How to Write a Case Conceptualization: 10 Examples (+ PDF)

Case Conceptualization Examples

Such understanding can be developed by reading relevant records, meeting with clients face to face, and using assessments such as a mental status examination.

As you proceed, you are forming a guiding concept of who this client is, how they became who they are, and where their personal journey might be heading.

Such a guiding concept, which will shape any needed interventions, is called a case conceptualization, and we will examine various examples in this article.

Before you continue, we thought you might like to download our three Positive CBT Exercises for free . These science-based exercises will provide you with detailed insight into positive Cognitive-Behavioral Therapy (CBT) and give you the tools to apply it in your therapy or coaching.

This Article Contains:

What is a case conceptualization or formulation, 4 things to include in your case formulation, a helpful example & model, 3 samples of case formulations, 6 templates and worksheets for counselors, relevant resources from positivepsychology.com, a take-home message.

In psychology and related fields, a case conceptualization summarizes the key facts and findings from an evaluation to provide guidance for recommendations.

This is typically the evaluation of an individual, although you can extend the concept of case conceptualization to summarizing findings about a group or organization.

Based on the case conceptualization, recommendations can be made to improve a client’s self-care , mental status, job performance, etc (Sperry & Sperry, 2020).

Case Formulation

  • Summary of the client’s identifying information, referral questions, and timeline of important events or factors in their life . A timeline can be especially helpful in understanding how the client’s strengths and limitations have evolved.
  • Statement of the client’s core strengths . Identifying core strengths in the client’s life should help guide any recommendations, including how strengths might be used to offset limitations.
  • Statement concerning a client’s limitations or weaknesses . This will also help guide any recommendations. If a weakness is worth mentioning in a case conceptualization, it is worth writing a recommendation about it.

Note: As with mental status examinations , observations in this context concerning weaknesses are not value judgments, about whether the client is a good person, etc. The observations are clinical judgments meant to guide recommendations.

  • A summary of how the strengths, limitations, and other key information about a client inform diagnosis and prognosis .

You should briefly clarify how you arrived at a given diagnosis. For example, why do you believe a personality disorder is primary, rather than a major depressive disorder?

Many clinicians provide diagnoses in formal psychiatric terms, per the International Classification of Diseases (ICD-10) or Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Some clinicians will state a diagnosis in less formal terms that do not coincide exactly with ICD-10 or DSM-5 codes. What is arguably more important is that a diagnostic impression, formal or not, gives a clear sense of who the person is and the support they need to reach their goals.

Prognosis is a forecast about whether the client’s condition can be expected to improve, worsen, or remain stable. Prognosis can be difficult, as it often depends on unforeseeable factors. However, this should not keep you from offering a conservative opinion on a client’s expected course, provided treatment recommendations are followed.

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Based on the pointers for writing a case conceptualization above, an example for summarizing an adolescent case (in this instance, a counseling case for relieving depression and improving social skills) might read as follows.

Background and referral information

This is a 15-year-old Haitian–American youth, referred by his mother for concerns about self-isolation, depression, and poor social skills. He reportedly moved with his mother to the United States three years ago.

He reportedly misses his life and friends in Haiti. The mother states he has had difficulty adjusting socially in the United States, especially with peers. He has become increasingly self-isolating, appears sad and irritable, and has started to refuse to go to school.

His mother is very supportive and aware of his emotional–behavioral needs. The youth has been enrolled in a social skills group at school and has attended three sessions, with some reported benefit. He is agreeable to start individual counseling. He reportedly does well in school academically when he applies himself.

Limitations

Behavioral form completed by his mother shows elevated depression scale (T score = 80). There is a milder elevation on the inattention scale (T score = 60), which suggests depression is more acute than inattention and might drive it.

He is also elevated on a scale measuring social skills and involvement (T score = 65). Here too, it is reasonable to assume that depression is driving social isolation and difficulty relating to peers, especially since while living in Haiti, he was reportedly quite social with peers.

Diagnostic impressions, treatment guidance, prognosis

This youth’s history, presentation on interview, and results of emotional–behavioral forms suggest some difficulty with depression, likely contributing to social isolation. As he has no prior reported history of depression, this is most likely a reaction to missing his former home and difficulty adjusting to his new school and peers.

Treatments should include individual counseling with an evidence-based approach such as Cognitive-Behavioral Therapy (CBT). His counselor should consider emotional processing and social skills building as well.

Prognosis is favorable, with anticipated benefit apparent within 12 sessions of CBT.

How to write a case conceptualization: An outline

The following outline is necessarily general. It can be modified as needed, with points excluded or added, depending on the case.

  • Client’s gender, age, level of education, vocational status, marital status
  • Referred by whom, why, and for what type of service (e.g., testing, counseling, coaching)
  • In the spirit of strengths-based assessment, consider listing the client’s strengths first, before any limitations.
  • Consider the full range of positive factors supporting the client.
  • Physical health
  • Family support
  • Financial resources
  • Capacity to work
  • Resilience or other positive personality traits
  • Emotional stability
  • Cognitive strengths, per history and testing
  • The client’s limitations or relative weaknesses should be described in a way that highlights those most needing attention or treatment.
  • Medical conditions affecting daily functioning
  • Lack of family or other social support
  • Limited financial resources
  • Inability to find or hold suitable employment
  • Substance abuse or dependence
  • Proneness to interpersonal conflict
  • Emotional–behavioral problems, including anxious or depressive symptoms
  • Cognitive deficits, per history and testing
  • Diagnoses that are warranted can be given in either DSM-5 or ICD-10 terms.
  • There can be more than one diagnosis given. If that’s the case, consider describing these in terms of primary diagnosis, secondary diagnosis, etc.
  • The primary diagnosis should best encompass the client’s key symptoms or traits, best explain their behavior, or most need treatment.
  • Take care to avoid over-assigning multiple and potentially overlapping diagnoses.

When writing a case conceptualization, always keep in mind the timeline of significant events or factors in the examinee’s life.

  • Decide which events or factors are significant enough to include in a case conceptualization.
  • When these points are placed in a timeline, they help you understand how the person has evolved to become who they are now.
  • A good timeline can also help you understand which factors in a person’s life might be causative for others. For example, if a person has suffered a frontal head injury in the past year, this might help explain their changeable moods, presence of depressive disorder, etc.

Case Formulation Samples

Sample #1: Conceptualization for CBT case

This is a 35-year-old Caucasian man referred by his physician for treatment of generalized anxiety.

Strengths/supports in his case include willingness to engage in treatment, high average intelligence per recent cognitive testing, supportive family, and regular physical exercise (running).

Limiting factors include relatively low stress coping skills, frequent migraines (likely stress related), and relative social isolation (partly due to some anxiety about social skills).

The client’s presentation on interview and review of medical/psychiatric records show a history of chronic worry, including frequent worries about his wife’s health and his finances. He meets criteria for DSM-5 generalized anxiety disorder. He has also described occasional panic-type episodes, which do not currently meet full criteria for panic disorder but could develop into such without preventive therapy.

Treatments should include CBT for generalized anxiety, including keeping a worry journal; regular assessment of anxiety levels with Penn State Worry Questionnaire and/or Beck Anxiety Inventory; cognitive restructuring around negative beliefs that reinforce anxiety; and practice of relaxation techniques, such as progressive muscle relaxation and diaphragmatic breathing .

Prognosis is good, given the evidence for efficacy of CBT for anxiety disorders generally (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012).

Sample #2: Conceptualization for DBT case

This 51-year-old Haitian–American woman is self-referred for depressive symptoms, including reported moods of “rage,” “sadness,” and “emptiness.” She says that many of her difficulties involve family, friends, and coworkers who regularly “disrespect” her and “plot against her behind her back.”

Her current psychiatrist has diagnosed her with personality disorder with borderline features, but she doubts the accuracy of this diagnosis.

Strengths/supports include a willingness to engage in treatment, highly developed and marketable computer programming skills, and engagement in leisure activities such as playing backgammon with friends.

Limiting factors include low stress coping skills, mild difficulties with attention and recent memory (likely due in part to depressive affect), and a tendency to self-medicate with alcohol when feeling depressed.

The client’s presentation on interview, review of medical/psychiatric records, and results of MMPI-2 personality inventory corroborate her psychiatrist’s diagnosis of borderline personality disorder.

The diagnosis is supported by a longstanding history of unstable identity, volatile personal relationships with fear of being abandoned, feelings of emptiness, reactive depressive disorder with suicidal gestures, and lack of insight into interpersonal difficulties that have resulted in her often stressed and depressive state.

Treatments should emphasize a DBT group that her psychiatrist has encouraged her to attend but to which she has not yet gone. There should also be regular individual counseling emphasizing DBT skills including mindfulness or present moment focus, building interpersonal skills, emotional regulation, and distress tolerance. There should be a counseling element for limiting alcohol use. Cognitive exercises are also recommended.

Of note, DBT is the only evidence-based treatment for borderline personality disorder (May, Richardi, & Barth, 2016). Prognosis is guardedly optimistic, provided she engages in both group and individual DBT treatments on a weekly basis, and these treatments continue without interruption for at least three months, with refresher sessions as needed.

Sample #3: Conceptualization in a family therapy case

This 45-year-old African-American woman was initially referred for individual therapy for “rapid mood swings” and a tendency to become embroiled in family conflicts. Several sessions of family therapy also appear indicated, and her psychiatrist concurs.

The client’s husband (50 years old) and son (25 years old, living with parents) were interviewed separately and together. When interviewed separately, her husband and son each indicated the client’s alcohol intake was “out of control,” and that she was consuming about six alcoholic beverages throughout the day, sometimes more.

Her husband and son each said the client was often too tired for household duties by the evening and often had rapid shifts in mood from happy to angry to “crying in her room.”

On individual interview, the client stated that her husband and son were each drinking about as much as she, that neither ever offered to help her with household duties, and that her son appeared unable to keep a job, which left him home most of the day, making demands on her for meals, etc.

On interview with the three family members, each acknowledged that the instances above were occurring at home, although father and son tended to blame most of the problems, including son’s difficulty maintaining employment, on the client and her drinking.

Strengths/supports in the family include a willingness of each member to engage in family sessions, awareness of supportive resources such as assistance for son’s job search, and a willingness by all to examine and reduce alcohol use by all family members as needed.

Limiting factors in this case include apparent tendency of all household members to drink to some excess, lack of insight by one or more family members as to how alcohol consumption is contributing to communication and other problems in the household, and a tendency by husband and son to make this client the family scapegoat.

The family dynamic can be conceptualized in this case through a DBT lens.

From this perspective, problems develop within the family when the environment is experienced by one or more members as invalidating and unsupportive. DBT skills with a nonjudgmental focus, active listening to others, reflecting each other’s feelings, and tolerance of distress in the moment should help to develop an environment that supports all family members and facilitates effective communication.

It appears that all family members in this case would benefit from engaging in the above DBT skills, to support and communicate with one another.

Prognosis is guardedly optimistic if family will engage in therapy with DBT elements for at least six sessions (with refresher sessions as needed).

Introduction to case conceptualization – Thomas Field

The following worksheets can be used for case conceptualization and planning.

  • Case Conceptualization Worksheet: Individual Counseling helps counselors develop a case conceptualization for individual clients.
  • Case Conceptualization Worksheet: Couples Counseling helps counselors develop a case conceptualization for couples.
  • Case Conceptualization Worksheet: Family Counseling helps counselors develop a case conceptualization for families.
  • Case Conceptualization and Action Plan: Individual Counseling helps clients facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
  • Case Conceptualization and Action Plan: Couples Counseling helps couples facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.
  • Case Conceptualization and Action Plan: Family Counseling helps families facilitate conceptualization of their own case, at approximately six weeks into counseling and thereafter at appropriate intervals.

The following resources can be found in the Positive Psychology Toolkit© , and their full versions can be accessed by a subscription.

Analyzing Strengths Use in Different Life Domains can help clients understand their notable strengths and which strengths can be used to more advantage in new contexts.

