Chapter 5

Integrative Case Formulation

2026 Abdelrahman Badri, PhD

 Chapter Outline
• What is diagnosis?
• What is case formulation?
• What is management?
• Revisiting the models
• The 4 Ps
• How to build an integrative formulation
• Common mistakes
 Chapter Learning Outcomes
• Explain what diagnosis, formulation, and management mean.
• Describe the difference between diagnosis and formulation.
• Identify biological, psychological, social, cultural, family, and spiritual
factors.
• Build a step-by-step integrative formulation for a real-looking case.
• Avoid the common mistakes students make in their first formulations.
• Today we will learn how to move from "naming the problem" to "understanding the
whole person" to "helping them get better."

• Imagine a friend tells you, "My stomach hurts." You can say, "Maybe it is a stomach
bug" (that is like a diagnosis).
• But a good doctor will also ask: What did you eat? Are you stressed? Did you sleep? Is
there clean water at home? That bigger picture is called a formulation.
• Then the doctor decides what to do — that is management.
 Integrative Case Formulation

• A clear story that brings together all the important parts of a person's life (body, mind,
family, culture, faith, community) to explain why they are struggling now and how to
help them.
• Example

• A first-year student at the University of Khartoum is failing exams and crying

often. Diagnosis alone might say "depression."

• Formulation asks: She lost her brother in the conflict, she sends money home to her
mother in Kassala, she sleeps in a crowded hostel, and she stopped praying because
she feels guilty. Now we understand her — and we can really help.
 What Is Diagnosis?

• Diagnosis is giving a name to a pattern of symptoms.

• The process of identifying a mental disorder by matching a person's symptoms to an
agreed list of criteria (for example, in the DSM-5-TR or ICD-11).

• A diagnosis is like the label on a medicine bottle.

• It tells you, in one short name, what kind of problem we are dealing with.

• Doctors and psychologists use books like the DSM-5-TR or ICD-11 to choose the
correct name.
• Example

• A 30-year-old teacher in Wad Madani has had low mood, no energy, poor sleep,
and loss of interest for 6 weeks.

• She meets the criteria for Major Depressive Disorder. That is her diagnosis.

• But the diagnosis does not yet tell us why she is depressed.
 What Diagnosis Is Not

• A diagnosis is not the whole person, and it is not an explanation.

• If I tell you a child has "asthma," you still do not know if the dust at home, the smoke
from cooking with charcoal, or stress at school is making it worse.

• The label does not explain the cause.

• Key idea
Diagnosis = what the problem is called.
Formulation = why this person has this problem, now, in this way.
• Example

• Two young men in Khartoum both receive a diagnosis of PTSD after the 2023
conflict.

• One was a soldier; the other was a child who watched his home burn.

• Same label, very different stories, very different treatment paths.

 What Is Case Formulation?

• Case formulation is the story behind the diagnosis.

• A formulation is like writing a short, honest story about a person that answers:

• Why is this person suffering? Why now? What is keeping it going? What strengths
do they have? What will help?

• Case Formulation

• A working explanation, built together with the client, that links the person's
symptoms to the biological, psychological, social, cultural, family, and spiritual
factors in their life, and that guides treatment.
• Example

• For the teacher in Wad Madani with depression: she lost her husband two years ago,
she is raising three children alone, she has anemia (low iron), her in-laws blame her for
the loss, and she stopped attending the women's gathering at the mosque where she
used to find comfort. That is her formulation.
 Diagnosis Vs. Formulation

• Diagnosis and formulation answer different questions.

• Diagnosis answers "What?" Formulation answers "Why?" and "What now?”

Diagnosis Formulation
Question What is it? Why is it happening to this person?
Source DSM-5-TR / ICD-11 The person's whole life story
Style Category, label Narrative, hypothesis
Same for everyone? Yes, if criteria met No — unique to each person
Changes over time? Rarely Often, as new info appears
• Example
• Two students at AUW both get the diagnosis "Generalized Anxiety Disorder."
• But one is anxious because of financial stress and displacement from Khartoum; the
other is anxious because of pressure from her family to marry.
• Same diagnosis, two completely different formulations.
 Why Formulation Matters

• Formulation makes treatment personal, respectful, and more likely to work.

• If you only treat the label, you give the same medicine to everyone.

