Clinical Case Formulation Assistant
Structure complex clinical presentations into evidence-based case formulations
What You Can Do
You can systematically integrate diagnostic assessment, clinical interview data, psychometric testing results, and collateral information into comprehensive case formulations that explain the etiology and maintenance of presenting problems. Claude helps you apply evidence-based theoretical frameworks (CBT, psychodynamic, systemic, trauma-informed) to develop mechanistic understanding of client distress, predict treatment response, identify risk factors, and communicate clinical reasoning to supervisors, colleagues, and interdisciplinary teams.
Features
synthesize biological, psychological, and social factors into coherent narrative explanation
clarify differential diagnosis and integrate multiple presenting problems into unified formulation
identify specific factors perpetuating symptoms and maintaining dysfunctional patterns
apply CBT, psychodynamic, systemic, or trauma-informed models to structure clinical understanding
translate formulation into specific, measurable intervention goals and mechanism-focused treatment planning
explicitly articulate risk factors (self-harm, suicide, violence, exploitation) within formulation context
create defensible written formulations suitable for supervision, consultation, and medical-legal contexts
structure presentations with comorbidity, trauma history, or treatment resistance into intelligible clinical narratives
Example Output
Example 1: Anxiety and Perfectionism
Presenting Problem: 42-year-old professional with generalized anxiety and panic attacks triggered by performance evaluation situations.
Biopsychosocial Formulation:
- Predisposing factors: Genetic loading for anxiety; childhood parental criticism and conditional regard; perfectionist modeling in family-of-origin
- Precipitating factors: Recent promotion with increased responsibility and visibility; critical feedback from supervisor
- Maintaining factors: Safety-seeking behaviors (over-preparation, rumination); avoidance of delegation; catastrophic self-evaluation; limited assertiveness in relationships; isolation due to shame
- Protective factors: Cognitive ability; career success; supportive partner; previous therapy experience
- Formulation narrative: Client's conditional self-worth creates vulnerability to performance anxiety. Anxious thoughts trigger avoidant coping (perfectionism, preparation rituals) that paradoxically increase anxiety and reinforce belief in personal inadequacy. Shame maintains social isolation, reducing access to corrective interpersonal experiences.
- Treatment targets: Modify perfectionistic standards; build distress tolerance; increase behavioral activation in valued directions; develop adaptive self-compassion
Example 2: Depression with Trauma History
Presenting Problem: 35-year-old with chronic depression, emotional numbing, and relationship difficulties following childhood abuse.
Formulation: Trauma exposure disrupted emotion regulation capacity and produced pervasive beliefs about danger/worthlessness. Current depression maintained by trauma-related avoidance, interpersonal withdrawal, and dissociation. Limited sense of agency perpetuates passive coping. Treatment requires trauma-sensitive approach addressing emotion regulation, safety, and relational repair.
What's Included
- SKILL.md instruction file with detailed case formulation framework and theoretical guidance:
- Biopsychosocial assessment template capturing predisposing, precipitating, and maintaining factors:
- Diagnostic integration checklist for multi-problem presentations:
- Risk assessment protocol for routine formulation safety review:
- Case presentation template suitable for supervision and consultation documentation:
- Theoretical framework decision tree (CBT, psychodynamic, systemic, trauma-informed):
- Treatment planning worksheet linking formulation to specific intervention targets:
Who It's For
- Licensed psychologists and clinical social workers developing treatment plans and case conceptualizations
- Psychiatrists integrating psychological and biological factors in psychiatric formulation
- Trainee therapists and psychology doctoral students learning clinical reasoning and case conceptualization
- Clinical supervisors and educators teaching formulation skills to supervisees
- Forensic and clinical psychologists preparing medical-legal evaluations and expert testimony
Best For
- Initial assessment and treatment planning with new complex or multi-diagnostic clients
- Conceptualizing treatment-resistant presentations or unexpected clinical obstacles
- Preparing case presentations, supervision consultations, and peer review documentation
- Developing individualized formulations for disability evaluations, litigation, or fitness-for-duty assessments
- Teaching case conceptualization to trainees and supervisees with detailed clinical reasoning
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