What’s in a Case Formulation?

Development and Use of a Content Coding Manual

T R A C Y D. EELLS, PH.D.
E D W A R D M. KENDJELIC, M.A.
C Y N T H I A P. LUCAS, M.A.

A case formulation content coding method is

described and applied to the formulation P sychotherapists appear to agree that case
formulation skills are fundamental to
providing effective treatment,1–3 particularly
section of 56 intake evaluations randomly
selected from an outpatient psychiatric clinic. for difficult-to-treat patients with comorbid
mental disorders.4 Sperry et al.3 reflect this
The coding manual showed good reliability
agreement in noting that “the ability to con-
(mean kappa = 0.86) across content and
ceptualize and write succinct case formulations
quality categories. Although 95% of the is considered basic to daily clinical practice”
formulations included descriptive infor- (p. vii). Some argue that the advent of managed
mation, only 37% addressed hypothesized care and time-limited psychotherapy has
predisposing life events accounting for the heightened the importance of case formulation
individual’s presenting problems, and 16% skills because psychotherapists are increas-
included a precipitating stressor. Only 43% ingly called on to work more efficiently and to
inferred a psychological mechanism, 2% justify the value and expense of their ser-
inferred a biological mechanism, and 2% vices.2,3,5
mentioned sociocultural factors. Formulations In light of the consensus that case formu-
were more descriptive than inferential, more lation skills are important, it is striking that little
simple than complex, and moderately precise research has addressed the formulation skills
of clinicians. Research in this area would not
in use of language. In sum, clinicians used
only provide feedback to clinicians that could
the formulation primarily to summarize aid in training, but would also serve the goal
descriptive information rather than to of consumer protection by ensuring that a well-
integrate it into a hypothesis about the causes, thought-out understanding of the patient has
precipitants, and maintaining influences of been attempted and an appropriate treatment
an individual’s problems. plan developed. In our review of the literature,
(The Journal of Psychotherapy Practice we found only two studies that directly ad-
and Research 1998; 7:144–153) dressed formulation skills and none in which
these skills are directly assessed. Both studies

Received July 9, 1997; revised October 10, 1997; ac-

cepted October 21, 1997. From the Department of Psy-
chiatry and Behavioral Sciences, University of Louisville,
Louisville, Kentucky. Address correspondence to Dr.
Eells, University Psychiatric Services, P.S.C., 550 South
Jackson Street, Louisville, KY 40202.
Copyright © 1998 American Psychiatric Press, Inc.

VOLUME 7 • NUMBER 2 • SPRING 1998

EELLS ET AL. 145

suggest that clinicians may not feel that they 3. The case formulation is compartmental-
are well trained in case formulation. Surveying ized into preset components that are ad-
a small sample of psychiatry program directors dressed individually in the formulation
and senior psychiatry residents, Fleming and process and then assembled into a com-
Patterson6 found that fewer that half of the pro- prehensive formulation.
grams provided guidelines for case formula-
tion, and most respondents agreed strongly A number of newer psychodynamic case
that standardized, biopsychosocially based formulation methods have good reliability
guidelines for case formulation were needed. and validity, according to Barber and Crits-
In an earlier survey, Ben-Aron and McCor- Christoph’s21 review of them. Separate compo-
mick7 found that 60% of psychiatry chairs and nents of Luborsky’s Core Conflictual
program directors believed that case formula- Relationship Theme (CCRT) method, for ex-
tion was important but was inadequately ample, had a mean weighted kappa coefficient
stressed in training. in the range of 0.61 to 0.70. Similarly, Curtis
These respondents’ views are echoed by et al.22 report intraclass correlation coefficients
numerous writers about psychotherapy. ranging from 0.78 to 0.90 for components of
Sperry et al.3 recently described case formula- their Plan Diagnosis Method.
tion as a poorly defined and undertaught clini- Validity studies have focused on how well
cal skill. Similarly, Perry et al.8 lament that adherence to a case formulation predicts
among psychotherapy supervisors, “a compre- psychotherapy process and outcome. Crits-
hensive psychodynamic formulation is seldom Christoph et al.23 showed that the accuracy
offered and almost never incorporated into the of therapist interventions, as defined by
written record” (p. 543). adherence to reliably constructed CCRTs, cor-
One reason that case formulation skills related positively with residual gain in psycho-
have not been more studied may be a lack of logical adjustment in a group of 43 patients
consensus as to what a case formulation should undergoing psychodynamic psychotherapy.
contain and what its structure and goals should Similarly, researchers at the Mount Zion Psy-
be. For example, in 1966 Seitz9 found that a chotherapy Group demonstrated that formu-
group of psychoanalysts showed little agree- lation-consistent interventions are associated
ment in the structure and content of formula- with a deeper level of experiencing in patients,
tions they constructed using the same clinical as compared with interventions that do not ad-
material. This explanation has less currency here to a formulation.24,25 A review of the be-
today, however, because several systematic havioral and cognitive-behavioral literature by
methods for constructing case formulations Persons and Tompkins15 showed more equivo-
have been developed in recent years. These cal findings as to the association between indi-
case formulation construction methods have vidualized case formulations and treatment
been developed within several psychotherapy outcome.
orientations, including psychodynamic,10–14 Although encouraging, these develop-
cognitive-behavioral,15 interpersonal,16 behav- ments in case formulation research should be
ioral,17,18 and blends of orientations.19,20 Most viewed in the light of certain limitations.
share three features:
1. The evidence for interrater reliability in
1. They emphasize levels of inference that many of the studies was based on relatively
can readily be supported by a patient’s small samples.
statements in therapy. 2. Most of the studies were done by devel-
2. The information they contain is based opers of the methods, which may have
largely on clinical judgment rather than introduced subtle biases in favor of higher
patient self-report. reliability.

