9 Applied Case Formulation

‘Now What?’

In this book, you have learnt some of the essential ideas, processes and skills that undergird the practice of counselling and psychotherapy. As you practise these skills in classes and role-plays, you would be beginning to develop the basic competencies of seeing a client, connecting with them, and hearing their story. By learning these essentials, you are preparing to be able to do client work.

Let us imagine, then, that you are ready to see your first client. Your client is Emily, a 39-year-old primary teacher who has self-referred to come to see you. You have very limited information on the referral, so you gently ask Emily what brings her to counselling and what she is hoping to get out of it. She initially responds that she “wants to get some clarity” and that lately there has been “kind of a lot” going on.

She explains that six months ago she has remarried. Her new husband, Sai, has two primary-school-aged children. This was initially exciting for Emily, as she had always wanted a family, but does not have any children of her own. Due to this, when they first got married, Emily cut back on her work to spend more time with the children. However, Emily explains to you that the children have reacted very differently to what she expected:

Again, Emily cries, physically expressing the loneliness, disappointment, guilt, hurt and fear that she has expressed verbally. Together you talk about life for her being like a “struggle” or a series of “battles”. At one point, she offers the following image:

At the end of such a session, it is perfectly normal for new counsellors to then ask a question like “Now what?” While you have an understanding of the theories, processes and skills of therapy, it is not always obvious how to apply these to the stories you hear in practice. For example, what would therapy look like for Emily? We will return to this question by the end of this chapter, but first we will discuss the importance of case formulation in the process of therapy.

What is ‘Case Formulation’ and Why Do We Need It?

In one of his well-known aphorisms, Irvin Yalom (2003) encourages therapists to “strive to create a new therapy for each patient”. This idea is not particular to Yalom. Rather, throughout the history of psychotherapy it has been widely held that practitioners of counselling and psychotherapy must tailor their approach to the individuality of the client (Norcross & Wampold, 2011). While Yalom’s phrase is uniquely evocative, the principle of ‘creating a new therapy for each client’ has been known by many names:

“The process of creating the optimal match in psychotherapy has been accorded multiple names over the years [including]: aptitude by treatment interaction (a research design), attunement, customizing, differential therapeutics, fitting, individualizing, matchmaking, personalizing, prescriptionism, responsiveness, specificity factor, tailoring, therapy fit, treatment adaptation, and treatment selection. In the professional literature, treatment adaptation and responsiveness tend to prevail… [while] in clinical work, patients tend to prefer the terms individualizing and personalizing“. (Norcross & Wampold, 2018, p. 1891, original emphasis)

As the above quote indicates, the desire for a tailored approach is not limited to practitioners. Rather, clients of counselling and psychotherapy regularly express preference for a personalised approach, and report discomfort when they feel like they are being made to fit the therapy rather than the other way around (Li et al., 2024).

Still, aspiring to practise this adaptive, responsive and personalised form of psychotherapy presents a distinctive challenge for new counsellors and psychotherapists. Gibney (2013) likens this challenge as the process of learning an improvised art. In this way, new practitioners must learn the theories and skills (such as those contained in this book) in the same way that artists must learn and practise the techniques of their medium or instrument. However, improvised artists – and therapists – must then deploy these skills in response to unexpected stimulus to produce a bespoke performance of their skills. Therefore, a common (yet often unexpected) challenge for new practitioners is dealing with the uncertainty that is inherent with every client and every session.

So, how do we go about creating a personalised therapeutic experience for the individuality of each client? An essential mechanism for this process is case formulation. Sometimes also called a case conceptualisation, a case formulation is a condensed summary of the client’s story, along with a set of hypotheses about things such as the nature of the client’s problems, underlying factors causing and maintaining the problem, and the factors that might support or impede progress. Often these hypotheses then form the basis of a plan of the therapeutic strategies that might resolve the issue.

There are three key features of a case formulation that make it an effective tool for guiding practitioners in creating a tailored course of therapy for clients:

1. Formulations are personalised to the client. There is no such thing as a generic formulation. Rather, the starting point for each formulation is the client’s story. The resulting hypotheses will be bespoke for that person.
2. Formulations are informed by theory and research. While the formulation starts with the client’s story, the counselling practitioner brings their professional knowledge of theory and research to help illuminate the story in new ways. By viewing the client’s story through those lenses, the therapist has the potential to notice previously unseen causes of problems or to reveal new avenues for change.
3. Formulations are evolving representations. Formulations generate hypotheses, not conclusions. They are always tentative and always subject to revision with new information. This stance helps the therapy to remain tailored to the person. Conversely, a practitioner who holds onto their formulation too tightly (disregarding all evidence to the contrary) is at risk of trying to make the client fit the therapy rather than the other way around!