Family Strength Spotting is another relevant resource. Each family member fills out a worksheet detailing notable strengths of other family members. In reviewing all worksheets, each family member can gain a greater appreciation for other members’ strengths, note common or unique strengths, and determine how best to use these combined strengths to achieve family goals.

Four Front Assessment is another resource designed to help counselors conceptualize a case based on a client’s personal and environmental strengths and weaknesses. The idea behind this tool is that environmental factors in the broad sense, such as a supportive/unsupportive family, are too often overlooked in conceptualizing a case.

If you’re looking for more science-based ways to help others through CBT, check out this collection of 17 validated positive CBT tools for practitioners . Use them to help others overcome unhelpful thoughts and feelings and develop more positive behaviors.

In helping professions, success in working with clients depends first and foremost on how well you understand them.

This understanding is crystallized in a case conceptualization.

Case conceptualization helps answer key questions. Who is this client? How did they become who they are? What supports do they need to reach their goals?

The conceptualization itself depends on gathering all pertinent data on a given case, through record review, interview, behavioral observation, questionnaires completed by the client, etc.

Once the data is assembled, the counselor, coach, or other involved professional can focus on enumerating the client’s strengths, weaknesses, and limitations.

It is also often helpful to put the client’s strengths and limitations in a timeline so you can see how they have evolved and which factors might have contributed to the emergence of others.

Based on this in-depth understanding of the client, you can then tailor specific recommendations for enhancing their strengths, overcoming their weaknesses, and reaching their particular goals.

We hope you have enjoyed this discussion of how to conceptualize cases in the helping professions and that you will find some tools for doing so useful.

We hope you enjoyed reading this article. For more information, don’t forget to download our three Positive CBT Exercises for free .

  • Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research , 36 (5), 427–440.
  • May, J. M., Richardi, T. M., & Barth, K. S. (2016). Dialectical behavior therapy as treatment for borderline personality disorder. The Mental Health Clinician , 6 (2), 62–67.
  • Sperry, L., & Sperry, J. (2020).  Case conceptualization: Mastering this competency with ease and confidence . Routledge.

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Biopsychosocial Model and Case Formulation

Table of contents, diagnosis versus formulation, the formulation table, "jane doe", biological and social factors, psychological factors, completed table, method 1 (sequential), method 2 (narrative), method 3 (advanced), method 4 (chronological), common phrases to use, do's and dont's, another example, "templates".

The Biopsychosocial Model and Case Formulation (also known as the Biopsychosocial Formulation ) in psychiatry is a way of understanding a patient as more than a diagnostic label. Hypotheses are generated about the origins and causes of a patient's symptoms. The most common and clinically practical way to formulate is through the biopsychosocial approach, first described in 1980 by George Engel. [1] [2] Biopsychosocial formulation combines biological, psychological, and social factors to understand a patient, and uses this to guide both treatment and prognosis. Your formulation of a patient evolves and changes as you collect more information. Formulation is like cooking, and there is no 'right' or 'wrong' way to do it, but most get better over time with increasing clinical experience.

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Diagnosis is not the same as formulation! In mental health, when there is a group of consistent symptoms seen in a population, these symptoms can be categorized into a distinct entity, called a diagnosis (this is what the DSM-5 does). For example, we diagnose someone with a major depressive episode if they meet 5 of the 9 symptomatic criteria. However, formulation tells us how the person became depressed as a result of their genetics , personality , psychological factors , biological factors, social circumstances ( childhood adverse events and social determinants of health ), and their environment.

You are probably already formulating, but just don't know it. Like most things in medicine, there are multifactorial causes of diseases, illnesses, and disorders. For example, type II diabetes does not develop because of a single pathophysiological cause. The patient may have a strong family history of the disease, a sedentary job, environmental exposures, and/or a nutritionally-poor diet. These factors all combine to cause the person to develop diabetes. Understanding how each factor contributes to a disease can better guide treatment decisions. In psychiatry, formulation appears more complicated because human behaviour and the brain itself is extraordinarily complex. However, like with anything, the more you practice, the better you will become at formulating.

What Are You Formulating?

Why is a biopsychosocial approach important, formulation in a nutshell.

The biopsychosocial model considers the “4 Ps” for each of the biological, psychological, and social factors:

  • Predisposing factors are areas of vulnerability that increase the risk for the presenting problem. Examples include genetic (i.e. -family history) predisposition for mental illness or prenatal exposure to alcohol.
  • Precipitating factors are typically thought of as stressors or other events (they could be positive or negative) that may be precipitants of the symptoms. Examples include conflicts about identity, relationship conflicts, or transitions.
  • Perpetuating factors are any conditions in the patient, family, community, or larger systems that exacerbate rather than solve the problem. Examples include unaddressed relationship conflicts, lack of education, financial stresses, and occupation stress (or lack of employment)
  • Protective factors include the patient’s own areas of competency, skill, talents, interest and supportive elements. Protective factors counteract the predisposing, precipitating, and perpetuating factors.

The “4 Ps” can be laid out in a 3 x 4 table to systematically do formulation and identity factors. Note that this table is extremely comprehensive and long, and not everything will (or should!) apply to your case. It is important to remember that not everything will fit neatly into each box. For example, many precipitating and perpetuating factors may overlap and fit in other boxes. Use this table as a general guide, but don't memorize it for the sake of memorizing it!

Biopsychosocial Model

Filling out the table.

  • As you can see in the table above, it's a lot of questions to ask and a lot of things to think about!
  • Let's do a simplified formulation for the patient (Jane Doe) below. The image ( figure 1 ) provides a guide on how to put information into the formulation table.
  • These psychological symptoms/factors are then observed by the clinician to give a psychiatric diagnosis.
  • This is why the psychological section of the table is filled last, so we can understand what biological and social factors led to the development of these symptoms.

what is a case formulation in social work

  • Jane Doe is a 30-year-old female who presents to the emergency room with acute suicidal ideation and self-harm
  • Jane has been working at a start up company for the past 2 years. She was suddenly fired from her job today due to conflicts at work with co-workers and being late at work several times from sleeping in. After being told she was fired from her job, she went home and self-harmed to cope with the distress of this loss. She also drank 10 beers prior to arriving in the hospital. She subsequently planned to overdose on her medications. A concerned best friend called and talked to her this evening, and brought her to the hospital. Her mood was stable prior to this job loss, and she had no self-harm or suicidal thoughts in the past 1 year.
  • Increasing alcohol use for the past 3 months, drinking up to 5 beers per day.
  • Sertraline (Zoloft) 75mg PO daily
  • She has a past history of borderline personality disorder , depression , and alcohol use disorder (moderate). She used to be a soccer player and has a history of multiple concussions. She does have a psychiatrist that she sees every month. She previously completed a course of dialectical behavioural therapy , which was helpful.
  • Depression and bipolar disorder on maternal side of her family. There is a history of alcohol use disorder on paternal side.
  • Born in Canada. University-educated. There was a parental divorce at age 5. She describes an invalidating childhood, where parents did not acknowledge or praise her. She experienced sexual abuse and trauma at age 12. She is in a 2-year relationship with a male partner, and there have been recent arguments about the direction of their relationship. She describes a long-standing fear of being abandoned in relationships, and reports having very intense relationships with friends/family. Financially, she is struggling to pay rent and living from paycheque-to-paycheque. Developmentally, there may have been some speech delay . Collateral information from the patient's older brother describe her childhood temperament as being avoidant and fearful of her parents.

Steps 1 and 2

Sample formulation for jane doe.

Now that you've filled in the easy parts from the history, the hardest part is conceptualizing the predisposing social factors (Step 3), and all of the psychological factors (Steps 4, 5, 6, 7). This is where you'll need to be creative and also think more in-depth about your patient. Ideally, each step should flow logically and intuitively into the next based on your framework, as you'll see in our case of Jane Doe. Having a framework for understanding of different psychological treatments and psychological theories can be helpful in making your psychological formulation flow intuitively (e.g. - attachment theory , cognitive behavioural therapy , dialectical behavioural therapy , interpersonal therapy , psychodynamic therapy ). However, this can be done intuitively even without an in-depth understanding of these frameworks (we don't need to be Freud to do this). The more cases you go through (and more of the sample formulations below) the more comfortable you will be with formulating!

Steps 3, 4, 5, 6, and 7

Jane doe's formulation, completed biopsychosocial formulation table, completed formulation of jane doe, presenting your formulation.

You've got your table all filled out now. Now what? How do you present all this information and data? Remember there is no “right” or “wrong” way to present your formulation. But the most important thing about formulation is that it should be intuitive and flow logically. Some different presentation styles are suggested here.

The “4 Ps” formulation table can be a very rigid and systematized way of presenting a formulation. At its most basic, you could present each box sequentially and describe each factor. Most learners will use this method as it is the most “simple.” It is usually presented as Predisposing → Precipitating → Perpetuating → Protective factors. As you get better and more expert at formulating, you may not need to use this rigid structured format, and instead, will be able to present a more intuitive and organic formulation of the patient instead (see other methods below).

  • Brief summarizing statement that includes demographic information, chief complaint, and presenting problems from patient's perspective and signs and symptoms (onset, severity, pattern)
  • Predisposing factors
  • Precipitating factors
  • Perpetuating factors
  • Strengths and protective factors
  • Integrative statement: how these factors interact to lead to the current situation and level of functioning, prognosis, and potential openings for intervention

Example: 4 Ps Table Formulation of Jane Doe

  • Jane Doe presents with a diagnosis of borderline personality disorder and history of depression. She presents to hospital today with acute suicidal ideation and self-harm after being fired from her job.
  • Predisposing factors : Her predisposing biological factors include a family history of mental disorders and substance use, concussion history, and a fearful/anxious temperament at birth. Her predisposing social factors include a history of sexual trauma at a young age, and early parental divorce. These led to her predisposing psychological factors, including a history of invalidation by her parents, and fears of abandonment during childhood.
  • Precipitating factors : Her precipitating biological factors include a 3-month history of increasing alcohol use. Her precipitating social factors is her being fired from her current job. These led to her precipitating psychological factors, which resulted in her underlying feelings of abandonment and invalidation re-activated after being fired from work.
  • Perpetuating factors : Her perpetuating biological factors include being on a subtherapeutic dose of her medication, and her ongoing alcohol use. Her perpetuating social factors includes her ongoing relationship conflicts and financial stressors. Her perpetuating psychological factors include her lack of adaptive coping strategies and ongoing self-harm.
  • Strengths and protective factors : She is medically healthy, and has previously responded well to therapy. She also is supported by a good friend, and sees a psychiatrist regularly.
  • Integrative Statement : The acute stressor of losing her job has re-activated the psychological processes described above. The patient is psychologically minded and thus would benefit from treatment with dialectical behavioural therapy. Her medications could also be further optimized as well. Overall, her prognosis is good due to her protective factors as mentioned above.

The narrative formulation of the patient is a less rigid presentation structure where you may not choose to present everything in the 4 Ps table, and instead focus on the key factors that you think are relevant:

  • [Patient] presents with a [diagnosis]. They are biologically predisposed because of [reasons]. They struggle with the following [psychological difficulties]. Their underlying temperament is [temperament], which further exacerbates the symptoms.
  • Childhood/adult trauma (if any)
  • Attachment style
  • About themselves
  • About others
  • About the world
  • (i) death of their spouse
  • (ii) stopping medications
  • (iii) loss of job
  • (iv) re-experiencing of trauma
  • They have the following: [protective factors]

Example: Narrative Formulation of Jane Doe

  • Jane Doe presents with a diagnosis of borderline personality disorder and history of depression. She is biologically predisposed, with a family history of depression and alcohol use disorder in her immediate family members. She struggles with the following psychological difficulties, including fears of abandonment. Her underlying temperament is anxious, which further exacerbates her symptoms.
  • Her underlying history of experiencing trauma and sexual abuse at a young age
  • A history of invalidating experiences in childhood
  • That she is not deserving of love or close relationships, a core belief of her being “unlovable”, and that self-harm is the main way of coping with stressors
  • That others may leave or abandon her any time, increased rejection sensitivity, and a future fear of being rejected
  • That the world can be a fearful and scary place
  • After being fired from her job, she experienced strong feelings of rejection, and was unable to cope with this major stressor. This may have reactivated/exacerbated her emotional dysregulation, and resulted in negative coping styles such as her self-harming and suicidal ideation. She also appears to use alcohol as a way of managing distressing emotions, but does not have any psychological coping strategies. This has further exacerbated her alcohol use disorder.
  • She has the following protective factors, including a supportive psychiatrist and friend. She has also previously responded well to psychotherapy and appears to be psychologically-minded.