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146 CASE FORMULATION

3. The content of a case formulation appears uses in conceptualizing a patient. Provisions

to be greatly dependent on its guiding the- are also included for rating the quality of the
ory. Collins and Messer26 showed that two formulation. The CFCCM was initially de-
psychotherapy research teams using the signed to provide a means for coding and com-
same case formulation method, but paring the “Case Formulation” and “Treatment
guided by different theoretical orienta- Goals and Plan” sections that are usually part
tions (Joseph Weiss’s cognitive-analytic of intake evaluations, but it can also be applied
theory27,28 and Fairbairnian object rela- to audio-recorded case formulations, narrative
tions theory), independently constructed case formulations specifically constructed for
formulations that were highly reliable as research purposes, or similar materials.
measured within each research team but In constructing the CFCCM we assumed
widely divergent in content when cross- that the primary function of a case formulation
team comparisons were made. is to integrate rather than summarize descrip-
4. There is evidence that therapist adherence tive information about the patient. We broadly
to an initial formulation in brief dynamic defined a case formulation as a hypothesis
therapy may predict a good outcome only about the causes, precipitants, and maintaining
for individuals with interpersonal relation- influences of a person’s psychological, inter-
ships that are of relatively good quality, and personal, and behavioral problems. The ap-
may predict a poor outcome for individuals proach views a case formulation as a tool that
with low-quality interpersonal relation- can help organize complex and contradictory
ships.29 McWilliams2 and Eells30 discuss information about a person. Further, it can
other caveats about case formulation. serve as a blueprint guiding treatment, as a
marker for change, and as a structure facilitat-
Although the case formulation construc- ing the therapist’s understanding of and empa-
tion methods mentioned above have not led thy for the patient. This definition is consistent
to a consensus on what the content, structure, with the newer formulation models reviewed
and goals of a case formulation should be, and earlier, and it contrasts with the view of some
regardless of their limitations, they do provide that a formulation is primarily a summary of
guidelines that can facilitate the evaluation of descriptive information.31,32
case formulations. A major goal in developing the CFCCM
The purpose of this study is to extend our was to make it applicable across several ap-
knowledge of how clinicians use their case for- proaches to psychotherapy. Toward this end,
mulation skills in daily practice. We first pre- we reviewed the case formulation construction
sent a multitheoretical system we developed methods mentioned earlier, as well as other
to evaluate the content of written case formu- writings on case formulation, and identified
lations. The system was guided by the case for- four broad categories of information that are
mulation construction methods just described. contained in most methods:
Second, we demonstrate the application of the
system to a set of case formulations as they 1. Symptoms and problems.
appeared in intake evaluations at an outpatient 2. Precipitating stressors or events.
mental health services clinic. 3. Predisposing life events or stressors.
4. A mechanism that links the preceding
T H E C F C C M categories together and offers an explana-
tion of the precipitants and maintaining
The primary purpose of the Case Formulation influences of the individual’s problems.
Content Coding Method (CFCCM) is to pro-
vide a tool for reliably and comprehensively Although these categories are consistent with
categorizing the information that a clinician a medical model for treating mental disorders,

