Comprehensive Study Guide to Psychiatric Case Formulation and Occupational Formulation

Foundations of Psychiatric Case Formulation

• Definition of Case Formulation (Case Conceptualisation):

  • Involves the systematic gathering of comprehensive information regarding factors relevant to treatment planning.
  • Requires formulating an explanatory hypothesis detailing how these factors interact to generate the client's current presentation of symptoms.
  • Built upon a collaborative biopsychosocial model.
  • Provides an in-depth understanding and descriptive overview of clinical problems.
  • Identifies, integrates, and leverages a person's individual strengths.
  • Operates as a longitudinal, dynamic conceptualization that accommodates client change over time.

• Role in Everyday Clinical Practice:

  • Guides individualised treatment selection and clinical intervention pathways.
  • Identifies diagnostic blind spots and indicates where further clinical assessment is required.
  • Anticipates potential therapeutic obstacles, relapses, and aids in overcoming future clinical problems.
  • Organises complex, multifaceted clinical data into an accessible, structured framework.
  • Encourages collaborative engagement between clinician and client, establishing therapeutic alliance and shared agency.

• Core Formulative Triad (The Three Whys):

  • Why this person?: Clarifies individual vulnerability, predisposing history, personality dynamics, and unique contextual factors.
  • Why this problem?: Evaluates the specific phenomenological, biological, psychological, and systemic mechanisms driving the presenting symptoms.
  • Why now?: Identifies the proximal precipitating events, acute stressors, and tipping points that triggered the current crisis or seeking of care.

The 5 P's Aetiological Formulation Framework

• Presenting Problems (Difficulties and Strengths):

  • Biological: Current substance use, physical illness, traumatic injury, and cognitive difficulties.
  • Psychological: Active psychiatric symptoms, specific cognitive impairments, and compromised impulse control.
  • Social: Difficulties across friendships, family relationships, employment stability, educational engagement, romantic relationships, and general functional decline.

• Predisposing Factors (Underlying Vulnerabilities):

  • Biological: Genetic loading and family psychiatric history, chronic illnesses, organic brain injury, neurodevelopmental disorders, and low intellectual quotient ($IQ$) or learning disorders.
  • Psychological: Enduring personality style (including characteristic vulnerabilities and coping strengths), core maladaptive beliefs, insecure attachment style, and baseline coping styles governing the ability to adapt to life stressors.
  • Social: Age, gender identity and expectations, cultural background, socioeconomic status ($SES$), migration history, and systemic attachment styles.

• Precipitating Factors ("Triggers"):

  • Biological: Acute substance intoxication or withdrawal, emergent physical illness, physical trauma, and organic-related cognitive decline.
  • Psychological: Acute psychological trauma, experiences of interpersonal loss, bereavement and grief, abuse, bullying, significant blows to self-esteem and self-worth, activation of negative core beliefs, and sudden functional decline.
  • Social: Disruption or loss of employment, school or study-related stress, acute conflicts within social networks and relationships, turbulent family dynamics, severe financial stress, adverse residential status (e.g., homelessness), and acute functional decline.

• Perpetuating Factors (Maintenance Factors Keeping Symptoms Active):

  • Biological: Medication side effects ($SE$), active and recurrent substance use, uncontrolled physical illness, and non-compliance with medication regimens.
  • Psychological: Unresolved trauma, unresolved grief and loss, historical abuse, maladaptive coping styles, poor level of insight, therapeutic disengagement, lack of psychological adaptation, maladaptive recovery styles, high symptom severity, rigid core beliefs, and dysfunctional cognitive patterns.
  • Social: Social stigma, lack of social engagement, ongoing social stressors, deficient social networks and relationships, adverse family dynamics, ongoing financial strain, academic hurdles, vocational instability, and persistent homelessness.

• Protective Factors (Mitigating Strengths and Buffers):

  • Biological: High level of medication compliance, robust biological response to medical/psychiatric treatment, and total absence of substance use.
  • Psychological: High level of clinical insight, constructive coping styles (e.g., adaptive stoicism), psychological adaptation and psychological-mindedness, healthy recovery style, positive personal characteristics/resilience, and active treatment engagement.
  • Social: Reliable social supports and healthy relationships, positive and supportive family dynamics, stable employment, school attendance and educational integration, meaningful skills and recreational interests, competent social skills, and broader community engagement.