A much more advanced and nuanced presentation might be using a more comprehensive formulation that integrates the 4Ps formulation through multiple lenses (e.g. - Eriksonian developmental stages , psychodynamic defenses , and dialectical behavioural ):

  • Current stressors, plus salient developmental history
  • “The patient presents at this time with [problem and symptoms], in the context of [situation and stressors]”
  • Genetics, temperament, medical history, substances, medications
  • “The patient has the following [genetic vulnerabilities, medical history]”
  • “The patient grew up in a family characterized by [factors], with a caregiver who was [distant/available/invalidating]”
  • “ Attachment was likely [secure/insecure/disorganized] given [developmental history]”
  • “The patient may have had difficulty in [stage of development], and this is reflected in [examples from adult relationships]
  • “It appears that the patient may have struggled with conflicts in early life. It also appears they may have had difficulty with [drives], stemming from [psychoanalytic concept]
  • Control/regulation of drives
  • “These experiences impacted the patient's view of themselves as being [view of self], and this has continued into adulthood based on [experiences].”
  • “The patient appears to have adopted [defense mechanisms] as coping strategies by early adulthood, and these have continued on…”
  • “The patient's interpersonal relationships appear to be [give examples of patterns of relationships]”
  • These underlying factors may have precipitated the patient's [current presentation]. These symptoms have been maintained by [psychological factors/personality factors], and [social/environmental factors]
  • “We would anticipate when engaging in treatment, the patient may have [resistance/transference/countertransference]. However, patient has the following [protective factors], which may be a good prognostic factor. Based on these factors, the following [treatment and management] would be the most helpful for this patient.

Example: Advanced Formulation of Jane Doe

  • Jane Doe is a 30-year-old female who presents with acute suicidal ideation in the context of a job loss. She notably has a past history of childhood trauma and abuse.
  • The patient has genetic vulnerabilities for mental illness in her family history, a history of anxious temperament, ongoing substance use, and subtherapeutic medication levels.
  • She has several early developmental and pathogenic psychological factors, including growing up in a family characterized by invalidation, with parents who were distant and unavailable. This likely led to an attachment style that was likely insecure and disorganized. Due to her history of abuse at age 12, she may have struggled with identity versus role confusion during that Eriksonian stage of psychosocial development. As she was unable to develop a sense of self and personal identity, these psychological factors are reflected in her adulthood with unstable relationships, and fears of abandonment. This has led to her adulthood self-perception of being unworthy of being loved, a constant fear of rejection, and increased rejection sensitivity. The patient appears to have adopted self-harming as a primitive coping strategy by early adulthood, and these have continued on in adulthood.
  • Precipitating and perpetuating factors: the stressor of losing her job has reactivated these more primitive defense mechanisms and coping strategies. These symptoms have been further perpetuated by the personality factors and traits described above, and her ongoing financial stressors. Her ongoing alcohol use is another example of a maladaptive coping strategy.
  • We would anticipate when engaging in treatment, the patient may have difficulties with using primitive defense mechanisms. However, the patient has protective factors including psychological mindedness and previous response to therapy, which is a good prognostic factor. Based on these factors, dialectical behavioural therapy would be the most helpful for this patient.

Yet another way to present a formulation is in chronological order, starting from birth until present time:

  • Genetics (family history)
  • Birth (issues at birth, developmental history, developmental stages)
  • Childhood (attachment style, neurodevelopment, milestones, trauma)
  • Adolescence (relationships, trauma, school performance, substances)
  • Adulthood (occupation, relationships, children, environment, stressors)
  • Integrative statement (of how genetics, birth, childhood, adolescence, and adulthood factors contribute to current presentation, and how this directs your treatment/management)

Having certain common phrases to use can be helpful to structure your presentation. Here are some examples:

  • “From a biological perspective, the patient is vulnerable because…”
  • “The patient's early childhood and developmental history suggest…”
  • “Used substances as a coping style in [the past], and now this is occurring again (or there is a relapse) due to [social factor].”
  • “Used substances as a coping style in [the past], and now this is occurring again (or there is a relapse) due to [psychological vulnerability].”
  • “I wonder if… [psychological factor] is contributing to [current symptoms/struggles]”
  • Use your own words and personal style
  • Tell a story and narrative that is unique to your patient
  • Be specific and demonstrate your understanding of the patient as a person and not a diagnosis
  • Use words like precipitating, protective, and perpetuating factors to anchor your listener
  • Focus on the most salient features and be concise
  • Try and use a psychological theory (but only if you understand it)
  • Be confident in your presentation!
  • Include too much extra detail
  • Try to be perfect only to overwhelm yourself
  • Be generic (your formulation needs to be unique to your patient)
  • Tell the patient's whole story all over again
  • Mention life events or trauma without an understanding of its meaning or impact
  • Try to formulate a “grand unified theory” of the patient and over-reach with your theory (if it doesn’t fit, it doesn’t fit! And that's okay!)
  • Cover every box in the 4 Ps just for the sake of doing it (not all boxes will always apply!)

Beyond Basic Formulation

A good formulation should be integrative, and let you understand how all of the patient's factors interact to lead to the current situation. This gives you a sense of their current level of functioning, prognosis, and guides your direction for treatment and management decisions.

A good biopsychosocial formulation allows you to come up with a comprehensive and holistic treatment plan for your patient. Here is an example of a set of treatment recommendations for Jane Doe:

  • What level of care is required (outpatient or inpatient)?
  • Jane is able to articulate a safe plan to stay with a friend, and is suitable for outpatient care
  • Jane might benefit from an increase of her sertraline from 75mg to 100mg and beyond (maximum dose of 200mg), for her mood dysregulation and depressive symptoms
  • Jane might benefit from the use of anti-craving medications such as gabapentin or acamprosate to reduce her cravings for alcohol use
  • Dialectical behavioural therapy (DBT) would be the most appropriate for Jane
  • Jane would also benefit from motivational interviewing for her alcohol use
  • Long-term, Jane might also benefit from a more in-depth understanding of how her past trauma affects her present self and symptoms. This could be achieved with more specific and in depth trauma therapy, but given the acuity of her symptoms, this is something that would follow after DBT.
  • Jane could benefit from accessing support from her company's HR department to understand what options she has after her job termination
  • Substance use groups such as Alcoholic's Anonymous
  • Increasing connections to her friends and social supports

For good measure, here is another sample formulation for someone with a diagnosis of schizophrenia . Note that in this example, since the precipitating cause for acute psychosis (also applies to manic episodes ) is more “biological,” it may be harder to identify underlying psychological factors (but that's OK too – even the most “biological” psychiatric disorders can often be precipitated by psychosocial stressors). Again let's fill out the easiest parts of the table first:

Sample Formulation for Schizophrenia (Initial)

Now here is one potential example of a predisposing social and psychological formulation of psychosis (again, there are no right or wrong ways to formulate, it depends on the patient you have in front of you!)

Example of A Possible Psychological Formulation of Psychosis/Schizophrenia

Here's what the completed table would look like with the psychological factors incorporated.

Completed Formulation for Schizophrenia (Initial)

As you do more formulation, you will notice that patients tend to present in “templates,” that is, certain diagnoses tend to follow a certain common theme of predisposing, precipitating, and perpetuating factors. The more you formulate, it can be helpful to have a rough template of different formulations for different diagnoses (e.g. - depression, self-harm, mania/psychosis, anxiety, etc.) It will make your job of formulating much easier.

The following readings below are excellent resources to further develop your formulation skills:

  • Selzer, R., & Ellen, S. (2014). Formulation for beginners. Australasian Psychiatry, 22(4), 397-401.
  • Winters, N. C., Hanson, G., & Stoyanova, V. (2007). The case formulation in child and adolescent psychiatry. Child and Adolescent Psychiatric Clinics, 16(1), 111-132.
  • Weerasekera, P. (1993). Formulation: A multiperspective model. The Canadian Journal of Psychiatry, 38(5), 351-358.

Beyond the Biopsychosocial Model

  • Kendler, K. S. (2012). The dappled nature of causes of psychiatric illness: Replacing the organic–functional/hardware–software dichotomy with empirically based pluralism. Molecular psychiatry, 17(4), 377-388.

what is a case formulation in social work

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What's in a Case Formulation?: Development and Use of a Content Coding Manual

A case formulation content coding method is described and applied to the formulation section of 56 intake evaluations randomly selected from an outpatient psychiatric clinic. The coding manual showed good reliability (mean kappa = 0.86) across content and quality categories. Although 95% of the formulations included descriptive infor- mation, only 37% addressed hypothesized predisposing life events accounting for the individual's presenting problems, and 16% included a precipitating stressor. Only 43% inferred a psychological mechanism, 2% inferred a biological mechanism, and 2% mentioned sociocultural factors. Formulations were more descriptive than inferential, more simple than complex, and moderately precise in use of language. In sum, clinicians used the formulation primarily to summarize descriptive information rather than to integrate it into a hypothesis about the causes, precipitants, and maintaining influences of an individual's problems.

Psychotherapists appear to agree that case formulation skills are fundamental to providing effective treatment, 1 – 3 particularly for difficult-to-treat patients with comorbid mental disorders. 4 Sperry et al. 3 reflect this agreement in noting that “the ability to conceptualize and write succinct case formulations is considered basic to daily clinical practice” (p. vii). Some argue that the advent of managed care and time-limited psychotherapy has heightened the importance of case formulation skills because psychotherapists are increasingly called on to work more efficiently and to justify the value and expense of their services. 2 , 3 , 5

In light of the consensus that case formulation skills are important, it is striking that little research has addressed the formulation skills of clinicians. Research in this area would not only provide feedback to clinicians that could aid in training, but would also serve the goal of consumer protection by ensuring that a well-thought-out understanding of the patient has been attempted and an appropriate treatment plan developed. In our review of the literature, we found only two studies that directly addressed formulation skills and none in which these skills are directly assessed. Both studies suggest that clinicians may not feel that they are well trained in case formulation. Surveying a small sample of psychiatry program directors and senior psychiatry residents, Fleming and Patterson 6 found that fewer that half of the programs provided guidelines for case formulation, and most respondents agreed strongly that standardized, biopsychosocially based guidelines for case formulation were needed. In an earlier survey, Ben-Aron and McCormick 7 found that 60% of psychiatry chairs and program directors believed that case formulation was important but was inadequately stressed in training.

These respondents' views are echoed by numerous writers about psychotherapy. Sperry et al. 3 recently described case formulation as a poorly defined and undertaught clinical skill. Similarly, Perry et al. 8 lament that among psychotherapy supervisors, “a comprehensive psychodynamic formulation is seldom offered and almost never incorporated into the written record” (p. 543).

One reason that case formulation skills have not been more studied may be a lack of consensus as to what a case formulation should contain and what its structure and goals should be. For example, in 1966 Seitz 9 found that a group of psychoanalysts showed little agreement in the structure and content of formulations they constructed using the same clinical material. This explanation has less currency today, however, because several systematic methods for constructing case formulations have been developed in recent years. These case formulation construction methods have been developed within several psychotherapy orientations, including psychodynamic, 10 – 14 cognitive-behavioral, 15 interpersonal, 16 behavioral, 17 , 18 and blends of orientations. 19 , 20 Most share three features:

  • They emphasize levels of inference that can readily be supported by a patient's statements in therapy.
  • The information they contain is based largely on clinical judgment rather than patient self-report.
  • The case formulation is compartmentalized into preset components that are addressed individually in the formulation process and then assembled into a comprehensive formulation.