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EELLS ET AL. 147

they were chosen to be theoretically neutral Inferred Mechanism: This factor, the most im-
and to provide a structure into which informa- portant, represents an attempt to link together
tion generated within any theoretical perspec- and explain information in the preceding
tive on formulation could be organized. We three categories. The inferred mechanism is
will first describe the content categories of the the clinician’s hypothesis of the cause of the
CFCCM, then discuss the quality ratings. person’s current difficulties. There are three
major categories under inferred mechanism:
Content Categories of the CFCCM psychological, biological, and sociocultural.
Psychological mechanisms may include a core
Each content category is given one of three conflict; a set of dysfunctional thoughts, be-
codes: absent, somewhat present, and clearly liefs, or schemas; skills or behavioral deficits;
present. Each piece of information in the for- problematic aspects or traits of the self; prob-
mulation is coded under only one category. lematic aspects of relatedness to others; de-
fense mechanisms or coping style; and
Symptoms and Problems: The first common fac- problems with affect regulation. Biological
tor is the identification of signs, symptoms, and mechanisms refer to both genetic and ac-
other phenomena that may be important clini- quired conditions that cause or contribute to
cally. This category incorporates the patient’s the patient’s problems. Examples include a
presenting symptoms and chief complaints as genetic predisposition for depression, a de-
well as problems that may be apparent to the pression associated with hypothyroidism, or a
clinician, but not to the patient. As noted by presumed constitutional predisposition to-
Henry,33 a patient’s problems, which Henry ward anxiety. Sociocultural mechanisms are fac-
defines as discrepancies between perceived tors such as ethnicity, socioeconomic status,
and desired states of affairs, may not be readily religious beliefs, degree of acculturation, and
apparent in the patient’s initial self-presenta- absence of social support. A separate mecha-
tion and thus could require skilled inter- nism was included for substance abuse or de-
viewing to reveal. pendency, since it spans the other categories.

Precipitating Stressors: These are events that Other Content Categories: In addition to the
catalyze or exacerbate the person’s current four major categories just reviewed, the
symptoms and problems. These events may CFCCM includes content categories for posi-
be construed either as directly leading to the tive treatment indicators such as strengths and
current problems or as increasing the severity adaptive skills; the clinician’s treatment expec-
of preexisting problems to a level of clinical tations; inferences as to the patient’s overall
significance. Examples: recent divorce or rela- level of adjustment; negative treatment indica-
tionship breakup, physical injury, illness, loss tors; and several categories of descriptive in-
of social support, and occupational setback. formation such as past history of mental health
care, developmental history, social or educa-
Predisposing Life Events: These are traumatic tional history, medical history, and mental
events or stressors that have occurred in the status.
person’s past and that are assumed to have
produced an increased vulnerability to devel- Quality Ratings in the CFCCM
oping symptoms. We separated these into
three categories: early life (childhood and ado- In addition to examining the content cate-
lescence), past adulthood, and recent adult- gories listed above, the CFCCM includes qual-
hood. We arbitrarily set a cutoff for recent ity ratings for the formulation as a whole, for
adult stressors as within 2 years of the date the each major subcategory (symptoms, predis-
patient is currently being seen. posing life events, precipitating factors, and

