Case Formulation

Assessment of a crisis begins by identifying the crisis. Clinicians should take care not to assume that the precipitating event is the crisis. In Bob’s case, the clinician initially assumed the crisis was the sorrow Bob was experiencing about the death of his wife. This assump- tion was corrected when Bob indicated that his crisis was also the loss of income caused by his wife’s death. Once the clinician understood the crisis, the meaning of many of Bob’s ear- lier statements, such as being doomed, became clear.

Affective Reaction. Bob’s affect was overtly evident in his red eyes, sobbing, and difficulty in articulating his thoughts. His revealing of personal information with an appar- ent lack of discretion indicated that his feelings were not entirely under his volitional control. In other words, he did not use forethought or good judgment in regard to what he was revealing or to whom. The easiest determinant of his affect, however, was his report- ing that he “was scared.” Assessing the severity reactions rested on observations made by the clinician during the first few minutes of the interview. Although Bob’s affect was primarily anxiety/fear, his feelings were bouncing around from fear to anger with some sadness mixed in. His affective reaction also seemed incongruent with the situation and his mood appeared too intense. In addition, Bob was having difficulty controlling his emotions. As a result, the clinician placed him in the moderate impairment category for affect with a score of 7.

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