A number of newer psychodynamic case formulation methods have good reliability and validity, according to Barber and Crits-Christoph's 21 review of them. Separate components of Luborsky's Core Conflictual Relationship Theme (CCRT) method, for example, had a mean weighted kappa coefficient in the range of 0.61 to 0.70. Similarly, Curtis et al. 22 report intraclass correlation coefficients ranging from 0.78 to 0.90 for components of their Plan Diagnosis Method.

Validity studies have focused on how well adherence to a case formulation predicts psychotherapy process and outcome. Crits-Christoph et al. 23 showed that the accuracy of therapist interventions, as defined by adherence to reliably constructed CCRTs, correlated positively with residual gain in psychological adjustment in a group of 43 patients undergoing psychodynamic psychotherapy. Similarly, researchers at the Mount Zion Psychotherapy Group demonstrated that formulation-consistent interventions are associated with a deeper level of experiencing in patients, as compared with interventions that do not adhere to a formulation. 24 , 25 A review of the behavioral and cognitive-behavioral literature by Persons and Tompkins 15 showed more equivocal findings as to the association between individualized case formulations and treatment outcome.

Although encouraging, these developments in case formulation research should be viewed in the light of certain limitations.

  • The evidence for interrater reliability in many of the studies was based on relatively small samples.
  • Most of the studies were done by developers of the methods, which may have introduced subtle biases in favor of higher reliability.
  • The content of a case formulation appears to be greatly dependent on its guiding theory. Collins and Messer 26 showed that two psychotherapy research teams using the same case formulation method, but guided by different theoretical orientations (Joseph Weiss's cognitive-analytic theory 27 , 28 and Fairbairnian object relations theory), independently constructed formulations that were highly reliable as measured within each research team but widely divergent in content when cross-team comparisons were made.
  • There is evidence that therapist adherence to an initial formulation in brief dynamic therapy may predict a good outcome only for individuals with interpersonal relationships that are of relatively good quality, and may predict a poor outcome for individuals with low-quality interpersonal relationships. 29 McWilliams 2 and Eells 30 discuss other caveats about case formulation.

Although the case formulation construction methods mentioned above have not led to a consensus on what the content, structure, and goals of a case formulation should be, and regardless of their limitations, they do provide guidelines that can facilitate the evaluation of case formulations.

The purpose of this study is to extend our knowledge of how clinicians use their case formulation skills in daily practice. We first pre-sent a multitheoretical system we developed to evaluate the content of written case formulations. The system was guided by the case formulation construction methods just described. Second, we demonstrate the application of the system to a set of case formulations as they appeared in intake evaluations at an outpatient mental health services clinic.

The primary purpose of the Case Formulation Content Coding Method (CFCCM) is to provide a tool for reliably and comprehensively categorizing the information that a clinician uses in conceptualizing a patient. Provisions are also included for rating the quality of the formulation. The CFCCM was initially designed to provide a means for coding and comparing the “Case Formulation” and “Treatment Goals and Plan” sections that are usually part of intake evaluations, but it can also be applied to audio-recorded case formulations, narrative case formulations specifically constructed for research purposes, or similar materials.

In constructing the CFCCM we assumed that the primary function of a case formulation is to integrate rather than summarize descriptive information about the patient. We broadly defined a case formulation as a hypothesis about the causes, precipitants, and maintaining influences of a person's psychological, interpersonal, and behavioral problems. The approach views a case formulation as a tool that can help organize complex and contradictory information about a person. Further, it can serve as a blueprint guiding treatment, as a marker for change, and as a structure facilitating the therapist's understanding of and empathy for the patient. This definition is consistent with the newer formulation models reviewed earlier, and it contrasts with the view of some that a formulation is primarily a summary of descriptive information. 31 , 32

A major goal in developing the CFCCM was to make it applicable across several approaches to psychotherapy. Toward this end, we reviewed the case formulation construction methods mentioned earlier, as well as other writings on case formulation, and identified four broad categories of information that are contained in most methods:

  • Symptoms and problems.
  • Precipitating stressors or events.
  • Predisposing life events or stressors.
  • A mechanism that links the preceding categories together and offers an explanation of the precipitants and maintaining influences of the individual's problems.

Although these categories are consistent with a medical model for treating mental disorders, they were chosen to be theoretically neutral and to provide a structure into which information generated within any theoretical perspective on formulation could be organized. We will first describe the content categories of the CFCCM, then discuss the quality ratings.

Content Categories of the CFCCM

Each content category is given one of three codes: absent, somewhat present, and clearly present. Each piece of information in the formulation is coded under only one category.

Symptoms and Problems:

The first common factor is the identification of signs, symptoms, and other phenomena that may be important clinically. This category incorporates the patient's presenting symptoms and chief complaints as well as problems that may be apparent to the clinician, but not to the patient. As noted by Henry, 33 a patient's problems, which Henry defines as discrepancies between perceived and desired states of affairs, may not be readily apparent in the patient's initial self-presentation and thus could require skilled interviewing to reveal.

Precipitating Stressors:

These are events that catalyze or exacerbate the person's current symptoms and problems. These events may be construed either as directly leading to the current problems or as increasing the severity of preexisting problems to a level of clinical significance. Examples: recent divorce or relationship breakup, physical injury, illness, loss of social support, and occupational setback.

Predisposing Life Events:

These are traumatic events or stressors that have occurred in the person's past and that are assumed to have produced an increased vulnerability to developing symptoms. We separated these into three categories: early life (childhood and adolescence), past adulthood, and recent adulthood. We arbitrarily set a cutoff for recent adult stressors as within 2 years of the date the patient is currently being seen.

Inferred Mechanism:

This factor, the most important, represents an attempt to link together and explain information in the preceding three categories. The inferred mechanism is the clinician's hypothesis of the cause of the person's current difficulties. There are three major categories under inferred mechanism: psychological, biological, and sociocultural. Psychological mechanisms may include a core conflict; a set of dysfunctional thoughts, beliefs, or schemas; skills or behavioral deficits; problematic aspects or traits of the self; problematic aspects of relatedness to others; defense mechanisms or coping style; and problems with affect regulation. Biological mechanisms refer to both genetic and acquired conditions that cause or contribute to the patient's problems. Examples include a genetic predisposition for depression, a depression associated with hypothyroidism, or a presumed constitutional predisposition toward anxiety. Sociocultural mechanisms are factors such as ethnicity, socioeconomic status, religious beliefs, degree of acculturation, and absence of social support. A separate mechanism was included for substance abuse or dependency, since it spans the other categories.

Other Content Categories:

In addition to the four major categories just reviewed, the CFCCM includes content categories for positive treatment indicators such as strengths and adaptive skills; the clinician's treatment expectations; inferences as to the patient's overall level of adjustment; negative treatment indicators; and several categories of descriptive information such as past history of mental health care, developmental history, social or educational history, medical history, and mental status.

Quality Ratings in the CFCCM

In addition to examining the content categories listed above, the CFCCM includes quality ratings for the formulation as a whole, for each major subcategory (symptoms, predisposing life events, precipitating factors, and mechanism), and for the complexity of the formulation, the degree of inference used, and the precision of language. (The latter three categories were adapted from Strupp. 34 )

Complexity:

This refers to the degree to which the formulation takes into account several facets of the person's current problems and integrates these facets into a meaningful account. This dimension was rated on a five-point scale (1 = simple, 5 = complex).

Degree of Inference:

This is the extent to which the formulation goes beyond descriptive information offered by the patient. On a five-point scale (1 = descriptive, 5 = highly inferential), the formulation is rated low if it includes almost exclusively descriptive information, and it is given a higher rating as it contains increasingly more hypothetical considerations. In the development of the scale we were guided by Henry and colleagues' 35 distinction between observable phenomena about a patient and assumptions about that patient's “deep structure.”

Precision of Language:

This category refers to the extent to which the language used in the formulation appears tailored to a specific individual or is more generic in nature. This was rated on a five-point scale (1 = general, 5 = precise).

Aims of the Study

We conducted an exploratory investigation intended to

  • Gather initial reliability data on the CFCCM.
  • Examine whether the categories are sufficiently broad and inclusive.
  • Assess the comprehensiveness and quality of a set of representative written case formulations.

Fifty-six intake reports at an inner-city outpatient psychiatry clinic were randomly selected from a pool of approximately 300, and their content was analyzed by using the CFCCM. Two advanced clinical psychology graduate students performed the coding on the 56 selected intake reports after independently coding and achieving consensus on a set of practice intake reports.

The interviewers were 9 psychiatry residents, 4 social workers, and 1 psychiatric nurse. The intake reports were written as part of the interviewers' typical clinical duties. Six of the 14 identified their primary orientation to psychotherapy as psychodynamic, 3 as cognitive-behavioral, 2 as a blend of psychodynamic and existential, and 1 as a blend of psychodynamic, cognitive-behavioral, and humanistic. Two did not respond to a questionnaire addressing orientation.

The 56 patients were representative of those seen in the clinic. The mean age was 40.0 years (range 20–66), and most were women ( n 20= 37; 66.1%). Forty-six (82.1%) were Caucasian, and 10 (17.9%) were African American. Eighteen (32.1%) were single, 17 (30.4%) were divorced, 11 (19.6%) were married, and the remainder were separated ( n = 6; 10.7%), widowed ( n = 2; 3.6%), or living with a significant other ( n = 2; 3.6%). Most were high school educated (mean years of education = 11.4, range 4—16 years) but unemployed ( n = 31, 55.4%). Fifteen (26.8%) were employed, 8 (14.3%) were on disability, and 2 (3.6%) were retired.

Reliability

The mean kappa coefficient 36 for both content and quality categories of the CFCCM was 0.86, with a range from 0.67 to 1.0. In computing reliability for the content categories, we collapsed “somewhat present” and “clearly present” into one category, leaving “not present” and “present” as the categories evaluated. Table 1 summarizes the reliability coefficients for each content category. The mean kappa for these items was 0.88. Kappa coefficients for the quality ratings of the four common factors were 0.79, 0.88, 0.83, and 0.74, respectively, for symptoms/problems, precipitating stressors, predisposing life events, and inferred mechanisms. The kappa for the ratings of the overall quality of the formulation was 0.70. Complexity, degree of inference, and precision of language had kappas of 0.82, 0.67, and 0.77, respectively. Overall, these data indicate good reliability across the CFCCM categories.

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Content Categories

Table 1 summarizes the numbers and percentages of case formulations in which each formulation element was judged as somewhat present or clearly present by both coders. Descriptive information was presented in 94.6% ( n = 53) of the formulations. The descriptive categories most frequently mentioned were symptoms/problem list (67.9%; n = 38), identifying information (64.3%; n = 36), and past psychiatric history (41.1%; n = 23). Only 37.5% ( n = 21) included a predisposing life event inferred as contributing to a patient's problems. Only about one-fifth (21.4%; n = 12) of the formulations contained references to childhood or adolescent events, 17.9% ( n = 10) dealt with past adult events, and 3.6% ( n = 2) referred to recent adult events. A precipitating stressor was considered in only 16.1% ( n = 9) of the formulations. A minority inferred a mechanism as contributing to the individual's problems: 42.9% ( n = 24) inferred a psychological mechanism, 1.8% ( n = 1) inferred a biological mechanism, and 1.8% inferred a social or cultural mechanism. In addition, only 21.4% ( n = 12) inferred a positive treatment indicator. In sum, the formulation section of the intake evaluations was dominated by descriptive information with a primary focus on symptoms and past psychiatric history.

Formulation Quality Categories

In addition to assessing whether each of the four “common factors” was present, it seemed important to measure the quality of its presentation. Therefore, we developed a five-point scale, with verbal anchors as follows: 1 = not present, 2 = rudimentary presentation, 3 = adequate presentation, 4 = good presentation, and 5 = excellent presentation. As shown in Table 2 , ratings are predominantly in the “not present,” “rudimentary,” or “adequate” categories.

