband. This individual’s prior trauma was paired with a fear of abandonment by her husband. Furthermore, I learned that her husband also liked to drink at night and was unwilling to give this up; he just wanted her to “drink less.” But when she started drinking, she often lost control and could not stop. It felt to her like a hopeless, no-win situation.
Widening Solutions with Deeper Questions
Drakulich: So by asking deeper questions that help to uncover precipitants to a patient’s problem, such as this woman’s problem, as well as their vulnerabilities and agendas, you are able to widen the door to possible solutions.
Dr. McGee: Yes. We are profoundly helpful to clients when, through our own inquiry, we help them to also inquire into their difficulties in this way. For this client, what she most wanted was a loving relationship with her husband without feeling triggered. And her husband wanted the same thing. The barrier, in her mind, was her trauma. So, what started as suicidality leading to an overdose over the loss of a job ended with a realization that unaddressed trauma was poisoning her life, literally, through her use of alcohol.
You can imagine how healing it was for her to be seen and understood in a way that made sense to her. From this place of understanding, we could then discuss alcohol as a solution that almost works, but not quite, and explore other alternatives that are non-triggering. Creating a foundation of trust and understanding in this way created the capacity to consider alternatives.
Drakulich: So to wrap up, would you define this approach as formulation-driven treatment delivered with empathy?
Dr. McGee: Yes, and it is a process that should unfold over time with each patient. I am repeatedly surprised and humbled when something new pops up, perhaps after years of providing treatment, that was unknown. As we model respectful, self-compassionate, and curious inquiry over time, we help our clients to gradually discover themselves.
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