• If you treat the story, you help the actual person in front of you.
 Why Formulation Matters

• Five reasons formulation matters

1. It guides what treatment to choose.

2. It helps the client feel understood, not judged.
3. It reveals strengths, not only problems.
4. It respects culture, faith, and family, which is essential in our context.
5. It improves teamwork — doctors, psychologists, social workers, and family all
share one map.
• Example

• A young man from Darfur with insomnia and flashbacks could be given sleeping
tablets (diagnosis-only).

• But a formulation reveals nightmares about war, guilt for surviving, and a wish to
speak with the fekki (religious healer).

• Good treatment will include trauma therapy and respect his spiritual practice.
 What Is Management?

• Management is the plan of action that comes out of the formulation.

• If diagnosis is the label and formulation is the story, management is the journey you
and the client take together to feel better.

• Management (in mental health) is the set of agreed actions — psychological,

biological, social, cultural, and spiritual — designed to reduce suffering, build coping,
and support recovery.
 What Is Management?

• Management usually includes

• Biological (e.g., medication, treating anemia, improving sleep)

• Psychological (e.g., CBT, trauma-focused therapy, counseling)
• Social (e.g., reconnecting with family, school support, income help)
• Cultural / spiritual (e.g., working with a trusted Imam, sheikh, priest, or elder)
• Safety (e.g., suicide risk plan, protection from violence)
• Follow-up (when to meet again, what to monitor)
• Example
• For the Wad Madani teacher: short course of an antidepressant from the local clinic + 8
sessions of supportive counseling + iron supplements + reconnecting with her mosque
group + a family meeting with her brother to share childcare on weekends.
 The Big Picture:
Diagnosis → Formulation → Management

• These three steps are a chain. Each one feeds the next.

• Think of cooking kisra or injera.

• First you recognize what dish you want (diagnosis).

• Then you understand the ingredients and the fire (formulation).

• Then you actually cook it (management).

• Skipping a step ruins the meal.

 The Big Picture:
Diagnosis → Formulation → Management

• The flow

1. Assess — listen, observe, ask, screen.

2. Diagnose — name the pattern (if one fits).
3. Formulate — explain why this person, why now.
4. Manage — plan and act, together with the client.
5. Review — check progress, update the formulation.
• Example

• A 16-year-old girl in Juba is brought to the clinic by her aunt. She is not eating and
barely speaking.

• Assessment → suspected Major Depression with possible trauma.

• Formulation → she was separated from her mother during displacement.

• Management → safe housing through a local NGO, family tracing, supportive

counseling, nutrition support.

• Review → after 4 weeks, mood improves; plan is updated.

 The Biopsychosocial Model:
The Foundation of Formulation
• Every formulation looks at the person from three angles at once: body, mind, and world.

• Imagine a three-legged stool. If one leg is broken, the stool falls.

• People are the same — body, mind, and the world around them all matter.

• Biopsychosocial Model (Engel, 1977) is a framework saying that health and illness arise from
the interaction of biological (body), psychological (mind), and social (relationships,
community) factors.

• For our context, we add two essential legs

• Cultural (beliefs, language, traditions, stigma)

• Spiritual / religious (faith, prayer, meaning, religious community)
• So in Sudan and East Africa, we often teach the Bio-Psycho-Socio-Cultural-Spiritual model.
• Example
• A boda-boda driver in Kampala with chronic anxiety:
• bio — chest pain, poor sleep, qat use;
• psycho — fear of failing his family;
• social — debt, long working hours;
• cultural — shame about seeing a psychologist;
• spiritual — stopped attending church, feels distant from God.
 Revisiting Biological Factors
The body shapes the mind. Always ask about the body.

Sometimes what looks like a "mental" problem is partly physical — like low iron making you tired and sad, or malaria
making you confused.

Examples to ask about

• Anemia (very common in women and girls)

• Malaria, typhoid
• Thyroid problems
• HIV and its treatments
• Chewing tobacco, alcohol, tobacco, cannabis
• Family history of mental illness
• Pregnancy, postpartum, menopause
• Poor sleep due to heat, mosquitoes, or noise in crowded housing
• Example
• A university student in Nyala who "cannot concentrate" turns out to have untreated
malaria and is sleeping only 3 hours a night because of generator noise.
• Treating the body changes the whole picture.
 Revisiting Psychological Factors

• The way a person thinks, feels, and copes is at the heart of formulation.

