Table of Contents
Type: Case Study | Subject: Psychology | Level: Masters | Word Count: ~3000 words
This model case study was produced by an Essays UK specialist as reference material for learning purposes only. For support in this field, see our psychology assignment specialists.
You have been asked to prepare a formulation-based case study of a client presenting with workplace-related anxiety, using a recognised formulation framework to structure your account of predisposing, precipitating, perpetuating and protective factors, and a cognitive-behavioural model to explain the maintenance of the presenting difficulties.
This case study presents a formulation-based analysis of a client experiencing significant anxiety related to their workplace, developed to illustrate how psychological formulation integrates presenting difficulties with the biological, psychological and social factors that create and maintain them, rather than relying on diagnostic labelling alone (Johnstone and Dallos, 2013). Formulation is central to psychological practice in the UK, endorsed by the British Psychological Society (BPS, 2011) as a means of developing a shared, individualised understanding of a client’s difficulties that directly informs intervention, in contrast to a purely diagnostic approach that groups clients by symptom checklist regardless of the different developmental pathways by which those symptoms arose.
This case applies two complementary frameworks. The first is the 5Ps formulation framework, structuring the client’s presenting problem alongside the predisposing, precipitating, perpetuating and protective factors relevant to it (Weerasekera, 1996), providing a broad, longitudinal account of why this client, at this point, developed these difficulties. The second is Clark and Wells’ (1995) cognitive model of social phobia, a more mechanistic, session-level account of how anxiety centred on social and performance evaluation is maintained moment to moment once triggered, chosen in preference to a more general anxiety model because David’s presenting difficulties are specifically organised around fear of negative evaluation by colleagues, the core feature this model was developed to explain. Together, the two frameworks move from a wide-angle developmental account to a detailed maintenance-cycle account, directly informing the intervention recommendations that follow.
As with other cases in this series, the client described, referred to here as “David” with identifying details altered, is a fictional construct created for academic illustration, consistent with the confidentiality principles that would apply to any real clinical formulation (BPS, 2018).
David is a 34-year-old marketing manager who self-referred to a workplace counselling service, accessed through his employer’s Employee Assistance Programme (EAP), reporting escalating anxiety centred on his role, particularly performance reviews, presentations to senior management and, more recently, everyday team meetings. He describes a gradual worsening over approximately eight months, coinciding with a promotion to a role that increased his visibility within the organisation and his personal responsibility for presenting results to the executive team, a marked change from his previous, more backroom-facing position.
David reports that in the days before any meeting where he might be asked to speak, he experiences a racing heart, sleep disturbance and a persistent worry that he will “freeze” or “say something stupid” in front of colleagues he respects. He has begun arriving early to meetings specifically to choose a seat near the door, and has, on two occasions in the past two months, taken a sick day specifically to avoid a scheduled presentation, on each occasion telling his manager he had a migraine. He describes considerable relief on the days he successfully avoids a presentation, followed by guilt and self-criticism for having avoided it, a pattern he says he finds increasingly difficult to break.
David’s developmental history includes being the younger of two brothers; he describes his older brother as “the confident one” and recalls being routinely compared unfavourably to him by their father, particularly around school presentations and sporting performance, from an early age. David did well academically and progressed steadily in his career until the recent promotion, describing his working life until then as “safely behind the scenes.” He is currently in a stable long-term relationship and describes his partner as supportive, though he has not disclosed the full extent of his anxiety, or the sick-day avoidance, to her, stating he is “embarrassed” by it. He has no prior contact with mental health services and describes his physical health as good, though he has begun drinking a glass or two of wine most evenings, which he did not previously do, “to switch off” after work. At initial assessment, David completed the GAD-7 (Generalised Anxiety Disorder 7-item scale), scoring 13, indicating moderate anxiety, and the Social Phobia Inventory (SPIN), scoring in the moderate-to-severe range, with his highest item scores concentrated on fear of speaking in front of others and fear of being watched or observed while working, a pattern consistent with anxiety specifically organised around social and performance evaluation rather than a more diffuse, free-floating worry about multiple unrelated life domains.
