Trauma-Informed Case Formulation and Structural Stress

Imagine a client sitting across from you in the therapy room. They seem both overwhelmed and disconnected. There is so much instability in their lives. Every question you ask is met with, “I don’t know.”

You notice your frustration or self-doubt beginning to build and you think:

There is too much going on. Why are they here if they cannot engage with my questions? I’m not sure I can help them.

But what if the way this client is showing up is not evidence of resistance or dysfunction?

What if it is helping them survive?

Instead of asking only, “What is the root of the problem?” or “How can I fix this?”, we might ask: “How has this way of responding helped this person navigate their life—past and present?”

That shift changes the case formulation. It moves us away from seeing a person as a problem to solve and toward understanding them as someone whose responses developed for a reason.

A Case Formulation Should Include the World Outside the Room

As therapists, we have been taught to case-formulate for our clients based on a medical model that deals with people as problems to solve rather than as people who make sense as they are, but are at a crossroads, struggling with how to grow or heal beyond their history.

What if we didn’t pathologize our clients? Isn’t our role to point out and normalize dialectics? It absolutely can be that a behaviour or response has been adaptive and is no longer helping.

The clients who come into our offices live in the real world, and unfortunately, it is not always a safe, fair, or loving place. As the feminist Carol Hanisch said: “the personal is political”. It stands to reason that our case-formulation should acknowledge the systems, beliefs, and people that oppress and/or privilege our clients.

A Case for Structural Stress as a Framework for Case Formulation

Structural stress references the systems, institutions, and circumstances that shape a person’s life. It is the systemic pressure an individual feels. Their social location is the specific place they occupy within that system.

As social workers, we are taught to look at a person within their social location and to acknowledge the systems around them. We are taught to examine the parts of our identity that privilege us and the elements that oppress us.

Do you remember the “Power Flower” exercise - a visual self-reflection tool used to examine your social location and how these different aspects of your identity intersect and align with or diverge from, societal power and privilege - you likely did in your undergrad? Structural stress builds on this examination of social location to acknowledge the impacts and adaptations around these identities.

As therapists, considering structural stress acknowledges that emotional distress may be a reasonable response to difficult life circumstances. What a relief to be told it makes sense you are angry, distrusting, hyperviligant, etc?! Validation and normalization is an important part of talk therapy. It can also build trust and create space to process the deeper pain underneath.

The Middle Ground: Why neither Over-Pathologizing nor Under-Recognizing are the way to go

I can’t tell you how often therapists share with me that they pulled out an assessment tool (e.g. PHQ-9, GAD-7, PCL-5) in a session with a client early on in the therapeutic relationship. While there’s nothing obviously wrong with that - in fact, it is probably encouraged in our training - it can be pathologizing. We need more context. We need to build a relationship on understanding the person in front of us. We don’t have to have a diagnosis. We don’t have to have an answer to the issues presented. Even if a symptom is intense or “extreme” it does not necessarily mean that the person has a disorder.

That said, there are of course circumstances where it is important to recognize a clinical condition that needs treating in some way (e.g. medications, outpatient programming, psychiatry assessment) and we don’t want to dismiss all ailments as “just their circumstances” either.

Assessment and Documentation Implications

Taking a structural stress approach to case formulation shifts the focus away from individual pathology toward systemic impact. This framework documents the environment as the primary source of distress rather than treating it as a mere backdrop to personal issues.

Assessment: Rethink the types of questions you ask your clients as you get to know them.

• Power Mapping: Evaluate the client’s access to institutional power, legal protections, and financial resources.
• Resource Deficits: Examine the client’s physical safety, housing stability, food security, access to healthcare and social supports.
• Historical Harm: Assess for intergenerational trauma and the historical impacts of systemic discrimination
• Bureaucratic Burdens: Explore the time and energy spent navigating hostile welfar, legal or immigration systems.
• Language shift: Instead of asking “what is wrong with you?” ask “what systems have/are failing you?”

Documentation: How you Record the Narrative matters.

• Systemic Diagnosis: Frame symptoms like anxiety or hypervigilance as adaptive, normal responses to chronic unsafety.
• Externalised Language: Write "Client experiences depressive symptoms secondary to systemic isolation and economic precarity" rather than "Client is unmotivated."
• Macro Objectives: Include advocacy goals in the treatment plan, such as connecting the client to housing legal aid.
• Defensive Deficit Framing: Document systemic resource gaps directly to protect the client from being labeled as "non-compliant."
• Strength Auditing: Record communal resilience, mutual aid networks, and systemic survival skills alongside explicit stressors.

Applications for Trauma Therapy

The structural stress approach lends itself well to trauma work. It is another frame from which to see trauma responses not as internal dysfunctsion, but as very normal adaptations to abnormal things that have happened to them.

It helps to facilitate self-compassion by honouring the adaptation rather than shaming it. This does not necessarily mean that the adaptation is still needed in the same way; however, it normalizes the history of responding in a certain way and helps the client to become more self-aware and able to separate past from present.

It helps to acknowledge what is within the client’s control and helps to bring focus to how the client can feel better within those constraints. Unfortunately, for many marginalized individuals, trauma is ongoing, continuous and systemic. The clinician needs to hold that in awareness for true safety and to collaborate with the client on realistic goals

It empowers clients through the concept of collective identity. It connects personal suffering to a broader socio-political reality. They are not alone.

An Invitation to Practitioners

If you are a therapist interested in developing more structurally informed approaches to case formulation, trauma treatment or documentation or you are looking for an environment-centred referral option, I welcome you to connect with Healing Space Therapy.

The work begins by becoming more curious about everything that enters the therapy room with a client, including what cannot immediately be seen.

References

American Psychological Association. (2017). Multicultural guidelines: An ecological approach to context, identity, and intersectionality. https://www.apa.org/about/policy/multicultural-guidelines.pdf

Hanisch, C. (1970). The personal is political. In S. Firestone & A. Koedt (Eds.), Notes from the Second Year: Women’s Liberation. Read the essay.

Metzl, J. M., & Hansen, H. (2014). Structural competency: Theorizing a new medical engagement with stigma and inequality. Social Science & Medicine, 103, 126–133. https://doi.org/10.1016/j.socscimed.2013.06.032

Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay and bisexual populations. Psychological Bulletin, 129(5), 674–697. https://doi.org/10.1037/0033-2909.129.5.674

Substance Abuse and Mental Health Services Administration. (2014). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. View the publication.

World Health Organization & Calouste Gulbenkian Foundation. (2014). Social determinants of mental health. View the report.