Case Formulation Report | Case Vignette
Mental State Examination
X was referred to your service for mood problems. She attended the appointment on time.
She was well-groomed as well as dressed in an age- and gender-appropriate manner. She sat
in a stooped posture, with adequate eye contact with you throughout the session. She
managed to understand and respond to your questions. Her speech was slow, coherent, and
logical. She spoke with a soft voice and at a pace uncharacterized of her age. Her answers
were brief; she was cooperative and attentive during the session. She appeared to have a low
mood, looked tired, and had lost her volition; she looked anxious when she was not speaking.
Affect was observed to be congruent and appropriate throughout the session. She showed no
active signs of delusion or hallucinations. X shared with you that she has fleeting thoughts of
committing suicide or harming herself when she experiences low mood. When prompted for
more details, X appeared guarded and reluctant to discuss such ideations. She has some
insights towards her mood issue, and she was ambivalent towards attending further
psychological counselling.
Clinical Information
X reported having depressive feelings and a heightened sense of free-floating anxiety over the
past 2 years. X has filled out the BDI and BAI in Chinese at the clinic, and she scored 24 and 26
on these tests, respectively, indicating moderate depression and anxiety symptoms. While at
the same time, she scored 10 on the Rosenberg Self-Esteem scale. She felt distressed by her
depression and anxiety; she gave a rating of 9 out of 10 on the Subjective Unit of Distress
(SUDs) during the intake interview.
X reported that she would suddenly feel awful about herself, cry in public and at night, feeling
a heightened sense of loneliness, as well as disrupted sleep and appetite. The depressive
mood will last for a week and is interrupted by a few days of tranquillity before the next
depressive episode. She was not sure about the onset of the depressive feelings, and she
opined that she has always been a depressive person since a young age.
X recalled herself having anxiety-like symptoms 10 years ago. X recalled she has anxiety during
stress-provoking situations, yet these anxiety-like symptoms have become more frequent and
long-lasting in the past 2 years. Although these symptoms were short-lived, they emerged
quickly and fast. She subjectively felt that “it is like a roller-coaster ride” and harboured the
thought that “she will go crazy” one day.
X reported having frequent sleep difficulties since a year ago. She recalled waking up with hot
flushes, racing heartbeats, sweating and palpitation, as well as nightmares. Although X
reported no details about her nightmare, she was preoccupied by her nightmares.
Medical records indicated that she has no major physical concerns or any psychotic symptoms,
except on a few occasions; she reported that she heard a female voice commenting that she is a failure and criticizing her as “stupid”. She shared that the voices could be heard the most prominently when she has an extremely low mood.
X has sought professional assistance for her presenting problems. She has consulted a
Traditional Chinese Medicine practitioner for a few months, seen a psychological counsellor,
and has attended psychiatric services at a public hospital. X opined that professional assistance
was not helpful; X regarded alcohol use as helpful to regulate her mood and to help her sleep
– a behaviour which made her feel guilty, shameful, and lacking a sense of purpose.
The Background
X is a 35-year-old Chinese lady, the only child of her parents. Her parents divorced after the
father left home and “disappeared” for 2 years before it was “official” when she was 18. X
currently lives with his mother in a rented flat.
X was brought up in a financially deprived family, and her mother was an alcoholic. X regarded
her mother as cold and uncaring, and she accused the mother of spending the family’s savings
on alcohol. Her mother insisted that “she (X) must study hard and have a good education”.
When X came home with just average school results, her mother would shout at her and use
abusive words, such as commenting that she was useless and that she was a failure; on a few
occasions, X recalled that her mother had physically assaulted her using wooden hangers. X
spent a lot of time checking her homework until late at night to ensure she had not made any
mistakes and tried hard to achieve better school results. Despite all her efforts, she did not do
as well as most of her classmates at school.
X’s father was the breadwinner of the household and had a very close relationship with the
daughter. After the divorce, her mother prohibited X from contacting her father; nevertheless,
X has secretly kept in touch with her father with the help of her uncle since she was 18; she
enjoyed the company of her father.
X ‘s father committed suicide by jumping from his flat 2 years ago. Police investigation
suggested that her father has psychotic disorder, and a suicide note for X was found in his flat.
On a suicidal note, her father apologized for leaving X behind with her mother when he left
home many years ago. X shared that she wanted to attend her father’s funeral, but her mother
did not allow her to do so. X felt angry about her mother’s decision; nevertheless, to please
her mother, she had not to attend the funeral, a decision which she still feels very guilty for.
X mentioned that she did not enjoy schooling because she had difficulty in making friends. She
felt increasingly anxious at school and had screwed up many of her exams due to her anxiety.
She “freaked out” during the exam, and she recalled having difficulty catching her breaths and
racing heartbeats during the exam. She was hospitalized for a few days, and medical checks
did not reveal any cardiac abnormality. As a result of this, she could not get into university for
further study. Since then, she was preoccupied by her own failures in examinations;
nevertheless, X was determined to return to school and completed a one-year secretaril training. Upon graduation, she found a job as a secretary in a business firm until her
resignation (about 12 years ago) because of conflicts with her immediate supervisor, who she
regarded as a bossy woman.
