Learn how a working case formulation can guide the next therapy session by linking client priorities, proposed mechanisms, interventions and review points.
A formulation can be clinically thoughtful and still do very little work.
It may describe presenting problems, developmental history, triggers, maintaining factors and strengths. It may explain why the client's difficulties make sense. But when the next appointment begins, the psychologist still has to decide what to focus on.
That is where formulation becomes useful or remains descriptive.
The practical question is not simply, "What is happening for this client?" It is:
Given what we currently understand, what should we do next, why this rather than something else, and how will we know whether it helped?
This article follows a fictional client through that decision. It shows how a change in formulation can change the priority for the next session, even when the diagnosis and presenting problem remain the same.
Case formulation brings information together into a provisional explanation of a client's difficulties. Depending on the therapeutic approach, it may emphasise different processes, but it generally connects the person's concerns and circumstances with hypotheses about what contributed to the problem, what triggers it and what may be maintaining it.
The word hypothesis matters. A formulation is not a hidden truth that the psychologist discovers and then applies to the client. It is an explanation to test, discuss and revise as new information becomes available.
In case-formulation-driven psychotherapy, the formulation is intended to guide treatment planning and be evaluated against what happens during therapy. Persons describes this explicitly as a hypothesis-testing approach rather than a one-off summary completed before treatment begins. Persons, 2006.
Collaboration matters here too. A qualitative systematic review found that clients' experiences of formulation vary, including reports that the process can be unhelpful or distressing. A formulation should therefore not be assumed to be collaborative merely because it was shared with the client. Thrower and colleagues, 2024.
Maya is a fictional composite created for this article. She is not based on an identifiable client.
Maya is 29 and seeks therapy for anxiety at work. She reports racing thoughts before meetings, difficulty sleeping on Sunday nights and repeated checking of emails before sending them. She worries that a mistake will expose her as incompetent.
Her initial goals are to feel less anxious, stop spending so long checking her work and speak more confidently in meetings.
Early assessment suggests the following working formulation:
This formulation leads to several plausible interventions: psychoeducation about anxiety, attention training, cognitive work, behavioural experiments, reducing reassurance seeking, sleep strategies or graded participation in meetings.
The formulation has generated options. It has not yet decided the next session.
Maya and the psychologist agree to examine the checking cycle. The proposed mechanism is that repeated checking provides short-term relief but preserves the belief that extensive checking prevents serious consequences.
They design a modest behavioural experiment. Maya will send one low-stakes internal email after two checks rather than her usual six or seven. Before sending it, she will record what she predicts will happen. Afterwards, they will review the actual outcome and what she learned.
The rationale is specific: reducing checking is not being prescribed simply because checking appears on a symptom list. It is being tested because the formulation proposes that checking is maintaining anxiety.
At this point, the plan can be stated clearly:
| Planning element | Working decision |
|---|---|
| Client priority | Spend less time checking routine work |
| Proposed mechanism | Checking reduces uncertainty briefly and prevents new learning |
| Intervention | A small behavioural experiment with one low-stakes email |
| Rationale | Test whether extensive checking is necessary to prevent the feared outcome |
| Review point | Prediction, number of checks, outcome, distress and what Maya concludes |
That chain from priority to review point is what makes the formulation operational.
At the next session, Maya has not attempted the experiment. It would be easy to conclude that anxiety prevented follow-through, reduce the task further and rehearse it again.
Instead, the psychologist asks Maya to walk through what happened when she considered trying it.
Maya explains that her manager has recently begun highlighting small errors in team meetings. A colleague was removed from a project after making a mistake, and expectations are often communicated after work has already begun. Maya says she checks because she genuinely cannot predict which details will be treated as serious.
This does not prove that every feared consequence is likely. It does change the context in which her checking occurs.
The original formulation located most of the maintaining process within Maya's response to uncertainty. The new information suggests that uncertainty is also being produced by inconsistent expectations and public criticism in the workplace. What looked like a straightforward safety behaviour may partly be an adaptation to a poorly defined environment.
The formulation now needs revision:
The diagnosis has not necessarily changed. The next-session priority has.
The psychologist does not abandon the original hypothesis or assume the workplace fully explains Maya's anxiety. They revise the order of work.