Applying the 5Ps framework (Weerasekera, 1996), the presenting problem is anxiety specifically triggered by anticipated or actual evaluation by others in a workplace context, manifesting in physiological arousal, avoidance behaviour and significant occupational and personal cost. Predisposing factors include David’s childhood experience of being repeatedly and unfavourably compared to his brother by their father around performance situations, plausibly contributing to an underlying core belief along the lines of “I am not good enough and will be found lacking if I am closely observed,” consistent with Beck’s (1976) account of how early experience shapes the negative self-schemas that later anxiety episodes activate. David’s long career in a lower-visibility role may have functioned as an unrecognised, long-running avoidance strategy in its own right, one that worked adequately until his promotion removed the option of remaining unobserved.
The precipitating factor is straightforward: the promotion increased both the frequency and the perceived stakes of situations in which David is directly observed and evaluated by senior colleagues, activating the predisposing schema described above in a context where, previously, it had rarely been tested. It is notable that the anxiety did not emerge gradually alongside general career progression but escalated specifically once visibility and evaluation risk increased sharply, consistent with a schema-activation account rather than a general, undifferentiated rise in workplace stress.
Perpetuating factors are the most clinically significant element of the formulation, since they identify what is sustaining the difficulty in the present and therefore what intervention needs to target. David’s avoidance behaviours, taking sick days to miss presentations, and his safety behaviours, arriving early to sit near the door, both provide short-term relief, but this relief is itself part of the problem: through negative reinforcement, the anxiety reduction David experiences when he successfully avoids a feared situation strengthens the avoidance behaviour, making it more likely he will avoid again next time, even though this prevents him from ever gathering evidence that he could, in fact, cope with the situation he fears. His post-avoidance guilt and self-criticism add a second, self-critical layer of distress on top of the original anxiety, which itself becomes a further source of negative affect requiring management, and his recently increased evening alcohol use functions as a further avoidance strategy, numbing anticipatory anxiety in the short term while doing nothing to address, and potentially over time worsening, the underlying pattern.
Protective factors, meanwhile, indicate a comparatively favourable prognosis. David sought help himself, indicating insight and motivation rather than the problem being identified and referred by others against his wishes. He has a stable, supportive relationship, even though he has not yet disclosed the full picture to his partner, a strong track record of career success prior to the recent difficulties, no prior mental health history or additional comorbidity, generally good physical health, and access to workplace support infrastructure through his employer’s EAP, all factors that a formulation should note explicitly, since intervention planning should build on existing strengths and resources rather than focusing solely on deficits.
Turning to the maintenance mechanism in more mechanistic detail, Clark and Wells’ (1995) cognitive model of social phobia offers a well-evidenced account of precisely the pattern David describes. When David anticipates a work situation involving possible evaluation, a meeting or presentation, the model proposes that perceived social danger triggers a shift into self-focused attention, becoming excessively focused on internal cues, his own physical sensations and performance, rather than on external cues from colleagues in the room; David’s acute awareness of his own racing heart, and his preoccupation with how he must appear to others, is consistent with this shift. This self-focused attention generates a negative self-image, a felt impression such as “I look like I’m about to fall apart,” which the mind processes as though it were an accurate impression of how he appears externally, a felt sense rarely checked against genuine external feedback from the room. Clark and Wells (1995) argue that safety behaviours, David’s habit of sitting near the door or, in its most extreme form, avoiding the meeting entirely, are deployed to prevent the feared catastrophe, freezing, being judged incompetent, but paradoxically increase symptoms in practice, since excessive self-monitoring for signs of anxiety itself raises physiological arousal, and, critically, prevent disconfirmation of the feared belief, because a meeting that is avoided altogether can never provide evidence that David could, in fact, cope. Finally, the model identifies anticipatory processing, worry in the days before a triggering event, and post-event processing, rumination afterwards reviewing perceived failures, as further maintenance mechanisms operating on either side of the triggering situation itself; David’s guilt and self-criticism following each avoided presentation is a clear instance of post-event processing, which paradoxically reinforces the belief that the situation was indeed genuinely threatening, since in his own reasoning it must have been serious enough to warrant this degree of continued mental rehearsal afterwards.
