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An integrated case formulation in social work: toward developing a theory of a client.

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Acknowledging the limitations of adhering to one particular theoretical orientation in helping clients with multiple issues, psychotherapy integration in treatment becomes a prominent trend in clinical practice. However, we have few guidelines for an integrated case formulation . Also, there have been some concerns that available treatment options limit and even pre-determine how clinicians understand and formulate cases. In order to address these concerns, this article first critically reviews the psychotherapy integration movement and highlights social work contributions to this movement. 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 options to custom-fit with the idiosyncratic needs of the client. This formulation is then truly client-centered. Thus, formulating a case is developing a theory of a client .

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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

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.

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.

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.


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.

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

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).

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

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 .

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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.

what is a case formulation in social work

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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:

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.

what is a case formulation in social work

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).

Example: 4 Ps Table Formulation of Jane Doe

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:

Example: Narrative Formulation of Jane Doe

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 ):

Example: Advanced Formulation of Jane Doe

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

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

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:

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:

Beyond the Biopsychosocial Model

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:

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.

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:

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 )


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

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.


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:


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.

Counseling Today

A Publication of the American Counseling Association

Counseling today , knowledge share, case conceptualization: key to highly effective counseling.

By Jon Sperry and Len Sperry December 7, 2020

what is a case formulation in social work

After processing this session in supervision, the intern was no longer surprised that Jane had not kept a follow-up appointment. The initial session had occurred near the end of the intern’s second week, and she had been eager to practice cognitive disputation, which she believed was appropriate in this case. In answer to the supervisor’s question of why she had concluded this, the intern responded that “it felt right.”

The supervisor was not surprised by this response because the intern had not developed a case conceptualization. With one, the intern could have anticipated the importance of immediately establishing an effective and collaborative therapeutic alliance and gently processing Jane’s emotional distress sufficiently before dealing with her guilt-producing thought.

This failure to develop an adequate and appropriate case conceptualization is not just a shortcoming of trainees, however. It is also common enough among experienced counselors.

What is case conceptualization?

Basically, a case conceptualization is a process and cognitive map for understanding and explaining a client’s presenting issues and for guiding the counseling process. Case conceptualizations provide counselors with a coherent plan for focusing treatment interventions, including the therapeutic alliance, to increase the likelihood of achieving treatment goals.

We will use the definition from our integrated case conceptualization model to operationalize the term for the purposes of explaining how to utilize this process. Case conceptualization is a method and clinical strategy for obtaining and organizing information about a client, understanding and explaining the client’s situation and maladaptive patterns, guiding and focusing treatment, anticipating challenges and roadblocks, and preparing for successful termination.

We believe that case conceptualization is the most important counseling competency besides developing a strong therapeutic alliance. If our belief is correct, why is this competency taught so infrequently in graduate training programs, and why do counselors-in-training struggle to develop this skill? We think that case conceptualization can be taught in graduate training programs and that counselors in the field can develop this competency through ongoing training and deliberate practice.

This article will articulate one method for practicing case conceptualization.

The eight P’s

We use and teach the eight P’s format of case conceptualization because it is brief, quick to learn and easy to use. Students and counselors in the community who have taken our workshops say that the step-by-step format helps guide them in forming a mental picture — a cognitive map — of the client. They say that it also aids them in making decisions about treatment and writing an initial evaluation report.

The format is based on eight elements for articulating and explaining the nature and origins of the client’s presentation and subsequent treatment. These elements are described in terms of eight P’s: presentation, predisposition (including culture), precipitants, protective factors and strengths, pattern, perpetuants, (treatment) plan, and prognosis.


Presentation refers to a description of the nature and severity of the client’s clinical presentation. Typically, this includes symptoms, personal concerns and interpersonal conflicts.

Four of the P’s — predisposition, precipitants, pattern and perpetuants — provide a clinically useful explanation for the client’s presenting concern.


Predisposition refers to all factors that render an individual vulnerable to a clinical condition. Predisposing factors usually involve biological, psychological, social and cultural factors.

This statement is influenced by the counselor’s theoretical orientation. The theoretical model espouses a system for understanding the cause of suffering, the development of personality traits, and a process for how change and healing can occur in counseling. We will use a biopsychosocial model in this article because it is the most common model used by mental health providers. The model incorporates a holistic understanding of the client.