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148 CASE FORMULATION

mechanism), and for the complexity of the for- M E T H O D S

mulation, the degree of inference used, and the
precision of language. (The latter three catego- Fifty-six intake reports at an inner-city outpa-
ries were adapted from Strupp.34) tient psychiatry clinic were randomly selected
from a pool of approximately 300, and their
content was analyzed by using the CFCCM.
Complexity: This refers to the degree to which
Two advanced clinical psychology graduate
the formulation takes into account several fac-
students performed the coding on the 56 se-
ets of the person’s current problems and inte-
lected intake reports after independently cod-
grates these facets into a meaningful account.
ing and achieving consensus on a set of practice
This dimension was rated on a five-point scale
intake reports.
(1 = simple, 5 = complex).
The interviewers were 9 psychiatry resi-
dents, 4 social workers, and 1 psychiatric nurse.
Degree of Inference: This is the extent to which The intake reports were written as part of the
the formulation goes beyond descriptive infor- interviewers’ typical clinical duties. Six of the
mation offered by the patient. On a five-point 14 identified their primary orientation to psy-
scale (1 = descriptive, 5 = highly inferential), chotherapy as psychodynamic, 3 as cognitive-
the formulation is rated low if it includes al- behavioral, 2 as a blend of psychodynamic and
most exclusively descriptive information, and existential, and 1 as a blend of psychodynamic,
it is given a higher rating as it contains increas- cognitive-behavioral, and humanistic. Two did
ingly more hypothetical considerations. In the not respond to a questionnaire addressing ori-
development of the scale we were guided by entation.
Henry and colleagues’35 distinction between
observable phenomena about a patient and Patients
assumptions about that patient’s “deep struc-
ture.” The 56 patients were representative of
those seen in the clinic. The mean age was 40.0
years (range 20–66), and most were women
Precision of Language: This category refers to (n = 37; 66.1%). Forty-six (82.1%) were Cauca-
the extent to which the language used in the sian, and 10 (17.9%) were African American.
formulation appears tailored to a specific indi- Eighteen (32.1%) were single, 17 (30.4%) were
vidual or is more generic in nature. This was divorced, 11 (19.6%) were married, and the re-
rated on a five-point scale (1 = general, 5 = mainder were separated (n = 6; 10.7%), wid-
precise). owed (n = 2; 3.6%), or living with a significant
other (n = 2; 3.6%). Most were high school edu-
Aims of the Study cated (mean years of education = 11.4, range
4—16 years) but unemployed (n = 31, 55.4%).
We conducted an exploratory investiga- Fifteen (26.8%) were employed, 8 (14.3%) were
tion intended to on disability, and 2 (3.6%) were retired.

R E S U L T S
1. Gather initial reliability data on the
CFCCM. Reliability
2. Examine whether the categories are suffi-
ciently broad and inclusive. The mean kappa coefficient36 for both
3. Assess the comprehensiveness and quality content and quality categories of the CFCCM
of a set of representative written case for- was 0.86, with a range from 0.67 to 1.0. In com-
mulations. puting reliability for the content categories, we