• Two people can face the same problem and feel very differently — because of how their
mind handles it.

• Examples to ask about

• "What goes through your mind when this happens?"

• "What do you believe about yourself? About the future?"
• "How did you cope with hard things as a child?"
• "Do you have memories that come back uninvited?"
• Example

• A young woman fails one exam and thinks, "I am a failure, my family will reject me,
my life is over."

• Another student fails and thinks, "This is hard, but I can re-sit."

• Same event, very different psychology — and very different mental health outcomes.
 Revisiting Social Factors
• We do not get sick or get better alone. The people and systems around us matter.

• A flower in good soil grows; the same flower in dry soil wilts. Our social world is the soil.

• Examples especially relevant in our region

• Armed conflict and displacement (IDPs, refugees)

• Loss of income, food insecurity
• Crowded housing, no electricity, water shortages
• Tribal or ethnic tensions
• School dropout, child labor, early marriage
• Gender-based violence
• Migration of family members (e.g., father in the Gulf)
• Discrimination against people with mental illness
• Example

• A 14-year-old boy in a refugee camp in Gedaref has stopped speaking.

• Social factors: he was separated from his father, lives with an overwhelmed aunt, has
not been in school for a year, and has witnessed violence.

• None of this is "in his head" — it is in his world.

 Cultural Factors

• Culture shapes how distress is felt, expressed, named, and treated.

• In one culture, a person says, "I feel depressed." In another, the same person says, "My
heart is heavy" or "My liver is burning" or "There is a weight on my chest."

• Both are real — culture gives words to suffering.

• Cultural factors are the shared beliefs, values, language, traditions, gender roles, and
explanatory models that influence how a person understands and expresses mental
health.
 Cultural Factors

• Examples in our context

• Idioms of distress: in Sudan, "ḍīq" (constriction, tightness of the chest) is often used
for what Western texts call anxiety or depression.
• Beliefs about jinn, evil eye (ʿayn), or sihr (sorcery) as causes of illness.
• Strong stigma around mental illness — fear of being called "majnūn" (mad).

• Preference for family and religious healers before mental health services.
• Gender expectations: men "must be strong," women "must endure."
• Example

• A mother in Omdurman brings her teenage son because "someone has put the eye on
him."

• He has classic symptoms of psychosis.

• A culturally competent psychologist takes her belief seriously, does not mock it,
explains a medical view alongside it, and works with the family — not against them.
 The Cultural Formulation Interview

• We can make use of the Cultural Formulation Interview (CFI)

• It is a 16-question, person-centered tool published in the DSM-5 to help clinicians
systematically assess how a patient's cultural background affects their mental health
presentation, illness experience, and care expectations.
 The Cultural Formulation Interview

• Core Domains and Objectives

• The interview typically takes about 20 minutes to complete and is organized into four main
thematic domains:
1. Cultural Definition of the Problem: Identifies how the patient conceptualizes their
symptoms and what they feel are the core issues.
2. Cultural Perceptions of Cause, Context, and Support: Explores the perceived causes
of the distress, how the patient's social network affects their condition, and the role of
their cultural identity.
3. Cultural Factors Affecting Self-Coping and Past Help-Seeking: Assesses what the
patient has tried on their own, their past experiences with treatments, and barriers to care
(e.g., stigma, discrimination, or language).
4. Current Help-Seeking Preferences: Gauges the patient's expectations for current
treatment and their relationship with the clinician.
 Family Factors

• In our region, the family is often the most powerful force in a person's mental health
— for better or worse.

• A person is not just an individual. They are a son, a daughter, a wife, a cousin, a clan
member.

• The family can be the wound — and also the medicine.

• Family factors refer to the structure, relationships, communication patterns, conflicts,

and supports within the family system.
 Family Factors

• Examples to ask about

• Who lives in the house? Who has authority?

• Is there family conflict, divorce, polygyny tensions, in-law pressure?
• Has anyone migrated abroad (e.g., to Saudi Arabia, UAE)?
• Are there family losses, especially from war or illness?
• Is there a family history of mental illness or suicide?
• How does the family talk about emotions?
• Example

• A 22-year-old woman in Kassala is depressed. She lives with her mother-in-law while
her husband works in Riyadh. The mother-in-law criticizes her daily, she has no
privacy, and her own mother lives far away.

