Case conceptualisation helps clinicians move from a description of a young person’s symptoms to an account of what may be keeping them going. In the session on science-informed case conceptualisation, Professor Bryce McLeod illustrated his five-step model with a single case of social anxiety in a young adolescent girl. The case shows how a formulation can bring maintaining factors into view, including the coping strategies of the girl and her mother, and then shape treatment and the conversation with the family.
What a formulation adds to a list of symptoms
A diagnosis or a symptom profile describes what a young person is struggling with. A formulation attempts to explain why those difficulties started and what keeps them in place. McLeod describes it as a map, one that sets out the territory of the problems and the processes that likely cause and maintain them. Maintaining factors are often modifiable, which makes them likely targets for treatment. They can sit within the young person or in the people around them, including parents or carers.
In this model, each link in the map is held as a hypothesis. If a factor is maintaining the problem, intervening on it should be followed by some change, and when no change follows, the formulation is revisited.
Maintaining factors in a case of social anxiety
The young person in the example had begun avoiding time with peers at school, and her attendance had started to slip. She also had asthma, and she was turning to her reliever inhaler often during the school day, at moments when she felt her body reacting in front of others. The assessment pointed to anxiety sensitivity, a tendency to monitor bodily signals closely and read them as a sign that something was wrong. Reliever inhalers can themselves raise heart rate, so the inhaler may have been adding to the sensations it was meant to settle. A prescribed treatment had become part of the cycle, and she had good reason to trust it.
The formulation also looked at the family. Her mother described some social anxiety of her own. When her daughter’s anxiety rose, so did hers, and letting her stay home on difficult mornings eased the distress of both.
How the formulation shaped treatment and monitoring
Once maintaining factors are set out as hypotheses, each one points towards an intervention. The clinician chose CBT with exposure and matched its components to the formulation. Psychoeducation helped the girl understand how her inhaler use could be adding to her physical symptoms, and part of the exposure work involved bringing on those sensations deliberately so she could experience them in session. For the mother, the work combined guidance on school refusal with support in managing her own anxiety.
The formulation also suggested what to measure. The girl brought her inhaler to each session so the clinician could note how many doses remained, and she recorded how often she spent time with peers at school. Both measures came from behaviours named in the formulation, and both gave some indication of whether the hypotheses held. Over the course of treatment, time with peers increased, and her inhaler use had moved closer to what her asthma alone would predict.
Sharing a formulation that includes the parent
The clinician shared a simplified drawing of the formulation with the family, adjusted to the girl’s age, and linked each part of the plan to a target. Sharing becomes harder when one of the maintaining factors is the parent’s own response, and families may feel blamed. McLeod acknowledged that such a hypothesis has to be shared delicately, and that part of the clinician’s task is finding terms in which it can be heard.
His suggestion was to build the explanation from words the family used during assessment, recalling, for instance, a parent’s remark about stepping in because they felt so bad for their child. He was also candid about the limits. No wording guarantees that a message will be well received, and where a parent who plays a central part cannot or will not attend, that line of work may be unavailable.
On a diagram, an inhaler and a day at home appear as maintaining factors. In daily life they are often what gets a young person through a lesson, or a parent through a morning. How far should a clinician go in naming a parent’s relief as a maintaining factor before the parent is ready to work on it? And when a coping strategy also has a medical purpose, who is best placed to help a young person tell the two uses apart?