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Consensus global ratings of the formulations appear in Table 3 . As shown, 31 of the 56 formulations (55.4%) contained no presentation of a mechanism; 16 (28.6%) contained a mechanism that was described as rudimentary, with little attention given to how the mechanism is linked to symptoms, problems, precipitating stressors, or other predisposing life events. Only 3 formulations (5.4%) were rated as having adequate to strong mechanisms.

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The mean complexity rating on the scale of 1 (simple) to 5 (complex) was 2.05 (SD = 0.94), indicating that the formulations were rated as relatively simple, with little evidence of interweaving and integrating of different types of information.

The inference ratings indicate that the formulations contained primarily descriptive information and little inference. On the scale of 1 (descriptive) to 5 (highly inferential), mean inference ratings were 1.80 (SD = 0.77). Of the 56 formulations rated, 23 (41.1%) were consensually rated at the most descriptive end of the scale; 21 (37.5%) were rated “2”; and the remaining 12 (21.4%) were rated “3.”

The formulations were rated as moderately precise in terms of the language used. The mean precision rating was 2.57 (SD = 0.93) on the scale of 1 (general) to 5 (precise).

D iscussion

This naturalistic study has a number of limitations. First, a written case formulation may not accurately or completely depict the therapist's understanding of the patient. Second, despite the consensus that case formulation skills are important, little is known about the relationship between case formulation skill and treatment efficacy. A poorly written case formulation may not predict poor psychotherapy outcome. Further, the effectiveness of therapists with good case formulation skills may be due to skills other than those related to case formulation. Third, the case formulations we evaluated were typically dictated after a single intake session with the patient. This may not have provided enough time for an adequate database to be collected. Fourth, the clinicians may not have used the case formulation skills that they have. In that sense, the study is better viewed as an investigation of representative written case formulations rather than as a clinician's best possible work.

Despite these considerations, this first study of case formulation skills in a naturalistic context showed that the CFCCM can be reliably scored and can measure an adequate range of information contained in a case formulation. The findings showed that the clinicians did not consistently use the formulation section to offer hypotheses about a patient's symptoms or to integrate previously presented descriptive information. Instead, they used the formulation primarily to summarize descriptive information. Our findings provide empirical support for surveys suggesting that case formulation is an insufficiently taught skill. 6 , 7

What are the implications of these findings? Three seem central:

  • There is a need for more training in formulation. The availability of newer, empirically supported case formulation models should facilitate this training. 37
  • The relationship between case formulation and treatment outcome should be studied further. Designs for doing so have been offered by Hayes et al. 38 and by Persons. 39 Such studies could help document the incremental validity of formulation: whether individualized formulations lead to better therapy processes and outcomes than do generic formulations or the absence of an explicit formulation. They could also advance our understanding of specific therapist skills that lead to positive treatment outcomes.
  • The relationship between formulation and treatment plans and goals deserves study. One hypothesis would be that a suitably comprehensive, complex, and objective formulation that “fits” the patient well facilitates better articulated and more attainable treatment plans and goals. Another would be that a good formulation helps the therapist anticipate and manage events that could hinder or prevent treatment success.

Acknowledgments

An earlier version of this work was presented at the 27th meeting of the Society of Psychotherapy Research, Amelia Island, FL, June 1996. Interested readers may obtain a copy of the CFCCM from the first author at the address shown in the headnote to this article.

Praxis Continuing Education and Training

Case Formulation in Cognitive-Behavioral Therapy: A Principle-Driven Approach

glowing ball of connected dots

By Gillian A. Wilson, MA, and Martin M. Antony, PhD––Department of Psychology, Ryerson University

Cognitive-behavioral treatments are often described in step-by-step manuals. They provide strategies for treating a specific psychological disorder or diagnosis as opposed to addressing the specific problems and symptoms of a particular person.

Manualized treatments may fall short as they tend to adopt a general approach to treatment versus creating a specific approach tailored to each client.

While manualized treatments may be useful under certain circumstances—for example when individuals with a specific diagnosis have highly overlapping symptoms and problems—there are circumstances that call for a more flexible, individualized approach.

Here, we will focus on this specialized method known as a case formulation .

What is case formulation and when is it useful?

A case formulation is a hypothesis about the psychological mechanisms that cause and maintain an individual’s symptoms and problems (Kuyken et al., 2009; Persons, 2008).

It’s a principle-driven approach that targets mechanisms grounded in basic psychological theories—such as cognitive theory, classical and operant conditioning.

As outlined by Persons (2008), a case formulation can be useful when:

  • A client has several disorders or problems.
  • No treatment manual exists for a particular disorder or problem.
  • A client has numerous treatment providers.
  • Problems arise that are not addressed in a manual—nonadherence or therapeutic relationship ruptures.

Steps in Case Formulation

The case formulation should be developed in collaboration with the client to ensure engagement and increase commitment to treatment.

To develop a strong case formulation, the following steps are recommended (Persons, 2008):

  • Conduct a thorough assessment to determine the presence of specific diagnoses, symptoms, and problems. It’s important to create a list of all of the client’s presenting symptoms and problems in various areas and life domains (i.e., panic attacks, excessive worry, low mood, poor academic performance, relationship difficulties).
  • Factors that predisposed the client to develop the symptoms and problems
  • Factors that precipitated the most recent episode
  • Maintaining factors
  • Protective factors
  • Set up experiments to test out the initial case formulation. The results of these tests will confirm or disprove hypotheses about factors that cause or maintain the client’s symptoms and problems. For example, a therapist may use a thought record to test out whether a client’s procrastination stems from perfectionistic beliefs, which may reveal that procrastination or difficulty initiating tasks is instead due to thoughts of hopelessness. The case formulation should be revised based on the results.
  • The case formulation should continue to be tested and revised throughout treatment with the goal of targeting mechanisms involved in the onset and maintenance of the client’s symptoms and problems. With ongoing consent of the client, it should be used as a guide for treatment planning and clinical decision making.

Components of Case Formulation 

A case formulation should provide a coherent summary and explanation of a client’s symptoms and problems. It should include the following components (Persons, 2008):

  • Problems: Psychological symptoms and features of a disorder, and related problems in various areas of life—social, interpersonal, academic, occupational.
  • Mechanisms: Psychological factors—cognitive, behavioral—that cause or maintain the client’s problems. Mechanisms are the primary treatment targets.
  • Origins: Distal factors or processes that lead to the mechanisms and thereby predispose the client to developing certain psychological symptoms and problems.
  • Precipitants: Proximal factors that trigger or worsen the client’s symptoms and problems. Precipitants can be internal—physiological symptoms that trigger a panic attack—or external—a stressful life event that triggers a depressive episode.

The following is an example of a case formulation, based on recommendations by Persons (2008). It illustrates how a case formulation approach provides a parsimonious description of the cognitive and behavioral mechanisms underlying a client’s myriad of symptoms and problems.

When Rachel was in elementary school, her classmates laughed at her during her class presentations and teased her because of her stutter (ORIGINS). This led Rachel to develop the core schemas “I am socially awkward,” and “People are overly critical.” (COGNITIVE MECHANISMS). As an adult, she was preparing for a presentation at work (PRECIPITANT), and thought to herself, “I am going to humiliate myself in front of my colleagues.” (COGNITIVE MECHANISM). This lead to feelings of anxiety (PROBLEM). As a result, she called in sick the day of her presentation (BEHAVIORAL MECHANISM) and thought “I am a failure” (COGNITIVE MECHANISM) which lead to feelings of sadness and shame (PROBLEMS). She stayed in bed all day (PROBLEM) to avoid these feelings (BEHAVIORAL MECHANISM).

See also: Exposure Therapy for Anxiety-Related Disorders

A case formulation is an invaluable tool for highlighting how a client’s problems and symptoms are related. It aids the therapist in accurately identifying and targeting underlying psychological mechanisms with increased efficiency, leading to improved therapeutic outcomes

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Recommended Readings

Kuyken, W., Padesky, C. A., & Dudley, R. (2009). Collaborative case conceptualization: Working effectively with clients in cognitive-behavioral therapy. New York, NY: Guilford Press.

Persons, J. B. (2008). The case formulation approach to cognitive-behavior therapy. New York, NY: Guilford Press.

The Process of Facilitating Case Formulations in Relational Clinical Supervision

  • Original Paper
  • Published: 21 June 2018
  • Volume 46 , pages 281–288, ( 2018 )

Cite this article

  • Brian Rasmussen   ORCID: orcid.org/0000-0002-6683-5575 1 &
  • Faye Mishna 2  

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This paper explores the supervisory process in relation to the ongoing challenge of developing (and re-developing) a case formulation. We adopt a relational approach to clinical practice and correspondingly to the supervisory domain. We argue that a relational approach to clinical practice firmly fits with social work values, including authenticity, mutuality and collaboration. We address typical challenges inherent in attaining and maintaining a relational formulation in the supervisory relationship.

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Rasmussen, B., Mishna, F. The Process of Facilitating Case Formulations in Relational Clinical Supervision. Clin Soc Work J 46 , 281–288 (2018). https://doi.org/10.1007/s10615-018-0662-9

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The Professional Counselor

Case Formulation and Intervention: Application of the Five Ps Framework in Substance Use Counseling

Volume 10 - Issue 3

Scott W. Peters

Substance use and misuse is exceedingly common and has numerous implications, both individual and societal, impacting millions of Americans directly and indirectly every year. Currently, there are a variety of empirically based interventions for treating clients who engage in substance use and misuse. The Five Ps is an idiographically based framework providing clinicians with a systematic and flexible means of addressing substance use and misuse that can be used in conjunction with standard substance use and misuse interventions. Additionally, its holistic and creative style provides opportunities to address concerns at various points with a variety of strategies and interventions that will best suit clients’ unique situations. It can assist both novice and experienced clinicians working with clients who present for counseling with substance use and misuse. Following a discussion of the Five Ps, a brief case illustration will demonstrate the framework.

Keywords : substance use and misuse, Five Ps, idiographic, systematic, flexible

Substance use and misuse in the United States is extremely common. For the year 2016, the Centers for Disease Control and Prevention (CDC) found that 18% of the U.S. population aged 12 and older had used illicit substances or misused prescription medications (CDC, 2018). The National Survey on Drug Use and Health asserted that close to 30% of respondents aged 12 and older reported use of illicit substances in the past month (Substance Abuse and Mental Health Services Administration [SAMHSA], 2017). Although these statistics are significant, it should be noted that “Most people who use abusable drugs, even most people who use them nonmedically, do so in a reasonably controlled fashion and without much harm to themselves or anyone else” (Kleiman et al., 2011, p. 2). In the context of this article, the word abusable indicates substances that when taken are pleasurable enough to result in excessive dosing or increased frequency of intake (Linden, 2011).

However, there are others who use substances to such an extent that it causes significant distress and impairment in their lives, a phenomenon clinically referred to as a substance use disorder (SUD). The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) bases an SUD on a “pathological pattern related to the use of a substance” (American Psychiatric Association, 2013, p. 483). In his report on alcohol, drugs, and health, the U.S. Surgeon General Vivek Murthy reported that more than 20 million Americans have an SUD (U.S. Department of Health and Human Services, 2016). Clients who engage in substance use and misuse can present with a variety of issues beyond use (Bahorik et al., 2017; Compton et al., 2014; Poorolajal et al., 2016). Thus, there exists a need to concurrently examine and address the potentially complex nature of client substance use and misuse.

Implications of Substance Use and Misuse

Substance use and misuse carries numerous potential repercussions. Societally, substance use and misuse consequences exceed “$400 billion in crime, health, and lost productivity” (U.S. Department of Health and Human Services, 2016, p. 2). Published data on those incarcerated appears to be several years old. However, it does suggest that more than 60% had a substance use disorder and 20% were under the influence at the time of their offense (National Center on Addiction and Substance Abuse at Columbia University, 2010). Regrettably, most do not receive treatment while incarcerated (Belenko et al., 2013). Additionally, many individuals who engage in substance use and misuse have co-occurring major medical conditions, such as cancers, cardiovascular accidents (strokes), and respiratory and cardiac illnesses (Bahorik et al., 2017). This population often experiences stigma and suboptimal health care results (McNeely et al., 2018; van Boekel et al., 2013). Substance use and misuse has significant impact on the occupational sector as well. Substance use and misuse has been correlated with both higher rates of absenteeism and workplace injuries (Bush & Lipari 2015). Those who engage in substance use and misuse often have higher rates of unemployment (Compton et al., 2014; Dieter, 2011). This can result in lack of access to treatment services, contributing to increased stress.