VOLUME 7 • NUMBER 2 • SPRING 1998

EELLS ET AL. 149

collapsed “somewhat present” and “clearly Formulation Quality Categories

present” into one category, leaving “not pres-
ent” and “present” as the categories evaluated. In addition to assessing whether each of
Table 1 summarizes the reliability coefficients the four “common factors” was present, it
for each content category. The mean kappa for seemed important to measure the quality of its
these items was 0.88. Kappa coefficients for the presentation. Therefore, we developed a five-
quality ratings of the four common factors were point scale, with verbal anchors as follows: 1
0.79, 0.88, 0.83, and 0.74, respectively, for = not present, 2 = rudimentary presentation,
symptoms/problems, precipitating stressors, 3 = adequate presentation, 4 = good presenta-
predisposing life events, and inferred mecha- tion, and 5 = excellent presentation. As shown
nisms. The kappa for the ratings of the overall in Table 2, ratings are predominantly in the
quality of the formulation was 0.70. Complex- “not present,” “rudimentary,” or “adequate”
ity, degree of inference, and precision of lan- categories.
guage had kappas of 0.82, 0.67, and 0.77, Consensus global ratings of the formula-
respectively. Overall, these data indicate good tions appear in Table 3. As shown, 31 of the 56
reliability across the CFCCM categories. formulations (55.4%) contained no presenta-
tion of a mechanism; 16 (28.6%) contained a
Content Categories mechanism that was described as rudimentary,
with little attention given to how the mecha-
Table 1 summarizes the numbers and per- nism is linked to symptoms, problems, precipi-
centages of case formulations in which each tating stressors, or other predisposing life
formulation element was judged as somewhat events. Only 3 formulations (5.4%) were rated
present or clearly present by both coders. De- as having adequate to strong mechanisms.
scriptive information was presented in 94.6%
(n = 53) of the formulations. The descriptive Complexity: The mean complexity rating on
categories most frequently mentioned were the scale of 1 (simple) to 5 (complex) was 2.05
symptoms/problem list (67.9%; n = 38), iden- (SD = 0.94), indicating that the formulations
tifying information (64.3%; n = 36), and past were rated as relatively simple, with little evi-
psychiatric history (41.1%; n = 23). Only 37.5% dence of interweaving and integrating of dif-
(n = 21) included a predisposing life event in- ferent types of information.
ferred as contributing to a patient’s problems.
Only about one-fifth (21.4%; n = 12) of the for-
mulations contained references to childhood Degree of Inference: The inference ratings indi-
or adolescent events, 17.9% (n = 10) dealt with cate that the formulations contained primarily
past adult events, and 3.6% (n = 2) referred to descriptive information and little inference.
recent adult events. A precipitating stressor On the scale of 1 (descriptive) to 5 (highly
was considered in only 16.1% (n = 9) of the for- inferential), mean inference ratings were 1.80
mulations. A minority inferred a mechanism (SD = 0.77). Of the 56 formulations rated, 23
as contributing to the individual’s problems: (41.1%) were consensually rated at the most
4 2.9% (n = 24) inferred a psychological descriptive end of the scale; 21 (37.5%) were
mechanism, 1.8% (n = 1) inferred a biological rated “2”; and the remaining 12 (21.4%) were
mechanism, and 1.8% inferred a social or cul- rated “3.”
tural mechanism. In addition, only 21.4% (n =
12) inferred a positive treatment indicator. In Precision of Language: The formulations were
sum, the formulation section of the intake rated as moderately precise in terms of the
evaluations was dominated by descriptive in- language used. The mean precision rating was
formation with a primary focus on symptoms 2.57 (SD = 0.93) on the scale of 1 (general) to
and past psychiatric history. 5 (precise).

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150 CASE FORMULATION

TABLE 1. Reliability and percentage present for formulation content elements (n = 56)

Somewhat Present or Clearly Present

(as seen by both coders)
Formulation Element Kappa n %

Four Common Factors

1. Symptom and problem list 0.96 38 67.9
2. Predisposing life events, traumas, stressors inferred as explanatory
a. Childhood or adolescence 0.95 12 21.4
b. Past adult 0.84 10 17.9
c. Recent adult 0.79 2 3.6
3. Precipitating stressors 0.77 9 16.1
4.1 Inferred mechanisms: psychological
a. Problematic aspects of the self 0.87 8 14.3
b. Problematic aspects of relatedness to others 0.95 12 21.4
c. Dysfunctional thoughts and/or beliefs (not self or others) — 2 3.6
d. Problematic traits 0.79 2 3.6
e. Affect regulation/disregulation 0.81 5 8.9
f. Defense mechanisms 1.00 1 1.8
g. Coping style 0.85 3 5.4
h. Skills or learning deficit — 1 1.8
i. Absence of or poor social support 0.74 5 8.9
j. Psychosocial stress from physical illness or accident 1.00 2 3.6
4.2 Inferred mechanisms: biological
a. Genetic influences 1.00 1 1.8
b. Acquired biological influences 1.00 1 1.8
4.3 Inferred mechanisms: sociocultural 1.00 1 1.8
4.4 Alcohol or substance abuse or dependence 0.79 2 3.6
Additional Formulation Categories
5. Descriptive information
a. Identifying information 0.92 36 64.3
b. Referral source 0.92 7 12.5
c. Appearance — 0 0.0
d. Diagnosis 0.75 14 25.0
e. History of present condition 0.72 16 28.6
f. Past psychiatric history 0.86 23 41.1
g. Family psychiatric history 0.85 3 5.4
h. Past medical history 0.71 6 10.7
i. Family medical history 1.00 2 3.6
j. Developmental/social history 0.86 13 23.2
k. Mental status information 0.79 2 3.6
6. Global level of adjustment 0.79 2 3.6
7. Iatrogenic factors 1.00 2 3.6
8. Positive treatment indicators
a. Strengths or adaptive skills 0.73 3 5.4
b. Positive motivation for treatment 0.85 7 12.5
c. Adaptive aspects of self 1.00 4 7.1
d. Adaptive perceptions/views of others 1.00 1 1.8
e. Adaptive wishes, hopes, or goals 1.00 2 3.6
f. Good psychosocial support 1.00 1 1.8
9. Treatment expectations
a. Negative treatment indicators 0.85 7 12.5
b. Prognosis 0.87 8 14.3