The formulation is strengthened by considering David’s presentation alongside the concept of contingent self-worth, the extent to which a person’s sense of value depends on meeting specific standards of performance or approval (Crocker and Park, 2004). David’s developmental history, in which paternal approval appeared closely tied to visible performance in front of others, plausibly contributed to a pattern in which his self-worth became substantially contingent on being seen to perform competently, rather than resting on a more stable, internally generated sense of value. Viewed this way, David’s anxiety is not simply a fear of public speaking as an isolated skill deficit, since his career history shows he is objectively competent, but a fear of what visible evaluation might reveal about his underlying adequacy, a distinction with direct implications for treatment, since purely skills-based interventions, presentation-skills coaching, for example, would be unlikely to resolve a difficulty rooted primarily in self-worth contingency rather than genuine performance ability.
A brief differential consideration is also warranted within the formulation. David’s presentation shares surface features with generalised anxiety disorder, sleep disturbance and persistent worry, and with a depressive presentation, given the guilt and self-criticism described; however, the specificity of his anxiety to evaluative workplace situations, the absence of pervasive low mood or anhedonia outside this domain, and his SPIN scores being proportionately higher than his GAD-7 score, together support a formulation centred on social and performance-specific anxiety rather than a primary generalised anxiety or depressive presentation, consistent with NICE (2013) diagnostic guidance distinguishing social anxiety disorder from generalised anxiety disorder on the basis of situational specificity. This distinction matters clinically because it directs intervention towards the evaluation-focused mechanisms identified by Clark and Wells (1995) rather than towards more generic anxiety-management techniques that would not specifically target David’s fear of negative judgement.
Several issues emerge from this formulation that should directly inform how David’s care is planned. First, the interplay between predisposing schema and current perpetuating behaviour means that symptomatic relief alone, simply reducing David’s day-to-day anxiety, is unlikely to be sufficient; without addressing the avoidance and safety-behaviour cycle identified through the Clark and Wells (1995) model, the underlying belief that he is at risk of being judged incompetent will remain untested and therefore unchanged.
Second, David’s concealment of the full extent of his difficulties from his partner, together with his emerging pattern of using alcohol to manage anticipatory anxiety, are both areas requiring sensitive, ongoing monitoring; neither currently meets a threshold suggesting a separate clinical concern in its own right, but both represent risk factors that could escalate if the underlying anxiety is not addressed, and both would benefit from being named openly and gently within the therapeutic relationship rather than left unaddressed.
Third, there is a genuine occupational risk dimension to this case: continued sick-day avoidance carries a realistic risk of triggering performance-management scrutiny at work, which would itself constitute precisely the kind of negative evaluation David fears, creating a vicious cycle with real-world, not merely internal, stakes, and underlining the practical urgency of addressing the avoidance pattern rather than treating it as a purely psychological abstraction.
Fourth, there is a scope-of-practice consideration relevant to the EAP setting in which this case arises: EAP provision is typically brief and non-diagnostic, and the practitioner should remain alert to whether David’s presentation meets a formal clinical threshold, for example for generalised anxiety disorder or social anxiety disorder as defined in relevant NICE guidance (NICE, 2011; NICE, 2013), in which case timely signposting to his GP or to NHS Talking Therapies for a fuller assessment and, if appropriate, a longer course of treatment would be professionally and ethically appropriate.
Fifth, David’s own insight and motivation, evidenced by his self-referral, are a significant protective factor supporting a good prognosis, but his visible embarrassment about the avoidance pattern suggests that a sufficiently trusting therapeutic relationship will need to be established before directly challenging the avoidance and safety behaviours identified above, since premature or overly direct challenge risks reinforcing the very shame-based self-criticism already identified as part of the perpetuating cycle.