Substance use and misuse also has a negative impact on intimate partners, such as assuming increased responsibility and navigating unpredictability (Hussaarts et al., 2012). More ominously, substance use and misuse has been correlated with intimate partner violence (Murphy & Ting, 2010). Further, substance use and misuse is a significant risk factor for suicidality (Poorolajal et al., 2016). Finally, the number of U.S. adults with a comorbid SUD and mental illness has been shown to be almost 8 million, with only about 5% receiving treatment for both (SAMHSA, 2017). Concurrently treating both is very complex, challenging, and expensive. This can be even more problematic given the lack of health care access for large numbers of Americans (Schoen, 2013).

A Holistic Alternative

Addressing client substance use and misuse can be quite complicated, and as mentioned previously, substance use and misuse impacts users and society in a variety of ways beyond substance intake. There are several approaches to managing client substance use and misuse that have demonstrated effectiveness. Among those are 12-step programs (Humphreys et al., 2004), mindfulness-based interventions (Chiesa & Serretti, 2014), evidence-based approaches such as cognitive behavioral therapy (McHugh et al., 2010), and family counseling (O’Farrell & Clements, 2012). These approaches can be accomplished via outpatient counseling, partial hospitalization programs, inpatient and medically managed substance treatment programs, as well as residential and therapeutic communities. However, each has some shortcomings. Twelve-step attendance is most beneficial with inpatient substance use and misuse treatment (Karriker-Jaffe et al., 2018). Evidence-based approaches, such as cognitive behavioral therapy, tend to be nomothetic, assuming homogeneity and generally geared toward symptom amelioration (Robinson, 2011). Mindfulness-based strategies are not as effective when used alone as when used with other approaches (Sancho et al., 2018). Research on the success of family-based interventions has methodological challenges, such as small sample sizes and the difficulty of examining long-term outcomes (Rowe, 2012).

In addition, using these approaches may result in omitting the uniqueness of clients as a consideration in treatment. SAMHSA (2020) pointed out the significance of addressing clients individually based on their distinctive needs in order to provide the best chance for recovery from substance use and misuse. SAMHSA’s recommendations fit well with a more holistic framework in that such a structure allows clinicians to develop a multidimensional picture of clients. By examining and exploring clients’ use or misuse within the context of a multidimensional framework, interventions can be personalized, and areas of concern can be targeted. Such a framework may enhance the effectiveness of the aforementioned interventions (Wormer & Davis, 2018). Some of these evidence-based approaches will be demonstrated later in a case illustration.

As shown above, there are numerous ways to examine and treat client substance use and misuse. For example, some interventions use an individual lens, such as cognitive behavioral therapy, which examines connections between thoughts, feelings, and behaviors (Morin et al., 2017). Other approaches observe substance use and misuse from a family or systems perspective, looking at familial patterns such as communication and normalization of substance use (Bacon, 2019). Delivery of mindfulness-based interventions may help to address stressful events that previously triggered substance use (Garland et al., 2014). In addition, there are frameworks that use a formulation model examining various aspects of clients (Johnstone & Dallos, 2013) such as causal, contributing, environmental, and personal features, providing a much more expansive view of clients’ concerns.

Client substance use and misuse can be quite challenging for counselors, both novice and experienced. Case formulation, also referred to as conceptualization, is a skill new counselors often lack (Liese & Esterline, 2015). Using a framework to assist in case formulation may prove useful to beginning counselors. Experienced counselors, even with competence in a variety of approaches, can also benefit from using a framework to help address anticipated challenges (Macneil et al., 2012). Case formulations have been used in a number of areas such as those with psychosis, anxiety, and trauma (Chadwick et al., 2003; Ingram, 2012; Persons et al., 2013). One such framework is the Five Ps (Macneil et al., 2012). Macneil and his colleagues (2012) posited that diagnosing was insufficient and it was critical to include other factors such as causal, lifestyle, and personal factors in conceptualizing the case and formulating a plan. Applying this approach with clients who engage in substance use and misuse would allow more individual and flexible ways to intervene with client substance use and misuse. In addition, the collaborative nature of the Five Ps reinforces the concept of an idiographic formulation. This is in keeping with the inherent uniqueness of clients, their concerns, and a variety of factors.

The Five Ps is a type of framework utilizing five factors developed by Macneil et al. (2012). They conceptualized a way to look at clients and their problems, systematically and holistically taking into consideration the (1) Presenting problem, (2) Predisposing factors, (3) Precipitating factors, (4) Perpetuating factors, and (5) Protective factors. Presenting problems are concerns that clients find difficult to manage. Predisposing factors include biological, environmental, or personality considerations that may put clients at risk of further substance use and misuse. Precipitating factors are those that proximally bring about substance use and misuse and its resulting difficulties. Perpetuating factors are those that sustain and possibly reinforce clients’ current substance use and misuse challenges. Protective factors are those that help to moderate actual or potential substance use and misuse impact. The Five Ps framework promotes a very clear and systematic approach to case formulation or assessment that potentially provides a wealth of data. It also provides opportunities for a variety of interventions and strategies targeted to clients and their substance use and misuse or contributing factors.

Given the variations of substances, the level of use, the functional impairment, co-occurrence with other mental disorders, and inherent client differences, an idiographically based framework seems particularly appropriate with this population. The Five Ps permits counselors to both assess and intervene essentially simultaneously. It allows for client individualization, use of a variety of strategies, ongoing assessment, and modifications as needed. Furthermore, the Five Ps helps clients and counselors explore relationships between each factor and the presenting problem. This framework is idiographic in nature, as it looks at clients individually and holistically (Marquis & Holden, 2008). Idiographic case formulation can be useful for complicated cases, such as those encountered with clients engaged in substance use and misuse (Haynes et al., 1997). It is systematic, while allowing for flexibility and creativity. It can be used in outpatient, inpatient, and residential settings and possibly as part of an aftercare program.

Following is a case illustration demonstrating how the Five Ps may be helpful in formulating and engaging in a clinical application. It should be noted that several evidence-based substance use and misuse approaches were integrated in an eclectic approach throughout the case example to demonstrate the idiographic nature of the Five Ps. Many formulation models are administered within a cognitive behavioral grounding (Chadwick et al., 2003; Easden & Kazantzis, 2018; Persons et al., 2013). The Five Ps does not adhere to any particular theoretical orientation, thus allowing for a greater repertoire of strategies to draw from to help clients with substance use and misuse.

Implementing the Five Ps: The Case of Dax

A brief description of Dax, a hypothetical client, and the events that prompted him to seek services is followed by a detailed application of the Five Ps in addressing Dax’s substance use and misuse. It should be noted that the strategies and interventions applied here are used as illustrations and are specific to Dax and his concerns. In addition, the interventions demonstrated are not to be assumed the only ones that can be applied to Dax. They are examples that the author chose to illustrate the Five Ps in practice.

Dax is a 33-year-old married father of two children: a 9-year-old son, Cam, and a 7-year-old daughter, Zoe. He was recently driving home from work in the evening and law enforcement stopped him because of erratic driving. The officers evaluated him, detained him, and subsequently arrested him for driving while intoxicated. As part of his adjudication, Dax was required to attend five counseling sessions and have a clinician’s report provided to the court. Dax presents as extremely frustrated and embarrassed at being mandated to attend counseling sessions. He is confident that he does not have a problem and that counseling should be reserved for those who cannot stop drinking. Dax drinks two to three times a week, usually having one or two shots of whiskey and two to three draft beers. The night he was pulled over, he had had two additional beers and one additional shot of whiskey on top of his usual consumption after a telephone argument with his wife, Sara. Additionally, he reports significant stress and conflict in his marriage as well as concerns over some upcoming diagnostic tests for their daughter related to a heart murmur. Dax denies any other negative consequences from his alcohol use. He denies any significant increase in alcohol use or any other substance use. Presenting Problem While being mandated to attend counseling, Dax shares concerns that he is afraid of what his daughter’s test results will show. He fears that she will need open-heart surgery and that she may die. The clinician can intervene here by simply normalizing and validating his fears about the test results. A logical analysis using gentle Socratic dialogue may help to challenge his emotional reactions to his daughter’s heart murmur (Etoom & Ratnapalan, 2014). In addition, mindfulness strategies can assist in helping Dax to cognitively diffuse from present to future events (Harris, 2019). He is also adamant that he does not have a problem with alcohol. Here, a conversation about what counseling entails as well as psychoeducation related to the effects of alcohol on executive functioning may prove beneficial (Day et al., 2015). Acknowledging that his reticence is due to being obligated to attend counseling may assist in relationship building (Tahan & Sminkey, 2012). The clinician may also seek more information on the cause of the reported stress between him and his wife.

Predisposing Factors Dax reports a strong paternal history of substance use and misuse. His father started out drinking occasionally and over the years slowly developed a dependency on alcohol. Dax further reports his paternal grandfather died from liver failure. Addressing the potential genetic link to substance use and misuse may prove beneficial in raising Dax’s awareness (Dick & Agrawal, 2008). For example, the clinician may ask Dax if they can share how genes are passed on and expressed, like genes for eye color or hypertension. This may open the door to a conversation regarding how his substance use and misuse may progress to alcohol use disorder and its definition as a pattern of alcohol use leading to clinically significant problems, including increase in use, failed attempts to stop, and use leading to an impaired ability to meet role obligations (American Psychiatric Association, 2013). There could be a discussion of alcohol use disorder being a disease, not that different from any other passed-on trait or disease. Additionally, Dax often struggles with strong and painful emotions, and alcohol helps to address them. Here the clinician may utilize strategies drawn from acceptance and commitment therapy related to his control strategy of using alcohol to avoid his emotions (Harris, 2019). The ball in the pool metaphor (i.e., holding a beach ball under the water works temporarily, but eventually it pops back up) can be compared to alcohol temporarily holding those painful emotions down, eventually to resurface. The clinician may also discuss strategies to help Dax regulate his reactions using emotion-focused interventions such as positive reframing to ameliorate the stress of his daughter’s cardiac condition (Plate & Aldao, 2017).

Precipitating Factors This area explores significant occurrences that preceded or triggered the presenting problem and its consequences. Dax shares that he and his wife are conflicted about how to proceed with their daughter’s medical care. Sara is unequivocal in her confidence in Zoe’s cardiologist and his competence. Dax, however, is hyper-focused on surgery and seems to dismiss Sara’s position. At the end of his workday, he and his wife got into an argument over the phone about an upcoming diagnostic test and the possible results. Dax was quite upset, cursed at her, and then hung up the phone. He then stopped at a local pub and had several drinks.

Here, the clinician may use reality-based strategies that address choice and consequences (Wubbolding & Brickell, 2017). This may include a direct conversation about Dax’s decision to drink, resulting in his becoming impaired, with the consequence of being detained, charged, and adjudicated. Dax can then share his and his wife’s perspectives on their daughter’s care. This conversation can lead to investigating strategies for how each can be heard, including short role-plays with opportunities to practice (Worrell, 2015). The clinician can provide a variety of potential spousal responses, allowing for more adaptability and flexibility in Dax’s responses. The goal here is to build Dax’s competence in communicating, both in listening and expressing. Additionally, there may be a discussion using aspects of existentialism to process inherent anxiety and its connection to unknowable future events (May, 1950; Wu et al., 2015).

Perpetuating Factors The emphasis here is on features that continue the presenting problem. For Dax, he shares that when he and his wife argue, it follows a very predictable pattern. They disagree, interrupt one another, yell, and he calms down by having several beers. He then withdraws and becomes sullen for a few days. Nothing gets resolved, and this cycle appears once again when they have conflict.