• The "patient" is one woman, but the problem lives in the family system.
 Spiritual and Religious Factors

• Faith is central in our region. Ignoring it is poor practice.

• For most people in Sudan and the region, religion is not a hobby — it is the air they
breathe.

• Faith can give comfort, meaning, and community.

• It can also bring guilt, fear, or conflict.

• Spiritual / religious factors refer to a person's beliefs about God, meaning, purpose,
prayer, religious community, and the relationship between faith and suffering.
 Spiritual and Religious Factors

• Examples to ask about (gently and respectfully)

• "What role does faith play in your life?"

• "Has your relationship with Allah/God changed since this began?"
• "Do you pray? Has prayer helped?"
• "Have you spoken to a sheikh, imam, priest, or fekki?"
• "Do you feel guilty before Allah/God about anything?"
• Example
• A man in Port Sudan with severe OCD has religious obsessions (waswās) about
whether his ablution (wuḍū') is valid.
• Working with a knowledgeable, moderate sheikh — alongside CBT for OCD — was
far more effective than therapy alone.
 Risk Factors

• Risk factors are the things that raise the chance of a mental health problem appearing.

• Think of risk factors like stones piling up on a person's back.

• The more stones, the harder it is to keep standing.

• Risk factors are characteristics or conditions that increase the likelihood of

developing or worsening a mental health problem.
 Risk Factors

• Examples in our context

• Exposure to war, displacement, sexual violence

• Childhood neglect or abuse
• Poverty, hunger, unemployment
• Substance use (tobacco, alcohol, cannabis)
• Family history of mental illness or suicide
• Chronic physical illness
• Female gender + low social power
• Being out of school for long periods
• Example
• A 17-year-old girl in Zamzam IDP shelter: lost her father, witnessed violence, dropped
out of school, sleeps in a tent with strangers, has anemia. That is at least five risk
factors.
• We should not be surprised if she develops depression or PTSD.
 Protective Factors and Strengths

• Every person has strengths. A good formulation always finds them.

• If risk factors are stones on the back, protective factors are the strong legs and the
helpers walking beside the person. We must count both.

• Protective factors are conditions, traits, or resources that reduce the impact of risk and
support recovery.

• Resilience is the ability to adapt and recover in the face of hardship.

• It is not "being unbreakable." It is "being able to bend and rebuild."

 Protective Factors and Strengths

• Examples in our context

• A loving grandmother, aunt, or older sibling

• Strong faith and a supportive religious community
• Being in school, having a teacher who cares
• A skill or talent (e.g., singing, sports, cooking, mechanics)
• Sense of humor, intelligence, hope
• Community ties (neighborhood, clan, women's groups)
• Access to even a small income
• Example

• The same 17-year-old girl in the IDP shelter has a strong friendship with two girls her
age, prays five times a day, loves reading, and has a maternal uncle who calls every
week.

• These are real, powerful resources to build on.

 Predisposing, Precipitating, Perpetuating, Protective
The "4 Ps"

• A famous, simple tool to organize any formulation is the 4 Ps.

• Ask four questions about the person's problem:

The 4 Ps Question Meaning
Predisposing Why is this person Long-standing factors that made them more
vulnerable? likely to develop the problem.
Precipitating Why now? Recent triggers that set the problem off.
Perpetuating Why does it keep Things maintaining the problem today.
going?
Protective What is helping? Strengths and supports that aid recovery.
 Predisposing, Precipitating, Perpetuating, Protective
The "4 Ps"

• Maintaining (perpetuating) factors are the current behaviors, thoughts, relationships,

or conditions that keep the problem alive, even when the original trigger is gone.
• Example

• A nursing student in Khartoum with panic attacks

• Predisposing: anxious temperament, mother had panic attacks, grew up during conflict.
• Precipitating: witnessed a bombing near her hostel last year.
• Perpetuating: avoids leaving her room, drinks too much coffee, scrolls news all night,
has not told her family.
• Protective: close friend on her floor, strong faith, supportive lecturer, no substance use.
 How To Build an Integrative Formulation
Step by Step

• A clear, repeatable method you can use in every case.