Biological: Biological factors include genetic, familial, temperament and medical factors, such as family history of a mental or substance disorder, or a cardiovascular condition such as hypertension.

Psychological: Psychological factors might include dysfunctional beliefs involving inadequacy, perfectionism or overdependence, which further predispose the individual to a medical condition such as coronary artery disease. Psychological factors might also involve limited or exaggerated social skills such as a lack of friendship skills, unassertiveness or overaggressiveness.

Social: Social factors could include early childhood losses, inconsistent parenting style, an overly enmeshed or disengaged family environment, and family values such as competitiveness or criticalness. Financial stressors can further exacerbate a client’s clinical presentations. The “social” element in the biopsychosocial model includes cultural factors. We separate these factors out, however.

Cultural: Of the many cultural factors, three are particularly important in developing effective case conceptualizations: level of acculturation, acculturative stress and acculturation-specific stress. Acculturation is the process of adapting to a culture different from one’s initial culture. Adapting to another culture tends to be stressful, and this is called acculturative stress. Such adaptation is reflected in levels of acculturation that range from low to high.

Generally, clients with a lower level of acculturation experience more distress than those with a higher level of acculturation. Disparity in acculturation levels within a family is noted in conflicts over expectations for language usage, career plans, and adherence to the family’s food choices and rituals. Acculturative stress differs from acculturation-specific stresses such as discrimination, second-language competence and microaggressions.


Precipitants refer to physical, psychological and social stressors that may be causative or coincide with the onset of symptoms or relational conflict. These may include physical stressors such as trauma, pain, medication side effects or withdrawal from an addictive substance. Common psychological stressors involve losses, rejections or disappointments that undermine a sense of personal competence. Social stressors may involve losses or rejections that undermine an individual’s social support and status. Included are the illness, death or hospitalization of a significant other, job demotion, the loss of Social Security disability payments and so on.

Protective factors and strengths

Protective factors are factors that decrease the likelihood of developing a clinical condition. Examples include coping skills, a positive support system, a secure attachment style and the experience of leaving an abusive relationship. It is useful to think of protective factors as being the mirror opposite of risk factors (i.e., factors that increase the likelihood of developing a clinical condition). Some examples of risk factors are early trauma, self-defeating beliefs, abusive relationships, self-harm and suicidal ideation.

Related to protective factors are strengths. These are psychological processes that consistently enable individuals to think and act in ways that benefit themselves and others. Examples of strengths include mindfulness, self-control, resilience and self-confidence. Because professional counseling emphasizes strengths and protective factors, counselors should feel supported in identifying and incorporating these elements in their case conceptualizations.

Pattern (maladaptive)

Pattern refers to the predictable and consistent style or manner in which an individual thinks, feels, acts, copes, and defends the self both in stressful and nonstressful circumstances. It reflects the individual’s baseline functioning. Pattern has physical (e.g., a sedentary and coronary-prone lifestyle), psychological (e.g., dependent personality style or disorder) and social features (e.g., collusion in a relative’s marital problems). Pattern also includes the individual’s functional strengths, which counterbalance dysfunction.


Perpetuants refer to processes through which an individual’s pattern is reinforced and confirmed by both the individual and the individual’s environment. These processes may be physical, such as impaired immunity or habituation to an addictive substance; psychological, such as losing hope or fearing the consequences of getting well; or social, such as colluding family members or agencies that foster constrained dysfunctional behavior rather than recovery and growth. Sometimes precipitating factors continue and become perpetuants.

Plan (treatment)

Plan refers to a planned treatment intervention, including treatment goals, strategy and methods. It includes clinical decision-making considerations and ethical considerations.

Prognosis refers to the individual’s expected response to treatment. This forecast is based on the mix of risk factors and protective factors, client strengths and readiness for change, and the counselor’s experience and expertise in effecting therapeutic change.  

Case example

To illustrate this process, we will provide a case vignette to help you practice and then apply the case to our eight P’s format. Ready? Let’s give it a shot.

Joyce is a 35-year-old Ph.D. student at an online university. She is white, identifies as heterosexual and reports that she has never been in a love relationship. She is self-referred and is seeking counseling to reduce her chronic anxiety and social anxiety. She recently started a new job at a bookstore — a stressor that brought her to counseling. She reports feeling very anxious when speaking in her online classes and in social settings. She is worried that she will not be able to manage her anxiety at her new job because she will be in a managerial role.