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EELLS ET AL. 151

TABLE 2. Quality ratings

Not Present Rudimentary Adequate Good Excellent

Formulation Component n % n % n % n % n %

Symptoms, problems 18 32.1 17 30.4 19 33.9 2 3.6 0 0.0

Precipitating stressors 47 83.9 3 5.4 4 7.1 1 3.6 1 1.8
Predisposing life events 35 62.5 10 17.9 9 16.1 2 1.8 0 0.0
Inferred mechanism 31 55.3 18 32.1 5 8.9 2 3.6 0 0.0

D I S C U S S I O N TABLE 3. Consensus global ratings of

formulation sections of intake
evaluations (N = 56)
This naturalistic study has a number of limita-
tions. First, a written case formulation may not Formulations
accurately or completely depict the therapist’s Receiving Rating
Rating Description n %
understanding of the patient. Second, despite
the consensus that case formulation skills No presentation of
are important, little is known about the rela- a mechanism 31 55.4
tionship between case formulation skill and Rudimentary mechanism
treatment efficacy. A poorly written case for- and inadequate links to
mulation may not predict poor psychotherapy symptoms/problems,
precipitating stressors,
outcome. Further, the effectiveness of thera- and/or more distant
pists with good case formulation skills may be predisposing antecedent
due to skills other than those related to case factors 16 28.6
formulation. Third, the case formulations we Presentation of a mechanism
evaluated were typically dictated after a single tied at least to symptoms/
intake session with the patient. This may not problems 6 10.7
have provided enough time for an adequate Adequate or strong
database to be collected. Fourth, the clinicians mechanism tied to
symptoms/problems,
may not have used the case formulation skills and either precipitating
that they have. In that sense, the study is better stressors or more distant
viewed as an investigation of representative predisposing antecedent
written case formulations rather than as a cli- factors 3 5.4
nician’s best possible work. Strong mechanism clearly
Despite these considerations, this first linked to symptoms,
precipitating stressors,
study of case formulation skills in a naturalistic and predisposing
context showed that the CFCCM can be reli- antecedent factors 0 0.0
ably scored and can measure an adequate
range of information contained in a case for-
mulation. The findings showed that the clini- What are the implications of these find-
cians did not consistently use the formulation ings? Three seem central:
section to offer hypotheses about a patient’s
symptoms or to integrate previously pre- 1. There is a need for more training in for-
sented descriptive information. Instead, they mulation. The availability of newer, em-
used the formulation primarily to summarize pirically supported case formulation
descriptive information. Our findings pro- models should facilitate this training.37
vide empirical support for surveys suggesting 2. The relationship between case formula-
that case formulation is an insufficiently taught tion and treatment outcome should be
skill.6,7 studied further. Designs for doing so have

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152 CASE FORMULATION

been offered by Hayes et al.38 and by Per- formulation that “fits” the patient well fa-
sons.39 Such studies could help document cilitates better articulated and more attain-
the incremental validity of formulation: able treatment plans and goals. Another
whether individualized formulations lead would be that a good formulation helps
to better therapy processes and outcomes the therapist anticipate and manage events
than do generic formulations or the ab- that could hinder or prevent treatment
sence of an explicit formulation. They success.
could also advance our understanding of
specific therapist skills that lead to positive An earlier version of this work was presented at the
treatment outcomes. 27th meeting of the Society of Psychotherapy Re-
3. The relationship between formulation and search, Amelia Island, FL, June 1996. Interested
treatment plans and goals deserves study. readers may obtain a copy of the CFCCM from the
One hypothesis would be that a suitably first author at the address shown in the headnote to
comprehensive, complex, and objective this article.

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