Questions and Discussion: Aetiological Formulation

• Question 1: Primary Purpose of Aetiological Formulation:

  • Question: What is the primary purpose of an aetiological formulation in clinical practice?
    • A. To develop a treatment plan
    • B. To understand the underlying causes of a condition
    • C. To evaluate the effectiveness of a medication
    • D. To conduct a physical examination
  • Correct Answer: B. To understand the underlying causes of a condition.
  • Explanation: While formulation directly informs treatment planning, the primary defining purpose of an aetiological formulation is identifying and understanding the underlying multifactorial causes that generate and maintain a disorder.

• Question 2: Definition of Precipitating Factors:

  • Question: Which of the following best describes the term 'precipitating factor' in aetiological formulation?
    • A. A long-standing condition that predisposes an individual to a disorder
    • B. A recent event or stressor that triggers the onset of a disorder
    • C. An environmental factor that prevents the development of a disorder
    • D. A genetic marker associated with a higher risk of developing a disorder
  • Correct Answer: B. A recent event or stressor that triggers the onset of a disorder.
  • Explanation: Precipitating factors represent proximal triggers or events immediately preceding symptom onset, distinguishing them from predisposing vulnerabilities or perpetuating drivers.

• Question 3: Identifying Biological Factors:

  • Question: Which of the following would be considered a 'biological' factor in the aetiological formulation of mental health disorders?
    • A. Family history of the disorder
    • B. Stressful life events
    • C. Socioeconomic status
    • D. Childhood upbringing
  • Correct Answer: A. Family history of the disorder.
  • Explanation: Family history reflects genetic loading and hereditary biological vulnerabilities, whereas life events, upbringing, and socioeconomic status fall under psychological or social domains.

• Question 4: Categorising Chronic Pain Exacerbating Depression:

  • Question: A patient has ongoing issues with chronic pain which exacerbates their depression. How would this be categorized in the 5 P’s framework?
    • A. Predisposing factor
    • B. Precipitating factor
    • C. Perpetuating factor
    • D. Protective factor
  • Correct Answer: C. Perpetuating factor.
  • Explanation: Because the chronic pain is an ongoing condition that continually maintains and exacerbates current depressive symptoms over time, it functions as a perpetuating factor.

• Question 5: Categorising Early Childhood Trauma:

  • Question: In aetiological formulation, how would you categorize a person’s early childhood trauma?
    • A. Precipitating factor
    • B. Protective factor
    • C. Predisposing factor
    • D. Presenting factor
  • Correct Answer: C. Predisposing factor.
  • Explanation: Early childhood trauma occurs long before the immediate onset of the current clinical episode, creating lasting developmental, psychological, and neurological vulnerabilities that predispose the person to psychiatric disorders.

• Question 6: Components of the 5 P's Framework:

  • Question: Which of the following is NOT a component of the 5 P’s framework?
    • A. Presenting
    • B. Precipitating
    • C. Preventative
    • D. Perpetuating
  • Correct Answer: C. Preventative.
  • Explanation: The standard 5 P's framework consists of Presenting, Predisposing, Precipitating, Perpetuating, and Protective factors. "Preventative" is not one of the five formal categories.

• Question 7: Identification of Protective Factors:

  • Question: Which of the following scenarios best illustrates a 'protective' factor?
    • A. Chronic anxiety
    • B. A supportive and stable social network
    • C. High levels of workplace stress
    • D. Recent history of trauma
  • Correct Answer: B. A supportive and stable social network.
  • Explanation: A supportive social network acts as an external buffer that mitigates risk, preserves functioning, and assists recovery, fitting the definition of a protective factor.

Occupational Formulation: Theoretical Frameworks and Structures

• Definition and Occupational Therapy Role:

  • A process of making sense of an individual's life circumstances informed directly by occupational theories, models, and concepts.
  • Represents a critical phase within the occupational therapy process emerging from structured professional reasoning.
  • Maintains occupation at its absolute core (occupation-centred practice).
  • Grounded fundamentally in the Model of Human Occupation (MOHO).
  • Employs a longitudinal approach tracking past history, present performance, and future trajectory.

• Structural Paradigms of Occupational Formulation:

  • Narrative Structure (Jamieson & Parkinson, 2017):
    • Beginning (establishing client background and life narrative).
    • Middle (examining the current life disruption and presentation).
    • End (projecting future pathways, resolutions, and potential).
  • Universal Structure (Brooks & Parkinson, 2018):
    • Occupational Influences (historical and contextual factors shaping occupation; the past).
    • Occupational Presentation (current functional status, routines, and performance; the present).
    • Occupational Focus (future-oriented intervention planning, adaptation, and targets; the future).
  • MOHO-Based Structure (Forsyth, 2017; Brooks & Parkinson, 2018; Parkinson & Brooks, 2021):
    • Occupational Identity (subjective self-definition and volition).
    • Occupational Competence (objective enactment of roles, routines, and skills).
    • Key Issues for Occupational Adaptation (identifying primary therapeutic targets to achieve adaptation).

