Case Formulation – a diagram illustrating the first stage


This is an illustration of the first step of case formulation – identifying patterns from the data collected, using a range of ways to obtain the information so that it can be relied upon for both accuracy and to cover the range of possible features of the person’s presentation.

In this case, I’ve shown some of the ways we collect information in the centre I work – from interview, observation, clinical testing, questionnaires, and other team members.  We use a semi-structured interview that allows the clinician to explore relevant areas in more detail through the interview.  If we have questionnaire results before the interview, we’re able to enquire about areas that these suggest could be problematic.  At the conclusion of our assessment morning, the team meets to discuss the various phenomena that have been detected, although the relationship between each of these areas is not completely certain at that time.

The next stage is to draw up a preliminary model of the various mechanisms (biophysical/biomedical, psychological and social) that interact to explain how and why the person presents in the way they do.  I’ll cover this in my next post.

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