Joyce reports that she has been highly anxious since childhood. She denies past psychological or psychiatric treatment of any kind but reports that she has recently read several self-help books on anxiety. She also manages her stress by spending time with her close friend from class, spending time with her two dogs, drawing and painting. She appears to be highly motivated for counseling and states that her goals for therapy are “to manage and reduce my anxiety, increase my confidence and eventually get in a romantic relationship.”

Joyce describes her childhood as lonely and herself as “an introvert seeking to be an extrovert.” She states that her parents were successful lawyers who valued success, achievement and public recognition. They were highly critical of Joyce when she would struggle with academics or act shy in social situations. As an only child, she often played alone and would spend her free time reading or drawing by herself.

When asked how she views herself and others, Joyce says, “I often don’t feel like I’m good enough and don’t belong. I usually expect people to be self-centered, critical and judgmental.”

Case conceptualization outline

We suggest developing a case conceptualization with an outline of key phrases for each of the eight P’s. Here is what these phrases might look like for Joyce’s case. These phrases are then woven together into sentences that make up a case conceptualization statement that can be imported into your initial evaluation report.

Presentation: Generalized anxiety symptoms and social anxiety

Precipitant: New job and concerns about managing her anxiety

Pattern (maladaptive): Avoids cl oseness to avoid perceived harm


Perpetuants: Small support system; believes that she is not competent at work

Protective factors/strengths: Compassionate, creative coping, determined, hardworking, has access to various resources, motivated for counseling

Plan (treatment): Supportive and strengths-based counseling, thought testing, self-monitoring, mindfulness practice, downward arrow technique, coping and relationship skills training, referral for group counseling

Prognosis: Good, given her motivation for treatment and the extent to which her strengths and protective factors are integrated into treatment

Case conceptualization statement

Joyce presents with generalized anxiety symptoms and social anxiety (presentation) . A recent triggering event includes her new job at a local bookstore — she is concerned that she will make errors and will have high levels of anxiety (precipitant) . She presents with an avoidant personality — or attachment — style and typically avoids close relationships. She has one close friend and has never been in a love relationship. She typically moves away from others to avoid being criticized, judged or rejected (pattern) . Some perpetuating factors include her small support system and her belief that she is not competent at work (perpetuants) .

Some of her protective factors and strengths include that she is compassionate, uses art and music to cope with stress, is determined and hardworking, and is collaborative in the therapeutic relationship. Protective factors include that she has a close friend from school, has access to university services such as counseling services and student clubs and organizations, is motivated to engage in counseling, and has health insurance (strengths & protective factors) .

The following biopsychosocial factors attempt to explain Joyce’s anxiety symptoms and avoidant personality style: a paternal history of anxiety (biological) ; she views herself as inadequate and others as critical and judgmental, and she struggles with deficits in assertiveness skills, self-soothing skills and relational skills (psychological) ; she has few friends, a history of social anxiety and parents who were highly successful and critical toward her (social) . Given Joyce’s upper-middle-class upbringing, she was born into a life of opportunity and privilege, so her entitlement of life going in a preferred and comfortable path may also explain her challenges with managing life stress (cultural) .

Besides facilitating a highly supportive, empathic and encouraging counseling relationship, treatment will include psychoeducation skills training to develop assertiveness skills, self-soothing skills and relational skills. These skills will be implemented through modeling, in-session rehearsal and role-play. Her challenges with relationship skills and interpersonal patterns will also be addressed with a referral to a therapy group at the university counseling center. Joyce’s negative self-talk, interpersonal avoidance and anxiety symptoms will be addressed with Socratic questioning, thought testing, self-monitoring, mindfulness practice and the downward arrow technique (plan-treatment) .

The outcome of therapy with Joyce is judged to be good, given her motivation for treatment, if her strengths and protective factors are integrated into the treatment process (prognosis) .

Notice how the treatment plan is targeted at the presenting symptoms and pattern dynamics of Joyce’s case. Each of the eight P’s was identified in the case conceptualization, and you can see the flow of each element and its interconnections to the other elements.

what is a case formulation in social work

Tips for writing effective case conceptualizations

1) Seek consultation or supervision with a peer or supervisor for feedback on your case conceptualizations. Often, another perspective will help you understand the various elements (eight P’s) that you are trying to conceptualize.