The MOHO-Based Occupational Formulation Process

• Sequential Stage Flow:

  • 1. Introduction.
  • 2. Occupational Identity.
  • 3. Occupational Competence.
  • 4. Key Occupational Issues / Needs.
  • 5. Summary.
  • 6. Measurable Occupational Goals.

• Stage 1: Introduction:

  • Core Content Requirements:
    • Personal identification details (client name, age, gender, diagnostic history).
    • Referral details and core referral questions.
    • Formal occupational assessments completed, explicitly referenced and dated.
    • Documentation of client collaboration and feedback regarding the formulation.
  • Guiding Interrogatives:
    • Who? (Personal demographics).
    • Why? (Referral purpose and therapeutic mandate).
    • What? (Standardised and non-standardised assessment tools utilised).
    • When? (Exact evaluation timeline and completion dates).
    • Where? (Setting and context of evaluation).
    • How? (Nature and depth of client involvement and collaborative review).

• Stage 2: Occupational Identity:

  • Captures the client's subjective viewpoint regarding who they are and who they desire to become.
  • Components:
    • Past and present roles and relationships combined with volition.
    • Brief occupational history (childhood, education, vocation, key life turning points) combined with volition.
    • Past and present interests combined with volition.
    • Expressed personal goals combined with volition.
  • Volition Definition: Comprises values (what is meaningful), personal causation (sense of capacity and effectiveness), and interests (what is enjoyable).
  • Representative Assessments Informing Identity:
    • Model of Human Occupation Screening Tool (MOHOST)
    • Occupational Self Assessment (OSA)
    • Role Checklist
    • Interest Checklists / Paediatric Interest Profiles / Activity Checklist
    • Occupational Circumstances Assessment Interview and Rating Scale (OCAIRS)
    • Volitional Questionnaire (VQ)
    • Worker Role Inventory (WRI)
    • Adult Sensory Profile
    • Canadian Occupational Performance Measure (COPM)

• Stage 3: Occupational Competence:

  • Reflects the occupational therapist's objective, assessment-informed analysis of how effectively the client sustains patterns of occupational behaviour.
  • Core Evaluative Domains:
    • Participation in everyday roles and regular routines.
    • Underlying motor, process, and communication skills.
    • Functional abilities (how well activities are performed across environments).
    • Current environmental demands and contextual barriers/supports.
    • Degree to which objective performance matches the person's occupational identity.
  • Categories of Assessments Informing Competence:
    • Skills-based evaluations.
    • Activities of Daily Living ($ADL$) measures.
    • Participation-focused assessments.
    • Environment-related tools.
  • Specific Competence Assessment Tools:
    • Allen Cognitive Level Screen ($ACLS$)
    • Assessment of Communication & Interaction Skills ($ACIS$)
    • Assessment of Motor & Process Skills ($AMPS$)
    • Assessment of Work Performance ($AWP$)
    • Perceive, Recall, Plan & Perform ($PRPP$) System of Task Analysis
    • Domestic & Community Skills Assessment ($DACSA$)
    • Functional Independence Measure ($FIM$)
    • Kohlman Evaluation of Living Skills ($KELS$)
    • Barthel Index
    • Assessment of Occupational Functioning ($AOF\text{-}CV$)
    • Occupational Gaps Questionnaire ($OGQ$)

• Parallel Presentation: Identity Versus Competence:

• Stage 4: Key Occupational Issues or Needs:

  • Defined as issues of "doing", which can emerge across any of the six dimensions of participation (De las Heras de Pablo et al., 2017a; Parkinson & Brooks, 2021):
    • 1. Participating in roles.
    • 2. Choosing an activity within a role.
    • 3. Participating in tasks.
    • 4. Participating in task steps.
    • 5. Skill performance.
    • 6. Experiences of performance.
  • Transforming Therapy/Symptom Focus to Authentic Occupational Needs:
    • Managing anxiety $\rightarrow$ Catching the bus.
    • Improving physical strength $\rightarrow$ Carrying shopping bags.
    • Addressing trauma $\rightarrow$ Developing new social and personal roles.
    • Sensory modulation $\rightarrow$ Focusing during class.
    • Improving standing tolerance $\rightarrow$ Returning to work.
    • Attending the gym $\rightarrow$ Building physical fitness for occupational tasks.
    • Participating in weekly cooking sessions $\rightarrow$ Increasing the frequency of independent meal preparation.
    • Attending aggression management groups $\rightarrow$ Expressing personal needs calmly during phone calls with family.
  • Formulation Rules for Articulating Needs (Parkinson & Brooks, 2021):
    • Select $3\text{--}4$ primary, numbered key needs.
    • Condense or group discrete sub-tasks into a unified occupational focus (e.g., combining making the bed, making lunch, and packing a school bag into "getting ready for school").
    • Ground every need firmly in client volition.
    • Utilise phrasing and language directly meaningful to the individual.
    • Format syntactically as "Doing something" or "To do something" using action-oriented verbs:
      • Recommended Action Verbs: Increase, Develop, Improve, Strengthen, Enhance, Acquire, Widen, Create, Extend, Enable, Build, Maintain.