The capacity to formulate is a core competency for practicing therapists (Kendjelic & Eells, 2007). As such, developing skills in case formulation has several benefits for your practice of counselling and psychotherapy (Johnstone & Dallos, 2013), including:

• bridging the gap between abstract, generalisable psychological theory and the specificity of the client’s situation;
• helping the therapist maintain intentionality and focus;
• giving the client an orderly understanding of what might have previously been a chaotic or confusing reality; and
• providing a road map for the work being done throughout the process of the therapeutic relationship.

As valuable and as important as case formulation is, it is also a task that new counsellors find hard to develop. The process is cognitively demanding, requiring the practitioner to synthesise complex (and sometimes contradictory) information, to discern factors such as causality, significance and implications of various elements of the story, and to inductively posit best-fit explanations on what is often a non-linear and inconclusive set of data. Given this, the remainder of this chapter will introduce you to key processes and skills to guide you in formulation.

Process: Description, Organisation and Double Description

Developing a case formulation is an example of a ‘black box process’. A black box process is a term used to describe what happens when you have an observable input or stimulus, and then an observable output or response, but an unseen or unobservable process in between the input and the output. We encounter black box processes every day. For example, when you type a query into a search engine, you provide the search engine with an input. The search engine then provides you with an output: a response to your query. But what happens in between to produce that result is a mystery to you. It is like it happens within a black box.

When applied to counselling, the input is the client’s communication of their story, and the output is the counsellor’s response or (in this case) their case formulation. What happens in between these two things can seem mysterious. However, an action research process showed that there were three major things that happened inside the black box to process the client’s story (input) and produce the formulation (output) (Schirmer, 2023). These processes are:

• Description
• Organisation
• Double Description.

This section will introduce these three processes, as well as the outcome of the processes in the form of a ‘working hypothesis’.

Description

In case formulation, the function of the process of description is to summarise – as accurately and as succinctly as possible – the major features and themes of the client’s story. As noted above, the client’s story is the starting point for all formulation. Therefore, before we can commence any reflection or interpretation of that story, we need to ensure that we understand it as completely and as accurately as much as it has been told to us.

In practice, therapists use the process of description to summarise the essential elements and themes of the client’s story that they have heard from them. For instance, as a client is talking, practitioners might make brief notes or mentally store the key features of the story. At the end of the session, practitioners might make a list of dot points that summarise the topics of the session. If this list covers all the topics, it is an effective description in that it is a reduced, workable summary of the major elements of the story.

It is important at this stage to make sure that the language is only describing rather than interpreting. For example, in this step, we would not talk about the client’s “avoidant attachment to her caregivers” but rather that the client said that she “didn’t feel close to her parents”. It is the task of subsequent steps to begin to layer hypotheses about this material. For now, it is sufficient to stay close to the client’s language and to summarise rather than interpret.

Organisation

In the case formulation process, the role of organisation is to take the key features of the client’s story and to categorise them into some sort of systematic framework. Think of this as a bit like starting a 1000-piece jigsaw puzzle. While the first step might be to turn over every piece so that you can see all of the individual units that will make up the whole picture, the second step would be to start to sort the pieces into meaningful groups (e.g. by shapes such as edge pieces, or by colour, etc.). This grouping moves you forward in the puzzle as it helps you see what might go where. Similarly, where the process of description shows you what elements you are working with, the process of organisation will help you to start to see where these elements fit in relationship to one another.

There are many different frameworks that practitioners use to organise a client’s story for formulation. Some of these frameworks are theory-specific models of organisation. These models use the categories of major theories (e.g., psychodynamic, CBT, narrative), and organise the client’s story into these categories.

Other approaches to organisation are issue-specific models. These types of organising models of formulation start with the client’s issue (e.g. addiction, trauma, relationship conflict), and outline common considerations that are consistent with that issue.

A final approach to organisation could be termed generic or transtheoretical models of formulation. These models use some major categories that could apply to any issue, no matter what theoretical framework the counsellor is using. The best know examples are the Biopsychosocial model (which organises the story into biological, psychological and social factors impacting the client), and the 5-Ps model (which organises the story into the presenting problem and its corresponding predisposing, precipitating, perpetuating and protective factors).

