CASE

FORMULATION
LAB LESSON 1
CASE FORMULATION

• A theory-driven conceptualization of information gathered

during a clinical assessment. It generates hypotheses about the
cause(s) and maintenance of client problems.
• Provides a framework for bringing together biological, societal,
cultural, and psychological factors that might be responsible for
the development and maintenance of psychological problems
and thus facilitate planning and implementing the most
appropriate intervention (Kinderman, 2005; Tarrier & Calam,
2002).
CASE FORMULATION

• A potential advantage over diagnosis of psychosis in being more

amenable to being developed as part of a collaborative process,
in incorporating strengths, and in considering personal meaning.
• Helpful in engaging the person in a process of understanding
their experiences.
• Useful when diagnosis has been experienced as disempowering
(Honos-Webb & Leitner, 2001).
 CASE FORMULATION

• A fundamental process in most schools of psychotherapy.

• A core competency for clinical psychologists at all levels of training, is
key to individualized treatment planning, and has been recognized as a
clinical skill in its own right (Beck, 1985; Dudley et al., 2010).
• Important for psychologists to research what theoretical models are
most used in their country and if there are any specific national
guidelines.
CASE FORMULATION: QUALITY ASSURANCE

• Reliability studies of the quality of a generated case

conceptualization focus on how reliably a conceptualization
can be replicated by another therapist.
• Validity studies largely focus on how well a case formulation
predicts psychotherapy outcomes.
WHAT TO INCLUDE…
 GUIDELINES

• PRESENTING COMPLAINT
• CLIENT DEMOGRAPHIC DATA
• CLIENT DEMEANOR AND PERSONAL APPEARANCE
• CLIENT CURRENT LIFESTYLE
• CLIENT HISTORY
• CLIENT GOALS
• AN EVENT
 GUIDELINES: CLINICIAN’S PERSPECTIVE

• THEORETICAL ORIENTATION • HISTORY

AND RATIONALE • CURRENT FACTORS
• RELEVANT AND • TREATMENT PLAN
IRRELEVANT VARIABLES
• THE EVENT
• ROLE OF RESEARCH AND
CLINICAL EXPERIENCE • OTHER ISSUES
• THE FORMULATION • SUMMARY
BIOPSYCHOSOCIAL
FORMULATION
 • Combines biological, psychological, and
social factors to understand a patient,
and uses this to guide both treatment
and prognosis.
• Formulation evolves and changes as you
BIOPSYCHOSOCIAL collect more information.
FORMULATION
• 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.
 • DIAGNOSIS – categorizing symptoms
into a distinct entity
• FORMULATION - tells us how the person
DIAGNOSIS VS became depressed because of
their genetics, personality, psychological
FORMULATION factors, biological factors, social
circumstances (childhood adverse
events and social determinants of
health), and their environment.
“Formulation asks what is wrong,
how it got that way, and what can be
done about it.”
 Predisposing factors are areas of
vulnerability that increase the risk for
the presenting problem.
Precipitating factors are typically
thought of as stressors or other events
THE (they could be positive or negative) that
FORMULATION may be precipitants of the symptoms.
Perpetuating factors are any conditions
in the patient, family, community, or
larger systems that exacerbate rather
than solve the problem.
Protective factors include the patient’s
own areas of competency, skill, talents,
interest and supportive elements.
 BIOPSYCHOSOCIAL MODEL
Psychological (psychological
Biological (genetic factors, Social (SES, relationships, school,
factors, coping skills, personality
medication, environmental and work, societal factors: racism,
styles, self-esteem, person’s
ecological factors) oppression; spirituality)
thoughts, feelings, & behaviors)

Predisposing (What is their “set

up?” What were they working
with initially?)

Precipitating (What acute event

happened and how did it affect
them?)

Perpetuating (What chronic

things are going on?)

Protective (What is protecting

them and keeping them well?)
FILLING THE TABLE
• As a general rule, when you
are filling out the table, try to
remember that biological
factors + social factors → (lead
to development of)
psychological
symptoms/factors.
LET’S CHECK YOUR WORK…
 Biological Psychological Social
Predisposing • Family history of mental Step 4 Step 3
disorders and substance use
• History of concussions
• Fearful/anxious temperament at
birth

Precipitating • Increase in alcohol use in the last Step 5 • Recently fired from job
3 months
Perpetuating • Current dose of sertraline is Step 6 • Ongoing discord in her romantic
subtherapeutic relationship
• Ongoing alcohol use • Ongoing financial difficulties

Protective • Medically healthy Step 7 • Good interpersonal support from her

best friend who brought her to hospital
• Has a psychiatrist that she sees every
month
Step Factor Description
Step 3 Social (Predisposing) Early parental divorce, unstable home life, history of trauma. History of
invalidation and lack of acknowledgement by parents

Step 4 Psychological (Predisposing) (Led to) fears of abandonment which developed early in childhood

Step 5 Psychological (Precipitating) Re-experienced these feelings of abandonment after being fired from
work

Step 6 Psychological (Perpetuating) Lack of adaptive coping mechanisms resulted in using self-harm to cope
and avoid further emotional dysregulation. Additionally, the lack of
coping mechanisms leading to intense thoughts of suicide.