After resigning from the business firm, X soon found another job in a local trading firm, and
she felt that she should pursue a degree to further her career, so she took a part-time
university program. She initially liked the job a lot, but as the job became more demanding,
she started to feel depressed. During the 2-year study period, she cried a lot and became
irritable toward her mother and her boyfriend at that time. She found difficulty falling asleep at
night and felt exhausted during the daytime. She coped by using alcohol and sleep pills. As
she quit her job, her moods were stabilized. She took up a part-time position with a small firm
to finance her studies. Her mother was not happy with her decision and blamed X for her
decision to change her job.
X managed to complete the course and got herself a job in a financial bank; she seemed to do
well in her position. About 4 years ago, while she was waiting to attend her promotion
interview, she suddenly felt panicky and left the waiting room without attending the interview.
She felt embarrassed, guilty, and shameful for screwing up the opportunity she had waited for
years. She felt hopeless regarding her future. X admitted that she harboured suicidal thoughts
and had a plan to commit suicide by jumping from heights.
X’s mother was given a diagnosis of postpartum depressive disorder after giving birth to her.
She was diagnosed with dementia 3 years ago. X is the only caregiver of his mother; she feels
burdened. Nevertheless, she believes that she has an obligation to take good care of her
mother. X seemed to harbour a lot of grievances and she was tearful when she told her story
about her mother; on at least two occasions, she admitted that she had intrusive thoughts of
wishing her mother dead, especially when she was sleepless at night – she felt upset about
herself for having such unfilial thought, and she coped by occupying herself at work and the
use of alcohol.
X shared that she preferred to date men who were much older in age. She shared that “older
and mature” men gave her a sense of emotional and financial security. X shared that she
enjoys being in a relationship, but she also shared that she would grow increasingly anxious
and agitated when her partners were not responsive to her calls or text messages. She would
call or send them messages more frequently until they responded to her. She frankly admitted
that none of her relationships lasted more than 2 years, and all her relationships ended up “in
a mess”. She reported that policemen were called in for assistance on two of these occasions.
X regarded herself as a shy and introverted person. She has a few friends in school and at
work. Most of the time, she would turn to her best friend – YY, a secondary school classmate
of X – to vent her emotions and share her problems in life. X shared that YY would spend
hours talking to her over the phone when she was in a low mood and could not sleep. X
believed that her world would be fine if everyone around her were as kind and compassionate
as YY.
X found alcohol helpful in relieving her anxiety and improving her sleep. She seemed to live by
the motto of “a dozen bottles a day, drink my trouble away”. Occasionally, she would spend
time in pubs till late and she may end up late to work the morning after. And in this case, X
would feel guilty about being late to work.
X found neither counselling nor medication helpful in improving her mood and restoring
balance in life. She regarded her life as miserable and hopeless and believed she was a
complete failure. During the interview, X expressed that she did not feel love from her
significant others; furthermore, she repeatedly sought affirmation from you and asked if she
was a failure.
Case Formulation Report | Requirements and Details
Term Paper
To complete an individual case formulation report based on the information provided. Your
individual case formulation report should (at least) include the following:
(1) A logical case formulation. Clearly indicate the factors predisposing, precipitating, and
perpetuating the presenting problems and the potential obstacles and strengths in
psychotherapy/counselling for X.
Your case formulation should be based upon existing theoretical framework(s) in
psychological intervention. You may wish to consider the following:
o What psychological theory(ies)/ principles will you use to explain the case situation?
Any other supplementary principles to guide your understanding? Either a single
theory (or principle), or an eclectic approach to the formulation is acceptable (note:
you don’t have to explain the theories in detail, but you need to integrate the
theory/ theories into your formulation and give citation/ reference to the source)
o In what ways do the selected principles help offer a case formulation which is logical
and coherent?
o Are there any limitations of the formulation you have chosen? Are there any other
areas of concern that you would like to explore, although they are not covered in
your case formulation? What can be done to compensate for these limitations?
(2) A treatment plan from either the perspective of Expressive Arts Therapies or Behavioral
health interventions – and to provide empirical support to your proposed treatment plan.
For example, you may consider the following questions:
o What are the treatment goals? You may consider a range of short-term and longterm goals.
o What can be done to achieve these treatment goals?
o Explain your recommendations in the context of your own formulation of the
presenting issues;
o Is there any evidence to support the strategies you have proposed?
For the final submission:
(1) You do not have to repeat the information given in the case file in your write-up; focus on
how they contribute to the presenting problem(s) e.g. the use of the matrix as a graphical
attachment may help to save words;
(2) You can write in any style you prefer (the report is in complete sentences, i.e. not pointform);
(3) You can provide up to 3 pages of non-text attachment (e.g. tables, charts, etc., in graphic
format) to help present your formulation;
(4) A clinical diagnosis is not mandatory, and;
(5) No point-form submission is accepted.
Overall Requirements
Word limits: not more than 2,500 words, excluding the reference section.