2) Be flexible with your hypotheses and therapeutic guesses when piecing together case conceptualizations. Sometimes your hunches will be accurate, and sometimes you will be way off the mark.

3) Consider asking the client how they would explain their presenting problem. We begin with a question such as, “How might you explain the (symptoms, conflict, etc.) you are experiencing?” The client’s perspective may reveal important predisposing factors and cultural influences as well as their expectations for treatment.

4) Be OK with being imperfect or being completely wrong. This process takes practice, feedback and supervision.

5) After each initial intake or assessment, jot down the presenting dynamics and make some guesses of the cause or etiology of them.

6) Have a solid understanding of at least one theoretical model. Read some of the seminal textbooks or watch counseling theory videos to help you gain a comprehensive assessment of a specific theory. Knowing the foundational ideas of at least one theory will help with your conceptual map of piecing together the information that you’ve gathered about a client.

We realize that putting together case conceptualizations can be a challenge, particularly in the beginning. We hope you will find that this approach works for you. Best wishes!

For more information and ways of learning and using this approach to case conceptualization, check out the recently published second edition of our book, Case Conceptualization: Mastering This Competency With Ease and Confidence .

Also, Len and Jon Sperry published a new book in November 2021, titled The 15 Minute Case Conceptualization: Mastering the Pattern-Focused Approach .

Jon Sperry is an associate professor of clinical mental health counseling at Lynn University in Florida. He teaches, writes about and researches case conceptualization and conducts workshops on it worldwide. Contact him at [email protected] or visit his website at drjonsperry.com .

Len Sperry is a professor of counselor education at Florida Atlantic University and a fellow of the American Counseling Association. He has long advocated for counselors learning and using case conceptualization, and his research team has completed eight studies on it. Contact him at [email protected] .

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.


Great article with clarication and step by step process to follow.

I will be checking out videos on counseling theory. Any recommendations?

Really appreciated this article! I come from a social work background so haven’t heard of the 8 P’s before but it helps to have that as a foundation for assessing clients. Thank you!

This is such an excellent article for professionals at every stage. It is greatly appreciated as this gives a new perspective on case conceptualization. The 8 P’s definitely help in clearly assessing all aspects of the client. I will keep this article as a reference.

Nice article! Give P’s a chance.

I really appreciate the article. This article has given me a much needed clear understanding of case conceptualization, thank you very much!

I love this article so much. It makes me more clearer about principlee and every steps of case conceptyualization. This is my first time to hear 8P’s which it includes 4P’s as I was familiar with before. It help me understand the whole process clearly. Thank you for your generosity and kindly share this knowledge. Would you mind alowing me to use this knowledge as a reference in the training of psychotherapists and counselors in my country.

Sincerely appreciate you, Jintana Singkhornard M.Sc. (Clinical Psychology) Senior Clinical Psychologist Thailand

Jintana, thank you for your kind words. Feel free to share this information in your training.

This article gave me a clear idea of what is a Case conceptualisation – 8ps – Excellent !!!

Counselling student

I’m a beginning counseling student (1st semester) and have to write a case conceptualization using a specific counseling theory. I went through and marked my own answers first, then reviewed your responses for the case conceptualization P’s in your example. This has helped me a ton in understanding how to do a proper case conceptualization with a clear example.

Great information and easy to understand! Thank you!!

Very informative, very helpful. great concept. Thank you

Love this concept and how conceptualization helps plan a treatment plan for clients. especially being a New Intern very helpful indeed and easy to understand.

A very good guideline for conducting counseling. Well done

This was a well written article. I really appreciate you sharing this as I find it valuable. My clinical background as an MSW did not include mastering this process , and since I graduated a few years ago and now an LMSW, still feeling like I need a lot of help. This article created a clear, process in achieving an effective case conceptualization. Thank you!

excellent work !!!helped me a lot!!! thanking you once again

Hello, thank you for the detailed informative article, I wonder is it enough to learn from the book and will I be able to apply the concepts on my own? do you have a course on case conceptualization? I think it will be more interactive, or any more interactive form of training would be more helpful for such a topic.