Double Description

Along with describing and organising the client’s story, the process of case formulation also starts to experiment with viewing the story through various lenses in an attempt to identify resonant hypotheses. This process could be called double description, a term first coined by Gregory Bateson (1985) to describe how the mind develops, organises, and uses knowledge. In Bateson’s framework, double description is the capacity for a person to describe something in more than one way in order to represent an object or phenomenon more precisely. For example, while one can accurately describe a crab as a crustacean, using a double description of a crustacean that also walks sideways is more precise, and thus distinguishes it from other crustaceans. Of course, with each extra descriptor the description becomes even more precise.

In case formulation the idea of double description applies to the practitioner’s use of theory and research as a language to re-describe our clients’ stories to see what these descriptions might reveal about causes and solutions to client problems (Gibney, 2003). In practice, both during and after a session of counselling, an experienced counsellor will likely be referring to theory as they think about the client’s story.

As can be seen in this example, any lens of theory has the potential (though not a guarantee) to illuminate previously unseen elements of the story. Consequently, if a practitioner can look from a multiple theoretical or even integrated theoretical point of view, it adds potential for the complexity of the formulation. In short, the human experience is so irreducibly complex that no single theory can adequately capture it. Consequently, being able to formulate using more than one perspective increases the chances of a helpful formulation to guide therapy. Appendix A contains a list of some basic hypothesis-generating questions from major theories of psychotherapy.

Outcome: The ‘Working Hypothesis’

As stated earlier, case formulation is an ever-evolving process. The processes of description, organisation and double description are not ‘steps’ that you do once and then are finished. Rather, they are more like movements in a cycle that you continually work through while in conversation with the client. Still, as the cycle repeats, you will increasingly return to particular hypotheses that are more informative and influential for the therapy.

Early on in a therapeutic relationship, you might have a relatively long list of possible hypotheses and potential purposes. As therapists we try to stay as open as possible for as long as possible, in order that we do not prematurely rule out potentially significant conceptualisations. Still, with the repeated iterations of the process of therapy, you are able to both hear more of the client’s material and also test your hypotheses with the client.

This repeated cycle should enable you to hone your hypotheses significantly. Some hypotheses will have more power than others in being able to explain the experiences of the client. It is possible that you will even develop a single-sentence statement of your primary hypothesis and priority plan for work with this client. At this stage, we would say that you have developed a ‘working hypothesis’: a hypothesis that is robust enough to use as a basis for your therapeutic intervention with the client.

It is important to clarify two things about this working hypothesis. Firstly, it is not the case that you have to get this 100% correct. It is likely that this hypothesis will continue to be refined or even changed as you get more information from the client (including how they might respond to any therapeutic processes you use). It is better to think of your hypothesis in terms of its usefulness or its consistency with the client’s story, rather than evaluate its perfection.

Secondly, your working hypothesis does not have to come from a single theory. While there may be one singular theoretical interpretation that makes sense of a particular client’s story, the working hypothesis may just as easily need to draw on two or more theories to provide an adequate conceptualisation for the story. The working hypothesis in the case study in the next section gives an example of exactly this.

Skills: Steps to Creating a One-page Formulation

This section will introduce you to one way of preparing a case formulation. The skill you are learning in this section is preparing a ‘one-page formulation’. The ability to be able to do this enables you to demonstrate all the key processes that are involved in being able to formulate competently.

The organising framework for this example is the Power-Threat-Meaning (PTM) Framework (Johnstone & Boyle, 2018b). The PTM Framework was launched as an alternative paradigm for understanding the lived experience of life and distress that was more comprehensive, holistic and contextually sensitive than traditional medical or diagnostic model

At its heart, the PTM replaces the diagnostic model’s core question of “What is wrong with you?” with the more holistic question of “What is your story?” More specifically, it proposes that it is helpful to organise the experience of psychological distress along three key axes: power, threat and meaning.

• Power: What has happened to you? How is this power operating in your life? What power do you have access to?
• Threat: What kind of threats did this pose? How did you respond to these threats in order to survive?
• Meaning: What sense did you make of these situations and experiences?

When integrated with the processes described in the previous section, the PTM give a six-step structure to preparing a one-page formulation. These are outlined in the following table:

The following example outlines how Emily made sense and meaning of her experience:

Step 6: Working Hypothesis, Purpose and Plan

At this point, you will have a succinct, organised version of the client’s story, a set of hypotheses of what is happening, and an awareness of how the client personally makes sense of it. Given all these points of information, it should be possible to begin to condense a working hypothesis – a succinct statement that summarises the conceptualisation on which you might base your intervention. This working hypothesis should aim to provide as much explanation of the client and the story as is possible with the information you have at this time. As noted in the previous section, it is open to change, and it can draw on more than one theory.