Step 7 Psychological (Protective) Previously responded well to DBT, and has a history of being
psychologically-minded and insightful. University educated
 Biological Psychological Social
Predisposing • Family history of mental • Fears of abandonment which • Early parental divorce,
disorders and substance use developed early in childhood unstable home life, history of
• History of concussions • History of invalidation and lack of trauma
• Fearful/anxious acknowledgement by parents
temperament at birth
Precipitating • Increase in alcohol use in • Re-experienced these feelings of • Recently fired from job
the last 3 months invalidation and abandonment after
being fired from work
Perpetuating • Current dose of sertraline is • Her lack of adaptive coping • Ongoing discord in her
subtherapeutic mechanisms resulted in using self- romantic relationship
• Ongoing alcohol use harm to cope • Ongoing financial difficulties
• Additionally, the lack of coping
mechanisms leading to intense
thoughts of suicide
Protective • Medically healthy • Previously responded well to DBT • Good interpersonal support
• History of being psychologically- from her best friend who
minded and insightful brought her to hospital.
• University educated • Has a psychiatrist that she
sees every month
FORMULATION IS
DONE…
NOW, WHAT?
 • SEQUENTIAL
PRESENTING • NARRATIVE
THE • ADVANCED
FORMULATION • CHRONOLOGICAL
TIPS…
 • Biological Factors

COMMON • “From a biological perspective, the

patient is vulnerable because…”

PHRASES TO • Social Factors

• “The patient's early childhood and

USE developmental history suggest…”

• “Used substances as a coping style in
[the past], and now this is occurring
again (or there is a relapse) due to
[social factor].”
• Psychological Factors
• “Used substances as a coping style in
[the past], and now this is occurring
again (or there is a relapse) due to
[psychological vulnerability].”
• “I wonder if… [psychological factor] is
contributing to [current
symptoms/struggles]”
DOs DON’Ts
• Use your own words and personal • Include too much extra detail
style
• Try to be perfect only to overwhelm yourself
• Tell a story and narrative that is
• Be generic (your formulation needs to be
unique to your patient
unique to your patient)
• Be specific and demonstrate your
• Tell the patient's whole story all over again
understanding of the patient as
a person and not a diagnosis • Mention life events or trauma without an
understanding of its meaning or impact
• Use words like precipitating,
protective, and perpetuating factors • Try to formulate a “grand unified theory” of
to anchor your listener the patient and over-reach with your theory
(if it doesn’t fit, it doesn’t fit! And that's
• Focus on the most salient features
okay!)
and be concise
• Cover every box in the 4 Ps just for the sake
• Try and use a psychological theory
of doing it
TREATMENT
 Disposition
1. What level of care is required
(outpatient or inpatient)?
2. Jane can articulate a safe plan to stay
with a friend, and is suitable for
outpatient care
Biological
1. Jane might benefit from an increase
TX FOR JANE DOE of her sertraline from 75mg to
100mg and beyond (maximum dose
of 200mg), for her mood
dysregulation and depressive
symptoms
2. Jane might benefit from the use of
anti-craving medications such
as gabapentin or acamprosate to
reduce her cravings for alcohol use
 Psychological
1. Dialectical behavioral therapy
(DBT) would be the most appropriate
for Jane
2. Jane would also benefit
from motivational interviewing for her
alcohol use
TX FOR JANE DOE 3. Long-term, Jane might also benefit from
a more in-depth understanding of how
her past trauma affects her present self
and symptoms. This could be achieved
with more specific and in-depth trauma
therapy, but given the acuity of her
symptoms, this is something that would
follow after DBT.
 Social
[Link] could benefit from accessing
support from her company's HR
department to understand what
options she has after her job
TX FOR JANE DOE termination
[Link] use groups such as
Alcoholic's Anonymous
[Link] connections to her
friends and social supports
 REFERENCES
Eells, T.D. (1997) Handbook of Psychotherapy Case Formulation, Guilford, New York.
Eells, T.D. (2007a) History and current status of psychotherapy case formulation, in Handbook of Psychotherapy Case
Formulation, 2nd edn (ed. T.D. Eells), Guilford, New York, pp. 33–2.
Eells, T.D. (2007b) Handbook of Psychotherapy Case Formulation, 2nd edn, Guilford, New York.
Selzer, R., & Ellen, S. (2014). Formulation for beginners. Australasian Psychiatry, 22(4), 397-401.
Winters, N. C., Hanson, G., & Stoyanova, V. (2007). The case formulation in child and adolescent psychiatry. Child and
Adolescent Psychiatric Clinics, 16(1), 111-132.
Weerasekera, P. (1993). Formulation: A multiperspective model. The Canadian Journal of Psychiatry, 38(5), 351-358.
Kendler, K. S. (2012). The dappled nature of causes of psychiatric illness: Replacing the organic–
functional/hardware–software dichotomy with empirically based pluralism. Molecular psychiatry, 17(4), 377-388.
Engel, G. L. (1977). The need for a new medical model: a challenge for biomedicine. Science, 196(4286), 129-136.