The clinician may discuss the concept of circularity and assist in moving from “vicious cycles” to “virtuous cycles and problem resolution” (Walsh, 2014, p. 162). This involves explaining that interactions can act as a kind of back-and-forth loop of action–reaction–action without any resolution, leaving both parties feeling unheard, misunderstood, and frustrated. The goals here are to both break the pattern and to facilitate healthy conversations. Here the clinician may incorporate a solution-focused strategy exploring a time with Dax when he and his wife have disagreed, but he did not interrupt and the outcome was positive (de Shazer, 1985). If he cannot identify a time, simple role-plays in which Dax does not interrupt or yell and instead experiences different outcomes may provide optimism to Dax. The counselor may also assist Dax in emotional regulation, which may prevent the initiation of arguments (Aldao & Nolen-Hoeksema, 2013). In addition, aspects of narrative therapy may provide an opportunity for Dax to re-author a unique outcome that gives meaning and provides a functional identity to him as a father and husband, thus building a sense of optimism (White & Epston, 1990).

Protective Factors Here the focus is on investigating resources and/or supports that may help prevent client substance use and misuse from further becoming problematic. This factor has generally been underutilized despite being shown as beneficial to clients (Kuyken et al., 2009). This is often the opportunity for the client to share what may help them move forward, what their assets are, who can support them, and any other self-identified skills (de Shazer, 1985). These can be in the form of personal characteristics such as tenacity, intellect, or insight. They may also present in the form of family, friends, or hobbies. Oftentimes, when the topic of protective factors is used in substance use and misuse, it is related to deterrence of substance use, notably with adolescents (Liao et al., 2018). In the Five Ps context, protective factors are used to potentially prevent substance use and misuse from having more negative impact as well as to increase client resilience. This factor differs markedly from the first four. Protective factors move away from the problem areas that need interventions to hope and optimism and look to future success and competence (Macneil et al., 2012). Once the protective factors are identified, the ensuing conversation provides opportunities to imagine future outcomes in which protective factors may come into play should situations occur that the client finds problematic. Second, it also tends to shift the conversation toward what is present and going well in their lives and away from those areas that cause distress and suffering (de Shazer, 1985).

In implementing the Five Ps framework with Dax, the clinician chose to use psychoeducation and strategies borrowed from acceptance and commitment, reality, Bowenian family systems, and solution-focused brief therapies to assist Dax with his substance use and misuse. The choice of the above approaches is only meant as an illustration and not as definitive ways to address this particular client. It is likely that other clinicians presented with Dax would use a different combination of approaches. The Five Ps is a systematic way to look at clients and their presentation, and its idiographic construction takes clients’ uniqueness into account. It also allows clinicians to target specific areas of concern (Macneil et al., 2012) and may be used in a variety of clinical settings. Moreover, the Five Ps align with SAMHSA’s recommendation that clinicians tailor treatment to each client because no single treatment is particularly superior (SAMHSA, 2020).

Limitations and Future Research

There are limitations to the Five Ps framework as a way to formulate and intervene with clients’ substance use and misuse. First and foremost, it should be emphasized that this particular framework has not been empirically tested with client substance use and misuse. However, as mentioned previously, case formulations have been used across a variety of client concerns (Chadwick et al., 2003; Ingram, 2012; Persons et al., 2013). Another potential limitation is that the Five Ps may not be particularly beneficial for substance use and misuse in which there is clinical evidence of an SUD that includes significant withdrawal symptoms. Client substance use and misuse at that level may need medical stabilization and detoxification prior to utilization of the Five Ps. In addition, there may be clients who are simply not ready or able to address some or most of the dimensions of the Five Ps. Furthermore, clients like Dax who are mandated to attend substance-related counseling may have service plans that are not congruent with the Five Ps framework. In spite of these limitations, there may be several potential areas of inquiry.

Previous studies using frameworks to formulate have often used cognitive behavioral therapy as the primary intervention (Chadwick et al., 2003; Persons et al., 2013). Given that client substance use and misuse can be quite complicated, using various approaches within the Five Ps framework may yield positive results. As Chadwick et al. (2003) noted, examining positive client experiences may be one way to discover how to increase client participation in substance use and misuse treatment. Another potential area of study might involve comparing novice counselors to more experienced counselors. As mentioned previously, novice counselors often lack sufficient case formulation skills (Liese & Esterline, 2015). Examining the two groups’ experiences using the Five Ps may provide insight to assist counselor training programs related to substance use and misuse skill development. The implementation of the Five Ps with clients with mild substance use and misuse and those with more significant substance use and misuse, possibly using the DSM-5 diagnosis for SUD, may be another area to explore. This research could point to populations for whom the Five Ps is more and less effective. Studies utilizing the Five Ps with mandated clients may demonstrate its efficacy, notably with agencies that require substance-related counseling.

Client substance use and misuse is a significant problem in the United States, and it continues to cause difficulty for individuals, families, and society. There are numerous methods and combinations of methods to address substance use and misuse, such as family therapy, cognitive behavioral therapy, and self-help groups. Their effectiveness has been well researched, and this paper does not propose a superior way to address substance use and misuse. However, the Five Ps presents a framework in which counselors can examine and intervene with client substance use and misuse using a variety of approaches and strategies. The Five Ps can be used in a variety of settings such as a community mental health agency, primary care clinic, and inpatient or residential treatment centers. The systematic but flexible nature of this framework affords clinicians numerous ways to address substance use and misuse. For some, receiving substance use and misuse services can be stigmatizing. In fact, this stigmatization can come from those who are treating them (Luoma et al., 2007). In addition, the vast majority of those with an SUD never receive treatment (Han et al., 2015). Incorporating the Five Ps, with its holistic framework, may prove attractive to clients and counselors, thus potentially increasing the numbers of clients engaged in substance use and misuse treatment. As mentioned previously, the Five Ps is not meant to replace any other substance use and misuse intervention. It is another way to address the multifaceted and complicated nature of client substance use and misuse. Novice clinicians, who often have a more limited repertoire of strategies, may find the Five Ps valuable because of its systematic framework to clients. Experienced clinicians understandably have a larger catalogue of strategies to choose from. However, they may find this framework valuable as it provides one more way to address the often-encountered complex challenges of substance use and misuse.

Conflict of Interest and Funding Disclosure The authors reported no conflict of interest or funding contributions for the development of this manuscript.

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(2012). Clinical case formulations: Matching the integrative treatment plan to the client (2nd ed.). Wiley. Johnstone, L., & Dallos, R. (Eds.). (2013). Formulation in psychology and psychotherapy: Making sense of people’s problems (2nd ed.). Routledge. Karriker-Jaffe, K. J., Klinger, J. L., Witbrodt, J., & Kaskutas, L. A. (2018). Effects of treatment type on alcohol consumption partially mediated by Alcoholics Anonymous attendance. Substance Use & Misuse, 53(4), 596–605. https://doi.org/10.1080/10826084.2017.1349800 Kleiman, M. A. R., Caulkins, J. P., & Hawken, A. (2011). Drugs and drug policy: What everyone needs to know. Oxford University Press. Kuyken, W., Padesky, C. A., & Dudley, R. (2009). Collaborative case conceptualization: Working effectively with clients in cognitive-behavioral therapy. Guilford. Liao, J.-Y., Huang, C.-M., Lee, C. T.-C., Hsu, H.-P., Chang, C.-C., Chuang, C.-J., & Guo, J.-L. (2018). Risk and protective factors for adolescents’ illicit drug use: A population-based study. Health Education Journal, 77(7), 749–761. https://doi.org/10.1177/0017896918763462 Liese, B. S., & Esterline, K. M. (2015). Concept mapping: A supervision strategy for introducing case conceptualization skills to novice therapists. Psychotherapy, 52(2), 190–194. https://doi.org/10.1037/a0038618 Linden, D. J. (2011). The compass of pleasure: How our brains make fatty foods, orgasm, exercise, marijuana, generosity, vodka, learning, and gambling feel so good. Penguin. Luoma, J. B., Twohig, M. P., Waltz, T., Hayes, S. C., Roget, N., Padilla, M., & Fisher, G. (2007). An investigation of stigma in individuals receiving treatment for substance abuse. Addictive Behaviors, 32(7), 1331–1346. https://doi.org/10.1016/j.addbeh.2006.09.008 Macneil, C. A., Hasty, M. K., Conus, P., & Berk, M. (2012). Is diagnosis enough to guide interventions in mental health? Using case formulation in clinical practice. BMC Medicine, 10(111), 1–3. https://doi.org/10.1186/1741-7015-10-111 Marquis, A., & Holden, J. (2008). Mental health professionals’ evaluations of the Integral Intake, a metatheory-based, idiographic intake instrument. Journal of Mental Health Counseling, 30(1), 67–94. https://doi.org/10.17744/mehc.30.1.j40256207h0581t1 May, R. (1950). The meaning of anxiety. Ronald Press. McHugh, R. K., Hearon, B. A, & Otto, M. W. (2010). Cognitive behavioral therapy for substance use disorders. Psychiatric Clinics of North America, 33(3), 511–525. https://doi.org/10.1016/j.psc.2010.04.012 McNeely, J., Kumar, P. C., Rieckmann, T., Sedlander, E., Farkas, S., Chollak, C., Kannry, J. L., Vega, A., Waite, E. A., Peccoralo, L. A., Rosenthal, R. N., McCarty, D., & Rotrosen, J. (2018). Barriers and facilitators affecting the implementation of substance use screenings in primary care clinics: A qualitative study of patients, providers, and staff. Addiction Science and Clinical Practice, 13(8), 1–15. https://doi.org/10.1186/s13722-018-0110-8 Morin, J.-F. G., Harris, M., & Conrod, P. J. (2017). A review of CBT treatments for substance use disorders. Oxford Handbooks Online, 1–49. https://doi.org/10.1093/oxfordhb/9780199935291.013.57 Murphy, C. M., & Ting, L. (2010). The effects of treatment for substance use problems on intimate partner violence: A review of empirical data. Aggression and Violent Behavior, 15(5), 325–333. https://doi.org/10.1016/j.avb.2010.01.006 National Center on Addiction and Substance Abuse at Columbia University. (2010, February). Behind bars II: Substance abuse and America’s prison population. https://www.centeronaddiction.org/addiction-research/reports/behind-bars-ii-substance-abuse-and-america’s-prison-population O’Farrell, T. J., & Clements, K. (2012). Review of outcome research on marital and family therapy in treatment for alcoholism. Journal of Marital and Family Therapy, 38(1), 122–144. https://doi.org/10.1111/j.1752-0606.2011.00242.x Persons, J. B., Lemle Becker, V., & Tompkins, M. A. (2013). Testing case formulation hypotheses in psychotherapy: Two case examples. Cognitive and Behavioral Practice, 20(4), 399–409. https://doi.org/10.1016/j.cbpra.2013.03.004 Plate, A. J., & Aldao, A. (2017). Emotion regulation in cognitive-behavioral therapy: Bridging the gap between treatment studies and laboratory experiments. In S. G. Hofmann & G. J. G. Asmundson (Eds.), The science of cognitive behavioral therapy (pp. 107–127). Academic Press. Poorolajal, J., Haghtalab, T., Farhadi, M., & Darvishi, N. (2016). Substance use disorder and risk of suicidal ideation, suicide attempt and suicide death: A meta-analysis. Journal of Public Health, 38(3), e282–e291. https://doi.org/10.1093/pubmed/fdv148 Robinson, O. C. (2011). The idiographic/nomothetic dichotomy: Tracing historical origins of contemporary confusions. History & Philosophy of Psychology, 13(2), 32–39. Rowe, C. L. (2012). Family therapy for drug abuse: Review and updates 2003–2010. Journal of Marital and Family Therapy, 38(1), 59–81. https://doi.org/10.1111/j.1752-0606.2011.00280.x Sancho, M., De Gracia, M., Rodríguez, R. C., Mallorquí-Bagué, N., Sánchez-González, J., Trujols, J., Sánchez, I., Jiménez-Murcia, S., & Menchón, J. M. (2018). Mindfulness-based interventions for the treatment of substance and behavioral addictions: A systematic review. Frontiers in Psychiatry, 9, 1–9. https://doi.org/10.3389/fpsyt.2018.00095 Schoen, C., Osborn, R., Squires, D., & Doty, M. M. (2013). Access, affordability, and insurance complexity are often worse in the United States compared to ten other countries. Health Affairs, 32(12), 2205–2215. https://doi.org/10.1377/hlthaff.2013.0879 Substance Abuse and Mental Health Services Administration. (2017, September 7). Results from the 2016 National Survey on Drug Use and Health: Detailed tables. https://www.samhsa.gov/data/report/results-2016-national-survey-drug-use-and-health-detailed-tables Substance Abuse and Mental Health Services Administration. (2020, April 21). Behavioral health treatments and services. https://www.samhsa.gov/treatment Tahan, H. A., & Sminkey, P. V. (2012). Motivational interviewing: Building rapport with clients to encourage desirable behavioral and lifestyle changes. Professional Case Management, 17(4), 164–172. https://doi.org/10.1097/NCM.0b013e318253f029 U.S. Department of Health and Human Services. (2016). Facing addiction in America: The Surgeon General’s report on alcohol, drugs, and health. https://addiction.surgeongeneral.gov/sites/default/files/surgeon-generals-report.pdf van Boekel, L. C., Brouwers, E. P. M., van Weeghel, J., & Garretsen, H. F. L. (2013). Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: Systematic review. Drug and Alcohol Dependence, 131(1–2), 23–35. https//doi.org/10.1016/j.drugalcdep.2013.02.018 Van Wormer, K., & Davis, D. R. (2018). Addiction treatment: A strengths perspective (4th ed.). Cengage. Walsh, F. (2014). Family therapy: Systemic approaches to practice. In J. R. Brandell (Ed.), Essentials of clinical social work (pp. 160–185). SAGE. White, M., & Epston, D. (1990). Narrative therapy to therapeutic ends. W. W. Norton. Worrell, M. (2015). Cognitive behavioural couple therapy. Routledge. Wu, J. Q., Szpunar, K. K., Godovich, S. A., Schacter, D. L., & Hofmann, S. G. (2015). Episodic future thinking in generalized anxiety disorder. Journal of Anxiety Disorders, 36, 1–8. https://doi.org/10.1016/j.janxdis.2015.09.005 Wubbolding, R. E., & Brickell, J. (2017). Counselling with reality therapy (2nd ed.). Routledge.