New counsellors often wonder how to articulate a working hypothesis given the range of information provided. However, if you are asking this question, it shows you are on the right track. It shows you are taking in the complexity of the client story and not settling for a simplistic response. Two questions might help you in this process:

• What makes the most sense for this person? This question helps us to find the right hypothesis for the client. It is about taking seriously the individuality of the client. This story is uniquely their own and their experience of it is uniquely their own. Nobody else could have had either the same series of events or indeed had the same lived experience, interpretations or goals.
• What makes most sense of the story? This question helps us to find the right hypothesis for the story. In other words, it helps us to look for the hypothesis that has the most explanatory power. In asking this question, it helps us to examine whether there are any aspects to the story that remain unaccounted for by your working hypothesis; if there are such aspects, the hypothesis needs to be developed or deepened.

From this working hypothesis, you can begin to consider options for your therapeutic work with the client. But before jumping to specific techniques or strategies, it is important to consider the broader purpose or objective of the therapy. While there seems to be hundreds of distinctive methods of psychotherapy, it has long been acknowledged that in actual fact all these therapies work according to a small, finite number of common mechanisms (Prochaska & Norcross, 2018). Given your working hypothesis, what is the best overall use of counselling for this person? For example, is it:

• creating an experience whereby the client can become aware of, express, accept and regulate their emotional material?
• increasing options available to the client to respond to their situation, either through new ways of thinking or new ways of acting?
• establishing safe, reliable and responsive relationships with the therapist, others or with broader systems?
• connecting with and integrating narratives that provide a sense of meaning, value or worth for the client?

From this broader goal, it is then possible to consider best-fit strategies for the client that would lead toward this purpose. Working from an integrated perspective, you can draw on the range of theoretical interventions to find strategies that help work towards this goal.

Bringing it Together: The One-page Formulation

One image for case formulation is that it is like putting light through a prism. When the client shares their story, it comes as one integrated, unified whole: like white light. When we put this story through the prism of case formulation, we become able to see the spectrum of colours that make up this story. An important step in this process, though, is being able to pull together these various elements back into a unified whole.

This is where you can do this through writing a one-page formulation. This comprises a succinct summary of the client’s story and your working hypotheses for work going forward. In the framework we are using, the one-page formulation would include the following elements:

1. A brief orientating statement of the client’s story, the reason they are seeking counselling, and any information on their motivation and theory of change
2. A summary of the various factors that have power in their life
3. A summary of how these powers may have threatened various needs
4. A statement of how the client is making meaning of their experience
5. A list of possible hypotheses that are refined into a working hypothesis
6. (As the process develops) A statement of the potential purpose of therapy for this client.

An example of the one-page formulation for Emily is included as Appendix B to this chapter.

Conclusion: The Intellectual Work of Counselling

In reading through this chapter, hopefully you will be left without a doubt that the art of counselling and psychotherapy is many things, including an inherently intellectual practice. This is evident in the research on master therapists that has indicated that, along with expert emotional and relational characteristics, the masters also commonly hold expert cognitive characteristics (Skovholt & Jennings, 2017). These characteristics include an embrace of cognitive complexity, the ability to be guided by accumulated wisdom, an insatiable curiosity and appetite for learning, and a profound depth of understanding of the human condition. This is commonly reflected in the complexity of thinking that expert therapists are able to apply to their case formulations (Eells et al., 2011; Mozdzierz et al., 2013).

Does this seem a long way off for you right now? Doubtless, mastery is a very high bar to set. Nevertheless, something that every novice should always remember is that every expert or master once was at your stage of development. Your development as a person and as a helper is a lifelong process. Encouragingly, there is evidence that – just like other skills – case formulation skills can improve with training, deliberate practice and feedback (Kendjelic & Eells, 2007).

When this type of development happens, it means that the counsellor has effectively metabolised the knowledge and theory that is part of the tradition of psychotherapy. At this moment, the theory stops being an abstract set of ink-on-paper ideas, and suddenly becomes living, breathing and potentially transformative ideas embodied in the person of the therapist. Therefore, theory was never designed to be ‘studied’, just a recipe was never designed to be studied. Both are meant to be used to create something new. Thus, as you start to metabolise theory, you will find that it will nourish you in your day-to-day work in a way that you probably never thought possible.