Case formulation

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Case formulation involves the gathering of information regarding factors that may be relevant to treatment planning, and formulating a hypothesis as to how these factors fit together to form the current presentation of the client’s symptoms [410, 411]. The case formulation process should be collaborative, in that the AOD worker contextualises the client’s experiences and knowledge of themselves within their own clinical expertise [410]. The primary goal of AOD treatment services is to address clients’ AOD use. However, in order to do so effectively, AOD workers must take into account the broad range of issues with which clients present. As discussed in Chapter A2, clients of AOD treatment services, and those with co-occurring conditions in particular, often have a variety of other medical, family, and social problems (e.g., housing, employment, welfare, or legal problems). These problems may be the product of the client’s AOD and mental health conditions, or they may be contributing to the client’s AOD and mental health conditions, or both. According to stress-vulnerability models (e.g., Zubin and Spring [412]), the likelihood of developing a mental health condition is influenced by the interaction of biological, psychological, and social factors. These factors also affect a person’s ability to recover from these symptoms and the potential for relapse.

After developing a case formulation, the AOD worker should be aware of:

  • What problems exist, how they developed, and how they are maintained.
  • All aspects of the client’s presentation, current situation, and the interaction between these different factors and problems.

This information should be considered the first step to devising (and later revising) the client’s treatment plan. There is no standardised approach to case formulation [413], but it is crucial that a range of different dimensions be considered. These include the history of presenting issue/s, AOD use history (type, amount and frequency, presence of disorder), physical/medical conditions, mental state, psychiatric history, trauma history, suicidal or violent thoughts, readiness to change, family history, criminal history, and social and cultural issues. Consideration also needs to be given to the client’s age, gender identity, sexual orientation, ethnicity, spirituality, socioeconomic status, and cognitive abilities.

Given the high rates of co-occurring mental health conditions among clients of AOD treatment services, it is essential that routine screening and assessment be undertaken for these conditions as part of case formulation. Screening is the initial step in the process of identifying possible cases of co-occurring conditions [200, 414]. This process is not diagnostic (i.e., it cannot establish whether a disorder actually exists); rather, it identifies the presence of symptoms that may indicate the presence of a disorder. Thus, screening helps to identify people whose mental health requires further investigation by a professional trained and qualified in diagnosing mental disorders (e.g., registered or clinical psychologists, or psychiatrists).

Abstinence is not required to undertake the screening process [415]. The potential clinical issues that these conditions can present suggest that screening for co-occurring mental health conditions should always be completed in the initial phases of AOD treatment. Early identification allows for early intervention, which may lead to better prognosis, more comprehensive treatment, and the prevention of secondary disorders [406, 416, 417].

Diagnostic assessment should ideally occur subsequent to a period of abstinence [418, 419], or at least when the person is not intoxicated or withdrawing [420]. While the length of this period is not well established, a stabilisation period of between two to four weeks is recommended [421, 422]. A lengthier period of abstinence is recommended for longer-acting drugs, such as methadone and diazepam, before a diagnosis can be made with any confidence, whereas shorter-acting drugs such as cocaine and alcohol require a shorter period of abstinence [39, 418]. If symptoms persist after this period, they can be viewed as independent rather than AOD-induced.

In practice, however, such a period of abstinence is rarely afforded in AOD treatment settings and, therefore, to avoid possible misdiagnosis, it has been recommended that multiple assessments be conducted over time [102, 423, 424]. This process allows the AOD worker to formulate a hypothesis concerning the client’s individual case and to constantly modify this formulation, allowing for greater accuracy and flexibility in assessment.

Screening and assessment are ongoing processes rather than one-off events, which involve the monitoring of clients’ mental health symptoms. Ongoing screening and assessment are important because clients’ mental health symptoms may change throughout treatment. For example, a person may present with symptoms of anxiety and/or depression upon treatment entry; however, these symptoms may subside with abstinence. Alternatively, a person may enter treatment with no mental health symptoms, but symptoms may develop after a period of reduced use or abstinence, particularly if the person has been using substances to self-medicate these symptoms.