• Stage 5: Summary Statement:

  • Must remain concise, adhering strictly to a length of $80\text{--}120$ words.
  • Must introduce no new information.
  • Opens with $1\text{--}2$ sentences celebrating positive occupational identity elements and client strengths.
  • Closes by restating and contextualising the key occupational needs, maintaining the identical wording and numerical order established in Stage 4.

• Stage 6: Measurable Occupational Goals:

  • Translates identified needs and synthesis into explicit, measurable, criterion-referenced goals driving direct therapeutic intervention.

Case Study: Comprehensive Formulation of Jessie

• Introduction:

  • Client Demographics: Jessie is a $42$-year-old woman with formal diagnoses of intellectual disability, anxiety, and depression.
  • Referral Objective: Referred for an occupational therapy evaluation to identify functional skills required for transitioning to independent living.
  • Completed Assessments and Administration Dates:
    • Model of Human Occupation Screening Tool ($MOHOST$; Parkinson et al., 2006) — Completed June 10.
    • Assessment of Motor and Process Skills ($AMPS$; Fisher & Jones, 2014) — Completed June 10.
    • Interest Checklist — Completed June 3.
    • The World Health Organization Disability Assessment Schedule ($WHODAS\;2.0$; Üstün et al., 2010; 36-question proxy version) — Completed June 3.
  • Collaborative Formulation Review: The formulation was reviewed directly with Jessie on June 17. She raised questions regarding the competence section; upon clarification, she affirmed that the formulation "seemed about right".

• Occupational Identity Narrative:

  • Living Arrangements and Relationships: Resides with her mother and values visiting her father on weekends. Enjoys having multiple friends and spending time with them, but reports frequent anxiety and stress regarding what her friends think of her.
  • Productive Roles: Works as a cleaner; values employment because it provides socialization with friends and financial income.
  • Interests and Leisure: Actively participates in shopping, playing netball, listening to music, crafting, and watching television.
  • Domestic Routines: Responsible for household cleaning, cooking dinners periodically, and providing daily care for her cat, Bob, who sleeps on her bed.
  • Volitional Obstacles and Aspirations: Experiences bouts of fatigue where she feels she "can't be bothered" completing domestic responsibilities. Strongly values autonomy and holds the long-term goal of living independently in her own home.

• Occupational Competence Analysis:

  • Interpersonal and Financial Routines: Strained relationship dynamics with her mother primarily centered on money management. Her mother retains financial conservatorship and provides a set weekly allowance; Jessie routinely exhausts her funds early and demands additional money.
  • Vocational Performance: Independently commutes to and attends her supported work environment. Her employer reports strong organizational skills and solid task knowledge. Interpersonal friction occurs intermittently with workplace peers due to misinterpreting social communications.
  • Leisure and Community Participation: Independently initiates and pursues preferred hobbies. Demonstrates marked impulsivity while shopping by purchasing non-essential items against advice, resulting in practical deficits such as running out of public transit money for the week.
  • Domestic Task Performance: Requires external verbal prompts from her mother to initiate and complete home duties. Standardised assessment reveals prominent task sequencing errors (executing steps out of order) and premature task termination.
  • Underlying Motor Capacities: Physical abilities and motor strength are intact, moving effectively without physical restrictions during daily tasks.

• Key Occupational Issues/Needs:

  • 1. To not run out of money (budget better).
  • 2. To get along well with friends.
  • 3. To do household tasks independently.

• Summary Statement:

  • Jessie values relationships with others in her life including her family and friends. She spends her time working, with her friends and family and pursuing her hobbies. Jessie lives at home with her mum who provides her with some support with her daily activities. Learning how to better manage her money, get along with her friends and do her household tasks independently will support Jessie toward her goal of living on her own.