Sixth, because David’s self-worth appears substantially contingent on visible performance, there is a risk that generic reassurance, telling him he is competent, will have limited lasting effect, since it does not address the underlying contingency itself; work that helps David build a broader, less performance-dependent basis for self-worth is likely to offer more durable protection against relapse than symptom management alone, even though this is realistically a longer-term goal beyond the immediate scope of brief EAP-based intervention.
Building on the formulation above, six recommendations are proposed for David’s ongoing support. First, begin with collaborative psychoeducation, sharing the Clark and Wells (1995) maintenance-cycle model with David directly and populating it together using his own recent examples, so that the formulation becomes something David co-owns and can use to make sense of his own experience, rather than an external label applied to him.
Second, introduce attention-training techniques aimed at reducing self-focused attention during feared situations and redirecting attention towards genuine external cues, for example by deliberately observing colleagues’ actual reactions during a meeting, providing a direct means of testing the accuracy of David’s internally generated negative self-image against real external evidence.
Third, design graded behavioural experiments that systematically test David’s specific feared predictions, for example attending a lower-stakes meeting without his usual safety behaviours and explicitly noting what did and did not happen, building an evidence base that directly challenges the beliefs the Clark and Wells (1995) model identifies as central to maintenance, rather than relying on reassurance or generic confidence-building alone.
Fourth, work collaboratively to reduce safety behaviours in a planned, graded way, beginning with the least anxiety-provoking behaviour, for example choosing a seat further from the door before a lower-stakes meeting, since the model indicates that these behaviours, though intended to protect David, are directly implicated in preventing recovery.
Fifth, address anticipatory and post-event processing directly, for example through a structured, time-limited “worry period” technique to contain pre-meeting anticipatory anxiety, and cognitive restructuring techniques applied to the self-critical thoughts that follow avoided presentations, targeting both the immediate maintenance cycle and the underlying predisposing schema identified through the 5Ps formulation.
Sixth, monitor David’s alcohol use and relationship disclosure sensitively across sessions rather than addressing either as a one-off topic, encouraging alternative coping strategies for managing anticipatory anxiety, and reviewing whether referral to his GP or NHS Talking Therapies becomes appropriate if his presentation intensifies or if either concern develops into a more significant, standalone difficulty beyond the scope of brief EAP-based support.
Seventh, with David’s consent, consider whether a brief, structured conversation with his line manager about reasonable, time-limited adjustments, for example advance notice of when he will be asked to present, or the option of circulating written updates alongside a shorter verbal contribution during the early stages of intervention, could reduce immediate occupational risk while the underlying formulation-guided work progresses, without this becoming a long-term avoidance accommodation that itself removes the exposure opportunities the intervention depends upon.
This case study has applied the 5Ps formulation framework and Clark and Wells’ (1995) cognitive model of social phobia to a client presenting with significant workplace-related anxiety. The formulation indicates that David’s difficulties are best understood as a longstanding, schema-level vulnerability, activated by increased visibility following a recent promotion, and actively sustained in the present by an avoidance and safety-behaviour cycle that provides short-term relief at the cost of preventing the disconfirming evidence David needs in order to recover. The recommendations proposed combine collaborative psychoeducation, attention-training, graded behavioural experiments and cognitive techniques targeting anticipatory and post-event processing, while remaining attentive to the occupational risk, alcohol use and relationship-disclosure concerns identified as part of the wider clinical picture. As with other cases in this series, David is a fictional construct created for academic illustration and does not describe a real client.
Need a Model Case Study Written to Your Exact Brief?
Our 350+ UK-qualified writers deliver referenced model documents from £15 per 250 words, with free plagiarism and AI-detection reports.
You May Also Like
All work is written by human writers. 100% AI free, guaranteed.
100% money back guarantee if you find plagiarism in our work.
COMPANY DETAILS