• Like building a house: gather materials, lay the foundation, raise the walls, put on the
roof, then check it is safe.
 How To Build an Integrative Formulation
Step by Step
1. Listen and gather — full history (presenting problem, past, family, social, cultural, spiritual,
medical, substance, risk).
2. Identify the main problems — what is the person actually suffering from? (1–3 problems, in
their words and yours)
3. Consider diagnosis — does a DSM-5-TR / ICD-11 label fit? (May be more than one, or none.)
4. Sort information into the 5 domains — Bio, Psycho, Social, Cultural, Spiritual.
5. Apply the 4 Ps — Predisposing, Precipitating, Perpetuating, Protective.
6. Write a short narrative — 5–10 sentences that tell the story of why this person, why now,
why this way, and what helps.
7. Plan management collaboratively — link each part of the plan back to the formulation.
 Example: Step 1–2 (Gather and Identify Problems)

• Case: Amna, 19, first-year student at Ahfad University for Women

• Step 1 — Gather
Amna comes to the campus counselor saying, "I can't sleep, I cry every day, I feel my chest
is tight (ḍīq), and I'm scared something bad will happen to my family." She is from El
Geneina, Darfur. Last year her family was displaced; her older brother is missing. She lives
with two cousins in Omdurman. She is praying less than before and feels guilty. No alcohol
or substance use. Periods irregular for 4 months. Eats once a day. No prior psychiatric
history. No suicide attempt, but sometimes thinks "it would be easier not to wake up."
 Example: Step 1–2 (Gather and Identify Problems)

• Step 2 — Main problems (in plain language)

1. Persistent sadness, crying, low energy.

2. Constant worry and chest tightness about her family's safety.
3. Sleep loss and poor appetite.
4. Passive thoughts of not wanting to wake up (must be assessed carefully).
 Example: Step 3 (Diagnosis)

• Considering diagnosis for Amna

• Looking at DSM-5-TR criteria:

• Major Depressive Disorder — likely (low mood, anhedonia, sleep/appetite changes, guilt,
passive death thoughts > 2 weeks).
• Generalized Anxiety Disorder or Adjustment Disorder with Anxiety — possible.
• PTSD — must be screened (displacement, missing brother — likely traumatic exposure; assess
intrusions, avoidance, hyperarousal, negative cognitions).
• Working diagnoses (provisional)

• Major Depressive Disorder, moderate.

• Probable PTSD — needs further assessment.
 Example: Step 3 (Diagnosis)

• The diagnosis is useful but limited.

• It does not yet tell us about Darfur, the missing brother, the cousins, the prayer, the
ḍīq.

• That is where formulation enters.

 Example: Step 4 (Five Domains)
• Sorting Amna's story into the 5 domains

• Biological: poor sleep, weight loss, irregular menses (possible hormonal/nutritional impact), no
substance use, anemia not yet ruled out.
• Psychological: high guilt ("I should have done more for my brother"), catastrophic thinking
("something bad will happen"), avoidance of news, low self-worth.
• Social: displaced from home, living with cousins (not parents), away from her village
community, financial pressure, university workload.
• Cultural: expresses distress as ḍīq (chest tightness), reluctant to be labeled "marīḍa
nafsiyyan" (mentally ill), strong family-honor concerns.
• Spiritual: prayed five times a day before; now prays irregularly, feels distant from God, feels
guilty for "complaining."
 Example: Step 5 (the 4 Ps)

• Applying the 4 Ps to Amna

• Predisposing

• Female adolescent in a conflict-affected region.

• Conscientious, sensitive personality (over-responsible since childhood).
• Possible family history of anxiety (her mother is "always worried").
• Precipitating

• Displacement from El Geneina.

• Disappearance of her brother.
• Move to a new city and university last year.
 Example: Step 5 (the 4 Ps)

• Perpetuating

• Isolation from her parents and home community.

• Scrolling news about Darfur for hours daily.
• Skipping meals and sleep.
• Reduced prayer (loss of a key coping resource).
• Silence — has not told her cousins or any lecturer.
 Example: Step 5 (the 4 Ps)

• Protective

• Intelligent, motivated student.

• Two cousins who care about her.
• Strong religious background she can return to.
• University counseling service available.
• No substance use.
• Willing to seek help (she came in).
 Example: Step 6 (the Formulation Narrative)

• Now we write the story — short, clear, respectful, in plain language.

