I recently started at a new practicum placement, and the agency assessment form includes a case formulation. I haven’t done this before, so I’m not sure how to write it and how I can use it in my work with clients.
A case formulation, also called a clinical or case conceptualization, is a theoretically based explanation for the client’s presenting problems and symptoms. You use the concepts from your chosen theoretical perspective to describe why this client has developed the particular issues that are the focus of treatment. The formulation follows your diagnosis and assessment and guides development of your treatment plan. Chapter 8 of my book is devoted to the topic of case formulation, including an illustration of a case formulation written from three different theoretical perspectives for the same case.
The case formulation model I present in my book includes the following five aspects of the case:
- Symptoms and presenting problems—Begin with a brief summary of the reason for treatment, both from the client’s initial presentation as well as additional issues that may be emerged from the assessment.
- Developmental history and recent events relevant to the symptoms—Summarize the life events that are relevant to the client’s symptoms. These would include traumatic events, losses, and significant psychosocial stressors that occurred in the past as well as recent precipitants that have contributed to the client’s current presentation.
- Factors that contribute to the symptoms—This is the core of your case formulation, making clinical inferences about the links between your client’s life events and symptoms. It is best to use one theoretical orientation as the basis of your formulation, in order to have a cohesive guide for your treatment. Sample statements are “client developed a core belief of that she is unworthy of love and attention” or “the early disruption in client’s family life led him to develop an avoidant attachment to his mother.”
- Cultural issues—Describe how cultural identities and other cultural factors impact the client’s symptoms and will be relevant in the treatment.
- Strengths and resources—Review the internal and external factors that will assist in lessening the client’s symptoms and will enhance the client’s progress in therapy.
Regarding the question of how you can use a case formulation in your work, it can enhance your work in several ways. When you hold and communicate an accurate understanding of the client’s difficulties, you are able to convey a deeper level of empathy than is possible based only on the client’s presenting symptoms themselves. Your case formulation also guides your choice of treatment goals and interventions, allowing you to target more specifically the underlying source of the client’s problems. Last, you are able to organize new clinical material more readily when you have a case formulation that structures your knowledge of the client’s present and past experiences.
I hope this model for case formulation enables you to develop clinically useful descriptions of the links between your clients’ symptoms and history. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.