Groth-Marnat [425] suggests that a combination of both informal and standardised assessment techniques is the best way to develop a case formulation, though some researchers also suggest that building a formulation framework using the 5Ps model may be useful [389, 426]. In this framework, case formulation is determined by identifying the ‘5Ps’ [427]:

  • Presenting issues.
  • Predisposing factors.
  • Precipitating factors.
  • Perpetuating factors.
  • Protective factors.

Figure 12 depicts how both informal and standardised assessment techniques work together. In addition to these assessments, with the client’s consent, it may be useful to talk with family members, friends, or carers; they can provide invaluable information regarding the client’s condition which the client may not recognise or may not want to divulge, provide support to the client, and improve treatment outcomes (see Chapter A3) [428, 429].

Figure 12: The ongoing case formulation process

Note: Figure 12 illustrates the need for assessment to be repeated throughout treatment, from intake through to discharge, to inform the ongoing revision of a person's treatment plan.

An example of how the 5Ps model can be used to build a case formulation, with Lena’s case study (Box 12) and the case formulation template (Appendix F), is illustrated in Table 23. This is just one example of how AOD workers may develop a case formulation, and not all client factors will necessarily apply to the template

Box 12: Case study L: Example case formulation: Lena’s story

Case study L: Lena’s story

Lena is a 27-year-old who identified as female, who had been living in a major city for most of her life. She had been living in the family home with her younger brother since their mother died five years earlier; their father died by suicide when Lena was 12 years old. He was diagnosed with depression several years earlier. Lena was sexually assaulted several times by a male neighbour when she was 5 or 6.

Lena had been working as a programmer at a web-design company for the past 18-months but lost her job last week after several conflicts with her co-workers resulted in complaints being made against her, and for missing several important client meetings because she had overslept. The day Lena lost her job, she immediately went home, locked herself in her bedroom and self-harmed. Since that time, she had been drinking a couple of bottles of wine every day and was thinking about taking an overdose of her Aropax medication.

Seeing that Lena had not left her room in a week, her concerned brother coaxed her out and brought her to their local hospital emergency. Prior to the loss of her job, Lena’s mood was stable, and she had not self-harmed or had any suicidal thoughts in the past two years. She was seeing a psychologist and a psychiatrist regularly, but had not maintained her routine appointments, preferring to have her GP prescribe her Aropax. Lena’s psychiatrist had previously diagnosed her with co-occurring depression, BPD and alcohol use disorder.

Lena had a bachelor’s degree in computer science. She used to play hockey but gave up last year after several injuries. She was in a one-year on/off relationship with a female partner who she had been friends with since University, and there had been recent arguments concerning the direction of their relationship. Lena described a fear of being abandoned in relationships and had very intense relationships with friends/family.

Adapted from PsychDB [430].

An example of how Lena’s presenting issues, predisposing, precipitating, perpetuating and protective factors may be developed into a case formulation is illustrated in Table 23. As biological and social factors often influence psychological symptoms, it can be useful to complete the biological and social sections of the table first, followed by the psychological section last.

Table 23: Example of a case formulation for Lena



(e.g., genetic factors, medications, physical health)


(e.g., resilience, personality, thoughts, feelings, behaviours)


(e.g., socioeconomic background, relationships, family, school, work, cultural factors, spirituality, community, social supports and connectedness)

Predisposing factors

Factors over a person's lifetime that may have contributed to problem

  • Possible family history of mental disorder
  • Fear of abandonment
  • History of childhood trauma
  • Early death of father
  • Death of mother

Precipitating factors

Any triggers or events that have initiated or exacerbated problem

  • Increase in alcohol use
  • Re-experiencing feelings of abandonment after loss of job
  • Recent loss of job
  • Difficulties with interpersonal relationships

Perpetuating factors

Factors that may  maintain problem or make it worse if not addressed

  • Current dose of paroxetine may be sub-therapeutic
  • Lack of adaptive coping mechanisms led to use of self-harm to cope, and thoughts of suicide
  • Ongoing disagreement in romantic relationship
  • Disengaged from psychologist and psychiatrist

Protective factors

Internal and external supports

  • Medically healthy
  • University educated
  • Previous engagement with psychologist/psychiatrist
  • Good support from brother who brought her to hospital
  • Interest in being physically active

Adapted from PsychDB [430].

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