Psychotherapy Case Formulation & Treatment Planning
Generate structured case formulations and evidence-based treatment plans from clinical data
What You Can Do
You can rapidly develop theoretically-grounded case formulations that integrate diagnostic findings, historical context, and clinical observations into a coherent narrative. The skill systematizes your conceptualization across multiple therapeutic modalities (CBT, psychodynamic, trauma-informed, systemic) and generates structured treatment plans with specific goals, interventions, and prognostic considerations—ideal for supervision presentations, case conferences, documentation, and complex diagnostic scenarios.
Features
organizes presenting problems, predisposing factors, precipitants, perpetuating factors, and protective resources into a coherent clinical narrative
generates formulations compatible with CBT, psychodynamic, trauma-informed, systemic, and integrative theoretical approaches
translates formulations into specific therapeutic goals, evidence-based interventions, and measurable outcomes
synthesizes DSM/ICD diagnostic data, comorbidity patterns, and differential diagnostic considerations into clinical reasoning
produces formulations suitable for case presentations, consultation notes, and clinical conference materials
handles multiple comorbid presentations, unclear diagnostic pictures, and treatment-resistant cases
generates accessible explanations of diagnosis and treatment rationale for non-clinical audiences
supports comprehensive assessments for legal and forensic evaluations
Example Output
Example 1: CBT-focused formulation for depression with anxiety
PRESENTING PROBLEM: 32-year-old presents with depressed mood, anhedonia, fatigue, and social withdrawal (3 months); comorbid generalized anxiety manifesting as worry, sleep disruption, and somatic tension.
CLINICAL FORMULATION: Client's depressive episode appears linked to occupational stress and perfectionist cognitions ("I must perform flawlessly or I'm a failure"). Anxiety maintains hypervigilance and avoidance of social situations, which reinforces depressive isolation. Predisposing factors include family history of mood disorder and early parental criticism. Current protective factors: stable marriage, intellectual curiosity, previous therapy experience.
TREATMENT PLAN: 16-20 sessions combining behavioral activation, cognitive restructuring of perfectionistic standards, sleep hygiene interventions, and graded social re-engagement. Target goals: return to baseline functioning within 12 weeks; reduce depressive symptoms by 50% (PHQ-9); establish daily structure and social contact.
Example 2: Trauma-informed formulation for PTSD with attachment disruption
PRESENTING PROBLEM: 28-year-old survivor of intimate partner violence (18 months post-separation) presenting with intrusive memories, hyperarousal, emotional numbing, and difficulty trusting romantic partners.
CLINICAL FORMULATION: Trauma has disrupted sense of safety and interpersonal trust. Hyperarousal and avoidance of intimacy serve protective functions but maintain isolation. Pre-trauma attachment anxiety predisposed client to tolerating boundary violations. Strengths: strong peer support network, sobriety, commitment to healing, previous resilience through other adversities.
TREATMENT PLAN: Trauma-focused CBT with emphasis on safety planning, graduated exposure, and attachment repair. 20-24 sessions. Goals: reduce PTSD symptom severity (PCL-5 score <20); increase window of tolerance; establish healthy relationship boundaries; restore self-compassion.
What's Included
- SKILL.md instruction file with complete formulation framework and clinical guidelines:
- Case formulation template with structured sections for presenting problems, predisposing/precipitating/perpetuating factors, protective factors, and diagnostic integration:
- Multi-modal conceptualization checklist supporting CBT, psychodynamic, trauma-informed, and systemic approaches:
- Treatment plan worksheet linking formulation to specific therapeutic goals, interventions, and outcome measures:
- Documentation and supervision guide for translating formulations into clinical notes, case presentations, and court-ordered reports:
Who It's For
- Licensed psychologists and clinical mental health counselors developing case formulations and treatment plans
- Therapists in supervision or consultation seeking structured formulation documentation
- Forensic psychologists and court-involved practitioners writing comprehensive evaluations
- Clinical supervisors and training directors evaluating trainee case conceptualization skills
- Psychiatrists and primary care providers integrating psychological formulation with medication management
Best For
- Initial intake assessments and comprehensive case formulation development
- Complex or comorbid presentations requiring multi-faceted conceptualization
- Treatment-resistant cases requiring formulation revisit and strategy adjustment
- Supervision presentations and case conference materials
- Forensic, court-ordered, and legal evaluations requiring detailed clinical reasoning
- Documentation for insurance authorization and treatment planning sessions with clients
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