• Amna's integrative formulation (sample paragraph)

Amna is a 19-year-old Darfuri student presenting with symptoms consistent with moderate Major Depressive Disorder
and probable PTSD. She is predisposed by her gender, sensitive temperament, and a family pattern of worry. Her
symptoms were precipitated by displacement from El Geneina and the disappearance of her brother, on top of the stress
of starting university far from home. The problem is perpetuated by social isolation, continuous exposure to distressing
news, disrupted sleep and nutrition, and a painful distance from her usual spiritual practice. She experiences and expresses
distress in a culturally specific way — as ḍīq — and fears the stigma of being seen as mentally ill. At the same time, she
has important protective factors: her intelligence and motivation, two supportive cousins, a deep (if currently strained)
faith, access to the university counselor, and her own willingness to seek help. Treatment should respect her cultural and
spiritual world, rebuild safety and routine, address her trauma at a pace she can manage, and reconnect her with the people
and practices that have sustained her in the past.
 Example: Step 7 (Management Plan)

• The management plan must mirror the formulation.

• Amna's collaborative management plan

• Safety first

• Assess suicide risk thoroughly today; agree a safety plan; share contact of
campus counselor and a trusted cousin.
 Example: Step 7 (Management Plan)

• Biological

• Refer to campus clinic: rule out anemia, thyroid issues; nutrition advice.
• Discuss possibility of an SSRI if symptoms persist after initial sessions, with full
informed consent.
• Psychological

• 8–12 sessions of culturally adapted CBT for depression.

• Stabilization first; trauma-focused work (e.g., trauma-focused CBT) only when she feels
safe and ready.
• Psychoeducation about depression, PTSD, and ḍīq in language she accepts.
 Example: Step 7 (Management Plan)

• Social

• Reconnect with her parents by phone weekly.

• Join a small peer-support group of displaced students at Ahfad.
• Limit doom-scrolling: agreed times to check news.
• Cultural and spiritual

• Validate the meaning of ḍīq in her experience.

• Gentle re-engagement with prayer and Quran recitation as she feels able; consider
speaking with a trusted, moderate female religious teacher.
 Example: Step 7 (Management Plan)

• Family

• With her consent, one family session by phone with her mother to share
concerns and reduce her sense of guilt.
• Review

• Weekly for 4 weeks, then fortnightly. Update formulation as new information

appears.
 Example: Khalid in Juba

• Case
Khalid, 28, a mechanic in Juba, South Sudan. Married, two children. Drinks local
aragi heavily on weekends. Comes to the clinic after his wife threatened to leave. He
says, "I am fine, she is the problem." He sleeps poorly, has nightmares about an attack
he survived in 2016, and gets angry quickly with his children.
 Example: Khalid in Juba

• Mini-formulation:
Khalid is a 28-year-old man with likely PTSD and alcohol use disorder, predisposed
by exposure to violence and a culture where men are expected to "not talk." His
problem was precipitated by the 2016 attack and worsened by ongoing economic
stress. It is perpetuated by alcohol use (which numbs but worsens sleep and anger),
avoidance of memories, and silence at home. Protective factors include his skill as a
mechanic, his wife's continued (if strained) commitment, and his religious upbringing,
which he could be invited to re-engage.
 Example: Khalid in Juba

• Management:
Engagement and motivational work around alcohol → safety planning at home →
trauma-focused therapy → couples session with his wife → community support group
for men.
 Common Mistakes Students Make
• Most beginner formulations fail in the same predictable ways. Knowing the traps helps you avoid them.

• The top 10 mistakes

1. Listing facts instead of connecting them into a story.

2. Diagnosis-only thinking — naming the disorder and stopping.

3. Ignoring culture and religion ("That's not clinical").

4. Ignoring strengths — only writing about what is wrong.

5. Pathologizing normal reactions (e.g., grief after losing a brother is not a disorder by default).

6. Copying textbook Western examples without adapting to Sudan / East Africa.

7. Forgetting the body — no questions about sleep, food, anemia, malaria.

8. Forgetting safety — not asking about suicide, violence, or abuse.

9. Writing in jargon the client could never understand.

10. Treating the formulation as final — not updating it as you learn more.
 Cultural Humility

• We work in a region of many languages, faiths, ethnicities, and histories. Cultural

humility is not optional.

