Practical assessment-to-formulation workflow

4.1 Assemble enough case evidence

The prompts below are an editorial checklist for reasoning. They are not diagnostic criteria, minimum test batteries or mandatory fields for every patient.

Time course: onset, episodes, persistence, fluctuations, baseline function, relationship to medication or substance changes, and why help is sought now. Preserve competing timelines.

Present experience and function: symptoms, distress, cognition, self-care, relationships, work or study and the person’s own priorities. Distinguish an acute change from a longstanding trait or environmental mismatch.

Context: relevant physical health, development, learning, adversity, current safety, relationships, culture, finances, housing and service access. Do not infer a specific adverse childhood experience from an adult coping style.

Strengths: what the person values, does well, wants to preserve and can draw upon. Include ordinary sources of meaning and competence, not only factors thought to reduce suicide risk.

Evidence quality: source, recency, corroboration, contradictions and whether the conclusion depends on an unverified account. Clinically useful uncertainty should remain visible.

4.2 Turn a factor list into a hypothesis

A factor is an observation or context. A mechanism is a proposed process connecting it with another part of the presentation. “Unemployment” is not itself a psychological mechanism. “Loss of routine reduces activity and contact, followed by lower mood and further withdrawal” is a possible sequence that still needs case evidence. Longitudinal unemployment evidence is relevant but its authors rated certainty low, so avoid individual causal certainty or assuming any job would be therapeutic. ^S33

For each candidate sequence, record trigger or context → appraisal or process → affect/body response → behaviour or interpersonal response → immediate consequence → later consequence. The sequence is optional: biological, social or systemic explanations need not be forced into a cognition-first loop.

4.3 Challenge before accepting

Ask: What supports it? What does not fit? What other explanation fits the same observations? What would meaningfully distinguish the alternatives? What is modifiable now? What does the patient make of the explanation?

Anxiety reduction after avoidance supports a possible relief cycle. It does not show that the avoided situation was objectively safe. Withdrawal after a difficult interaction may reflect fear, fatigue, sensory overload, privacy, abuse, discrimination or a reasonable boundary. “Poor fit” prompts are alternatives to investigate, not a binary exclusion test.

4.4 Link to management without overclaiming

For a supported hypothesis, specify a feasible intervention and the observable change that would matter. Include barriers, preferences and competing priorities. Treatment response can inform the formulation but is not a specific diagnostic test. Improvement may reflect multiple mechanisms, nonspecific support, natural fluctuation or removal of a practical barrier.

Equally, non-response does not by itself falsify a formulation. Check whether the intended intervention was delivered, engaged with, tolerable, sufficiently sustained and measured appropriately. A failure to provide transport is not evidence that the patient lacks motivation. This testing approach is an editorial reasoning safeguard, not a rule derived from a particular trial.

4.5 Review when information matters

Revisit the formulation after meaningful collateral, investigation results, altered cognition or mental state, safety change, treatment response or non-response, a major contextual change, and transitions in care. Follow applicable service review requirements as well. Do not represent an editorial source-review interval as a clinically validated reassessment frequency. ^S04S08S09