Case Formulation

• Case conceptualization - Process for developing a hypothesis about the causes, precipitants, and maintaining influences of a person’s problems in the context of that individual’s culture and environment
• Causes

  Origins
• Precipitants

  Triggers
• Maintaining influences

  Sustain behaviour
• Case formulation

  Provides a conceptual account of a client’s problem and a procedure for improving it, including a ‘blueprint’ guiding treatment
• Case formulation

  Subject to revision as new information emerges, new problems develop, new insights are gained
• Case formulation


  Content will vary widely depending on which theory of psychotherapy and psychopathology the clinician uses
• Useful case conceptualizationshave these two types of power


  • Explanatory power
  • Predictive power
• Formulating is the "first principle" underlying therapy and the "heart of evidence-based practice"
• Case formulation bridges the gap between diagnosis and treatment

  Gauge for measuring change
• Case formulation allows for a tailored treatment approach to address the specific client


  May be beneficial to formulate collaboratively
• Challenges of case formulation: Value is relative to its reliability and validity
• Challenges of case formulation: Therapists are vulnerable to systematic errors or biases in reasoning and judgment (e.g., heuristic thinking)
• Kramer et al. (2014) study

  Group with case formulation had greater reduction in symptoms and interpersonal problems, and stronger therapeutic alliance
• Ghaderi (2006) study


  Formulation-guided group improved more than the other group on some key measures, including symptom remission
• Components of case conceptualization


  • Diagnostic formulation: what?
  • Clinical formulation: why? Approach will influence the explanation
  • Cultural formulation: what role does culture play?
  • Treatment formulation: how can it be changed?
• Clinical formulation: Psychoanalytic/psychodynamic approaches

  • Conceptualize a person’s psychological functioning in terms of conflicting wishes, needs, or motives, the anxiety or distress caused by this conflict, the unconscious strategies used to avoid awareness of this conflict and minimize discomfort, role of early childhood experiences in the development of intra/interpersonal patterns
• Clinical formulation: Humanistic approach


  • Diagnosis and formulation not traditionally associated with humanistic approaches, evolved as a collaborative, co-constructive process between client and therapist, considers impediments to authentic expression of self, therapy facilitates congruence
• Emotion-focused therapy

  1. Integrates understanding of attachment context (i.e., developmental injuries or traumas) that activate core painful emotions

  2. Continual focus on the client’s current state of mind and current cognitive/affective problem states

  3. Uses in-session markers to drive interventions
• Behavioural therapy


  1. Identifies the client’s maladaptive behaviours through a behavioural lens

  2. Focuses on the function of the problem behaviours

  3. Emphasis on understanding and modifying symptoms

  4. Uses principles of learning to explain the development, maintenance, and process of changing problem behaviours

  5. Analyze environmental influence on behaviour
• Cognitive behavioural therapy


  1. Summarizes the central dysfunctional beliefs and focuses about self, others, and the world that cause the client’s symptoms/behaviours

  2. Identifies the stressful life events that have precipitated or interacted with the client’s dysfunctional attitudes

  3. Used to design active, problem-focused interventions intended to help the client change problematic cognitions and behaviours

  4. Core beliefs, underlying assumptions, automatic thoughts
• Dialectical behaviour therapy


  1. Uses biosocial theory to formulate understanding of individual

  2. Uses behavioural analysis (BA) to generate understanding of function of problem behaviours

  3. Uses information derived from BAs to generate solutions (e.g., skills, interventions)
• Postmodern approaches


  1. Understanding socially storied lives

  2. Understand the problem and exceptions to the problem, as well as strengths, to focus on solutions

  3. A collaborative, co-constructive process between client and therapist
• Transtheoretical approach to case formulation

  1. Create Problem List – Describe full range of client’s problems

  2. Diagnose

  3. Develop an explanatory hypothesis

  4. Plan Treatment
• Transtheoretical approach to case formulation - Step 1

  1. Create Problem List – Describe full range of client’s problems

  2. Symptoms: complaints of distress by the client

  3. Signs: disturbances observable to the therapist and others, but not reported or acknowledged by the client

  4. Problems in living: issues in self-functioning, social/interpersonal functioning, societal functioning
• Transtheoretical approach to case formulation - Step 2

  Diagnose - Provide a diagnosis for both practical requirements and future treatment planning
• Transtheoretical approach to case formulation - Step 3

  1. Develop an explanatory hypothesis: the therapist’s account of what is causing, maintaining, and precipitating the client’s problems

  2. Identify precipitants (proximal) – triggers of symptoms and problems

  3. Identify origins (distal) – predisposing events, traumas, stressors, and risk factors that are inferred as causally related to the development of client’s current problems

  4. State the core hypothesis – a brief statement of the central mechanism that is generating problems, based on a specific theoretical approach
• Transtheoretical approach to case formulation - Step 4

  1. Plan Treatment – explicit statement of how selected problems will be addressed in treatment

  2. Identify treatment goals (process and outcome goals)

  3. Identify resources – strengths client brings to therapy to facilitate recovery (internal and external)

  4. Identify obstacles – aspects of client’s life that may interfere with treatment success

  5. Plan interventions to address goals
• The Counselor

  Relationship factors - Clients who experience certain relationship factors benefit more from psychotherapy than clients who experience less of these
• Clients who benefit more from psychotherapy

  • Experience high quality alliance
  • positive regard/affirmation
  • therapist congruence, empathy
  • alliance rupture-repair episodes, work with therapists trained to repair alliance ruptures
• Some therapists consistently achieve better outcomes than others, some therapists consistently achieve poorer outcomes
• Therapist effects appear to be stronger with highly distressed or impaired clients

  • Characteristics of the therapist are going to matter more when symptoms are more severe
• Qualities of effective therapists


  • Ability to form a strong alliance with a broad range of clients, facilitative interpersonal skills, professional self-doubt, deliberate practice
• Deliberate practice involves observing your own work, getting expert feedback, setting incremental learning goals just beyond your ability, repetitive behavioural rehearsal of specific skills, continuously assessing performance, taking care of yourself
• Self-care


  To protect against burnout, self-monitoring is important, therapeutic lifestyle changes: physical activity, diet and nutrition, being in nature, relationships, recreation, religious/spiritual involvement, providing service to others
• Qualities of effective therapists


  • Have an identity, respect and appreciate themselves, are open to change, make choices that are life-oriented, are authentic, sincere, and honest, have a sense of humour, may make mistakes and are willing to admit them, generally live in the present, appreciate the influence of culture, have a sincere interest in the welfare of others, possess good interpersonal skills, become deeply involved in their work and derive meaning from it, are passionate, are able to maintain healthy boundaries
• Therapist factors NOT associated with outcome


  • Demographics (age, gender), training and experience, adherence to specific treatment protocols
  • While some clients may have preferences, it doesn't seem to greatly affect outcome
• Cultural competence includes the role of the feminist approach to psychotherapy, effort to increase awareness and understanding of cultural factors that affect psychotherapy, the knowledge and skill set necessary to work effectively in any cross-cultural therapeutic encounter, the knowledge and skill set necessary to work effectively with a specific ethnocultural community if necessary
• Culture includes beliefs, values, attitudes, expectations, social customs, social practices
• Cultural factors are multidimensional and therefore influences can vary among people from seemingly similar backgrounds