Scott W. Peters, PhD, LPC-S, is an associate professor at Texas A&M University – San Antonio. Correspondence may be addressed to Scott Peters, One University Way, San Antonio, TX 78224, [email protected].

what is a case formulation in social work

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Case formulation

Case formulation involves the gathering of information regarding factors that may be relevant to treatment planning, and formulating a hypothesis as to how these factors fit together to form the current presentation of the client’s symptoms [410, 411]. The case formulation process should be collaborative, in that the AOD worker contextualises the client’s experiences and knowledge of themselves within their own clinical expertise [410]. The primary goal of AOD treatment services is to address clients’ AOD use. However, in order to do so effectively, AOD workers must take into account the broad range of issues with which clients present. As discussed in Chapter A2 , clients of AOD treatment services, and those with co-occurring conditions in particular, often have a variety of other medical, family, and social problems (e.g., housing, employment, welfare, or legal problems). These problems may be the product of the client’s AOD and mental health conditions, or they may be contributing to the client’s AOD and mental health conditions, or both. According to stress-vulnerability models (e.g., Zubin and Spring [412]), the likelihood of developing a mental health condition is influenced by the interaction of biological, psychological, and social factors. These factors also affect a person’s ability to recover from these symptoms and the potential for relapse.

After developing a case formulation, the AOD worker should be aware of:

  • What problems exist, how they developed, and how they are maintained.
  • All aspects of the client’s presentation, current situation, and the interaction between these different factors and problems.

This information should be considered the first step to devising (and later revising) the client’s treatment plan. There is no standardised approach to case formulation [413], but it is crucial that a range of different dimensions be considered. These include the history of presenting issue/s, AOD use history (type, amount and frequency, presence of disorder), physical/medical conditions, mental state, psychiatric history, trauma history, suicidal or violent thoughts, readiness to change, family history, criminal history, and social and cultural issues. Consideration also needs to be given to the client’s age, gender identity, sexual orientation, ethnicity, spirituality, socioeconomic status, and cognitive abilities.

Given the high rates of co-occurring mental health conditions among clients of AOD treatment services, it is essential that routine screening and assessment be undertaken for these conditions as part of case formulation. Screening is the initial step in the process of identifying possible cases of co-occurring conditions [200, 414]. This process is not diagnostic (i.e., it cannot establish whether a disorder actually exists); rather, it identifies the presence of symptoms that may indicate the presence of a disorder. Thus, screening helps to identify people whose mental health requires further investigation by a professional trained and qualified in diagnosing mental disorders (e.g., registered or clinical psychologists, or psychiatrists).

Abstinence is not required to undertake the screening process [415]. The potential clinical issues that these conditions can present suggest that screening for co-occurring mental health conditions should always be completed in the initial phases of AOD treatment. Early identification allows for early intervention, which may lead to better prognosis, more comprehensive treatment, and the prevention of secondary disorders [406, 416, 417].

Diagnostic assessment should ideally occur subsequent to a period of abstinence [418, 419], or at least when the person is not intoxicated or withdrawing [420]. While the length of this period is not well established, a stabilisation period of between two to four weeks is recommended [421, 422]. A lengthier period of abstinence is recommended for longer-acting drugs, such as methadone and diazepam, before a diagnosis can be made with any confidence, whereas shorter-acting drugs such as cocaine and alcohol require a shorter period of abstinence [39, 418]. If symptoms persist after this period, they can be viewed as independent rather than AOD-induced.

In practice, however, such a period of abstinence is rarely afforded in AOD treatment settings and, therefore, to avoid possible misdiagnosis, it has been recommended that multiple assessments be conducted over time [102, 423, 424]. This process allows the AOD worker to formulate a hypothesis concerning the client’s individual case and to constantly modify this formulation, allowing for greater accuracy and flexibility in assessment.

Screening and assessment are ongoing processes rather than one-off events, which involve the monitoring of clients’ mental health symptoms. Ongoing screening and assessment are important because clients’ mental health symptoms may change throughout treatment. For example, a person may present with symptoms of anxiety and/or depression upon treatment entry; however, these symptoms may subside with abstinence. Alternatively, a person may enter treatment with no mental health symptoms, but symptoms may develop after a period of reduced use or abstinence, particularly if the person has been using substances to self-medicate these symptoms.

Groth-Marnat [425] suggests that a combination of both informal and standardised assessment techniques is the best way to develop a case formulation, though some researchers also suggest that building a formulation framework using the 5Ps model may be useful [389, 426]. In this framework, case formulation is determined by identifying the ‘5Ps’ [427]:

  • P resenting issues.
  • P redisposing factors.
  • P recipitating factors.
  • P erpetuating factors.
  • P rotective factors.

Figure 12 depicts how both informal and standardised assessment techniques work together. In addition to these assessments, with the client’s consent, it may be useful to talk with family members, friends, or carers; they can provide invaluable information regarding the client’s condition which the client may not recognise or may not want to divulge, provide support to the client, and improve treatment outcomes (see Chapter A3 ) [428, 429].

Figure 12: The ongoing case formulation process

Note: Figure 12 illustrates the need for assessment to be repeated throughout treatment, from intake through to discharge, to inform the ongoing revision of a person's treatment plan.

An example of how the 5Ps model can be used to build a case formulation, with Lena’s case study (Box 12) and the case formulation template ( Appendix F ), is illustrated in Table 23. This is just one example of how AOD workers may develop a case formulation, and not all client factors will necessarily apply to the template

Box 12: Case study L: Example case formulation: Lena’s story

Adapted from PsychDB [430].

An example of how Lena’s presenting issues, predisposing, precipitating, perpetuating and protective factors may be developed into a case formulation is illustrated in Table 23. As biological and social factors often influence psychological symptoms, it can be useful to complete the biological and social sections of the table first, followed by the psychological section last.

Table 23: Example of a case formulation for Lena

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  1. Printable case formulation template Templates to Submit Online in PDF

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  2. The Case Formulation Approach to Cognitive-Behavior Therapy

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  2. Case Studies

COMMENTS

  1. How to Write a Case Conceptualization: 10 Examples (+ PDF)

    References What Is a Case Conceptualization or Formulation? In psychology and related fields, a case conceptualization summarizes the key facts and findings from an evaluation to provide guidance for recommendations.

  2. PDF Using DSM-5 in Case Formulation and Treatment Planning

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  3. Biopsychosocial Model and Case Formulation

    The Biopsychosocial Model and Case Formulation (also known as the Biopsychosocial Formulation) in psychiatry is a way of understanding a patient as more than a diagnostic label. Hypotheses are generated about the origins and causes of a patient's symptoms.

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    A case formulation content coding method is described and applied to the formulation section of 56 intake evaluations randomly selected from an outpatient psychiatric clinic. The coding manual showed good reliability (mean kappa = 0.86) across content and quality categories. Although 95% of the formulations included descriptive infor- mation ...

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  6. An Integrated Case Formulation in Social Work: Toward Developing a

    Next, using a clinical case example, we illustrate an integrated case formulation in clinical social work practice, which comprehensively assesses a client-in-context from psychodynamic, behavioral, and cognitive approaches. We also delineate how social workers can directly link this integrated assessment to selecting the integrated treatment ...

  7. Social Work Assessment: Case Theory Construction

    To intervene effectively, social workers need to make sense of clients and their situations. A case theory approach to assessment provides a framework to formulate assessments that are clear and directly related to the real-world problems clients present Explaining the problem situation, case theory forms the foundation for selection of Intervention strategies and methods to achieve change.

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  12. An Integrated Case Formulation in Social Work: Toward Developing a

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  13. Case Formulation in Cognitive-Behavioral Therapy: A Principle-Driven

    A case formulation should provide a coherent summary and explanation of a client's symptoms and problems. It should include the following components (Persons, 2008): Problems: Psychological symptoms and features of a disorder, and related problems in various areas of life—social, interpersonal, academic, occupational.

  14. The Process of Facilitating Case Formulations in Relational Clinical

    Similarly, social work scholars Dean and Poorvu define formulations "as a focused, brief conceptualization of the client or situation based on the assessment" (p. 597). Case formulation is therefore a necessary blueprint for the intervention strategy and has an important relationship to the form of treatment offered (McWilliams 1999 ).

  15. An integrated case formulation in social work: Toward developing a

    An integrated case formulation in social work: Toward developing a theory of a client. Citation Lee, E., & Toth, H. (2016). An integrated case formulation in social work: Toward developing a theory of a client. Smith College Studies in Social Work, 86 (3), 184-203. https:// https://doi.org/10.1080/00377317.2016.1191804 Abstract

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  18. An integrated case formulation in social work: toward developing a

    The authors also delineate how social workers can directly link this integrated assessment to selecting the integrated treatment options to custom-fit with the idiosyncratic needs of the client. This formulation is then truly client-centred. Thus, formulating a case is developing a theory of a client.

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  21. Assessment and Formulation: A Contemporary Social Work Perspective

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  22. An overview of case formulation

    Case formulation involves the gathering of information regarding factors that may be relevant to treatment planning, and formulating a hypothesis as to how these factors fit together to form the current presentation of the client's symptoms [410, 411].

  23. An Integrated Case Formulation in Social Work: Toward Developing a

    Next, using a clinical case example, we illustrate an integrated case formulation in clinical social work practice, which comprehensively assesses a client-in-context from psychodynamic, behavioral, and cognitive approaches. We also delineate how social workers can directly link this integrated assessment to selecting the integrated treatment ...