• Cultural humility is a lifelong commitment to self-reflection, learning from clients

about their world, and being aware of power differences — rather than claiming to be
"culturally expert."
 Cultural Humility

• Three habits to build

1. Ask, don't assume — "Help me understand what this means in your family /
culture / faith."
2. Notice your own biases — your training, class, gender, ethnicity, faith all shape
your eyes.
3. Use the client's words — keep terms like ḍīq, ʿayn, fekki, jinn, waswās in your
formulation when the client uses them, with your clinical interpretation alongside.
• Example

• A Nuer client in Juba and a Beja client in Port Sudan may both meet criteria for
depression — but the meaning, the family response, the language, and the path to
healing will differ.

• The formulation must reflect their world, not yours.

 Ethics and Safety in Formulation
• Key principles

• Confidentiality — the formulation contains very sensitive information. Store it securely.

• Informed consent — the client should know you are building a formulation and broadly
what it contains.
• Shared formulation — when possible and helpful, share it with the client in plain language;
they may correct or add to it.
• Do no harm — avoid speculation that could be used against them (e.g., custody disputes).
• Safety first — always include risk of suicide, self-harm, violence, GBV, child protection.
• Refer when out of depth — formulation is a clinical act; if the case exceeds your training
(e.g., psychosis, complex trauma), refer to a senior clinician or psychiatrist.
• Example
• If you are working with a survivor of GBV in a small town, a careless written
formulation that leaks could endanger her.
• Use initials, keep files locked, and follow your institution's data policy.
 Reflective Questions

• Good clinicians keep questioning themselves.

• Take-home reflection

1. When you imagine your own life as a formulation, what would your 4 Ps be? What protects you?
2. Whose story in your family was reduced to a label ("majnūn," "lazy," "weak") that a good
formulation would have understood differently?
3. What part of your culture or faith would you want a foreign therapist to ask about, not assume?
4. What is one common mistake that you can already see in your own thinking?
5. If you had only 15 minutes with a client (which is realistic in many of our clinics), what 5
questions would you keep?
 KEY TAKEAWAYS
• Three different questions, three different tools
• Diagnosis answers what the problem is (a label from DSM-5-TR / ICD-11).
• Formulation answers why this person, why now, why this way.
• Management answers what we do about it, together.
• A diagnosis without a formulation treats the disorder. A formulation treats the person.
• Formulate across six domains, not three
• The classic biopsychosocial model is not enough in our region. Always
add culture and spirituality / faith, and pay close attention to family as a system
— not just a background detail.
 KEY TAKEAWAYS

• Use the 4 Ps as your engine

• Predisposing — why is this person vulnerable?
• Precipitating — why now?
• Perpetuating — what keeps it going today?
• Protective — what is helping, and what strengths can we build on?
• If you can do the 4 Ps well, you can formulate almost any case.
 KEY TAKEAWAYS
• Strengths matter as much as symptoms
• Every formulation must name what is right with the person — faith, family, a caring
aunt, a skill, hope, willingness to seek help. Resilience is not "being unbreakable"; it
is "being able to bend and rebuild."
• Culture and faith are clinical variables, not decoration
• Idioms like ḍīq, beliefs about ʿayn, jinn, or sihr, the role of the fekki, sheikh, or
imam, the stigma of being called majnūn — these shape how distress is felt,
expressed, and healed. Ignoring them is poor practice.
 KEY TAKEAWAYS

• The management plan must mirror the formulation

• Every line of treatment should trace back to a line in the formulation. If it doesn't,
either the plan is off — or the formulation is incomplete.
• A formulation is a living, shared story
• It is a hypothesis, not a verdict. Build it with the client in plain language, update it
as you learn more, and never treat it as final.
 KEY TAKEAWAYS
•Avoid the classic traps
•The most common failures are: diagnosis-only thinking, listing facts without
connecting them, ignoring the body, ignoring culture and faith, ignoring strengths,
pathologizing normal reactions to abnormal events (like war and loss), and writing
in jargon the client could never understand.
 KEY TAKEAWAYS
•Safety is always part of the picture
•Suicide risk, GBV, child protection, substance use, and confidentiality are not
"extra" — they are core to any responsible formulation.
•The one-sentence summary to carry forever
Diagnosis says what. Formulation says why. Management says what now — and in
our region, none of it works without culture, family, and faith at the table.
 Conclusion

• In Sudan and the region, our clients live inside histories of conflict, displacement,
faith, family, and remarkable resilience.

• They deserve more than a label.

• They deserve to be understood — and an integrative case formulation is how we begin

to truly understand.