In the helping profession, working effectively with clients depends on understanding them well.
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 this client, how they became who they are, and where their 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.
. These science-based exercises will provide detailed insight into positive Cognitive-Behavioral Therapy (CBT) and give you the tools to apply it in your therapy or coaching.
What Is a Case Conceptualization or Formulation?
A case conceptualization in psychology and related fields summarizes an evaluation’s key facts and findings to guide 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).
4 Things to Include in Your Case Formulation
A case often includes these key components, in the following order:
- Summary of the client’s identifying information, referral questions, and timeline of important events or factors in their life.
A timeline can be especially helpful in understanding how the client’s strengths and limitations have evolved. - Statement of the client’s core strengths. Identifying core strengths in the client’s life should help guide any recommendations, including how forces might be used to offset limitations.
- Statement concerning a client’s limitations or weaknesses.
This will also help guide any recommendations. If a weakness is worth mentioning in a case conceptualization, it is worth writing a proposal about it.
Note: As with mental status examinations, observations in this context concerning weaknesses are not valued judgments about whether the client is a good person, etc. The comments are clinical judgments meant to guide recommendations.
- A summary of a client’s strengths, limitations, and other essential information informs diagnosis and prognosis.
It would help if you briefly clarified how you arrived at a diagnosis. For example, why do you believe a personality disorder is a 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 precisely with ICD-10 or DSM-5 codes. What is arguably more important is that a diagnostic impression, traditional 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.
A Helpful Example & Model
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.
Strengths
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 benefits. He is agreeable to starting individual counseling. He reportedly does well in school academically when he applies himself.
Limitations
The behavioral form completed by his mother shows an 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 exceptionally social with peers.
Diagnostic impressions, treatment guidance, prognosis
This youth’s history, presentation on the 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 due 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.
The 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.
- Background and referral information:
- Client’s gender, age, level of education, vocational status, marital status
- Referred by whom, why, and for what type of service (e.g., testing, counseling, coaching)
- Strengths:
- Consider listing the client’s strengths before any limitations in a strengths-based assessment.
- Consider the full range of positive factors supporting the client.
- These factors might include:
- Physical health
- Family support
- Financial resources
- Capacity to work
- Resilience or other positive personality traits
- Emotional stability
- Cognitive strengths, per history and testing
- Limitations:
- The client’s limitations or relative weaknesses should be described to highlight those most needing attention or treatment.
- These factors might include:
- Medical conditions affecting daily functioning
- Lack of family or other social support
- Limited financial resources
- Inability to find or hold suitable employment
- Substance abuse or dependence
- Proneness to interpersonal conflict
- Emotional–behavioral problems, including anxious or depressive symptoms
- Cognitive deficits, per history and testing
- Diagnostic impressions, treatment guidance, prognosis:
- Diagnoses that are warranted can be given in either DSM-5 or ICD-10 terms.
- There can be more than one diagnosis given. If that’s the case, consider describing these in terms of primary diagnosis, secondary diagnosis, etc.
- The primary diagnosis should best encompass the client’s key symptoms or traits, explain their behavior, or most need treatment.
- Take care to avoid over-assigning multiple and potentially overlapping diagnoses.
When writing a case conceptualization, remember the timeline of significant events or factors in the examinee’s life.
- Decide which events or factors are significant enough to include in a case conceptualization.
- When these points are placed in a timeline, they help you understand how the person has evolved to become who they are now.
- A reasonable timeline can also help you understand which factors in a person’s life might be causative for others. For example, if a person has suffered a frontal head injury in the past year, this might help explain their changeable moods, presence of depressive disorder, etc.
3 Samples of Case Formulations
The following samples can be taken as basic templates for case conceptualization in the context of Cognitive-Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), and family therapy.
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 the treatment, high average intelligence per recent cognitive testing, supportive family, and regular physical exercise (running).
Limiting factors include 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 during the interview and medical/psychiatric records review shows a history of chronic worry, including frequent concerns about his wife’s health and finances. He meets the criteria for DSM-5 generalized anxiety disorder. He has also described occasional panic-type episodes, which do not currently meet the 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 the Penn State Worry Questionnaire and Beck Anxiety Inventory; cognitive restructuring around negative beliefs that reinforce anxiety; and relaxation techniques, such as progressive muscle relaxation and diaphragmatic breathing.
The prognosis is reasonable, given the evidence for the 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 a personality disorder with borderline features, but she doubts the accuracy of this diagnosis.
Strengths/supports include a willingness to engage in the 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 partly to depressive affect), and a tendency to self-medicate with alcohol when feeling depressed.
The client’s presentation on the interview, medical/psychiatric records review, and results of the MMPI-2 personality inventory corroborate her psychiatrist’s diagnosis of borderline personality disorder.
A longstanding history of unstable identity supports the diagnosis, volatile personal relationships with fear of being abandoned, feelings of emptiness, a reactive depressive disorder with suicidal gestures, and a 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 has not yet gone to. 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). The prognosis is guardedly optimistic, provided she engages in both group and individual DBT treatments weekly. 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 independently, her husband and son 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 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.”
In an 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.
In an interview with the three family members, each acknowledged that the above instances occurred at home. However, father and son tended to blame most of the problems, including the 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 the 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, including the 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 on each other’s feelings, and tolerance of distress at the moment should help to develop an environment that supports all family members and facilitates effective communication.
In this case, all family members would benefit from engaging in the above DBT skills to support and communicate.
The prognosis is guardedly optimistic if the family will engage in therapy with DBT elements for at least six sessions (with refresher sessions as needed).
Relevant Resources From PositivePsychology.com
Analyzing Strengths Use in Different Life Domains can help clients understand their notable strengths and which strengths can be used more in new contexts.
Family Strength Spotting is another relevant resource. Each family member fills out a worksheet detailing the 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 to help counselors conceptualize a case based on a client’s personal and environmental strengths and weaknesses. The idea behind this tool is that ecological factors, in the broad sense, such as a supportive/unsupportive family, are too often overlooked in conceptualizing a case.
A Take-Home Message
In helping professions, success in working with clients depends on how well you understand them.
This understanding is crystallized in a case conceptualization.
Does case conceptualization help answer critical questions? Who is this client? How did they become who they are? What support do they need to reach their goals?
The conceptualization 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 professionals 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 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 helpful.