The next session focuses on distinguishing three things:
Maya decides that her immediate priority is to seek clearer expectations for one recurring task. She and the psychologist prepare questions for her manager, consider how she might respond to an unclear answer and identify a colleague who can help her understand the usual standard.
The behavioural experiment is not discarded. It is postponed and refined. Once Maya has better information about the task, she may compare a proportionate checking process with her habitual one.
| Planning element | Revised decision |
|---|---|
| Client priority | Clarify expectations and reduce time lost to checking |
| Proposed mechanism | Anxiety and an unpredictable work environment may both be sustaining uncertainty |
| Intervention | Map actual requirements, prepare a clarification conversation and then reconsider a checking experiment |
| Rationale | Separate realistic task demands from anxiety-driven checking before asking Maya to reduce it |
| Review point | What clarification was obtained, what remained uncertain, how checking changed and whether the original hypothesis still fits |
The revised plan is not automatically better because it is more complex. It is better justified by the information currently available and more closely aligned with Maya's stated priority.
Not every review of an uncompleted task will uncover an important contextual factor. Maya might instead have said, "I don't know. I just didn't do it." That would still be information to explore without inventing a deeper explanation. The task may have been avoided, forgotten, poorly timed or miscalibrated. The next step could be to examine what happened, practise it in the session, simplify it or agree on a different task.
Formulation does not require every difficulty to reveal a hidden mechanism. It requires the psychologist to keep competing explanations open long enough to test them. The related guide on what to do when clients already know the coping skills explores how implementation barriers, treatment fit and therapeutic rupture can call for quite different responses.
The formulation did four jobs.
First, it proposed a mechanism rather than merely renaming the problem. "Maya has workplace anxiety" describes the presentation. "Checking briefly reduces uncertainty and may prevent new learning" proposes something that can guide and be tested through intervention.
Second, it connected that mechanism to the client's priority. Maya wanted to spend less time checking, which made the initial experiment relevant to something she had actually asked to change.
Third, it made the rationale visible. Both psychologist and client could understand why the exercise had been proposed. When Maya did not attempt it, they could investigate the explanation rather than treating non-completion as a generic problem with motivation.
Fourth, it included a review point. Without an agreed way to evaluate the intervention, almost any result can be absorbed into the original explanation. Improvement may be credited to the formulation, while difficulty may be attributed to insufficient effort. A review point creates the possibility that the psychologist's hypothesis is wrong or incomplete.
Before choosing the next session's focus, it can help to write down five things:
This may differ from the psychologist's preferred target. It can also change as therapy progresses. If several priorities compete, decide together which one is most important or feasible now.
Name the process you think is contributing to the difficulty. Avoid stopping at a label such as low self-esteem, avoidance or poor coping if it does not explain how the problem is being maintained in this client's circumstances.
The link should be explainable. If the proposed mechanism is unclear expectations, another relaxation exercise may not test or change it. If avoidance prevents corrective learning, a carefully designed behavioural experiment may be relevant.
An intervention can be plausible without being the most useful next step. Consider urgency, risk, client preference, readiness, practical barriers and whether another step must occur first.
Specify what would support, weaken or complicate the hypothesis. Review the client's experience as well as symptom change: feasibility, burden, unexpected effects and whether the intervention addressed the agreed problem.
These prompts do not replace assessment, clinical judgement or an evidence-based treatment protocol. They make the reasoning between formulation and intervention easier to examine. A concise record of that reasoning can also make subsequent care easier to follow; see the guide to writing psychology progress notes.
A broad formulation can be compatible with almost any intervention. That flexibility may feel comprehensive, but it makes the formulation difficult to test.
A useful formulation narrows the field. It helps explain why one intervention is being prioritised, what it is expected to change and what information would lead to a different decision.
It also leaves room for the client to disagree. Evidence-based practice integrates research and clinical expertise with the client's characteristics, culture and preferences, rather than treating any one component as sufficient on its own. American Psychological Association.
In Maya's case, the formulation initially pointed towards reducing checking. New information did not make that formulation worthless. It showed where it was incomplete. The next session changed because the hypothesis changed.
That is the practical value of formulation: not producing the most polished explanation of the client, but making the next clinical decision more transparent, collaborative and open to revision.
For more articles on clinical reasoning, documentation and treatment planning, explore the Therapist Resources hub. You can also browse assessment and planning tools and report templates and formulation guides created for clinical practice.
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