Thank you for sharing this information. I am an LMSW, working with people (18 +) who are diagnosed with schizophrenia plus other disorders. This article will help me with a more definitive plan of action. My position is to assess their mental stability and guide those who have goals or want to improve their lives.

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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:

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):

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):

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 Professional Counselor

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

Aug 18, 2020 | 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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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:

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]:

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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Case Formulation in Psychotherapy


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How does a therapist know what to do next during a session? One key method for determining what to do in therapy is case formulation, a systematic process for developing hypotheses about and plans to address the causes and precipitants of a client's presenting problems.

Dr. Tracy Eells presents an evidence-based, integrative method of psychotherapy case formulation that can be adapted to single-theory approaches to therapy, any specific treatment manual, or any component of a theory or manual. This pragmatic case formulation model works for simple and straightforward cases as well as those involving many problems in many spheres of life.

In this video, Dr. Eells explains his case formulation model, works with a client in a therapy demonstration, then uses examples from the demonstration to illustrate how to apply his case formulation model.

This DVD presents an evidence-based, integrative method of psychotherapy case formulation. The method facilitates the integration of evidence-based theories and models of psychotherapy. It also adapts to single-theory approaches to therapy, any specific treatment manual, or any component of a theory or manual. The case formulation model is pragmatic and works for simple and straightforward cases, as well as those involving many problems in many spheres of life and multiple diagnostic co-morbidities.

The model is evidence-based in three ways:

This evidence includes findings from developmental psychology, psychopathology research, epidemiology, and cognitive science. Each of these domains has something to offer in explaining a client's presenting problems and in guiding treatment. The approach is consistent with the perspective on evidence-based practice in psychology as adopted by APA 1 . That perspective emphasizes integrating the best available research with clinical expertise, while also accounting for patient characteristics and preferences, as well as cultural factors.

The method emphasizes collaboratively identifying problems and working toward solutions. Toward this end, a set of empirically grounded, culturally informed explanatory templates are posited that the therapist may choose from and consider with the client. A diathesis-stress conceptualization is presented as an overarching and quintessentially integrative initial template to consider. Other templates are drawn from relational-psychodynamic psychotherapy, behavior therapy, cognitive therapy, and humanistic/experiential therapy.

These templates facilitate consideration of a client's problems from the perspective of wishes, fears, and compromises; representations of self, others, and relationships; functional analysis; cognitive appraisals; and deficits of emotional awareness.

A three-step approach to treatment planning is presented:

Regular progress monitoring is considered essential to assess whether the selected interventions are helping. When considering the next intervention in psychotherapy, the method encourages the therapist to seek the answer in the case formulation and the mutually agreed upon treatment plan.

In summary, the case formulation method presented in this DVD facilitates a systematic process for developing hypotheses about and plans to address the causes, precipitants and maintaining influences of a client's psychological, interpersonal, and behavioral problems in the context of that individual's culture and environment. While comprehensive, the method is not daunting to use. Above all, it emphasizes a systematic case formulation frame of mind as a guide to treatment.

Tracy D. Eells, PhD, is a clinical psychologist, a professor in the department of psychiatry and behavioral sciences, and vice provost for faculty affairs at the University of Louisville. He maintains an individual psychotherapy practice, working with adults presenting with a wide variety of relationship, mood, anxiety, and life problems. He regularly supervises clinical psychology graduate students and psychiatry residents. Psychological assessment is also a major part of his practice.

He has taught and conducted research on psychotherapy case formulation for more than 20 years and more recently has researched the role of computer assisted cognitive behavior therapy for treatment of depression. He is a fellow of APA Division 29 (Society for the Advancement of Psychotherapy).

Dr. Eells obtained his PhD in clinical psychology at the University of North Carolina, Chapel Hill in 1989 and completed a postdoctoral fellowship at the John D. and Catherine T. MacArthur Foundation Program on Conscious and Unconscious Mental Processes of the University of California, San Francisco.

In addition to many journal articles and book chapters, he is author of Psychotherapy Case Formulation , and editor of the Handbook of Psychotherapy Case Formulation , now in its second edition.

This concise and engaging primer helps beginning therapists systematically organize their thoughts and ideas about a client, using an evidence-based approach to case formulation.

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